Nonoperating room anesthesia (NORA) has experienced significant growth over the past decade, with projections indicating continued expansion (Anesth Analg 2017;124:1261-7). NORA presents unique challenges, such as confined spaces, remote locations, and medically complex patient populations. Increased volumes in NORA necessitates adaptation to new procedures, staff, equipment, and anesthetic requirements across various hospital locations and freestanding ambulatory surgery centers (ASCs). Maintaining the same high standard of care as in the OR is paramount for ensuring patient, physician, and staff safety amid this growth. Despite the less invasive nature of these procedures, patients often have complex medical conditions, increasing the potential for emergencies (J Patient Saf 2018;14:9-16). It is crucial to prepare for these emergencies to ensure a rapid response, prioritizing patient and team safety.

Dedicated teams in the OR enhance patient outcomes (World J Surg 2019;43:431-8; Front Public Health 2022;10:1060473). The same patient safety benefit could be extended to NORA, yet only some facilities have established dedicated NORA teams. A cohesive group of anesthesiologists and CRNAs comfortable with the patient population and varied environments is vital for a successful NORA service.

NORA is an all-inclusive term that encompasses interventional radiology, the cardiac catheterization laboratory, gastroenterology suite, and more. Each of these locations presents unique challenges, including room setup, proximity to the OR, and environmental considerations (e.g., radiation, magnetism, etc.). Standardizing equipment like the anesthesia machine, medications, and supply carts to the OR setup creates a familiar environment for all team members, expediting actions during critical moments or transitions between teams.

A dedicated NORA team forges relationships with proceduralists, enhancing their understanding of new procedures, their anesthetic approach, potential complications, and emergency preparedness. The team is more comfortable managing emergency resources and specific medication administration in these remote areas.

Once established, this team can efficiently onboard new members, uphold standards of care, and optimize workflow. Clear communication with key team members facilitates collaborative planning and problem-solving, promoting an ideal care environment.

While some areas of NORA rely exclusively on anesthesia services, others incorporate a mix of conscious sedation without anesthesia involvement, which can complicate scheduling and impact daily flow. To ensure smooth operation, a morning huddle is recommended in each area. It is an opportunity to keep the team informed, anticipate challenges, and develop solutions. This huddle should include operational leadership from anesthesiology and the NORA location to discuss room status, staffing availability, and potential delays. Complex patients or procedures should be prioritized to occur early in the day when more resources are typically available. Quickly reviewing emergency protocols and confirming contact information for rapid communication are essential actions during this time.

In addition to the morning huddle, all concerns should be openly discussed during the time-out or equivalent process at the start of each case. A detailed action plan ensures the team is prepared to respond if issues arise.

With the team and huddle established, one might assume emergency response will be swift and effective. However, NORA locations are often far from the OR, and assistance may not be readily available. Moreover, if the emergency response team is unfamiliar with these environments, help may take additional time. This is why conducting mock codes is invaluable (J Laparoendosc Adv Surg Tech A 2017;27:475-80). These activities help NORA staff learn whom to call and what to communicate in an emergency, locate emergency equipment, and afterward review and discuss lessons learned for better preparedness. Initially, mock codes should be conducted as frequently as necessary until the team feels comfortable with the process and equipment. The mock codes should occur at least every six months, or more frequently if new equipment or procedures require alterations to the process.

At our institution, we agreed that hospital code teams should respond to out-of-OR emergencies, even if anesthesia is involved, for three reasons: 1) they already respond to these areas in cases where the anesthesia care team is not present, 2) if our anesthesia care team is somewhere assisting other colleagues or codes, help is available, 3) and they can help navigate ICU admission and family contact. When calling for help, detailed location information (unit name, floor room number, etc.) should be clearly stated overhead, and the proper phone number should be posted next to phones to minimize response delays. Typically, a gatekeeper will manage the crowds, and the anesthesiologist leads the code; however, this task can be delegated to another code team member when necessary.

The following are considerations for specific areas:

  • MRI suite: In an emergency, the patient should be removed from zone 4 to a designated resuscitation area where emergency equipment is allowed. A gatekeeper is essential to limit the personnel in the room and prevent them from accessing zones 3 and 4 (Figures 1 and 2).
  • IR and PET: Awareness of equipment hazards (booms, X-ray machines, wires) is critical. A gatekeeper can alert the responders of potential dangers and facilitate safe access. If the procedure must continue after stabilizing the patient, or the patient has received a radioactive drug and the team must continue resuscitation, lead protection should be available and distributed as needed.
  • NORA in the ASC: Typically, initial emergency management is handled by on-site teams that promptly alert 911. After stabilizing the patient, arrangements are made to transfer to a higher-acuity care center.
Figure 1: MRI Emergency Workflow

Figure 1: MRI Emergency Workflow

Figure 2: MRI Zones

Figure 2: MRI Zones

While all the above are important for safety in NORA emergencies, having a NORA medical director is fundamental for a strong team. The NORA medical director is pivotal for ensuring adequate patient selection, fostering relations with key stakeholders, creating protocols, and participating in quality and safety projects. This individual is the point person to initiate conversations and to collaborate in future procedure room designs to guarantee a safe space for both the anesthesia team and patients. Furthermore, they review and debrief all emergencies and identify opportunities for improvement.

The optimal response to emergencies in NORA requires significant preparation and planning. A dedicated NORA anesthesia care team with a strong culture of open communication is ideal and should be harnessed for safe patient care outside the OR.