Chapter 7: Guidelines for the Provision of Anaesthesia Services in the Non-theatre Environment 2020
There are increasing numbers of surgical diagnostic and therapeutic procedures performed outside of the main theatre environment. These procedures may require anaesthetic interventions through monitored care, sedation, regional anaesthesia or general anaesthesia. The challenge for anaesthesia is to develop a framework that supports and regulates the safe delivery of care.
Commercial and NHS healthcare providers are expanding non-theatre environments to deliver surgical and diagnostic procedures. The framework guidance should be applied to all non-theatre services delivered that require anaesthetic interventions.
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.
1. Staffing requirements
A clinical lead (see glossary) for anaesthesia in the non-theatre environment (ANTE) should be appointed with adequate time provided within their job plan. They should be involved in developing the service, training and revalidation of staff, and ensuring that safety standards and audit are appropriate.1,2
A dedicated, skilled anaesthetic assistant should be available in all locations outside the operating theatre where anaesthesia is undertaken by an anaesthetist.3
If sedation is administered by an anaesthetist, then a suitably trained individual should be present to assist the anaesthetist.
If sedation is performed without an anaesthetist present, a designated, appropriately trained individual should be responsible for monitoring the patient and keeping records. This should be their sole responsibility1 and should comply with the hospital’s sedation policy.
Patients recovering from anaesthesia or sedation in an isolated unit should receive the same standard of care as that required in an operating theatre post anaesthetic care unit (PACU).4 For major vascular surgery, transfer to the main PACU by appropriately trained personnel may be required.
2. Equipment, services and facilities
Access to lifts for easy trolley transfer should be available.
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.
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.9
The procedure room should be easily accessible to the resuscitation team and large enough to accommodate them and appropriate equipment if required.
It should also be possible to arrange transfer of a patient from the procedure room to other areas within the institution if necessary.
A PACU or equivalent should be available for each patient at the end of the procedure.
Facilities to allow access to online information, such as electronic patient records, local guidelines and clinical decision aids, should be available.
All patient trolleys should be capable of being tipped into the head-down position and be easily transferrable to the rest of the hospital.19
Equipment for monitoring should be available at all sites where patients receive anaesthesia or sedation.10 For patients receiving conscious sedation, this should include pulse oximetry.
Continuous waveform capnography should be available for all patients undergoing general anaesthesia and moderate or deep sedation.10,11
The anaesthetist should ensure that an adequate supply of oxygen is available before starting any procedure. Many of the sites where anaesthesia is provided outside the main operating theatres do not have piped oxygen; if anaesthesia is provided frequently in such a location, the use of the location should be reviewed or piped oxygen provided.
Where piped oxygen is available, back-up cylinders should always be available and appropriately stored.
All anaesthetic equipment should be standardised where possible in all areas providing anaesthetic services, including equipment for resuscitation and life support, and such equipment subject to a standardised programme of maintenance.
All staff should be provided with opportunities to familiarise themselves with all equipment by way of documented formal training sessions.
All anaesthetic equipment should be checked before use in accordance with the Association of Anaesthetists published guidelines.12 Anaesthetic machine checks should be recorded in a log and on the anaesthetic chart.
All procedures should be compliant with National Safety Standards for Invasive Procedures (NatSSIPs) and the Safe Surgery Checklist.13,14 An appropriate ‘pre list check’ of the anaesthesia systems, facilities, equipment, supplies and resuscitation equipment should be performed prior to the start of each list.
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.
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.
The anaesthetist should consider all environmental factors when planning administration of anaesthesia or sedation.
When rooms are darkened hindering direct observation of the patient, availability of an alternative light source to record notes and observe the patient should be considered.
Appropriate equipment should be available to minimise heat loss by the patient and to provide active warming.
Patients should be appropriately monitored during their recovery.24
The care of the patient remains the responsibility of the anaesthetist up to discharge for ambulatory procedures or ward transfer for inpatient procedures.
