The past two decades have seen advances in medical technology that now allow physicians to treat a patient with noninvasive or minimally invasive procedures. Patients who would have been subjected to sternotomy, thoracotomy, major vascular surgery, or laparotomy just a few years ago may now be treated more effectively, more economically, and more comfortably by nonsurgical intervention in specialized areas outside of the operating room. These procedures are changing medicine, and the specialty is learning to change with it. Anesthesia cases occurring in non–operating room locations make up approximately 30% of all cases in the Department of Anesthesiology and Critical Care at the University of Pennsylvania, following a nationwide trend.
Indeed, we are witnessing the development of a new subspecialty: Non–Operating Room Anesthesia (NORA). NORA cases are frequently challenging procedures that involve compromised patients deemed poor candidates for more invasive procedures. NORA cases may additionally involve sharing, or sometimes ceding, the airway to the proceduralist, as in interventional pulmonology. In the NORA procedure room, both people and the airway are managed. NORA practitioners are ideally able to manage a high volume of rapid-turnover cases and attend to the needs of patients, proceduralists, and staff.
In NORA settings, the room, the procedure, and the staff are all highly specialized to perform a specific task. The locations where these procedures are done are often designed for a specific subspecialty, such as gastroenterology or electrophysiology; anesthesia services are sometimes an afterthought, although incorporating plans for anesthesia services is occurring more frequently as new space is developed. In contrast, operating rooms are generally designed to accommodate a variety of case types, with interchangeable staff. Staff roles such as the circulating nurse or scrub technician are usually quite structured. Such standardization leads to a consistency that produces an acceptable level of care at minimum and a standard of excellence at best. The same standardization is not necessarily present in the NORA room, which may compromise the provided quality of care.
If NORA rooms are not held to the same set of standards as the operating room, how do you provide consistently superior care? Consistent success in NORA, as in the operating room, may be achieved by adhering to the structural and organizational standards addressed in this and other chapters. This chapter will focus on the organizational aspects of designing—or engineering—excellence in NORA. Such aspects include protocols, checklists, communication during the procedure and during transfer of patient care, quality improvement methods, and continuing education. The following chapters will discuss structural aspects of engineering safety in the physical plant, where seemingly mundane questions such as “Where does the anesthesia machine go?” or “How many electrical outlets are needed?” become very important when designing a NORA area.
The deliberate pursuit of excellence in NORA is important because this venue represents the future of anesthesia. Complex procedures on sicker patients, many of which would be canceled or postponed in a traditional operating room setting, will become more common. It is important to hold remote NORA locations to the same high standards of quality as those of the operating room. Engineering a high standard of excellence will lead to the ultimate goal—improvements in both quality and safety for the patient receiving NORA.
Achieving Excellence in Health Care
The seminal report in 2000 by the Institute of Medicine (IOM) titled To Err is Human: Building a Safer Health System sparked the modern movement to improve patient safety and increase health care quality. One year later, the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century, in which six aims for health care improvement are advanced. According to the report, care should be safe, effective, patient-centered, timely, efficient, and equitable. Cases in NORA settings are well poised to meet these goals, because shorter, less-invasive procedures may enable more rapid discharge and return to preprocedure function.
Nevertheless, it is important to consider how NORA systems may be engineered to optimize the likelihood of desirable patient outcomes. This chapter explores proactive and reactive approaches to operating in high-stress, high-stakes environments. To explore proactive systems design, we draw examples from medical and nonmedical settings. As part of this discussion, we consider organizational structures that promote safe care and effective communication among teams. Next, we present several protocols that have been useful in guiding NORA care at our institution.
Even though effective organizations take steps to prevent adverse incidents, problematic events still occur. It is therefore vital that organizations have a defined approach to reacting to adverse events, including errors and near-misses. We consider how anesthesia and perioperative providers respond to these events within NORA settings and describe how to use these opportunities to improve care.
