Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2

Abstract

Purpose of review With an ageing population, mounting pressure on the healthcare dollar, significant advances in medical technology, and now in the context of coronavirus disease 2019, the traditional paradigm in which operative procedures are undertaken is changing. Increasingly, procedures are performed in more distant, isolated and less familiar locations, challenging anaesthesiologists and requiring well developed situational awareness. This review looks at implications for the practitioner and patient safety, outlining considerations and steps involved in translation of systems and processes well established in the operating room to more unfamiliar environments. Recent findings Despite limited nonoperating room anaesthesia outcome data, analysis of malpractice claims, anaesthesiarelated medical disputes and clinical outcome registries have suggested higher morbidity and mortality. Complications were often associated with suboptimal monitoring, nonadherence to recommended guidelines and sedationist or nonanaesthesiologist caregivers. More recently, clear monitoring guidelines, global patient safety initiatives and widespread implementation of cognitive aids may have contributed to nonoperating room anaesthesia (NORA) outcomes approaching that of traditional operating rooms. Summary As NORA caseloads increase, understanding structural and anaesthetic requirements is essential to patient safety. The severe acute respiratory syndrome coronavirus 2 pandemic has provided an opportunity for anaesthesiologists to implement lessons learned from previous analyses, share expertise as patient safety leaders and provide valuable input into protecting patients and caregivers.

The Impact of the Pandemic on Acute Ischaemic Stroke Endovascular Treatment from a Multidisciplinary Perspective: A Nonsystematic Review

“…During the pandemic, NORA for AIS care brings more challenges to safe anaesthesia care, but MDT work can facilitate safe and efficient procedural care in the IR suite [57,58].…”

Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review

“…Environment Lighting during the procedure 19,21 Noise level during the procedure 19,37 Physical access to monitors or other equipment 29,37 Physical access to the patient 19,21,29,37 Positioning of the patient 37 Cramped workspace 1,4,19,21,37 Temperature in the procedure room 19 Interference of other equipment with anaesthesia monitors 29 Lack of electrical outlets 21 Standardising workspace organisation 30 Adequate lighting and plan for limited illumination with additional or backup lighting options 3,42 Anaesthesiologist input for NORA facilities 3 Ensure availability and use of warming devices 14,21 Necessary number of electrical outlets 19,42 High-resolution, remotely controlled cameras for monitoring 34,39,40…”

“…Lack of rigorous preoperative check-in procedures 21,23 Lack of knowledge of other personnel in the room about anaesthesia administration 3,21,23,29,37 Lack of access to anaesthesia backup or support staff 1,3,23,29,37 Lack of communication amongst team members during the procedure regarding anaesthesia administration 29 Inexperienced postoperative care team 29 Checklists 47 Team huddles, time outs, and debriefings 23,44 Displays, handbooks, and cognitive aids 39,45 Training staff in emergency anaesthesia procedures 3,21 Detailed/standardised preoperative screenings 3,4,14,21,29,37,38 Availability of additional anaesthesia assistance 29,42 Team-based approaches to emergency procedures for anaesthetic complications 46…”

“…Lack of essential medication or backup medication 1,3,4,19,21,23,29 Non-standardised workplace set-up across NORA settings 1,23,37 Insufficient time to conduct preoperative assessment 23,29,37 Pressure to produce high patient turnover rates Lack of time to debrief with colleagues after the procedure 23 Substandard postoperative environment (i.e. limited monitoring capabilities) 29,37 Adherence to the same standards of care as the OR 3,4,18,42,46 Incident reporting 48,49 Prospective hazard identification 50,51 Sophisticated analytical tools and frameworks for investigating error 52e54 An organisational culture that approaches error at the systems level 39 Education on unique environments, such as imaging suites 3 Ensuring same post-anaesthesia care for NORA patients as for OR patients 19,37,42 Anaesthesiologists must be able to voice concerns of working in locations that do not meet safety standards 3,23 OR standards for intraoperative and postoperative monitoring 37,38 Post-anaesthesia evaluation 3,37 Anaesthesia carts for remote locations 40 Familiarisation of anaesthesia providers with the NORA environment before the case 4…”

“…Lack of specific training in the NORA domain 19 Lack of familiarity with the procedures being performed 3 Mental fatigue 56 Lack of team familiarity 23 NORA specific or geriatric anaesthesia training 55 Effective communication and leadership 3,4,23,29,37,39 Anaesthesiologist must be familiar with surgical plan and needs of other staff 3 NORA simulation training, especially for emergency situations 38,40 on NORA. This could include a focus on specific requirements for intraoperative management of older and more frail patients 55 and team-based approaches to emergency procedures for anaesthetic complications.…”