Part 2/2: Non-Operating Room Anaesthesia – Creating a safer environment

Thank you to GE HealthCare for sponsoring this podcast.

Dr Krish Radhakrishna: Welcome to this podcast on non operating room anesthesia. NORA is a frequently used acronym for non operating room anesthesia to indicate that anesthesia is administered in a setup that is different from traditional theaters. These areas may be situated in other parts of the hospitals and very often far removed from the main theater complex. Increasing number of patients in different age groups are done here, and for a variety of procedures. In this podcast, we will be talking to doctors with considerable experience in the field to learn more about the subject. Our focus is to identify issues that may arise and how we can make Nora a safe place for delivering care. I am Krish Radhakrishna. I'm a consultant anesthetist in the University of Coventry and Warwickshire, and I'll be chairing this session. We had a good discussion about the subject from a consultant in London and one from Birmingham Children's Hospital. And also now we have a different perspective looking outside UK, far away in California, somewhere in Los Angeles, and we have a speaker from Los Angeles, Doctor Emily Methangkool. And we are going to today discuss a non operating room anesthesia as happens in your hospital.

And I know you have an excellent record of managing this service for quite some time, and we would like to learn from you how you do it in California. So we will start by asking exactly how is your non operating room anesthesia distributed in your trust?

Dr Emily Methangkool: Thank you so much for having me on this podcast. So, I work at two different hospitals. So one is a large academic medical center and one is a public hospital. And so they're set up a little bit differently. We do provide services to gastroenterology suite, interventional pulmonology, interventional radiology, cardiac catheterization laboratory, and various other places that may need anesthesia services, for example, like PET seat scan or MRI. Now, in the larger academic medical center, the hospital is a little bit newer, so it's about probably 15 or 16 years old. So in the planning phase, it was actually determined that the procedural areas would be on the same exact floor as the operating room. So the interventional radiology cath lab, the GI suites, all of those are located on the same floor and in very close part proximity to the main operating room, meaning that we can have the same anesthesia work room, that there are people very available to come and help if needed. Now, that's in stark contrast to the public hospital that I also work at, which was built about 40 years ago, at which time anesthesia services in these areas was not quite as needed.

And so the different areas such as IR cath lab. GI suites are actually located on a different floor from the main operator. And so to get help, it would require a little bit more time, a little bit more resources. And, in fact, our MRI suite is in a completely different building. I visited several other institutions, and while the Nora setup varies, there are many hospitals in the United States where the Nora locations are in completely different buildings from their main operating rooms.

Dr Krish Radhakrishna: So we can understand the challenges they bring in. One manning this department in providing emergency care when things go wrong and so on. So it means a considerable amount of responsibility lies on the person delivering care in these remote areas. And when you have been involved with this, when you are in a remote area in one of these hospitals, when you go to work and do a list there, what are your priorities? How do you make sure that safety is paramount?

Dr Emily Methangkool: So I think it's being cognizant that you are in a location that you're not necessarily used to and that is not necessarily optimized for anesthesia care. It's a very different location compared to the operating room. And so you do have to have a higher index of suspicion or a higher threshold that something could possibly go wrong. So, for me personally, when I work in these areas, I always make sure that I know the team that I am working with, nurses, technicians, proceduralists, that I'm familiar with the case, because, you know, things are advancing so quickly in these procedural areas that the case mix can be very different. If you had just, you know, done a case there two months ago, the cases can be far advanced two months later. And that my patients are optimized for surgery. That can be significant because a lot of these patients are very sick. They may not necessarily be good candidates for open surgery, but they're still coming to these areas for care because they qualify for some minimally invasive or some paleo procedure that can be done in these areas. So, for me, my priorities when I work in these areas is making sure that we have good communication, we have good teamwork, that we know what every other person is doing, so that we establish our roles and responsibilities, and that our patients are optimized for the area and for the procedure.

Those are very similar to goals overall that I have as a leader in Nora as well

Dr Krish Radhakrishna: So there is obviously this, a big advantage in doing cases in non operating room anesthesia, because it takes a load of the main thetas. If you're going to do everything in main thetas, that would not be possible. But what proportion of these cases, compared to the total number of cases that are done, what is the ratio between what is done in non operating room anesthesia and what is done in traditional theaters?

