QUALITY AND SAFETY IMPROVEMENT EFFORTS OUTSIDE OPERATING ROOM
1. QUALITY & SAFETY
IMPROVEMENT EFFORTS
OUTSIDE OPERATING
ROOM.
28.10.17
Dr. PALLAVI AHLUWALIA,
PROFESSOR,
TEERTHANKER MAHAVEER
MEDICAL COLLEGE,
MORADABAD.
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2. Common locations for Non-
Operating Room
Anaesthesia(NORA)
Radiology
Neurointerventional
Radiology
Vascular Radiology
MRI/CT/ PET Scan
Endoscopy Suite
Gastrointestinal Suite
Bronchoscopy
Intensive Care Unit
Tracheostomy,
Percutaneous
gastrostomy
Intracranial catheter
placement
Abdominal/pelvic
Invasive Cardiology
Suite
Cardiac Catheterization
Lab
Cardioversion
Electrophysiology Suite
Radiation Therapy
Emergency Medicine
Suite
Psychiatry
E C T suite
Urology - Lithotripsy
2
3. Why there is concern for
safety?
Anaesthesia providers are now asked more
frequently to provide complete, integrated
anaesthetic care outside the traditional OR
setting.
The number and the complexity of such cases is
increasing over time.
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4. Problems faced by the
Anaesthesiologists
1. Lack of adequate space
2.Unfamiliar surroundings and equipments
3.Central pipeline will be missing and cylinders will
have to be used.
4.Unphysiological postures needed for some
procedures.
5.Out patients for investigations are inadequately
prepared/investigated/have associated medical
illness.
6.Adverse reactions to contrast media
7.Lack of post anaesthetic care
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7. Morbidity & Mortality in
NORA
M&M data related to NORA infrequently studied and poorly described
Robbertze R, Posner KL, Domino KB. Closed claims review of anesthesia for
procedures outside the operating room. Curr Opin Anaesthesiol 2006;19:436-
42.
Mortality increased with NORA as opposed to
conventional operating room anesthesia
Substandard care is more prominent in NORA, many
complications could have been prevented with better
monitoring
NORA claims were mostly associated with monitored
anaesthesia care and with extremes of age
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9. American Society of
Anaesthesiologists guidelines for
NORA locations.
Reliable O2 source with backup
Sufficient space for anaesthesia personnel,
equipment
Suction apparatus, Emergency cart,
defibrillator, drugs, etc.
Waste gas scavenging
Reliable means for two-way communication
9
11. AAP guidelines for NORA
paediatric patients
1. No administration of sedating medication without
safety net of medical supervision.
2. Careful presedation evaluation
3.Appropriate fasting for elective procedures
4.In urgent procedures balance between depth of
sedation and risk
5.A focused airway examination
6.Clear understanding of pharmacokinetic &
pharmacodynamics
7.Training skills in airway management
8.Equipment for airway management and venous
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12. How can we improve safety?
Goal = improve the reliability of
achieving a safe NORA anesthetic
success in NORA may be achieved by
adhering to structural and organizational
standards
Need for evaluation & analysis of steps
required for each type of NORA
The reliability of each step determines
whether the a particular
algorithm/protocol is reproducible
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13. Tools & Targets for Improving
Safety
Organizational tools
Quality improvement methods
Protocols
Checklists
Communication during the procedure and during
transfer of patient care
Continuing education
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14. Protocols & Checklists
Haynes AB, Weiser TG, Berry WR, et al. A
surgical safety checklist to reduce
morbidity and mortality in a global
population. N Engl J Med 2009;360:491-9.
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16. Specific conditions that warrant special
care for anaesthesia / sedation outside
OR
Non-cooperate patient (e.g. intellectual
disability)
Procedures limiting access to the airway
Prone /Uncomfortable position
Lengthy, complex or painful procedures
Medical conditions predisposing patients to
reflux e.g. gastroparesis secondary to DM
Increased intracranial pressure
Decreased level of consciousness/depression
of protective airway reflexes
Acute trauma & Extremes of age
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17. Red flags for sedation
Infants <37 weeks GA
Apnea- OSA/morbid obesity
History of airway compromise during
sedation/GA
Adverse reaction to sedation previously
Potential for difficult airway
Hypotonic/lack of head control.
Gastroesophageal reflux
Unstable cardiac disease-
cyanotic/hemodynamic instability.
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18. Personnel requirements for safe
sedation / anaesthesia outside
OR.
Anaesthesia staff
Trained in the clinical assessment of patients
Trained & experienced in airway management &
CPR
Trained in the use of anaesthetic & resuscitation
drugs & equipment,
must ensure that the equipment is present and
functional prior to induction
Vigilant and Dedicated to the continuous
monitoring of the patient’s physiologic
parameters.
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19. Non-anaesthesia staff
Appropriately trained to help deal with a
cardiopulmonary emergency
Assistant for the anaesthesiologist-this
person must be familiar with anaesthetic
procedures and equipment
Assistant to help with positioning
Staff trained in
post-procedure observation
and resuscitation
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20. Standardization & Anaesthesia
Safety
Eichhorn JH, Cooper JB, Cullen DJ, et al: Standards for patient monitoring
during anesthesia at Harvard Medical School . JAMA 1986;256:1017-1020
The Harvard Anesthesia Practice Standards
written in the 1980s
Example of the standardization of anesthesia
care has helped improve the safety .
Identified minimum monitoring expectations (now
commonly used in every anesthetic procedure )
Influenced widespread adoption of pulse
oximetry and capnography
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21. Quality Improvement
Even though effective organizations take steps
to prevent adverse incidents, problematic
events still occur.
