System Safety in Non-Operating Room Anesthesia
TimeWednesday, April 1411:40am - 12:00pm EDT
Non-operating room anesthesia (NORA) describes anesthesia care delivered outside a traditional operating room (OR) setting. NORA cases, including those in gastroenterology, neurosurgery, interventional radiology, and cardiology, have increased significantly in the last 20 years and are projected to account for half of all anesthetics delivered in the next decade. In contrast to most other anesthesia medication administration contexts, NORA is performed in high volume, fast-paced environments that may not be optimized for anesthesia care. These underlying systems issues combined with increasing case volume, less provider experience, and older, higher acuity patients significantly increases the potential for preventable adverse events. Prior research has suggested higher rates of morbidity and mortality in NORA cases, however, there is little research examining adverse events in NORA. Our study surveyed anesthesia providers to examine near-misses, patient harm, and system safety risks in NORA. The findings from our study will help inform specific and precise recommendations to improve care and patient safety in NORA.
The study was conducted at 700-bed academic medical center in the Southeast US. The hospital maintains 31 ORs and 21 NORA suites. In FY 2018-2019, anesthesia was provided for 20,072 NORA cases, which accounted for 39% of the total case volume. The study was approved by the Institutional Review Board [IRB# Pro00099592].
We first identified studies examining medication errors and patient harm incidents in the OR using surveys and adapted questions from six of these studies to develop a survey investigating near-misses and harm in NORA. The survey also included NORA risk factors identified from a literature search of studies investigating morbidity and mortality as well as system safety risks in NORA from 1994 – 2020 using PubMed. The survey was deployed to the hospital’s anesthesia listserv - which included all attending anesthesiologists, anesthesia fellows and residents, and certified registered nurse anesthetists (CRNAs) at the institution (n=174) - from June 6, 2020 to June 18, 2020. To be eligible to complete the survey, providers must have worked a NORA case within the past year. Participation was voluntary and anonymous. REDCap (Research Electronic Data Capture) was used to administer the survey and the statistical analysis was conducted using SAS (SAS Institute Inc. 2012).
Literature review. We identified 27 NORA risk factors from the literature review. Environmental concerns were commonly noted and included inadequate lighting, loud noise levels, restricted patient access, lack of electrical outlets, and cramped workspaces. Technological issues included old or malfunctioning equipment and limited monitoring capabilities in the post-operative environment. Lack of rigorous pre-operative check in procedures and insufficient time to conduct pre-operative assessment were task-related challenges. Person-related factors included poor team familiarity and communication, and limited knowledge of anesthesia administration. Organizational challenges noted included lack of essential equipment, lack of backup medication, non-standardized workstation setups, and inexperienced post-operative care team.
Survey results. There were a total of 95 respondents for the survey - CRNA (65.26%), attending anesthesiologist (27.37%), and resident anesthesiologists (6.32%). Most respondents’ were in practice between 5 and 15 years (n = 44, 47.36%) and worked less than 5 NORA cases per week (n = 47, 49.47%). Of the 77 anesthesia providers who responded, 41 (37.89%) reported experiencing a near miss or patient harm. Approximately 58.54% of the 34 near-miss events and 48.78% of the 33 harm events reported occurred within the past year. Near miss events occurred more frequently, with the majority of providers reporting multiple a year (n = 21, 61.8%), while the majority of harm events were reported once a year or less (n = 27, 81.8%). Out of the 27 factors risk factors identified from prior research, anesthesia providers rated five factors as “likely” or “highly likely” to contribute to a near-miss or harm event in NORA cases (e.g. median equal to 4). This included cramped workspaces, restricted access to patient and equipment, lack of standardization across NORA setting, and limited access to support (e.g., anesthesia staff, pharmacy, and blood bank).
A little more a third of the anesthesia providers reported a near-miss or patient harm event in NORA; including the majority of anesthesia attendings and over 40% of CRNAs. Interestingly, none of the six residents reported a near-miss or harm incident in NORA. While residents do not spend a long rotation in NORA underreporting of events by residents is well-known. Developing mechanisms to increase incident reporting among providers, and residents particularly, provides a significant opportunity to improve organizational learning, proactively respond to risks, and design appropriate interventions. As near miss events occurred more frequently than harm events, organizations will also need to encourage providers to report incidents even in the absence of clinical significance.
Anesthesia providers conduct most of their training in the OR and prior literature suggests providers feel less comfortable working in NORA. In the survey, concerns were raised regarding providers’ limited experience in NORA as well as the lack of teamwork and support provided by OR staff. A greater emphasis on technical training to address the specific clinical concerns of NORA would reflect the growing frequency of these cases. These patients are often geriatric, so training for NORA with specific requirements for intraoperative management of older and frailer patients might be warranted. Anesthesia providers were less familiar with the surgeons and nursing staff in NORA, with less resident and CRNA training focused on NORA. Robust orientation and teamwork training can help providers and postoperative care teams develop team familiarity and cohesion, which could also benefit the rest of the NORA team who are less familiar was anesthesia administration, caring for anaesthetized patients, and emergency procedures for anesthetic complications. Wider use of physical artifacts that place “knowledge in the world,” team huddles, and “time outs” may also assist all team members in supporting anesthesia care.
While anesthesia providers also highlighted unique concerns for specific NORA suites, workflow, and environmental challenges across NORA sites were particularly problematic. Protocols, tasks and technologies may need to be designed to address the particular clinical concerns of NORA, especially high case volumes, fast turnover times, and large number of urgent and emergent cases. Processes that support communication, proactive planning, and efficient workflows are needed. Installing devices supporting monitoring, documentation, drug storage and delivery that are particularly suited to the space, tempo and clinical demands of NORA would help improve workflow, teamwork, communication and situational awareness. Unlike ORs, which have been designed around common principles, often for specific specialties, NORA spaces can be highly variable and may need to accommodate an array of specialties and procedures. While architectural features that compromise performance can be difficult to address, appropriate task lighting, sufficient work surfaces, and standardizing workspace organization are more amenable to improvement.
Higher rates of morbidity and mortality found in NORA are likely attributable to a broad range of system factors compromising safety and quality of care. Our study described anesthesia providers’ self-reported near-misses and harm events in NORA and offered recommendations for improvement. Additional research is needed to proactively and systematically identify challenges faced by anesthesia providers in the various NORA suites and the contribution of systems factors to adverse events. While redesigning NORA suites, developing standard processes, and optimizing resource utilization represent positive steps for improving safety in NORA, these efforts alone have not eliminated harm and adverse outcomes in the OR. Given the significant increase in NORA cases expected in the next decade, developing a safe, resilient anesthesia delivery process will be critical in reducing patient harm.