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November 1, 2013 Volume 77, Number 11
Not Them, Not Us, But We: The Importance of Teamwork in the NORA Environment Leonardo Gendzel, M.D.

Philip D. Bailey, Jr., D.O.

Jeffrey M. Feldman, M.D.,
Committee on Equipment and Facilities



It is noon on a Friday and the head technician from radiology calls to schedule an MRI with anesthesia for 2 p.m. and says: "I really need YOU people to accommodate this patient and we have a busy schedule today so a long ANESTHESIA DELAY will be a big problem."

 

Not long ago, this type of conversation would not have been unusual at the Children’s Hospital of Philadelphia. There are many challenges to providing anesthesia services outside the O.R. while maintaining the same safety and patient flow we enjoy in the O.R. complex. The comments by the technician in the quote highlight one of the most significant obstacles to success, namely a lack of a sense of teamwork when caring for patients in the non-O.R. anesthesia (NORA) environment. Comments such as “you people” and “anesthesia delay” underscore the notion that we are not part of the usual team caring for their patients and our challenges in caring for patients in the NORA environment are not appreciated. There is an intense focus on patient throughput in procedural areas, and the time required to provide safe anesthesia care is often viewed as just delaying the schedule. In truth, anesthesia professionals who do not view NORA locations as having the same importance as the O.R. contribute to the lack of teamwork. It only takes one person to make it clear he or she is not happy to be working in a NORA environment to create a lasting bad impression and difficult working relationship.

 

In the past few years, NORA has become an area of increasing activity at our institution, approaching 25 percent of our overall case volume (Figure 1). NORA locations include all radiology modalities, GI suite, radiation therapy and oncology clinic. In the last five years, there has been an overall growth of 117 percent with significant changes in GI suite (159 percent), radiology (113 percent) and radiation therapy (175 percent) (Figure 2, page 14). Since most young children will not remain motionless for studies or procedures, the need to provide anesthesia services outside the O.R. is especially pressing in a children’s hospital. Many of these patients have significant co-morbidities that complicate their anesthetic care, making it even more challenging to provide safe and efficient care. Our approach to developing NORA services has been multifaceted. Staffing models, facility redesign, equipment acquisition, patient selection and scheduling procedures have all required attention but in themselves are not sufficient ingredients for success. The most important ingredient has been to build a team of people in each NORA location dedicated to the success of the procedural area and the safety and efficiency of the anesthetic care. In this article, we outline the process being used to develop anesthesia services outside the O.R. at the Children’s Hospital of Philadelphia, with an emphasis on the efforts to create teams at both the administrative and patient care levels.

Figure 1

Figure 1: Percentage of overall case volume by location. NORA: Non-operating Room Anesthesia approaching 25% in 2013.

Figure 2

Figure 2: Total case volume by NORA location over the last five years at the Children’s Hospital of Philadelphia.

 

Team Building

There are many obstacles to successfully developing a safe and efficient team in a NORA location. To understand these obstacles, consider the common scenario where a NORA location has been providing nurse-administered sedation to patients under the direction of the proceduralist. The nurses and proceduralists will typically have a strong working relationship and established expectations about patient flow. The anesthesia team will always be able to offer a more efficient and safer patient flow, but achieving that goal requires developing a new set of expectations for everyone’s job responsibilities.

Since the NORA anesthesia team does not have backup from other anesthesia personnel in the O.R., engaging the NORA location staff during induction, emergence and room turnover is important. Actively working with the anesthesia team requires a new skill set for most staff in those environments. The NORA staff will not understand their potential roles in supporting the anesthesia team and can feel anxious, scared, inadequate or reluctant to perform tasks they view as outside their job responsibilities when asked to assist. Anesthesia professionals in a new NORA environment can quickly become frustrated when the staff does not seem to understand their needs. Since the NORA staff does not work in the O.R., it is unrealistic to expect they will understand the anesthetic process and potential problems. Unless the team roles are clearly communicated, the underlying emotions can quickly lead to behaviors that undermine efforts to create a positive work environment.

