Office Based Anesthesia by aanapublishing

Office-Based Anesthesia Position Statement

Certified Registered Nurse Anesthetists (CRNAs), also referred to as nurse anesthesiologists or nurse anesthetists, have long been the predominant anesthesia professional and leaders in providing anesthesia services in ambulatory or office settings. As the professional organization representing CRNAs/nurse anesthesiologists, the American Association of Nurse Anesthesiology (AANA) advocates high-quality, appropriate standards of care for all patients in any environment where anesthesia is delivered, including the office-based practice setting. As in other settings, CRNAs/nurse anesthesiologists work collaboratively with professional colleagues such as physicians, surgeons, physician anesthesiologists, and, where authorized, podiatrists, dentists, and other healthcare professionals to deliver anesthesia to patients requesting or requiring such services.

AANA has been at the forefront in establishing clinical practice standards, including patient monitoring standards. The document for care in the office setting is congruent with the AANA Standards for Nurse Anesthesia Practice and the AANA Dental Office Sedation and Anesthesia Care Position Statement. These documents are intended to support the delivery of patientcentered, consistent, high-quality, and safe anesthesia care and assist the public in understanding the CRNA’s role in anesthesia care.

Although this position statement is intended to promote high-quality patient care, it cannot ensure specific outcomes. There may be patient-specific circumstances (e.g., informed consent for emergency cases that may be difficult to obtain, mass casualty incidents) that require modification. The CRNA must document modifications in the patient’s healthcare record, along with the reason for the modification. When integrating new technologies or skills into practice, the CRNA will obtain any necessary education and evidence competency.

Anesthesia in the Office Setting

There are some unique and specific responsibilities that should be considered prior to the administration of anesthesia in the office setting. When considering an office-based practice, anesthesia professionals should determine if there are appropriate resources to manage the various levels of anesthesia for planned surgical and invasive procedures and patient conditions. Some office-based practice settings are not regulated. Therefore, the CRNA should have the appropriate education, training, and experience for the specific setting and the patient population. Additionally, the CRNA should work with facility leadership to ensure that the facility, its equipment, and its policies can support the patient's safety during surgical, invasive and anesthesia procedures in the office setting.

At a minimum, the CRNA must determine that there are policies to address:

a. Patient selection criteria

b. Preoperative testing, patient verification, assessment and evaluation, site marking, timeout, and appropriate consultations

c. Monitoring equipment with a sufficient backup electrical source to power life-support systems for a minimum of 2 hours is recommended

d. Adequate numbers of appropriately trained personnel to support the planned surgery/procedure and anesthetic plan, including patient preoperative preparation,

intraoperative management, and postoperative recovery and the treatment of foreseeable complications

e. Accessibility and suitability of emergency drugs and resuscitative equipment, as deemed appropriate based on the facility’s patient population and needs, and procedures performed according to the anesthesia professional’s experience with the patient population

f. Patient transfer to other healthcare facilities, whether routine, urgent, or emergent

g. Infection prevention and control practices,1 including Occupational Safety and Health Administration (OSHA),2 Centers for Disease Control and Prevention (CDC), and state and local requirements3

h. Ancillary services (e.g., laboratory, pharmacy, consultation with outside specialists)

i. Equipment maintenance

j. Response to fire, safety, and other catastrophic events

k. Recovery and discharge of patients

l. Procedures for follow-up care

The CRNA must comply with all applicable laws, rules, and regulations relating to licensure, certification, and accreditation of an office practice.

AANA Supporting Documents and Resources:

• Standards for Nurse Anesthesia Practice

• Code of Ethics for the Certified Registered Nurse Anesthetist

• Documenting Anesthesia Care

• Infection Prevention and Control Guidelines for Anesthesia Care

• Facility Accreditation Resources

• Facility Considerations

Adopted by the AANA Board of Directors March 2019 Revised by the AANA Board of Directors Feb 2025

Minimum Elements for Providing Anesthesia Services in the OfficeBased Practice Setting Assessment Checklist

Practitioners

CRNA

 Will the Board of Nursing and local/state laws and regulations allow the CRNA to work with the specific proceduralist/operating clinician type?

 Will liability insurance cover office anesthesia?

 Is prescriptive authority or a Drug Enforcement Agency (DEA) license required?

 Are there specific local/state laws and regulations that regulate office-based anesthesia?

 Is the patient population appropriate for the type/complexity/duration of procedures/surgeries and anesthesia to be performed?

 Are established policies and procedures in place?

 Are anesthesia procedures performed within the scope of practice of the CRNA and capabilities of the facility?

 How does reimbursement work? Follow the specific local, state, and federal reimbursement laws and regulations.

Proceduralist/Operating Clinician

 Does the proceduralist/operating clinician have an active and unencumbered license?

 Does the operating clinician/proceduralist have privileges to perform the same procedure in the hospital as in the office setting or has the operating clinical/proceduralist provided a sufficient explanation for the lack thereof? Consider if the operating clinician/proceduralist can demonstrate that loss of, or inability to obtain such privileges was not related to lack of clinical competence, ethical issues, or problems other than economic competition.

