RCOA Guideline AOT

Question 1

Intro

Answer 1

The complexity and challenges of providing anaesthesia care in the non-theatre environment should be acknowledged through appropriate regulation of healthcare providers and training and certification of anaesthesia providers. Personnel should be certified resuscitation providers.

Facilities delivering anaesthesia and sedation by anaesthetic providers should develop a culture of safety that reflects anaesthesia guidelines. Patients should expect uniform standards of service provision wherever the service is provided and whoever is the provider.

The development of deep sedation techniques and general anaesthesia with total intravenous anaesthesia (TIVA)/target-controlled infusion (TCI) techniques may remove the requirement for complex gas delivery systems and anaesthetic machines. The safe delivery of anaesthesia through preoperative assessment, case selection, anaesthesia delivery, recovery and post-operative care should not be compromised through cost pressures.

The physical environment can be challenging for the safe provision of anaesthesia when compared with the main theatre environment. The anaesthesia providers should develop safe practice guidelines that consider the assessment, induction, recovery and discharge of patients. In addition, procedure-specific risks such as radiation exposure and infection control should be considered. Compliance with the safe surgery checklist is obligatory. Complication management should be written into patient pathways with consideration of access to other medical, surgical and critical care services.

Question 2

Staffing

Answer 2

1. Clinical Lead
2. Skilled assistant
3. Sedation - also assistant
4. Sedation without Anaes - trained person monitoring patient / keep records
5. Recovery - same standard as PACU
   - consider transfedr
6. Radiology emergency interventional service
   staffing considerations

Question 3

Services and facilities

Answer 3

1. Access to lifts for easy trolley transfer should be available
2. Procedure rooms should be large enough to accommodate equipment and personnel, with enough space to move about safely and to enable easy access to the patient at all times.
3. Environments in which patients receive anaesthesia or sedation should have full facilities for resuscitation available, including a defibrillator, suction, oxygen, airway devices and a means of providing ventilation
4. he procedure room should be easily accessible to the resuscitation team and large enough to accommodate them and appropriate equipment if required.
5. Recovery Area

Question 4

Equipment

Answer 4

1. Trolleys - head down
2. Monitoring
3. Waveform capnography - deep sedation / GA
4. O2 supply
   If not piped - conisderred
   bacup cylinders
5. standardised - maintenance
6. Machine checks

Question 5

Medication

Answer 5

1. Wherever anaesthesia or sedation is undertaken, a full range of emergency drugs including specific reversal agents such as naloxone, sugammadex and flumazenil should be made available.

2.
In remote locations where anaesthesia is undertaken, drugs to treat rare situations, such as dantrolene for malignant hyperthermia, or intralipid for local anaesthetic toxicity should be immediately available and located in a designated area.

3. There must be a system for ordering, storage, recording and auditing of controlled drugs in all areas where they are used, in accordance with legislation

Question 6

Environment

Answer 6

Dark room - light source view patients

Heat loss reduced

Question 7

Sevices

Answer 7

Monitored during recovery

Question 8

3. Areas of special requirement

Children

Answer 8

1. Same standard of care as in theatre
2. Complexity patient considered

3.Equipment - same as main facility

Question 9

ED

Answer 9

Trauma team should include anaesthetist

ED staff trained with intubation

Induction checklist

Tranfer guidelines

Transfer not without risk
Tipping transfer trolley
O2 Cylinders
Transport vent
pups
monitor
portabel defiv

Question 10

Radiology

Answer 10

Exposure - secreens and gowns

As not all radiology tables tilt into a head down position, a tipping trolley should be available for patients who require general anaesthesia.

Skilled Anaesthetist

Question 11

Interventional radiology

Answer 11

Procedure specific agents, such as those required to manipulate coagulation, intracranial pressure or arterial blood pressure, should be available.

Interventional vascular radiology may involve treating unstable patients with severe haemorrhage. Such patients may include those with significant gastrointestinal bleeding or patients with post partum haemorrhage.40 Equipment to deal with these patients should be immediately available. This includes that necessary to introduce and monitor a variety of intravascular catheters, rapid infusion devices, blood and fluid warming devices and patient warming devices.