 

We have employed both lectures and simulation as highly effective tools for training and team building in NORA environments. Successful simulation exercises typically focus on an adverse patient event that requires all members of the team working in the NORA environment to work together to rescue the patient. Common scenarios used in our hospital are laryngospasm, cardiac arrest, difficult mask ventilation and parental presence during induction that does not go well. For these exercises to be successful, it is essential that all members of the group working in the NORA environment participate. Coordinating disparate schedules for anesthesia, nursing, technician and proceduralist staff is challenging but necessary. The time must be set aside from the busy clinical schedule, and creating that time sends a message from administration that developing this teamwork is an important priority. Not only does the simulation exercise improve staff skills, but just as important, it creates an opportunity to develop working relationships without the pressure of the patient care schedule. Lectures on topics such as preoperative evaluation, basics of airway management and how to call for help are also valuable and enhance the credibility of the anesthesia department by advertising our unique expertise and demonstrating leadership.

 

Since the NORA environment takes anesthesia professionals outside the “familiar” environment of the O.R., not all members of the department share the same comfort level providing NORA care. The work is challenging and ideally shared by all members of the group. At the outset of a NORA program, it is useful to identify a smaller group of people from the department who can work successfully and understand the challenges of building the services. As systems are established and the team develops in each NORA location, it becomes easier to provide safe and efficient care, and the group staffing the NORA environment can be expanded.

 

Communication in the NORA environment can be especially challenging and an important obstacle to team building. The device or devices used for communication need to be determined, and there needs to be a clear understanding by all personnel in the NORA environment of how to contact one another. For example, if the anesthesiologist is supervising care and is seeing the next patient, how is he or she best contacted if needed quickly in the procedure room? If there is a problem in the recovery area, how can help be summoned? Areas such as MRI or radiation therapy are especially challenging since many devices cannot be carried or simply do not work in those locations. We have developed different solutions for each environment, and the perfect solution remains elusive. Nevertheless, communication can be facilitated by reviewing, on a daily basis if necessary, how to communicate with one another. It is also useful to identify a central person responsible for patient flow each day who can serve as the common contact when people or resources need to be coordinated.

 

Administrative planning and support are essential to developing a successful NORA service. Indeed, the team-building starts at the administrative level. Much joint planning is required between the proceduralists and nursing and technical staff as well as the anesthesia department. Scheduling processes, facilities design, equipment needs, staffing allocations, and policies and procedures all need to be developed. An effective administrative team will be able to solve problems rapidly and set the example of teamwork for the entire group. We have found that regular meetings of the administrative team for each NORA location that include physician and nursing leadership, at a minimum, and technician leadership as well when indicated, are invaluable. Radiology is one of our largest and most diverse NORA locations, and the administrative team for our radiology anesthesia service is a standing group that has been meeting monthly for several years. We have learned that you can have the best facilities and most highly trained personnel, but without a team of people working together to achieve the same goals, success will be elusive.

 

Anesthesiology has not universally embraced NORA as part of the specialty; in many cases, other professionals not trained in anesthesia have stepped in to provide the needed patient care. Non-anesthesiologists will continue to assume this activity unless anesthesiologists take the initiative to care for patients in the NORA location. Looking to the future, we see the need for anesthesia services continuing to increase outside of the O.R. as diagnostic methods and non-invasive therapies advance. We believe that an anesthesiology-based NORA service, as described in this article, can significantly enhance the patient care experience and leverage our unique skills. Although there are significant organizational and logistical challenges to establishing such a service, involvement by the anesthesiology department in the planning and execution will help to ensure successful implementation. Partnering with multiple modalities that require our services to provide patient care is an opportunity to demonstrate our value to the patient care experience. Anesthesiology departments should embrace the growth and challenges in non-operating room anesthesia so that we can serve patients wherever our skills are needed.

 

Figure 1: Percentage of overall case volume by location. NORA: Non-operating Room Anesthesia approaching 25% in 2013.

 

Figure 2: Total case volume by NORA location over the last five years at the Children’s Hospital of Philadelphia.



Leonardo Gendzel, M.D. is Pediatric Anesthesiologist, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, and Assistant Professor of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Children’s Hospital of Philadelphia.

 

Philip D. Bailey, Jr., D.O. is an anesthesiologist, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, and Assistant Professor of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Children’s Hospital of Philadelphia.

 

Jeffrey M. Feldman, M.D., MSE is Division Chief, General Anesthesia, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, and Professor of Clinical Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Children’s Hospital of Philadelphia.



 

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