Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review

Abstract

Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.

Effectiveness of pre-anaesthetic assessment clinic: a systematic review of randomised and non-randomised prospective controlled studies

“… 14 A narrative review found higher rates of morbidity and mortality in non-operating room anaesthesia, and one of the main reasons was limited preoperative evaluation. 6 In this systematic review, the assessment of PAC was significantly associated with reduced mortality following complex orthopaedic surgery in only one study. 34 Retrospective studies have reported similar results, but with different surgeries.…”

“… 4 However, a previous review found higher rates of morbidity and mortality in non-operating room anaesthesia, which was attributed to limited preoperative evaluation. 6 A retrospective study found significant associations between perioperative mortality and age <1 year or >65 years, American Society of Anesthesiologists (ASA) Physical Status Classification System, emergency case status and operative start time after 18:00. 7 This might indicate that risk factors are both patient and surgery related and may be linked to organisational structures.…”

Anaesthesia cart standardisation expedites supply retrieval: A simulation study with patient safety implications

“…Working in unfamiliar perioperative environments has also been associated with increased morbidity. In a narrative review of factors contributing to morbidity, mortality, and safety concerns in non-OT anaesthesia locations, Herman et al (2021) reported a lack of familiarity regarding the team, location, and equipment as contributing concerns. Furthermore, as shown by Frasier et al (2019), a decreased familiarity between perioperative team members is also associated with reduced cross-disciplinary communication; Wacker and Kolbe (2014) report that these scenarios can negatively impact patient outcomes.…”

Systems safety in nonoperating room anesthesia locations

“…The ‘systems approach’ to safety suggests that accidental harm may be perpetuated by inadequacies in work system design [8 ▪ ]. Numerous safety systems have been proposed to provide hospitals and care providers a framework by which meaningful advances in the safety of patient care may be achieved.…”