 Are there any additional requirements that restrict the level of sedation or anesthesia that the CRNA may use to the level that the operating clinician is authorized to use, e.g., dental anesthesia/sedation permits?

 Does the proceduralist/operating clinician have liability coverage and a current DEA number?

 Does the proceduralist/operating clinician have admitting privileges at the nearest hospital?

 Are procedures or surgeries performed within the scope of practice of the proceduralist/operating clinician and the capabilities of the facility?

Facility

 Is the facility licensed or registered?

 By whom? Indicate name:________________________

 Is the facility accredited?

 By whom? Indicate name:________________________

 Is the size of the operating room (OR), recovery room, and preoperative area adequate for anesthesia and surgical procedures, including for all necessary equipment and personnel?

 Does the facility make space and equipment available as needed for the provision of care, treatment, or services (e.g., sufficient electrical outlets needed for anesthesia equipment)?

 Does the facility have an effective procedure for the immediate transfer, to a hospital, of patients requiring emergency medical care beyond the capabilities of the facility?

 Does the facility have an emergency services agreement?

 Available communication resources: Are telephone numbers accessible and posted for Emergency Medical Services (EMS), Malignant Hyperthermia (MH) hotline, translation services, nearby hospital, etc.?

 Is the facility billing a facility fee?

 Does the facility offer training and have policies and procedures to address compliance with applicable law, such as federal and state anti-fraud laws (e.g., HIPAA (Health Insurance Portability and Accountability Act), Federal Physician Self-Referral Law (Stark Law), Federal Anti-Kickback Statute, Federal False Claims Act)?

Equipment

Local Anesthesia, Intravenous Sedation, Regional and General

All equipment should be maintained, tested and inspected according to the manufacturers’ specifications. Equipment that is appropriate for the unique needs of the patient must be available at the facility.

 Oxygen supplies: Minimum of two oxygen sources must be available with regulators attached

 Continuous positive-pressure ventilation source tested and in working order (e.g., adjustable bag-mask, nonrebreathing units) appropriate to the specific patient population

 Charged automated external defibrillator (AED) or Defibrillator that has recorded monthly function testing, at minimum

 Primary and secondary suction machine, tubing, suction catheters, and Yankauer suctions

 Accessible anesthesia storage unit to provide for the organization of supplies, including endotracheal equipment, masks, airway adjuncts, syringes, needles, intravenous catheters, intravenous fluids and tubing, alcohol, stethoscopes, and medications appropriate for the patient population

 Sufficient lighting to provide necessary illumination of the patient, anesthesia machine, and monitoring equipment

 Emergency resuscitation medications, including at a minimum ACLS or PALS protocol medications, if appropriate, to include atropine, epinephrine, ephedrine, lidocaine, diphenhydramine, cortisone, and a bronchial dilator inhaler

Monitors include: pulse oximetry; electrocardiogram; blood pressure; O2 analyzer when O2 is delivered through the breathing system of the anesthesia machine; end-tidal CO2 when administering sedation or anesthesia; expired carbon dioxide monitoring when administering sedation; a body temperature monitor when clinically significant changes are intended, anticipated, or suspected; and peripheral nerve stimulator as indicated when administering neuromuscular blocking agents. Use of monitors should be appropriate to specific patient population, procedure, and type of anesthesia.

General Anesthesia

 An authorized factory technician or qualified service personnel has documented the anesthesia machine(s) and monitoring equipment is operable and that preventative maintenance has been performed. The following items are available as an integral part of the anesthesia delivery system or equivalent stand-alone equipment:

 O2 fail-safe system

 Oxygen analyzer

 Waste gas exhaust system

 End-tidal CO2 analyzer

 Vaporizers-calibration and exclusion system

 Audible alarm system (variable pitch and low threshold capabilities)

 Pulse oximeter, electrocardiogram, blood pressure monitors

 Temperature monitor as appropriate for patient age, physical status, and surgical procedure

Emergencies

 Emergency equipment

 Basic airway equipment (adult and pediatric)

 Nasal and oral airways of varying sizes appropriate to the patient population

 Face mask (appropriate for the patient)

 Laryngoscopes, endotracheal tubes of varying sizes appropriate to the patient population

 Ambu bag or other positive pressure ventilation device

 Difficult airway equipment (laryngeal mask airway, cricothyrotomy kit, and consider video laryngoscopy equipment)

 Defibrillator

 Supplemental O2

 Emergency drugs

 Compression back-board

 Suction equipment (suction catheter, Yankauer type)

 Drugs and equipment to treat MH on site, unless the facility is an “MH trigger-free site”

 Battery-powered illumination source other than a larynogoscope

 In the event of a LAST incident, the ASRA Checklist for Treatment of Local Anesthetic Systemic Toxicity (LAST) and 20% lipid emulsion should be immediately available4

 Back-up power supply for all lighting, suction, anesthesia, and surgical equipment necessary to complete the procedure

Pharmaceutical Accountability5

For any concerns related to drugs or alcohol, call the AANA Helpline at 800-654-5167 for 24/7, live, and confidential support for yourself, a colleague, or a resident.

