Non-Operating Room Anesthesia

Key Points

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The non-operating room arena represents an expansion of the traditional environment for anesthesia practice with significant implications for patients and providers. As technology advances and patient acuity increases, non-operating room anesthesia (NORA) cases have become more demanding in terms of both patient management and required resources and support services.
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Financial and operational constraints create additional challenges. Significant differences in practice result from the fact that NORA cases occur in places remote from the operating room (OR) and are performed frequently by medical proceduralists who are less familiar with the scope and clinical issues related to the practice of anesthesiology. In addition, anesthesiologists may be less familiar with the demands of providing an anesthetic in an environment outside of the OR and, in some cases, in which the proposed procedure and needed equipment restrict mobility and access to patients or where radiation exposure or other risks pose other challenges.
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This chapter serves as a general guide to the key principles of anesthetic management associated with procedures performed outside of the OR, and highlights some of the adaptations, both cultural and practical, that must be addressed in order to provide safe and optimal care that meets the need of the providers and patients.

Acknowledgment

The editors and publisher thank Dr. Wendy Gross, who was a contributing author to this topic in the prior edition of this work. It has served as the foundation for the current chapter.

Overview: Defining Non-Operating Room Anesthesia—What It Is and How We Got Here

Non-operating room anesthesia (NORA) refers to all procedures performed in locations other than the operating room (OR) and includes diverse environments and procedures, often associated with challenges not regularly confronted for procedures performed in the OR. Historically, cases managed outside of the OR were minor, infrequent, and involved relatively stable patients with limited comorbidities. They seldom required involvement of an anesthesia provider; more commonly sedation, if needed, was provided by a nurse supervised by the proceduralist. Over the past 2 to 3 decades, NORA cases have expanded considerably, now involving care provided by every medical specialty and, for many hospitals, accounting for increasing volume and revenue equivalent to that of the OR. Most important for the anesthesiologists is that the NORA cases are now often as demanding as the most advanced surgical OR procedures. They constitute a major expansion of our practice perimeter and require the same, if not more, planning and attention to operational efficiency as is required for cases performed in the OR.

In the United States, the number of NORA cases has continued to climb over the past decade. The percentage of cases increased from 28% to 36% from 2010 to 2014 alone. This continued escalation of NORA procedures now requiring the care of an anesthesia provider is based on rapid technologic developments and innovations that have expanded the array of possible procedures ranging from simple same-day procedures to complex cardiac procedures that necessitate postprocedure monitoring and care in the intensive care unit. Anesthesiology support is also required because patients with underlying medical conditions and increasing age are now being offered procedures that were previously unavailable to them. As a result, an increasing number of patients undergoing NORA procedures are older and more likely to be classified as having American Society of Anesthesiologists (ASA) class III-V physical status as compared with patients undergoing procedures in the OR. In fact, many NORA cases are performed on patients deemed “high risk for surgery,” including patients who in the past would not have been considered candidates for any medical intervention. Although some of these “minimally invasive” procedures are considered to be lower risk for the patient, the anesthetic issues are often very complex with significant potential for physiologic changes that require intensive management.

The increase in procedures performed outside of the OR has been accompanied by increasing oversight related to the safety of anesthesia in remote locations. An analysis of the ASA Closed Claims database found that remote location claims demonstrated a higher proportion of claims for death compared with OR claims (54% vs. 29%) and involved older and sicker patients. Fifty percent of remote location claims involved monitored anesthesia care—a reflection of the importance of close monitoring and management of patients by a skilled anesthesia provider who is able to transition the management to include initiation of general anesthesia or other interventions to address complex clinical issues. Predictably, respiratory events and inadequate oxygenation and ventilation were more common in these remote location claims than in OR claims. These findings suggest that patients are at a higher risk of adverse events when undergoing anesthesia for procedures in remote locations. These data underscore the need for conscientious preparation and greater vigilance when caring for patients in these environments. The goal of anesthesia providers must be to mitigate systemic factors that contribute to the excess hazard in these environments.

The purpose of this chapter is twofold: first, to highlight the inherent, common, as well as the unique characteristics of NORA cases that impose unusual challenges for anesthesiologists providing care outside of the OR; and second, to describe the goals, methodologies, and pitfalls of interventions in these environments that might be unfamiliar to some anesthesiologists. This chapter does not reiterate basic principles of anesthesiology practice described elsewhere in the text, nor does it describe the technical details of novel procedures. Instead, it serves as a general guide to the NORA environment and procedures performed outside of the OR and delineates some of the critical issues faced by anesthesiologists. The intention is to promote awareness that encourages preemptive planning, and equips anesthesia providers with a vocabulary with which to establish effective dialogue to cultivate a collaborative practice with colleagues and to maximize the safety of patients.

Novel Characteristics of Nora Cases

NORA cases are characterized by three distinctive features: location, operator, and relative novelty. First, the procedure does not take place in a standard operating suite and is typically remote to the main OR section. Second, the operator performing the procedure is generally a medical interventionalist rather than a surgeon. Finally, the procedures and technologies used are constantly evolving. Innovative applications of these procedures and technologies pose a challenge for a number of reasons as well. With advances in technology and expertise of the operators performing procedures outside of the OR, the procedures can be performed on patients with complex comorbidities and often on patients who are not candidates for a traditional surgical procedure or for whom surgery is no longer the only therapeutic option. For example, carotid artery stenosis can be treated in the OR, the catheterization laboratory, or the interventional radiology (IR) suite. The ultimate choice of venue may be a function of acuity of presentation but often depends on the referral—who the patient sees first, and who is available. As important, for many patients undergoing a NORA procedure, the scheduling is urgent, emergent, or unknown to the anesthesia provider until immediately before the procedure is to be performed, preventing an adequate periprocedural evaluation. These ever-expanding clinical services requiring anesthesia services outside of the OR provide an opportunity for anesthesiologists to reevaluate and reaffirm the importance of a preoperative assessment, as well as periprocedural and postprocedural needs, for this diverse group of patients. As a result, the perimeter of our landscape has expanded beyond the familiar domain of the OR and requires collaboration with a broad array of medical practitioners including interventional cardiologists, interventional radiologists, gastroenterologists, radiation oncologists, and electrophysiologists. Given the physical, medical, political, and economic challenges that may arise and that are often unanticipated, the goal must be to adapt to the new environments. We must also strive to evolve our anesthesia practice to meet the demands of a changing patient population.