3. Areas of special requirement
Children presenting for anaesthesia outside the operating room may present challenges relating to the procedure, the environment, or physical, physiological and psychological challenges. Children may often require repeat treatments or investigations. Minor procedures and diagnostic tests may be performed with sedation techniques.
Each facility should develop written policies, designating the types of paediatric operative, diagnostic and therapeutic procedures requiring anaesthesia.
The paediatric anaesthetist should consider the patient age, physical capacity, complexity of the procedure and the status of the surgical facility before administering anaesthesia.
The standard of care provided to children during sedation or anaesthesia outside of theatre should be delivered to the same standards of care as applied to procedures performed in theatre.27
Equipment available in remote sites should mirror equipment available in the main paediatric facility.
Guidance for paediatric sedation should be developed for the local context, by a multidisciplinary team.27
Paediatric sedation should be managed in accordance with recognised national guidelines.29
The emergency department
Patients requiring anaesthesia in the emergency department (ED) are frequently critically ill or injured. Their physiological derangement and sensitivity to anaesthetic agents, coupled with the potential for increased difficulty in tracheal intubation, requires the presence of an anaesthetist competent to manage these challenges in a timely and effective manner.30
The safe management of unstable patients depends on close liaison between emergency physicians and anaesthetists,32,33 to ensure that clear guidelines are in place, emergency department support staff are trained to assist with tracheal intubation, and audit and discussion of complications is undertaken regularly.
Emergency airway management in the ED should follow the joint guidance from the RCoA and Royal College of Emergency Medicine (RCEM).33
Transfer of patients within the hospital to the intensive care unit (ICU), radiology or the operating theatre is not without risk and will require the use of a tipping transfer trolley, oxygen cylinders, suction, a transport ventilator, infusion pumps, monitor with adequate battery life and a portable defibrillator if appropriate. Local guidelines along with use of a formal intra-hospital transfer form should be considered to mitigate procedure specific issues.
Procedural sedation and analgesia in the ED should follow the recommendations from the RCoA and the RCEM.36
The radiology department
The frequency with which complex procedures are carried out in the radiology department is increasing. Patients requiring general anaesthesia in the radiology department may have life-threatening conditions. The radiology department represents a more challenging environment in which to provide anaesthesia compared with an operating theatre.2
Exposure to ionising radiation should be kept to a minimum by the use of screens or lead gowns; remote slave monitors in screened viewing areas should be provided and staff should remain as distant from the imaging source as possible if they must remain in the x-ray environment.37
The anaesthetist accompanying transferred patients from the ED should be suitably skilled and experienced to manage all eventualities in an isolated environment and should be accompanied by a dedicated trained assistant.38
As not all radiology tables tilt into a head down position, a tipping trolley should be available for patients who require general anaesthesia.
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.39 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.
The hospital’s protocol for major haemorrhage should be available and periodically rehearsed.
Magnetic resonance imaging
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.
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.42
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.43 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.41
The patient and all staff should have an MRI safety and exclusion questionnaire completed before entering the magnetic field.
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.2
Anaesthesia for electroconvulsive therapy
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.44
The ECT clinic should adhere to the ECT Accreditation Service (ECTAS) or Scottish ECT Accreditation Network (SEAN) standards for administration of ECT and have been assessed and accredited by ECTAS or SEAN.
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.44,45
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 contraindications.44
Standards specific to ECT clinics include a minimum of four rooms: a waiting room, treatment room, recovery area and post ECT waiting area.45 The clinic should have a reliable source of oxygen supplied either by pipeline or cylinder with a reserve supply immediately available.
Equipment for managing the airway, including the difficult airway, emergency drugs, resuscitation equipment and defibrillator should all be available.
Standards for monitoring and recovery are stipulated by the Association of Anaesthetists and should be adhered to for all ECT cases.10
Anaesthesia for direct current cardioversion
Patients requiring direct current (DC) cardioversion 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.