Proactive Versus Reactive Approach to Problems
It is imperative that individuals and organizations engaged in high-risk activities develop an approach to dealing with problems, including errors, near-misses, and adverse events. Health care has historically taken a reactive stance to problems by waiting to enact fixes until a pattern of adverse events such as wrong-side surgeries, medication errors, and health care–associated infections emerges. Health care organizations are learning how to anticipate reasonably expected problems, which allows them to engineer systems to avoid a bad outcome before it can happen. We first describe the discipline of human factors engineering, explaining how principles from this field can inform perioperative systems design. Next, we explore the rise of protocols and checklists in perioperative medicine and discuss how these tools can prevent adverse events.
Proactive Versus Reactive Approach to Problems
It is imperative that individuals and organizations engaged in high-risk activities develop an approach to dealing with problems, including errors, near-misses, and adverse events. Health care has historically taken a reactive stance to problems by waiting to enact fixes until a pattern of adverse events such as wrong-side surgeries, medication errors, and health care–associated infections emerges. Health care organizations are learning how to anticipate reasonably expected problems, which allows them to engineer systems to avoid a bad outcome before it can happen. We first describe the discipline of human factors engineering, explaining how principles from this field can inform perioperative systems design. Next, we explore the rise of protocols and checklists in perioperative medicine and discuss how these tools can prevent adverse events.
Proactive Approaches: Anticipating Problems
Human Factors Engineering
Human factors engineering (HFE; also known as human factors and ergonomics) is a discipline that considers individuals’ physical and mental/cognitive limitations in task development and evaluation. The use of color-coding, such as yellow-striped epidural infusion tubing, and pin-index safety systems are two examples of HFE applied to the respective problems of inadvertent medication administration and medical gas mix-ups.
HFE is especially important in the selection of devices employed in clinical care. Undesirable device features may prompt users to create workarounds that compromise safety features. Poorly designed user interfaces can predispose to malfunction or error. Lin et al showed patient-controlled analgesia pumps with cumbersome interfaces contributed to adverse events, including overdose. In NORA settings, devices are used by practitioners from multiple disciplines. The training, needs, and expectations of these users should be considered in the selection of monitors, drug-dispensing systems, airway support equipment, and other shared devices.
Protocols and Checklists
Despite concerns about diminishing clinical autonomy and the rise of “cookbook medicine,” robust evidence demonstrates that the use of protocols and checklists in certain clinical settings decreases error and improves clinical outcomes. Perhaps the most well-known recent example is the work done by Atul Gawande and the Safe Surgery Saves Lives study group that used presurgical checklists to standardize care and serve as a safety check (an example is provided in Table 1-1 ). This group demonstrated that use of checklists was associated with decreased morbidity and mortality in eight international hospitals. Peter Pronovost’s work has similarly demonstrated a decrease in complications—specifically, central line–associated bloodstream infections—when checklists are used before central line insertion. Use of a daily goals sheet in the intensive care unit improved health care team communication and decreased length of stay.
| Before Induction of Anesthesia | Before Procedure Start | Before Patient Leaves Procedure Room |
|---|---|---|
| Has the patient confirmed his or her identity, site (if applicable), procedure, and consent? □ Yes | Confirm all team members have introduced themselves by name and role. | Nurse verbally confirms: The name of the procedure Completion of instrument counts (if applicable) Specimen labeling (read specimen labels aloud, including patient name) Whether any equipment problems need to be addressed |
| Is the site marked? □ Yes □ Not applicable | Confirm the patient’s name and procedure | |
| Is the anesthesia machine and medication check complete? □ Yes | Has antibiotic prophylaxis been given within the last 60 minutes? □ Yes □ Not applicable | To the proceduralist, anesthetist and nurse: What are the key concerns for recovery and management for this patient? |
| Does the patient have a: Known allergy? □ No □ Yes Difficult airway or aspiration risk? □ No □ Yes, and equipment and assistance are available Risk for >500 mL blood loss (7 mL/kg in children)? □ No □ Yes, and two intravenous lines or central access and fluids planned | Anticipated critical events: To proceduralist: What are the critical or nonroutine steps? How long will the case take? What is the anticipated blood loss? To anesthetist: Are there any patient-specific concerns? To nursing team: Has sterility (including indicator results) been confirmed? Are there any equipment issues or concerns? | |
| Is the pulse oximeter on the patient and functioning? □ Yes | Is essential imaging displayed? □ Yes □ Not applicable |
Protocols and guidelines can be especially helpful in infrequently encountered situations. In our institution, a core group of anesthesiologists provides care for patients receiving NORA. However, it is common for NORA locations to be staffed by someone who is not in this core group during evenings and weekends. Guidelines for particular NORA settings, such as for endoscopy and electrophysiology, were designed to ensure uniformity of care ( Box 1-1 ). Ideally, protocols provide guidance without unnecessarily constricting providers’ ability to customize care plans for individual patients.
