Office-Based Anesthesia: How to Start an Office-Based Practice

https://doi.org/10.1016/j.anclin.2010.02.006Get rights and content

Section snippets

Patient safety

Triggered by media coverage of tragic mishaps that allegedly occurred due to a lack of the resources usually available in hospitals, the growth of OBA has led to considerable concerns about its safety. Statistics on the morbidity and mortality of OBA are difficult to analyze and compare, because most literature is based on retrospective studies with limited sample sizes. There are no uniform criteria for morbidity and mortality (some studies use 24-hour mortality vs 7-day or 30-day mortality,

Sources of information for the novice anesthesia provider

The American Society of Anesthesiology (ASA) has had a long-standing interest in guiding the safety of OBA and, under the auspices of the ASA Committee on Ambulatory Surgical Care and in conjunction with the Society for Ambulatory Anesthesia (SAMBA), in 1999 developed and approved the Guidelines for Office-Based Anesthesia, which were subsequently endorsed by the ASA House of Delegates as the nation's most comprehensive medical guidelines for OBA care.6

In 2002, because of continued member

Facility accreditation

Despite the increasing popularity of OBA and the persistent concerns about its safety, there still remains a relative lack of oversight; currently only 25 states in the United States have fully functional guidelines or regulations in place to ensure adequate facility and equipment standards, patient care provider qualification, and proper patient selection. Many states now require accreditation through one of several agencies to evaluate the office-based practice setting. At present there are 3

Facility administration

An appropriate administrative structure includes a medical director who is ultimately responsible for facility as well as personnel, and who must ensure that all applicable local, state, and federal laws, codes, and regulations are observed. A formal policy and procedure manual should be available to address various issues, including provider qualification, records and documentation, quality improvement activities, professional liability, handling of controlled medications, and policies for

Facility safety

Due to several factors, patients in health care facilities are particularly vulnerable; they may not be able to self-evacuate in the event of an emergency (ie, fire) because of being temporarily immobilized (ie, operating room [OR], postanesthesia care unit [PACU]); they may be exposed to electrical hazards, as they are often connected to medical electronic equipment (ie, electrocautery, electrocardiography, and so forth); and they are regularly in close proximity to biomedical hazards and

Practice management

Many providers of OBA will enjoy the flexibility and control, along with financial opportunities that have contributed to the rapid growth of out-of-hospital surgery. However, this also means being confronted with the reality of running a personal business (either solo or in a group), interacting with and recruiting clients, managing a schedule (at times with transit between different offices, perhaps even with fully mobile anesthesia equipment), employing staff (eg, other anesthesia providers,

Preoperative care: patient and procedure selection

Offices should have policies regarding criteria for patient selection that consider the patient's medical conditions and the intrinsic risk or invasiveness of the procedure. Some states define which procedures can be done in offices while others leave such decisions to the health care provider. As a general rule, patients whose preexisting medical conditions or surgical procedure may pose a risk of perioperative complications beyond the office's resources should not have their procedures done

Intraoperative care

Intraoperative monitoring and management are expected to be of hospital standard.20 Several techniques, ranging from local infiltration with minimal sedation (anxiolysis) to major regional and/or general anesthesia (total intravenous anesthesia, total intravenous anesthesia (TIVA), or general inhalational anesthesia with LMA or endotracheal tube) may be chosen, depending on the patient, the procedure, and the level of comfort of the clinician. The anesthesia provider, however, must make plans

Postoperative care and discharge

The recovery in an office can present challenges, as there may not be a permanent recovery area. Often patients are expected to recover rapidly in the surgical area or in an adjacent procedure room or holding area. Regardless of the location, applicable standards apply.26 There should be policies and procedures that specify monitoring, staff qualifications, responsibilities, documentation, and a formal discharge protocol (including predefined anesthesia discharge criteria for “street-fitness”).

Special considerations: liposuction

Liposuction, one of the most common cosmetic procedures, consists of the surgical removal of subcutaneous fat. There are several different surgical techniques in use, but the more common ones now include so-called tumescent and superwet liposuction, during which the area for surgery is injected with large volumes of a dilute solution of local anesthetic, usually crystalloid and lidocaine with epinephrine (1 mL for each mL of planned adipose removal; in some cases 2–3 times the volume of

Special considerations: pediatrics

The most important consideration for pediatric OBA is the presence of adequately qualified staff, confident in caring for the child, as well as the availability of a selection of age-appropriate monitoring and equipment. Even though a minimum age in OBA for an otherwise healthy infant has not been established, it has been suggested to restrict the selection to infants older than approximately 6 months and to exclude ex-premature infants due to the increased risk of apnea. Most children require

Special considerations: dental

The American Dental Association (ADA) has issued guidelines that define educational requirements for dentists to provide anesthesia, and qualified dentists have to apply for state board issued anesthesia permits. In some states, physician anesthesiologists are also required to obtain dental anesthesia permits from their respective dental state board. In general, the state medical board requires an inspection of the facility instead of a formal accreditation.

