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How About the Elective Non-Operating Room Anesthesia (NORA) Procedures?  Are the NORA Post COVID rules different than the OR?

Posted by Joshua Miller on May 18, 2020 11:00:00 AM
Joshua Miller

Over the past ten weeks hospitals, ASCs, and physician offices have seen a decline in physical patient visit volume between 50-90%. There has been a virtual standstill of elective OR surgery as well as procedures in endoscopy, cardiology, and interventional radiology suites.

Hospitals and ASCs are developing intricate plans and checklists for resumption of elective surgeries. (Click here for a blog on our protocol checklist.) There are numerous checklists for safe post-COVID surgical care, and we will see a gradual return of elective surgical volume, although for many reasons the rate of return will not equal the previous rate of decline.

What about elective procedures not requiring the OR? For example: pain management intraspinal blocks, endoscopy, or oral surgery. NORA procedures carry different patient and provider risks depending on the patient’s underlying health issues, the nature of the procedure, the anesthesiology requirements, and the physical location of the procedure.

These procedures often are high volume and short duration.  It is not unusual for a busy endoscopy suite to schedule 25-50 patients a day.  The COVID checklists for NORA look similar to checklists for elective OR procedures with unique patient action to enhance rapid throughput. Minimal pre-anesthesiology waiting in the facility utilizing cell phone contact to decrease the number of patients in holding rooms. Routine checklist items would include point of care COVID testing, temperature, and oxygen saturation before the patient enters the facility day of procedure. PPE for patients entering the facility is necessary as there is a small, but real number of asymptomatic, false negative patients who could shed virus and close a facility. The family members should be instructed to wait outside the facility. 

An ASC or hospital physician operations committee will be useful in deciding the timing, case type, and pace of return for facility elective NORA procedures. For example, a gastroenterologist would be comfortable performing a routine upper endoscopy in the endo suite for a patient with reflux. The ASC or hospital committee may see this differently as the patient may require general anesthesia and endotracheal intubation, which produces aerosolized oral secretions for 15-30 minutes post intubation. In addition, the endo suite may not be equipped with negative pressure procedure rooms (traditional ORs have sophisticated air exchange systems and capability to generate positive or negative pressure). Compare this with an ASC where pain management spinal blocks are performed. The patient receives local anesthesia (a little lidocaine in the skin), no sedation, and the procedure is performed through a needle. Risk of a patient transmitting COVID from the procedure would appear to be much smaller in this latter example.

This illustrates the complex issues hospital and ASC leaders are navigating in real time. Surgical Directions can help you navigate these issues. We have spent 25 years in over 400 hospitals, ASCs and healthcare systems improving efficiency, productivity, and quality. We are clinical professionals with decades of experience in patient care and health system leadership. We use advanced predictive analytics to mesh clinical results with business results. We understand your issues and are ready to assist with solutions. Please contact me, Josh Miller, at jmiller@surgicaldirections.com if you have any questions.


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Tags: Anesthesia, OR Schedule, Ambulatory Surgery, Surgical Volume, Ambulatory Surgery Center, Healthcare, COVID-19, Operations, NORA

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