When requests for anesthesia assistance outside the main operating room first occurred more than a decade ago, they were regarded as nuisance calls and often ignored. The requests were haphazard and usually asked for an urgent response in a remote location where nurse-administered moderate sedation was not sufficient to sedate a patient for a procedure or diagnostic study. This request was further complicated by the fact that most patients had multiple comorbidities. The response to this problem has evolved into the practice of non–operating room anesthesia (NORA). NORA’s challenge is to coordinate anesthesia in reaction to its service requests. It involves multiple issues—preoperative assessment, standardized procedure room requirements, standardized anesthetic equipment, knowledge of the procedure, availability of backup help, having the proceduralists take some ownership of the patient, and being involved in the planning of any new procedure rooms. Macario has noted other issues in scheduling cases in locations outside the operating room, as follows:
- 1.
Scheduling differences in NORA locations make it difficult to assess demand for anesthesia staff.
- 2.
Cancellation and rebooking of cases is not always passed on to the anesthesia scheduler.
- 3.
NORA locations are not interchangeable as in the main operating room.
- 4.
Turnover time in NORA locations can be longer than in the main operating room.
- 5.
NORA services are generally small with a variable daily workload.
- 6.
The geographical distance between locations might necessitate separate staff rather than a staff covering residents or certified registered nurse anesthetists.
In spite of these issues, the central need was and still is, as in the main operating room, a predictable schedule.
This chapter briefly summarizes the associated issues that have to be dealt with before scheduling and providing anesthesia care in NORA locations. A discussion of the developing approaches to scheduling cases and procedures will follow. The approach our institution has taken will be presented, detailing problems noted and solutions tried. The final discussion will be about where scheduling needs to move forward to best serve the needs of the patient, staff, and hospital.
Associated Background Issues
Physical Space
The procedure room has to be large enough to allow adequate room for all members of the care team to function, as well as anesthetic equipment, imaging apparatus, and tables or trays. Doors must be large enough to allow easy entry of a bed. Adequate electric outlets and suction, standard gases, and waste anesthetic gas disposal outlets are needed. Needless to say, almost all of the locations available for use did not meet these requirements. Some accommodations to allow procedures were made in most locations, but some spaces were so small and inadequate that they could not be used because of patient safety concerns. With subsequent rebuilding, most locations are now adequate and safe for anesthetizing patients. A nitrous oxide yoke is no longer a requirement in NORA locations because of changes in anesthetic techniques and practice, as well as abuse potential in remote locations.
Standardized Anesthetic Equipment
The goal of NORA rooms is to replicate what is available in the main operating room from the anesthesia machine to the equipment cart. Drug dispensers in each location are stocked with standard anesthetic medications. The anesthesia machines are smaller models than those in the main operating room for portability. In the computed tomography (CT) scanner area, the anesthesia machine is moved out of the procedure room to a nearby storage room when not in use. Emergency airway equipment such as C-Mac (Karl Storz, El Segundo, Calif.) or Glidescope (Verathon, Bothell, Wash.) and a fiberoptic difficult airway cart are conveniently located in each location.
The use of ionizing radiation in NORA locations is common in most areas except for the area of magnetic resonance imaging (MRI). Proper shielding, which consists of a lead apron, vest and thyroid protector, lead eyewear (to minimize cataract formation ), and clear lead screens, is available and important to the long-term health of the anesthesia caregiver.
Knowledge of the Procedure
Because many NORA cases occur during nights and weekends, all staff who take overnight call in the main operating room are rotated through the non–operating room locations so that they have some familiarity with each area and the procedures done. A non–operating room block of lectures has been added to the weekly educational series to update members of our department about advances in the various non–operating room areas. Talks about radiation and MRI safety also occur. Several staff anesthesiologists present to the non–operating room location staff about anesthetic issues, particularly the intersection of moderate sedation and anesthesia. This new educational emphasis highlights the decision-making needed to decide which technique to use and how to go about scheduling anesthesia support.
Availability of Help for Emergencies
The daily roster of non–operating room personnel includes a team leader, who is able to quickly respond to any emergent situation such as unanticipated difficult intubation. Two or three anesthesia technicians are daily assigned to NORA locations and quickly respond to emergencies. The anesthesiologist who runs the main operating room is apprised regularly throughout the day by the non–operating room team leader and is attuned to quickly provide help as needed.
Preoperative Assessment
Every patient undergoing a procedure undergoes a preoperative anesthetic assessment. The Preoperative Evaluation Service (PES), housed within the hospital, was established to provide this service for the main operating room. Outpatients with procedures in non–operating room areas have also been gradually added to this service. However, the PES, which was already full with patients from the main operating room, has become overburdened with the non–operating room volume. This overloading has led to a restructuring of how patients from the non–operating room are seen and evaluated. More non–operating room cases have the preoperative assessment done on the day of the procedure in that location. Inpatients undergoing procedures on the same day are also seen in the procedure location. Inpatients for the next day are seen by the main operating room call team on the previous night. The system for non–operating room preoperative evaluations is evolving to be separate from the PES, a brick-and-mortar service for the main operating room, to a more mobile preanesthesia assessment service that covers both inpatients and outpatients. This is being done in conjunction with each location, providing a place to interview a patient; it also requires old records and referral notes to be as complete as possible.
