August 2001
Volume 65 |
Number 8
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STATE BEAT
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| States Address
Issues of Anesthesiologist Assistants, Office-Based Anesthesia |
S. Diane Turpin
Assistant Director of Governmental Affairs (State)
Anesthesiologist Assistants
Louisiana H.B. 1828, legislation that
would prohibit anesthesiologists from delegating any tasks or
duties to anesthesiologist assistants (AAs), passed both the House
and Senate but was vetoed by the Governor on July 6. This legislation,
strongly supported by the nurse anesthetists, would have prohibited
AAs from practicing in the state and would have derailed Louisiana
State University’s plans to open an AA training program next
year. The Governor not only vetoed H.B. 1828, but stated that
he will form a commission to draft “legislation to be considered
and adopted at the next special session of the legislature”
to license AAs to practice in the state. The next special session
will be held in October. Members of the Louisiana Society of Anesthesiologists
(LSA) spent a significant amount of time and energy to defeat
this onerous legislation and are to be commended for their efforts.
LSA was also successful in defeating legislation this session
that would have allowed nurse anesthetists to practice independently.
New Jersey S.B. 1811 would license anesthesiologists’
assistants (AAs) in New Jersey. AAs would be permitted to assist
anesthesiologists in developing and implementing an anesthesia
care plan for a patient pursuant to a written practice protocol
developed by the supervising anesthesiologist. AAs would be permitted
to perform the following procedures in a hospital or ambulatory
surgical setting: 1) obtain a patient history and present it to
the supervising anesthesiologist; 2) pretest and calibrate anesthesia
delivery systems; 3) monitor, obtain and interpret information
from anesthesia delivery systems and monitoring equipment; 4)
assist the supervising anesthesiologist with the implementation
of medically accepted monitoring techniques; 5) establish basic
and advanced airway interventions including intubation of the
trachea and performing ventilatory support; 6) administer intermittent
vasoactive drugs; 7) start and adjust vasoactive infusions; 8)
administer anesthetic drugs, adjuvant drugs and accessory drugs;
9) assist the supervising anesthesiologist with the performance
of epidural anesthetic procedures and spinal anesthetic procedures;
10) administer blood, blood products and supportive fluids; 11)
participate in administrative activities and clinical teaching
activities; 12) participate in research activities; 13) provide
assistance to cardiopulmonary resuscitation teams in response
to life-threatening situations; and 14) perform such other procedures
suitable for discretionary and routine performance by an AA as
designated by the Medical Board. The supervising anesthesiologist
shall develop a written practice protocol that delineates the
services that the AA is authorized to provide and the manner in
which the anesthesiologist will supervise and provide medical
direction. A supervising anesthesiologist shall not have more
than two AAs under his or her supervision and medical direction
at any one time. An AA Advisory Committee would be created under
the Board of Medical Examiners.
Ohio The Ohio Society of Anesthesiologists
continues to work with the Board of Medical Examiners to develop
regulations for AAs practicing in Ohio. Licensure legislation
was signed into law last year.
Office-Based Anesthesia
Mississippi The Board of Medical Licensure
has proposed regulations for the office-based surgical setting.
The proposed regulations classify surgeries as level I, level
II and level III. Level I surgeries are minor procedures performed
under topical or local anesthesia not involving drug-induced alteration
of consciousness other than minimal preoperative tranquilization
of the patient. Level II surgeries are those in which perioperative
medication and sedation are used intravenously, intramuscularly
or rectally; this includes any surgery in which the patient is
placed in a state that allows the patient to tolerate unpleasant
procedures while maintaining adequate cardiorespiratory function
and the ability to respond purposefully to verbal command and/or
tactile stimulation. For these procedures, the surgeon must have
a written transfer agreement from a licensed hospital “within
reasonable proximity to the office” if the surgeon does not
have staff privileges at a hospital “within reasonable proximity
to the office” to perform the same procedure as that being
performed in the office. The surgeon must have privileges at a
“local” hospital to perform the same procedure as that
being performed in the office or must be able to document satisfactory
completion of surgical training such as board certification or
board eligibility. An anesthesiologist, nurse anesthetist or registered
nurse may be utilized to assist with the anesthesia if the surgeon
is certified in advanced cardiac life support. Level III surgeries
are those that involve or reasonably should require the use of
general anesthesia or major conduction anesthesia and preoperative
sedation. ASA physical status I, II or III may be appropriate
for level III surgery. For ASA physical status III patients, the
surgeon must document in the patient’s record the justification
and precautions that make the office an appropriate forum for
the procedure. The surgeon must have privileges at a “local”
hospital to perform the same procedure as that being performed
in the office. An anesthesiologist or nurse anesthetist must administer
the general or regional anesthesia. For level III surgery, the
office “in terms of general preparation, equipment and supplies,
must be comparable to a freestanding ambulatory surgical center
including, but not limited to, recovery capability and must have
provisions for proper record keeping.”
For all office procedures, the surgeon is required to report
any adverse incidents within 15 days of occurrence to the Mississippi
Board of Medical Licensure. The surgeon must maintain a log of
all level II and level III procedures that must include a confidential
patient identifier, the type of procedure, the type of postoperative
care and any adverse incidents. The log and all surgical records
must be provided to the Board of Medical Licensure upon request.
The regulations shall become effective on September 1, 2001.
Rhode Island The Rhode Island Department
of Health has proposed amending regulations adopted last year
regarding office-based surgery. The existing regulations, challenged
by nurse anesthetists, require a board-certified anesthesiologist
to be responsible for developing certain policies and procedures
in the office setting and require the operating physician and
a board-certified anesthesiologist to concur in writing prior
to the surgery that an ASA physical status III patient is an acceptable
candidate for a surgical procedure in the office setting. The
proposed regulations would require both a board-certified anesthesiologist
and a certified registered nurse anesthetist (if the facility
uses nurse anesthetists to administer anesthesia) to be responsible
for developing the policies and procedures in the office setting.
The proposed regulations would require the operating physician
and a board-certified anesthesiologist to concur in writing prior
to the surgery that an ASA physical status III patient is an acceptable
candidate for a surgical procedure in the office setting only
if the procedure requires “types of anesthesia that may fail
mid-procedure necessitating the use of general anesthesia or procedures
for which general anesthesia is planned.” ASA has provided
comments to the Department of Health objecting to the proposed
change that would require a nurse anesthetist to develop policies
and procedures for the office setting in conjunction with an anesthesiologist.
ASA explained that anesthesiologists have this responsibility
in hospitals and that nurse anesthetists, as nonphysicians, are
ill-suited for making such policy decisions. Meanwhile, the litigation
on this issue continues.
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