Non operating room anesthesia (NORA) guidelines and organization

1. NORA:
Non Operating Room Anesthesia
organization (suggestions…) and
guidelines
by C.Melloni
Libero professionista
Roma,May 2010

2. Norah Jones Nora Amile

3. Harry ti presento Sally (1989),Meg Ryan
& Billy Christal)
This Is My Life (1992),
Insonnia d'amore ( Tom Hanks & Meg
Ryan),
Agenzia salvagente (1994) (Steve
Martin)
Michael (1996), (John Travolta & Andie
MacDowell.)
C'è post@ per te (1998) (Tom Hanks &
Meg Ryan)
Magic Numbers (John Travolta & Lisa
Kudrow )
Vita da strega (2005) ( Nicole Kidman )
Julie & Julia (2009) (Meryl Streep).
Nora Ephron

4. NORA classification
• In hospital,but outside
OR:radiology,cardiology,endoscopy
etc.:NORA,but in hospital.
• Efficient scheduling
• resource use
• emerg.
• Out of hospital
– day surgery center;OR! NO NORA
–office:NORA

5. Procedures outside op.room(POOR):with/without anesth?
NORA
• “Imaging”
– CAT
– MRI
– Functional cerebral imaging
– Interventional neuroadiol
– US/CAT guided
procedures:biopsies,therapies…
– Radiother.
– Telether:children!
– Brachiter
– Radiother intraop
– radiochir
• Psichiatry
– ECT
• Cardiology:
– Catheter.
– CS
– Radiofreq.ablation
• Gastroenterology
– Sup;esofago,gastro…varici esof….
– Colon
– Liver biopsies
• T.I:,tracheo chir – percut,dren
tor,bronch
,cs,medull.biops.,ventriculostomy
• Emerg.Room;CVC,dren tor,tracheo,ICP
monitor, orthop manipul,wounds….
• Surg.offices:everything:
– ophtalmology:retinoscopy,tonometry,elettr
oretinography,,ant chmaber
surg(cataract,iridectomy ,angiofluoro…
– Plastic surgery :liposuctions,blepharoplasty
otoplasty,facial miniliftings
– Dental chair assist:implants,max sinus
..odontostomatologia
• Urology
– ECSWLT
– cistoscopy
Laserther

6. Definitions
• IT:ambulatorio=office
– Day surgery=chirurgia di giorno=struttura
attrezzata e riconosciuta:equipped and recognized
• USA: office=ufficio (del chirurgo)(of the
surgeon)
– Ambulatory:equipped and recognized -struttura attrezzata e
riconosciuta
–Ufficio:non attrezzato,non riconosciuto a
meno che non si abiliti per chirurgia
–Not recognized,unless accredited for
surgery…………….

7. Office based surgery

8. What are we taking about?
0
50000
100000
150000
200000
250000
300000
350000
400000
2000 2002 2003 2004
National USA Plastic Surgery Statistics
Cosmetic procedure trends.
mastoplast addit
mentoplastica
dermabrasione
otoplastica
blefaroplastica
lift facciale
lift frontale
trap capelli
liposuz
addominoplast

10. 2007 %2007 %2006
Mortality:2/100.000=0,002%
Nearly 11.8 million cosmetic surgery
procedures were performed in 2007: up 59 %
since 2000 !

11. Problem dimension
• Membership Audit, American Society for Aesthetic Plastic
Surgery, Inc., Spring 1993.
• survey of members of the American Society for Aesthetic Plastic
Surgery (ASAPS)
• 48.7 % of members perform their aesthetic surgery in
an office surgical facility.
• Office-based surgery (OBS) accounts for 10 million of all elective
procedures performed in the United States double from a
decade ago. Although there are no good national registries to
accurately determine the amount of surgery done in office, the
projections have ranged from 17-24% of all elective
ambulatory surgery
• AHA.Trends affecting hospitals and health systems May 2005. AHA TrendWatch ChartBook
2009. Available at:http://www.aha.org/aha/trendwatch/chartbook/2009/chart2-9.pdf.
(Accessed May 12, 2009)

12. Patient(s)
• In Hosp :
– The patients undergoing
procedures outside the
operating room are
often older, medically
higher-risk patients
• most NORA claims involve
higher-risk, elderly
patients undergoing
nonemergency surgery
• office
• Elective,clients….

13. Diagnosis:
• In Hosp:
• not made
• You see patients during
the workup…………
• Unknown diseases
• Unknown patients….
• Incomplete sense of
what we may encounter
during the procedure…
• Office:
• Hopefully dg made
• Pt well known
• Client..
• …But be
aware!Dentists..Ophtal
mologists …..

14. Preanesthetic preparation
• Preparation for NORA should be no different from
the preparation in the operating room.
– Preanesth.visit
– Fasting
– Premed.
– consent
• Preanesthetic preparation is very often done by
others, who may not consider the interactions
between a patient’s physical condition, medications
taken and the effects of anesthesia
• At worst pts coming direct from home;no prep …

15. Specific conditions that warrant special care when
providing anesthesia or sedation outside the operating room
• Patient unable to cooperate, e.g. severe intellectually disability
• Severe gastroesophageal reflux
• Medical conditions predisposing patients to reflux, e.g. gastroparesis secondary to diabetes mellitus
• Orthopnea
• Severe increased intracranial pressure
• Decreased level of consciousness/depression of protective airway reflexes
• Known difficult intubation
• Dental, oral, craniofacial, neck or thoracic abnormalities that could compromise the airway
• Presence of respiratory tract infection or unexplained fever
• Obstructive sleep apnea
• Morbid obesity
• Procedures limiting access to the airway
• Lengthy, complex or painful procedures
• Uncomfortable position
• Prone position
• Acute trauma
• Extremes of age

16. inappropriate OBA patients
• unstable ASA 3 or greater
• recent MI in past 6 months
• severe cardiomyopathy
• uncontrolled HTN
• brittle or poorly controlled diabetes
• active multiple sclerosis
• acute substance abuse (drugs and alcohol)
• MH history
• severe morbid obesity (BMI >35, if equipment and stretcher size is limited), or morbid obesity (BMI
>30 with poorly controlled comorbidities)
• severe COPD/ obstructive sleep apnea,
• pacemaker or AICD
• end-stage renal disease
• sickle cell disease
• patient on transplant list
• dementia (not oriented)
• psychologically unstable (rage/anger problems),
• Recent stroke within 3 months
• myasthenia gravis
• lack of adult escort

17. Location/space requirements for nonoperating room
anesthesia
• Adequate size with good access to the patient
• Uncluttered floor space
• An operating table, trolley or chair which can be readily
tilted into Trendelenburg position
• Adequate lighting including emergency lighting
• Sufficient electrical outlets including clearly marked
electrical outlets connected to an emergency back-up
power source
• Suitable clinical area for recovery of the patient which
must include oxygen, suction, resuscitation drugs and
equipment
• Emergency back-up call system to summon assistance
from the main operating room

