Chapter 3: Guidelines for the Provision of Anaesthesia Services for Intraoperative Care 2019
All patients who undergo anaesthesia or sedation are at risk of intraoperative complications during induction, maintenance, and emergence from anaesthesia, including compromise to the airway, breathing and circulation. When considering the provision of anaesthetic services in all locations in which an anaesthetist provides care to patients undergoing elective or emergency procedures, the Royal College of Anaesthetists recommends that specific areas of clinical and non-clinical care should be addressed to reduce complications and harm, improve outcomes and promote patient wellbeing. These areas include appropriate staffing, equipment, services and facilities; training and education; research and quality improvement; financial management and appropriate organisation and administration.
The effects of anaesthesia, and of the surgical procedure itself, can have profound physiological consequences for the patient and so always requires monitoring and constant attention throughout anaesthesia. The continuous presence of an appropriately trained and experienced anaesthetist, or Anaesthesia Associates (AAs), is essential for patient safety during anaesthesia, along with the help of competent dedicated anaesthetic assistance at all times. Sufficient rest breaks for staff are also vital for patient safety. The skill mix of the anaesthetist should match the case mix of the operating list, with adequate support for doctors in training.
Availability of equipment, support services and other facilities need to be as per the recommended standards in this document to minimise the risks to the patient posed by anaesthesia. Monitoring needs to comply with the minimum monitoring standards, and additional monitoring should be available as required. Reliable medicine-management systems should be in place, and appropriate safety measures should be taken to minimise errors.
Anaesthetists are an essential part of the theatre team. Optimum organisation is described in the ‘Preoperative Preparation’ module of the NHS Institute for Innovation and Improvement ‘Productive Operating Theatre’ tool. This toolkit has been designed to help theatre teams work together more effectively, and to improve the quality of patient experience, the safety and outcomes of surgical services, the effective use of theatre time, and overall staff experience. If appropriate resources are not available, the level of clinical activity should be limited to ensure safe provision of intraoperative care.
Ultimately, the goal of these guidelines is to ensure a comprehensive, quality service dedicated to the care and wellbeing of patients at all times, and to the education and professional development of staff.
1. Staffing requirements
The outcomes for patients undergoing elective surgery are largely dependent on the complexity of the procedure and the associated comorbidities of the patient. Nevertheless appropriate staffing to match the skill mix to the case mix is crucial.
In exceptional circumstances, anaesthetists working singlehandedly may be called on briefly to assist with or perform a life saving procedure nearby. This is a matter for individual judgement and the dedicated anaesthetic assistant should be present to monitor the unattended patient.4
Anaesthesia departments should have a nominated anaesthetist immediately available to provide cover in clinical emergencies, as well as advice and support to other anaesthetists.5
The Anaesthesia Associates (AAs) should work at all times within an anaesthesia team led by a consultant anaesthetist who has overall responsibility for anaesthesia care of the patient and whose name should be recorded in the individual patient’s medical notes.3
The consultant anaesthetist should be easily contactable, and should be available to attend within two minutes of being requested by the AAs.3
The supervising consultant anaesthetist should not be responsible for more than two anaesthetised patients simultaneously, where one involves supervision of a AAs.3
The RCoA and Association of Anaesthetists currently do not support enhanced roles for AAs until the statutory regulation for AAs is in place. Where such role enhancement exists or is proposed, responsibility should be defined by local governance arrangements.3
Clinical governance of AAs should follow the same principles as applied to medically qualified staff. This should include training that is appropriately focused and resourced, supervision and support in keeping with practitioners’ needs and practice responsibilities, and practice centred audit and review processes.
There should be a dedicated trained assistant, i.e. an operating department practitioner (ODP) or equivalent, who holds a valid registration with the appropriate regulatory body, immediately available in every location in which anaesthesia care is being delivered, whether this is by an anaesthetist or a AAs.3,5
Staff assigned to the role of anaesthetic assistant should not have any other duties that would prevent them from providing dedicated assistance to the anaesthetist during anaesthesia.5
2. Equipment, services and facilities
The operating theatre, and anaesthetic room where available, should conform to Department of Health building standards and be appropriately maintained.7
There should be provision of an emergency call system, including an audible alarm.7 A visible indication of where the emergency is should also be considered.