- 1.
Evaluate the patient for anesthesia (airway, cardiac function, allergies, etc.) and fill out the anesthesia assessment form.
- 2.
Verify patient identity and procedure.
- 3.
Make sure consent for the procedure and anesthesia have been obtained.
- 4.
Check NPO status (solids 6 hours, clear liquids 2 hours). If not NPO, discuss with the cardiologist whether the risk for aspiration is outweighed by the risk for postponing the cardioversion. If not, postpone until patient status is NPO; if so, proceed with the head of the bed elevated and apply cricoid pressure while the patient is unconscious and consider succinylcholine and intubation.
- 5.
Place routine monitors.
- a.
Electrocardiogram: If sinus rhythm is observed, cancel the procedure.
- b.
Pulse oximeter: Make it audible.
- c.
Blood pressure: Place cuff on limb that does not have intravenous line or pulse oximeter and start automatic measurement every minute.
- a.
- 6.
Make sure patient has a free-flowing intravenous line.
- 7.
Make sure necessary supplies are available.
- a.
Yankauer suction
- b.
Airway supplies (bring a “tackle box” from the electrophysiology anesthesia workroom; a list of suggested contents is taped inside the lid).
- c.
Emergency medications (including epinephrine, atropine, succinylcholine, phenylephrine, and ephedrine)
- a.
- 8.
Denitrogenate the patient with 100% oxygen mask and bag.
- 9.
If using a non–central venous line, pretreat the vein with 1 mg/kg IV lidocaine ∗
∗ See also Davis, MF. Lidocaine for the prevention of pain due to injection of propofol. Anesth Analg 74:246-249, 1992; based on 2013 protocol at the Hospital of the University of Pennsylvania.
unless the patient is allergic to it.
- 10.
If the patient is allergic to propofol, soybeans, or eggs or has a left ventricular ejection fraction <25%, induce with etomidate 0.1 mg/kg IV; otherwise, use propofol 1 mg/kg IV.
- 11.
If the patient becomes hypotensive, notify the cardiologist, consider intravenous fluid and phenylephrine, and use etomidate rather than further propofol.
- 12.
If the patient responds to tapping his or her forehead or shouting his or her name, tell the patient to take deep breaths, then give propofol 0.4 mg/kg or etomidate 0.04 mg/kg and reassess.
- 13.
Check for loss of eyelash reflex; if not, give propofol 0.4 mg/kg or etomidate 0.04 mg/kg and reassess.
- 14.
Support the patient’s airway as needed.
- 15.
Tell the cardiologist that he or she may proceed.
- 16.
Check for pulse and check blood pressure.
- 17.
If the patient is bradycardic, ask the cardiologist if he or she wants you to administer atropine.
- 18.
If cardioversion is unsuccessful, ask the cardiologist if he/she will attempt again. If so, go back to step 11.
- 19.
Check that the patient moves all extremities on command when awake.
- 20.
Give report to the cardiology nurse.
- 21.
Be sure that the front pages of the anesthesia record and of the anesthesia assessment form get on the patient’s chart.
- 22.
Return the “tackle box” to the EP anesthesia workroom, and do not leave medications, syringes, or needles lying around.
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