It is vital to have a defined approach to
reacting to adverse events, including errors
and near-misses.
Proactive vs. reactive approach
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22. NORA Safety Issues
- Location -
Crowded rooms with limited access to
the patient
Suboptimal light, insufficient power
supplies
Distance from pharmacy / supply
rooms
Availability of anesthesia staff/
help if needed
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23. Location/space requirements
for NORA (guidelines)
Adequate size with good access to the patient
Uncluttered floor space
An operating table, trolley or chair which can be
tilted into Trendelenburg position
Adequate lighting including emergency lighting
Sufficient electrical outlets including connected
to an emergency back-up power source
Suitable clinical area for recovery of the patient
which must include oxygen, suction,
resuscitation drugs and equipment
Emergency back-up call system to summon
assistance from the main OR.
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24. Equipment/monitoring
requirements for NORA
Appropriate (for deep sedation, GA and a cardio-
respiratory emergency)
Immediately available
Regularly serviced (service date indicated on the
equipment)
Same standard as in the OR (minimum
SPO2,ETCO2 , NIBP, ECG and temperature)
Alarms activated (with appropriate settings) and
sufficiently audible
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25. Monitoring req. contd....
Airway gas with the recognized safety
devices (e.g. Indexed gas connection
system,
reserve supply of oxygen,
oxygen analyzer,
oxygen supply failure alarm,
multiple gas analyzer,
a volatile anesthetic agent monitor,
a breathing system disconnection alarm
a scavenging system)
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26. Monitoring req. contd....
Anaesthesia work cart
stocked to OR standard (including
anaesthetic and resuscitation drugs,
airway management equipment,
a self-inflating hand resuscitator bag
(AMBU)
Suction
Defibrillator and emergency cart
26
27. COMPLICATIONS ASSOCIATED
WITH SEDATION AND
ANALGESIA
Airway
Airway obstruction
Aspiration
Regurgitation
Dental/soft tissue injury
Respiratory
Respiratory depression
Hypoxemia
Hypercarbia
Apnea
Cardiovascular
Hypotension
Cardiac arrhythmias
Neurologic
Deeper level of sedation
Unresponsiveness
Other
Undesirable patient
movement
Drug interactions
Adverse reactions
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28. Goals of sedation in patients for
diagnostic & therapeutic procedures.
Guard the patient’s safety and welfare
Minimize physical discomfort and pain
Control anxiety, minimize psychological
trauma,
and maximize potential for amnesia
Control behaviour and movement to allow
safe
completion of procedure
Return patient to a state in which safe
discharge from medical supervision is
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30. Concerns in Radiology Suite
Radiology hazard.
(Principle of ALARA-As Low As Reasonably
Achievable),Lead aprons/thyroid
shields/leaded eyeglasses.
Intravenous contrast agents
• Hypersensitivity reactions
• Contrast induced Nephropathy-Rise in S.Cr.
By 0.5mg/dl with in 24 hrs, with peak at 5
days.
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33. Problems of MRI
Ferro magnetic materials within 30 G contour- X
Implanted biological devices- cardiac
pacemaker, vascular clips, mechanical heart
valves, automatic implantable cardioverter-
defibrillator, cochlear implants –
Contraindicated.
Ear protection-noise exceeds permissible limits.
Heat generation in wires-electromagnetic
induction.
Malfunction of electric equipment-magnetic
fields.
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34. Contd....
NIBP –connections of cuffs and hoses=plastic
Capnography-long sampling lines=delay upto
20 sec.
Temperature monitoring=probes with
radiofrequency filters.
MRI safe infusion pumps=TIVA.
IF NOT AVAILABLE-
Standard machine +long breathing
circuit=secured to wall outside 5G contour.
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35. Precautions :GA for MRI
ET, LMA, connections- no ferromagnetic
material.
Laryngoscope-plastic, lithium batteries&
aluminium spacers.
ECG/Pulse Ox. Wires –straight/no loops/should
not touch patient at more than one location.
MRI Compatible Pulse Ox.- use fiber-optic
signal.
ECG-Artifacts minimized by high impedence,
braided, short leads.
MRI safe electrodes are available. To be placed
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36. Interventional Neuro-radiological
procedures
Considerations-
Radiation exposure
Contrast reactions
Difficult access to patient airway
Need for IBP monitoring/EEG/Brain stem
evoked potentials.
INHALATIONAL ANAESTHETICS avoided
for their confounding effects on EEG
&evoked potentials.
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37. Interventional
gastroenterology
Endoscopy-opioid/BDZ sedation+ LA spray
Colonoscopy concerns-
Preparatory bowel regimen induced
hemodynamic instability.
Uncompensated anemia-severe GI bleeding.
ERCP- prone
Concerns: limited airway access, avoidance
of drugs affecting tone of
sphincter of oddi.
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38. IVF-Oocyte retrieval
OPTIONS-Concious sedation,
paracervical block, electroacupuncture,
GA, RA.
SPINAL adv. Over GA- Excellent
anaesthesia with min. I.V. Medication.
Consider-short anaesthetic exposure with
min. penetration to follicular fluid.
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39. ECT
INITIAL-parasympathetic followed by sympathetic
response.
BP- cuff inflated before MR to monitor seizure.
Bite block to prevent injuries.
Concerns-
avoid sedative premedicants,
use glycopyrrolate to prevent bradycardia&
secretions,
interaction of anaesthetic agent with
antidepressants,
need to obtund hemodynamic response to ECT.
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40. TAKE HOME MESSAGE
Follow minimum guidelines ASA
Knowledge about procedure, Its requirements
& complications
Have close communication with proceduralist.
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