NORA Redux: Consensus recommendations for safe conduct from the APSF
Lynne G. Maxwell MD and Myron Yaster MD
Original Article
Beard J, Methangkool E, Angus S, Urman RD, Cole DJ. Consensus Recommendations for the Safe Conduct of Nonoperating Room Anesthesia: A Meeting Report From the 2022 Stoelting Conference of the Anesthesia Patient Safety Foundation. Anesth Analg. 2023 Aug 1;137(2):e8-e11. Epub 2023 Jul 14. PMID: 37224074.
Three months ago, the focus of the PAAD was the growing proportion of pediatric anesthetics that occur in non-operating room locations (NORA), based on data from the National Anesthesia Clinical Outcomes Registry (NACOR), by Louer et al.1 Those authors focused on the higher mean ASA PS of NORA patients and increased risk of adverse events in locations far from the operating room and available help, while suggesting thoughtful consideration of staffing and equipment in order to promote optimal safety.
Today’s PAAD adds to our previous discussion in reviewing the output of the Anesthesia Patient Safety Foundation (APSF) 2022 Stoelting Conference.2 This report describes an iterative method using a modified Delphi process which started with an APSF committee developing recommendations for best practices which promote safe conduct of anesthesia in NORA locations, focusing on issues of “facility and location, equipment and supplies, staffing and teamwork, patient selection, periprocedural care, and quality improvement.” The published document highlights a few key problematic areas, including failure to include anesthesiology personnel in decision-making about location configuration, procedural and emergency equipment and issues of poor team dynamics between anesthesia and procedural teams, which may lead to poor performance in emergency situations.
The specific delineation of their consensus development process and their 42 recommendations are not in the published article, but rather are in supplemental digital content (word documents) available online. The recommendations apply to all patient populations, rather than pediatric patients. The facilities, equipment, medications, and supplies recommendations provided may be helpful to those of you who may be involved in the design and/or development of anesthesia-compatible NORA locations in your institutions, now or in the future.
Finally, “the consensus recommendations are the “bare minimum” for safe patient care in NORA and are intended to apply to all NORA locations. These recommendations represent another step toward improving patient safety for NORA patients. They are intended to facilitate the reengineering of health care systems in the best interests of the patient so that medical errors are designed out of the NORA component of the system. NORA cases will continue to comprise an ever-increasing portion of anesthetic practice, and clinicians must continue to remain advocates for patient safety.”2
Please send your comments to Myron who will post them in a Reader’s response
References
1. Louër R, Szeto M, Grasfield R, McClain CD, Urman RD, Brovman EY. Trends in pediatric non-operating room anesthesia: Data from the National Anesthesia Clinical Outcomes Registry. Pediatric Anesthesia. 2023;33(6):446-453. doi:https://doi.org/10.1111/pan.14644
2. Beard J, Methangkool E, Angus S, Urman RD, Cole DJ. Consensus Recommendations for the Safe Conduct of Nonoperating Room Anesthesia: A Meeting Report From the 2022 Stoelting Conference of the Anesthesia Patient Safety Foundation. Anesthesia and analgesia. Aug 1 2023;137(2):e8-e11. doi:10.1213/ane.0000000000006539