egislation has been introduced into the General Assembly of North Carolina that would license anesthesiologist assistants (AAs). H.B. 1492 would authorize licensed AAs to provide anesthesia services under the direct supervision of an anesthesiologist. The supervising anesthesiologist would be actively engaged in clinical practice and immediately available on site to provide assistance to the AA. The anesthesiologist would supervise no more than two AAs at one time; however, such limitation would not restrict the number of other qualified anesthesia service providers an anesthesiologist may concurrently supervise. The same supervision ratio would apply to student AAs. After January 1, 2010, the Board of Medicine could amend the supervision ratio to allow an anesthesiologist to supervise up to four licensed AAs concurrently. The Board at that time could also amend the supervision limitations of student AAs so that requirements for student AAs and student nurse anesthetists would be similar. Finally, student AAs would be prohibited from using the terms “intern,” “resident” or “fellow.” AA licensure legislation that was introduced into the 2006 legislative session passed the full Senate and House Health Committee.

AAs are licensed to practice in Alabama, the District of Columbia, Florida, Georgia, Kentucky, Missouri, New Mexico, Ohio, South Carolina and Vermont. States that allow AAs to practice through physician delegation include Colorado, Michigan, New Hampshire, Texas, West Virginia and Wisconsin.* In addition to North Carolina, licensure legislation is currently pending in Texas.

Legislation also has been introduced in Louisiana that would allow nurse anesthetists to perform interventional pain management procedures. H.B. 684 expands the nurses’ scope of practice to perform procedures including, but not limited to, those involving the injection of local anesthetics, steroids and analgesics for pain management purposes under the direction and supervision of a physician. The procedures for pain management purposes include, but are not limited to, peripheral nerve blocks, epidural injections and spinal facet joint injections when the registered nurse anesthetist can document education, training and experience in performing such procedures. The language mirrors the advisory opinion issued by the Louisiana State Board of Nursing that has been the subject of litigation www.ASAhq.org/Newsletters/2007/02-07/stateBeat02_07.html.

The performance of interventional pain management procedures by nurse anesthetists has already been addressed by the Louisiana State Board of Medical Examiners. In 2006, the medical board issued an advisory opinion stating that nurse anesthetists could provide anesthetics for acute pain associated with surgery, but procedures for interventional pain management purposes constitute the practice of medicine and can only be performed by a physician.

Ambulatory Surgical Centers
Regulation of the ambulatory surgical center (ASC) setting and limitations on the types of procedures that can be performed in such a setting is the focus of H.B. 3269. The sponsors of the bill introduced H.B. 3269 at the request of the Oregon Association of Hospitals and Health Systems.
In addition to requiring an inspection conducted by the Oregon Department of Human Services or an accreditation organization approved by the department prior to licensure, H.B. 3269 sets forth criteria that limit the type of procedure that can be performed in an ASC. Some of the criteria listed in the introduced version of this legislation mirrors federal law as set forth in 42 CFR 416.65. For example:

1. The procedure does not generally exceed a total of 90 minutes operating time and four hours of recovery time.

2. If the procedure requires anesthesia, the anesthesia must be local or regional anesthesia; or general anesthesia that is no more than 90 minutes.

3. The procedure may not be of a type that:

a. generally results in extensive blood loss;

b. requires major or prolonged invasion of body
cavities;

c. directly involves major blood vessels; or

d. is emergency or life-threatening in nature.†

At the suggestion of the Oregon Society of Anesthesiologists and the Oregon Medical Association, the requirements that the procedure does not generally exceed 90 minutes and four hours of recovery time were deleted from the enrolled version.

Additionally H.B. 3269 would require an evaluation of a patient’s risk factors before surgery. During the evaluation, the ASC would be prohibited from considering whether the patient has coverage by a third party, health insurance, Medicaid or Medicare. Lastly, if the physician or podiatric physician and surgeon obtain informed consent for treating the patient in an ASC, the licensed independent practitioner performing the procedure would be required to disclose the medical risks, benefits and alternatives associated with performing the procedure in an ASC or hospital and how care will be provided should complications occur that require services beyond what the ASC provides.

Lisa Percy, J.D., manages state affairs for ASA’s Office of Governmental and Legal Affairs in Washington, D.C.