Unique Obstacles: from Physical Environment to the Medicine–Anesthesiology Culture Gap

When anesthesiologists are faced with the need to provide services for non-surgeons in non-OR locations, issues such as scheduling inconsistencies, ad hoc requests, and resource limitations can be difficult to resolve, particularly if the usual scheduling process is not available. In addition, the increasing incidence of medically complex cases with patients needing urgent intervention, but lacking periprocedural evaluation, can create challenges. The two most common challenges are poor communication between providers exacerbated by the medicine–anesthesiology culture gap and, for many of the NORA procedures, inadequate physical space to accommodate the needs of a patient requiring anesthesia services.

Procedural suites are often remotely located. This increases the time lag between a request for assistance and the arrival of help, both with technological and medical problems. In addition, the lack of nearby supplies may exacerbate the timely resolution of common electrical and mechanical malfunctions or complicate the resolution of a medical emergency. This situation demands that care be taken before the start of the procedure to ensure that equipment is supplied and working and that backup options (emergency supplies, difficult airway equipment) are functioning and readily available.

In addition, non-OR procedure suites are frequently organized from the perspective of the proceduralist, and unfortunately, the needs of anesthesiologists are often overlooked. For example, procedure suites that use fluoroscopy for guidance are often configured so that the C -arm limits access to the patient’s head and obstructs direct communication between the anesthesiologist and the proceduralist. Inadequate access to the patient may be exacerbated if the area around the head of the patient is crowded due to constraints of the room and equipment. Lack of visibility of procedural screens may also make it difficult to follow the progress of the intervention without compromising the attention to the patient. Perhaps most important, hemodynamic monitors may be difficult to visualize by the anesthesiologist or, for some procedures, may not function properly because of interference with mapping systems or other electronic interfaces. Lead protective screens may not be available, and when they are available and positioned to protect the anesthesiologist from radiation, pumps and intravenous lines may become inaccessible. Gas scavenging may be unavailable, and oxygen and suction outlets may be suboptimally placed. For these and other reasons, anesthesiologists should be mindful of how best to orient both the patient and providers spatially within a procedure room, particularly if the setup of the room is unfamiliar. Distraction of focus away from patient care due to an unfamiliar environment can be potentially disastrous in the face of a novel or complex procedure.

The ASA has formulated a statement regarding NORA locations that articulates minimum standards for all procedures performed in these areas, but these standards are quite fundamental. Recognition of the constraints of the environment and anticipatory planning allow for the safe administration of anesthesia within this environment. The challenge is communicating the importance of these issues to the proceduralist and others involved in the care of the patient as well as hospital leadership to ensure that the needs of all parties are met. With newer procedures requiring anesthesia services in nontraditional environments, there may be a need to implement significant environmental changes to optimize the ability of anesthesiologists to deliver safe care.

Communication with the medical proceduralist is key to providing an optimal anesthetic; taking time to discuss the procedure and the patient allows for thoughtful consideration of anesthetic options in the context of both the principles of the procedure and the physiology of the patient. However, mismatches in culture can dominate interactions between medical practitioners and anesthesiologists and undermine communication. These conversations can be challenging since, unlike surgeons, medical providers may be unfamiliar with the skill sets of anesthesiologists and the needs for patient care or unaware of the intricacies associated with administering an anesthetic. For example, while surgeons are accustomed to sharing their procedures with other medical practitioners, proceduralists may be habituated to working alone and ordering sedation to be administered by a nurse. Medical interventionalists may also lack experience with relatively rare but serious complications that might arise during the procedure, such as loss of airway. In addition, proceduralists are frequently consultants who are enlisted by primary care providers to perform procedures, but who may not have received all relevant information that may be needed for a patient requiring anesthesia services. Even when all information is provided, specialization predisposes the proceduralists to concentrate on their point of expertise, so many of the concerns of the anesthesiologists are not taken into account.

Similar issues regarding the needs of the patient and the proceduralist may not be taken into account by the anesthesiologist who is unfamiliar with the procedure. In many cases, the anesthesiologist may have only a basic understanding about what is happening during the course of a noninvasive procedure and may not have asked enough questions about the plans, especially when they are new to a particular venue, the procedure is not observable, and fluoroscopy screens are out of the field of view or uninterpretable. Anesthesiologists may be unaware of pitfalls and likely complications of the procedure even though in the OR, they normally would not administer an anesthetic without understanding the idiosyncrasies of the surgery. These issues are important in planning for the anesthesia and procedure but are equally important during the procedure. Extra initiative is often required by the anesthesiologist since the proceduralist may not communicate the course of the procedure during the case. Other aspects of the procedure, such as how coughing on extubation might predispose patients who have had groin sheaths to serious hematomas, may not have been emphasized by the procedural team or likewise appreciated by anesthesiologists. Bridging the communication gap requires effort, but it is absolutely critical to optimizing outcomes.

When interventionalists undertake novel procedures using new technologies, the situation can become even more challenging. The course of the procedure may be unknown, the timing and sequence of events may be ill-defined, and the focus of the procedure may change midstream. At times, the proceduralist may be unsure of what is happening. In these situations, extensive preplanning, a commitment to communication, and the explication of goals for all involved in the care of the patient is crucial to the success of the procedure and, more importantly, the safety of the patient.

