South Carolina Task Force Targets Office Anesthesia Safety

Jeanna Havidich, MD

With patient safety as a prime driving force, in February of 2000, the South Carolina Medical Association and the South Carolina Board of Medicine formed a task force to propose guidelines for office-based surgical procedures. The task force consisted of twenty-one physicians representing eleven specialties. Members of the task force included the leadership of state societies, two members from the Board of Medicine, three nurse anesthetists, an anesthesiologist with expertise in local anesthetic toxicity, and a physician-attorney. Dr. Hector Vila, an anesthesiologist practicing in Anderson, SC, chaired the task force. The primary goal of the task force was to insure that all patients in South Carolina receive high quality anesthesia and surgical care, regardless of venue. Patient safety issues were the foremost concern for all members of the task force. The task force also sought to avoid unnecessary administrative and economic burdens. In addition, uniform professional standards would be provided for all physicians participating in office-based surgical procedures.

Over the next 8 months, members of the task force implemented over 80 modifications to the proposed guidelines. This document, which is over 20 pages in length, is divided into several sections addressing office administration, standards for office procedures, credentialing, patient admission and discharge, and a patient Bill of Rights. Outpatient offices are classified into three levels based upon the anesthesia required and the complexity of the surgical procedure.

Level I office surgery includes minor surgical procedures performed under topical or local anesthesia. Only medications providing minimal anxiolysis are permitted. The risk of anesthetic or surgical complications during these procedures is extremely remote. These offices should maintain basic emergency equipment including a reliable oxygen source, airway equipment, suction, and a positive pressure ventilation device. In addition, resuscitative drugs must be available to treat an inadvertent intravascular injection of local anesthetic or an anaphylactic reaction to medications administered. Monitors, including a non-invasive blood pressure cuff and pulse oximetry, are recommended if there is a possibility of complications that may compromise the patient’s hemodynamic status.

Level II office surgery includes any procedure requiring the administration of minimal or moderate sedation as defined by the ASA House of Delegates. The surgical procedures are considered low-risk, and the risk of complications is remote. Level III surgical procedures require the use of deep sedation/analgesia, general anesthesia, or major regional conduction blockade. Both Level II and Level III offices must be accredited by the Joint Commission for Accreditation of Health Care Organizations (JCAHO), the Accreditation Association for Ambulatory Health Care (AAAHC), or the American Association for Ambulatory Surgical Facilities (AAASF). All basic emergency equipment and monitoring standards are applicable, as described above. In addition, these offices must participate in performance improvement programs, possess emergency transfer protocols, infection control policies, malpractice coverage, and documentation of credentials of all personnel involved in patient care.

Specific qualifications of each practitioner involved in patient care are outlined in this document. Surgeons should possess privileges at a local hospital or ambulatory surgical facility to perform the same or similar surgical procedures or demonstrate an appropriate level of training and experience for the specific surgical procedure performed. A physician qualified by law, regulation, or hospital appointment to administer or medically direct the administration of the anesthetic must be physically present throughout the perioperative period. The physician is responsible for conducting an appropriate physical exam and prescribing the anesthesia. Certified registered nurse anesthetists (CRNAs) participating in the administration of anesthesia should collaborate with the physician in the evaluation of the patient. Registered nurses who administer conscious sedation must have documented competency to enable them to assist in any support or resuscitation measures. Individuals who are providing anesthesia and/or monitoring the patient cannot assist the surgeon in performing the surgical procedure. It is recommended that the surgeon and one other individual possess certification in Advanced Cardiac Life Support (ACLS).

Upon completion of the surgical procedure, the physician who administered or medically directed the anesthesia should evaluate the patient prior to transferring the care to a qualified licensed nurse. The nurse assuming care of the patient should be certified in Advanced Cardiac Life Support and qualified to identify surgical and anesthetic complications that may occur during the postoperative period. Discharge criteria should include confirmation of stable vital signs, return to preoperative mental status, adequate pain control, and minimal bleeding, nausea, or vomiting. The patient should be discharged in the company of a competent adult. Information regarding postoperative complications and the designated treatment facility in the event of an emergency should be provided prior to discharge.

These guidelines were presented to the South Carolina Medical Association Board of Trustees, the Inter-specialty Council, and the SCMA House of Delegates. After considerable discussion and debate, these guidelines were accepted with few recommendations, and submitted to the Board of Medicine. Currently, there are several issues under debate, including the amount of allowable tumescent liposuction and the mandatory reporting of adverse events to the Board of Medicine. Modification of this document will continue as more data regarding patient safety during office-based surgical procedures become available.

Dr. Havidich is Assistant Professor of Anesthesiology, Medical College of South Carolina, and President, South Carolina Society of Anesthesiologists.