Recently, I was consulted about Medicaid coverage for nurse anesthesia services for procedures provided in a physician’s office. As I did a little research, it became apparent that my state had no standards for an office to provide procedures involving intravenous sedation other than a requirement by the department of health that such care be provided only in a licensed ambulatory surgery center. My state is not alone. Only 20 have regulations pertaining to office based surgery. See a list of regulations in each state here.
This situation is disturbing for many reasons. Many procedures probably can be performed in a properly equipped and staffed office at a substantial reduction of cost to the health system. On the other hand, lack of standards could result in use of intravenous sedation without prudent safeguards such as pulse oximetry, advanced cardiac life support training, or emergency drug availability. Complacency and overconfidence could result in poor outcomes when the predictable “unexpected” occurs during intravenous sedation in an unprepared office setting. Unstable physiology occurring in as few as 1/500 cases represents a significant amount of avoidable morbidity and mortality when viewed from a population-based analysis. Geriatric and pediatric patients might represent populations at particular risk. Many dental boards are ahead of the medical community in setting standards.
Office-based procedures have grown in number and are under the radar of state regulations and verification procedures. Internists should make sure that their offices are safe and that their patients are referred to properly organized facilities. It is an area that needs attention to get local standards up to speed with fast-changing medical practices.