As medical procedures, particularly those performed outside of the OR environment, become even more technically demanding and patient clinical conditions more complex, the best possible patient management strategies will arise from collaboration and teamwork between medical proceduralists and anesthesiologists. This requires mutual respect, excellent communication, common vocabulary, shared experience, and overlapping competencies. In pursuit of this goal, we can build on the outstanding record of improved patient safety and outcomes that characterizes the history of anesthesiology.

Financial and Operational Constraints

The impact of performing procedures in new environments has significant financial and operational implications that must be addressed. In the desire and enthusiasm to advance clinical care and extend care to settings outside of the operating room, medical, financial, and operational implications often become blurred. As a result, it is important to understand the difference between what does and what should drive the direction of new program development related to NORA procedures and for all parties to address the specific operational needs while taking into account the financial implications of transitioning care to these alternative settings.

Effects of Payment Systems

A variety of payment methodologies are used to compensate providers and facilities for clinical services. While government payment methods remain important, private insurance has become the financial underpinning of the healthcare system in the United States—often allowing hospitals and providers to advance new technologies and innovative care that would otherwise be financially impossible. Private health insurance evolved as hospitals transitioned from repositories for the impoverished and dying into institutions where people actually recovered from illness. Hospitalization plans, initially developed by hospitals in the 1930s, were a way to supplement the economic resources needed for growth and expansion. At that time, hospitals often functioned as extensions of private offices and payment was, and continues to be, a fee-for-service system. As health care has become more expensive and the clinical options have expanded, both the public and private systems have had to adapt, becoming more complex and sophisticated—with the goal to minimize payment to those practices that have documented, evidence-based outcomes. These changes, and the goal to reduce costs of care, have both encouraged care outside of traditional and expensive environments, such as the OR, but also challenged providers to prove that the care remains safe and of high quality. These conflicting goals make expansion of care to non-OR locations challenging and, in some cases, undermine attempts to innovate.

Medical optimization and financial efficiency are predictably not the end products of fee-for-service payments. With increasing demand for clinical services, the need to reduce costs, hospital length of stay, and readmissions is critical. As the population ages, care is increasingly specialized and complex. The Medicare Payment Advisory Commission (MedPAC) reported that as of 2006, the average Medicare beneficiary saw five doctors per year and Medicare beneficiaries with three or more chronic conditions saw more than 10 physicians a year. With advances in care, transitions of some procedures from the OR to new settings, and care provided by a “new” group of providers that previously did not perform procedures (cardiologists, neurologists, and others), more providers participate in the care of patients. The implications of these changes are numerous. For example, for patients whose care involved four or more doctors, MedPAC reported that 48% experienced medical errors, medication errors, or laboratory errors. As technology advances and the population ages, risks and benefits change and new genres of service emerge and expand. Imaging services, which have exploded across disciplines in the last decade, are now provided by radiologists, vascular surgeons, cardiologists, internists, anesthesiologists, and surgical subspecialists. Traditional fee-for-service payment systems are not designed to ensure that the right treatment is performed on the right patient at the right time by the right physician in the right venue. The result is that groups of assorted medical proceduralists provide in-hospital care that is often fragmented, perpetuated by silos of specialized care despite the interdependent nature of specialty services. Coordination of care, particularly for the newer procedures requiring anesthesia services and performed outside of the OR, is needed but often not provided for a variety of reasons. Unfamiliarity with anesthesia services and requirements as well as lack of payment for coordination of care are primary reasons. This uncoordinated or fragmented care creates challenges for the patient and provider, often resulting in duplication of some service, variability of resource use, and inconsistent application of quality standards. Payment silos create misalignment of goals across specialties, creating competition rather than collaboration among disciplines and, in some cases, pitting the needs of one set of providers against another without intending to do so.

Another factor that contributes to the challenges associated with performing procedures requiring anesthesia care in NORA environments is the lag in payment for new technologies by Medicare and other payors. While delaying implementation of new procedures into the clinical environment until peer-reviewed evidence documents the value may be appropriate, particularly when new and/or proprietary, high-cost equipment is required, the lack of payment may actually contribute to higher costs of care or reduced quality.

Anesthesiologists are particularly vulnerable to inadequate or no compensation for some of the procedures performed outside of the OR. In some cases, the lack of payment is related to “historical controls”—healthier patients undergoing procedures outside of the OR with sedation provided by a nurse or proceduralist. The anesthesia service is only compensated when the patient meets criteria for “medical necessity”—and there may be inadequate documentation of the need for anesthesia care by the proceduralist. As important, for some patients there are associated services for which there may be no compensation. Routine preprocedure evaluation and postprocedure care are included in the anesthesia fee; other services often needed to optimize clinical management so the patient is able to undergo the procedure may not be compensated. Discussion of some of these issues related to payment for anesthesia services for the NORA procedures is ongoing at a national level.

Some newer payment methods may help address the challenges of providing anesthesia services for procedures performed outside of the OR. Bundled payment methodologies, accountable care organizations, and the perioperative surgical home are three payment reforms intended to improve coordination and interdisciplinary collaboration. While these models of payment may effectively improve delivery of care in the most appropriate environment with improved outcomes, it remains to be seen how effective these undertakings will be in improving care. In any case, payment models remain a key determinant of behavior. It is incumbent on anesthesiologists to remain at the forefront of new developments as demand for anesthesia services in less traditional arenas broadens in an environment that diminishes control over the revenues we generate.

