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TITLE 22EXAMINING BOARDS
PART 9TEXAS MEDICAL BOARD
CHAPTER 192OFFICE-BASED ANESTHESIA SERVICES
RULE §192.2Provision of Anesthesia Services in Outpatient Settings

(a) The purpose of this chapter is to identify the roles and responsibilities of physicians providing, or overseeing by proper delegation, anesthesia services in outpatient settings and to provide the minimum acceptable standards for the provision of anesthesia services in outpatient settings.

(b) The rules promulgated under this title do not apply to:

  (1) an outpatient setting in which only local anesthesia, peripheral nerve blocks, or both are used in a total dosage amount that does not exceed 50 percent of the recommended maximum safe dosage per outpatient visit;

  (2) any setting physically located outside the State of Texas;

  (3) a licensed hospital, including an outpatient facility of the hospital that is separately located apart from the hospital;

  (4) a licensed ambulatory surgical center;

  (5) a clinic located on land recognized as tribal land by the federal government and maintained or operated by a federally recognized Indian tribe or tribal organization as listed by the United States secretary of the interior under 25 U.S.C. §479-1 or as listed under a successor federal statute or regulation;

  (6) a facility maintained or operated by a state or governmental entity;

  (7) a clinic directly maintained or operated by the United States or by any of its departments, officers, or agencies;

  (8) an outpatient setting where the facility itself is accredited as an office-based surgery facility or treatment room by:

    (A) The Joint Commission relating to ambulatory surgical centers;

    (B) the American Association for Accreditation of Ambulatory Surgery Facilities; or

    (C) the Accreditation Association for Ambulatory Health Care; and

  (9) the performance of Mohs micrographic surgery.

(c) Standards for Anesthesia Services. The following standards are required for outpatient settings providing anesthesia services that are administered within two hours before an outpatient procedure. If personnel and equipment meet the requirements of a higher level, lower level anesthesia services may also be provided.

  (1) Level I services:

    (A) at least two personnel must be present, including the physician who must be currently certified by AHA or ASHI, at a minimum, in BLS; and

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

      (i) bag mask valve; and

      (ii) oxygen.

  (2) Level II services:

    (A) at least two personnel must be present, including the physician who must be currently certified by AHA or ASHI, at a minimum, in ACLS or PALS, as appropriate;

      (i) another person must be currently certified by AHA or ASHI, at a minimum, in BLS; and

      (ii) a licensed health care provider, who may be one of the two required personnel, must attend the patient, until the patient is ready for discharge; and

    (B) a crash cart must be present containing drugs and equipment necessary to carry out ACLS protocols, including, but not limited to, the following age-appropriate equipment:

      (i) bag mask valve and appropriate airway maintenance devices;

      (ii) oxygen;

      (iii) AED or other defibrillator;

      (iv) pre-measured doses of first line cardiac medications, including epinephrine, atropine, adreno-corticoids, and antihistamines;

      (v) IV equipment;

      (vi) pulse oximeter;

      (vii) EKG Monitor;

      (viii) benzodiazepines for intravenous or intramuscular administration; and lipid emulsion if, (except as provided by subsection (b)(9) of this section) 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, or if administering tumescent anesthesia, for treating local anesthetic systemic toxicity; and

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

  (3) Level III services:

    (A) at least two personnel must be present, including the physician who must be currently certified by AHA or ASHI, at a minimum, in ACLS or PALS, as appropriate;

      (i) another person must be currently certified by AHA or ASHI, at a minimum, in BLS;

      (ii) a licensed health care provider, which may be either of the two required personnel, must attend the patient, until the patient is ready for discharge; and

      (iii) a person, who may be either of the two required personnel, must be responsible for monitoring the patient during the procedure; and

    (B) except for lipid emulsion, the same drugs and equipment required for Level II;

    (C) establishment of a working intravenous feed;

    (D) the presence of appropriate antagonists (i.e. Naloxone and Flumazenil); and

    (E) adherence to ASA Standards for Postanesthesia Care.

  (4) Level IV services: Physicians who practice medicine in this state and who administer anesthesia or perform a procedure for which anesthesia services are provided in outpatient settings at Level IV are not required to stock lipid emulsion. Physicians who practice medicine in this state and who administer anesthesia or perform a procedure for which anesthesia services are provided in outpatient settings at Level IV 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) - (H) of this paragraph:

    (A) Basic Standards for Preanesthesia Care;

    (B) Standards for Basic Anesthetic Monitoring;

    (C) Standards for Postanesthesia 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; and

    (H) Guidelines for Office-Based Anesthesia.

(d) A physician delegating the provision of anesthesia or anesthesia-related services to a certified registered nurse anesthetist shall be in compliance with ASA standards and guidelines when the certified registered nurse anesthetist provides a service specified in the ASA standards and guidelines to be provided by an anesthesiologist.

(e) In an outpatient setting, where a physician has delegated to a certified registered nurse anesthetist the ordering of drugs and devices necessary for the nurse anesthetist to administer an anesthetic or an anesthesia-related service ordered by a physician, a certified registered nurse anesthetist may select, obtain and administer drugs, including determination of appropriate dosages, techniques and medical devices for their administration and in maintaining the patient in sound physiologic status. This order need not be drug-specific, dosage specific, or administration-technique specific. Pursuant to a physician's order for anesthesia or an anesthesia-related service, the certified registered nurse anesthetist may order anesthesia-related medications during perianesthesia periods in the preparation for or recovery from anesthesia. In providing anesthesia or an anesthesia-related service, the certified registered nurse anesthetist shall select, order, obtain and administer drugs which fall within categories of drugs generally utilized for anesthesia or anesthesia-related services and provide the concomitant care required to maintain the patient in sound physiologic status during those experiences.

(f) The anesthesiologist or physician providing anesthesia or anesthesia-related services in an outpatient setting shall perform a pre-anesthetic evaluation, counsel the patient, and prepare the patient for anesthesia per current ASA standards. If the physician has delegated the provision of anesthesia or anesthesia-related services to a CRNA, the CRNA may perform those services within the scope of practice of the CRNA. Informed consent for the planned anesthetic intervention shall be obtained from the patient/legal guardian and maintained as part of the medical record. The consent must include explanation of the technique, expected results, and potential risks/complications. Appropriate pre-anesthesia diagnostic testing and consults shall be obtained per indications and assessment findings. Pre-anesthetic diagnostic testing and specialist consultation should be obtained as indicated by the pre-anesthetic evaluation by the anesthesiologist or suggested by the nurse anesthetist's pre-anesthetic assessment as reviewed by the surgeon. If responsibility for a patient's care is to be shared with other physicians or non-physician anesthesia providers, this arrangement should be explained to the patient.

Cont'd...

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