Emergencies in Non-Operating Room Anesthesia (NORA)

Educational Objectives

The goal of this program is to improve outcomes in non-operating room anesthesia (NORA) settings. After hearing and assimilating this program, the clinician will be better able to:

1. Identify common challenges encountered in NORA environments.
2. Minimize clinician exposure to hazards encountered in NORA environments.
3. Compare the staff and procedures needed in the NORA setting with those needed in the traditional operating room setting.
4. Develop strategies for crisis management in NORA settings.
5. Delegate tasks effectively during crisis situations in a NORA environment.

Summary

Non-operating room anesthesia (NORA): a heterogeneous domain that includes anesthesia for endoscopy, cardiology, and radiology; it can be used for diagnostic or interventional procedures and in hybrid operating rooms (ORs) for complicated procedures that are minimally invasive but lengthy, cause physiologic changes, and incur specific anesthesia requirements; NORA may also be used for nuclear medicine, radiation oncology, minor procedures (eg, dentistry, electroconvulsive therapy, bone marrow biopsy, fertility procedures), or bedside procedures that occur in intensive care units or emergency departments

Challenges

Ergonomics: anesthesiologists have less space in the crowded rooms used for NORA than in the OR, and less space is available for supplies; supplies may need to be kept outside of the room during procedures that involve magnetic resonance imaging (MRI) due to the ferromagnetic effect; ergonomics may interfere with the ability to single-handedly manage anesthesia and deliver timely patient care

Technology: include difficulties with connecting to the electronic medical records, use of outdated or heavily used machinery, monitor artifacts (eg, electromagnetic interference from MRI that distorts electrocardiography), and inadequate connections; eg, it can be difficult to determine whether a low blood pressure reading is a real clinical event or a result of monitor interference; troubleshooting every possible issue can excessively prolong the procedure; if the data are not captured in the electronic anesthesia record (EAR), the anesthesiologist needs to write everything down on paper or take screenshots of the monitor to later update the EAR, which can significantly distract from patient care; too much technology in hybrid suites (eg, image-guided procedure tools) also causes problems (eg, inadequate electrical outlets)

Hazardous environment: nonoperating sites can be hazardous environments, eg, radiation oncology procedures involve radiation exposure; because patients are monitored from outside a shielded door, patient care is compromised; direct radiation exposure may occur during computed tomography (CT) or other image-guided procedure; the multiple layers of protective clothing and personal protective equipment needed can interfere with movement

Familiarity with the non-OR environment: anesthesiologists are less familiar with the non-OR environment; they need to check the equipment available at the receiving location and may need to bring emergency equipment with them to a case; unfamiliarity with the complete process may result in distraction from patient care

Unexpected events: MRI may need to be performed with the patient in a prone position and may require breath holds; many potential issues cannot be predicted if the anesthesiologist does not understand how the off-site procedure works and the details are not routinely communicated; data from the National Anesthesia Clinical Outcomes Registry (NACOR) database show increases over time in the number of procedures outside the OR, the age of patients undergoing NORA, and the American Society of Anesthesiologists (ASA) physical status (ie, comorbidity burden); despite these complications, most procedures are expected to be performed on an outpatient basis

Safety: the top priority of the Anesthesia Patient Safety Foundation (APSF); the NACOR database does not support the claim that the NORA environment is inherently less safe than the OR, but they are not comparable because the mortality associated with NORA procedures (eg, CT) should be less than that associated with OR procedures (eg, colectomy); challenges identified by the APSF include environment, equipment, processes, technicians, and assistance of staff (eg, nurses who are not used to an operative environment and have a different skill set); remoteness from the OR is an issue that cannot be changed easily and may cause delays in receiving extra help and supplies; procedures often take place after normal OR hours, in unfamiliar locations, and in increasingly ill patients

Human factor: concerns the application of what is known about people, their abilities and characteristics, limitations to the design of the equipment that they use, environments in which they function, and jobs they perform; it is difficult to perform tasks correctly in a NORA environment; human factor models evaluate the interplay between people (ie, clinicians) and the tasks, technology, and physical environment, and the effect of this interplay on clinical outcomes, patient safety, quality of care, system efficiency, and clinician stress and frustration

Effect on delivery of care: efficiency is lower in NORA environments than in the main OR; according to the International Anesthesia Research Society, delays can occur as a result of the environment and setup, safety regulations, and the process of moving patients to the post-anesthesia care unit (PACU) for recovery; the process in the NORA environment is different from that of the OR; extra processes and individuals are often needed for NORA, leading to delays and greater physical and mental effort; if there are complications during a procedure (eg, abnormal vital signs), it is much easier to call for and accommodate extra help in the OR than in NORA