Dr Emily Methangkool: Yeah. So there was a great study published in anesthesia and analgesia in 2017 from Nagarbadsky et al. And they actually looked at older data. So they looked at data from 2010 to 2015, and they found that nora cases in the United States had increased from about 28% to 36% by 2014. And the numbers now in 2024. So ten years later is greatly higher than 36% because now we are doing a lot of cases for screening colonoscopy. So anesthesia is very heavily involved in the GI suite doing a lot of cases there. 2014 is when transcatheter aortic valve replacements were really started to be done in the United States. We do a lot of those. We do a lot of transcatheter, mitral valve edge to edge repairs. A lot more is being done in the cardiac catheterization laboratory. There are a lot more advanced procedures that are happening in interventional radiology. When I look at my own institutions data, our non operating room anesthesia cases are approximately getting close to about 50% of the total cases that we do.

Dr Krish Radhakrishna: So you are actually catching up because some of the publications were indicating that by 2030, there will be 50%. But I think. Looks like you already caught up with that number in Los Angeles.

Dr Emily Methangkool: Yes, getting close, for sure.

Dr Krish Radhakrishna: That's amazing. Now, what is interesting is, is your hospital able to fund such an increase? Is that dedicated funding for Nora?

Dr Emily Methangkool: So that is a great question. I think Nora is being increasingly recognized by hospital administration as a core area of hospital growth. So there have been resources dedicated to increasing Nora capacity. Now, the problem also when you increase neurocapacity, means that you have to also increase anesthesia staffing. And with the continued issues with staffing shortages, burnout that is plaguing anesthesiologists and, frankly, nurse anesthetists in the United States. That has been a little bit more challenging. So I would say, yes, there is funding and resources dedicated to Nora. I think the personnel piece is a little bit more challenging.

Dr Krish Radhakrishna: Yeah, but as an anesthesiologist, you learn there's nothing like special training somebody gives you for working in a non operating room anesthesia. You just learn as you go. Is that right?

Dr Emily Methangkool: Yeah, completely.

Dr Krish Radhakrishna: And that means that when a new person comes in, he has to be trained or gradually introduced. Are there opportunities for your trainees to come with you and learn the intricacies of non operating room anesthesia?

Dr Emily Methangkool: So our training programs do require dedicated time spent in the non operating room area. So, according to the ACGME, which governs residency programs in anesthesiology, there is a specification that residents spend dedicated time in these areas so that they learn the intricacies of working with these teams and with these procedures. Unfortunately, that time is quite short, can range anywhere from two weeks to four weeks. I'm not sure that that's enough time to completely learn all of the procedures and all of the things that can happen in Noura. So this, I think, is where after graduation, where newer faculty or newer members of a department can really participate in team training, that would be really helpful for Noura.

Dr Krish Radhakrishna: Yeah. And in your practice, Emily, do you find that the team that you work with, I'm not talking about the surgeons, I'm not talking about those who perform the procedures, I'm talking about your support team, like the nurses, the paramedics. Do you find them to be a dedicated team working for Nora alone, or they're always a changing group?

Dr Emily Methangkool: So, yeah, that's this one good thing about Nora, is that the technicians and the nurses who work in those areas are dedicated to those areas. There are specific cath lab nurses, specific nurses for interventional radiology, specific nurses for gastroenterology. They are the consistent factor amongst all of those different locations. That does make the work a little bit easier because they are so consistent.

Dr Krish Radhakrishna: That is quite good compared to what I heard from my other colleagues in pediatrics in London, that they felt that in certain areas, they were the same, but in some, sometimes they were changing, which made it a lot more complex for them than with the team briefing, getting everybody on board, put a lot of pressure on the anesthesiologist who would do the task there.

Dr Emily Methangkool: Yeah, I can definitely imagine.

Dr Krish Radhakrishna: We talked about the dedicated Nora team. I think there are certain advantages to that. But despite all that, it has been noted that there's an increased mortality morbidity in non-operating room anesthesia. Are you able to tell us about factors that might actually contribute to that?

