Is a solo anesthesia provider inherently unsafe compared to an anesthesia care team in offsite non-Operating Room (OR) settings?

Safety of Solo Anesthesia Provider vs. Anesthesia Care Team in Non-OR Settings

Current guidelines do not provide definitive evidence that a solo anesthesia provider is inherently unsafe compared to an anesthesia care team in offsite non-OR anesthesia settings, provided that proper safety protocols are followed and the provider has appropriate training and experience.

Key Safety Requirements for Solo Anesthesia Providers

Provider Qualifications and Training

• Solo anesthesia providers must undergo specific safety assessments and documented sign-offs before undertaking cases in non-OR settings 1
• Providers must demonstrate documented experience with directly supervised anesthesia in the specific non-OR environment 1
• Knowledge of safety aspects specific to the environment (e.g., MRI safety for magnetic fields) must be demonstrated 1
• Providers must show competence in managing medical emergencies, including cardiac arrest, within the specific non-OR setting 1

Environmental and Procedural Requirements

• An appropriately skilled and trained anesthetic assistant with nationally recognized qualifications must be present when anesthetic intervention is anticipated 1
• Pre-list checks of anesthesia systems, facilities, equipment, supplies, and resuscitation equipment must be performed before each session 1
• All procedures should comply with National Safety Standards for Invasive Procedures and Safe Surgery Checklist protocols 1
• Standards of equipment and monitoring used for non-OR anesthesia should match those applied to in-hospital anesthetic practice 1

Special Considerations for Different Non-OR Settings

MRI Suites

• It is not acceptable for inexperienced staff unfamiliar with the MR environment and safety issues to manage patients in this environment, particularly out-of-hours 1
• Local policies should address supervision requirements, especially for trainees attending to children 1
• Some hospitals may prohibit solo trainee anesthetists from working in MR units 1

Pre-Hospital Emergency Anesthesia

• Pre-hospital emergency anesthesia requires specific training and competencies 1
• Crew resource management techniques are particularly important in pre-hospital environments 1
• In challenging environments, the standards of care described in guidelines remain applicable, but careful consideration must be given to whether PHEA is appropriate if these standards cannot be met 1

Research Evidence on Solo vs. Team Anesthesia

• A 2019 observational study showed that anesthesia care teams (anesthesiologist plus anesthesia nurse) were associated with decreased 30-day postoperative mortality (0.76% vs. 1.56%) and shorter hospital stays compared to solo anesthesiologists 2
• Non-operating room anesthesia (NORA) settings have been associated with higher rates of morbidity and mortality compared to OR settings, with complications often attributable to inadequate oxygenation and preventable adverse events 3
• NORA presents specific challenges including insufficient lighting, noise, cramped workspace, restricted patient access, unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation 3, 4
• However, a 2018 study examining different anesthesia care team compositions found no significant differences in mortality, length of stay, or spending between different team configurations 5

Practical Recommendations

• Local safety assessments and documented sign-offs should be established before allowing solo anesthesia practice in non-OR settings 1
• Appropriate assistance must be available when anesthetic intervention is anticipated 1
• Solo providers must have specific training for the non-OR environment they'll be working in 1
• Regular practice and simulation of emergency scenarios specific to the non-OR environment are essential 1
• The decision to use a solo provider versus a team approach should consider:
  • Provider experience and training 1
  • Complexity of the procedure 1, 3
  • Patient factors (age, comorbidities, ASA status) 3, 2
  • Environmental challenges specific to the non-OR setting 3, 4

Common Pitfalls and Caveats

• Inadequate preparation for emergencies specific to the non-OR environment 1
• Unfamiliarity with specialized equipment in non-OR settings 3, 4
• Insufficient monitoring capabilities compared to traditional OR settings 4, 6
• Reduced situational awareness when concentrating on anesthesia in challenging environments 1
• Lack of clear protocols for obtaining assistance when needed 1