Board certification urged for office-based surgeons

Guidelines target moderate, deep, general sedation

Physicians who offer moderate, deep, or general sedation in their offices should be board-certified in the type of surgery they perform in the office setting, under new guidelines for office-based surgery approved by the American College of Surgeons (ACS) and the American Medical Association (AMA), both in Chicago.

"That was controversial because the AMA has a policy of not invoking board certification or terminology," such as board qualified or board eligible, explains Richard B. Reiling, MD, FACS, Medical Director of Presbyterian Cancer Center in Charlotte, NC. Reiling served on the ACS Board of Governors Committee on Ambulatory Surgery, which developed the guidelines.

With the increasing regulation of office-based surgery at the state level, ACS and AMA members grew concerned that states were developing guidelines that were prescriptive but weren’t scientifically based and didn’t really make sense, he adds. "There would be figures that were drawn out of the air, such as physicians need 12 hours of CME [continuing medical education] every year on delivery anesthesia," Reiling says.

"We thought the experts, surgeons and anesthesiologists, needed to develop guidelines that make sense and can be used in other states," he says.

The 10 core principles of the guidelines are:

1. Guidelines or regulations should be developed by states for office-based surgery according to levels of anesthesia defined by the American Society of Anesthesiologists’ (ASA’s) "Continuum of Depth of Sedation" statement dated Oct. 13, 1999, excluding local anesthesia or minimal sedation. The statement is available at www.asahq.org/publicationsandservices/standards/20.htm.

2. Physicians should select patients by criteria, including the ASA Patient Selection Physical Status Classification System, and document accordingly. The ASA physical status classification system is available at www.asahq.org/clinical/physicalstatus.htm.

3. Physicians who perform office-based surgery should have their facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations, the Accreditation Association for Ambulatory Health Care (AAAHC), the American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF), the American Osteopathic Association (AOA), or by a state- recognized entity such as the Institute for Medical Quality, or be state licensed and/ or Medicare-certified.

4. Physicians performing office-based surgery must have admitting privileges at a nearby hospital, have a transfer agreement with another physician who has admitting privileges at a nearby hospital, or maintain an emergency transfer agreement with a nearby hospital.

5. States should follow the guidelines outlined by the Dallas-based Federation of State Medical Boards (FSMB) regarding informed consent. (Source: Report of the FSMB Special Committee on Outpatient [Office-Based] Surgery.)

6. States should consider legally privileged adverse incident reporting requirements as recommended by the FSMB (Source: Report of the FSMB Special Committee on Outpatient [Office-Based] Surgery) and accompanied by periodic peer review and a program of continuous quality improvement.

7. Physicians performing office-based surgery must obtain and maintain board certification by one of the boards recognized by the American Board of Medical Specialties, AOA, or a board with equivalent standards approved by the state medical board within five years of completing an approved residency training program. The procedure must be one that generally is recognized by that certifying board as falling within the scope of training and practice of the physician providing the care.

8. Physicians performing office-based surgery may show competency by maintaining core privileges at an accredited or licensed hospital or ambulatory surgical center for the procedures they perform in the office setting. Alternatively, the governing body of the office facility is responsible for a peer review process for privileging physicians based on nationally recognized credentialing standards.

9. At least one physician, who is credentialed or currently recognized as having successfully completed a course in advanced resuscitative techniques (advanced trauma life support, advanced cardiac life support, or pediatric advanced life support), must be present or immediately available with age-and size-appropriate resuscitative equipment until the patient has met the criteria for discharge from the facility. In addition, other medical personnel with direct patient contact should at a minimum be trained in basic life support.

10. Physicians administering or supervising moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia should have appropriate education and training.

The guidelines were based on a document that was approved by the following groups and others during a March 17, 2003, ACS/AMA coordinated consensus meeting:

  • AAAHC;
  • AAAASF;
  • ASA;
  • American Society of Cataract and Refractive Surgery;
  • FSMB;
  • Joint Commission on Accreditation of Healthcare Organizations.