Operational Constraints

It is quite clear that despite a multitude of publications documenting significant OR inefficiency, institutional tradition, provider idiosyncrasy, and surgical convenience continue to compromise efficient OR scheduling practices and policies. Outside of the OR, these issues have even greater significance. Medical proceduralists and surgeons performing procedures in unfamiliar environments often do not understand the physical limitations that affect anesthesia care and the need for appropriate preprocedure evaluation and management, and in many cases are not aware of some of the underlying clinical conditions of the referred patient. To make matters worse, the specific procedure(s) to be performed on the patient may not be well-defined until the procedure begins while in other cases the procedure is “novel,” often involving equipment and supplies unfamiliar to the proceduralist or assisting staff. All of these variables make scheduling non-OR cases extremely difficult.

With respect to scheduling and staffing non-OR cases, a number of issues must be considered, including:

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Non-OR anesthetizing locations are often adapted to the specific procedure being undertaken and the needs of the medical proceduralist. Unlike ORs, they are non-interchangeable. They are often neither designed for nor take the needs of the anesthesia provider into account.
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Most of the venues for these procedures are smaller and less flexible than traditional OR environments.
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Block time may not be utilized to facilitate scheduling of NORA cases, making it difficult to utilize anesthesiology staff productively and increasing the likelihood of underutilized personnel and space.
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Non-OR procedures may take place a long distance from the OR suite. Lack of storage space for anesthesia equipment may also impose longer turnover time and the need for additional anesthesia technical services.
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Many non-OR procedure suites perform procedures on patients referred from outside providers or services that are booked through a central scheduling office. For most of these patients, the usual preprocedure evaluation process is not used to facilitate assessment and preparation of the patient. Periprocedural evaluations are often very cursory—if performed at all. This imposes an additional bottleneck for the anesthesiologist who may need to perform a preoperative evaluation immediately before the procedure and cancel or delay cases at the last minute.
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Because many non-OR procedures are novel, it is difficult to estimate the length of time the procedure will take. Booking times may be unrealistic, and scheduling anesthesiology time may be difficult. Additionally, with new technology and noninvasive methods, it is very easy for the proceduralist to modify or extend the procedure after it is started.

As noted, non-OR cases tend to be more variable, less predictable, and, therefore, more difficult to staff cost-effectively. Some of these difficulties are technical, but some are the result of cultural discontinuity and poor communication between anesthesiologists and proceduralists. To ensure effective management for these cases, a number of requirements should be met:

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Prospectively establish a contract between the anesthesiology and procedural departments that encourages appropriate utilization of available time and minimization of differences between “staffed (contracted) time” and “productive time.” In addition, in those environments where NORA cases cannot or are not scheduled efficiently, the department may need to define a “backstop” to compensate the anesthesia providers for “availability” time that is not associated with a specific case.
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All non-OR cases should be scheduled and managed within the electronic database for OR cases, so that resource deployment can be planned and modified as needed.
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Create a block schedule that takes into account all of the procedural areas and the most effective utilization of the space. The block time should account for the needs of all providers. For example, if cases in some areas tend to run late, anesthesia providers should be scheduled appropriately to reflect the actual times for the cases to be completed.
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Implement real-time scheduling, including patient arrival times and other issues affecting utilization. Calculate earliest start times, optimal arrival times, and adjusted preoperative fasting (nothing by mouth [NPO]) guidelines for all patients. Avoid having patients sitting in preoperative holding areas for extended periods and account for postprocedure evaluation and monitoring needs wherever recovery of the patient is provided.
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Improve specialized triage for scheduled outpatients in each procedural area to ensure that patients are appropriately evaluated and prepared for the anticipated procedure. The use of triage forms and staffing intake procedures, either locally within each environment or centrally, will minimize delays and cancellations. Ensure that the proceduralist is invested in the preprocedure process and supports the needs of the patient and anesthesia providers.
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Oversight of periprocedural triage and postprocedure recovery areas should be provided by the anesthesia department to ensure that the appropriate preprocedure assessment has been completed and, when necessary, that additional preprocedure optimization is required. As part of the oversight process, tracking of unexpected admissions, prolonged recovery times, throughput, efficiency, length of stay, and medical outcomes should be performed and reviewed with all providers.

The scheduling of space, staff, and resources for NORA procedures should be standardized within the institution but can be performed in a number of ways. In general, the principles that apply in the OR should also be used for cases performed outside of the OR. These principles include reducing variability, scheduling to minimize variability as much as possible, and using actual institutional data to guide decision making whenever possible (i.e., real-time scheduling for blocks). In addition, the scheduling should take into account available time and actual productive time. Full schedules and adequate revenue collection should be incentivized; otherwise a subsidy of the anesthesia department is needed because the opportunity cost incurred is often significant. In situations where specific contracts for NORA cases are negotiated, the contracts should take into account full costs and not differentiate costs associated with specific procedures individually. Whenever possible, proceduralists should be involved in scheduling schemes so they are invested in the process. When the institution has specific, predefined areas in which these procedures will be performed, identifying a dedicated anesthesia team, as is done for selected OR service lines, should be considered. Identifying a dedicated team that understands the specific issues in each NORA environment and collaborates with the proceduralists, nurses, and others can greatly improve operational issues, patient and provider satisfaction, and clinical outcomes.

Transitional Priorities for Anesthesiologists Outside of the Operating Room

As more and more procedures are performed outside of the traditional OR environment, we can anticipate that there will be many new opportunities as well as obstacles to overcome. While many have already been articulated, new venues must take the same approach as has been taken so far to best meet patient and provider needs. Unusual procedural venues and practitioners who are unfamiliar with the scope and practice of anesthesiology challenge standard procedure. Adaptation requires that we confront, explain, reorient, and reinforce our traditional concepts of safe practice and standards of care. Anesthesiology as a specialty has improved OR safety enormously in the past 45 years, and as the scope of anesthesiology broadens, there is even more reason to redefine and remain steadfast in utilizing the same well-established standards of safe practice in new environments.

