The following is a continuation of the “State Beat” column that appeared in the December 2002 NEWSLETTER.


Office-Based Anesthesia

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Colorado — The medical board adopted a policy statement on office-based surgery and anesthesia. The policy statement does not have the force of law and applies to any procedure involving general, regional or conscious sedation. It is the responsibility of the surgeon and the “qualified anesthesia provider” to determine that the patient is an appropriate candidate for anesthesia in the office. A “qualified anesthesia provider” is defined as “an appropriately trained and qualified physician, a certified registered nurse anesthetist (CRNA) or a physician assistant appropriately trained and qualified in anesthesia working under the on-site supervision of a physician.”

Florida — A Florida District Court of Appeals upheld the medical board’s office-based surgery rules as follows: 1) an anesthesiologist must be present for all Level III office surgeries; 2) physicians without staff privileges who perform Level II office surgeries must have a transfer agreement with a licensed hospital within reasonable proximity of the office; 3) physicians who perform Level III office surgeries must have staff privileges at a licensed hospital within reasonable proximity of the office.

The Florida Senate considered an amendment that would have eliminated the provision requiring anesthesiologist participation in all Level III procedures performed in the office setting, but it was defeated.

In July, the Board of Medicine established guidelines whereby a physician may apply for a waiver of the requirement for anesthesiologist participation in all Level III cases. Physicians who are granted a waiver are permitted to supervise a nurse anesthetist in Level III cases.

Georgia — Two bills carried over from last year that would have regulated office surgery (H.B. 632) and would have provided comprehensive regulation of physicians in office-based surgical settings (H.B. 784) were not considered this year.

Illinois — The Illinois Department of Professional Regulation adopted regulations for the supervision of nurse anesthetists in the office setting. If the operating physician supervises the nurse anesthetist, the physician must have training and experience in the delivery of anesthesia services. Training and experience requirements can be met by either 1) maintaining clinical privileges to administer anesthesia in a hospital or ambulatory surgical center or 2) completing continuing medical education (CME) hours. For sedation analgesia, a minimum of eight hours within a three-year renewal period in delivery of anesthesia, including the administration of sedation analgesia, is required; for deep sedation, regional anesthesia and/or general anesthesia, a minimum of 34 hours in the delivery of anesthesia within the three-year renewal period is required. Advanced cardiac life support certification is required for anesthesiologists, nurse anesthetists and operating physicians.

Mississippi — Office-based surgery regulations became effective June 1, 2002. The regulations require: the reporting of any potentially harmful or life-threatening episode to the Board of Medical Licensure within 15 days of the event; establishment of standards for training surgeons; identification of necessary equipment and supplies and state personnel requirements. The regulations also strongly recommend that ASA’s “Guidelines for Office-Based Anesthesia” be utilized for Level III surgery (general anesthesia or major conduction anesthesia and preoperative sedation). The board has proposed an amendment to the regulations that would strongly recommend that the ASA’s Guidelines “and/or American Association of Nurse Anesthetists’ Standards for Office-Based Anesthesia” be utilized.

New Jersey — The Board of Medical Examiners has adopted regulations to establish a mechanism by which physicians who do not hold hospital privileges can become “privileged” by the board to administer and supervise anesthesia in the office setting. The regulations must be approved by the Division of Consumer Affairs and Department of Law and Public Safety prior to November 19, 2003. Litigation by the nurse anesthetists is anticipated upon final adoption of the regulations.

Under the proposed regulations, a physician who does not hold hospital privileges must apply for board privileges no later than one year after the effective date of the rule. For board privileges, a physician who administers or supervises the administration of general anesthesia must, during every consecutive three-year period, complete at least 60 category 1 hours of CME in anesthesia. A physician privileged to administer or supervise regional anesthesia must, during every consecutive three-year period, complete at least eight category 1 hours of CME in anesthesia exclusively or as it relates to the physician’s field of practice. A physician privileged to administer or supervise conscious sedation must, during every consecutive three-year period, complete at least eight category 1 hours of CME in any anesthesia services, including conscious sedation exclusively, or in anesthesia as it relates to the physician’s field of practice. Nurse anesthetists must be supervised by physicians.

