Communication failures contribute to adverse events, morbidity, and mortality and may be complicated by both interprofessional and interdisciplinary dynamics within the procedural setting (J Surg Res 2012;177:37-42; Qual Saf Health Care 2004;13:i85-90; J Am Coll Surg 2007;204:236-43; Can J Anaesth 2019;66:1251-60). Non-operating room anesthetizing (NORA) locations such as the gastrointestinal endoscopy suite, cardiac catheterization laboratory, or interventional radiology suite are areas where these underlying communication difficulties – along with existing systematic design problems such as inadequate lighting, limited access to the patient, and poor ergonomics of the anesthesia workstation – can lead to preventable adverse events and patient harm. Indeed, retrospective analyses have demonstrated that mortality and complications tend to be higher in some NORA locations compared to the OR and that many of these complications are related to problems with sedation and inadequate oxygenation and ventilation (J Patient Saf 2018;14:9-16; Anesthesiol Clin 2017;35:569-81). Nevertheless, the proportion of anesthetic cases performed in NORA locations will continue to increase in the next decade (Anesth Analg 2017;124:1261-7). Unfortunately, many systematic design problems in these areas are not easily modifiable and may continue to pose problems for patient safety. On the other hand, factors such as communication, teamwork, and collaboration are more easily addressed and can improve safety in NORA significantly.
Factors affecting communication and teamwork
Unlike teams in the OR, teams in NORA may not work together regularly, as many interventions are performed under proceduralist-directed sedation without the involvement of the anesthesia provider. However, as procedures become more complex, and as patient comorbidity increases, the need for anesthesia services in these areas will only rise, necessitating greater integration into the patient’s care team. A recent qualitative study by Shroeck et al. cited one particular anesthesiologist’s experience: “I’m always a visitor to that team [MRI-OR] … There’s not a feeling of exclusion, but I’m clearly a visitor down there” (Br J Anaesth 2021;127:e95-e98). In addition, nurses and technicians in these areas may not be as familiar with anesthetic concerns and emergencies as are the OR nurses. Furthermore, proceduralists may have varied experience of working side by side with an anesthesia provider. As a result, efforts should be made to educate each other about all critical aspects of the procedure and the anesthetic.
Many cases in NORA are performed under sedation-analgesia techniques (aka, monitored anesthesia care, or MAC). This has led to the common misperception among both proceduralists and NORA staff (and perhaps even some anesthesia providers) that “just a MAC” is needed, regardless of the patient or procedure. However, MAC does not necessarily confer additional safety benefit; in fact, the majority of malpractice claims related to NORA were in cases performed under MAC and were due to respiratory events deemed to be preventable (Anesthesiol Clin 2017;35:569-81). Similarly, anesthesia providers may not appreciate procedural complexity because of the “minimally invasive” nature of the procedure and may not be able to anticipate potential periods of high risk.
The lack of defined roles and responsibilities during a perioperative emergency in NORA may exacerbate patient safety problems. NORA locations are often physically located far away from the main OR and may be on a different floor of the hospital altogether. This poses a patient safety risk when essential personnel, equipment, and supplies are needed in a perioperative emergency. However, we must ensure every team member’s familiarity with code protocols, including the essential steps needed during such an emergency. In addition, roles and responsibilities must be well defined and may change based on the circumstances; for example, in the cardiac catherization laboratory setting, cardiologists are used to running their own codes, when in fact the anesthesiologist may be essential in such a situation while the cardiologist is continuing to intervene on a culprit coronary artery.
Opportunities for improving communication
There have been several studies on improving communication and teamwork in the operative setting – although there have been very few studies to date on how to improve multidisciplinary and interprofessional teamwork in NORA (Surgery 2011;150:771-8; Jt Comm J Qual Patient Saf 2010;36:133-42). Excellent communication may be even more important in NORA given the difficulties with physical location and ergonomics. Interventions should be specifically targeted toward improving team member familiarity with one another, situational awareness, and psychological safety. For example, the Figure shows one practical framework for improvement, consisting of team training, protocols and pathways, safety huddle, NORA site leadership, and interdisciplinary conferences. Given the sheer number of people who should be involved in team training, utilization of a designated simulation center may not be feasible. Rather, hospitals should consider in situ simulations and drills, which have team members gather at the site (cardiac catheterization laboratory, interventional radiology, gastrointestinal endoscopy suite) to practice managing a patient emergency and talking through logistical issues in real time. In addition, structured protocols on specific cases or pathologies, created through multidisciplinary collaboration, can provide a shared mental model that can help optimize pre-procedure planning for both the procedural team and the anesthesiologist. Finally, especially for complex procedures or patients, a pre-procedure huddle with all team members present – nurse, technician, proceduralist, anesthesia provider – should occur even before the patient is in the room to discuss pertinent safety considerations as well as specific procedural or anesthetic concerns.
“Care in NORA is being increasingly recognized as an urgent patient safety issue; the APSF has recognized both NORA and communication as 2022 Perioperative Patient Safety Priorities.”
Communication should also improve at the systematic level. Departments should consider combined morbidity and mortality conferences as well as regular quality and safety “rounds” to discuss upcoming patients or to debrief particularly complicated cases. Finally, a dedicated liaison from the anesthesiology department should be appointed; a “Director of NORA” or specified liaison can help triage and evaluate upcoming complex cases, handle scheduling conundrums, and optimize quality and safety protocols. Finally, a smaller anesthesia team dedicated to working within the NORA locations may help ease communication issues as well as facilitate prompt adoption of protocols and pathways.
NORA as a patient safety issue
Care in NORA is being increasingly recognized as an urgent patient safety issue; the Anesthesia Patient Safety Foundation (APSF) has recognized both NORA and communication as 2022 Perioperative Patient Safety Priorities. In fact, the topic of this year’s APSF Stoelting Conference will be on “Crucial Patient Safety Issues in Office-Based and Non-Operating Room Anesthesia (NORA).” Safety experts from around the country will come together to discuss how to improve safety in NORA and propose possible systematic solutions. Any potential solutions will have to incorporate improvements in communication and teamwork in this challenging area. We must base all of our efforts on the premise that interdisciplinary collaboration is key to improving quality and safety in NORA.