Anaesthesia activity outside of theatre is increasing; it is now estimated that up to 30% of anaesthetics are administered in the non-operating room environment. [1.] Growth in requests for non-operating- room anaesthesia (NORA) is multi-factorial. The increase in demand can be attributed to our ageing population, the advent of minimally invasive techniques as well as the introduction of newer technologies requiring sedation and/or anaesthesia in remote locations. Delivering safe anaesthesia in a non-theatre environment presents many challenges which can be broadly divided into three categories.

The Three P's:

Is NORA a Risky Business?

It is frequently hypothesised that due to the above challenges and barriers, out of theatre anaesthesia has the potential to carry a higher risk than anaesthesia carried out in the operating room. There are however, difficulties in quantifying this risk. There is a paucity of data relating to patient safety and anaesthesia in general in Ireland, as outlined in the June 2021 issue of this newsletter. And there is therefore a complete lack of data relating to out of theatre anaesthesia safety issues in Ireland. There are conflicting results of international studies of NORA risk, some finding that cardiology and radiology suites are the highest risk locations, [1] while another analysis of closed claims pertaining to NORA in the US revealed that most of the adverse incidents occurred in the endoscopy suite. [4.] Most of these claims related to respiratory events. Oversedation, culminating in respiratory depression, was implicated in a third of all claims. In most of these events, there was limited use of expired carbon dioxide monitoring or any respiratory monitoring at all. Further analysis in the same study, suggested that more than half of the deaths associated with remote anaesthesia could have been prevented by improved monitoring techniques.[4,5,]

Risk Assessement

Anaesthesiologists are constantly risk assessing and adjusting perioperative plans accordingly. To truly risk assess and ultimately mitigate any increased risk associated with out of theatre anaesthesia, we need to know what risks exist and why. We must routinely and robustly collect data pertaining to safety and anaesthesia outside of the operating room environment. We need to disclose any adverse event, near miss or equipment failure that occurs in these environments and interrogate the resultant data. Open disclosure, as discussed eloquently by Dr. Aislinn Sherwinn, in a previous issue, is paramount to this process.

Human Factors

We also need to dissect and proactively establish the contribution of human factors to an elevated risk of adverse events in the out-of-theatre environment. Schroeck et al [2.], found that the challenges of remote anaesthesia contribute to a higher workload, increased stress and anxiety for anaesthesia providers in these circumstances. Potential remedies include crisis resource management sessions involving all service providers. Good communication and adherence to routine anaesthesia safety procedures are crucial to maintaining the high safety standards in place in theatre in a non-theatre environment. It is recommended by the Royal College of Anaesthetists that each department nominate an out-of-theatre lead, to spearhead multi-departmental education programmes and aim to better integrate these services.[6] Multidisciplinary simulation training is another excellent method of negating some of the cultural or team factors implicated in adverse events.[7.]

NORA - An Emerging Sub-Specialty?

The demand for anaesthesia care outside of the theatre environment is increasing and NORA is emerging as a sub-specialty of anaesthesiology practice. Establishing risk related data specific to non-operating room anaesthesia would allow anaesthesiologists to guide the multi-disciplinary approach to ensure the safety of these complex patients [8.]. Incorporation of the checklists, team briefings, protocols and monitoring techniques ubiquitous in theatre, to these remote locations is intuitive given their proven safety record. It is our duty that these complex patients, regardless of location, remain ‘Safe Whilst We Watch. Salus Dum Vigilamus’.

References: [1.] 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;14:9- [2.] Schroeck H, Taenzer AH and Schifferdecker KE, ‘Team factors influence emotions and stress in a non-operating room anaesthetising location’, British Journal of Anaesthesia, July 2021, bja.2021.06.018 [3.] Nagrebetsky A, Gabriel RA and Dutton RP et al. ‘Growth of nonoperating room anaesthesia care in the United States: a contemporary trends analysis. Anesth Analg. 2017;124:1261-7 [4.] Woodward ZG, Urman RD, Domino KB. ‘Safety of non-operating room anaesthesia:a closed claims update. Anaesthesiol Clin. 2017;35:569-581. [5.] Metzner J, Posner KL, Domino KB. ‘The risk and safety of anaesthesia at remote locations: the US closed claim analysis. Curr Opin Anaesthesiol. 2009;22:502-508. [6.] Royal College of Anaesthetists 2021, ‘Guidelines for the Provision of Anaesthesia Services in the Non-theatre Environment 2021’. Available online at: https://www.rcoa.ac.uk/gpas/chapter-7 Accessed 08/09/2021. [7.] Schroeck H, Boone MD, Rubenberg LA, Bryan YF. ‘Anesthesia emergencies in hybrid operating rooms: multidisciplinary crisis resource management.’ APSF NewsFlash; 2020. Available from: https://www.apsf.org/article/anesthesia-emergencies-inhybrid-operating-rooms-multidisciplinary-crisis-resourcemanagement. Accessed 12/09/2021 [8.] Schroeck H, Welch TL, Rovner MS, Johnson HA, Schroeck FR.’ Anesthetic challenges and outcomes for procedures in the intraoperative magnetic resonance imaging suite’: A systematic review. J Clin Anesth. 2019 May;54:89-101.