The geographical arrangement of theatres, emergency departments, critical care units, cardiac care, interventional radiology and imaging facilities should allow for the rapid transfer of critically ill patients.7
Anaesthetic sites must have scavenging systems that meet the Health and Safety Executive’s occupational exposure standards for anaesthetic agents.8
Appropriate blood storage facilities should be in close proximity to the operating theatre and clearly identifiable.7
Transport and distribution of blood and blood components at all stages of the transfusion chain must be under conditions that maintain the integrity of the product.9
Facilities to allow access to online information, such as electronic patient records, local guidelines and clinical decision aids, in the theatre suite should be considered.
Access to theatres and associated clinical areas should be appropriately restricted.7
Services should be available for:
- blood transfusion
- clinical pathology
Near patient testing for blood sugar should be readily available for theatres.
Near patient testing for haemoglobin, blood gases, lactate, ketones and coagulation should be considered, particularly in areas where major blood loss is likely.16 If near patient testing is not available, laboratory testing should be readily and promptly available.
The separation of clinical and non-clinical recyclable waste should be considered.21
The following ancillary anaesthetic equipment is required for the safe delivery of anaesthesia, and should also be available at all sites where patients are anaesthetised:
- oxygen supply
- self-inflating bag
- airways (nasopharyngeal and oropharyngeal)
- laryngoscopes including videolaryngoscopes and fibreoptic scopes as clinically required
- appropriate range of tracheal tubes and connectors
- intubation aids (bougies, forceps, etc)
- supraglottic airways
- heat and moisture exchange filters
- defibrillators and equipment for external cardiac pacing23
- trolley/bed/operating table that can be tilted head down rapidly
- positioning equipment24 (stirrups for lithotomy, arm boards, head rest for prone positions, bariatric supports etc)
- ultrasound imaging equipment for vascular access
- equipment for administering a volatile free anaesthetic, including infusion pumps or volatile free anaesthetic machine and/or activated charcoal filters
- adequate numbers and types of infusion pumps and syringe drivers available for high risk medicines.25
Anaesthetic machines should never be able to supply a hypoxic gas mixture.26
Appropriate equipment should be available to minimise heat loss by the patient and to provide active warming.30
A fluid warmer, allowing the warmed transfusion of blood products and intravenous fluids, should be available.31
A rapid infusion device should be available for the management of major haemorrhage.
Equipment for placement and monitoring of local and regional blocks should be available where necessary.
All anaesthetic equipment should be checked before use in accordance with the Association of Anaesthetists published guidelines.32 Anaesthetic machine checks should be recorded in a log and on the anaesthetic chart.
A named anaesthetist should oversee the provision and management of anaesthetic equipment.33
All anaesthetists and anaesthetic assistants should receive systematic training in the use of new equipment. This should be documented.33
User manuals should be available as needed for anaesthetic equipment.33
The recommended standards of monitoring, by instrument or otherwise, should be met for every patient.4
The following equipment should be available:4
- oxygen analyser
- device to display airway pressure whenever positive pressure ventilation is used, with alarms that warn if the pressure is too high or too low
- vapour analyser whenever a volatile anaesthetic agent is in use
- pulse oximeter
- non-invasive blood pressure monitor
- a means of measuring the patient’s temperature
- a nerve stimulator when a neuromuscular blocking drug is used.
All monitors should be fitted with audible alarms.4
Robust systems should be in place to ensure reliable medicines management, including storage facilities, stock review, supply, expiry checks, and access to appropriately trained pharmacy staff to manage any drug shortages.36
All local anaesthetic solutions should be stored separately from intravenous infusion solutions, to reduce the risk of accidental intravenous administration of such drugs.41
All drug containing infusions and syringes should be clearly labelled.42
3. Areas of special requirement
Recommendations on the provision of anaesthesia services for children are comprehensively described in chapter 10.
Recommendations on the provision of anaesthesia services for the obstetric population are comprehensively described in chapter 9.
Non-peripartum pregnant patients
A policy should be in place for the management of non-peripartum pregnant patients. This should detail the involvement of the multidisciplinary obstetric team, including midwives, neonatologists and obstetricians, depending on gestational stage.43
Frail older patients
With the change in population demographics, a larger number of elderly patients require operative procedures. In older patients, a decreased physiological reserve, cognitive decline, higher incidence of comorbidities and of multiple comorbidities, polypharmacy, and frailty add to the complexity of decision making and medical management. Poor cognition, hearing and eyesight may make communication difficult. Older patients are at a relatively higher risk of mortality and morbidity after elective and emergency surgery.