Defining Interdisciplinary Safety in Non-Operating Room Locations: Standardization, Reliability, and Communication

The unparalleled record of OR safety established by surgeons and anesthesiologists has been dependent on implementation of standardized, routinized practice. Anesthesiologists depend on the predictable characteristics of ORs and surgical procedures to gauge the process of procedures and optimize anesthetic outcomes. While unplanned challenges arise even in the most standardized environment, a dedicated team with an understanding of the expected (and unexpected) events is best able to tailor care to meet the needs of the patient and providers. For non-OR cases, many of the standards are not predefined and the procedures often are not yet considered routine. In some cases, the technology is novel and, for some patients, preprocedure optimization is not ensured. For many procedures, anesthesia is required because of the inherent challenges and inability to predict clinical responses and needs. In each of these situations, communication at every step in the process is critical to optimizing patient care and outcomes. If communication is poor between proceduralist and anesthesiologist, the potential for error and a less-than-optimal outcome increases.

Frankel and others have emphasized that environments that facilitate safety and reliability are characterized by the following:

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Encouragement of continuous learning among all participants
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A just and fair culture of accountability and responsibility
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Support for teamwork
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Data-based drive for safety and reliability
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Effective communication and flow of information

Depending on the specific venue, routines can be defined for many NORA procedures—though for many NORA procedures, the routines may differ from those developed for specific OR procedures. Specialty-specific procedure units can accommodate each of the above with varying degrees of difficulty, depending on the medical, financial, and operational constraints and priorities in place. All of these elements are critical characteristics of a safe environment.

Other General Considerations for Nora Care

A number of other processes are relevant to the practice of anesthesiology in general with some specific examples of their importance for anesthesia provided in settings outside of the OR environment. They include continuous learning, accountability, teamwork, and communication, all of which are critical to improving systems to optimize care.

Continuous Learning

The concept of continuous learning as an element of process improvement was initiated for other industries but also applies to anesthesia practice and patient care. The principles associated with continuous learning have relevance to the delivery of anesthesia in environments outside of the OR suite, in large part because NORA services continue to expand and evolve. Lessons learned from current practices can be applied to new models of care delivery, while also implementing and evaluating the use of new technologies to expand anesthesia services to new patient populations and new locations. As clinical opportunities evolve and modifications are made to the delivery of anesthesia care, the use of objective data (where available) will be an essential element of the continuous learning process. Inherent to the concept of continuous learning is the need to evaluate clinical practices with input from all participants, including the patient, and to consider needs from a multidimensional perspective.

Culture of Accountability and Responsibility

As is true for all clinical environments of care, the anesthesiologist and all other providers must assume responsibility and accountability for patient safety and quality of care. An ongoing evaluation as to what is working and what is not—and an understanding of the reasons for adverse outcomes—is critical to process improvement. In some cases, individual actions may be responsible for an unanticipated event, though for many (if not most) adverse events, both individual and systems issues contribute. To successfully analyze adverse events and the contributing factors, formal root cause analyses (RCAs) with participation of all parties is most effective in defining how to avoid similar events in the future. This type of analysis can be very helpful in assessing the quality of care for patients undergoing anesthesia outside of the relatively controlled OR environment. The RCA process should be collaborative and non-punitive. If the actions of an individual need to be addressed, this process should be done using human resources or medical staff processes outside of the RCA process. We can learn how to initiate these reviews from other industries. For example, the launching and recovery of US Navy aircraft is a well-known process in which this type of outcome-focused, non-punitive review takes place.

Support for Teamwork Structure

Support for a teamwork structure is a crucial foundation of successful interdisciplinary work. It requires that jobs are clearly defined, that debriefing occurs constructively and within a reasonable time frame, and that outcomes are reviewed to continually refine and improve care and reduce the likelihood of repeating errors. Fundamental to this is an attitude of mutual respect for other team members; this is often the most difficult for physicians to generate, because they are educated and trained to be self-sufficient, independent, and non-delegating. “Virtuoso teams” are characterized by smart people who are opinionated, strident, and challenged by an acute need to perform. They get the job done by confronting each other and arriving at a mutually acceptable solution. Leadership is clearly important in this endeavor; conflict resolution and negotiation are significant parts of the process.

Effective Communication and Flow of Information

As is true in any clinical environment, communication among providers is critical to the delivery of care. Effective communication is particularly relevant in the care of patients outside of the OR for a number of reasons, many of which have already been outlined. Novel interventions and technologies used by proceduralists create potential for misunderstanding or unintended consequences due to unfamiliarity with the supplies, equipment, or maintenance. As is true for procedures performed in the OR, time-outs that include identification of the patient, description of underlying medical conditions that might impact care, and other relevant issues are perhaps even more important for NORA cases. In some cases, the primary proceduralist may be unaware of underlying medical conditions or comorbidities that impact anesthesia care, selection of sedatives and analgesics, and monitoring needs. The issues of concern to the anesthesia provider must be discussed with the proceduralist and those that might impact how a procedure will be performed must be discussed with the anesthesia provider, nurses, and others. Even medically correct actions on the part of the anesthesiologist or proceduralist, if not communicated to the other party, could drastically alter outcome. If, for example, the anesthesiologist supports decreasing blood pressure but fails to tell the proceduralist about the hemodynamic instability, s/he might continue under the assumption that the patient is tolerating the procedure when in fact a search for a cause for the blood pressure fall, such as evaluation for possible retroperitoneal bleed, is more appropriate. To create the same degree of safety and reliability outside of the OR as exists in the OR, compromise and adjustment of cultural and medical assumptions is required by all parties. Without good communication this cannot occur.

Non - Operating Room Anesthesia Locations: Some Logistical Issues

Sites of Care

Potential sites for procedures performed outside of the OR continue to expand. As new sites are proposed, they must be carefully and thoroughly evaluated to ensure that care can be provided safely with appropriate monitoring and all supplies, equipment, and support are available. The needs must take into account the patient population(s) that will be served, including consideration of the complexity of the intervention and common comorbidities.

