Tough NJ law targets office-based anesthesia, holds providers to ambulatory surgery center standards

Certified nurse anesthetists balk at stricter supervision requirements

New Jersey regulators are following the shift of health care to outpatient settings with implementation of tough new laws—some say the strictest in the nation—governing office-based anesthesia. With managed care pushing more and more procedures into the outpatient setting, many states may view New Jersey’s law as a new benchmark for upgrading their own regulations.

Enactment of the 1998 law caps a 15-year battle during which opponents claimed that regulation of office-based anesthesia would lead to increased health care costs and the closing of some physician practices due to higher overhead.

But it was imperative for regulation to follow the migration of health care services from the hospital to the outpatient settings in order to protect the quality of patient care, says Ervin Moss, MD, executive medical director of the New Jersey State Society of Anesthesiologists in Princeton Junction, NJ.

"I don’t worry about the cost; I am concerned about patient safety," says Mr. Moss. He cites examples of deaths that occurred during procedures performed by a physician who administered anesthesia after viewing a 30-minute educational videotape, as well as instances in which anesthetized patients were given intravenous sedation by the office receptionist.

Although Florida and California have had regulations governing office-based anesthesia for three years, New Jersey’s regulations are stricter and better defined, says Mr. Moss. "The regulations address standards for training, monitoring equipment, staffing, and credentialing for physicians and staff members administering anesthesia," he adds. (See story on anesthesia regulations, p. 2.)

Out-of-date anesthesia machines are a big problem in many physicians’ offices, explains Mr. Moss. Typically, a physician will purchase equipment that a hospital is discarding because it is obsolete and doesn’t contain the most recent safety mechanisms, he adds. "The regulations define a safe machine and give physicians six months to update their machines to meet the standards," says Mr. Moss.

This doesn’t mean physicians must purchase brand-new equipment, explains Mr. Moss. "A refurbished machine with all of the up-to-date safety equipment costs about $20,000. When you add the monitors and defibrillator cart, the total comes to $50,000 to save lives," he notes.

Two other key areas addressed by the regulations include credentialing and reporting of untoward events. Basically, a physician may provide any service in the office that he or she is credentialed to provide in a hospital, explains Moss. If the physician is not credentialed on any hospital medical staff, the regulations describe an alternate credentialing process.

"A hospital has to report untoward events such as an injury, close call, or death that may be related to anesthesia, but we really don’t know what has been happening in physicians’ offices," says Mr. Moss. For this reason, he counts the mandatory reporting requirements contained in the regulations as one of the major benefits of his society’s efforts.

"We will now be able to collect data and evaluate patient safety related to anesthesia in a physician’s office," he explains.

Certified nurse anesthetists who provide anesthesia in an office setting must be certified by the American Association of Nurse Anesthetists in Park Ridge, IL, and be supervised by a physician who meets the criteria to administer anesthesia within the office. The New Jersey Association of Nurse Anesthetists is suing the New Jersey Board of Medical Examiners. The certified registered nurse anesthetists claim that their practice is a nursing practice and should not be supervised by an organization that licenses and oversees physicians. They also claim that their training should allow them to perform anesthesia in an office without anesthesiologist supervision.

Mr. Moss is pleased that the American Society of Anesthesiologists (ASA) in Park Ridge, IL, and the Society of Ambulatory Anesthesia (SAMBA), a subgroup of the ASA, are looking at the issue of office-based anesthesia. The ASA is developing practice guidelines, and SAMBA is providing education to surgeons, anesthesiologists, and patients through its Web site, says Marc E. Koch, MD, an anesthesiologist in Whitestone, NY, who serves as chairman of SAMBA’s Committee on Office-based Anesthesia.

"The numbers and types of procedures performed in office settings has grown rapidly and will continue to grow, so it is important for us to look at how practitioners can provide anesthesia safely," says Mr. Koch.

The guidelines emphasize that there should be one standard of care for all ambulatory anesthetics, whether in a surgery center, doctor’s office, or hospital-based ambulatory surgery program, says Rebecca Twersky, MD, president of SAMBA and member of the New York State Task Force on Office Surgery and Anesthesia.

SAMBA members are in the preliminary stages of developing protocols for an anesthesia outcomes study. They also are developing an article that will review current literature on office-based anesthesia, state-of-the-art anesthesia technology, legislation regarding office-based anesthesia, and patient safety issues a practitioner should take into account when providing office-based anesthesia.

Mr. Moss says Medicare is forcing more procedures into office settings, such as those requiring only local or regional anesthesia. He also points out that managed care organizations in New Jersey and other states have attempted to limit certain surgical procedures to offices. (See story on insurance incentive, below.)

For these reasons, Mr. Moss adamantly maintains that state regulations are the best way to protect patient safety.

"Practice guidelines are helpful, but they are not enforceable, and they are offered as advice only," he says. "Regulations are law, and a physician in New Jersey who doesn’t follow the regulations is committing a crime. This is the best way to ensure that any patient receiving anesthesia in an office setting will be safe."

Contact Mr. Moss at (973) 744-8158, the American Society of Anesthesiologists at (847) 825-5586, and the Society of Ambulatory Anesthesia at (847) 825-5586.