Minor conduction blocks, with the exception of retrobulbar blocks, shall be administered only by a physician or podiatrist, a nurse anesthetist, a certified nurse midwife, advanced-practice nurse or physician assistant who has training and experience in the administration of minor conduction blocks. Retrobulbar blocks shall be administered only by a physician.

A.B. 2689 would require that a physician who administers or supervises the administration and monitoring of anesthesia services in an office be privileged to provide that service by a hospital or the Board of Medical Examiners. The bill would require that the physician have a written transfer agreement with a licensed hospital that can be reached within 20 minutes if the hospital where the physician is privileged is not reachable within 20 minutes or if the physician is privileged by the board. The physician shall have a written policy for handling emergency transport to a hospital at which the practitioner is privileged through a 9-1-1 call or a written transfer agreement with a licensed ambulance service that assures immediate transport of patients. The legislation mirrors existing regulations and is not expected to pass.

New York — A.B. 5548 and S.B. 3457 would require the Commissioner of Health to promulgate regulations for office-based surgery and would require the reporting of adverse incidents. A.B. 5549 and S.B. 3458 would require all health care practitioners performing office-based surgery to report adverse incidents.

In a lawsuit brought by the New York State Association of Nurse Anesthetists (NYSANA), a New York court ruled that the “Clinical Guidelines for Office-Based Surgery,” adopted by the State Department of Health (DOH) are “null and void and of no force and effect” and prohibited DOH from publishing, distributing or enforcing the guidelines. The Court’s ruling does not address the merits of the guidelines. The court held that DOH did not have legal authority to adopt guidelines that, by DOH’s admission, were intended to be standards to be applied in physician disciplinary proceedings and evidence of local community medical standards in medical malpractice actions. The Attorney General’s Office has filed an appeal, and the New York State Society of Anesthesiologists and ASA have filed a joint amicus brief on behalf of the department. AANA has filed an amicus brief on behalf of NYSANA. A decision is anticipated by the beginning of the year.

North Carolina — The state medical society presented recommendations on office-based surgery guidelines to the medical board in July. Board action is pending. The recommendations include written emergency policy and procedures, including a transfer protocol with a nearby hospital; credentialing of physicians by a hospital, ambulatory surgical center or the medical board; and administration of anesthesia by an anesthesiologist or a nurse anesthetist supervised by a physician. Offices where Level II or III procedures are performed must be approved by the Medical Board or accredited by an approved accreditation agency within the first year of operation following approval of the guidelines. The recommendations also address patient screening, discharge and procedures to report complications.

Ohio — The Board of Medicine has finalized the proposed language for office-based surgery regulations and voted to take the proposal into the formal rule-making process. It is expected that final rules will be approved by the end of the year. The proposed regulations provide for accreditation of office settings and reporting of adverse incidents and would require the supervising nonanesthesiologist physician to develop expertise based on CME credits or training. For moderate sedation/analgesia, a nurse anesthetist must be supervised by a physician who holds privileges to provide same in a local hospital or ambulatory surgical center or by a physician who has completed at least five hours of category 1 CME relating to the delivery of moderate sedation/analgesia during the current or most recent past biennial registration period. For general anesthesia, a nurse anesthetist must be supervised by a physician who holds privileges to provide same in a local hospital or ambulatory surgical center or by a physician who has completed at least 20 hours of category 1 CME relating to the delivery of moderate sedation/analgesia during the current or most recent past biennial registration period.

Virginia — H.B. 213 was signed into law, requiring the Board of Medicine to promulgate regulations governing the administration of anesthesia in physicians’ offices. The board’s Ad Hoc Committee on Outpatient Anesthesia has proposed regulations regarding anesthesia. The proposed regulations require physician supervision of nurse anesthetists. Deep sedation, general anesthesia or major conductive blocks may be administered only by an anesthesiologist or nurse anesthetist. Moderate sedation/conscious sedation may be administered by the operating physician with the assistance of and monitoring by a licensed nurse, PA or licensed intern or resident. Physicians must obtain four hours of CME in anesthesia each biennium.

Future installments of the “State Beat” column will summarize other activities in the states, including those related to tort reform.

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