25. LockAlert Automatic
Relocking
with a motion sensor
prevents the cart from
locking while in use but
automatically relocks it
when left unattended.
The system includes an
adjustable timer and
rechargeable batteries
Keypad with Display
(LockAlert IV)*
allows multiple operators to
have unique entry codes and
can be enhanced with keyless
narcotic drawers and/or
auditing. This comprehensive
system includes automatic
relocking and keypadaccessible
manager and
diagnostic routines

26. • Lightweight aluminum
construction,
proprietary self-closing drawer slides
and multiple caster options.
• Complete customization available,
including multiple colors, drawer sizes
and accessories.
• Available Entry Management
system
including AutoRelock, Audit Trail,
ID Card Reader, Proximity Reader,
Keyless Narcotic Drawer, 250 Users/
Supervisors.
• Extended base for maximum
stability

27. FSC Handbook Shands Florida Surgery Center:
instructions for residents
• Anesthesia Carts
• Take a minute to review the cart and supplies.
• All carts are set up with the same supplies in the same
place in each room.
• Anesthesia carts are stocked nightly by an anesthesia
tech and NOT in between every case.
• Keys can be obtained from Tammy Thomas, the FSC anesthesia tech. You can
also ask the charge nurse or another CRNA to open the cart for you in the
morning so you can set up.
• Laryngoscope blades are stored in the carts in the rooms and additional blades
can be found in the anesthesia work room. There is a container for used
laryngoscope blades and reusable LMAs on the sides of each anesthesia cart.
Limit opening multiple ETT’s, LMA’s. If you end up not using an opened, non-
lubricated ETT, please place a date and time on the package and store in cart.

28. DEPARTMENT OF ANESTHESIOLOGY
University of Florida
• Stocking Anesthesia Carts and/or Emergency Carts
• Anesthesia carts are standardized throughout the operating suite,
radiology suite, and labor and delivery.
• A list of all items to be included on these carts is used to restock
them each day.
• The drugs are checked once a month and outdated drugs are
replaced.
• Sharps disposal containers with small openings in the top, are well marked and
everyone is instructed to use them. They are easily accessible on the top of each cart.
Florida law requires sharps containers be dated and not in service for more than 30
days.
• The containers on the anesthesia carts are exempt from the dating requirement
because of frequent turnover.
• There are no emergency carts, per se, in the operating room area since an anesthesia
cart from the involved room would be utilized.
• There are special carts for pediatric, cardiac, burn unit, MRI, OB, X-ray and cysto.

29. FSC Handbook
Shands Florida Surgery Center: II
• Many cases are done with an LMA.
• Each OR should have one size 3, 4, and 5 LMA.
• Additional LMAs are located in the anesthesia workroom and
on the side of the anesthesia supply cart.
• Difficult Airway Cart
• This cart is located outside of OR 1 and 2 near the OR code
cart. It is different from the typical Shands UF difficult airway
cart. In addition, a glidescope is available next to the difficult
airway cart.
• Please take a moment to familiarize yourself with this
equipment.

30. • International Anesthesiology Clinics:
• Winter 2006 - Volume 44 - Issue 1 - pp 159-
177
• Anesthesia Supply Chain
• Adler, Elena MD

31. Staff
• A strict adherence to
minimum;scrubbed+circulating nurses?2?
• staff with appropriate training?
• Interdepartmental cooperation and
understanding
– All very important when working outside the
familiar environment of the operating room

36. Procedure
• The anesthesiologist needs to understand the
requirements of the procedure, its potential
complications, its anticipated duration and the
specific needs of the proceduralists.
• Specific requirements differ with each type of
procedure and are discussed below
• New technologies…
• New people …

38. SIAARTI Linee guida 2005
• …La mancata disponibilità di quanto prescritto o
l’impossibilità di sanarne le carenze in tempo reale possono
costituire giusta causa,al di fuori delle situazioni di emergenza
e necessità inderogabile,per il rinvio della prestazione e per la
riprogrammazione a carenze sanate…
• The absence of what is prescribed or the
impossibility of real time restocking is enough
to cancel or postpone the case ,except in cases
of emergency…

39. Monitoraggio durante la procedura e
risveglio:intraoperative and postoperative monitoring
SIAARTI
• Racc.” Monitoraggio di minima durante
anestesia”
• Racc.”controllo dell’apparecchio di anestesia”
• Racc “Per la sorveglianza postanestetica”
• Racc”clinico organizzative per l’anestesia in
day surgery”

40. OBA :ASA point of view
• Succinctly stated, the 1999 HOD-approved
guidelines for OBA state, with respect to
perioperative care... “The anesthesiologist
should adhere to:
• Basic Standards for Preanesthesia Care,
• Standards for Basic Anesthetic Monitoring,
• Standards for Postanesthesia Care
• Guidelines for Ambulatory Anesthesia and
Surgery as promulgated by ASA.

41. Requisiti specifici per l’accreditamento
delle Strutture di ...RER
• Formato file: PDF
• RER

42. REQUISITI SPECIFICI
• 3.8
• REQUISITO DA SODDISFARE :
• Per ambulatorio chirurgico (o ambulatorio per interventi chirurgici) si intende la struttura intra od
extraospedaliera nella quale sono eseguite prestazioni di chirurgia ambulatoriale, ovvero procedure
diagnostiche e/o terapeutiche invasive o semi-invasive, nelle situazioni che non richiedono ricovero ordinario o
a ciclo diurno; tali procedure possono essere eseguite in anestesia locale o loco-regionale e non necessitano di
un’osservazione post-operatoria prolungata.
•
•
• Criteri per la verifica del possesso del requisito
• Situazione attuale
• 3.8
• Esiste la documentazione (*) formalizzata che esplicita l’organizzazione interna dell’ambulatorio chirurgico, con
particolare riferimento a:
• organigramma;
• livelli di responsabilità;
• strutture e modalità di funzionamento;
• descrizione quali-quantitativa dell’attività svolta.
• (*) Può coincidere con la documentazione utilizzata per attestare il possesso dei requisiti della lista di controllo n.
1
• SI
• NO
•
•
•

