NORA Design Checklist

Non-Operating Room Anesthetizing (NORA) Location Design Checklist

ASA NORA Design Checklist (PDF)

The following checklist is predicated on the overarching principle that at least one representative from the anesthesiology department should be involved in the design process whenever a facility is constructing new NORA locations or renovating existing locations. The anesthesiologist or anesthesiologists who represent their department in NORA design processes should consider presenting this document to the committee leading local NORA construction.

The checklist reflects design best practices for anesthesia care as they relate to patient safety, quality of care, occupational health, workflow optimization, departmental efficiency, and financial stewardship. While not exhaustive, this list represents the basic, essential, and anesthesia-specific principles ASA recommends for inclusion in the design process for NORA locations. Anesthesia leaders making local design decisions should adapt these recommendations to account for a facility’s space, layout, and any constraints the physical environment presents.

For the purpose of this document, “non-operating room anesthesia services” is defined as care provided by anesthesiology personnel for inpatients/outpatients undergoing diagnostic or therapeutic procedures performed at locations outside an operating room pavilion within the hospital. A NORA location refers to a procedural suite or area within a facility, such as a bronchoscopy suite or a gastrointestinal endoscopy lab. A NORA room refers to any procedure room within a NORA location.¹

A. Incorporation of Anesthesiology in NORA Design

A1. The anesthesiology department has designated a representative to consult with the architects and other relevant stakeholders throughout the design and construction process.
A2. In medical direction or medical supervision models, anesthesiologists have an adequate workspace outside of the procedure rooms for medical oversight responsibilities.
A3. Each NORA location is designed and equipped for deep sedation as a minimum, with adequate provisions for unintended general anesthesia.

B. NORA Location Space and Basic Setup

B1. Each NORA location includes adequate waiting areas for patients and families.
B2. NORA leaders have determined where induction and recovery for NORA patients will take place and identified transportation protocols, including necessary equipment.
B3. Each NORA room is large enough to permit the needs of the procedural and anesthesia care that will occur therein. This includes space to accommodate fixed imaging equipment, anesthesia equipment, monitors, medications and supplies, and the patient and support staff.²
B4. The number and capabilities of the anesthesia workstations (i.e., anesthesia gas delivery system, ventilator, intravenous (IV) delivery system and pumps, patient monitor, and drug cart) are adequate for the procedures that will be performed in the NORA locations.
B5. Each NORA location includes enough space for an emergency cart and any tools for difficult airway management that are not stored in the cart.
B6. Each NORA room contains adequate overall space to move anesthesia equipment if patient positioning changes or imaging equipment moves.
B7. Each NORA room allows anesthesia personnel access to patients from at least two sides.
B8. Suction, scavenging, medical gas lines, and electrical outlets are located within each room to account for patient positioning changes.
B9. Each NORA location includes adequate storage space for present and future equipment, as well as disposable items.
B10. Invasive monitoring lines and regional blocks are placed in an optimal location with adequate space and supplemental equipment, including monitors, as needed.
B11. NORA locations have readily accessible regional anesthesia carts, where necessary.
B12. NORA leaders have identified a clinical engineering support location.
B13. The post-anesthesia care unit (PACU) is located in close proximity to each NORA location.
B14. The nearest PACU has adequate patient capacity.
B15. The nearest PACU considers optimal workflows that account for patient, family, and staff traffic patterns.
B16. There is adequate equipment at bedside to provide safe PACU care.

C. Resources for Emergency Situations

C1. All anesthesia workstations meet American Society of Anesthesiologists Standards for Basic Anesthetic Monitoring.
C2. NORA policy incorporates backup anesthesia equipment and emergency needs.
C3. Special equipment is organized and available for managing critical patient needs such as cardiac arrest, difficult airway, and malignant hyperthermia.
C4. NORA leaders have developed a plan to manage the access and storage of blood products in emergency situations, if applicable.

