VIEWPOINT Thoughts and reflections on issues of interest to perioperative practitioners KEYWORDS Anaesthetic room Provenance and Peer review: Commissioned, Not peer reviewed; Accepted for publication January 2013.
Anaesthetic rooms.
Do we actually need them? It’s funny what an impact an innocent remark or observation made by someone can have. I have a number of sayings that I use to illustrate things in everyday life as well as in nursing and education. I also find that I tend to use these aphorisms increasingly with, shall we just say, maturity. It was one such throwaway remark a while back from a practitioner colleague who works in anaesthesia. I had been undertaking my ‘Cook’s Tour’ with a group of student nurses on the first day of their theatre placement. I try to show them all three areas of perioperative practice when it is possible to do so starting with the first part of the process, anaesthesia. It was at this time that my colleague remarked “I don’t know why we bother with anaesthetic rooms”. This colleague is a dyed-in-the-wool theatre practitioner and not someone prone to coming out with ill-considered statements and, coming from a background in anaesthetics, I was surprised by his comment. It is not something I would have gone around saying myself as it is not my background and I wouldn’t want to cause discord. We carried on the conversation for a bit and continued to find ourselves in agreement. I first started thinking about this many years ago when visiting a hospital in Boston, Massachusetts where I noticed that anaesthetic rooms did not exist. I later spoke to a British anaesthetist friend and colleague (the two are not always synonymous) who told me about his time spent at a different hospital in that same city. He described having to be in the operating room (OR) at 7am so that he could get all he needed ready for the day’s list. This was because he had no assistance and had to get everything he needed ready for himself and check the equipment required for the session including the anaesthetic machine and the monitoring equipment as well as drawing up of the drugs required. The list often started at 7.30am (remember this is the American healthcare system and OR time is money). When the patient arrived and after all the preoperative checks had been carried out, the patient was transferred onto the operating table in the operating room. When the anaesthesiologist (as he became in the USA) required some assistance to put in the IV cannula or tie in the endotracheal tube he simply asked one of the OR nurses present to help. So with no anaesthetic room there is no need for the transfer of the patient and no need to disconnect the patient from
the anaesthetic machine or gather up the IV infusion, urinary catheter or monitoring lines. To the risk adverse US healthcare system this transfer between one room and another comes with an unacceptable risk; here in the UK the patient is unlikely to be monitored during the transfer so that any hypoxia or cardiac arrhythmia would not be recognised until the patient was reconnected to the monitoring equipment in the theatre/operating room. So why do we have anaesthetic rooms in the UK? Well I am not sure that anyone really knows the answer to that other than to provide a quiet area for the induction of anaesthesia for both the patient and the anaesthetist. I certainly could not find historic reasons for the anaesthetic room on an internet search while an article that appears on the Royal College of Anaesthetists web site (RCoA 2012) mentions that the first ether general anaesthetic being given in England was administered on 19th December 1846. The anaesthetic was administered to a Miss Lonsdale to facilitate the removal of a tooth by a dentist named James Robinson. Curiously on the same day an ether anaesthetic was given in Dumfries in Scotland to a patient who it is believed was run over by a cart; it is also believed that the unnamed patient subsequently died seemingly of his injuries. Neither of these early GAs seems to have been administered in a separate room. An article from the South African Journal of Anaesthesia and Analgesia (Obideyi 2009) noted that anaesthetic rooms seldom exist in North America, Scandinavia or Australia but are accepted in anaesthetic practice in the UK. The article further states that despite the fact that anaesthetic rooms have been used for decades that “…a robust argument for their continuous use is largely lacking from the literature”. The survey conducted by the author found that 84% of anaesthetists at a hospital in southern England preferred to use the anaesthetic room to anaesthetise patients (38% used it for high risk patients) for a variety of reasons. These included that they felt that it afforded greater privacy for the patient, it was quiet, it was where they could concentrate better, it was custom and practice, fewer distractions, equipment to hand and three said that “surgeons leave you alone”(!). It would be hard to disagree with the reasons given by the anaesthetists since they are genuinely felt and have the welfare of patients in
September 2013 / Volume 23 / Issue 9 / ISSN 1750-4589
