N.J. Admin. Code § 13:35-4A.7

Current through Register Vol. 56, No. 11, June 3, 2024

Section 13:35-4A.7 - Standards for administering or supervising the administration of anesthesia services in an office; pre-anesthesia counseling; patient monitoring; recovery; patient record; discharge of patient

(a) A practitioner who administers or supervises the administration and monitoring of anesthesia services in an office shall be privileged by a hospital to provide the particular anesthesia service. If a practitioner is not privileged but wishes to administer or supervise the administration of anesthesia services, the practitioner shall apply to the Board pursuant to 13:35-4A.12 to seek Board-approved privileging.

(b) A practitioner who administers or supervises the administration and monitoring of anesthesia services in an office shall provide pre-anesthesia counseling and preparation as follows:

1. Any patient to whom anesthesia services are to be provided shall be appropriately screened by the individual administering anesthesia services. Patients who, by reason of pre-existing medical or other conditions, are at undue risk for complications (for example, morbidly obese patients; patients with severe cardiac, pulmonary, airway, or neurological problems; substance abusers) shall be referred to an appropriate specialist for a pre-procedure consultation or to another treatment setting or other appropriate facility. Only patients with an ASA physical status classification of I or II are appropriate candidates for an office surgery or special procedure for which general or regional anesthesia are to be used. Patients with an ASA physical classification of I, II, or III are appropriate candidates for moderate sedation.

2. A medical history shall be conducted including a review of abnormalities in any organ system; previous adverse experience with anesthesia services; any history of stridor, snoring or sleep apnea, or of advanced rheumatoid arthritis or spinal disorder; current medications being taken; drug allergies; or any history of substance abuse;

3. The risks and benefits of anesthesia and alternative methods or treatments shall be fully explained by the physician or certified registered nurse anesthetist (CRNA), and written informed consent for the anesthesia services contemplated shall be obtained from the patient, guardian or authorized representative;

4. An appropriate fasting protocol shall be explained and timely provided to the patient, guardian or authorized representative;

5. Pre-procedure laboratory test results shall be reviewed and recorded;

6. A focused physical examination shall be conducted, including auscultation of the heart and lungs, and an evaluation of the airway, particularly an assessment of anatomical abnormalities (that is, jaw, mouth, head and neck) which may increase the likelihood of an airway obstruction;

7. A plan of anesthesia shall be developed by the physician administering anesthesia services or personally reviewed by the supervising physician if the plan has been developed by other authorized personnel;

8. A patient shall be counseled prior to the procedure that the procedure will be canceled if the patient plans to drive home after the procedure and has not made arrangements to be accompanied home by an individual who accepts responsibility for the patient; and

9. Prior to the administration of anesthesia services, the physician shall ensure that the patient removes all cosmetics, jewelry, contact lenses, dental appliances and prosthetic devices which might reasonably jeopardize patient safety.

(c) A physician who administers or supervises the administration or monitoring of any anesthesia services (general anesthesia, regional anesthesia, or moderate sedation) in an office shall ensure that monitoring is provided as follows when clinically feasible for the patient:

1. Direct observation of the patient and, to the extent practicable, observation of the patient's responses to verbal commands;

2. Pulse oximetry shall be performed continuously. Any alternative method of measuring oxygen saturation may be substituted for pulse oximetry if the method has been demonstrated to have at least equivalent clinical effectiveness;

3. An electrocardiogram monitor shall be used continuously on the patient;

4. The patient's blood pressure, pulse rate, and respirations shall be measured at least every five minutes; and

5. The body temperature of a pediatric patient shall be measured continuously.

(d) In addition to the monitoring requirements in (c) above, a physician who administers or supervises the administration or monitoring of general anesthesia services in an office shall ensure that additional monitoring is provided as follows:

1. End-tidal carbon dioxide monitoring shall be performed on the patient continuously during endotracheal anesthesia;

2. An in-circuit oxygen analyzer shall be used to monitor the oxygen concentration within the breathing circuit, displaying the oxygen percent of the total inspiratory mixture;

3. A respirometer (volumeter) shall be used to measure exhaled tidal volume whenever the breathing circuit of a patient allows;

4. The body temperature of each patient shall be measured continuously; and

5. An esophageal or precordial stethoscope shall be available and utilized on the patient when indicated.

(e) A practitioner who administers or supervises the administration and monitoring of anesthesia services in an office shall establish within that office a recovery area and ensure that recovery services are provided as follows:

1. Immediately after the surgery or special procedure, the practitioner who performed the surgery or the individual who administered the anesthesia shall evaluate the patient;

2. The individual responsible for the administration or monitoring of anesthesia shall accompany the patient into the recovery area;