For anesthesia care provided outside of the OR, appropriate emergency supplies and procedures should be clearly identified, including posting of phone numbers or other contact information for accessing emergency help. In addition to considering the specific space needs to facilitate completion of a procedure, appropriate space must be identified to provide pre- and postprocedure care. In addition, any patient receiving anesthesia for a procedure must be monitored in an appropriate location equipped for that purpose with skilled nursing staff and the availability of an anesthesia provider during the recovery period. The same safety standards implemented for procedures performed in the OR must be assured for all NORA cases regardless of where they are provided.

Supplies and Equipment

No matter what type or level of anesthetic care is anticipated to be required to facilitate completion of a procedure, for the majority of locations and clinical situations an anesthesia machine should either be present or readily available in anticipation of the need to convert to general anesthesia and/or require mechanical ventilatory support. If the proposed location for a procedure cannot accommodate anesthesia equipment (for size, electrical, or other spatial reasons), an alternative location should be identified.

All anesthetizing locations should have appropriate monitoring equipment. While the monitoring needs may vary for each procedure, the usual monitoring equipment should be available, preferably the same equipment that is available in the ORs to ensure that all providers know how to use and troubleshoot the equipment. The ASA Standards for Basic Anesthesia Monitoring may serve as a fundamental guide, but often specific procedures require more than basic monitoring. As sicker patients are increasingly cared for in NORA locations, monitoring needs must be considered to ensure that the patient receives appropriate care to address both procedural needs and any clinical issues that may arise as a result of underlying medical conditions. The appropriate monitors increase the likelihood of early detection and amelioration of problems and undesirable outcomes. The success in establishing and maintaining unparalleled safety records in the OR results largely from the consistent use of appropriate monitoring equipment. The same standards should apply in NORA settings.

Monitoring in Non-Operating Room Anesthesia Locations

Physiologic monitoring is a critical feature of safe anesthesiology practice wherever the anesthetic is delivered (see also Chapter 36, Chapter 41 ). Just as monitoring standards of care exist throughout the OR, they must be consistently in place in NORA locations as well. Some studies suggest that adverse events occurring outside of the OR may in fact be associated with more deleterious outcomes and serious injury than those in the OR because minimal monitoring standards are lacking. Monitoring in NORA locations is often suboptimal because the need is not identified by anesthesiologists and, in some cases, the proceduralist is not well-educated about what may be required. Until recently, pulse oximetry was the primary monitoring used to assess adequacy of oxygenation and ventilation, despite the fact that pulse oximetry has significant limitations. Several publications indicate significant misunderstanding among non-anesthesiologists using pulse oximetry to monitor patients outside of the OR. Anesthesiologists providing services outside of the OR should clarify the need for both pulse oximetry and monitors of ventilation. Several excellent articles and websites are available as resources. Over the last 20 years, capnography has become the standard of care for monitoring not only for ventilation, but also for circulation and metabolism by directly measuring expired carbon dioxide levels and indirectly measuring production of CO ₂ at the tissue level and delivery of CO ₂ to the lungs. Despite broad utility and clear clinical superiority, capnography is not always available in non-OR locations. The mandate for capnography may not be understood by either proceduralists or hospital administrative staff without significant education about its utility. Capnography equipment is bundled with other monitoring equipment on the anesthesia machine. Similar monitoring should be routinely available in NORA locations independent of the anesthesia machine which may not be required for every case.

Preprocedural Evaluation for Non-Operating Room Anesthesia Cases

Preprocedural evaluation is an essential component of anesthesia practice, regardless of where the procedure is performed or who is performing it (see also Chapter 31 ). Increasingly, patients with serious comorbidities and/or significant compromise are scheduled to undergo procedures outside the OR. For many of these patients, preprocedure assessment identifies clinical issues that may be difficult to optimize prior to proceeding with the procedure. In some cases the procedure is an emergency or of such urgency that a delay to address underlying clinical issues is not possible. For all NORA cases, the ASA Guidelines for Preanesthesia Evaluation of 2012, should guide management. They specifically define a preanesthesia evaluation which should, at a minimum, include the following:

1.
A patient interview that includes a physical examination and a review of medical, surgical, anesthetic, and medication history
2.
Diagnostic laboratory tests and other relevant diagnostic information
3.
Assessment of ASA status
4.
Formulation of potential anesthetic plans and presentation of these to the patient

Because several studies have dispelled the notion that there is a body of routine testing that reduces anesthetic risk, anesthesiologists should obtain testing based on the patient’s history, the procedure they are to undergo, and anesthesia requirements. Since many NORA cases are performed as urgent referrals to a proceduralist, patients may not have been evaluated by any provider prior to the procedure. As a result, accumulating the appropriate clinical information in a timely manner may be challenging, if possible at all. For patients known to have significant underlying medical conditions, the proceduralist should require that, if possible, the patient be evaluated in a preoperative evaluation clinic (if one is available). If not, the patient may require an extensive preprocedure assessment that could delay the procedure or necessitate rescheduling at a later time. Occasionally, periprocedural admission or consultation with a specialty service is required. Guidelines regarding preanesthetic evaluation can be found in Chapter 31 and many other texts ; in general, the same guidelines apply to procedures performed in the OR or non-OR locations.