D. Ergonomics and Workflow

D1. NORA leaders have considered how patients, anesthesia personnel, proceduralists, support staff, supplies, and equipment will move through the planned facility. NORA leaders have assessed the need for appropriate anesthesia tech support or anesthesia support personnel to improve patient care transitions and be prepared for emergency situations.
D2. Once workflows are designed, NORA leaders have simulated them to identify any potential inefficiencies or hazards. Simulations are used to ensure appropriate changes are made to improve efficiencies and workflows as needed.
D3. NORA personnel are aware of the most direct way to transport patients to higher acuity areas.
D4. NORA leaders have considered the workflows of the tasks end users will repeatedly perform in the planned facility and location. The NORA space design prioritizes the most common tasks. Ideally, the design also accounts for uncommon and acute scenarios for which the room layout may play a significant role in patient outcomes and/or staff safety.
D5. NORA leaders ensure the procedure room design accounts for common hazards to clinical staff, such as “head (boom) strikes.”
D6. The NORA room lighting design considers the specific requirements of procedures, the physicians performing those procedures, anesthesia personnel, nurses, and other staff.
D7. Each NORA location is optimized to control noise pollution, provide different temperature zones, and distribute electrical power and compressed gases.
D8. NORA leaders have determined how many anesthesia workrooms are needed, how close those workrooms are to the procedure rooms, and how much space is required.
D9. Patient and equipment visualization, either through a window or cameras directed at the patient and monitors, is made available for scenarios in which anesthesia staff must remain outside the room (e.g., radiotherapy, MRIs).
D10. Adequate lead shielding and other protective gear are provided to the anesthesia care team where necessary.

E. Supply Chain

E1. NORA leaders have identified a location for storing gas cylinders.
E2. NORA leaders have codified a process for medication storage and distribution.

F. Gas and Vacuum Supplies

F1. Optimal locations and number of outlets for oxygen, air, nitrous oxide, vacuum, and scavenging are considered in the design process.
F2. NORA leaders have determined appropriate access to nitrous oxide, if nitrous oxide is deemed necessary for that site.
F3. NORA leaders have determined whether additional gas outlets at alternate locations within each room are needed.
F4. Each NORA location has a process for keeping hoses neat and off the floor.
F5. An adequate and reliable dedicated source of suction is available in all NORA rooms.

G. Electrical Service

G1. NORA leaders have established a clear definition of "wet location" and labeled those rooms as such.
G2. NORA leaders have determined whether shock protection will be provided and whether any shock protection will use isolated power or ground fault circuit interrupters.
G3. NORA leaders have determined the type, location, and number of electrical outlets.³
G4. NORA leaders have identified any need for uninterruptible power supplies (UPS) and/or standby generators.
G5. NORA leaders have accounted for any energy hazards in each NORA location. Local policy lays out how patients, staff, and equipment will be protected from these hazards, as well as optimal observation of, and access to, the patient.

H. Room Ventilation Systems

H1. The ventilation systems in each NORA location meet relevant standards as determined by the authority having jurisdiction (AHJ) such as the National Institute of Occupational Safety and Health (NIOSH), American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), Centers for Disease Control and Prevention (CDC), and American Institute of Architects (AIA).
H2. NORA room temperature is adequately regulated.
H3. NORA room humidity is adequately regulated.

I. Communications

I1. The NORA room has access to adequate equipment for communication to external locations and personnel. Communication may include, but is not limited to, telephones, intercoms, and information displays for schedules, laboratories, and radiology departments.
I2. NORA leaders have identified a primary technology for person-to-person communication.
I3. NORA leaders have planned how communication equipment will be located and tracked.
I4. Each NORA location has an established process for how emergency situations requiring calls for assistance will be communicated.
I5. Backup plans and systems are developed for each primary communication scheme.
I6. Communication solutions are compliant with federal and state-specific laws and regulations.
I7. Noise and potential interruptions from communication systems do not interfere with the work of each NORA location.
I8. NORA leaders have determined whether the communication plan is compatible with other staff workflows and whether it can be realistically executed during busy periods.

J. Electronic Medical Record Systems

J1. NORA leaders have implemented a well-organized team approach to choosing, installing, and maintaining EMR systems, as well as any other specialized systems used for scheduling or for managing procedural and patient-related data.
J2. Each NORA location and all relevant personnel have access to perioperative data management tools and all hospital information systems, including electronic medical record (EMR) systems. Backup paper documentation and personnel familiar with its use are available in the event of EMR failure or downtime.
J3. Each NORA room includes data ports on any wall where an anesthesia machine might be positioned.

1. For further information, see American Society of Anesthesiologists “Statement on Nonoperating Room Anesthesia Services.”
2. Anesthesiologists or their department leaders should consult the Facilities Guidelines Institute (FGI) for further guidance on the adequate size for anesthesia workspaces.
3. Anesthesiologists and their department leaders should consider the National Fire Prevention Association regulations related to operating rooms and electric outlets (NFPA-99).