he culmination of a 2.5-year effort of the Arizona Society of Anesthesiologists and Arizona Medical Association resulted in the adoption of office-based surgery regulations in January. The rules govern the use of sedation in the office setting. Physicians who use general anesthesia in the office or outpatient setting that is not part of a licensed hospital or ambulatory surgical center must obtain a health care institution license as required by the Arizona Department of Health Services.

The rules address the following: administrative procedures, procedure and patient selection, and sedation monitoring standards; perioperative and patient discharge; and emergency and transfer provisions.

Administrative Procedures
The physician who performs office-based surgery using sedation must establish, document and implement written policies and procedures that cover patient rights, informed consent, patient transfer and patient care in an emergency. Additionally, such physician must ensure that staff members who assist in, or health care professionals who participate in, surgery have sufficient education, training and experience to perform the assigned duties and perform only those acts that are within their scope of practice. The physician must also ensure that the office has all equipment necessary to safely perform surgery and to safely administer and monitor the sedation. The physician must also ensure that the office has all equipment necessary for the physician and health care professional administering the sedation to rescue a patient should the patient enter into a deeper state of sedation than what was intended by the physician. Lastly, the rules also provide that the physician who performs the surgery obtain informed consent from the patient prior to surgery.

Procedure and Patient Selection
A physician must ensure that each surgery can be safely performed with the equipment, staff members and health care professionals at the physician’s office. A physician is also responsible for ensuring that the surgery is of the duration and complexity that allows the patient to be discharged within 24 hours and is within the education, training, experience and licensure of the physician, staff members and health care professionals at the physician’s office. If the patient has a condition that indicates the procedure should not be performed in the office or will require inpatient services at a hospital, the physician must not perform the surgery.

Sedation Monitoring Standards
A licensed and qualified health care professional other than the physician performing the surgery, whose sole responsibility is attending to the patient, must be present throughout surgery. When minimal, moderate or deep sedation is administered, the physician performing the surgery must ensure that a quantitative method of assessing a patient’s oxygenation is used from the time sedation is administered until post-sedation monitoring. For moderate or deep sedation, the patient’s ventilatory and circulatory functions must be monitored. The rules address how the patient should be monitored.

Perioperative Period, Patient Discharge
During surgery, the physician performing surgery must be physically present in the room where the surgery is performed. After surgery, a physician must be at the office and sufficiently free of other duties to respond to an emergency until the post-sedation monitoring is discontinued. If using deep, moderate or minimal sedation, the physician or a health care professional certified in advanced cardiac life support or pediatric advanced life support must be at the physician’s office and sufficiently free of other duties to respond to an emergency until discharge. For minimal sedation, the physician or health care professional can be basic life support-certified. The patient must receive discharge instructions, and the medical record must reflect that the patient has been provided with the instructions. It is the responsibility of the physician performing surgery to ensure that the provisions above are followed.

Emergency and Transfer Provisions
Prior to surgery, health care professionals and staff members must receive instruction in the policy and procedures for emergencies, office evacuation and patient transfer. When performing surgery, the physician shall not use any drug or agent that would trigger malignant hyperthermia. The rules also provide for the type of equipment that must be available should an emergency occur. The physician performing the surgery must ensure that all the equipment is maintained, tested and inspected according to manufacturer specifications.

Legislation was included into the New Mexico Legislature that would expand who could become licensed as an anesthesiologist assistant (AA) in New Mexico. Existing law defines AAs as persons employed by a university in New Mexico with a medical school, and anesthesiologists as employees of the department of anesthesiology of a medical school in New Mexico. S.B. 485 would eliminate both limitations so that AAs could now practice in facilities beyond the university setting. Moreover, S.B. 485 would also expand the number of AAs who could be supervised by an anesthesiologist. Current law limits the number to three AAs, except in emergency cases. Under this bill, the number would be the maximum number of supervised providers permitted by the Centers for Medicare & Medicaid Services.

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