Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Did you know that Clinician Safety is one of the APSF Patient Safety Priorities? It is so important to keep clinicians safe so that they are able to provide safe anesthesia care. Clinician safety includes occupational safety as well as wellness. In fact, clinician safety, including burnout, was the topic for the 2021 APSF Stoelting Conference and there have been several articles including our featured article today published in APSF newsletters. Another APSF Patient Safety Priority is Non-Operating Room Anesthesia or NORA which includes safety in locations such as endoscopy, cardiac catheterization, and interventional radiology suites. This was the featured topic for the 2022 APSF Stoelting Conference as well as numerous APSF Newsletter articles. Our featured article today combines these two priorities into one high-yield article. That’s right, we are returning to our conversation on keeping anesthesia professionals safe when they are providing patient care in non-operating room anesthesia locations. This is Part 2 in our two-part series. If you haven’t done so already, make sure you check out episode #177 for part 1.
Before we dive into the episode today, we'd like to recognize Nihon Kohden America, a major corporate supporter of APSF. Nihon Kohden America has generously provided unrestricted support to further our vision that "no one shall be harmed by anesthesia care". Thank you, Nihon Kohden America - we wouldn't be able to do all that we do without you!"
Our featured article is once again “Clinician Safety in NORA” by Candance Chang and colleagues. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well.
Here’s a quick recap from last week. We talked about hazards and obstacles in NORA locations due to room set up since many NORA suites are small spaces that were not originally designed to include an anesthesia machine, automated medication dispensers, and other necessary equipment. Here are some strategies that may help decrease the tripping risk: Using a commercially available cable sleeve and specially designed mats or placing anti-fatigue mats over the cables or braiding the gas lines. Going forward, the best solution may be to design the procedure room with the gas and electrical outlets on the mobile overhead booms so that the lines remain off the floor and behind the anesthesia machine.
We also talked about room design, and this is when anesthesia professionals need to get involved to help with the design, planning, and construction of any new procedure suites. Well-designed procedure rooms decrease floor tripping hazards, hanging obstacles, and reduce the overall physical strain on clinicians who need to provide anesthesia care in this space.
Here are some practical recommendations for room design that the authors provide in the article:
1. Patients should enter on the side of the room opposite the anesthesia machine, gas lines, and cords.
2. Rooms should have two doors to promote easy access for equipment and personnel for regular workflow and during an emergency.
3. If there is only 1 door, the anesthesia professional and the patient’s head should be positioned closest to the door which allows for immediate assistance in case of an emergency.
4. Gas lines should be piped close to and behind the anesthesia machine with a dedicated line for waste anesthesia gas disposal. This is a recommendation from the National Fire Protection Agency that states that a waste anesthesia gas disposal inlet should be in any location where nitrous oxide or halogenated anesthetic gas are administered. This is not a legal requirement, but it is a consensus standard that is referenced by the Joint Commission.
5. There should be appropriate pre-procedure and post-procedure recovery locations that are close to the procedure room.
6. There should be a designated pathway for safe patient transfer to the intensive care unit from the procedure room when needed.
Now, it’s time to return to the article. Another important consideration is patient transfers. If you have provided care in a NORA location, then you have likely been involved in an awkward patient transfer due to the lack of sufficient workspace and necessary equipment or staff to assist. Remember, these areas were designed to be places where patients move themselves. There are some options to help keep the healthcare team members safe during patient transfers including AirTap or HoverMatt. These patient repositioning systems can help keep patients safe as well as decrease musculoskeletal strain for clinicians.