Crisis Management

Challenges in the NORA environment: in a crisis situation, it can be difficult for an anesthesiologist to call for help because they need to attend to the patient and cannot walk over to the phone or administer medications; the basic tenets of crisis management (eg, calling for help, managing the airway) are difficult to follow in the NORA environment; anesthesiologists should be aware of who to call for help and the person on the team who can initiate the call (eg, endoscopy technician, imaging technician); it takes time for help to arrive after making the call; identify which team members have the skills to perform different tasks during emergencies while waiting for extra help

Multitasking: it is physically impossible to assess the patient and manage the machine and equipment single-handedly; cognitive aids or communication devices may not be available or accessible due to MRI restrictions; emergency equipment (eg, code cart, ultrasonography machines) may not be accessible or fit in the room where NORA is taking place; having a single anesthesia clinician during a crisis in the NORA environment is not ideal, even if they are adept at task-shifting; anesthesiologists also perform several technical tasks (eg, reintubation, securing an airway, drawing up medications, placing an intravenous line) that require cognitive tunneling (not being aware of one’s surroundings while performing the task); although this is necessary to perform the task, it may be problematic in a crisis situation, especially if the clinician is the only person with the skills and knowledge to assess the full clinical picture; it is important to strategize about how to deal with a crisis in advance

Crisis management: anesthesia crisis resource management involves decision-making and cognition; know the environment, anticipate and plan, use all available information, cross-check, and manage fixation errors (ie, focusing on a proxy problem when a more serious problem is present); cognitive aids can support the individual and entire team

Teamwork and resource management: exercise leadership and followership; call for help early and communicate effectively to distribute the workload and mobilize resources; Stanford Emergency Manual is available for free online and as a hard copy

Familiarization with the environment: individuals working in an environment where they are not completely comfortable pose a risk to patients; this can be mitigated by site-specific orientation and cognitive aids; preparing a core team can be helpful but may contribute to inflexible scheduling and unavailability of team members after hours; focus on problems that occur frequently in the NORA environment and practice calling for help and managing airway issues; have clarity around leadership and followership roles

Task saturation: whenever possible, back up and assess the situation more globally; train and practice in team settings to empower non-anesthesia staff to bring up issues (eg, abnormal monitor readings) that would not normally be their purview; distributing workloads and mobilizing resources is important in remote settings because the resources are limited; preemptively assign tasks and standardize procedures (eg, calling for help)

Delegation: certain technical tasks (eg, ventilation, intubation, airway instrumentation) cannot be delegated; other tasks (eg, reaching for equipment, turning on oxygen, reaching for suction) can be learned and practiced by other team members; most technicians are not allowed to administer medications and may feel anxious if asked to mix something unless it is very basic; nurses are more comfortable with these tasks; technicians may not be familiar with the equipment that the clinician is asking for; delegating the call for help may also pose difficulties if the person making the call does not know who they are calling or how to use the pager system

Combining anesthesia crisis resource management and NORA: remember the human factor approach and focus on coordinating the larger team to manage factors that cannot be changed, eg, remote and unfamiliar environments

Remoteness: people skilled in anesthesia crisis management are not readily available in NORA; remoteness can be accommodated for by having 2 people present for critical stages, eg, induction of and emergence from anesthesia; consider patient selection; very ill or frail patients are safer in the main OR after hours (if possible); situational awareness and proactive team training are important to reduce the consequences of remoteness; anesthesiologists should have temporizing strategies to mitigate the threat until help arrives

Unfamiliarity: can be reduced with standardized cognitive aids and team training; use a “back to basics” approach for initial resuscitation, focusing on calling for help, managing the airway, and performing basic advanced cardiac life support principles

Crisis management training: practice communication skills, temporizing measures, and team relations; use simulation training sessions in different environments outside the OR to practice collaboration with team members, including nurses and technicians; during these sessions, the team goes through all the motions; low-technology simulations are adequate for crisis management training

Interprofessional training: according to a qualitative interview study (Schroeck et al [2021]), the primary stressor for anesthesiologists in crisis situations is the team factor within the anesthesia team and in relation to the NORA team (trust, communication, respect, working together effectively); interprofessional simulation allows trainees to gain situational awareness and practice nontechnical, interprofessional skills; going through a mock crisis together supports team building and establishes trust and a shared language; it highlights elements that were taken for granted but not working during a code, eg, the pole used to support the imaging table to prevent it from swinging during cardiopulmonary resuscitation (CPR) was so high that no normal-sized person could effectively perform CPR unless provided with a step; debriefing afterward is crucial; the basic assumption is that all participants are intelligent, capable, and want to do their best; the goal is to show gentleness and avoid embarrassing the participants

