Current through Register Vol. 49, No. 9, September, 2024
A physician shall not perform any office-based surgery, as
defined by Act 587 of 2013, unless the office meets the requirements of this
regulation. Except in an emergency, a physician shall not perform any
office-based surgery on and after July 1, 2014, unless they are in compliance
with the provisions of this regulation.
1.
Definition Section -
a. Office Based Surgery means surgery that:
i. Is performed by a physician in a medical
office that is not a hospital, outpatient clinic, or other facility licensed by
the State Board of Health;
ii.
Requires the use of general or intravenous anesthetics; and
iii. In the opinion of the physician, does
not require hospitalization.
b. General or intravenous anesthetics:
i. Deep Sedation/Analgesia - A drug induced
depression of consciousness during which patients cannot be easily aroused but
respond purposefully following repeated or painful stimulation. The ability to
independently maintain ventilator function may be impaired. Patients may
require assistance in maintaining a patent airway, and spontaneous ventilation
may be inadequate. Cardiovascular function is usually maintained. (Source: 2009
American Society of Anesthesiologist Continuum of Depth of
Sedation).
ii. General
Anesthesia is a drug induced loss of consciousness during which patients are
not arousable, even by painful stimulation. The ability to independently
maintain ventilator function is often impaired. Patient often require
assistance in maintaining a patent airway, and positive pressure ventilation
may be required because of depressed spontaneous ventilation or drug-induced
depression of neuromuscular function. Cardiovascular function may be impaired.
(Source: same as above)
2.
Personnel -
a. All health care personnel shall be
qualified by training, experience, and licensure as required by law.
b. At least one person shall have training in
advanced resuscitative techniques and shall be in the patient's immediate
presence at all times until the patient is discharged from anesthesia
care.
3.
Office-based surgery -
a. Each
office-based surgery shall be within the scope of practice of the
physician.
b. Each office-based
surgery shall be of a duration and complexity that can be undertaken safely and
that can reasonably be expected to be completed, with the patient discharged,
during normal operational hours.
c.
Before the office-based surgery, the physician shall evaluate and record the
condition of the patient, any specific morbidities that complicate operative
and anesthesia management, the intrinsic risks involved, and the invasiveness
of the planned office-based surgery or any combination of these.
d. The person administering anesthesia shall
be physically present during the intraoperative period and shall be available
until the patient has been discharged from anesthesia care. They must be
licensed, qualified and working within his/her scope of practice as defined by
state law.
e. Each patient shall be
discharged only after meeting clinically appropriate criteria. These criteria
shall include, at a minimum, the patient's vital signs, the patient's
responsiveness and orientation, the patient's ability to move voluntarily, and
the ability to reasonably control the patient's pain, nausea, or vomiting, or
any combination of these.
4.
Equipment -
a. All operating equipment and materials
shall be sterile, to the extent necessary to meet the applicable standard of
care.
b. Each office at which
office-based surgery is performed shall have a defibrillator, a
positive-pressure ventilation device, a reliable source of oxygen, a suction
device, resuscitation equipment, appropriate emergency drugs, appropriate
anesthesia devices and equipment for proper monitoring, and emergency airway
equipment including appropriately sized oral airways, endotracheal tubes,
laryngoscopes, and masks.
c. Each
office shall have sufficient space to accommodate all necessary equipment and
personnel and to allow for expeditious access to the patient, anesthesia
machine, and all monitoring equipment.
d. All equipment shall be maintained and
functional to ensure patient safety.
e. A backup energy source shall be in place
to ensure patient protection if an emergency occurs.
5.
Administration of anesthesia
- In an emergency, appropriate life-support measures shall take
precedence over the requirements of this subsection. If the execution of
life-support measures requires the temporary suspension of monitoring otherwise
required by this subsection, monitoring shall resume as soon as possible and
practical. The physician shall identify the emergency in the patient's medical
record and state the time when monitoring resumed. All of the following
requirements shall apply:
a. A preoperative
anesthetic risk evaluation shall be performed and documented in the patient's
record in each case. In an emergency during which an evaluation cannot be
documented preoperatively without endangering the safety of the patient, the
anesthetic risk evaluation shall be documented as soon as feasible.
b. Each patient receiving intravenous
anesthesia shall have the blood pressure and heart rate measured and recorded
at least every five minutes.
c.
Continuous electrocardiography monitoring shall be used for each patient
receiving intravenous anesthesia.
d. During any anesthesia other than local
anesthesia and minimal sedation, patient oxygenation shall be continuously
monitored with a pulse oximeter. Whenever an endotracheal tube or laryngeal
mask airway is inserted, the correct functioning and positioning in the trachea
shall be monitored throughout the duration of placement.
e. Additional monitoring for ventilation
shall include palpation or observation of the reservoir breathing bag and
auscultation of breath sounds.
f.
Additional monitoring of blood circulation shall include at least one of the
following:
i. Palpation of the
pulse;
ii. Auscultation of heart
sounds;
iii. Monitoring of a
tracing of intra-arterial pressure;
iv. Pulse plethysmography; or
v. Ultrasound peripheral pulse
monitoring.
g. When
ventilation is controlled by an automatic mechanical ventilator, the
functioning of the ventilator shall be monitored continuously with a device
having an audible alarm to warn of disconnection of any component of the
breathing system.
h. During any
anesthesia using an anesthesia machine, the concentration of oxygen in the
patient's breathing system shall be measured by an oxygen analyzer with an
audible alarm to warn of low oxygen concentration.
6.
Administrative policies and
procedures -
a. Informed consent for
the nature and objectives of the anesthesia planned and surgery to be performed
should be in writing and obtained from patients before the procedure is
performed. Informed consent should only be obtained after a discussion of the
risks, benefits and alternatives and should be documented in the medical
record.
b. Each office shall have
written protocols in place for the timely and safe transfer of the patients to
a prespecified medical care facility within a reasonable proximity if extended
or emergency services are needed.
The protocols shall include one of the following:
i. A plan for patient transfer to the
specified medical care facility;
ii. A transfer agreement with the specified
medical care facility; or
iii. A
requirement that all physicians performing any office-based surgery have
admitting privileges at the specified medical care facility.
c. Each physician who performs any
office-based surgery that results in any of the following quality indicators
shall notify the board in writing within 15 calendar days following discovery
of the event:
i. The death of a patient during
any office-based surgery, or within 72 hours thereafter;
ii. The transport of a patient to a hospital
emergency department;
iii. The
discovery of a foreign object erroneously remaining in a patient from an
office-based surgery performed at that office; or
iv. The performance of the wrong surgical
procedure, surgery on the wrong site, or surgery on the wrong
patient.