Standards for Office Based Anesthesia Practice


Certified Registered Nurse Anesthetists (CRNAs) have long been the predominant anesthesia professional and leaders in providing anesthesia services in physicians’ offices. As the professional organization representing nurse anesthetists, the American Association of Nurse Anesthetists (AANA) advocates high quality, appropriate standards of care for all patients in all settings, including the office based practice setting. As in other settings, CRNAs provide anesthesia working with physicians such as surgeons, anesthesiologists and, where authorized, podiatrists, dentists and other healthcare professionals.

The AANA has been at the forefront in establishing clinical practice standards, including patient monitoring standards. The standards for care in the office based setting are congruent with the AANA Scope and Standards for Nurse Anesthesia Practice and are intended to:

  1. Provide assistance to CRNAs and other practitioners by promoting a common base for the delivery of quality patient care in the office based setting.
  2. Assist the public in understanding what to expect from the practitioner.
  3. Support the basic rights of patients.

Although the standards are intended to promote high quality patient care, they cannot assure specific outcomes.

There may be exceptional patient-specific circumstances that require deviation from a standard.  The CRNA shall document any deviations from these standards (e.g., surgical interventions or procedures that invalidate application of a monitoring standard) and state the reason for the deviation on the patient’s anesthesia record.

Anesthesia in the Office Setting
There are some unique and specific responsibilities that should be considered prior to 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 the planned surgical procedures and the condition of the patient. Most office based practice settings are not regulated, therefore the CRNA should consider the benefit of uniform professional standards regarding practitioner qualifications and training, equipment, facilities and policies that ensure the safety of the patient during operative and anesthesia procedures in the office setting. 

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

  1. Patient selection criteria
  2. Monitoring equipment with a back up electrical source
  3. Adequate numbers of well trained personnel to support the planned surgery and anesthesia
  4. The treatment of foreseeable complications
  5. Patient transfer to other healthcare facilities
  6. Infection control practices, including OSHA requirements
  7. Minimal preoperative testing, including required consultations
  8. Ancillary services (e.g., laboratory, pharmacy, consultation with outside specialists)
  9. Equipment maintenance
  10. Response to fire and other catastrophic events
  11. Recovery and discharge of patients
  12. Procedures for follow-up care

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

Section I

Standard I
Perform and document a thorough preanesthesia assessment and evaluation.

Application to Office Practice
Preanesthesia assessment of the patient undergoing office based surgery should include documentation of at least:

  1. assigned physical status
  2. airway assessment
  3. previous anesthetic history
  4. allergies
  5. fasting status
  6. history and physical
Standard II
Obtain and document informed consent for the planned anesthetic intervention from the patient or legal guardian, or verify that an informed consent has been obtained and documented by a qualified professional.
 

Application to Office Practice
The CRNA shall confirm that consent has been given for the planned surgical or diagnostic procedure and that the patient understands and accepts the plans and inherent risks for anesthesia in the office setting.

Standard III
Formulate a patient-specific plan for anesthesia care.
 

Application to Office Practice
A patient specific plan of care is based on patient assessment and the anticipation of potential problems in the unique setting. The operating practitioner concurs that the patient is cleared for the planned anesthetic.

Standard IV
Implement and adjust the anesthesia care plan based on the patient’s physiologic status. Continuously assess the patient’s response to the anesthetic, surgical intervention, or procedure.  Intervene as required to maintain the patient in optimal physiologic condition.

Application to Office Practice
The CRNA shall continuously assess and monitor the patient’s response to the anesthetic. Prior to administration of anesthesia the CRNA shall verify a means to deliver positive pressure ventilation and treat emergency situations including availability of necessary emergency equipment and drugs. If "triggering agents" associated with malignant hyperthermia are used, adequate dosages of dantrolene should be immediately accessible. (For malignant hyperthermia resources, see the Malignant Hyperthermia Association of the United States (MHAUS) at www.mhaus.org; Emergency 24 hour hotline: 800-644-9737)

Standard V
Monitor, evaluate, and document the patient’s physiologic condition as appropriate for the type of anesthesia and specific patient needs. When any physiological monitoring device is used, variable pitch and threshold alarms shall be turned on and audible. The CRNA should attend to the patient continuously until the responsibility of care has been accepted by another anesthesia professional.

  1. Oxygenation
    Continuously monitor oxygenation by clinical observation and pulse oximetry. If indicated, continually monitor oxygenation by arterial blood gas analysis.
  2. Ventilation
    Continuously monitor ventilation. Verify intubation of the trachea or placement of other artificial airway devices by auscultation, chest excursion, and confirmation of expired carbon dioxide. Use ventilatory pressure monitors as indicated. Continuously monitor end-tidal carbon dioxide during controlled or assisted ventilation and any anesthesia or sedation technique requiring artificial airway support. During moderate or deep sedation, continuously monitor for the presence of expired carbon dioxide.
  3. Cardiovascular
    Continuously monitor cardiovascular status via electrocardiogram. Perform auscultation of heart sounds as needed. Evaluate and document blood pressure and heart rate at least every five minutes.
  4. Thermoregulation
    When clinically significant changes in body temperature are intended, anticipated, or suspected, monitor body temperature in order to facilitate the maintenance of normothermia.
  5. Neuromuscular
    When neuromuscular blocking agents are administered, monitor neuromuscular response to assess depth of blockade and degree of recovery.
  6. Positioning
    Monitor and assess patient positioning and protective measures, except for those aspects that are performed exclusively by one or more other providers.

