NonOR Anesthesia Stepping outside of the OR HOW

What is NORA? �Non-operating room (OR) anesthesia, or “NORA, ” involves sedation and monitoring

Rise of NORA �Complex (and not so complex) interventions are amenable to minimally invasive

Copyright © 2015 Mark S Weiss All Rights Reserved

Challenges � Fewer resources, facilities often retrofitted for anesthesia care � Greater variation in

Challenges, continued �Interpersonal/design issues in OR become magnified in OR setting Proceduralists/Nursing/Staff � support

Addressing challenges �Potential difficulties can be addressed in advance by cooperative interdepartmental planning �Some

How to thrive in NORA? Diligence & vigilance Maintenance of same ASA standards &

Preparing for the worst � When things go wrong… Metzner J 1, Posner KL,

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What is NORA? �Non-operating room (OR) anesthesia, or “NORA, ” involves sedation and monitoring for procedures performed outside of the traditional operating room �NORA has become routinely necessary for patients undergoing procedures or tests in: Gastroenterology/Endoscopy Electrophysiology (EP) and catheterization labs Interventional radiology Neuroradiology MRI and CT scan suites, among others �The need for NORA services continues to expand new challenges for interventionalists, anesthesiologists, and patients Copyright © 2015 Mark S Weiss All Rights Reserved

Rise of NORA �Complex (and not so complex) interventions are amenable to minimally invasive approaches often provides substantial advantages over traditional open surgical alternatives, particularly in more medically complex or unstable patients �Improvements in anesthesia technology & safety allows for surgical innovation �Heavy operating room volume forces interventions to the “periphery” or remote locations �Patient satisfaction Copyright © 2015 Mark S Weiss All Rights Reserved

Challenges � Fewer resources, facilities often retrofitted for anesthesia care � Greater variation in physical set-ups and anesthesia and monitoring equipment � Decreased practitioner familiarity (environment, staff, organization) � Patient comorbidities often unique to the particular specialty � Physical access to patient may vary � Shared airway Copyright © 2015 Mark S Weiss All Rights Reserved

Challenges, continued �Interpersonal/design issues in OR become magnified in OR setting Proceduralists/Nursing/Staff � support personnel may not follow rigorous pre-procedure check-in or safety processes Language/Teamwork/Culture Volume/Time management/ Efficiency without sacrificing safety �Fewer ancillary staff available for help if needed Copyright © 2015 Mark S Weiss All Rights Reserved

Addressing challenges �Potential difficulties can be addressed in advance by cooperative interdepartmental planning �Some shortcomings can be identified by staff in the remote location before the anesthesia provider delivers the anesthetic �Other challenges require the anesthesia provider’s ongoing attention when preparing for case and while providing patient care Copyright © 2015 Mark S Weiss All Rights Reserved

How to thrive in NORA? Diligence & vigilance Maintenance of same ASA standards & quality as expected in main operating room Communication and collaboration with facility team Strict patient selection criteria, including thorough preoperative evaluation and screening Adequate staffing and recovery care protocols Copyright © 2015 Mark S Weiss All Rights Reserved

Preparing for the worst � When things go wrong… Metzner J 1, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol. 2009 Aug; 22(4): 502 -8. Copyright © 2015 Mark S Weiss All Rights Reserved