For the first several years of my career, the demand for anesthesia services outside the OR suite was an infrequent event. I remember when the volume of such requests began to increase in the late 20th century; we created a single non-OR block at our institution into which interventional radiology procedures, endoscopies, and various other remote cases could be scheduled. Nonoperating room (NORA) volumes have grown dramatically since then, comprising 28% of all procedures requiring anesthesia in 2010, with a projected increase to more than 50% of anesthetic cases over the next decade (Anesth Analg 2017;124:1261-7; Curr Opin Anaesthesiol 2017;30:644-51). Numerous factors have driven this growth, particularly advances in procedural technology, and the recognition by patients and proceduralists that our expertise improves the quality of care provided as well as patient satisfaction. This growth is coinciding with and compounding the ongoing workforce imbalances that have swamped health care systems since the pandemic.
“Although your institution’s C-suite may not know it, they need our help in managing this explosive NORA growth amid workforce challenges, while ensuring high-quality outcomes and maintaining the institution’s strategic priorities.”
While these advances are making care more accessible, all patients deserve the highest-quality anesthesia care no matter the setting – that’s where anesthesiologists come in. Although your institution’s C-suite may not know it, they need our help in managing this explosive NORA growth amid workforce challenges, while ensuring high-quality outcomes and maintaining the institution’s strategic priorities. To help you communicate your leadership to your C-suite and let them know how you can assist them in solving the challenges of expanding NORA safely, ASA is offering new content in the Be the Solution Toolkit: Enabling Growth in Nonoperating Room Anesthesia (asamonitor.pub/3ybWw4A).
The demand for NORA is so great that it is impossible for anesthesiologists to provide anesthesia care in every case, particularly for low-risk patients having low-risk procedures like routine screening endoscopies. Nor is it the best use of resources. Nonetheless, to ensure safe and effective care, it is vital that anesthesiologists oversee anesthesia care throughout the hospital or health system, whether general anesthesia or procedural sedation, in the OR or NORA.
But your health care executives may not realize that, and the toolkit materials can help educate them on exactly what you can do and why it is important. While they don’t take place in an OR, NORA procedures require similar leadership, management, and oversight as ORs. And anesthesiologists have the deep knowledge and experience to ensure that NORA is as safe, effective, and efficient as OR-based anesthesia.
Anesthesiologist oversight, from preoperative evaluation to training
The toolkit includes approaches, solutions, and resources for ASA members. A complementary white paper also is available to share with your system’s leaders. It specifies the NORA oversight that anesthesiologists can and should provide, focusing on three areas:
- Optimizing preoperative evaluation, scheduling, and staffing. Just as in the OR, NORA patients should have a preoperative assessment, which has multiple benefits. The information helps in evaluating the resources needed for anesthesia services – including whether an anesthesiologist is required or if another health care professional can safely provide sedation – based on the patient’s health and procedure risk. It also reduces the risk of costly same-day cancellations or complications by identifying patients who require interventions before proceeding with surgery.
- Improving procedural throughput. NORA rules and culture should be equivalent to those of the OR, including measuring first-case on-time starts and tracking them in dashboards along with other metrics such as delays, cancellations, and utilization of anesthesia minutes. All team members should be accountable for the findings and work together to develop solutions. Scheduling should be centralized for all NORA procedures system-wide, and the information should be included in the electronic health record (EHR) so the schedule can be viewed in real-time. Surgical block time overutilization and underutilization should be minimized and optimized with anesthesia block time.
- Streamlining communications and providing training and guidelines. EHRs and health information exchanges can improve communication between anesthesiologists, surgeons, and proceduralists. Anesthesiologists should develop guidelines and specialized training for proceduralists and nurses so they can safely provide sedation services when appropriate and know when it’s important to consult an anesthesiologist before proceeding.
For more detailed information on baseline recommendations for NORA, review ASA’s Statement on Nonoperating Room Anesthesia Services (asamonitor.pub/3UFSqg9). It focuses on facility design and equipment, environment of care, staffing and schedule optimization, quality and safety, regulatory issues, supporting technology and IT systems (including the electronic medical record, finance, and budget), and materials management and sterile processing.
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