Interpretation
Continuous clinical observation and vigilance are the basis of safe anesthesia care. Consistent with the CRNA's professional judgment, additional means of monitoring the patient’s status may be used depending on the needs of the patient, the anesthesia being administered, or the surgical technique or procedure being performed.

Application to Office Practice
Minimum monitors in the office based setting 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 general anesthesia; a monitor for the presence of expired carbon dioxide when administering moderate or deep 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.

Standard VI
Document pertinent anesthesia-related information on the patient’s medical record in an accurate, complete, legible, and timely manner. 

Application to Office Practice
The CRNA confirms there is a plan for accurate record keeping and documentation of the following:

  1. informed consent
  2. preanesthesia and postanesthesia evaluations
  3. course of the anesthesia, including monitoring modalities and drug administration, dosages and wastages
  4. discharge follow-up

The CRNA shall confirm that there is a systematic mechanism for documentation of compliance with U.S. Drug Enforcement Agency rules, Board of Pharmacy regulations, Food and Drug Administration requirements, and U.S. Department of Transportation regulations for accountability and appropriate storage.  

Documentation of provider licensure and credentials, facility licensure, and continued competence is recommended.

Standard VII
Evaluate the patient’s status and determine when it is safe to transfer the responsibility of care. Accurately report the patient’s condition, including all essential information, and transfer the responsibility of care to another qualified healthcare provider in a manner that assures continuity of care and patient safety.

Application to Office Practice
Postanesthesia care is consistent with other practice settings in that there is a designated area staffed with appropriately trained personnel. At least one qualified provider—a surgeon, anesthesia professional, or ACLS-certified registered nurse—should remain in the facility until all patients are discharged. An accurate postanesthesia record is documented.

Standard VIII
Adhere to appropriate safety precautions as established within the practice setting to minimize the risks of fire, explosion, electrical shock and equipment malfunction. Based on the patient, surgical intervention or procedure, ensure that the equipment reasonably expected to be necessary for the administration of anesthesia has been checked for proper functionality and document compliance. When the patient is ventilated by an automatic mechanical ventilator, monitor the integrity of the breathing system with a device capable of detecting a disconnection by emitting an audible alarm. When the breathing system of an anesthesia machine is being used to deliver oxygen, the CRNA should monitor inspired oxygen concentration continuously with an oxygen analyzer with a low concentration audible alarm turned on and in use.

Application to Office Practice
The CRNA confirms equipment is routinely maintained by appropriately trained professionals. Prior to use, equipment is inspected for risk of malfunction and electrical/fire hazards.

Standard IX
Verify that infection control policies and procedures for personnel and equipment exist within the practice setting.  Adhere to infection control policies and procedures as established within the practice setting to minimize the risk of infection to the patient, the CRNA, and other healthcare providers.

Application to Office Practice
The CRNA shall confirm that policies are in place and a process exists to document compliance with Occupational Safety and Healthcare Administration (OSHA) standards relating to blood borne pathogens; medical waste and hazardous materials; personal protection devices; and disposal of needles, syringes and contaminated supplies.

Standard X
Participate in the ongoing review and evaluation of anesthesia care to assess quality and appropriateness.

Application to Office Practice
Prior to administration of any anesthetic in an office facility, the CRNA shall review the AANA minimal elements (Section II) and evaluate for compliance and applicability to the setting. The CRNA shall participate in assessment and review of appropriateness of anesthesia care provided in the office setting. There should be a process to document patient satisfaction and outcomes.

Standard XI
Respect and maintain the basic rights of patients.

Application to Office Practice
The CRNA shall act as the patient’s advocate. The patient has the right to dignity, respect and consideration of legitimate concerns in the office setting. Patients should be involved with all aspects of their care.

Section II
Supplemental Resources

Minimum Elements for Providing Anesthesia Services in the Office Based Practice Setting
Assessment Checklist
 