Other Considerations

Additional issues must be considered for patients undergoing NORA procedures, particularly related to the management of underlying clinical conditions or periprocedure needs that might not be anticipated by other providers. These include the following limitations that should be considered before proceeding:

1.
Many procedure suites have beds with lower weight limits and less mobility than OR beds.
2.
Procedure suites for fluoroscopy have beds that cannot be placed in Trendelenburg or reverse Trendelenburg position.
3.
Anticoagulation status is often an issue and guidelines may be extended for some procedures.
4.
Renal status may impact the use of contrast.
5.
During percutaneous procedures, bleeding may be occult, and the potential need for transfusion should be addressed preprocedurally.
6.
Percutaneous procedures often require that the patient remain still. Patients with extreme anxiety, chronic pain, claustrophobia, mental disability, movement disorders, obesity, or obstructive sleep apnea (OSA) or those who are at the extremes of age may not tolerate lying on a table for long, even if the proposed procedure is not very stimulating. For these patients, deeper sedation or general anesthesia may be needed.

Current NPO guidelines for procedures are 6 hours for a light meal, 8 hours for a full meal, and 2 hours for clear liquids applied to patients without increased risk for aspiration (gastroesophageal reflux disease, gastric dysmotility, hiatal hernia, diabetes mellitus, bowel obstruction, or intraabdominal pathologic conditions). This is often a source of disagreement between anesthesiologists and proceduralists, who may not realize the ramifications of a full stomach or may insist that contrast or barium be administered before the procedure. Timely preprocedure evaluation and enforcement of clear standards for NPO status can help prevent scheduling mishaps and unnecessary delays and cancelations. This may require education of the proceduralists and their staff.

Specific Procedure-Related Issues

Gastrointestinal Procedures in The Endoscopy Suite

Over the past 10 years, enormous growth in the number of gastrointestinal (GI) endoscopic procedures related to an aging patient population, increased awareness of cancer screening benefits, broad-based reimbursement for screening colonoscopies, and better technology is quite evident. Increasingly complex procedures, higher-acuity patients, and increased case volume broaden the scope of challenges anesthesiologists face in caring for these patients. The choice of anesthetic approach requires a thorough understanding of both the procedure and the comorbidities of the patient. Similarly, preprocedure evaluation and postprocedure care, which carry financial and operational constraints, assume greater importance. Historically, most endoscopists managed healthy patients undergoing minor procedures with moderate sedation administered by nurses. However, moderate sedation is often inadequate in the context of sicker patients for simple procedures or healthy patients for complex procedures. Therefore, this chapter discusses the focus and methods of common GI procedures, reimbursement issues that may affect practice, the frequent comorbidities associated with patients undergoing those procedures, and anesthetic approaches suggested by anesthesiologists with expertise in the area.

A broad spectrum of GI procedures takes place in the endoscopy suite, ranging from routine screening colonoscopies to complex endoscopic pancreatic necrosectomies. Each of these requires specific levels of anesthesia depending on the invasiveness and stimulation imposed by the procedure as well as patient factors relating to their comorbidities. The most common procedures are esophagogastroduodenoscopy (EGD), sigmoidoscopy and colonoscopy, and endoscopic retrograde cholangiopancreatography (ERCP).

Reimbursement Constraints

Rapid increases in charges to Medicare and private insurance companies for anesthesiology support of colonoscopies provoked the attention of both Medicare and commercial payers. As a result, in 2008, a major insurance company amended its reimbursement policies stating that they would no longer pay for anesthesiologists to administer propofol for screening colonoscopies in routine cases and that costs would be reimbursed only if the patients had documented comorbidities that would likely contraindicate moderate sedation. The carrier’s actions were prompted by an acute rise in billing, significant regional differences in the use of propofol for routine colonoscopies, and the growth of independent colonoscopy centers that treated many patients per day facilitated by the use of propofol, which permitted very rapid turnover of cases. Despite the fact that the list of acceptable comorbidities included more than 200 diagnoses, nationwide protests from patients and physicians prompted the carrier to delay and then cancel implementation of this policy change. The finances of this situation continue to drive practice, and the debate continues. Anesthesiologists must continue to consider patient need and procedural requirements as the criteria by which anesthetic plans are formulated because the political and economic aspects of the debate will undoubtedly continue.

Esophagogastroduodenoscopy

EGD involves examination of the upper GI tract (esophagus, pylorus, and stomach) using a fiberoptic endoscope. The most difficult parts of the procedure for the patient include passing the scope into the esophagus (past the cricopharyngeus muscle) and through the pylorus. Any interventions that occur during the procedure (biopsy, resection, dilation) should be discussed with the endoscopist before the procedure because they constitute additional procedure time. Important and potentially stimulating therapeutic undertakings during endoscopy include hemostasis, biopsy, stenting, dilation, and mucosal or submucosal dissection.

Most patients tolerate this procedure well with opioid or benzodiazepine sedation, but for those who are hemodynamically unstable, at risk for obstruction or aspiration, very anxious patients, or for children, general anesthesia may be the best alternative. Unfortunately, many patients presenting for EGD are in this high-risk category, including patients with severe GI reflux disease, morbid obesity, asthma, or OSA. In some cases, thorough topicalization is all that is needed, but in some patients, this is inadequate for the procedure or is difficult to achieve. ProSeal laryngeal mask airways (LMA), which have a built-in gastric drainage port, permit the passage of a pediatric endoscope, and this approach may be the best option for children and other patients who require general anesthesia and are appropriate for LMA use. As with all procedures above the nipple line that use cautery, precautions must be taken to reduce the potential for airway fires. This subject is discussed in Chapter 44 . Rare, but serious complications include aspiration and gastroesophageal injury including perforation.

Sigmoidoscopy and Colonoscopy

Sigmoidoscopy and colonoscopy can be diagnostic and/or therapeutic and involve the examination of the lower GI tract, including either the sigmoid colon only or up to the distal ileum. This examination can be difficult for some, although most patients tolerate it with a combination of benzodiazepines and opioids. Interventions such as biopsies or polyp removal may require increased analgesia. Most anesthesiologists provide sedation with propofol; however, even in situations in which GI endoscopists are permitted to direct nurses to administer propofol, one study found that the mean bispectral index (BIS) score of patients was 59, indicating they were under general anesthesia. Some gastroenterologists maintain that this depth of sedation or anesthesia allows for more thorough examination, but no data have indicated that a better examination is performed. Remifentanil has been compared with propofol in the context of sedation for colonoscopy. Although patients given remifentanil recovered earlier, they also had more nausea and respiratory depression than the propofol groups. When inhaled anesthetics such as sevoflurane and nitrous oxide were compared with total intravenous anesthesia (TIVA) using drugs such as propofol, fentanyl, and midazolam in patients undergoing colonoscopy, the TIVA group emerged faster but had longer-lasting psychomotor impairment than the inhalational group.