43. 3.8.1 REQUISITI MINIMI STRUTTURALI
• 3.8.1
• REQUISITO DA SODDISFARE :
• I locali e gli spazi devono essere correlati alla tipologia e al volume delle prestazioni erogate.
• La dotazione minima di ambienti per l’ambulatorio chirurgico, oltre a quanto previsto per l’assistenza specialistica ambulatoriale, è la seguente:
• locale/spazio per la sosta del paziente al termine della prestazione chirurgica;
• locale/spazio spogliatoio per il personale;
• locale/spazio per la preparazione del personale alla prestazione chirurgica;
• uno o più locali/spazi per il lavaggio, la disinfezione, il confezionamento e la sterilizzazione dello strumentario chirurgico e degli altri presidi utilizzati;
• armadi per il deposito del materiale sterile e dello strumentario chirurgico.
• Nei locali ove si svolgono attività sanitarie, i pavimenti e le pareti, fino ad una altezza di due metri, devono essere lavabili e disinfettabili.
• Criteri per la verifica del possesso del requisito
• Situazione attuale
• Ogni ambulatorio chirurgico dispone, in aggiunta/integrazione a quanto previsto per l’assistenza specialistica ambulatoriale, almeno di:
• 3.8.1 - a
• un’area per la sosta del paziente nel periodo di sorveglianza immediatamente successivo alla prestazione stessa, collocata in prossimità dell’ambulatorio e con un
numero di posti a sedere adeguato al numero di pazienti che mediamente lo frequenta (anche in comune con il locale/spazio per l’attesa);SI NO
• 3.8.1 - b
• un locale/spazio spogliatoio per il personale (anche in comune con altri ambulatori e/o aree di degenza);SI NO
• 3.8.1 - c
• un’area per la preparazione del personale alla prestazione chirurgica, dotata di un lavello a comando non manuale e costituita da un locale a sé stante, oppure da uno
spazio opportunamente delimitato all’interno dello spogliatoio per il personale, oppure da uno spazio opportunamente delimitato nel locale dedicato all’esecuzione
delle prestazioni sanitarie purché, nei primi due casi, siano direttamente comunicanti con il locale stesso destinato all’esecuzione delle prestazioni sanitarie;
• SI NO
• 3.8.1 - d
• aree per il lavaggio, la disinfezione, il confezionamento e la sterilizzazione dello strumentario chirurgico e degli altri presidi utilizzati costituite da uno o più locali a sé
stanti, oppure da uno o più spazi opportunamente delimitati all’interno dello spogliatoio per il personale, oppure da uno o più spazi opportunamente delimitati nel
locale dedicato all’esecuzione delle prestazioni sanitarie; SI NO
• 3.8.1 - e
• armadi per il deposito del materiale sterile e dello strumentario chirurgico. SI NO
• 3.8.1 - f
• I locali destinati ad attività sanitarie consentono il lavaggio e la disinfezione dei pavimenti e delle pareti fino a due metri.SI NO

44. 3.8.2 REQUISITI MINIMI IMPIANTISTICI E
TECNOLOGICI
• 3.8.2
• REQUISITO DA SODDISFARE :
• La dotazione minima impiantistica e tecnologica per l’ambulatorio chirurgico, oltre a quanto previsto per l’assistenza specialistica
ambulatoriale, è la seguente:
• lettino tecnico o tavolo operatorio;
• lampada scialitica o altro sistema di illuminazione del campo operatorio;
• apparecchiature per il lavaggio, il confezionamento, la disinfezione e la sterilizzazione dello strumentario chirurgico e degli altri
presidi utilizzati.
•
•
• Criteri per la verifica del possesso del requisito
• Situazione attuale
• Ogni ambulatorio chirurgico dispone, in aggiunta/integrazione a quanto previsto per l’assistenza specialistica ambulatoriale, almeno
di:
• 3.8.2 - a
• un lettino tecnico, una poltrona o un tavolo operatori, adeguati alle prestazioni chirurgiche erogate; SI NO
• 3.8.2 - b
• una lampada scialitica o un altro sistema di illuminazione del campo operatorio, adeguati alle prestazioni chirurgiche erogate;
• SI NO
• 3.8.2 - c
• apparecchiature per il lavaggio, il confezionamento, la disinfezione e la sterilizzazione efficaci e compatibili con le caratteristiche e gli
impieghi dello strumentario chirurgico e degli altri presidi utilizzati. SI NO
•

45. 3.8.3 REQUISITI MINIMI ORGANIZZATIVI
• 3.8.3
• REQUISITO DA SODDISFARE :
• In ogni ambulatorio chirurgico, oltre a quanto previsto per l’assistenza specialistica ambulatoriale, sono formalizzate e applicate le seguenti procedure (cartacee o informatizzate)
riguardanti:
• il consenso informato;
• l’esecuzione delle procedure chirurgiche maggiormente invasive o rischiose;
• la gestione delle emergenze;
• la compilazione del registro chirurgico ambulatoriale;
• il lavaggio, il confezionamento, la disinfezione e la sterilizzazione dello strumentario chirurgico e degli altri presidi utilizzati;
• la prevenzione del rischio infettivo per i pazienti e il personale.
•
• Criteri per la verifica del possesso del requisito
• Situazione attuale
• In ogni ambulatorio chirurgico esistono e vengono applicate, in aggiunta/integrazione a quanto previsto per l’assistenza specialistica ambulatoriale, procedure (cartacee o
informatizzate) per :
• 3.8.3 - a
• - informare il paziente sulla diagnosi, sulle motivazioni scientifiche a sostegno della prestazione chirurgica proposta, sui benefici attesi, sugli effetti collaterali e sui rischi ragionevolmente
prevedibili, sulle eventuali alternative possibili e, successivamente, per acquisire il consenso del paziente stesso all’esecuzione della prestazione; SI No
• 3.8.3 - b
• - eseguire, secondo le norme di buona pratica, le prestazioni chirurgiche maggiormente invasive o rischiose effettuate, definendo:
• il personale necessario per l’esecuzione delle prestazioni chirurgiche, comprese le eventuali presenza o pronta disponibilità dell’anestesista;
• le attrezzature, la strumentazione e i presidi necessari;
• le attività assistenziali da svolgere nella fase di preparazione del paziente, nell’esecuzione della prestazione e nel periodo di sorveglianza immediatamente successivo la prestazione
stessa. SI NO
• 3.8.3 - c
• - gestire le emergenze cliniche, incluse le modalità di trasferimento del paziente in una struttura di ricovero in caso di necessità; SI NO
• 3.8.3 - d
• - compilare la scheda chirurgica ambulatoriale, nella quale sono riportati:
• gli elementi identificativi del paziente;
• la diagnosi;
• i nomi e il ruolo del chirurgo e degli altri professionisti coinvolti;
• la prestazione chirurgica eseguita;
• la data, l’ora di inizio e fine della prestazione;
• i farmaci somministrati e la via di somministrazione;
• gli elementi identificativi per la rintracciabilità degli eventuali impianti;
• le eventuali complicanze immediate. SI NO
• 3.8.3 - e
• - eseguire, secondo le norme di buona pratica, il lavaggio, il confezionamento, la disinfezione e la sterilizzazione dello strumentario chirurgico e degli altri presidi utilizzati, ed i
controlli sistematici per la verifica di efficacia dei processi di sterilizzazione; SI NO
• 3.8.3 - f
• - prevenire il rischio infettivo per i pazienti e il personale. SI NO
•

46. UK?
• SURGERY AND GENERAL ANAESTHESIA IN
GENERAL PRACTICE PREMISES
• Published by The Association of Anaesthetists
of Great Britain and Ireland
• 9 Bedford Square, London WC1B 3RA
• Tel: 0171 631 1650 Fax: 0171 631 4352
•1995

