The Wild West of Non-Operating Room Anesthesia


By Emily Methangkool, MD, MPH 

In the past decade, the need for anesthesia services outside of the operating room (OR) has increased dramatically. While this can be partially attributed to the expansion of gastrointestinal endoscopy services due to lowering of the recommended age for colonoscopy screening, there has been exponential innovation in the arena of minimally invasive interventions, from complete heart valve replacements to cancer treatment in the interventional radiology suite.

While these innovations have expanded the ability to care for patients who otherwise might not have been surgical candidates, anesthetic care in these non-OR areas do pose a significant challenge for patient safety. In fact, non-OR anesthesia (NORA) cases are projected to account for more than 50% of all anesthesia cases in the next decade. If we don't find a way to tackle the myriad issues with NORA procedures, the quality of care received by patients will suffer.

NORA is defined as any anesthesia care provided in a setting that is not an OR. This can include interventional cardiology suites or cardiac catheterization labs, interventional radiology suites, or gastroenterology suites where endoscopies and colonoscopies are performed. NORA can also refer to cases done outside of the OR in ambulatory surgery centers, or even in dental or medical offices.

Here's what we know: NORA cases are characterized by many tough issues, including problematic schedules, long internal commutes between the main OR and procedure suites, and the lack of access to tools typically available in the OR. These are all things that contribute to a less than ideal scenario for doctor and patient.

Even though the use of procedural suites outside of the OR has become more commonplace, the logistics do not get easier. NORA remains an urgent concern for patient safety, and a stress-inducer for anesthesiologists.

These problems are compounded by a rapidly aging population with increasingly complex comorbidities, the introduction of new technology, and the economics of a healthcare environment looking to improve value by cutting costs.

Regardless of the reason, people should be concerned about the overall quality of care patients receive outside of a well-resourced OR.

Among anesthesiologists, it is well recognized that non-OR locations pose risks. The mental work is tougher. More preparation is required up front to feel comfortable in a different setting. And problems can arise because doctors are working outside of the OR with not-the-usual standards of equipment and monitoring and teamwork they're used to.

Additionally, a lack of space for anesthesia equipment, as well as poor positioning for the anesthesia provider in relation to the patient are also commonly cited grievances from those operating in a NORA setting.

Patient safety concerns came to the forefront after a series of studies showed higher rates of complications and death with NORA cases versus regular OR cases. One such study using malpractice claims data also found that respiratory issues such as inadequate oxygenation and ventilation were more common in NORA cases.

Patient safety has since become a common phrase that accompanies most mentions of NORA among anesthesia providers. The good news is several anesthesia groups have worked to create education on how to improve patient safety in NORA cases. The Anesthesia Patient Safety Foundation has a specific task force dedicated to NORA safety and held a consensus conference last year to put forward recommendations for best practices in NORA.

Additionally, the journal Current Opinion in Anesthesiology dedicated an entire issue last year to the many concerns anesthesiologists have about working on NORA cases. Some items discussed include the need for more strategic planning, checklists, and consistent staffing models specifically to help reduce pulmonary complications.

Anesthesiologists and patient safety advocates want to see more collaboration and communication between anesthesiologists and the various procedural specialties to help identify and address areas of concern with NORA cases.

We need to focus on developing guidelines together to better address these concerns about NORA and patient safety. We know the risks NORA poses, and I believe we're making progress in a way that we haven't in quite some time, but we need all of us working together to make a real difference.

Emily Methangkool, MD, MPH, is the vice chair of quality and patient safety at the University of California Los Angeles.


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    • Editor-in Chief:
    • Theodore Massey
    • Editor:
    • Robert Sokonow
    • Editorial Staff:
    • Musaba Dekau
      Lin Takahashi
      Thomas Levine
      Cynthia Casteneda Avina
      Ronald Harvinger
      Lisa Andonis

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