NORA The first pediatric patient at Proton International was cared for by a NORA core team that included Bethany Yopp, CRNA; Brad Page CRNA; and Justin Routman, M.D.NORA, or Non-Operating Room Anesthesia, is a rapidly expanding and evolving segment of the Department of Anesthesiology and Perioperative Medicine’s clinical initiatives. NORA locations can be as familiar as the Cardiac Catheterization Lab or as novel as UAB’s new Proton International, one of only 36 proton therapy sites in the country and the only site in Alabama. What these diverse locations share is a need for standardization, efficiency, and teamwork, with the ultimate goal of safe, high-quality, evidence-based patient care.

In 2020, NORA cases accounted for nearly 30 percent of the department’s case volume, a number that increased from 27 percent in 2019. As procedures and therapies grow more complex and the patient population increasingly presents with multiple comorbidities, NORA team members face an evolving set of challenges. As the NORA medical director, Justin Routman, M.D.’s role is to ensure that consistent protocols and efficient strategies are established and followed in a diverse variety of settings. Ensuring that safety measures and outcomes are optimized just as they would be in the OR setting is his priority. “It takes a dedicated team to make that happen. It’s hard to say how many people are involved—there are so many—but we operate as core teams throughout the system,” said Routman.

Whether administering deep sedation or general anesthesia, the core teams include physician anesthesiologists and certified registered nurse anesthetists. Core teams for each location routinely rotate through that location, allowing them to more completely understand the nuances of the procedures and the comorbidities of those particular patients.

NORA locations at UAB include:

Radiation Oncology

Cardiac Catheterization Lab

Computed Tomography

Proton Institute


Interventional Cardiology

Advanced Gastroenterology

Transesophogeal Echocardiography


Electroconvulsive Therapy

Interventional Radiology

A future site for NORA includes Intraoperative MRI (iMRI), which is expected to roll out in Summer 2021. This will be a new location in the WIC consisting of two OR suites bordering a central diagnostic MRI room. The mobile MRI machine can be moved between the operating rooms as needed, allowing for intraoperative MRI scans during surgery. “This setup will expand our current ‘MRI under anesthesia’ capabilities as well as allow for significantly more complex neurosurgical procedures. Both adult and pediatric patients will benefit from this new facility, one of only 36 such facilities nationwide,” said Routman, who also noted that UAB will be one of only four institutions in the country with an iMRI facility and proton therapy center on the same physical campus. (The others are Massachusetts General Hospital, Washington University, and Baptist Hospital Miami.)

For more information about NORA, read this paper by Justin S. Routman, M.D.; Melissa Mines Ramsey, CRNA, MSN; Mark Phillips, MD, FASA; Jeffrey Dobyns, DO, MSHA, MSHQS, FASA.