Dr Emily Methangkool: So as with any problem in patient safety, there are a number of factors, I think, that contribute to problems with increased morbidity and mortality in Nora. One that we mentioned a little bit already is the actual physical location of Nora. So it can be located very far away from the main operating rooms, and that can make accessing additional equipment and additional personnel very difficult, especially in the case of an emergency. The ergonomics of the actual location can also be quite challenging. The rooms are often small. They're not necessarily optimized for placement of the anesthesia machine or additional anesthesia equipment. In fact, yesterday, I was just in a CT scanner that was being remodeled, and we were trying to figure out where the pipeline oxygen and nitrous and air was supposed to go. Where they had it was in a location that would make us having to place the anesthesia machine in a completely non-ergonomic location. The rooms themselves are actually often very dark, making it very hard to see a patient. That can be very challenging if you have a patient who is under sedation and not under general anesthesia, you're not really able to see them or monitor them very closely when the room very dark.

All those ergonomic issues really create an environment that is very unfamiliar and is primed for adverse events. There's also a teamwork component to this as well. The teams that work in Nora locations often work together on an ad hoc basis, meaning that over the course of a year, a single anesthesiologist may be in those locations very infrequently, maybe once a month, maybe twice a month. That's not enough time to really to build rapport with the team or to really be really familiar with all of the procedures that can happen. An additional risk factor is also the patients themselves. They're very sick, as I mentioned. They may not be good candidates for open surgery, and they're coming to these areas for minimally invasive procedures. Finally, these cases are often shorter than the average operating room case. There's a lot of production pressure to get these cases moving in in and out quickly. So there can be shortcuts that are being taken. There's also this push to do sedation or monitored anesthesia care in these patients compared to general anesthesia, which could be another risk factor for increased morbidity and mortality as well.

Dr Krish Radhakrishna: What about the post-anesthetic care unit? Do you have a dedicated PACU with dedicated nurses? Is that well-stopped? How is that work in LA?

Dr Emily Methangkool: So the majority The majority of patients who are in Nora go to the main postoperative anesthesia care units. So they go to the same unit that the operating room patients go to. We have some areas that have a very, very small dedicated area with only one or two beds for the more simple, less complicated patients. But the vast majority of them go to our main recovery area.

Dr Krish Radhakrishna: Or they travel back to the main recovery area from the procedure side.

Dr Emily Methangkool: It can It can be. It can be a cross floor, so it can be a long area. It does require additional vigilance while monitoring the patient up there.

Dr Krish Radhakrishna: And do you have to go with the patient or do you send one of the nurses to go with him?

Dr Emily Methangkool: The anesthesiologist accompanies the patient to the recovery room.

Dr Krish Radhakrishna: Which is what we do in UK as well. We can't let them go. That is quite interesting to see how the system... Now, I'm going to be very generous and give you, suppose I I suppose I give you a billion dollar check and say, Emily, improve the non-operating room anesthesia in UCLA. What would you do with it?

Dr Emily Methangkool: That is a great question. If I had a billion dollars, I think restructuring the Nora areas to be in very close proximity to the operating room, but also within the areas and within the rooms themselves to be more ergonomic, to have a little bit more space to accommodate all the equipment that is needed, would be excellent. I would also spend a large chunk of that money working on team training in these areas. I think it's really important to do simulation, team training, drills, the same way that we do in the operating room with nurses, technicians, and proceduralists who work in more locations. And that actually requires quite significant significant financial resources to take these people out of procedures to do that. But I think that can be really a key factor in improving patient safety by improving communication and teamwork.

Dr Krish Radhakrishna: Yeah, I think you're spot on there. You see, you have Actually, by answering this question, you have indicated that the problems we have across the world, in even the developed countries like UK and USA, and I'm sure a lot of European countries, is that there is an the inadequacies in the design of the work system that exists across, and any future hospitals that come up should really involve the teams to see what is the best way to set it up. Isn't it? That's a wonderful statement that is coming out of what you just said. Another issue which we have discussed before is this issue of human factors where people do not know one another by name or they cannot identify one another. They're not sure what each person's role is. Though there is a team briefing who checklist everything is done, still people forget the names. Some people say the name, but it's not heard. So we have ways of doing it by putting names on the theater hats or putting name back. So people know each other by name. It says anesthesiology on my hat. So people know my role as well. So do you have anything like that in LA that you're working on?