47. AAGBI: SURGERY AND GENERAL ANAESTHESIA
IN GENERAL PRACTICE PREMISE
• Section I Introduction 1
• Section II Necessary Facilities 3
– (i) Personnel
– (ii) Support Staff
– (iii) Organisational arrangements
• Section III Specialist Services 5
– (i) Anaesthetic services
– (ii) Surgical services
• Section IV Sterilisation Services 6
• Section V Technical Services 8
– (i) Anaesthetic, resuscitation and monitoring equipment
– (ii) Medical gases
– (iii) Volatile anaesthetic agents
– (iv) Waste anaesthetic agents
• Section VI Quality, Financial and Contractual 10
• Arrangements
• References 11

49. Anesthesiologist(s) . . . and not only, other
consultants as well
• The National Confidential Enquiry into perioperative deaths
(UK) found that the number of yearly procedures performed by
some consultant endoscopists was too low to ensure proficiency
and skill. It recommended that competency in endoscopy
should be assured by national guidelines.
– Scoping our practice 2004 ,pub. by the National Confidential Enquiry into Patient Outcome and
Death(NCEPOD),Epworth House, 25 City Road, London EC1Y 1AA.
• No such recommendations exist for anesthesiologists, however,
whose competency is simply assumed by the specialist
diploma…..think about the skills of many
Direttori/Primari…………

50. NORA special skills
• NORA requires special skills and attitudes
– among 25 neuroanesthesiologists, only 3 were found to administer anesthesia with the magnet inside
the operating room intrinsically recognizing the need for a higher level of technical skills.
– Archer DP, McTaggart Cowan RA, Falkenstein RJ, et al. Intraoperative mobile magnetic resonance
imaging for craniotomy lengthens the procedure but does not increase morbidity. Can J Anesth 2002; 49:420426
• Nontechnical skills are also important since NORA also stresses other qualities, like task
management, team-working capability and coordination, situation
awareness, and decision-making.
– Fletcher, G.,Flin, R.,McGeorge, P et al. Anaesthetists' Non-Technical Skills (ANTS): evaluation of a
behavioural marker system. Br. J. Anaesth. 2003; 90:580-588.
• Since NORA involves special risks and difficulties, anaesthetists that
are unsafe due either to a lack of knowledge and skills or old age
need to be identified
– Atkinson RS. The problem of the unsafe anaesthetist. Br J Anaesth 1994;73:29–30.
– Katz JD. Issues of concern for the aging anesthesiologist. Anesth Analg 2001;92:1487–1492.

52. Sedationist ……….
• Nurses
– Bluemke DA, Breiter SN. Sedation procedures in MR imaging: safety, effectiveness,
– and nursing effect on examinations. Radiology 2000; 216:645–652.
– Sury MRJ, Hatch DJ, Dicks Mireaux C, Chong WK. Development of a nurse led sedation service for paediatric magnetic resonance imaging. Lancet
1999; 353:1667–1671
• Physician
– Endoscopists……….
• quality of care and outcome ???Costs??
• Abenstein JP, Warner MA. Anesthesia providers, patient outcomes, and costs. Anesth Analg
1996; 82:1273–1283.
• Silber JH, Kennedy SK, Even-ShoshanO, et al. Anesthesiologist direction and patient
outcomes. Anesthesiology 2000; 93:152–163.
• Cromwell J, Snyder K. Alternative cost-effective anesthesia care t eams. Nurs Econ 2000;
18:185–193.[13], and the cost implications of anesthesia services .
• Martin-Sheridan D, Wing P. Anesthesia providers, patient outcomes, and costs: a critique.AANA J.
1996; 64:528-34.

53. • Anesthesia is a discipline that requires the constant
vigilance of well trained and experienced providers;
safety derives from high-level dedicated care,
teamwork,and rapid availability of physicians,
especially during medical crises.
• Clinical evidence supports the anesthesiologist-led
anesthesia care team as the safest and most cost-
effective method of delivering anesthesia.
– Death and failure to rescue were more frequent when care
was not directed by anesthesiologists
• However…….Sedation cannot be restricted to
anesthesiologists.

54. Guidelines for sedation by non anesthesiologists
• ASA practice guidelines for sedation and
analgesia by non-anesthesiologists.American
Society of Anesthesiologists Task Force on
Sedation and Analgesia by Non-
Anesthesiologists. Anesthesiology 2002;
96:1004–1017.

56. MAC
• Monitored Anesthesia Care does not describe the
continuum of depth of sedation, rather it
describes “a specific anesthesia service in
which an anesthesiologist has been
requested to participate in the care of a
patient undergoing a diagnostic or
therapeutic procedure.”
• From Stand by to GA!

57. main questions
• What would happen when a patient’s condition abruptly
changes
» or
• the patient moves to another stage of sedation?
• Who would be responsible for complications?
• every patient may become unstable, every single sedation
analgesic given outside the operating room should be done by
• one anesthesiologist/patient/unit of time
• the anaesthesiologist should be an experienced intensivist
should a crisis occur.

58. Equipment in nonoperating room anesthesia
• Old equipment is often kept in NORA areas
– New anesthesiologists may be unfamiliar with it
– Machines may no longer meet standards
– Since such equipment is not used on a daily basis,
it has to be carefully checked before each use and
a program of maintenance should be instituted.
The same considerations apply for monitors.

61. Equipment and machines in NORA
• It is important that the equipment and
machines used are maintained, tested and
inspected on a regular basis and not become a
repository for obsolete equipment
(www.asahq.org/publicationsAndServices/ma
chineobsolescense.pdf

62. Location and equipment
• Wherever the sedation or anesthetic is
performed, appropriate resuscitative equipment
and medications for cardiopulmonary
resuscitation must be immediately available
• ASA.Guidelines for non operating room anesthetizing
locations.Http:/www.asahq.org/publicationsAnd
Services/sgstoc.htm
• Capnography and pulse oximetry are invaluable
in a setting where patient observation is limited
(e.g. darkened room) or with limited access to
the patient (e.g. radiation oncology,MRI…).

73. • the standard of
anesthetic care does not
decrease because of
venue change

74. ASA guidelines for OBA
• 1.Adequate professional and administrative staff, as well as housekeeping and maintenance
personnel.
• 2.Preoperative evaluation with necessary tests and consultations as medically indicated.
• 3.The development of an anesthesia plan acceptable to the patient, the administration or
medical direction of same, as well as the discharge of the patient remain physician
responsibilities.
• 4.Patients who receive other than unsupplemented local anesthesia must be discharged
with a responsible adult and provided written postoperative and follow-up instructions.
• Because the office facilities vary considerably, anesthesiologists must ensure that the facility is
adequately equipped, with the following as a minimum:
• 5.Sufficient space and electrical outlets plus adequate illumination must be provided,
including backup power (this is listed first because space is something for which
anesthesiologists frequently must fight in the office as well as the hospital or ASF).
• 6.A reliable source of oxygen adequate for the length of the procedure plus a backup supply,
the latter to be at least equivalent to an E cylinder, and the ability to administer positive
pressure ventilation.
• 7.Emergency cart with defibrillator and appropriate drugs.
• 8.A reliable source of motor-driven suction.
• 9.If inhaled anesthetics are to be used, an anesthesia machine equivalent to that of the
hospital operating room and a system for scavenging waste anesthetic gas must be available.
• 10.Basic monitoring of oxygenation (pulse oximetry), ventilation (minute ventilation for
general anesthesia and capnography for intubation), circulation (blood pressure every 5 min
and continuous electrocardiogram display), and temperature (when clinically significant
changes in temperature are intended, anticipated, or suggested) is essential.
• 11.All applicable building and safety codes and facility standards must be observed and
federal, state, and local laws obeyed.