Feedback: avoid judgmental feedback (ie, what went wrong); nonjudgmental feedback (what could have been better) may not be ideal because the core issue may not get addressed; instead, a debriefing with good judgment involves verbalizing what was done or not done and asking the person to explain their reasons

Putting feedback into action: the speaker’s center has standardized how to call for help and prepared brief cognitive aids (ie, phone numbers, clear and brief instructions); they developed an airway grab bag that can be used for temporary positive pressure ventilation even if the clinician is far from the anesthesia machine; the equipment is available in adult and pediatric versions and is safe for the MRI room; participants in the speaker’s MRI-OR course reported that they learned new information and were more confident in their roles and support of one another; some participants asked for longer or more sessions

Questions and Answers

Participants in simulation training: it is generally easier to get staff members involved than to get physicians; in some cases, neurosurgeons may be called in MRI operating room; training was stronger due to the participation of 2 attending physicians; there is usually no radiologist for diagnostic MRI; scheduling logistics are also challenging; MRI machines may only be available on weekends, after hours, or during staff meetings due to heavy utilization on weekdays; in the speaker’s experience, non-anesthesia staff members were more positive at the end of the simulation training after initial reservation; time constraints and late arrival of staff members to training are an ongoing issue; speaker also noticed that certain groups, eg, women, junior, or minority people, are not heard, which the trainer addresses during training

Drawbacks: constant transportation and continuous evaluation of machines in a NORA setting increase wear; MRI scanners have limited compatibility, especially for pediatric patients; replacing or upgrading the machines in a reasonable timeframe can be difficult

Readings

Borshoff DC, Sadleir P. Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2. Curr Opin Anaesthesiol. 2020;33(4):554-560. doi:10.1097/ACO.0000000000000895; Chang B, Kaye AD, Diaz JH, et al. Interventional procedures outside of the operating room: Results from the National Anesthesia Clinical Outcomes Registry. J Patient Saf. 2018;14(1):9-16. doi:10.1097/PTS.0000000000000156; Chang B, Urman RD. Non-operating room anesthesia: The principles of patient assessment and preparation. Anesthesiol Clin. 2016;34(1):223-240. doi:10.1016/j.anclin.2015.10.017; Herman AD, Jaruzel CB, Lawton S, et al. Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review. Br J Anaesth. 2021;127(5):729-744. doi:10.1016/j.bja.2021.07.007; Kim DK. Nonoperating room anaesthesia for elderly patients. Curr Opin Anaesthesiol. 2020;33(4):589-593. doi:10.1097/ACO.0000000000000883; Liau A, Havidich JE, Onega T, et al. The National Anesthesia Clinical Outcomes Registry. Anesth Analg. 2015;121(6):1604-1610. doi:10.1213/ANE.0000000000000895; Maddirala S, Theagrajan A. Non-operating room anaesthesia in children. Indian J Anaesth. 2019;63(9):754-762. doi:10.4103/ija.IJA_486_19; McGhee I, Tarshis J, DeSousa S. Improving Ad Hoc medical team performance with an innovative "I START-END" Communication tool. Adv Med Educ Pract. 2022;13:809-820. Published 2022 Aug 4. doi:10.2147/AMEP.S367973; Metzner J, Domino KB. Anesthesia and sedation outside of the operating room: outcomes, regulation, and quality improvement. anesthesia outside of the operating room, 1 edn (New York, 2011; online edn, Oxford Academic, 1 Aug. 2013), https://doi.org/10.1093/med/9780195396676.003.0008, accessed 4 Aug. 2023; Schroeck H, Taenzer AH, Schifferdecker KE. Team factors influence emotions and stress in a non-operating room anaesthetising location. Br J Anaesth. 2021;127(3):e95-e98. doi:10.1016/j.bja.2021.06.018; Wong T, Georgiadis PL, Urman RD, et al. Non-operating room anesthesia: Patient selection and special considerations. Local Reg Anesth. 2020;13:1-9. Published 2020 Jan 8. doi:10.2147/LRA.S181458; Youn AM, Ko YK, Kim YH. Anesthesia and sedation outside of the operating room. Korean J Anesthesiol. 2015;68(4):323-331. doi:10.4097/kjae.2015.68.4.323.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Schroeck was recorded at the 27th Annual Vermont Perspectives in Anesthesia, held virtually on March 2-4, 2022, and presented by The Robert Larner, MD, College of Medicine at the University of Vermont. For information on future CME activities from this presenter, please visit https://med.uvm.edu/cmie/home. Audio Digest thanks Dr. Schroeck and the Robert Larner, MD, College of Medicine at the University of Vermont for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

AN653801

Qualifies for:

ABA MOCA, Risk Mgmt/Patient Safety/Medical Errors

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.