Multidisciplinary care improves outcomes. Protocol driven integrated pathways guide care effectively, but should be individualised to suit each patient, with emphasis on management of postoperative pain and avoidance of postoperative delirium.44
Morbidly obese patients
Obesity is an increasingly significant health issue in the UK, with 25% of the population classed as obese, and more than 3% as Class 3 obese (previously termed morbid obesity).45
Every hospital should nominate an anaesthetic lead for obese patients undergoing surgery.45
Medical records should include patients’ weight and body mass index.45
The safe movement and positioning of obese patients may require additional staff and specialised equipment. An operating table, hoists, beds, positioning aids and transfer equipment appropriate for the care of obese patients should be available, and staff should be trained in its use.45 Additional members of staff should be available where necessary, and manual handling should be minimised where possible.
Specialist positioning equipment for the induction of anaesthesia and intubation in the morbidly obese should be available.45
There should be a policy for the clinical and technical management of the obese patient.45
Critically ill patients
This guideline relates only to critically ill patients undergoing procedures in theatre. General provision of critical care is outside the scope of this document. Further information can be found in the Faculty of Intensive Care Medicine and Intensive Care Society publication, ‘Guidelines for the Provision of Intensive Care Services.
Critically ill patients coming to theatre should have access to ongoing organ support.46
Diabetes affects 10–15% of the surgical population, and patients with diabetes undergoing surgery have greater complication rates, mortality rates and length of hospital stay. Modern management of the surgical patient with diabetes focuses on:47
- thorough preoperative assessment and optimisation of their diabetes in a multiprofessional team
- deciding if the patient can be managed by simple manipulation of pre-existing treatment during a short starvation period (maximum of one missed meal) rather than use of a variable rate intravenous insulin infusion
- safe use of the latter when it is the only option.
Consideration should be given to scheduling patients with diabetes at the start of the theatre list, to minimise disruption to the patient’s glycaemic control.
Hospitals should provide the services and resources required for the management of the surgical patient with diabetes, including explicit managerial and clinical policies.47
Hospitals should consider appointing a lead anaesthetist for diabetes.
Hospitals should have clinical guidelines, including:47
- involving patients in the management of their own diabetes
- ensuring that surgical patients with diabetes have an individualised explicit plan for managing their diabetes during the periods of starvation and surgical stress; this may require the involvement of senior anaesthetic staff and the availability of equipment to continue or institute variable-rate intravenous insulin infusions
- ensuring the prevention, and prompt recognition and treatment of hypo and hyperglycaemia, and hospital acquired diabetic ketoacidosis
- recognising that the surgical patient with diabetes is at additional risk of pressure ulcers and having policies to prevent these.
4. Training and education
Trusts should commit themselves to provide the time and resources to educate those who provide intraoperative care for patients.2
Theatre teams should undergo regular, multidisciplinary training that promotes teamwork, with a focus on human factors, effective communication and openness.2
All staff should have access to adequate time, funding and facilities to undertake and update training that is relevant to their clinical practice, including annual mandatory training such as basic life support.2
All members of the anaesthetic team should receive non-clinical training and education, which should be reflected in job plans and job planning. This might include a locally arranged list of topics – for example, fire safety, consent, infection control, blood product administration, mental capacity, safeguarding children and vulnerable adults, communication skills. Some of this will be mandatory under the legislation for health and safety at work.48,49
All trainees must be appropriately clinically supervised at all times.50
All patients undergoing anaesthesia should be under the care of a consultant anaesthetist whose name is recorded as part of the anaesthetic record. A staff grade, associate specialist and specialty doctors (SAS) anaesthetist could be the named anaesthetist on the anaesthetic record if local governance arrangements have agreed in advance that, based on the training and experience of the individual doctor and the range and scope of their clinical practice, the SAS anaesthetist can take responsibility for patients themselves in those circumstances, without consultant supervision.51
Departments of anaesthesia should ensure that a named supervisory consultant is available to all non-consultant anaesthetists (except those SAS anaesthetists that local governance arrangements have agreed in advance are able to work in those circumstances without consultant supervision) based on the training and experience of the individual doctor and the range and scope of their clinical practice.51 Where an anaesthetist is supervised by a consultant, they should be aware of their supervisor’s identity, location and how to contact them.
There should be induction programmes for all new members of staff, including locums. Induction for a locum doctor 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.
5. Organisation and administration
Optimum organisation is described in the ‘preoperative preparation’ module of the NHS Institute for Innovation and Improvement’s ‘Productive Operating Theatre’ tool. This toolkit has been designed to help theatre teams work together more effectively to improve the quality of the patient experience, the safety and outcomes of surgical services, the effective use of theatre time and staff experience.52
If appropriate resources are not available, the level of clinical activity should be limited to ensure safe provision of intraoperative care.53
The theatre team should all engage in the use of the WHO surgical safety process,53,54 commencing with a team brief, and concluding the list with a team debrief. Debrief should highlight things done well and also identify areas requiring improvement. Teams should consider including the declaration of emergency call procedures specific to the location as part of the team brief.