75. Equipment/monitoring requirements for nonoperating room
anesthesia
• Appropriate (for deep sedation, general anesthesia and a
cardiorespiratory emergency) Immediately available
• Regularly serviced (service date indicated on the equipment)
• Same standard as in the operating room (minimum pulse oximetry, end-
tidal capnography, blood pressure, electrocardiogram and temperature)
• Alarms activated (with appropriate settings) and sufficiently audible
• Airway gas with the recognized safety devices (e.g. indexed gas connection
system, reserve supply of oxygen, oxygen analyzer, oxygen supply failure
alarm, multiple gas analyzer, a volatile anesthetic agent monitor, a
breathing system disconnection alarm and a scavenging system)
• Anesthesia work cart stocked to operating-room standard
– Including: appropriate anesthetic and resuscitation drugs,
– airway management equipment,
– a self-inflating hand resuscitator bag
– range of intravenous equipment
• Suction ( be sure it reaches the patient….)
• Ready access to a defibrillator and a fully stocked emergency cart

86. PORTABLE ANESTHESIA
MACHINE(S)

87. Standard configuration of the
OBA-1®
SPECS:
WIDTH: 16 inches
(40.6 cm)
DEPTH: 9.5 inches
(24.1 cm)
HEIGHT: 15
inches
(38.1 cm) to
top of
Inspiratory/E
xpiratory
valves
WEIGHT: 35
pounds
(15.7 kg)
Including the following items:
Obamed 1

88. DRE Integra SP VSO2 Portable
Anesthesia Machine

89. MIE Anmedic Hawk Anesthesia
Machine

90. MRI Anesthesia Machine 2200
Magmedix

91. Highland ME 109

92. Anebox Shinova Systems(China)

93. How to proceed
• anesthetic and monitoring equipment check
• Make a plan :sedation only.sedation+analgesia ,light,deep,GA
• be prepared for a change in procedure.
– It is my personal opinion that sedation and analgesia with spontaneous
respiration requires greater skills and experience than GA with airway control.
– Monitored anesthesia care for disabled children is much less expensive in the
dental rehabilitation office than GA in the operating room, but more sentinel
events have been reported
• All data should be obtained during the procedure, especially when
the anesthesiologist is away from the patient;
• this may require remote monitoring, special extension tubing, among
other means.
• be prepared for bad surprises, including sudden movement of the
patient, allergies, anaphylactic shock, need for vasopressors.

94. Pre prepared…..be prepared
• Pre prepared syringes:
– Atropine
– Effortil
– Midazolam
– Fentanyl
– Propofol??
– Clonidine(catapresan)
– Electrolytes
– ???specific for the procedure???

95. Special problems of NORA
• remote locations
• limited working space
• electrical interference with monitors and phones
• lighting and temperature inadequacies
• lack of skilled personnel, drugs, and supplies.
• Noises …..are unsettling for the patient and disturb the anesthesiologist. As alarm
recognition occurs 34% of the time under ideal conditions [76], noisy areas like MRI centers make
sound recognition and alarm perception very difficult. A presumed reason is that many alarms
• have similar sounds [77]..

96. • Since alarm volume and recognition rate are
correlated, we suggest that alarms be set at
maximum levels in NORA environments
– Anesth Analg. 2007 ;105(6 Suppl):S95-9, Effective standards and regulatory
tools for respiratory gas monitors and pulse oximeters: the role of
the engineer and clinician.Weininger S.

97. Postoperative surveillance/transportation
• Almost all the potentially preventable office-based
injuries result from adverse respiratory events in the
recovery or postoperative periods; therefore, strict
surveillance should be exercised until full recovery.
• During transportation all the equipment necessary for
a safe journey should be at hand.
• The ideal recovery area should be ‘near’ the location
where the patient was treated. The safe solution is to
place patients in the postanesthesia care unit (PACU) or
recovery room, as for surgical patients.

100. Measures of outcome
• Critical incidents may be more frequent in NORA; emergency
treatment of airways is paradigmatic [90].
• The availability of a difficult intubation cart in the ICU or PACU that
can be called upon for rescue would be optimal, but distant
locations should have their emergency trolley with a reasonable
choice of airways.
• Since outcome is influenced by care quality specific protocols
should be adopted for NORA and personnel organized accordingly.
• NORA activities require time, which means adequate staffing:
consider how many NORA activities should be covered every day.
• An invitation is being made to schedule fixed days for different tasks
in order to organize the anesthesia services.

101. Some quality indicators
• a. death, cardiac or respiratory arrest
• b. unplanned re-intubation
• c. central nervous system or peripheral nervous system deficit appearing
within two days of anesthesia
• d. myocardial infarction within two days of anesthesia
• e. pulmonary edema within one day of anesthesia
• f. aspiration pneumonia
• g. anaphylaxis or adverse drug reactions
• h. post dural puncture headache within four days of spinal or epidural
anesthesia
• i. dental injury
• j. eye injury
• k. surgical infection rate
• l. excessive blood loss
• m.unplanned admission to a hospital or other acute care facility

102. Quality indicators II
Review of quality indicators, to include measures of patient satisfaction.
• The quality improvement plan should include at least an annual review and
check of anesthesia equipment to ensure compliance with current safety
standards and the standards for the release of waste anesthetic gases.
• For each office facility at which anesthesia is provided on a regular or ongoing
basis, facility quality improvement reviews should be conducted. The reviews
should be performed by a group that includes, at a minimum, the medical
director, a representative of the anesthesiologists currently providing patient
care and a representative of the operating room or recovery nursing staff. The
frequency of the reviews would be appropriate for the number of procedures
performed, but they should be conducted at least annually and result in
written minutes and conclusions

103. NORA RISK EVALUATION……

104. The risk and safety of anesthesia at remote locations: the US
closed claims analysis .Julia Metzner, Karen L. Posner and Karen B.
Domino.Current Opinion in Anaesthesiology 2009,22:502–508
• ASA Closed Claims database of 8496 claims
• 87 claims associated with anesthesia in remote locations
compared with 3287 operating room claims.
• Patients in remote locations were older (20% >70 years and sicker
(69%, ASA PS 3-5)
• > 1/3 of remote location claims involved emergent procedures as
compared with only 15% of OR claims
• The predominant anesthetic technique in remote location claims
was MAC, 8 times more frequent (50 vs. 6%) than in OR claims.
• 21% of remote location claims involved no anesthesia (e.g.
emergency endotracheal intubation or resuscitation )

105. The risk and safety of anesthesia at remote locations: the US
closed claims analysis .Julia Metzner, Karen L. Posner and Karen B.
Domino.Current Opinion in Anaesthesiology 2009,22:502–508

106. Severity of injury
The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L.
Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508
• The severity of injuries for remote location claims was
greater than those associated with operating room
claims
• The proportion of
death was almost double
in remote location claims
(54 vs. 29% ) in OR claims.
• OR claims were mostly associated with temporary
injuries (49%.)
• The proportion of claims for other nonfatal injuries showed a similar
tendency in both groups, except nerve damage, which was more common
among OR claims .

