Level III Office Surgery

Level III Office Surgery. 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.