Observations: Operating Outside the Box

< Back

November 1, 2013 Volume 77, Number 11
Observations: Operating Outside the Box N. Martin Giesecke, M.D.

Cases where anesthesia care is provided outside of the standard O.R. setting are the fastest-growing portion of my practice. It is also my impression that non-O.R. anesthesia (NORA) is becoming a regular occur-rence in most anesthetic practices. At least that is what I’m hearing from the residents who are out there interviewing for private practice jobs. They are asking to have us give them a rotation in NORA. This will enable them to feel prepared for those procedures they will be assigned to do upon taking that first job after graduating from their residency program.


NORA is not new. Those of us in my residency took care of patients having MRIs back when that technology was brand new. And we provided daily totalintravenous anesthesia with sodium thiopental to pediatric patients under-going radiation therapy procedures. But even back in the late 1980s, going to another physician’s office to practice anesthesia was not widespread.


Seven years after my training was completed, in 1996, California was one of the first states to pass office-based anesthesia regulations. Still, it wasn’t until 1998 when the “topic” of NORA first came to my attention. As with many new, practice-related concerns, guidance on office-based anesthesia came to me from ASA, in the form of one of its grassroots patient safety efforts. As a member of the ASA’s House of Delegates, news spread to me about the efforts of the New Jersey State Society of Anesthesiologists’ (NJSSA’s) push to have the New Jersey Legislature pass its own set of office-based anesthesia regulations.


In early 1999, the NJSSA was successful. New Jersey lawmakers passed their state’s version of office-based anesthesia rules. The New Jersey law required physicians who practiced office-based anesthesia to have hospital privileges (or some other form of credentialing). The statute created strict regulations that governed the administration of anesthetics in this environment, including the fact that general anesthesia had to be administered or supervised by a physician or anesthesiologist. Furthermore, the supervising physician could not also be involved in performing the surgical procedure. NJSSA and Dr. Ervin Moss were instrumental in passage of this legislation.


Let’s move back to Texas in that same year, 1999. In the face of office-based anesthesia catastrophes in Florida, the Texas Legislature was discussing concerns about the safety of office-based anesthesia. Again, grassroots involvement played a part in what was to happen. Having heard about Dr. Moss through my involvement in ASA, I contacted him. He was kind enough to share with me a good deal of information related to the passage of the law in New Jersey. Some of this material was put to good use when the Texas Society of Anesthesiologists promoted the passage of S.B. 1340. That bill passed the Texas Legislature in May 1999. This law, which went into effect that September, required that the Texas State Board of Medical Examiners (now the Texas Medical Board) and the Texas Board of Nurse Examiners (now the Texas Board of Nursing) create minimum standards for the provision of anesthesia care in outpatient settings.


Later that year, the ASA House of Delegates confirmed that the Society was focused on patient safety. In October 1999, the Society adopted its first “Guidelines for Office-Based Anesthesia.” Subsequently, ASA has produced its “Statement on Non-operating Room Anesthetizing Locations.” These two documents continue the culture of safety the Society has so often brought to the American public (and the world at large).


Much has happened since these documents were first prepared by ASA. Many other states have passed legislation similar to that of California, New Jersey and Texas. The practice of office-based anesthesia has greatly expanded. Nevertheless, challenges remain.


Office-based surgical injuries and deaths continue to make the regional and national news. Physicians practicing in these clinical arenas need to familiarize themselves not only with their state’s office-based surgery regulations, but also need to be comfortable working outside of the box – outside of the O.R. Though our Society’s guidelines and statements cover the issues well, an anesthesiologist providing office-based anesthesia must be prepared to perhaps be the only person in the room who is facile with resuscitation. Anesthesiologists need to be comfortable working in a scenario where there may not be any back up; thus, the buck really does stop with them. If they are unable to obtain an airway, for instance, they will need the ability to quickly adapt their care for patient safety.


Enjoy reading the feature articles in this edition of the ASA NEWSLETTER. They will help illuminate the practice of operating outside of the box.