107. Mechanism of injury
The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L.
Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508
• adverse respiratory events : double that of OR
claims (44 vs. 20%)
• Inadequate oxygenation/ventilation was the
most common respiratory-related remote
location claim,occurring 7 times more
frequently than in OR claims (21 vs. 3%, )
• Difficult intubation , esophageal intubation and
aspiration of gastric contents were the other
specific respiratory events in remote location
claims

108. Preventability of injury and etiology
The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L.
Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508
• The anesthesia care was judged by the reviewers as
substandard in 54% of remote location claims
compared with 37% of OR claims
• In addition, a large proportion of injuries in remote
location claims were considered to be preventable by
better monitoring (32 vs. 8% in OR claims),
• Oversedation leading to respiratory depression due to
an absolute or relative overdose of sedative–hypnotic–
analgesic drugs was responsible

109. The risk and safety of anesthesia at remote locations: the US
closed claims analysis .Julia Metzner, Karen L. Posner and Karen B.
Domino.Current Opinion in Anaesthesiology 2009,22:502–508

110. Conclusion
The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L. Posner and
Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508
• Analysis of closed claims suggests that administration of
anesthesia and sedation at remote locations is associated with a
significant risk of adverse effects. In spite of the relatively
noninvasive nature of the procedures, our analysis suggests
that anesthesia at remote locations, particularly
those involving MAC, represents a growing area of
liability for the anesthesiologist. Knowledge of the
pharmacokinetic properties of sedative/analgesic drugs, careful
monitoring using ASA standards, including continuous
monitoring of respiration by capnography, and vigilance can aid
in minimizing the risk of permanent injury to the patient. In
addition, general anesthesia with endotracheal intubation may
be safer than deep sedation in some patients and procedures

111. • These findings emphasize the
seriousness of the preanesthetic
assessment and the need to identify
pts at risk for cardiac,respiratory and
airway issues

112. Comput Assist Tomogr. 2009 Mar-Apr;33(2):312-5.
Increased risk of general anesthesia for high-risk patients undergoing
magnetic resonance imaging.
Girshin M, Shapiro V, Rhee A, Ginsberg S, Inchiosa MA Jr.
• Department of Anesthesiology, Metropolitan Hospital Medical Center, New York, NY 100129, USA.
m_girshin@yahoo.com
• A total of 47,389 anesthetics have been administered to pediatric patients
in the Montefiore Medical Center between February 1998 and September
2007, of which 11,700 (25%) were administered for procedures performed
outside the OR.
• 3 deaths from general anesthesia occurring in the MRI suite, the resulting
non-OR mortality rate at our institution was approximately 1 in 3900.
Comparatively, in the same period, our mortality rate for procedures
performed intraoperatively under general anesthesia was 1 in 7138.
• Therefore, there is almost a 2-fold increased risk in mortality associated
with non-OR versus OR anesthetics at our institution.
• CONCLUSION: Our analysis shows that the administration of anesthesia in
MRI suite possesses inherent risks that might be the same or even higher
than those in the OR. .

113. Risky patients in NORA………
• Out of operating room procedure selected as
a less risky alternative to an OR procedure in
an extremely risky patient:
• E.g.
– : vascular stenting in interventional or
neuroradiology vs open procedure in OR
– Oesoph. Varices ligature in endoscopy….
– Gastroduodenal ulcer bleeding in endoscopy…….
– Coronary stenting in cardiology………….

114. MAC(MONITORED ANESTHESIA CARE)
SHOULD STAND FOR
MAXIMUM ANESTHESIA
CAUTION,NOT MINIMAL
ANESTHESIOLOGY CARE
C.C.HUG.EDITORIAL. ANESTHESIOLOGY 2006; 104:221–3

115. Quality issues
• Quality improvement should rely on raising the
standards of every location where sedation and
anesthesia are possible to operating
room standards.
• In the meantime, the recommendations taken
from the ASA guidelines for NORA locations
should be followed and implemented..

116. Conclusion
• NORA means challenges
• providing care for more medically complex
patients while adapting to fewer resources, with
lack of support system commonly available in the
operating room
• No anesthesia or sedation performed outside the
operating room should be considered minor; it
requires skill, experience, and organization.
• Anesthetic needs should be evaluated from a
safety point of view.
• Patient preparation, consent, sedation, analgesia
or GA should be performed utilizing the same
standards as adopted for the operating room

117. Office-Based Surgery Practices in
New York State.
• Alert
• Practices which perform office-based
surgery were required to be
accredited on July 14, 2009.
– To find a list of accredited practices go to Office-
Based Surgery Practices in New York State.

118. Office-Based Surgery Practices in New York State
• Effective July 14, 2009, physician offices that perform
surgical or invasive procedures using more than mild
sedation must be accredited by one of these agencies:
• Accreditation Association for Ambulatory Health Care
(AAAHC)
• American Association for Accreditation of Ambulatory
Surgery Facilities, Inc. (AAAASF)
• The Joint Commission (TJC)
• Accreditation, though not the same as state regulation,
is a way to ensure a level of standardization among
office-based surgical practices with the goal of assuring
quality of care and patient safety.

119. Consequences…..
• Beginning July 14, 2009, a physician who is found to
have operated in an unaccredited office is guilty of
professional misconduct and risks his license.
• “New York’s law has teeth,” ….
• Some states that have mandated office
oversight still don’t see much accreditation
activity, but “in New York, people took notice
because there was a penalty in the law,”

121. Joint Commission
• The Universal Protocol for Preventing Wrong
Site, Wrong Procedure, and Wrong Person
Surgery™
• Guidance for health care professionals
• SpeakUP

122. Conduct a pre-procedure
verification process
Mark the procedure site
.
Perform a time-out

123. Office buildings …

132. Partnership vs solo practice
• partnership of surgeons (well established)
from the community who have come together
to provide a wide breadth of quality surgical
care……….

133. Plastic Surgery of Southern Connecticut

134. • Recommendations for anesthesia and
sedation in nonoperating room locations
• Raccomandazioni per l’esecuzione
dell’anestesia e della sedazione al di fuori dei
blocchi operatori .
• SIAARTI Study Group for Safety in Anesthesia
and Intensive Care .
• Coordinator. E. Calderini
• Minerva Anestesiologica 2005;71:17-21.

