The New York Commissioner of Health, Antonia C. Novello, M.D.,
has endorsed Clinical Guidelines for Office-Based Surgery that
were approved by the New York Public Health Council.1
The guidelines are recommended as an appropriate standard of care
subject to review by the Department of Health through the Board
for Professional Medical Conduct (for physicians) and through
the State Education Department (for dentists, podiatrists and
nurses). The Committee on Quality Assurance in Office-Based Surgery,
in its report to the New York State Public Health Council and
the New York State Department of Health, stated that surgical
and anesthesia care, regardless of where performed or by whom
should be provided in accordance with accepted standards of practice
and in a manner that ensures the safety of the patient during
the performance of surgery, administration of and recovery from
anesthesia and discharge from the facility.
Anesthesia should be administered only by a licensed, qualified
and competent practitioner. Registered professional nurses (RNs)
who administer anesthesia as part of a medical, dental or podiatric
procedure (including but not limited to CRNAs) should have training
and experience appropriate to the level of anesthesia administered,
and function in accordance with their scope of practice. Supervision
of the anesthesia component of the medical, dental or podiatric
procedure should be provided by a physician, dentist or podiatrist
who is physically present, who is qualified by law, regulation
or hospital appointment to perform and supervise the administration
of the anesthesia and who has accepted responsibility for supervision.
The physician, dentist or podiatrist providing supervision should:
1. perform a preanesthetic examination and evaluation;
2. prescribe the anesthesia;
3. assure that qualified practitioners participate;
4. remain physically present during the entire perioperative
period and immediately available for diagnosis, treatment and
management of anesthesia-related complications or emergencies;
and
5. assure the provision of indicated postanesthesia care.
The guidelines state that anesthesia should be administered
in the office in accordance with the Department of Health regulations
for hospitals and ambulatory surgical centers. These regulations
require, among other things, that nurse anesthetists must practice
under the supervision of an anesthesiologist who is immediately
available as needed or under the supervision of the operating
physician who has been found qualified by the governing body
and the medical staff to supervise the administration of anesthetics
and who has accepted responsibility for the supervision of the
CRNA. 2
The guidelines also set forth the type of equipment that should
be available for conscious sedation and supplemented local anesthesia,
regional anesthesia, unconscious/deep sedation and general anesthesia
and identify the personnel required for each level of anesthesia.
The New York State Association of Nurse Anesthetists has filed
a lawsuit challenging the guidelines. The nurse anesthetists
claim that the guidelines require that anesthesia be administered
only by or under the supervision of an anesthesiologist. The
nurse anesthetists also allege that the guidelines require that
only an anesthesiologist can perform the preanesthetic examination
and evaluation and that only an anesthesiologist can determine
the appropriate anesthetic agent. In general, nurse anesthetists
claim that the guidelines unlawfully limit the scope of practice
of nurse anesthetists. The Department of Health will, of course,
defend the lawsuit.
Two ASA members, Scott B. Groudine, M.D., and Rebecca S. Twersky,
M.D., served on the committee on Quality Assurance in Office-Based
Surgery along with representatives from other specialties. The
committee spent 18 months developing the guidelines that, in
addition to the anesthesia provisions, include guidelines for
written policies and procedures, a performance improvement program,
credentialing of physicians, patient admission and discharge
procedures and emergency care transfer policies.
Further developments will be reported in this column. The
guidelines are available online at www.health.state.ny.us/nysdoh/obs/colleague.htm
or from the ASA Washington Office upon request.