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.47
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.32
Anaesthesia for radiotherapy
Anaesthesia may be required for radiotherapy, 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.46,48 The anaesthetic should be provided by an appropriately experienced anaesthetist.
Anaesthetists should be familiar with the specific needs of patients with cancer, including the following:
- the adverse effects of high concentrations of oxygen in the presence of some antineoplastic agents, for example Bleomycin, and adjust their technique accordingly.49,50 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 oxygenation50
- the interference of nitrous oxide with vitamin B12 and folate metabolism.
Patients with tumours of the lower body may be amenable to regional anaesthesia,49 and so equipment and facilities to instigate, monitor and manage regional blockade should be available.
General anaesthesia and sedation for dental procedures
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.52
Guidelines including those published by the Association of Paediatric Anaesthetists of Great Britain and Ireland for the management of children referred for dental extractions under general anaesthesia should be followed.53
Many of the initial concerns relating to the 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.
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.
Anaesthetic staff providing care in the endoscopy suite should be familiar with the facility, equipment and techniques.
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.
4. Training and education
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.54 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.58
Hospitals should consider involving an anaesthetist in the training of non-anaesthetists in the provision of safe sedation.
5. Organisation and administration
Organisation and administration
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 getting help if needed, recognising the risk of, and preparing adequately for, high blood loss, and life-threatening loss of the airway or respiratory function.59
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.
In remote off site locations, such as psychiatric hospitals where anaesthesia is provided for ECT, advanced plans should be made to manage patient transfer if required.
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 environment.
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.
The department of anaesthesia should be involved in the design and planning of any service requiring the provision of anaesthesia or deep sedation.61
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.64
The RCoA recognises the definitions of minimal, moderate and deep sedation as outlined in the Academy of Medical Royal Colleges’ guidance on safe sedation.1 Deep sedation equates to anaesthesia and the recommendations outlined in chapters 2-5 should be followed.
The RCoA does not provide recommendations for sedation given by non-anaesthetists and they are encouraged to follow the guidance of their own College’s and the Academy of Medical Royal Colleges.
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.63 Hospitals should report these incidents to the National Reporting and Learning System.
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.
6. Financial considerations
Part of the methodology used in this chapter in making recommendations 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, but 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.
7. Research, audit and quality improvement
There should be a multidisciplinary programme for auditing anaesthesia and sedation in the non-theatre environment.
Audit should be under regular review by a clinical lead and those relating to sedation should be coordinated by a hospital sedation committee.
Regular feedback and improvement of standards should be provided to anaesthetic staff.
Compliance with agreed guidelines should be audited including World Health Organization (WHO) checklists, team brief, and a post anaesthesia discharge checklist.
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. Recommendations about the provision of information and consent processes outlined in chapter 2 should be followed.64
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.
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.1
Information to patients should include what to expect in the anaesthetic room and treatment room.65
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.66 Patients with learning and other difficulties may need special assistance and consideration.
Hospitals should have local policies in place for the identification, support and safeguarding of vulnerable adults.70
Areas for future development
- A more detailed national audit of critical incidents associated with anaesthesia in the non-theatre environment should be considered.
- 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.
- 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.
Clinical lead – 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
Deep sedation – Describes a state where the patient cannot easily be roused but responds purposefully to repeated or painful stimulation. It may be accompanied by clinically significant ventilatory depression. The patient may require assistance maintaining a patent airway, and positive pressure ventilation.
Immediately – Unless otherwise defined, ‘immediately’ means within five minutes.
Minimal sedation – Is a drug-induced state during which the patient responds normally to verbal commands. Cognitive function and physical coordination may be impaired, but airway reflexes, and ventilatory and cardiovascular functions are unaffected.
Moderate sedation – Describes a state where a purposeful response to verbal commands either alone (~ conscious sedation), or accompanied by light tactile stimulation, is maintained.
MR compatible – Equipment that is designated as MR compatible is MR safe, functions normally in the MR environment, and does not interfere with the correct operation of the MR imaging equipment providing instructions concerning its proper use are correctly followed.