• This guideline covers all anaesthetic services delivered at all remote sites, excluding the MRI department, across Frimley Health NHS Foundation Trust.
• The aim of the guideline is to minimise risk and ensure quality during provision of anaesthesia at remote sites across the Trust, thus ensuring our commitment to excellence.
• The delivery of anaesthesia at remote sites requires a robust approach to risk management to ensure safety.
• Staff involved should be experienced, trained and have documented evidence of competency.
• Rigorous standards should be applied to safety and equipment checks.
• Clear lines of communication and local support should be established.

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Abbreviations

1.1 The provision of anaesthetic services in remote sites presents potentially significant risks for the patient. These risks are related to the unfamiliarity of the anaesthetist with the isolated environment, the available equipment, the assistance provided, the procedure being undertaken.

1.2 Difficulties with communication and the immediate availability of senior/additional assistance confer additional risks to procedures conducted at remote sites.

1.3 This guideline sets out the way in which anaesthetic services will be delivered at remote sites – excluding the MRI department which is covered by a separate guideline – across Frimley Health NHS Foundation Trust.

1.4 Remote sites at which anaesthesia (including sedation) is undertaken include; Endoscopy suite, Interventional Radiology Suite, Emergency Department, Endoscopy Suite, Cardiac Catheterisation Laboratory and Cardiac Recovery.

1.5 Frimley Health NHS Foundation Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals.

A remote site is defined as any location at which an anaesthetist is required to provide general/regional anaesthesia, or sedation away from the main theatres suite and/or anaesthetic department and in which it cannot be guaranteed that the help of another anaesthetist will be available. This may either be within or away from the base hospital.

3.1 All anaesthetists as part of their Trust induction process should be fully familiarised with all remote areas of anaesthetic provision prior to their undertaking anaesthetic processes in that location.

3.2 Anaesthetic equipment, including that used for resuscitation and life support, should be standardised across all areas providing anaesthetic services.

3.3 Where standardisation of equipment is not possible all staff should have opportunities to fully familiarise themselves with the equipment used through formalised equipment training sessions.

3.4 A Departmental record of equipment, training and competency will be kept in each hospital site.

3.5 Mandatory monitoring during anaesthesia includes a pulse oximeter, ECG, non-invasive blood pressure and end-tidal CO2 as a minimum requirement. A peripheral nerve stimulator is recommended where muscle relaxants are used. Where additional monitoring is required, this should be checked to ensure proper function prior to the start of the case.

3.6 In remote areas where general anaesthesia is routinely delivered an anaesthetic machine should be available. This machine should be checked prior to use for each patient.

3.7 In remote sites where an anaesthetic machine is not available an alternative means of positive-pressure ventilation should be immediately available.

3.8 A fully trained and dedicated anaesthetic assistant should be available at all times to allow provision of an identical level of anaesthetic support to that being provided in non-remote sites.

3.9 Prior to conducting anaesthesia a team-based safety briefing, individual safety checks and a WHO checklist should be carried out.

3.10 Patients who have a procedure under general anaesthesia or deep sedation require expert recovery care. This may be provided either in the procedure room by appropriately qualified staff, or by transferring the patient to the recovery room of operating theatres.

3.11 Where transfer of the patient is required the appropriate equipment for both monitoring and organ support must be available prior to the transfer being undertaken.

3.12 If ventilation or organ support is required post-procedure the availability of an ICU bed should be confirmed prior to the procedure.

3.13 It is the responsibility of the anaesthetist conducting the case to check the machine, anaesthetic drugs, emergency drugs and equipment prior to starting the case.

3.14 Accurate documentation of the anaesthetic procedures undertaken as well as a detailed record of the patient monitoring used is essential in all cases.

3.15 Wherever possible anaesthesia in remote sites should be delivered by appropriately experienced consultants.

3.16 A trainee or non-consultant grade judged by the Chief of Service (or Deputy) to possess the knowledge, skills and experience to undertake such duties may deliver remote site anaesthesia provided; Consultant assistance is available within 30 minutes of being requested, skilled and dedicated assistance is available at all times and the trainee/non-consultant grade has the confidence to work at the proposed level of supervision.

3.17 Trainees or non-consultant grades providing anaesthesia in remote sites must have a designated consultant to provide remote supervision and/or advice when required. This would usually be the starred consultant unless an alternative is formally identified and documented at the start of the list.

3.18 Anaesthetists providing anaesthesia at remote sites should be able to provide competency-based evidence of their ability to provide both advanced life support and safe intra-hospital transfer of a patient potentially requiring multi-system support.

3.19 Anaesthetic services should only be provided in nationally certified locations, to patients whose clinical care is being provided by appropriately trained and qualified staff, all of whom have undergone annual appraisal of their workload and outcomes.

Anaesthetic providers are responsible to the Chief of Service, their Trust and their regulatory body.

5.1 All personnel involved with the provision of anaesthetic services at remote sites are to be familiar with this guideline.

5.2 Implementation of this guideline is the responsibility of the Chief of Service and their nominated representative.

5.3 Training in remote site anaesthesia should be made available to all department personnel.

5.4 A record of competency should be maintained and is the responsibility of the Chief of Service.

6.1 It is the responsibility of the Chief of Service to ensure compliance with this guideline.

6.2 The provision of anaesthetic services at remote sites should be the subject of annual audit to ensure compliance with the guideline. A record should be kept, and any shortcomings should be addressed with immediate training, education and re-auditing.