3. Healthcare personnel who were present with the patient at the anesthetizing location shall remain with the patient in the recovery area at least until the patient's vital signs, including blood pressure, pulse, and respiration are recorded;

4. An oral report on the patient's condition shall be given to any healthcare personnel in the recovery area not present in the anesthetizing location;

5. Whenever a patient is present in the recovery area, the recovery area shall be staffed by at least one registered professional nurse or physician assistant who is trained and experienced in advanced cardiac life support and post anesthesia care. This includes recognizing the actions and interactions of anesthetic techniques, managing of airway and ventilatory function and managing patients during altered states of consciousness, as well as cardiopulmonary resuscitation, monitoring of caridiac function, recognition of arrhythmias, and the recognition and treatment of life-threatening emergencies. For every additional two patients present in the recovery area, there shall be one additional professional registered nurse or physician assistant present, having the requisite training;

6. In addition to the healthcare personnel specified in (e)5 above, at least one other additional healthcare personnel shall remain on site in a position to render immediate assistance whenever a patient is in the recovery room; and

7. From the time of entry into the recovery area until discharge, the condition of the patient shall be regularly evaluated and the patient's vital signs checked at least every five minutes. If the patient's vital signs remain unchanged, documentation can be reflected with a straight line on the chart; any changes shall be specifically noted. Electrocardiographic monitoring and pulse oximetry monitoring shall be continued in the recovery area for each patient who has received anesthesia services.

(f) A practitioner who administers or supervises the administration and monitoring of anesthesia services may allow a patient dischargeable to home pursuant to 13:35-4A.4(a)9 and 4A.6(d) to remain in the office for a period not to exceed 23 hours in an overnight stay area, if the patient may benefit from additional care. The overnight stay area shall be staffed by at least one registered professional nurse or physician assistant for each two patients in the overnight stay area, the patient's vital signs shall be taken and recorded at least every four hours and a physician shall be able to reach the office within 20 minutes. Appropriate sleeping accommodations, as well as food, shall be provided for the patient.

(g) A practitioner who administers or supervises the administration and monitoring of anesthesia services in an office shall ensure the following prior to discharge:

1. That at least one practitioner shall remain on the premises until the patient is discharged to home or transferred to the special overnight stay area;

2. That the patient shall be given written and verbal instructions for follow-up care and advice concerning complications;

3. That before the patient leaves the office or is transferred to the overnight stay area, the physician shall evaluate the patient and shall review and sign the post-anesthesia record; and

4. That the patient shall be discharged only into the company of a responsible individual.

(h) A practitioner who administers or supervises the administration and monitoring of anesthesia services in an office shall ensure that a patient record is prepared which contains the following:

1. A pre-anesthesia note, including pre-anesthesia vital signs (blood pressure, temperature, respiration rate and pulse), and a plan of anesthesia;

2. Signed informed consent from the patient, guardian or authorized representative;

3. An intra-procedure record which includes anesthetic agents and techniques used, any changes since the inception of anesthesia in vital signs, oxygen saturation, electrocardiogram interpretation, temperature and end-tidal carbon dioxide measurements when required, as well as the volume and type of fluids administered;

4. A post-anesthesia note entered prior to the patient's discharge from the office which shall include at least such post-procedure data as the patient's vital signs and general condition, respiration, consciousness, circulation, special problems or precautions and a summary of fluids received during surgery or any complication or untoward event which occurred;

5. The identity of each healthcare personnel providing services, as evidenced by the staff member's legible signature on each entry made by that staff member in the patient record; and

6. The plan for follow-up care.

(i) No practitioner who administers or supervises the administration and monitoring of anesthesia services in an office shall:

1. Prescribe, or advise a patient to take, an anesthetic agent to be administered prior to arrival at the office or outside of the anesthetizing location; or

2. Accept for the performance of surgery or a special procedure a patient to whom an anesthetic agent had been administered for that surgery or special procedure prior to arrival at the office or outside of the anesthetizing location, other than in life threatening circumstances, unless the patient is accompanied by medical personnel from an acute care facility.

N.J. Admin. Code § 13:35-4A.7

Public Notice: Suspension of enforcement.
See: 30 N.J.R. 4485(b).
Amended by R.2002 d.404, effective 12/16/2002.
See: 33 N.J.R. 3870(a), 34 N.J.R. 4449(a).
Rewrote the section.
Administrative correction.
See: 35 N.J.R. 1936(a).
Amended by R.2011 d.155, effective 6/6/2011.
See: 42 N.J.R. 1310(a), 43 N.J.R. 1359(b).
In (f) and (g)3, substituted "overnight stay" for "overstay" throughout.

Amended by 53 N.J.R. 2013(a), effective 12/6/2021