 Is there an appropriate mechanism for documenting and tracking use of pharmaceuticals including controlled substances?

 Double locked box

 Count sheets verified at start and end of the surgical day by two licensed professionals

 Waste policy

 Expiration checklist or policy

Policies/Procedures and Protocols

 Policies/procedures and protocols are in place regarding:

 Preoperative lab requirements

 Patient selection (i.e., exclusion criteria by pre-existing medical condition or complications of undue risk)

 Nothing by mouth (NPO) status

o Visit AANA Anesthesia Care of the Patient on a GLP-1 Receptor Agonist

 Discharge criteria

 Case cancellations

 Advanced Cardiac Life Support (ACLS) algorithms

 MH protocols

 Latex allergy protocols

 Pediatric drug dosages

 Emergencies

 Cardiopulmonary

 Chemical spill

 Fire

 Building evacuation

 Bomb threat

 Active shooter incidents

 Impaired CRNA or operating clinician

 Reporting adverse reactions

 Infection prevention and control, including adherence to OSHA rules for control of medical and hazardous waste and CDC recommendations for disposal of sharps and personal protection6

 Compliance with HIPAA patient information protection

Record Keeping

 Record-keeping system in place for patients and providers

 Anesthesia record

o Preanesthesia patient assessment and evaluation

o Anesthesia record

o Postanesthesia assessment and evaluation

 Informed consent

 Credentials and privileges

 Quality assurance and improvement mechanism

 Patient satisfaction/follow-up

 Preanesthesia equipment and supplies

 Purchasing agreements

Staffing Recommendations

 OR/Procedure Room

 RN

 LPN/OR technician

 CRNA cannot perform any other function while administering anesthesia

 PACU

 CRNA/operating clinician/RN

o It is recommended that two licensed personnel with an RN license or higher are in the same area where the patient is receiving Phase 1 care7

 LPN/Medical Assistant (MA)

 Refer to state-specific guidelines for staffing requirements

Required Certification or Recertification

 ACLS/PALS-certified

 Operating clinician recommended

 Anesthesia professional

 RN

 BCLS-certified

 RN

 LPN/MA/OR technician

 Others

Anesthesia Equipment and Supplies Checklist

(To be kept in log book)

Date: Checked-out by:

Location: ________________

 Oxygen pipeline pressure or primary source ________ pounds per square inch

 Oxygen tank pressure (second source) ________ pounds per square inch

 Sufficient back-up power source

 Charged AED or Defibrillator and crash cart available

 Anesthesia cart supplies checked, i.e., intravenous equipment, anesthetics, stethoscope

 Suction equipment tested

 Ambu bag tested

 Electrocardiogram (ECG) operational

 Pulse oximeter operational

 Capnometer operational

 Blood pressure monitor

 Back-up blood pressure cuff

 Atropine

 Epinephrine

 Ephedrine

 Lidocaine

 Other emergency medications as indicated

 Endotracheal equipment, airways

If general anesthesia is planned: Anesthesia machine and/or positive pressure device no._____

 Leak test and other tests performed as indicated

 Oxygen analyzer is on

 Capnometer connected

 Temperature monitor source available

 Emergency airways available, i.e., laryngeal mask airway, combitube, or cricothyrotomy kit

 Paralytic agent and reversal (i.e., succinylcholine or rocuronium/suggamadex)

 Dantrolene/Ryanodex (unless succinylcholine and volatile anesthetics are not in use)

 Other anesthesia medications as indicated

Note (if problem):

Follow-up (who, what):

References

1. Infection Prevention and Control Guidelines for Anesthesia Care. Rosemont, IL: American Association of Nurse Anesthesiology; 2015.

2. Occupational Safety and Health Administration (OSHA). Infectious Diseases. https://www.osha.gov/healthcare/infectious-diseases

3. U.S. Centers for Disease Control and Prevention (CDC). Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. https://www.cdc.gov/healthcareassociated-infections/hcp/prevention-healthcare/outpatientexpectations.html?CDC_AAref_Val=https://www.cdc.gov/HAI/settings/outpatient/outpatientcare-guidelines.html

4. Regional Anesthesia and Analgesia Techniques - An Element of Multimodal Pain Management. Rosemont, IL: American Association of Nurse Anesthesiology; 2018.

5. AmericanAssociation of Nurse Anesthesiology. SecuringPropofol.Position Statement. 2023. https://issuu.com/aanapublishing/docs/15_-_securing_propofol?fr=sZjUzZDU2NDAxMjU

6. American Association of Nurse Anesthesiology. Safe Injection Guidelines for Needle and Syringe Use. 2022.

7. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, New Jersey: American Society of PeriAnesthesia Nurses; 2023-2024. p. 49-51.