he South Carolina Board of Medical Examiners adopted regulations that were approved by the South Carolina General Assembly and Governor Mark Sanford. This was an effort by the South Carolina Society of Anesthesiologists to codify guidelines that had governed the office setting since 2001. The regulations require accreditation for Level II and III offices. Written policies and procedures include emergency care and transfer plan; medical record maintenance and security; infection control; performance improvement; reporting of adverse events; and a Patients’ Bill of Rights. With respect to Level II and III offices, the physician must hold staff privileges at a hospital to perform the same procedure as in the office or document completion of training (i.e., board-certification or eligibility) or demonstrate comparable background, training or experience as approved by the medical board. The physician must maintain current certification in advanced resuscitative techniques as appropriate (advanced cardiac life support [ACLS], advanced trauma life support [ATLS] or pediatric advanced life support). The supervising physician must ensure that the pre-anesthesia evaluation/examination is performed proximate to surgery; order sedation/analgesia or anesthesia; ensure that qualified health care personnel participate; remain immediately available until discharge criteria are met; and ensure provision of post-sedation/analgesia or anesthesia care.

For Level III offices, physicians who supervise nurse anesthetists must have sufficient knowledge of anesthesia provided in a particular procedure to provide effective care should an emergency occur. If not, a qualified physician must administer or supervise the administration of anesthesia.

Arizona — For more than two years, the Arizona Medical Board has been developing office-based surgery rules. The medical board recently amended its proposal after the death of two patients who had undergone surgery in the same office within a four-month period. The rules would apply to office-based surgery using sedation. Physicians who use general anesthesia would be excluded from the rules but would obtain a health care institution license as required by the Arizona Department of Health Services.

The proposal would require the physician who performs the surgery using sedation to establish, document and implement written policies and procedures that address patient rights, informed consent, emergency care and patient transfer. The procedures and policies would be reviewed annually. Such physicians would also ensure that the office has all necessary equipment to safely perform the surgery and for the physician or health care professional to safely administer and monitor the use of sedation. The physician performing surgery would also ensure that the office has all equipment necessary for the patient to be rescued if he or she enters into a deeper state of sedation than what was intended by the physician. A recent change in the proposal eliminates the physician’s responsibility to rescue the patient.

The rules would provide for procedure and patient selection. A physician would ensure that each surgery performed is of a duration and degree of complexity that allows a patient to be discharged within 24 hours. The physician would also ensure that each surgery is within the education, training, experience skills and licensure of the physician, staff members and health care professionals at the office.

The proposal provides guidance with respect to sedation monitoring. A licensed and qualified health care professional, other than the physician performing the surgery, whose sole responsibility is attending to the patient, would be present throughout the surgery. During the surgery, a physician would be physically present in the room where the surgery is performed; after surgery, a physician in the office would be sufficiently free of other duties to respond to an emergency until the patient’s post-sedation monitoring is discontinued. If using deep or moderate sedation, a physician or health care professional certified in ACLS or PALS would remain in the office and be sufficiently free of other duties until the patient is discharged. With respect to minimal sedation, the physician or health care professional could be basic life support-certified.

Health care professionals and staff members would receive instructions regarding the office’s emergency procedures, policies, evacuation and patient transfer. A physician would not be allowed to use any drug or agent that triggers malignant hyperthermia.
If adopted, the rules would be reviewed by the Governor’s Regulatory Review Council (GRRC). The rules would be effective upon the date of GRRC’s approval.

AMA House of Delegates Adopts ASA’s Resolution Regarding Interventional Pain Management
To address an increase in the number of nonphysician providers who are attempting to expand their scope of practice to include pain medicine, ASA introduced to the AMA House of Delegates, Resolution 903: “Interventional Pain Management: Advancing Advocacy to Protect Patients from Treatment by Unqualified Providers.” This resolution reflects a growing concern that patients who suffer from chronic pain are being treated by individuals without medical training in pain medicine. Interventional pain management by unqualified providers carries serious risks to patients, such as infection, brain damage, paralysis or even death. Due to the complexities involved in the treatment of pain, pain medicine is recognized as a separate medical subspecialty. Physicians who choose to specialize in pain medicine must complete a one-year multidisciplinary pain fellowship or training beyond their anesthesiology residency, after which they may seek board-certification in pain medicine. The requirement for multidisciplinary training is recognized by the Accreditation Council for Graduate Medical Education.

AMA is directed to encourage and support state medical boards and state medical societies in adopting advisory opinions and advancing legislation, respectively, that interventional pain management of patients suffering from chronic pain constitutes the practice of medicine. Additionally, AMA will collect, synthesize and disseminate information regarding the educational programs in pain management and palliative care offered by nursing programs and medical schools in order to demonstrate the differences in training and quality between both programs.

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