In this section, some key regulations and guidelines related to the office-based anesthesia (OBA) practice are reviewed. Over the last 10 years, a large increase in office-based procedures has forced the American Society of Anesthesiologists (ASA) and other professional societies to come up with specific guidelines to promote patient safety and professional quality. Most of the information can be found in the ASA literature, and much of the detailed, current information is available on the ASA website (www.asahq.org). Unfortunately, there is still limited regulation of the office-based facilities in most states, and most federal and state laws do not go far enough (1).

The ASA encourages the anesthesiologist to play a leadership role as a perioperative physician in all hospitals, ambulatory surgical centers, and office-based settings. The guidelines and recommendations discussed in the subsequent text apply to anesthesiology personnel administering ambulatory anesthesia in all settings. Most are minimal basic guidelines, which may be exceeded at any time based on the judgment of the involved anesthesia personnel. It is also noted that these guidelines encourage high-quality patient care, but by observing them one cannot guarantee any specific patient outcome. One of the recent positive developments came in July 2002, when all American Society for Aesthetic Plastic Surgery (ASAPS) members agreed to perform surgeries that require anesthesia (other than local anesthesia and/or minimal oral or intramuscular tranquilization) only in an accredited, state-licensed, or Medicare-certified facility. The ASA believes that when proper guidelines are followed, office-based surgery is a safe, convenient, and cost-effective option for properly selected patients.

One of the most thorough documents recently published by the ASA is an information manual assembled by the ASA Committee on Ambulatory Surgical Care and the ASA Task Force on Office-Based Anesthesia (2). This work, titled Office-Based Anesthesia: Considerations for Anesthesiologists in Setting Up and Maintaining a Safe Office Anesthesia Environment, is available on the ASA website. Its authors wanted to “expand on the recommendations of the ASA guidelines for office-based anesthesia,” and provide “advice and resources for anesthesiologists who currently practice, or plan to practice, in the office setting.” This document discusses various topics critical to maintaining a safe office-based practice, such as facility accreditation; provider credentials and qualifications; principles of facility safety, medication management, preoperative, intraoperative, and postoperative care; and monitoring and equipment. It also discusses the management of emergencies.

While it is impossible to cover all aspects of OBA-related rules and guidelines in this chapter, it is important to mention a few major developments in this area. Box 5.1 shows the list of recent ASA documents that are relevant to the anesthesia practice in an office setting (see Appendix 1).

The ASA Guidelines for Office-Based Anesthesia were first approved by the ASA House of Delegates in 1999, and reaffirmed in 2004. It was primarily intended for anesthesiologists practicing ambulatory anesthesia in office-based environments (1). The ASA recognizes the unique needs of an OBA setting and the increased requests for ASA members to provide anesthesia for health care practitioners (physicians, dentists, podiatrists) in their office-based operating rooms. The ASA states that because OBA is a subset of ambulatory anesthesia, the ASA guidelines for ambulatory anesthesia should be followed in the office-based setting as well as the ASA standards and guidelines that are applicable.

The ASA also recognizes the fact that compared with acute care hospitals and licensed ambulatory surgical facilities, office suites have limited, if any, regulation or control by federal, state, or local laws. Therefore, the onus is on the anesthesiologist to satisfactorily investigate areas taken for granted in the hospital or ambulatory surgical facilities, such as governance, organizations, construction, and equipment, as well as policies and procedures, including fire, safety, drugs, emergencies, staffing, training, and unanticipated patient transfers. The anesthesiologist is encouraged to address those issues in an office setting before administering anesthesia. It involves the personnel, facility, administration, and developing a plan for the pre-, intra-, and postoperative care of the patient. Because of the rapidly growing numbers of procedures being performed in the office-based setting, further recommendations were approved by the House of Delegates in 2004. These involve the quality of care and patient safety in the office setting.

The Guidelines for Office-Based Anesthesia address six major aspects of office-based practice.

It is important to consider each of the topics listed in the preceding text in detail, because each is critical to a safe, effective, and quality anesthetic. This chapter will address each aspect of the guidelines separately, and discuss other relevant literature, regulations, and recommendations.