As with upper endoscopy, specific interventions during sigmoidoscopy and colonoscopy constitute additional stimulation including introduction of the endoscope, colonic insufflation, advancement of the endoscope, and additional endoscopic intervention such as biopsy, polypectomy, stenting dilation, and mucosal resection.

The ability and need to titrate a drug quickly and appropriately drive the choice of anesthetic, and new studies looking at patient-controlled sedation pumps are under way. Studies of patient satisfaction and indicators of procedural success are ongoing, as are several trials of patient-administered sedation and other types of computerized pumps.

One potential complication is bowel perforation, which is heralded by ongoing abdominal pain; emergent surgical intervention is indicated in this situation. Bleeding is another complication that can occur during therapeutic lower GI procedures. A current blood bank sample is imperative as well as adequate intravenous access.

Endoscopic Retrograde Cholangiopancreatography

ERCP is a fluoroscopic examination of the biliary or pancreatic ducts accomplished through an endoscopically guided injection of contrast through the duodenal papilla. This type of procedure constitutes the up-and-coming interventional gastroenterology field. Patients are usually in the prone position. Many patients who require ERCP are compromised. Their diagnoses include cholangitis (with or without sepsis), pancreatitis, bile duct obstruction secondary to stones, or pancreatic or hepatocellular tumor masses. Potentially stimulating interventional maneuvers during ERCP include sphincterotomy, hemostasis, stent placement, stone extraction, pancreaticobiliary visualization, and laser lithotripsy.

These procedures can range from straightforward to highly complex interventions. Furthermore, gastric insufflation is required and most proceduralists prefer CO ₂ instead of air. Consequently, prolonged procedures can lead to very high arterial CO ₂ levels. Procedural failure rates are twice as high for sedation patients as they are for general anesthesia patients, and the complication rate for general anesthesia cases may be lower. In addition, the patient’s airway is effectively inaccessible to the anesthesiologist and ventilation can be challenging. For this reason, many anesthesiologists prefer general anesthesia for ERCP.

Natural orifice transluminal endoscopic surgery: the next frontier?

Natural orifice transluminal endoscopic surgery (NOTES) represents an approach to abdominal and peritoneal procedures that integrates the perspectives of endoscopic medicine and minimally invasive surgery. The use of NOTES in humans is in the early phases, and several cases have been reported of transvaginal and transgastric cholecystectomy. Thus far these cases have required a pneumoperitoneum and general anesthesia; however, as technology improves, these parameters may change and NOTES procedures may take their place among the numerous other interventions performed outside the OR.

An example of a NOTES used by GI endoscopists to treat esophageal achalasia is peroral endoscopic myotomy (POEM). Esophageal achalasia is characterized by poor peristalsis of the esophagus in combination with increased muscle tone and incomplete relaxation of the lower esophageal sphincter (LES). Symptoms arising from impaired entry to the stomach include nausea and vomiting, dysphagia, and/or pain. The POEM procedure has been developed as a minimally invasive procedure to correct achalasia by endoscopically insufflating the esophagus with CO ₂ and then making an incision into the mucosa from the mid-esophagus (through the gastroesophageal [GE] junction) to 2 to 3 cm into the proximal stomach. During insufflation, patients may have an increase in ETCO ₂ that can be controlled using mechanical ventilation. Potential risks of insufflation range from subcutaneous emphysema to pneumothorax, pneumomediastinum, and pneumoperitoneum. This procedure commonly requires several hours and is best accomplished using general anesthesia with an endotracheal tube, which protects the patient from aspiration of gastric contents and allows the anesthesiologist to minimize the perils of CO ₂ insufflation. As with all NORA procedures, vigilance, teamwork, and communication are vital to ensure not only the success of the procedure but the safety of the patient as well.

Interventional Pulmonary Procedures

Innovations in interventional pulmonology have expanded the pulmonary field tremendously. Bronchoscopic interventions have grown to encompass many traditional surgical procedures performed in the OR. Anesthesiology services are required for high-risk patients and given the nature of the procedures involving the airway, the potential for complications is high. Fluoroscopy plays a major role for these procedures. Discussion, communication, planning, and radiation safety are particularly critical in this environment.

Common Bronchoscopic Procedures

Common bronchoscopic procedures include the following (see also Chapter 53 ):

1.
Endobronchial stenting: placement of self-expanding metallic stents to treat stenosis
2.
Endobronchial biopsy, laser treatment, and cauterization
3.
Balloon dilation and cryotherapy

Technological advances in this field have given rise to new innovative procedures used in treating a broader patient population. Several interventions that represent amalgamations of preexisting technologies in the bronchoscopy suite are as follows:

1.
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). This procedure is used to image the bronchial wall and adjacent structures. It allows ultrasonic visualization of mediastinal lymph nodes and other peribronchial lesions and therefore is a useful staging tool.
2.
Electromagnetic navigation bronchoscopy (ENB). This technique permits biopsy of endobronchial tissue that is not visible using computer software that creates a virtual multiplanar lung reconstruction from computed tomography (CT) data. A sensor probe and electromagnetic location board guides the operator to the appropriate location during the bronchoscopy.
3.
Fiducial marker implant. Markers are placed before stereotactic radiosurgery via bronchoscopy or ENB.

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