Question 12

MRI

Answer 12

1. Anaesthetic equipment that is used in the magnetic resonance imaging (MRI) scanning room should be MR compatible
2. Remote monitoring of the patient with slave screens should be available to allow the anaesthetic team to monitor the patient from outside of the magnetic field.
3. Particular consideration should be given to the problems of using infusion pumps. All non-essential pumps and equipment should be removed from the patient before entering the magnetic field. MRI compatible infusion pumps should be available wherever anaesthesia is provided regularly. Infusions with extra-long giving sets can be used when MRI-specific pumps are not available.
4. All staff involved with transferring a patient to the MRI scanner should understand the unique problems caused by monitoring and anaesthetic equipment in this environment.44 It is not acceptable for inexperienced staff unfamiliar with the MR environment to escort or manage a patient in this environment, particularly out of hours
5. The patient and all staff should have an MRI safety and exclusion questionnaire completed before entering the magnetic field.
6. In the event of an adverse incident in the MRI scanning room, the patient should be removed from the scanning room without delay; immediate access to an anaesthetic preparation room or resuscitation area is essential

Question 13

MRI

Answer 13

1. Anaesthetic equipment that is used in the magnetic resonance imaging (MRI) scanning room should be MR compatible
2. Remote monitoring of the patient with slave screens should be available to allow the anaesthetic team to monitor the patient from outside of the magnetic field.
3. Particular consideration should be given to the problems of using infusion pumps. All non-essential pumps and equipment should be removed from the patient before entering the magnetic field. MRI compatible infusion pumps should be available wherever anaesthesia is provided regularly. Infusions with extra-long giving sets can be used when MRI-specific pumps are not available.
4. All staff involved with transferring a patient to the MRI scanner should understand the unique problems caused by monitoring and anaesthetic equipment in this environment.44 It is not acceptable for inexperienced staff unfamiliar with the MR environment to escort or manage a patient in this environment, particularly out of hours
5. The patient and all staff should have an MRI safety and exclusion questionnaire completed before entering the magnetic field.
6. In the event of an adverse incident in the MRI scanning room, the patient should be removed from the scanning room without delay; immediate access to an anaesthetic preparation room or resuscitation area is essential

Question 14

Anaesthesia for electroconvulsive therapy

Answer 14

1. Anaesthesia provided for electroconvulsive therapy (ECT) is frequently performed in remote locations. Ideally, a consultant or suitably experienced SAS doctor should provide general anaesthesia; the guidance provided for anaesthetic provision in remote sites should be followed
2. There should be a clinical lead (see glossary) for ECT who is responsible for provision of the service in each anaesthetic department. The named consultant should be responsible for determining the optimal location for provision of anaesthesia for patients of American Society of Anesthesiologists (ASA) Classification III or above. Contingency plans for transfer to an acute care facility should also be in place.45,46
3. Anaesthetists should have specialised knowledge of the effect of concurrent medications, anaesthetic agents and anaesthetic techniques on the conduct and efficacy of ECT, as well as the specific anaesthetic contraindication
4. Standards specific to ECT clinics include a minimum of four rooms: a waiting room, treatment room, recovery area and post ECT waiting area.46 The clinic should have a reliable source of oxygen supplied either by pipeline or cylinder with a reserve supply immediately available.
5. Equipment for managing the airway, including the difficult airway, emergency drugs, resuscitation equipment and a defibrillator should all be available.

Question 15

Anaesthesia for direct current cardioversion

Answer 15

may present as an emergency or be elective cases. The disturbance of physiological rhythm, the reduction in cardiac performance and the risk of embolic phenomena all place these patients at risk of serious complications when undergoing both anaesthesia and DC cardioversion.

1. Precautions prior to embarking on DC cardioversion should include the immediate availability of external pacing equipment.
2. Facilities to check recent serum electrolytes, in particular potassium, and preferably magnesium, as well as the patient’s anticoagulation status and a recent electrocardiogram (ECG) should be available prior to embarking on anaesthesia. A preprocedure echocardiogram is likely to provide useful information
3. The anaesthetist should not be responsible for performing the cardioversion; an appropriately trained physician, cardiologist or supervised nurse specialist is responsible for this role. Wherever possible, the anaesthetic should be administered by an appropriately experienced anaesthetist.

