22 Tex. Admin. Code § 173.3 - Specific Requirements Based on Level of Anesthesia Provided

In addition to the general standards that apply to all outpatient settings, the following standards are required for outpatient settings, based upon the level of anesthesia being administered. If personnel and equipment meet the requirements of a higher-level, lower-level anesthesia services may also be provided.

(1) Level I Services:

(A) A physician and at least one other personnel must be present during the procedure. Both the physician and the personnel must be currently certified by AHA or ASHI, at a minimum in BLS.

(B) The following age-appropriate equipment must be present:

(i) a bag mask valve; and

(ii) oxygen.

(2) Level II services:

(A) A physician and at least one other personnel must be present during the procedure and recovery until ready for discharge. The physician must be currently certified by AHA, ASHI, or ASA in ACLS, PALS, or PeRLS as appropriate. The additional personnel member(s) must be currently certified by AHA or ASHI, at a minimum in BLS.

(B) A crash cart must be present containing drugs and equipment necessary to carry out ACLS protocols, including, but not limited to:

(i) the age-appropriate monitoring and emergency equipment required under subsection (b) of this section;

(ii) first line cardiac medications, including epinephrine, atropine, adreno-corticoids, and antihistamines;

(iii) benzodiazepines for intravenous or intramuscular administration;

(iv) lipid emulsion to treat local anesthetic systemic toxicity, if administering local anesthesia, peripheral nerve blocks, or both in a total dosage amount that exceeds 50 percent of the recommended maximum safe dosage per outpatient visit (except for Mohs micrographic surgery), or if administering tumescent anesthesia; and

(v) specific reversal agents, Flumazenil and Naloxone, if benzodiazepines or narcotics are used for sedation.

(3) Level III services:

(A) A physician and at least one other personnel must be present during the procedure and recovery until ready for discharge. The physician must be currently certified by AHA, ASHI, or ASA in ACLS or PALS, or PeRLs as appropriate. The additional personnel member(s) must be currently certified by AHA, ASHI, or ASA in ACLS, PALS, or PeRLS, as appropriate.

(B) A crash cart must be present containing the same drugs and equipment required for Level II, and a backup cylinder of oxygen, except for lipid emulsion.

(C) Intravenous access must be established.

(D) Providers must adhere to ASA Standards for Post Anesthesia Care.

(4) Level IV services: Level IV services do not require physicians to maintain a stock of lipid emulsion. Physicians who provide Level IV anesthesia services in outpatient settings shall follow current, applicable standards and guidelines as put forth by the American Society of Anesthesiologists (ASA) including, but not limited to, the following listed in subparagraphs (A) - (I) of this paragraph:

(A) Basic Standards for Preanesthetic Care;

(B) Standards for Basic Anesthetic Monitoring;

(C) Standards for Post Anesthesia Care;

(D) Position on Monitored Anesthesia Care;

(E) The ASA Physical Status Classification System;

(F) Guidelines for Nonoperating Room Anesthetizing Locations;

(G) Guidelines for Ambulatory Anesthesia and Surgery;

(H) Guidelines for Office-Based Anesthesia; and

(I) Practice sites shall maintain a separate oxygen cylinder as a secondary supply.

Notes

22 Tex. Admin. Code § 173.3

The provisions of this §173.3 adopted to be effective March 5, 2000, 25 TexReg 1623; amended to be effective November 3, 2002, 27 TexReg 10026; amended to be effective November 30, 2003, 28 TexReg 10489; amended to be effective July 3, 2007, 32 TexReg 3993; amended to be effective May 12, 2008, 33 TexReg 3741; amended to be effective March 7, 2012, 37 TexReg 1514; Amended by Texas Register, Volume 47, Number 26, July 1, 2022, TexReg 3820, eff. 7/7/2022; Adopted by Texas Register, Volume 50, Number 02, January 10, 2025, TexReg 0358, eff. 1/9/2025