Level II Office Surgery

Level II Office Surgery. A. Scope 1. Level II Office Surgery is that in which perioperative medication and sedation are used orally, intravenously, intramuscularly, or rectally. If perioperative or intraoperative medication is administered, intraoperative and postoperative monitoring is required. Such procedures include, but are not limited to: hernia repair, hemorrhoidectomy, reduction of simple fractures, large joint dislocations, breast biopsies, dilatation and curettage, thoracentesis, and colonoscopy. 2. Level II Office surgery also includes any surgery in which the patient is sufficiently sedated to allow the patient to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command and/or tactile stimulation. Patients whose only response is reflex withdrawal from a painful stimulus are sedated to a greater degree than encompassed by this definition. 3. Any procedures that may yield an excessive loss of blood should be covered under Level II. B. Transfer Agreement Required The surgeon must have a written transfer agreement from a licensed hospital within reasonable proximity. The transfer agreement should also include physician coverage of transferred patients if the physician does not have privileges at the hospital. C. Level of Anesthetic Local or peripheral nerve block, including Bier Block, plus intravenous or intramuscular sedation, but with preservation of vital reflexes. D. Training Required 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 Director. 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. E. Equipment and Supplies Required 1. Full and current crash cart at the location the anesthetizing is being carried out. The crash cart must include, at a minimum, the following resuscitative medications, or other resuscitative medication subsequently marketed and available after initial adoption of this regulation, provided said medication has the same FDA approved indications and usage as the medications specified below: i. Adrenalin (epinephrine) Abboject 1mg-1:10,000; 10ml ii. Adrenalin (epinephrine) ampules 1mg-1:1000; 1ml iii. Atropine Abboject 0.1mg/ml; 5ml iv. Benadryl (diphenhydramine) syringe 50mg/ml; 1ml v. Calcium chloride Abboject 10%; 100mg/ml; 10ml vi. Dextrose Abboject 50%; 25g/50ml vii. Dilantin (phenytoin) syringe 250mg/5ml viii. Dopamine 400mg/250ml pre-mixed ix. Heparin 10,000 units/ml; 1 ml vial x. Inderal (propranolol) 1mg/ml; 1 ml ampule xi. Isuprel (isoproterenol) 1mg/5ml; 1:5000 ampule xii. Lanoxin (digoxin) 0.5 mg/2ml ampule xiii. Lasix (furosemide) 40 mg/4ml vial xiv. Lidocaine Abboject 2%; 100mg/5ml xv. Lidocaine 2 grams/500ml pre-mixed xvi. Magnesium sulfate 50%; 20ml vial (1g/2ml) xvii. Narcan (naloxone) 0.4mg/ml; 1ml ampule xviii. Pronestyl (procainamide) 100mg/ml; 10ml vial xix. Romazicon 5ml or 10 ml (0.1mg/ml) xx. Sodium bicarbonate Abboject 50mEq/50ml xxi. Solu-medrol (methylprednisolone) 125mg/2ml vial xxii. Verapamil syringe 5mg/2ml The above dosage levels may be adjusted, depending on ages of the patient population. 2. Suction devices, endotracheal tubes, laryngoscopes, etc. 3. Positive pressure ventilation device (e.g., Ambu) plus oxygen supply. 4. Double tourniquet for the Bier Block procedure. 5. Monitors for blood pressure/EKG/Oxygen saturation and portable approved defibrillator. 6. Emergency intubation equipment. 7. Adequate operating room lighting with onsite backup sufficient to supply required equipment perioperative equipment and monitors for a minimum of two (2) hours. 8. Sterilization equipment or facilities meeting Joint Commission requirements. 9. IV solution and IV equipment. F. Assistance of Other Personnel Required 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. A registered nurse may only administer analgesic doses of medications on the direct order of a physician. An assisting anesthesia provider, including nurse providing sedation, may not function in any other capacity during the procedure. If additional assistance is required by the specific procedure or patient circumstances, such assistance must be provided by a physician, registered nurse, licensed practical nurse, or operating room technician.