135. General organization of the guideline:
• Definitions and aims
• Organization :model
• it is suggested that every Dept of Anesth. draft a organization model for
treatments outside OR’s….…
• Indications
• Patient selection:I & II: ASA III with limitations
• Supply and communications

136. ASA Guidelines concerning OBA
•
Guidelines for Office-Based Anesthesia
http://www.asahq.org/publicationsandServices/standards/12.pdf
• Guidelines for Qualifications of Anesthesia Providers in the Office-Based Setting
http://www.asahq.org/NEWSLETTERS/2000/01_00/statement0100.html
• Guidelines for Ambulatory Anesthesia and Surgery
http://www.asahq.org/publicationsAndServices/standards/04.pdf
• Guidelines for Nonoperating Room Anesthetizing Locations
http://www.asahq.org/publicationsAndServices/standards/14.pdf
• Position on Monitored Anesthesia Care
http://www.asahq.org/publicationsAndServices/standards/23.pdf
• Statement on Regional Anesthesia
http://www.asahq.org/publicationsAndServices/standards/26.pdf
• Statement on the Anesthesia Care Team
http://www.asahq.org/publicationsAndServices/standards/16.html
• Basic Standards for Preanesthesia Care, Standards for Basic Anesthesia Monitoring, and Standards
for Postanesthesia Care
http://www.asahq.org/publicationsAndServices/standards/02.pd
• fContinuum of Depth of Sedation Definition of General Anesthesia and Levels of sedation/Analgesia
http://www.asahq.org/publicationsAndServices/standards/20.pdf

137. Servizio di Anestesia e
Rianimazione Ospedale di
Faenza(RA)
SIAARTI guidelines useful for OBA
• LINEE GUIDA PER LA SICUREZZA IN ANESTESIA LOCO-REGIONALE
• Commissione SIAARTI/AAROI,sull’anestesia in day surgery.
– Coordinatore: M. SOLCA
• G.BETTELLI, M.LEUCCI, C.MATTIA, V.A.PEDUTO, E.RECCHIA, P.RUJU, I.SALVO, A.TERREVOLI
RACCOMANDAZIONI CLINICO-ORGANIZZATIVE PER L’ANESTESIA IN DAY-SURGERY
• Raccomandazioni per l’anestesia nel Day Hospital
• Raccomandazioni per il monitoraggio di minima del paziente durante
anestesia.I Edizione febbraio 1990,II Edizione giugno 1996.
• RACCOMANDAZIONI PER LA VALUTAZIONE ANESTESIOLOGICA
IN PREVISIONE DI PROCEDURE DIAGNOSTICHE - TERAPEUTICHE IN
ELEZIONE
Ecc,ecc

138. Other good articles
• Recommendations on minimum facilities for safe
anaesthesia practice outside operating suites.
Last Updated July 3, 2002. Australian and New
Zealand College of Anaesthetists Professional
Document T2.[Online] 2002.
http://www.anzca.edu.au/publications/profdocs/
technical/T2_2000.htm.
• Kotob F, Twersky RS. Anesthesia outside the
operating room: general overview and
monitoring standards. Int Anaesthesiol Clin 2003;
41:1–15.

140. • GUIDELINES FOR OFFICE-BASED ANESTHESIA
• Committee of Origin: Ambulatory Surgical
Care
• (Approved by the ASA House of Delegates on
October 13, 1999, and last affirmed on
October 21, 2009)
• These guidelines are intended to assist ASA
members who are considering the practice of
ambulatory anesthesia in the office setting:
office-based anesthesia (OBA).

141. • ….ASA recognizes the unique needs of this
growing practice and the increased
requests for ASA members to provide
OBA for health care practitioners* who
have developed their own office
operatories…..

142. • ..special problems that ASA members must
recognize when administering anesthesia in the office
setting. Compared with acute care hospitals and
licensed ambulatory surgical facilities, office
operatories currently have little or no
regulation, oversight or control by federal,
state or local laws.

143. ASA ….
• …..Therefore, ASA members must satisfactorily
investigate areas taken for granted in the
hospital or ambulatory surgical facility such as
governance, organization, construction
and equipment, as well as policies and
procedures, including fire, safety, drugs,
emergencies, staffing, training and
unanticipated patient transfers

144. NORA
• Governance
• organization
• construction and equipment
• policies and procedures, including :
– Fire
– safety
– drugs
– emergencies
– staffing
– training
– unanticipated patient transfers

145. Expanding the role
of the
anesthesiologist

146. THE END

147. SPECIAL PROBLEMS

148. Risks commonly associated with gastrointestinal
endoscopy
• Hemodynamic instability due to:
• Elderly population with limited cardiovascular reserve
• Dehydration due to osmotic bowel preparation
• Vagal responses to gastrointestinal distention
• Risk of aspiration due to:
– Ingestion of large amounts of bowel preparation
– Gastric bleeding
• Difficult airway access:
– Shared airway in upper endoscopy
– Prone positioning
– Dark procedure room

149. Risks commonly associated with MRI
• Emergencies?full stomach,depressed
consciousness……
• Presence of the magnet….
• Anesthesiologist out of room
• Telemonitoring
• Mainly children with cerebral problems or
claustrophobic/non cooperative adults

169. ASA recommendations 2003
• (a) Reliable oxygen source including a backup supply.
• (b) Adequate and reliable suction.
• (c) Adequate and reliable scavenging system if anesthetic gases are to be used.
• (d) Self-inflating resuscitation bag capable of delivering an inspired oxygen fraction
(FiO2) of 0.90.
• (e) Adequate drugs, supplies and equipment for the planned activity.
• (f) Adequate monitoring equipment to adhere to standards for basic anesthetic
monitoring.
• (g) Sufficient electrical outlets, isolated electric power or electric circuits with ground
fault interruption in ‘wet areas’ like cystoscopy, arthroscopy, labor and delivery suites,
with access to emergency power supply.
• (h) Sufficient space for equipment and personnel and transportation.
• (i) Immediate suitability of an emergency cart with defibrillator, emergency drugs, etc.
• (j) Reliable two-way communication.
• (k) Observation of all applicable building and safety codes and facility standards.
• (l) Appropriate postanesthesia management.

170. Specific items:
• Self inflating resusci bag (FiO2 0.90)
• Drugs and devices for anesthesia
• Monitor ECG with HR display
• NIBP ;sphygmomanometer…..
• Pulse oximeter
• Cart with emergency devices and drugs + defibrillator
• Anesthesia machine if GA
• Capnometer or apnea monitor only when …..next paragraph…..or
no direct patient vision
• Prerequisites
• Checks and maintenance to be defined appropriately

171. Anesthesia supply cart
• H+H systems?
• What is needed..
• Same content for all
• Cart insert and dividers easily configured
• Who is checking? And when?

