69: Non–Operating Room

Anesthesia
Mabel Chung, and Rafael Vazquez

K E Y PO IN TS

▪ The non–operating room space represents an expanding area of

anesthetic practice. Technological advancements in medicine
have given way to the evolution of complex percutaneous
procedures. As a result, the volume of non–operating room
anesthesia (NORA) cases continues to increase. Patient safety
and satisfaction have continued to be a priority. This, in turn, has
increased the demand for anesthesia services to deliver a wide
variety of care, ranging from sedation to general anesthesia with
invasive monitoring.
▪ Operational constraints create additional challenges. Significant
differences in practice result from the fact that NORA cases
occur in locations remote from the operating room (OR) and are
performed frequently by medical proceduralists who are less
acquainted with the scope of anesthesiology practice. In
addition, anesthesiologists may be less familiar with the
demands of providing an anesthetic in a suboptimal
environment in which equipment restricts mobility and access to
 patients, setups distinct from the OR are utilized, and where
radiation hazards are significant.
▪ This chapter serves as a general guide to the cadence and focus of
procedures performed outside of the OR, and highlights some of
the adaptations, both cultural and practical, that are needed to
provide a safe and optimal anesthetic.

Overview: Defining Non–Operating

Room Anesthesia – What It Is and How
We Got Here
Non–operating room anesthesia (NORA) refers to all procedures
performed in off-site locations and includes a diverse set of
interventions. Historically, cases managed outside of the operating
room (OR) were minor, infrequent, involved relatively stable
patients, and seldom required anesthesiology support. However, in
the current era, NORA cases involve nearly every medical specialty,
generate (in many hospitals) volume and revenue equivalent to that
of the OR, and are as demanding of anesthesiologists as the most
advanced surgical OR procedures. They constitute a major expansion
of our practice perimeter and require the same, if not more, planning
and attention to operational efficiency with which the OR is
managed.
In the United States, the proportion of NORA cases increased from
28% to 36% from 2010 to 2014.1 The flood of NORA procedures now
requiring anesthesia support originated from rapid technological
developments and innovations that have expanded the array of
possible procedures ranging from simple same day procedures to
complex cardiac procedures requiring after care in the intensive care
unit (ICU). Anesthesiology support is also required as a result of
increases in patient complexity caused by chronic medical conditions
due to the aging population. It’s not surprising that patients
undergoing NORA procedures are older and more likely to be
American Society of Anesthesiologists (ASA) class III–V physical
status as compared with patients undergoing procedures in the
operating room.1 In fact, many NORA cases are performed on
patients deemed “high risk for surgery,” such as patients that are
medically complex and/or critically ill, therefore requiring
specialized anesthesiology care.
The increase in procedures performed outside of the OR has been
accompanied by increasing scrutiny regarding the safety of
anesthesia in remote locations. An analysis of the ASA Closed Claims
database found that remote location claims demonstrated a higher
proportion of claims for death compared with operating room
claims, and involved older and sicker patients. Sixty-nine percent of
remote location claims involved monitored anesthesia care;
respiratory events including aspiration pneumonitis and inadequate
oxygenation and ventilation comprised one-third of the NORA
claims.2 Substandard care and non-adherence to standard ASA
guidelines were cited as contributing factors to poor outcomes. These
findings suggest that patients are at a higher risk of adverse events
when undergoing anesthesia for procedures in remote locations and
underscores the need for conscientious preparation, adherence to
care standards, and greater vigilance when caring for these patients;
ultimately, the goal must be to remediate systemic factors that
contribute to the excess hazard experienced by these patients.
 The purposes of this chapter are twofold. The first is to highlight
the intrinsic, common, and unique characteristics of NORA cases
that impose unusual constraints on anesthesiologists in the out-of-
OR arena. The second is to present goals, methodologies, and pitfalls
of interventions that may be unfamiliar to anesthesiologists. This
chapter does not reiterate basic principles of anesthesiology practice
described elsewhere in the book; nor does it describe the technical
details of novel procedures. Instead, it intends to serve as a general
guide to NORA procedures and the environment itself, to delineate
the hurdles we face in the NORA environment in order to promote
awareness and encourage preemptive planning, and to equip
anesthesiologists with a vocabulary with which to establish effective
dialogue so as to cultivate a collaborative practice with our colleagues
and to maximize the safety of our patients.

Novel Characteristics of Nora Cases

NORA cases are characterized by three distinctive features: location,
operator, and relative novelty. First, the procedure does not take
place in a standard operating suite and is typically remote to the
main OR section. Second, the operator performing the procedure is
generally a medical interventionalist rather than a surgeon. Finally,
the procedures and technologies used are constantly evolving.
Innovative applications of these procedures and technologies pose a
challenge. The increasing incidence of medically complex patients
needing urgent intervention but lacking periprocedural evaluation
creates additional stress. An expanding need for anesthesiology
services outside the OR presents an opportunity for us to reaffirm
our skills and mission.
 Technological advances have resulted in the rise of medical
procedures that now target problems previously treated only with
surgery. For a rapidly broadening spectrum of acute and chronic
problems, surgery in the OR is no longer the only potential route of
treatment. For example, carotid artery stenosis can be treated in the
OR, the catheterization laboratory, or the interventional radiology
suite. The ultimate choice of venue may be a function of acuity of
presentation, but likely also depends on referral, who the patient
sees first, and who is available.
As a result, the perimeter of our landscape now expands beyond
the familiar domain of the OR and requires collaboration with a
broad array of medical practitioners including interventional
cardiologists, interventional radiologists, gastroenterologists,
radiation oncologists, and electrophysiologists. Given the physical,
medical, political, and economic challenges that arise and are often
unanticipated, our goal must be to adapt successful and innovative
clinical practices developed in the perioperative environment to new
venues, patients, and practitioners. We must also strive to evolve our
anesthesia practice to meet the demands of a changing patient
population.3

