Is office-based anesthesia really safe?


Many physician offices and clinics have fewer resources to deal with anesthesia emergencies than hospitals

March 27, 2018

As a Houston, Texas medical malpractice attorney, I have handled a number of cases involving complications from office-based anesthesia services.

Of course, the most famous case that comes to mind is the 2014 death of Joan Rivers from respiratory and cardiac arrest that occurred when she was placed under anesthesia with Propofol for a routine endoscopy.

In recent years, many physicians have realized how profitable it can be for them to perform services in an office or non-hospital setting. In other words, there is an opportunity for physicians to obtain “facility fee” profit in addition to the compensation that they receive for their professional services.

Unfortunately, in my experience, many of these facilities and office practices lack adequate emergency equipment, staffing, and policies and procedures to provide anesthesia services in a manner that is safe for patients.

Even though Texas has passed some rather comprehensive regulations that apply to office-based anesthesia services, I have seen many instances in which physicians flagrantly violate these standards.

Requirements of Texas law

Texas Administrative Code Chapter 192 defines the legal requirements for office-based anesthesia services.

There are two major exclusions from the chapter’s scope. First, the chapter does not apply to outpatient anesthesia services including local anesthesia, peripheral nerve blocks, or both, in a total dosage amount of no more than 50% of the recommended maximum safe dosage per outpatient visit. Second, the regulations do not govern any outpatient facility accredited as an office-based surgery facility by The Joint Commission, American Association for Accreditation of Ambulatory Surgery Facilities, or Accreditation Association for Mandatory Health Care.

The regulations describe standards for anesthesia services based on three different levels, defined as Levels I-III.

Level I services are defined as the delivery of analgesics or anxiolytics by mouth, as prescribed for the patient by a physician, at a dose level low enough to allow the patient to remain ambulatory (able to walk). These services require at least two personnel to be present, including a physician who must be certified in Basic Life Support (BLS). In addition, the office or facility must have age-appropriate equipment including a bag mask valve and oxygen. In many cases that I have handled, physician offices have offered anesthesia services to pediatric patients but did not have age-appropriate equipment available in case resuscitation was needed.

Level II services include the administration of tumescent anesthesia; delivery of analgesics or anxiolytics by mouth and dosages greater than allowed at Level I; or, with some exclusions, administration of local anesthesia, peripheral nerve blocks, or both in a total dosage amount that exceeds 50% of the recommended maximum safe dosage per outpatient visit. These services require at least two personnel to be present, including a physician who must be certified in Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life Support (PALS). Another person must be present who is certified, at a minimum, in BLS. Further, the facility or office must have a crash cart containing drugs and equipment necessary to carry out ACLS protocols, including a bag mask valve, appropriate airway maintenance devices, oxygen, an automated external defibrillator (AED) or other defibrillator, pre-measured doses of first-line cardiac medications (including epinephrine, atropine, adrenal-corticoids, and antihistamines), IV equipment, a pulse oximeter, an EKG monitor, and benzodiazepine and reversal agent medications if certain procedures are performed.

Level III services are defined as delivery of analgesics or anxiolytics other than by mouth, including intravenously (by IV), intramuscularly (injected into a muscle), or rectally. These services require at least two personnel to be present, including a physician who must be certified in ACLS or PALS. Another person must be present who is certified, at a minimum, in BLS. A licensed healthcare provider must attend to the patient until the patient is ready for discharge, and a person must be responsible for monitoring the patient during the procedure. The office or facility must have all of the same drugs and equipment as required for Level II. In addition, there must be provision for establishment of a working intravenous (IV) feed, availability of antagonist medications, and compliance with the American Society of Anesthesiologists (ASA) Standards for Postanesthesia Care.

Level IV services are the most regulated, and are defined as delivery of general anesthetics, including regional anesthetics and monitored anesthesia care; spinal, epidural, or caudal blocks for the purposes of providing anesthesia or monitored anesthesia care (MAC). Physicians providing Level IV services must follow all current applicable standards and guidelines of the ASA. The regulations specifically allow a physician to delegate anesthesia services to a certified registered nurse anesthetist (CRNA), including the pre-anesthetic evaluation, patient counseling, patient preparation for anesthesia, and actual provision of anesthesia services. The regulations require physiologic monitoring of the patient and maintenance of all anesthesia-related equipment and monitors to current operating room standards. In addition, the regulations require the facility or office to have extensive emergency supplies on hand.

What you can do

In my experience, the safest place to undergo anesthesia is in a hospital setting. Hospitals should be equipped with extensive emergency personnel, equipment, and supplies that can be immediately tapped in the event of an emergency. Even further, in my opinion, having anesthesia managed by a fully-trained physician anesthesiologist is preferable to a less-trained certified registered nurse anesthetist (CRNA).

If your physician recommends a procedure in an office-based setting and anesthesia will be part of the care provided, then I suggest that you ask about the emergency equipment and supplies that are available in case something goes wrong. You may also wish to ask who will be providing the anesthesia care. In my opinion, the practice of having an anesthesiologist meet with the patient before the procedure and then pass off the anesthesia care to CRNA is a bait and switch.

If you or a loved one has been seriously injured because of office-based anesthesia services, call the experienced medical malpractice lawyers at Painter Law Firm, in Houston, Texas, at 281-580-8800, for a free consultation about your potential case.


Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who files medical malpractice and wrongful death lawsuits on behalf of patients and family members against hospitals, clinics, physicians, surgeons, anesthesiologists, and other healthcare providers. He frequently writes and speaks on topics related to healthcare and medical negligence. He previously served as editor-in-chief of The Houston Lawyer magazine and currently serves on the editorial board of the Texas Bar Journal.

Robert Painter

Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.


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