A. Scope
1. Level III Office Surgery is that surgery
which involves, or might foreseeably require, the use of a general anesthesia
or major conduction anesthesia and perioperative sedation. This includes the
use of:
i. Intravenous sedation beyond that
defined for Level II office surgery;
ii. General Anesthesia: loss of consciousness
and loss of vital reflexes with probable requirement of external support of
pulmonary or cardiac functions; or
iii. Major Conduction
anesthesia.
2. Only
patients classified under the American Society of Anesthesiologist's (ASA) risk
classification criteria as Class I, II, or III are appropriate candidates for
Level III office surgery. For ASA Class III patients, the surgeon must document
in the patient's record the justification for an office procedure rather than
other surgical venues. The record must also document precautions taken that
make the office a preferred venue for the particular procedure to be
performed.
B. Transfer
Agreement Required
The surgeon must have a written transfer agreement from a
licensed hospital within reasonable proximity. The transfer agreement must
include physician coverage of transferred patients if the physician does not
have privileges at the hospital. Level of Anesthetic
1. General Anesthetic: loss of consciousness
and loss of vital reflexes with probable requirement of external support of
pulmonary or cardiac functions.
2.
Major Conduction: epidural, spinal, caudal or any block of a nerve or plexus
more proximal than the hip or shoulder joint including visceral nerve blocks.
C. Training Required
1. To perform office based surgery, the
physician must be able to document satisfactory completion of surgical training
such as board certification or board eligibility by a board approved by the
American Board of Medical Specialties or American Board of Osteopathic
Specialties. The certification should include training in the procedures
performed in the office setting. Alternative credentialing for procedures
outside the physician's core curriculum must be applied for through the
Mississippi State Board of Medical Licensure and reviewed by a multi-specialty
board appointed by the Executive Director.
2. In addition to the surgeon there must be
at least one assistant certified in Basic Life Support present during any Level
II or III procedure. There should be at least one person certified in Advanced
Cardiac Life Support present during any Level II or III procedure unless there
is an anesthesiologist or certified registered nurse anesthetist to manage the
anesthetic.
3. Emergency
procedures related to serious anesthesia complications should be formulated,
periodically reviewed, practiced, updated, and posted in a conspicuous
location.
D. Equipment
and Supplies Required
1. Equipment,
medication and monitored post-anesthesia recovery must be available in the
office. If anesthetic agents include inhaled agents, other than nitrous oxide,
medications must include a stock of no less than 12 vials of Dantrolene.
2. The facility, in terms of
general preparation, equipment, and supplies, must be comparable to a free
standing ambulatory surgical center, including, but not limited to, recovery
capability, and must have provisions for proper record keeping.
3. Blood pressure monitoring equipment; EKG;
end tidal CO2 monitor; pulse oximeter, precordial or esophageal stethoscope,
emergency intubation equipment and a temperature monitoring device must be
available for all phases of perioperative care.
4. Table capable of Trendelenburg and other
positions necessary to facilitate the surgical procedure.
5. IV solutions and IV equipment.
6. All equipment and supplies listed under
Part 2635, Rule
2.5, Level II.
E. Assistance of Other Personnel Required
An anesthesiologist or certified registered nurse
anesthetist must administer the general or regional anesthesia and a physician,
registered nurse, licensed practical nurse, or operating room technician must
assist with the surgery. The anesthesia provider may not function in any other
capacity during the procedure. A licensed physician or a licensed registered
nurse with post-anesthesia care unit experience or the equivalent, and
credentialed in Advanced Cardiac Life Support, or in the case of pediatric
patients, Pediatric Advanced Life Support, must be available to monitor the
patient in the recovery room until the patient has recovered from
anesthesia.