Up to date, clear and complete information about operating lists should be available to the preoperative area, theatre and recovery area.
The language in all communications relating to the scheduling and listing of procedures should be unambiguous. Laterality should always be written in full, i.e. ‘left’ or ‘right’.2
Any changes to the list should be agreed by all relevant parties, to ensure that the correct operation is performed on the correct side (if relevant) of the correct patient. List amendments should be clear and unambiguous. The list should be rewritten or reprinted, including the date and time of the update.
All anaesthetic records should contain the relevant portion of the recommended anaesthetic data set for every anaesthetic and be kept as a permanent document in the patient’s medical record.55
Organisation strategy and organisational culture
Hospitals should have a clear and explicit strategy for developing a strong safety culture that includes the following characteristics: recognition of the inevitability of errors, commitment to discuss and learn from errors, proactive identification of latent threats, and the incorporation of non-punitive systems for reporting and analysing adverse events.56,57
Hospitals should review their local standards to ensure that they are harmonised with the relevant national safety standards, e.g. National Safety Standards for Invasive Procedures in England or the Scottish Patient Safety Programme in Scotland.58 Organisational leaders are ultimately responsible for implementing local safety standards as necessary.2
The organisation should ensure that patient safety concerns are addressed and that the recommendations or changes that result are fed back to procedural teams.2
Medical leadership structure
There should be clarity of leadership and roles in the supervision of the day to day running of theatres.
Day to day management of workload
Elective theatres should offer spare capacity (such as that resulting from cancellations) to the emergency theatres.65 Elective cases may be cancelled to make way for emergency work if required.
When members of the healthcare team are involved in a critical incident, the personal impact on individual team members can be significant.56 A team debriefing should take place after a significant critical incident. Critical incident stress debriefing by trained facilitators, with further psychological support, may assist individuals to recover from a traumatic event.66 After a significant critical incident, the clinical director should review the immediate clinical commitments of the staff concerned promptly.
Hospitals should have local guidelines for when a patient dies in theatre or recovery. This should include arrangements to maintain dignity for the patient and to give relatives the best support possible. It should also include arrangements to minimise the impact on other patients being treated in the theatre complex.66
Appropriate clinical policies, checklists and standard operating procedures for operating theatres should be in place.
The following policies should be immediately and reliably available at sites where anaesthesia and sedation are provided:
The following policies should be held and easily accessible for:
- WHO checklist, including time out53
- ‘Stop Before You Block’71
- ‘Do not attempt cardiopulmonary resuscitation’72
- death in theatre66
- major incident
- infection control (including antibiotic prophylaxis, staff protection and post exposure prophylaxis)19
- prevention of hypothermia30
- management of the obese patient45
- management of the older patient44
- major haemorrhage73
- blood and blood products administration74,75,76
- thromboprophylaxis (including management of patients receiving any anticoagulant therapy)77,78,79
- diabetes management47
- handover and continuity of clinical care57
- medicines management
- local anaesthetic toxicity.
Access to paperless guidelines through a readily available hospital intranet repository is encouraged.
Further recommendations on handover are included in chapter 4.
Handover, including on moving to the postoperative care environment or to the intensive care unit, should always be to a member of staff who is competent to look after the patient at that time, and this should be clearly documented.81
Handover should be structured to ensure continuity of care.57
A system for reporting and regular audit of critical incidents and near misses is an essential part of a well-led safety structure, and there should be multiprofessional involvement in this. The methodology must be explicit and identify underlying relevant factors to inform learning and development of safe systems. All staff must recognise the duty of candour and foster a culture for reporting incidents and concerns.2,50,82
All critical incidents should be reported.83
Hospitals should have systems in place to facilitate multidisciplinary Morbidity and Mortality meetings.
6. Financial considerations
Part of the methodology used for making recommendations in the chapter is a consideration of the financial impact for each of the recommendations. Very few of the literature sources from which these recommendations have been drawn have included financial analysis.
The vast majority of the recommendations are not new recommendations; rather they are a synthesis of already existing recommendations. The current compliance rates with many of the recommendations are unknown, and so it is not possible to calculate the financial impact of the recommendations in this chapter being widely accepted into future practice. It is impossible to make an overall assessment of the financial impact of these recommendations with the currently available information.