Unique Obstacles: from Physical Environment to

The Medicine–Anesthesiology Culture Gap
When anesthesiologists are faced with the need to provide services to
non-surgeons in non-OR locations, issues such as scheduling
inconsistencies, ad hoc requests, and resource limitations can be
difficult to resolve expeditiously. In addition, the increasing
incidence of medically complex patients needing urgent intervention
but lacking preprocedural evaluation can create additional stress.
Two especially prominent challenges of working in the NORA
environment are inadequate physical environment and poor
communication exacerbated by the medicine–anesthesiology culture
gap.
Procedural suites are often remotely located. This increases the
time lag between a request for assistance and the arrival of help, both
with technological and medical problems. In addition, the lack of
nearby supplies may exacerbate the timely resolution of common
electrical and mechanical malfunctions or complicate the resolution
of a medical emergency. This situation demands that care be taken
before the start of the procedure to ensure that equipment is stocked
and working and that backup options (i.e., emergency supplies and
difficult airway equipment) are functioning and readily available.
In addition, the existing non-OR procedure suites were designed
to meet the needs of the proceduralist, and unfortunately, the needs
of the anesthesiology team are difficult to meet. For example,
procedure suites that use fluoroscopy for guidance are often
configured so that the C-arm limits access to the patient’s head and
obstructs direct communication between the anesthesiologist and
the proceduralist. Modern fluoroscopy systems have evolved to be
mounted from the ceiling to render better access to the patient.
Inadequate access to the patient may be exacerbated if the area
around the head of the patient is crowded due to room and
equipment constraints. Lack of visibility of procedural screens make
it difficult to follow the progress of the intervention. Even worse,
hemodynamic monitors may be difficult to visualize by the
anesthesiologist and may not function properly because of
interference with mapping systems or other electronic interfaces.
Lead screens may not be available, and when they are available and
positioned to protect the anesthesiologist from radiation, pumps and
intravenous lines may become inaccessible. Gas scavenging may be
unavailable, and oxygen and suction may be suboptimally placed.
Anesthesiologists should be mindful of orienting themselves spatially
to a procedure room, particularly if the setup of a room is unfamiliar.
Distraction of our focus away from patient care due to an unfamiliar
environment can be potentially disastrous in the face of a novel or
complex procedure.
The ASA has formulated a statement regarding NORA locations
that articulates minimum standards for all procedures performed in
these areas,4 but these standards are quite fundamental. Recognizing
the constraints of the environment and anticipatory planning often
allows for the safe administration of anesthesia within this
environment. The challenge is communicating the importance of
these issues and subsequently implementing changes that will
optimize the ability of anesthesiologists to deliver care.
Communication with the medical proceduralist is key to providing
an optimal anesthetic; taking time to discuss the procedure and the
patient allows for thoughtful consideration of anesthetic options in
the context of both the principles of the procedure and the
physiology of the patient. However, mismatches in culture can
dominate interactions between medical practitioners and
anesthesiologists and undermine communication. These
conversations can be challenging since, unlike surgeons,
proceduralists may be unfamiliar with the skill sets that an
anesthesiology team provides and unaware of the intricacies of
administering an anesthetic. While surgeons are accustomed to
sharing their procedures with other medical practitioners,
proceduralists may be habituated to working alone and ordering
sedation by a nurse. Medical interventionalists may also lack
experience with relatively rare but serious complications such as loss
of airway. Proceduralists are frequently consultants who are enlisted
by primary care professionals who may not have conveyed all
relevant information. Even when all information is provided,
specialization predisposes proceduralists to concentrate on their
point of expertise.
Likewise, many anesthesiologists may have limited knowledge
about what is happening during the course of a noninvasive
procedure and do not ask enough questions, especially when they are
new to a particular venue, the procedure is not observable, and
fluoroscopy screens are out of the field of view or uninterpretable.
Anesthesiologists may be unaware of pitfalls and likely complications
of the procedure even though in the OR they normally would not
administer an anesthetic without understanding the surgery. Extra
initiative is often required as the proceduralist may not communicate
the course of the procedure during the case. Other aspects of the
procedure, such as how coughing on extubation might predispose
patients who have had jugular or groin sheaths to serious
hematomas, may not have been emphasized by the procedural team
or likewise appreciated by anesthesiologists. Bridging the
communication gap requires effort, but it is absolutely critical to
optimizing outcomes.
When interventionalists undertake novel procedures using new
technology, the situation can become even more challenging. The
course of the procedure may be unknown, the timing and sequence
of events may be unclear, and the focus of the procedure may change
midstream. At times, the proceduralist may be unsure of what is
happening. In these situations, extensive preplanning, a
commitment to communication, and the explication of goals is
crucial to the success of the procedure and, more importantly, the
safety of the patient.
As medical procedures become even more technically demanding
and patient conditions more complex, the best possible patient
management strategies will arise from collaboration and teamwork
between medical proceduralists and the anesthesiology team. This
requires mutual respect, excellent communication, common
vocabulary, shared experience, and overlapping competencies. In
pursuit of this goal, we can build on the outstanding record of
improved patient safety and outcomes that characterizes the history
of anesthesiology.