The majority of dental facilities are

Emergencies and transfers

Due to the limited resources of office-based facilities as compared with hospitals, the management of emergencies requires a detailed policy and procedure for careful planning and preparation, along with regular rehearsals and drills. The goal of handling an emergency in the office is to stabilize the patient and promptly transfer the patient to an acute-care facility with personnel and resources more suited to handle the emergency. Medications and equipment in the office-based setting should

Summary

OBA continues to grow due to the popularity among patients and health care providers alike. Increasing regulation will ensure that patient safety remains the primary focus. In the meantime, the anesthesia provider must take adequate steps to ensure that the quality of care is comparable to that in a hospital.

First page preview

First page preview
Click to open first page preview

References (32)

  • M. Galati

    Practice management issues in office-based anesthesiology

    Semin Anesth Perioperat Med Pain

    (2006)
  • American Hospital Association (AHA)

    Trendwatch chartbook 2007: trends affecting hospital and health systems, April 2007 chapter 2, organization trends

  • H.S. Byrd et al.

    Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases

    Plast Reconstr Surg

    (2003)
  • H. Vila et al.

    Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers

    Arch Surg

    (2003)
  • A.P. Venkat et al.

    Lower adverse event and mortality rates in physician offices compared with ambulatory surgery centers: a reappraisal of Florida adverse event data

    Dermatol Surg

    (2004)
  • L.A. Fleisher et al.

    Inpatient hospital admission and death after outpatient surgery in elderly patients

    Arch Surg

    (2004)
  • American Society of Anesthesiologists (ASA)

    Guidelines for office-based anesthesia

  • American Society of Anesthesiologists (ASA)

    Office-based anesthesia: considerations for anesthesiologists in setting up and maintaining a safe office anesthesia environment

  • F.E. Shapiro

    Manual of office-based anesthesia procedures

    (2007)
  • L. Hausman et al.

    Office-based anesthesia

  • H. Vila et al.
  • The Joint Commission (TJC)
  • Accreditation Association for Ambulatory Health Care (AAAHC)
  • American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF)

    Manual for accreditation of ambulatory surgical facilities

  • American Society of Anesthesiologists (ASA) Task Force on Operating Room Fires

    Practice advisory for the prevention and management of operating room fires

    Anesthesiology

    (2008)
  • N.D. Thompson et al.

    Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998–2008

    Ann Intern Med

    (2009)
  • Cited by (20)

    • Communication, Teamwork,and trust in an office-based practice

      2015, AORN Journal
      Citation Excerpt :

      For safe and reliable equipment function, staff members should perform preventative maintenance and daily and case-specific safety equipment checks according to manufacturers’ recommendations.1 Additionally, policies for transferring patients to a higher level of care must be readily available.1,12,13 Physiological monitors, medications, supplies for routine and emergent care, and equipment should be available to care for the patient, perform the procedure, and provide emergency care (eg, difficult airway management,14 local anesthetic toxicity,15 malignant hyperthermia crisis,16 surgical fires17).

    • Initial results from the national anesthesia clinical outcomes registry and overview of office-based anesthesia

      2014, Anesthesiology Clinics
      Citation Excerpt :

      The American Society of Anesthesiologists (ASA) originally estimated that more than 10 million office procedures were performed in 2005, which doubles the approximations from just 10 years prior.3 Current assessments show 17% to 24% of all elective ambulatory surgeries take place in an office.4 It is apparent that this trend will continue; thus, the ability to deliver OBA must be in the repertoire of current and future anesthesiologists.

    • Office-based sperm retrieval for treatment of infertility

      2013, Urologic Clinics of North America
      Citation Excerpt :

      In addition to a cord block, one must inject the skin at the incision site, because scrotal skin is supplied by pudendal nerve and a perineal branch of the posterior cutaneous nerve of the thigh,6 which are not blocked by the cord block. Use of conscious sedation in an office setting requires that the facility be accredited by the Joint Commission, Accreditation Association for Ambulatory Health Care, or the American Association for Accreditation of Ambulatory Surgical Facilities.7 It also requires appropriate staff training, airway management capability, emergency transfer protocol, and appropriate postprocedural monitoring as well as detailed discharge policies.

    • Office-based anesthesia for the urologist

      2013, Urologic Clinics of North America
      Citation Excerpt :

      The compact size and portability of an intravenous infusion pump have made TIVA a popular choice for small offices because it minimizes the need for bulky anesthesia equipment, a scavenging system, and a malignant hyperthermia (MH) cart. However, if succinylcholine is to be used, MH supplies need to be available on site.14 TIVA usually comprises a propofol infusion with a benzodiazepine and an opioid.

    View all citing articles on Scopus

    No conflicts of interest are declared.

    Disclaimer: Care has been taken to assure the accuracy of the information presented, however the investigators are not responsible for errors, omissions or for any consequences from application of the information in this article and make no warranty, expressed or implied, with respect to the currency, completeness or accuracy of the contents of this publication. The application of this information in a particular situation remains the professional responsibility of the practitioner, particularly in view of ongoing changes in regulations.

    View full text