173. Portable anesthesia machines su
Travelmate

174. Office features
• building
• Spaces:parking
• Transportation
• In nearness of
:highways,railways,underground,
• Which services would be offered?which staff?
• Demands of patients,physicians,surgeons…

175. Reasons behind office surgery
• Advancements in medicine have always been made
by new discoveries or technologies ….
– Instead…
• Day surgery originates from savings need!
– Office-based anesthesia represents a potential for cost-effective
approaches for many surgical procedures…..
• but now the third payer ,after having pushed
ambulatory surgery in order save money ,is
hampering the office based option because is afraid
of increasing the expenses………..

176. Which are the driving forces behind the changes in the
surgical & anesthesiological approach?
• Cost containment politics
– USA Medicare and other Insurances
• New technologies
– Instrumentations:user friendly
– Drugs;fast on and fast off
– Resp. Devices less invasive
– Portability of equipment and monitors
– Minimally invasive surgical techniques
• Increase in competition on the health market;the
informed patient……..

177. Advantages of Office Based Anesthesia (OBA)
• facility fees in a hospital can be expensive and often unpredictable, the costs in an office are
more readily controllable and predictable
– WETCHLER BV: Online shopping for ambulatory surgery: let the buyer beware!
[Editorial].Ambulatory Surg; 8:111, 2000.
– . QUATTRONE MS: Is the physician office the wild, Wild West of health care? J Ambulatory Care
Manage; 23:64-73, 2000
– SCHULTZ LS: Cost analysis of office surgery clinic with comparison to hospital outpatient facilities
for laparoscopic procedures. Int Surg; 79:273-277, 1994.
• Patients undergoing a procedure in an office can be made aware of all costs prior to
consenting to surgery:costs typically include the surgeon’s, and anesthesiologist’s fees as
well as the facility fee.
– Medically necessary procedures can be reimbursed by third-party payers.
• ease of scheduling,
• patient and surgeon convenience,
• maintenance of patient privacy,
• decrease in patient exposure to nosocomial infections
• improved continuity of care, since an office is often staffed by a small group of consistent
personnel
– BING JB, MCAULIFFE MS, LUPTON JR: Regional anesthesia with monitored anesthesia care for dermatologic laser surgery. Dermatol
Clin; 20:123-134, 2002
• . IVERSON RE, LYNCH DJ: ASPS Task Force on Patient Safety in Office-based Surgery Facilities. Patient safety in office-based surgery facilities:
II. Patient selection. Plast Reconstr Surg; 110:1785-1790, 2002.

178. 2000/2006/2007 National Plastic Surgery Statistics
Cosmetic Procedure Trends:I

179. 2000/2006/2007 National Plastic Surgery Statistics
Reconstructive Procedure Trends:II
2000 2006 2007

180. • These recommendations focus on quality
anesthesia care and patient safety in the
office. These are minimal guidelines and may
be exceeded at any time based on the
judgment of the involved anesthesia
personnel. Compliance with these guidelines
cannot guarantee any specific outcome. These
guidelines are subject to periodic revision as
warranted by the evolution of federal, state
and local laws as well as technology and

184. 2004 Patient Safety Principles for Office-Based Surgery
Utilizing Moderate Sedation/Analgesia, Deep
sedation/Analgesia, or General Anesthesia :I
Courtesy, American College of Surgeons ,March, 2004
• Core Principle #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 October 13, 1999, excluding local anesthesia or minimal sedation.
• Core Principle #2 - Physicians should select patients by criteria,
including the ASA Patient Selection Physical Status Classification System, and so
document.
• Core Principle #3 - Physicians who perform office-based surgery should
have their facilities accredited by the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), Accreditation Association for Ambulatory Health
Care (AAAHC), American Association for Accreditation of Ambulatory Surgical
Facilities (AAAASF), American Osteopathic Association (AOA), or by a state-
recognized entity such as the Institute for Medical Quality (IMQ), or be state
licensed and/or Medicare certified.

185. 2004 Patient Safety Principles for Office-Based Surgery
Utilizing Moderate Sedation/Analgesia, Deep
sedation/Analgesia, or General Anesthesia :II
Courtesy, American College of Surgeons ,March, 2004
• Core Principle #4 - Physicians performing office-based surgery must
have admitting privileges at a nearby hospital, or a transfer agreement with
another physician who has admitting privileges at a nearby hospital, or maintain an
emergency transfer agreement with a nearby hospital.
• Core Principle #5 - States should follow the guidelines outlined by the
Federation of State Medical Boards regarding informed consent.
• Core Principle #6 - States should consider legally privileged adverse
incident reporting requirements as recommended by the FSMBiv and accompanied
by periodic peer review and a program of Continuous Quality Improvement.

186. 2004 Patient Safety Principles for Office-Based Surgery
Utilizing Moderate Sedation/Analgesia, Deep
sedation/Analgesia, or General Anesthesia :III
Courtesy, American College of Surgeons ,March, 2004
• Core Principle #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, American Osteopathic Association, 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 is generally recognized by that certifying board as falling within
the scope of training and practice of the physician providing the care.
• Core Principle #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.

187. 2004 Patient Safety Principles for Office-Based Surgery
Utilizing Moderate Sedation/Analgesia, Deep
sedation/Analgesia, or General Anesthesia :IV
Courtesy, American College of Surgeons ,March, 2004
• Core Principle #9 - At least one physician, who is credentialed or
currently recognized as having successfully completed a course in advanced
resuscitative techniques (ATLS®, ACLS, or PALS), 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 (BLS).
• Core Principle #10 - Physicians administering or supervising moderate
sedation/analgesia, deep sedation/analgesia, or general anesthesia should have
appropriate education and training

188. The risk and safety of anesthesia at remote locations: the US
closed claims analysis .Julia Metzner, Karen L. Posner and Karen B.
Domino.Current Opinion in Anaesthesiology 2009,22:502–508

189. The risk and safety of anesthesia at remote locations: the US
closed claims analysis .Julia Metzner, Karen L. Posner and Karen B.
Domino.Current Opinion in Anaesthesiology 2009,22:502–508

190. Oral Surgery Office Building and Site Design

191. Plastic Surgery in Modesto

194. Nora focal points :quality and safety
Patient
selection
Surgical
choices
Complication
rate
Training
Equipment
and support
of the facility

200. PRN-15
Secure digital access LED touch panel for access
Multi-level administrative and user access
Automatic locking mechanism
Manual lock override
500 unique user IDs on each cart
Solid metal construction for durability and security
Low center of gravity for easy maneuvering
5" casters for quiet operations
Multiple drawer configuration: 6-5.5" or 4-8.25" patient
bin cassettes or 3"/6"/9"/12" x 17" metal drawers
Large easy to clean work surface with SpillGuard
Protect for the electronics
Optional dual password Narcotic Lock Drawer
Optional items include-IV Pole, pass thru trash, pill
and water cu

201. Busing Co.Stock carts