mind. Obideyi (2009) further asked if the anaesthetists would be prepared to give up the anaesthetic room if peace and quiet can be assured in the operating theatre with 55% in this small study said that they would be prepared to do this. Another of the things that strikes me about the use of an anaesthetic room is the necessity to replicate the equipment in the anaesthetic room and in the operating theatre. The cost of an anaesthetic is difficult to establish since the prices vary depending on type, model and country of purchase and sales tax. However I found a refurbished Datex Ohmeda Aestiva 3000 on the internet for $US17,000 (excluding anaesthetic monitor and vaporiser) so if we go for that, in Sterling, as a rough guide, it would be about £10,500 plus VAT at 20% makes £12,600 per machine. In the directorate in which I work there are approximately 40 operating theatres that carry out surgery under GA making the cost of replacing the machines in both anaesthetic rooms and operating theatres around £504,000. If you were to add on the maintenance costs and the spare machines required and take into account the doubling up of vital sign monitoring equipment it comes to … well an awful lot. It is a wonder to me why some acute hospital managers have not got onto this on the basis of cost savings alone. It seems that there are some good reasons for no longer using anaesthetic rooms for the induction of anaesthetic and that perhaps there at least needs to be a discourse about this from a patients safety perspective. There might also be some consideration about how those anaesthetic practitioners, that would no longer be required, might be utilised…but that is story for a different article. n Andy Mardell Practice Educator, University Hospital of Wales
References Obideyi A 2009 Should patients be anaesthetized in a dedicated anaesthetic room? A survey of attitude of anaesthetists and patients in a District General Hospital South African Journal of Anaesthesia and Analgesia 15 (2) 8-9 Royal College of Anaesthetists 2012 The History of Analgesia [online] Available from: http:// www.rcoa.ac.uk/about-the-college/history-ofanaesthesia [Accessed June 2013]
181
Disclaimer The views expressed in articles published by the Association for Perioperative Practice are those of the writers and do not necessarily reflect the policy, opinions or beliefs of AfPP. Manuscripts submitted to the editor for consideration must be the original work of the author(s). © 2013 The Association for Perioperative Practice All legal and moral rights reserved.
The Association for Perioperative Practice Daisy Ayris House 42 Freemans Way Harrogate HG3 1DH United Kingdom Email: [email protected] Telephone: 01423 881300 Fax: 01423 880997 www.afpp.org.uk
Anaesthetic rooms.
Do we actually need them? It’s funny what an impact an innocent remark or observation made by someone can have. I have a number of sayings that I use to illustrate things in everyday life as well as in nursing and education. I also find that I tend to use these aphorisms increasingly with, shall we just say, maturity. It was one such throwaway remark a while back from a practitioner colleague who works in anaesthesia. I had been undertaking my ‘Cook’s Tour’ with a group of student nurses on the first day of their theatre placement. I try to show them all three areas of perioperative practice when it is possible to do so starting with the first part of the process, anaesthesia. It was at this time that my colleague remarked “I don’t know why we bother with anaesthetic rooms”. This colleague is a dyed-in-the-wool theatre practitioner and not someone prone to coming out with ill-considered statements and, coming from a background in anaesthetics, I was surprised by his comment. It is not something I would have gone around saying myself as it is not my background and I wouldn’t want to cause discord. We carried on the conversation for a bit and continued to find ourselves in agreement. I first started thinking about this many years ago when visiting a hospital in Boston, Massachusetts where I noticed that anaesthetic rooms did not exist. I later spoke to a British anaesthetist friend and colleague (the two are not always synonymous) who told me about his time spent at a different hospital in that same city. He described having to be in the operating room (OR) at 7am so that he could get all he needed ready for the day’s list. This was because he had no assistance and had to get everything he needed ready for himself and check the equipment required for the session including the anaesthetic machine and the monitoring equipment as well as drawing up of the drugs required. The list often started at 7.30am (remember this is the American healthcare system and OR time is money). When the patient arrived and after all the preoperative checks had been carried out, the patient was transferred onto the operating table in the operating room. When the anaesthesiologist (as he became in the USA) required some assistance to put in the IV cannula or tie in the endotracheal tube he simply asked one of the OR nurses present to help. So with no anaesthetic room there is no need for the transfer of the patient and no need to disconnect the patient from