Ownership of a Patient
For proceduralists who view themselves as “just doing a case,” the task of knowing their patients’ medical backgrounds is a required effort before assuming responsibility for moderate sedation. This task is made harder when patients’ medical conditions or drug requirements disqualify them for moderate sedation. It is generally the moderate sedation nurse who initiates the request for anesthesia support. This reflects the fact that historically the proceduralist often did not know and take “ownership” of the patient, even for the brief period of the procedure. This has led to an increased emphasis during moderate sedation training and yearly talks about the use of anesthesia and knowing the patient well. With time, it is hoped that this training will lead to proceduralists knowing the patients better so that they will take ownership of “their” patients.
Booking Cases
The decision was made early in the process to keep the scheduling office for the main operating room as the funnel for entry to book elective cases. This provides a consistent, central place that interacts with the anesthesia scheduling office to ensure that the preoperative anesthesia assessment is scheduled and that procedures are put in the appropriate time slots. Procedures that need to be done within 24 hours are booked through the main operating room front desk and are treated as add-on cases.
Knowledge of the Procedure
Because many NORA cases occur during nights and weekends, all staff who take overnight call in the main operating room are rotated through the non–operating room locations so that they have some familiarity with each area and the procedures done. A non–operating room block of lectures has been added to the weekly educational series to update members of our department about advances in the various non–operating room areas. Talks about radiation and MRI safety also occur. Several staff anesthesiologists present to the non–operating room location staff about anesthetic issues, particularly the intersection of moderate sedation and anesthesia. This new educational emphasis highlights the decision-making needed to decide which technique to use and how to go about scheduling anesthesia support.
Availability of Help for Emergencies
The daily roster of non–operating room personnel includes a team leader, who is able to quickly respond to any emergent situation such as unanticipated difficult intubation. Two or three anesthesia technicians are daily assigned to NORA locations and quickly respond to emergencies. The anesthesiologist who runs the main operating room is apprised regularly throughout the day by the non–operating room team leader and is attuned to quickly provide help as needed.
Preoperative Assessment
Every patient undergoing a procedure undergoes a preoperative anesthetic assessment. The Preoperative Evaluation Service (PES), housed within the hospital, was established to provide this service for the main operating room. Outpatients with procedures in non–operating room areas have also been gradually added to this service. However, the PES, which was already full with patients from the main operating room, has become overburdened with the non–operating room volume. This overloading has led to a restructuring of how patients from the non–operating room are seen and evaluated. More non–operating room cases have the preoperative assessment done on the day of the procedure in that location. Inpatients undergoing procedures on the same day are also seen in the procedure location. Inpatients for the next day are seen by the main operating room call team on the previous night. The system for non–operating room preoperative evaluations is evolving to be separate from the PES, a brick-and-mortar service for the main operating room, to a more mobile preanesthesia assessment service that covers both inpatients and outpatients. This is being done in conjunction with each location, providing a place to interview a patient; it also requires old records and referral notes to be as complete as possible.
Ownership of a Patient
For proceduralists who view themselves as “just doing a case,” the task of knowing their patients’ medical backgrounds is a required effort before assuming responsibility for moderate sedation. This task is made harder when patients’ medical conditions or drug requirements disqualify them for moderate sedation. It is generally the moderate sedation nurse who initiates the request for anesthesia support. This reflects the fact that historically the proceduralist often did not know and take “ownership” of the patient, even for the brief period of the procedure. This has led to an increased emphasis during moderate sedation training and yearly talks about the use of anesthesia and knowing the patient well. With time, it is hoped that this training will lead to proceduralists knowing the patients better so that they will take ownership of “their” patients.
Booking Cases
The decision was made early in the process to keep the scheduling office for the main operating room as the funnel for entry to book elective cases. This provides a consistent, central place that interacts with the anesthesia scheduling office to ensure that the preoperative anesthesia assessment is scheduled and that procedures are put in the appropriate time slots. Procedures that need to be done within 24 hours are booked through the main operating room front desk and are treated as add-on cases.
Related posts:
Critical Monitoring Issues for Non–Operating Room Anesthesia
Intravenous Anesthesia and Sedation Outside the Operating Room
High-Frequency Ventilation for Respiratory Immobilization
Anesthesia for Colonoscopy
Anesthesia Concerns in the Magnetic Resonance Imaging Environment
Anesthesia and Competitive Strategies
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