The current tariffs for some of the complex major surgical procedures, particularly those done in tertiary referral centres, do not reflect the true cost incurred. Under the circumstances, the utilisation of theatre time and theatre efficiency will come under the spotlight to balance the expenses incurred versus the revenue generated.
The use of electronic health records, with their precise documentation of start times, finish times and the ability to differentiate the time taken to set the patient up for surgery versus the actual duration of the surgical procedure means that intraoperative anaesthetic practice will come under close scrutiny. As the implementation of electronic health records diffuses across the health service it is vital that anaesthetists engage with the design and standardise documentation to ensure that the data collected is valid and can be meaningfully used to generate information contributing to theatre utilisation and efficiency, and in the future to national data sets.
7. Research, audit and quality improvement
There should be a multidisciplinary programme for auditing intraoperative care.
There should be a system in place to allow reporting and regular audit of critical incidents and near misses.
Anaesthetists should be involved in audit and quality improvement cycles, preferably using a ‘rapid cycle’ quality improvement approach. This approach benchmarks standards of care, and may be an effective change driver. It is also an excellent way of providing evidence of good practice as defined by the GMC, and mapping the contribution that individuals make to any service within their hospitals.85
8. Implementation support
The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, aims to provide support for departments of anaesthesia to implement the recommendations contained in the GPAS chapters. The scheme provides a set of standards, and asks departments of anaesthesia to benchmark themselves against these using a self-assessment form available on the RCoA website. Every standard in ACSA is based on recommendation(s) contained in GPAS. The ACSA standards are reviewed annually and republished approximately four months after GPAS review and republication to ensure that they reflect current GPAS recommendations. ACSA standards include links to the relevant GPAS recommendations so that departments can refer to them while working through their gap analyses.
Departments of anaesthesia can subscribe to the ACSA process on payment of an appropriate fee. Once subscribed, they are provided with a ‘College guide’ (a member of the RCoA working group that oversees the process), or an experienced reviewer to assist them with identifying actions required to meet the standards. Departments must demonstrate adherence to all ‘priority one’ standards listed in the standards document to receive accreditation from the RCoA. This is confirmed during a visit to the department by a group of four ACSA reviewers (two clinical reviewers, a lay reviewer and an administrator), who submit a report back to the ACSA committee.
The ACSA committee has committed to building a ‘good practice library’, which will be used to collect and share documentation such as policies and checklists, as well as case studies of how departments have overcome barriers to implementation of the standards, or have implemented the standards in innovative ways.
One of the outcomes of the ACSA process is to test the standards (and by doing so to test the GPAS recommendations) to ensure that they can be implemented by departments of anaesthesia and to consider any difficulties that may result from implementation. The ACSA committee has committed to measuring and reporting feedback of this type from departments engaging in the scheme back to the CDGs updating the guidance via the GPAS technical team.
9. Patient information
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. Detailed recommendations about the provision of information and consent processes are contained in the chapter 2.
Information to patients should include what to expect in the anaesthetic room and operating theatre.86
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).This information should comply with the NHS England ‘Accessible information Standard’.87 Patients with learning and other difficulties may need special assistance and consideration.
The Mental Capacity Act 2005 must be complied with.88 Staff should have regular training in the application of the Mental Capacity Act 2005 and have defined access to patient advocates. This is a rapidly changing area, and clinicians should have access to expert advice.
Hospitals must have local policies in place for the identification, support and safeguarding of vulnerable adults.60
Hospitals should have policies to support patients and staff of diverse religious beliefs and cultural backgrounds.60
Areas for future development
Following the systematic review of the evidence, the following areas of research are suggested:
- utility of anaesthetic rooms
- utility of multimodal monitoring, including haemodynamic and EEG depth of anaesthesia monitoring on outcomes
- use of ethnographers in theatre to develop an understanding of why certain bundles/checklists work
- long-term follow up of intraoperative complications
- the logistics of matching complexities of surgical procedure and skills of anaesthetists, particularly as subspecialty expertise develops.
- there is significant association between poor quality of communication in the team reported during robotic surgery and poor outcome.89 Strategies to improve communication in high complexity environments including robotic surgery are recommended for study.
Clinical lead - Staff grade, associate specialist and specialty (SAS) doctors undertaking lead roles should be autonomously practicing doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues. They should usually have experience in teaching and education relevant to the role and they should participate in quality improvement and CPD activities. Individuals should be fully supported by their clinical director and be provided with adequate time and resources to allow them to effectively undertake the lead role.