Question 16

Anaesthesia for radiotherapy

Answer 16

to facilitate patient positioning and to alleviate pain. Owing to the unique nature of the procedures involved in radiotherapy, the remoteness of the location and the lack of direct access to the patient, only anaesthetists familiar with the therapy should embark on anaesthesia for these patients

1. Anaesthetists should be familiar with the specific needs of patients with cancer, including the following:
2. the adverse effects of high concentrations of oxygen in the presence of some antineoplastic agents, for example Bleomycin, and adjust their technique accordingly
3. Recent evidence confirms the association between unnecessarily high intraoperative FiO2 and increased risk of major respiratory complications and 30-day mortality. Inspired oxygen levels may require adjustment to maintain an acceptable level of tissue oxygenation
4. the interference of nitrous oxide with vitamin B12 and folate metabolism
5. Patients with tumours of the lower body may be amenable to regional anaesthesia,51 and so equipment and facilities to instigate, monitor and manage regional blockade should be available.

Question 17

General anaesthesia and sedation for dental procedures

Answer 17

General anaesthesia for dentistry should be administered only by anaesthetists in a hospital setting as defined by the Department of Health report reviewing general anaesthesia and conscious sedation in primary dental care

Question 18

Gastrointestinal procedures

Answer 18

safety of patients receiving sedation and anaesthesia outside operating theatres relate to gastrointestinal endoscopy. Despite marked improvements in procedures, this is still a high risk area with problems frequently caused by inadequate oxygenation or ventilation

Anaesthetists are not usually involved in the routine sedation of patients for endoscopy, and non-anaesthetic personnel should follow the guidance on sedation provided by their respective colleges. Anaesthetic involvement may be requested for high risk patients, or complex procedures.

3. The complexity of endoscopic techniques is increasing and patient comorbidities are challenging to operator delivered sedation. Hospitals should have a protocol for the delivery of sedation. Appropriately trained personnel should deliver these techniques and follow locally developed protocols.
4. Anaesthetic staff providing care in the endoscopy suite should be familiar with the facility, equipment and techniques.
5. Protocols should be in place to manage high risk patients, e.g. those with significant gastrointestinal bleeds within an operating theatre, especially out of hours.

Question 19

4. Training and education

Answer 19

All anaesthetists should be fully familiarised with all remote areas of anaesthetic provision, e.g. as part of their induction process, prior to undertaking anaesthetic procedures in that location

This should include familiarisation with the layout of the hospital and the location of emergency equipment and drugs, access to guidelines and protocols, information on how to summon support/assistance, and assurance that the locum is capable of using the equipment in that hospital. All inductions should be documented.

Anaesthetic trainees should have successfully completed the relevant higher units of training.

All anaesthetists with a job plan including sessions in non-theatre anaesthesia should be able to demonstrate continued competency through maintenance of an appropriate level of experience, and ongoing participation in relevant continuing professional development

Difficult tracheal intubation equipment, waveform capnography and training for the management of the emergency airway should be available

Sedation techniques are frequently used in the non-theatre environment along with anaesthetic techniques. Sedation is regarded as a core competency for anaesthetic practice and training/exposure should be provided to current standards at basic, intermediate and higher levels.

Question 20

Organisation and administration

Answer 20

Patient safety is, as always, of paramount importance, and particular attention should be paid to teamwork, communication and the use of checklists when working in less familiar environments. At the team briefing, an explicit plan should be agreed for requesting help if required, recognising the risk of, and preparing adequately for, high blood loss, and life-threatening loss of the airway or respiratory function

Many patients undergoing elective procedures outside the operating theatre can be managed as day cases and should be assessed accordingly in conjunction with local guidelines. More complex patients require assessment to at least the same standard as that required for surgery.