Operational Constraints
Scheduling non-OR cases can be challenging as the procedural
duration and booking are not defined well or are inaccurately
booked. Key challenges in scheduling and staffing non-OR cases
include the following:

1. Non-OR anesthetizing locations are often adapted to the

specific procedure being undertaken and the needs of the
medical proceduralist. Unlike ORs, they are
noninterchangeable.
2. Variability may be more problematic because the number of
staff in any one non-OR venue is smaller and less flexible.
 3. Block time may not be in place with anesthesia cases placed
anywhere on the schedule, making it difficult to utilize
anesthesiology staff productively and increasing the
likelihood of underutilized but deployed resources.
4. Non-OR procedures may take place far from the OR. Lack of
storage space for anesthesia equipment may impose longer
turnover time and the need for additional anesthesia
technical services.
5. Many non-OR procedure suites perform procedures on
patients referred from outside practitioners or services that
are booked through a central scheduling office. Preprocedural
evaluations are often very cursory or not done at all. This
imposes an additional bottleneck for the anesthesiologist who
may need to perform a preprocedural evaluation before the
procedure and cancel or delay cases at the last minute.
6. Some non-OR procedural areas do not employ real-time
scheduling. They do not rely on historic times for procedures.
The challenge is that some procedures vary depending on the
patient needs. For example, with a patient needing various
interventions, it is difficult to estimate the length of the
procedure. Booking times may be unrealistic, and scheduling
anesthesiology time may be difficult. Additionally, with new
technology and noninvasive methods, it is very easy for the
proceduralist to redirect or expand the procedure during the
case.5
As a group, non-OR cases tend to be more variable, less
predictable, and, therefore, more difficult to staff cost-effectively.
Some of these difficulties are technical, but some are the result of
cultural discontinuity and poor communication between
anesthesiologists and medical proceduralists. Effective management
control of this arena requires the following at the very least:

1. If possible, establish a contract between the anesthesiology

and procedural departments that encourages uninterrupted
utilization of available time and minimization of differences
between “staffed (contracted) time” and “productive time.” In
addition, it is worth considering a transfer price that confers
cost neutrality to anesthesia departments while leaving open
the option to bill for services to cover costs.
2. Include all non-OR cases within the electronic database for
OR cases, so that resource deployment can be planned and
modified as needed.
3. Create a block schedule that makes sense for the procedural
area; that is, if the area tends to run late, then book an
anesthesiologist to be there for those hours instead of
running overtime on the days that more or longer procedures
are done. Try to encourage productive utilization of
anesthesiology contracted time.
4. Implement real-time scheduling. Calculate earliest start
times, optimal arrival times, and adjusted preoperative
fasting (nothing by mouth [NPO]) guidelines for all patients.
Avoid having patients sitting in preprocedural areas for
extended periods because this overloads nurses and puts a
hold on patients exiting procedure rooms while waiting for
recovery area beds.
5. Improve specialized triage for scheduled outpatients in each
procedural area by creating triage forms and staffing an
 intake office to minimize delays and cancellations. Create a
situation in which specialists are invested in appropriate
preprocedure evaluations.
6. Anesthesiology oversight of periprocedural triage and
postprocedure recovery areas should aim to ensure both
optimization of patient comorbidities and prompt treatment
of postprocedure complications. Oversight includes keeping
track of unexpected admissions, longer than necessary
recovery times, throughput, efficiency, length of stay, and
medical outcomes in non-OR arenas just as they do in the
OR.
Staff and non-OR locations can be scheduled in many ways. The
principles outside of the OR are the same as they are in the OR,
whose goals are to reduce variability, schedule to minimize ad hoc
solutions as much as possible, and use real data when available (i.e.,
real-time scheduling for blocks). In addition, consideration of
available time and productive time is important. Contracts should
discourage situations in which procedural areas use their rooms at
rates lower than those of the OR. Full schedules and adequate
revenue collection should be incentivized; otherwise a subsidy of the
anesthesia department is needed because the opportunity cost
incurred is often significant. Without doubt the demand for non-OR
anesthetics will increase. Whenever possible, proceduralists should
be involved in scheduling schemes so they are invested in the process
and vice versa. A long-term goal may be the formation of a dedicated
NORA anesthesia team who resides in these areas full time. The
objective is to collaborate, so anesthesiology goals are aligned with
those of the proceduralists and integration of mutual competencies