| (a) Purpose. The purpose of these rules is to identify the
roles, and responsibilities of certified registered nurse anesthetists authorized
to provide anesthesia services in outpatient settings and to provide the minimum
acceptable standards for the provision of anesthesia services in outpatient
settings.
(1) On or after August 31, 2000 certified registered nurse
anesthetists shall comply with subsections (b)(2)-(e) of this section in order
to be authorized to provide general anesthesia, regional anesthesia, or monitored
anesthesia care in outpatient settings. This requirement shall include certified
registered nurse anesthetists administering any inhaled anesthetic agents,
including, but not limited to, nitrous oxide, due to the significant variability
in patient response to such drugs.
(2) Subsections (b)(2)-(e) of this section do not apply to
the registered nurse anesthetist who practices in the following:
(A) an outpatient setting in which only local anesthesia, peripheral
nerve blocks, or both are used;
(B) an outpatient setting in which only anxiolytics and analgesics
are used and only in doses that do not have the probability of placing the
patient at risk for loss of the patient's life-preserving protective reflexes;
(C) a licensed hospital, including an outpatient facility of
the hospital that is separately located apart from the hospital;
(D) a licensed ambulatory surgical center;
(E) 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. Section 479-1 or as listed under a successor federal
statute or regulation
(F) a facility maintained or operated by a state or governmental
entity;
(G) a clinic directly maintained or operated by the United
States or by any of its departments, officers, or agencies; and
(H) an outpatient setting accredited by
(i) the Joint Commission on Accreditation of Healthcare Organizations
relating to ambulatory surgical centers;
(ii) the American Association for the Accreditation of Ambulatory
Surgery Facilities,
(iii) the Accreditation Association for Ambulatory Health Care.
(b) Roles and Responsibilities
(1) Certified registered nurse anesthetists shall follow current,
applicable standards and guidelines as put forth by the American Association
of Nurse Anesthetists (AANA) and other relevant national standards regarding
the practice of nurse anesthesia as adopted by the AANA or the Board.
(2) Certified registered nurse anesthetists shall comply with
all building, fire, and safety codes. A two-way communication source not dependent
on electrical current shall be available. Each location should have sufficient
electrical outlets to satisfy anesthesia machine and monitoring equipment
requirements, including clearly labeled outlets connected to an emergency
power supply. Sites shall also have a secondary power source as appropriate
for equipment in use in case of power failure.
(3) 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.
(c) Standards
(1) The certified registered nurse anesthetist shall perform
a pre-anesthetic assessment, counsel the patient, and prepare the patient
for anesthesia per current AANA standards. 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.
(2) Physiologic monitoring of the patient shall be determined
by the type of anesthesia and individual patient needs. Minimum monitoring
shall include continuous monitoring of ventilation, oxygenation, and cardiovascular
status. Monitors shall include, but not be limited to, pulse oximetry and
EKG continuously and non-invasive blood pressure to be measured at least every
five minutes. If general anesthesia is utilized, then an O
2 analyzer and end-tidal CO2 analyzer
must also be used. A means to measure temperature shall be readily available
and utilized for continuous monitoring when indicated per current AANA standards.
An audible signal alarm device capable of detecting disconnection of any component
of the breathing system shall be utilized. The patient shall be monitored
continuously throughout the duration of the procedure by the certified registered
nurse anesthetist. Postoperatively, the patient shall be evaluated by continuous
monitoring and clinical observation until stable by a licensed health care
provider. Monitoring and observations shall be documented per current AANA
standards. In the event of an electrical outage which disrupts the capability
to continuously monitor all specified patient parameters, at a minimum, heart
rate and breath sounds will be monitored on a continuous basis using a precordial
stethoscope or similar device, and blood pressure measurements will be reestablished
using a non-electrical blood pressure measuring device until electricity is
restored.
(3) All anesthesia-related equipment and monitors shall be
maintained to current operating room standards. All devices shall have regular
service/maintenance checks at least annually or per manufacturer recommendations.
Service/maintenance checks shall be performed by appropriately qualified biomedical
personnel. Prior to the administration of anesthesia, all equipment/monitors
shall be checked using the current FDA recommendations as a guideline. Records
of equipment checks shall be maintained in a separate, dedicated log which
must be made available upon request. Documentation of any criteria deemed
to be substandard shall include a clear description of the problem and the
intervention. If equipment is utilized despite the problem, documentation
must clearly indicate that patient safety is not in jeopardy. All documentation
relating to equipment shall be maintained for a period of time as determined
by board guidelines.
(4) Each location must have emergency supplies immediately
available. Supplies should include emergency drugs and equipment appropriate
for the purpose of cardiopulmonary resuscitation. This must include a defibrillator,
difficult airway equipment, and drugs and equipment necessary for the treatment
of malignant hyperthermia if "triggering agents" associated with malignant
hyperthermia are used or if the patient is at risk for malignant hyperthermia.
Equipment shall be appropriately sized for the patient population being served.
Resources for determining appropriate drug dosages shall be readily available.
The emergency supplies shall be maintained and inspected by qualified personnel
for presence and function of all appropriate equipment and drugs at intervals
established by protocol to ensure that equipment is functional and present,
drugs are not expired, and office personnel are familiar with equipment and
supplies. Records of emergency supply checks shall be maintained in a separate,
dedicated log and made available upon request. Records of emergency supply
checks shall be maintained for a period of time as determined by board guidelines.
(5) Certified registered nurse anesthetists shall maintain
current competency in advanced cardiac life support and must demonstrate proof
of continued competency upon re-registration with the Board. Competency in
pediatric advanced life support shall be maintained for those certified registered
nurse anesthetists whose practice includes pediatric patients. Certified registered
nurse anesthetists shall verify that at least one person in the setting other
than the person performing the operative procedure maintains current competency
in basic life support (BLS) at a minimum.
Cont'd... |
