Anaesthesia without induction rooms

I read with interest the experience of anaesthetic care without anaesthesia rooms (AR) at Ipswich Hospital (Broadway et al. Anaesthesia 2001; 56: 82–3). I am a British specialist registrar currently doing a clinical fellowship in Canada, and as such have over the last year been inducing anaesthesia in the operating room (OR). This was a new experience to me, and I too was very sceptical; however, my opinion has crystallised somewhat over the last year. Traditional arguments for anaesthesia in an AR have been: reduction of anxiety by protecting the patient from the sights and sounds of the OR, reduction of case turnover time by anaesthetising the next case while the previous operation is being completed, and provision of space for storing anaesthetic equipment. Whereas the main arguments against given by the authors include: duplication of expensive equipment to provide adequate monitoring at induction, reduced training opportunities (by avoiding trainees starting the next case in the AR towards the end of the previous operation) and the hazards of transferring an anaesthetised, unmonitored patient. Broadway et al. stated that patients found it acceptable and delays were insignificant. There seem to be contradictory studies about the effect of using the OR for induction on anxiety. Soni and Thomas prospectively demonstrated in 100 patients, no difference in visual anxiety scores, heart rate, systolic blood pressure and respiratory rate between those induced in the AR and OR [1]. Lui and Tan have shown more recently that 33 out of 100 patients induced in the OR found the environment noisy, with 16 patients being distressed. They also demonstrated that continuous noise levels during induction were a mean (SD) 70.3 (16.8) dB, a level higher than international recommendations for critical care areas, and higher than the threshold that causes physiological effects [2]. It was noted that much ambient noise in the OR at induction could and should be reduced. Hence, it seems that if care is taken to restrict unnecessary noise at induction, then induction in the OR should be feasible without undue anxiety. It seems logical that premedication may facilitate this, although this is becoming increasingly difficult to arrange with the increasing popularity of same day admissions. I would tend to agree with the authors that unsupervised induction of anaesthesia by trainees in the induction room to speed up lists reduces training opportunities. However, there is much to be said for more experienced trainees getting themselves in and out of trouble to learn the specialty. However, if this is to be done safely, there needs to be a senior anaesthetist immediately available to assist if required, and this would necessitate the previous case to have finished. It could obviously occur either in the AR or OR, thus negating any time benefit of induction in the AR. During my experience in Canada, it has become clear that the overwhelming argument against OR induction is the wasted time during case turnover. Contrary to the authors' experience, the delay is not ‘insignificant’. In a detailed prospective study of 1881 patients and the reasons for OR delays in an academic institution in the USA, the lowest mean turnover time (time from patient leaving the OR and the next patient entering the OR) achieved, even after intensive staff education and reorganisation, was 35 min (SEM – 2.5) [3]; my own ad-hoc audit of turnover times I have experienced in our institution over the last two weeks demonstrated a turnover median of 20 min (range 5–40, n = 42). Given my mean number of cases of 21 per week, this suggests my wasted time would be in the region of 420 min or 7 h per week, and assuming 6 weeks annual leave per year, 46 weeks × 7 h = 322 h per year. If you extrapolate this wasted time to an entire department, I am sure that it is easy to see the potential impact on operating lists, waiting lists and efficiency of the OR. I am certain the cost implications of this reduced efficiency more than pay for the cost of duplicated AR monitoring. Certainly there are good reasons to anaesthetise potentially unstable, usually emergency cases in the OR (with the surgeons already scrubbed). However, I am unaware of the incidence of adverse events during the transfer of elective anaesthetised patients from the AR to OR. Though traditionally argued to be safe (with direct supervision of the patient and prompt reapplication of the monitoring by the anaesthetist), critical incidents can and will happen during this phase. Therefore, this is the only convincing argument for induction in the OR. In conclusion, I agree that induction in the OR is acceptable to patients, but disagree that the time wasted between cases is negligible. Any change to OR induction should look closely at wasted time, and the cost/efficiency implications of this. Despite the obvious attraction of coffee breaks for anaesthetists between cases, I would argue that the hazard of transfer between the OR and AR is the only real issue. Also, do we really want to become part of the increasing global Americanisation?

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