Hospitals should have a system for multidisciplinary involvement in reporting and regular audit of critical incidents and near misses

Environmental hazards such as radiation exposure, magnetic resonance (MR) fields and lack of a scavenging system should be considered by staff before the start of each list. Volatile agent scavenging canisters, air-oxygen mixtures and avoidance of nitrous oxide can mitigate environmental risks. Pregnant personnel may be particularly at risk in these environments and should follow local occupational health policy.

If there is any concern about the safety of the procedure being undertaken at a remote location, for example ECT in a psychiatric hospital, then arrangements should be made to perform the procedure in an operating theatre environmen

Documentation, to the standard used in the operating theatre, should be kept for all cases and this should include the grade and specialty of the doctor performing and supervising the anaesthetic along with the name of the supervising consultant designated to provide direct or indirect advice.19 Access to the electronic patient record should be available at all remote sites.

Patients meeting discharge criteria following anaesthesia or sedation who are to be discharged home should be discharged into the care of a responsible third party. Verbal and written instructions for post-procedural care should be provided if a procedure has been performed.

Question 21

Sedation

Answer 21

Deep sedation equates to anaesthesia and the recommendations outlined

A named anaesthetist should be responsible for liaising with consultants in other departments with responsibility for sedation, to establish local guidelines and training for the provision of safe sedation by non-anaesthetists

Each facility should develop written policies, designating the types of operative, diagnostic and therapeutic procedures requiring anaesthesia or sedation.

Guidelines for the management of rare emergencies must be prominently displayed at all sites where sedation is administered.

Midazolam over sedation during sedation is defined as a ‘never event’ by the Department of Health.

All institutions where sedation is practised should have a sedation committee. This committee should include key clinical teams using procedural sedation and there should be a nominated clinical lead for sedation. In most institutions, the sedation committee should include an anaesthetist, at least in an advisory capacity.

Question 22

7. Research, audit and quality improvement

Answer 22

1. There should be a multidisciplinary programme for auditing anaesthesia and sedation in the non-theatre environment.
2. Audit should be under regular review by a clinical lead and those relating to sedation should be coordinated by a hospital sedation committee.
3. Regular feedback and improvement of standards should be provided to anaesthetic staff
4. Compliance with agreed guidelines should be audited including World Health Organization (WHO) checklists, team brief, and a post anaesthesia discharge checklist

Question 23

9. Patient information

Answer 23

1. All patients (and relatives where appropriate and relevant) should be fully informed about the planned procedure and be encouraged to be active participants in decisions about their care. Recommendations about the provision of information and consent processes outlined in chapter 2 should be followed.
2. Although separate written consent for anaesthesia is not mandatory in the UK, there should be a written record of all discussions with patients undergoing sedation or anaesthesia for diagnostic procedures such as MRI scans about methods of induction, associated risks and side effects.
3. In cases when rolling consent is used, e.g. radiotherapy treatment, appropriate documentation should be kept as part of the patient record, including dates for review of consent. This should be included in the trust’s policy on consent.
4. Information regarding planned procedures outside of the operating theatre and the requirement for sedation or anaesthesia should be given to the patient in advance of their admission. Details on fasting times and medications to continue or omit should be included. The patient needs to be aware that they require a competent adult to escort them home after receiving sedation
5. Information to patients should include what to expect in the anaesthetic room and treatment room
6. Patients from non-English speaking groups may need interpreters. Hospitals should have arrangements in place to provide language support, including interpretation and translation (including sign language and Braille)
7. The relevant mental capacity legislation must be complied with
8. Hospitals should have local policies in place for the identification, support and safeguarding of vulnerable adults

Question 24

Areas for future development

Answer 24

1. A more detailed national audit of critical incidents associated with anaesthesia in the non-theatre environment should be considered.
2. Paediatric surgical techniques and practices are evolving,
   and it is likely that the demand for out of
   theatre surgical procedures and radiological investigations will increase.
3. The use of upright MRI scanners for claustrophobic patients as an alternative to anaesthesia or sedation is available in some hospitals.

Current evidence shows that the image quality is not yet comparable to that of enclosed MRI scanners. However, with further research and improvements this may become a consideration for the future.