Practitioners
CRNA
  • Will the Board of Nursing and state laws allow the CRNA to work with this physician type?
  • Will your liability insurance cover office anesthesia?
  • Does the state have rules/regulations specific to office-based anesthesia?
    • What classes of patients, types of surgical procedures, and anesthesia will be performed?
    • Are there established policy and procedure processes in place?
Operating Physician
  • Does the physician have liability coverage and a current licensure/Drug Enforcement Agency (DEA) number?
  • Does the physician have hospital privileges for procedures?
  • Does the physician have admitting privileges at the nearest hospital?
Facility
  • Is the facility licensed?
    • By whom?  Indicate name:_______________________
  • Is the facility accredited?
    • By whom?  Indicate name:_______________________
  • Size of operating room (OR), recovery room, and preoperative area adequate for anesthesia and surgical procedures?
  • Is there a transfer agreement?
  • Does the facility have an emergency service agreement?
  • Available communication resources: Are telephone numbers accessible and posted for Emergency Medical Services (EMS), Malignant Hyperthermia (MH) hotline, nearby hospital, etc.?
Equipment
Local, Intravenous Sedation, Regional and General Anesthesia
  • 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 general anesthesia; a monitor for the presence of expired carbon dioxide when administering moderate or deep 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 patient, procedure and type of anesthesia
  • 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 patient population
  • Defibrillator (charged)
  • Suction machine, tubing, suction catheters, and Yankaur suctions
  • Accessible anesthesia storage unit to provide for organization of supplies including endotracheal equipment, masks, airways, syringes, needles, intravenous catheters, intravenous fluids and tubing, alcohol, stethoscopes, and medications appropriate for patient population
  • 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. 
General Anesthesia
  • An authorized factory technician or qualified service personnel has documented that the anesthesia machine(s) and monitoring equipment are operable.

    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 airway
      • Face mask (appropriate for patient)
      • Laryngoscopes, endotracheal tubes (adult and pediatric)
      • Ambu bag or other positive pressure ventilation device
    • Difficult airway equipment (laryngeal mask airway, light wand, cricothyrotomy kit)
    • Defibrillator
    • Supplemental O2
    • Emergency drugs
    • Compression board
    • Suction equipment (suction catheter, Yankaur type)
    • Drugs and equipment to treat MH on site
  • Back-up power 
Pharmaceutical Accountability
  • Is there an appropriate mechanism for documenting and tracking use of pharmaceuticals including controlled substances?
    • Lock box
    • DEA 222 forms
    • Count sheets
    • Waste policy
    • Expiration checklist or policy
Policies/Procedures and Protocols
  • Policies/procedures and protocols are in place regarding:
    • Preoperative lab requirements
    • Patient selection
    • Nothing by mouth (NPO) status
    • 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
    • Reporting adverse reactions
    • Infection control in adherence to OSHA rules for control of medical waste, and CDC recommendations for disposal of sharps and personal protection
  • Compliance with HIPAA patient information protection
Record Keeping
  • Record-keeping system in place for  patients and providers
  • Anesthesia record
  • Consent forms
  • Credentials
  • Q/A mechanism
  • Patient satisfaction/followup  
  • Preanesthesia equipment and supplies
  • Purchasing agreements
Personnel
  • OR 
    • RN  
    • LPN  
    • OR technician
  • PACU  
    • RN
    • LPN
    • Anesthetist/surgeon
  • ACLS certified
    • Surgeon
    • Anesthetist
    • RN
  • BCLS certified
    • RN
    • LPN
    • 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
  • Back-up power
  • 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 no._____
  • Leak test and other tests performed as indicated
  • Oxygen analyzer is on
  • Capnometer connected
  • Temperature monitor available
  • Emergency airways available, i.e., laryngeal mask airway, combitube, or cricothyrotomy kit
  • Succinylcholine
  • Dantrolene
  • Other anesthesia medications as indicated
 
Note (if problem): ____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Follow-up (who, what):_________________________________________________________

Resources
1. Scope and Standards for Nurse Anesthesia Practice. American Association of Nurse Anesthetists. Park Ridge, IL: 2012.
2. Standards and Checklist for Accreditation of Ambulatory Surgery Facilities. Mundelein, Ill:  American Association for Accreditation of Ambulatory Surgery Facilities, Inc. Accreditation Office; 1997.
3. Accreditation Handbook for Ambulatory Health Care. Skokie, Ill: Accreditation Association for Ambulatory Health Care, Inc.; 1998.
4. Center for Healthcare Environmental Management.  Special Report: Physician Office Safety Guide. Plymouth Meeting, Pa: ECRI; 1998.
5. A Crosswalk Between the American College of Surgeons’ Guidelines for Optimal Office-based Surgery and the Joint Commissions’ Ambulatory Care Standards. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 1998.
6. Guidelines for Optimal Office-based Surgery. 2nd ed. Chicago, Ill: American College of Surgeons; 1996.
7. Carroll R, ed. American Society for Healthcare Risk Management. Risk Management Handbook. Chicago, Ill: AHA Publishing, Inc; 1997.
8. Patient Assessment. Parameters of Care for Oral and Maxillofacial Surgery. Rosemont, Ill: American Association of Oral and Maxillofacial Surgeons. 1995;53(9):1-29.
9. The Use of Conscious Sedation, Regional Anesthesia and General Anesthesia in Dentistry. Chicago, Ill: American Dental Association; 1998.
10. Malignant Hyperthermia Association of the United States.  Available at: http://www.mhaus.org. Accessed March 11, 1999.
 
 

Approved by the AANA Board of Directors in 1999.
Revised by the AANA Board of Directors in 2001, 2002, November 2005, and January 2013.