These guidelines are intended to assist ASA members who are considering the practice of ambulatory anesthesia in the office setting: office-based anesthesia (OBA). These recommendations focus on quality anesthesia care and patient safety in the office. These are minimal guidelines and may be exceeded at any time based on the judgment of the involved anesthesia personnel. Compliance with these guidelines cannot guarantee any specific outcome. These guidelines are subject to periodic revision as warranted by the evolution of federal, state and local laws as well as technology and practice.

ASA recognizes the unique needs of this growing practice and the increased requests for ASA members to provide OBA for health care practitioners* who have developed their own office operatories. Since OBA is a subset of ambulatory anesthesia, the ASA "Guidelines for Ambulatory Anesthesia and Surgery" should be followed in the office setting as well as all other ASA standards and guidelines that are applicable.

There are special problems that ASA members must recognize when administering anesthesia in the office setting. Compared with acute care hospitals and licensed ambulatory surgical facilities, office operatories currently have little or no regulation, oversight or control by federal, state or local laws. Therefore, ASA members must satisfactorily investigate areas taken for granted in the hospital or ambulatory surgical facility such as governance, organization, construction and equipment, as well as policies and procedures, including fire, safety, drugs, emergencies, staffing, training and unanticipated patient transfers.

ASA members should be confident that the following issues are addressed in an office setting to provide patient safety and to reduce risk and liability to the anesthesiologist.

• The facility should have a medical director or governing body that establishes policy and is responsible for the activities of the facility and its staff. The medical director or governing body is responsible for ensuring that facilities and personnel are adequate and appropriate for the type of procedures performedPolicies and procedures should be written for the orderly conduct of the facility and reviewed on an annual basis.
• The medical director or governing body should ensure that all applicable local, state and federal regulations are observed.
• All health care practitioners* and nurses should hold a valid license or certificate to perform their assigned duties.
• All operating room personnel who provide clinical care in the office should be qualified to perform services commensurate with appropriate levels of education, training and experience.
• The anesthesiologist should participate in ongoing continuous quality improvement and risk management activities.
• The medical director or governing body should recognize the basic human rights of its patients, and a written document that describes this policy should be available for patients to review.

• Facilities should comply with all applicable federal, state and local laws, codes and regulations pertaining to fire prevention, building construction and occupancy, accommodations for the disabled, occupational safety and health, and disposal of medical waste and hazardous waste.
• Policies and procedures should comply with laws and regulations pertaining to controlled drug supply, storage and administration.

• The anesthesiologist should be satisfied that the procedure to be undertaken is within the scope of practice of the health care practitioners and the capabilities of the facility.
• The procedure should be of a duration and degree of complexity that will permit the patient to recover and be discharged from the facility.
• Patients who by reason of pre-existing medical or other conditions may be at undue risk for complications should be referred to an appropriate facility for performance of the procedure and the administration of anesthesia.

• The anesthesiologist should adhere to the "Basic Standards for Preanesthesia Care," "Standards for Basic Anesthetic Monitoring," "Standards for Postanesthesia Care" and "Guidelines for Ambulatory Anesthesia and Surgery" as currently promulgated by the American Society of Anesthesiologists.
• The anesthesiologist should be physically present during the intraoperative period and immediately available until the patient has been discharged from anesthesia care.
• Discharge of the patient is a physician responsibility. This decision should be documented in the medical record.
• Personnel with training in advanced resuscitative techniques (e.g., ACLS, PALS) should be immediately available until all patients are discharged home.

• At a minimum, all facilities should have a reliable source of oxygen, suction, resuscitation equipment and emergency drugs. Specific reference is made to the ASA "Guidelines for Nonoperating Room Anesthetizing Locations."
• There should be sufficient space to accommodate all necessary equipment and personnel and to allow for expeditious access to the patient, anesthesia machine (when present) and all monitoring equipment.
• All equipment should be maintained, tested and inspected according to the manufacturer's specifications.
• Back-up power sufficient to ensure patient protection in the event of an emergency should be available.
• In any location in which anesthesia is administered, there should be appropriate anesthesia apparatus and equipment which allow monitoring consistent with ASA "Standards for Basic Anesthetic Monitoring" and documentation of regular preventive maintenance recommended by the manufacturer.
• In an office where anesthesia services are to be provided to infants and children, the required equipment, medication and resuscitative capabilities should be appropriately sized for a pediatric population.

• All facility personnel should be appropriately trained in and regularly review the facility’s written emergency protocols.
• There should be written protocols for cardiopulmonary emergencies and other internal and external disasters such as fire.

• The facility should have medications, equipment and written protocols available to treat malignant hyperthermia when triggering agents are used.

The facility should have a written protocol in place for the safe and timely transfer of patients to a prespecified alternate care facility when extended or emergency services are needed to protect the health or well-being of the patient.

Copyright ©1999 American Society of Anesthesiologists.

All rights reserved.