Entering the Twilight Zone - Non Operating Room Anaesthesia (NORA)

anaesthesia checklist protocol safety Oct 21, 2024

Entering the Twilight Zone - Non Operating Room Anaesthesia (NORA)

Each year there are an increasing number of diagnostic and therapeutic interventions performed outside of the Operating Suite (OS) 🏥 that require anaesthesia. Consistently, anaesthetic providers report lower levels of perceived safety 🛡️ when facilitating NORA, which not only impacts patient safety 👨‍⚕️ but causes higher levels of stress 😟, anxiety, and an increased workload for staff 👩‍⚕️.

The challenges of providing NORA can be broken into three subcategories:

Location factors: 

🩺 Remote location far away from OS supply and equipment
🔊 Noisy environments
📏 Limited/Small workspace
💡 Inadequate lighting
⚡ Interference from equipment (e.g., MRI)
☢️ Radiation safety
🔌 Limited power/gas supply

Patient factors: 

👵 Statistically - older cohort of patients when compared to OS
🧑‍⚕️ More likely to be medically complex
🚷 Limited access to patient during procedure
🚑 Movement of patient throughout procedure (e.g., CT guided angio)

Staffing factors: 

👥 Limited staff skilled in anaesthesia
📊 Differing levels of experience for staff working within the department (e.g., are they ALS trained?)
🆕 Unfamiliar staff - difficulties identifying names/roles
📚 Lack of knowledge from visiting staff regarding local processes for department
🧠 Increased mental load for visiting staff

How can we prepare for NORA?

The most important aspect to consider for safe NORA delivery is that the same standards of perioperative care 🏥 are maintained. This can be achieved through:

✅ Adequate case preparation
🏢 Familiarisation with workspace
🛡️ Develop and maintain safety and emergency protocols
📦 Maintain safe stock supply
📈 Maintain minimum standard for monitoring

The development of safety checklists and protocols ensures that standards are maintained in a consistent manner by all staff facilitating NORA. Local level policies should be guided by standards of governing bodies, such as PS55(A) from ANZCA, which outlines the minimum facilities for safe administration of anaesthesia.

Build Knowledge ✅

Improve Safety ✅

References:

ANZCA (2021). PS55(A) - Position Statement on minimum facilities for safe administration of anaesthesia in operating suites and other anaesthetising locations. https://www.anzca.edu.au/getattachment/7ee1b267-8c29-414e-86c2-6d0e50933d43/PS55(A)-Position-statement-on-minimum-facilities-for-safe-administration-of-anaesthesia-in-operating-suites-and-other-anaesthetising-locations-(PS55)

Walls, J.D., Weiss, M.S. (2019) Safety in Non-Operating Room Anaesthesia (NORA). Journal of Anaesthesia Patient Safety Foundation. V34(1) pp 3-4. https://www.apsf.org/wp-content/uploads/newsletters/2019/3401/APSF3401.pdf

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