We have talked about some of the obvious and visible hazards that are present in NORA locations for the clinicians providing anesthesia care, but what about the invisible hazards. These include chemical hazards such as solvents, adhesives, paints, toxic dust, and waste anesthetic gas which all may be dangerous for clinicians. Did you know that long-term exposure to waste anesthetic gas may affect the antioxidant defense system and vital organ function? Many of these hazards are not visible and may be odorless. Identification and quantification of a gas leak may require infrared spectrophotometry. Here are some preventive measures that may help:
· Daily machine checks
· Effective scavenging and ventilation systems
· Proper vaporizer filling
· Prompt cleanup of spills
Another invisible hazard is radiation safety since the use of fluoroscopy during procedures has increased and this is in operating rooms and NORA locations. Have you participated in any radiation safety training at your institution? The most important consideration is that the exposure dose varies proportionally to the unprotected area of the person and inversely with the square of the distance. But remember we have been talking about the limited space available in many NORA locations and it may be difficult for anesthesia professionals to move away from the X-ray tube or even to move a rolling shield between the anesthesia professional and the radiation source. There are some options to help decrease exposure area for clinicians in the procedure rooms including shielding with skirts fixed to the procedural table, rolling lead shields, or protective aprons worn by individual clinicians. Eye protection is another important consideration to decrease the risk for cataracts. If lead glasses are not available, glass or plastic lenses do provide some protection by reducing the radiation exposure. Anesthesia professionals may need to don circumferential lead aprons with thyroid shields to provide appropriate protection when turning their backs to the X-ray tube. These aprons and thyroid shields should be provided by the institution for clinicians to use while working in locations with fluoroscopy.
There are guidelines for annual limits of radiation exposure set by the National and or International Council on Radiation Protection. It is recommended that radiation dosimeters be worn by all clinicians who experience this occupational exposure. For clinicians who are pregnant or those with greater than 10% of the recommended annual exposure need to have monthly dosimeter assessments. It is important for institutions to distribute and monitor dosimeters and to complete a yearly check for the integrity of all the lead shields. These steps may be a challenge for large anesthesia departments and when multiple sites are covered, but these are important considerations for helping to keep clinicians safe when providing anesthesia care in NORA locations. The good news is that if we look in the literature, studies have shown that radiation exposure for anesthesia professionals usually remains well below established safety limits. The caveat here is that when the X-ray tube is next to the anesthesia professional, their exposure level may be three times greater than the operator. This occurs when the anesthesia professional must move beyond any rolling shied in order to administer medications or closely assess the patient. Another consideration is that for new equipment and techniques during NORA procedures, there may be inadvertently high radiation exposure. The authors provide the example of neuro-interventional and cardiac interventional suites that use continuous high-resolution imaging.
We made it to the end of the article. The authors highlight the increased hazards and threats to clinician safety in NORA locations compared to the standard operating room especially as NORA procedures continue to increase. Ad hoc safety measures may help to decrease clinician injury in these locations, but there is a call to action for an organized, multidisciplinary effort to improve clinician safety and anesthesia professionals need to be part of the conversation and decision-making. The following steps are vital for improve clinician safety and decreased risks in NORA locations:
· Clinician input in room design
· Careful and practical arrangement of anesthesia equipment and associated cords and lines to decrease obstructions.
· Following a safety checklist that accounts for appropriate equipment.
· Removal or mitigation of physical hazards
Before we wrap up for today, we are going to here from Chang again. I also asked her what she hopes to see going forward. Here is her response.
[Chang] “I hope that anesthesia providers will focus on more than getting through the case in front of them today. But we'll see that with a little advanced planning, conversations with our procedural colleagues, and a collaborative commitment to common sense solutions, we can make the NORA working environment safer for all the clinicians in the room.
This is a call to action for anesthesia providers to get involved in the planning, design, setup, and improvement of both new and existing NORA locations. Ensuring clinician safety will help us focus on patient safety.
[Bechtel] Thank you so much to Chang for helping to contribute to the show today.
If you have any questions or comments from today’s show, please email us at podcast@apsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.
Do you have any plans for December? The 77th Postgraduate Assembly in Anesthesiology is in New York City, December 8 - December 11 and the APSF will be there! That’s right you can check out the APSF panel on Saturday December 9th at 1pm on Emerging Medical Technologies – A Patient Safety Perspective on Wearables, Big Data, and Remote Care. We hope you can make it to learn more about wearable monitoring devices, healthcare analytics, remote bedside care, and more!! For more information, head over to APSF.org and click on the Conferences and Events heading. First one down is Upcoming Events Featuring the APSF. I will include a link in the show notes as well. This is a great way to learn all about the latest in perioperative patient safety.
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
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