the anaesthetic machine or gather up the IV infusion, urinary catheter or monitoring lines. To the risk adverse US healthcare system this transfer between one room and another comes with an unacceptable risk; here in the UK the patient is unlikely to be monitored during the transfer so that any hypoxia or cardiac arrhythmia would not be recognised until the patient was reconnected to the monitoring equipment in the theatre/operating room. So why do we have anaesthetic rooms in the UK? Well I am not sure that anyone really knows the answer to that other than to provide a quiet area for the induction of anaesthesia for both the patient and the anaesthetist. I certainly could not find historic reasons for the anaesthetic room on an internet search while an article that appears on the Royal College of Anaesthetists web site (RCoA 2012) mentions that the first ether general anaesthetic being given in England was administered on 19th December 1846. The anaesthetic was administered to a Miss Lonsdale to facilitate the removal of a tooth by a dentist named James Robinson. Curiously on the same day an ether anaesthetic was given in Dumfries in Scotland to a patient who it is believed was run over by a cart; it is also believed that the unnamed patient subsequently died seemingly of his injuries. Neither of these early GAs seems to have been administered in a separate room. An article from the South African Journal of Anaesthesia and Analgesia (Obideyi 2009) noted that anaesthetic rooms seldom exist in North America, Scandinavia or Australia but are accepted in anaesthetic practice in the UK. The article further states that despite the fact that anaesthetic rooms have been used for decades that “…a robust argument for their continuous use is largely lacking from the literature”. The survey conducted by the author found that 84% of anaesthetists at a hospital in southern England preferred to use the anaesthetic room to anaesthetise patients (38% used it for high risk patients) for a variety of reasons. These included that they felt that it afforded greater privacy for the patient, it was quiet, it was where they could concentrate better, it was custom and practice, fewer distractions, equipment to hand and three said that “surgeons leave you alone”(!). It would be hard to disagree with the reasons given by the anaesthetists since they are genuinely felt and have the welfare of patients in
September 2013 / Volume 23 / Issue 9 / ISSN 1750-4589
mind. Obideyi (2009) further asked if the anaesthetists would be prepared to give up the anaesthetic room if peace and quiet can be assured in the operating theatre with 55% in this small study said that they would be prepared to do this. Another of the things that strikes me about the use of an anaesthetic room is the necessity to replicate the equipment in the anaesthetic room and in the operating theatre. The cost of an anaesthetic is difficult to establish since the prices vary depending on type, model and country of purchase and sales tax. However I found a refurbished Datex Ohmeda Aestiva 3000 on the internet for $US17,000 (excluding anaesthetic monitor and vaporiser) so if we go for that, in Sterling, as a rough guide, it would be about £10,500 plus VAT at 20% makes £12,600 per machine. In the directorate in which I work there are approximately 40 operating theatres that carry out surgery under GA making the cost of replacing the machines in both anaesthetic rooms and operating theatres around £504,000. If you were to add on the maintenance costs and the spare machines required and take into account the doubling up of vital sign monitoring equipment it comes to … well an awful lot. It is a wonder to me why some acute hospital managers have not got onto this on the basis of cost savings alone. It seems that there are some good reasons for no longer using anaesthetic rooms for the induction of anaesthetic and that perhaps there at least needs to be a discourse about this from a patients safety perspective. There might also be some consideration about how those anaesthetic practitioners, that would no longer be required, might be utilised…but that is story for a different article. n Andy Mardell Practice Educator, University Hospital of Wales
References Obideyi A 2009 Should patients be anaesthetized in a dedicated anaesthetic room? A survey of attitude of anaesthetists and patients in a District General Hospital South African Journal of Anaesthesia and Analgesia 15 (2) 8-9 Royal College of Anaesthetists 2012 The History of Analgesia [online] Available from: http:// www.rcoa.ac.uk/about-the-college/history-ofanaesthesia [Accessed June 2013]
181
Disclaimer The views expressed in articles published by the Association for Perioperative Practice are those of the writers and do not necessarily reflect the policy, opinions or beliefs of AfPP. Manuscripts submitted to the editor for consideration must be the original work of the author(s). © 2013 The Association for Perioperative Practice All legal and moral rights reserved.
The Association for Perioperative Practice Daisy Ayris House 42 Freemans Way Harrogate HG3 1DH United Kingdom Email: [email protected] Telephone: 01423 881300 Fax: 01423 880997 www.afpp.org.uk
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