Dr Emily Methangkool: Yeah, we actually have the same thing. We actually put names and who we are, anesthesiologist or resident on the cap so people know exactly who we are. Yes. Because people change, people come in and out of the room very quickly. So it's really important to know who everyone is and what their role is.

Dr Krish Radhakrishna: Yeah. And also the communication, which has to be a closed-loop communication that you're addressing a particular person to do a particular talk. Part of the job and role allocation in a crisis scenario. All these are factors that actually are more complex in a remote area far away from the theater that help is readily available. Now, Emily, can you tell me about any incident that happened that you successfully managed, which resulted in a change in practice or a change in what you do?

Dr Emily Methangkool: Yeah, I think a great example is: I was taking care of a patient in the catherization laboratory, a very sick patient. It was a cath lab that it did not only have fluoroscopy equipment, but it also had an MRI within it as well. To do cardiac procedures. So you can image the introduction of the MRI along with a fluoroscopy equipment. It can be very, very challenging just for normal patient care. Add on top of that, a very sick patient who actually did not do very well after induction of anesthesia, proceeded to cardiac arrest. We had to call for people to come to the room. First of all, people didn't know where it was. It's behind a locked door, so they had to figure that out to get in. Then to come into the MRI suite, you have to make sure that you don't have any metal or anything like that that could potentially interfere with the MRI. Getting additional people into the suite took a little bit of time. Then we decided that... Also, one thing I will say is that the space was very limited in the suite as well just because of the fluoroscopy equipment, the MRI. With additional people coming in to help, they made it very challenging to communicate and for people to actually physically get close to the patient. We decided to put the patient on ECMO, and then we realized it would be a problem to get the ECMO circuit into the lab because of the MRI.

Dr Emily Methangkool: We ended up resuscitating the patient as best we could, move the patient to a different location for the ECMO canulation. In the end, the patient did fine, ended up being decannulated from ECMO and survived the event, fortunately. But this really highlighted an opportunity for improvement and really an opportunity for good team training in this very unusual, unique situation. So we have started work on doing drills, doing simulation, specifically in this area, to make sure that we address all of those inadequacies.

Dr Krish Radhakrishna: Wow. That is fantastic. Interesting tale. So much to learn from incidents and the positive and negative incidences, and particularly in remote areas, we come across them. So you have a good system of reporting instances as well?

Dr Emily Methangkool: We do. We do. We actually have an automated system where people just put all events that happened right when they are working on their anesthesia record. So it's in the same computer system.

Dr Krish Radhakrishna: Excellent. To those who are taking up, I know you're quite well accomplished in what you do. It's fascinating to read your bio, Emily. What advice would you give to those who take on this role in their hospitals? What about youngsters who say, I want to take up Nora as one in my job plan? What would you say to them?

Dr Emily Methangkool: I will say that number one, the work is not going to be easy. It will be challenging, but it is very important to do because doing the work will help improve patient safety. I will also say that everyone is trying to work in very small spaces that may not necessarily be designed for having both anesthesia and procedural services within it. It's really important to listen, to take into consideration the concerns of all of the people involved. You have to learn to be adaptable and flexible and be willing to reach out to many different disciplines across physicians, surgeons, and technicians. But at the same time, I think it's very, very critical that we make it a priority to have the same kinds of standards in Nora that we do in the operating room. So whatever monitoring standards, whatever safety standards, whatever equipment standards we have in the OR, that has to be applied to every single Nora location as well. So that has to be the number one priority.

Dr Krish Radhakrishna: It's amazing. Emily, thank you very much. This has been such a wonderful talk. And talking to you, we've learned so much. And this brings us to the end of the podcast. Thank you indeed.

Thank you to GE HealthCare for sponsoring this podcast.