Statement on Office-Based Anesthesia

Developed By: Committee on Ambulatory Surgical Care
Last Amended: October 23, 2024 (Original Approval: October 13, 1999)

These guidelines are intended to assist ASA members who are considering the practice of ambulatory anesthesia in the office setting: office-based anesthesia (OBA). These recommendations focus on quality anesthesia care and patient safety in the office. These are minimum 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 practice.

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 or procedure rooms. Since OBA is a subset of ambulatory anesthesia, all applicable Standards and Guidelines including the ASA Statement on Ambulatory Anesthesia and Surgery should be followed in the office setting.

There are 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-based settings may have little or no regulation, oversight or control by federal, state or local laws. 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.

ASA members should be confident that the following issues are addressed in an office setting to provide patient safety and to reduce risk and liability to the anesthesiologist.

Administration and Facility

Quality of Care

• The facility should have a medical director or governing body that establishes policies and procedures and is responsible for the activities of the facility and its staff. The medical director or governing body is responsible for ensuring that facilities and personnel are adequate and appropriate for the type of procedures performed. 
• Policies and procedures should be written for the orderly conduct of the facility and reviewed on an annual basis. 
• The medical director or governing body should ensure that all applicable local, state and federal regulations are observed.
• All health care practitioners* and nurses should hold a valid license or certificate to perform their assigned duties. 
• All operating room personnel who provide clinical care in the office should be qualified to perform services commensurate with appropriate levels of education, training and experience.
• The anesthesiologist should participate in ongoing continuous quality improvement and risk management activities. 
• The medical director or governing body should recognize the basic human rights of its patients, and a written document that describes this policy should be available for patients to review.

Facility and Safety

• Facilities should comply with all applicable federal, state and local laws, codes and regulations pertaining to fire prevention, building construction and occupancy, accommodations for the disabled, occupational safety and health, and disposal of medical waste and hazardous waste. 
• Policies and procedures should comply with laws and regulations pertaining to medication handling, controlled drug supply, storage and administration.

Clinical Care

Patient and Procedure Selection

• The anesthesiologist should be satisfied that the procedure to be undertaken is within the scope of practice of the health care practitioners and the capabilities of the facility. 
• The procedure should be of a duration and degree of complexity that will permit the patient to recover and be discharged from the facility.
• Patients who by reason of pre-existing medical or other conditions may be at undue risk for complications should be referred to an appropriate facility for performance of the procedure and the administration of anesthesia.

Perioperative Care

• The anesthesiologist should adhere to the Basic Standards for Preanesthesia Care, Standards for Basic Anesthetic Monitoring, Standards for Postanesthesia Care, and Statement on Ambulatory Anesthesia and Surgery as currently promulgated by the American Society of Anesthesiologists. 
• The anesthesiologist should be physically present during the intraoperative period and immediately available until the patient has been discharged from anesthesia care. 
• Discharge of the patient is a physician responsibility. This decision should be documented in the medical record. 
• Personnel with training in advanced resuscitative techniques (e.g., PeRLS, ACLS, PALS) should be immediately available until all patients are discharged home.

Monitoring and Equipment

• At a minimum, all facilities should have:
  • A reliable source of oxygen adequate for the length of the procedure and recovery, including a backup supply. The backup system should include the equivalent of at least a full E cylinder.
  • An adequate and reliable source of suction.
  • Adequate anesthesia drugs, intravenous fluids, and other supplies and equipment for the intended anesthesia care. 
  • Basic resuscitative equipment, including a self-inflating hand resuscitator bag capable of administering at least 90 percent oxygen as a means to deliver positive pressure ventilation. 
  • An emergency cart with a defibrillator, emergency drugs, and other equipment adequate to provide basic and advanced cardiopulmonary resuscitation.
  • Emergency difficult airway management equipment.
  • In locations where inhalation anesthetics are administered, an anesthesia machine must be available and maintained to current standards when inhalation anesthesia is to be administered in addition to an adequate and reliable system for scavenging waste anesthetic gases.
• There should be sufficient space to accommodate all necessary equipment and personnel and to allow for expeditious access to the patient, anesthesia machine (when present) and all monitoring equipment. 
• All equipment should be maintained, tested and inspected according to the manufacturers’ specifications. 
• Sufficient electrical outlets to satisfy anesthesia equipment (anesthesia machine, when in use, syringe pumps, videolaryngoscopes, etc), and monitoring equipment requirements, including clearly labeled outlets connected to an emergency power supply, if available. In any anesthetizing location determined by the health care facility to be a “wet location” (e.g., cystoscopy, arthroscopy), either isolated electric power or electric circuits with ground fault circuit interrupters should be provided. 
• Adequate illumination of the patient, anesthesia machine (when present) and monitoring equipment. In addition, a form of battery-powered illumination other than a laryngoscope should be immediately available.
• Back-up power sufficient to ensure patient protection in the event of an emergency should be available. 
• In any location in which anesthesia is administered, there should be appropriate anesthesia apparatus and equipment, including capnography when indicated, which allow monitoring consistent with ASA “Standards for Basic Anesthetic Monitoring” and documentation of regular preventive maintenance as recommended by the manufacturer. 
• In an office where anesthesia services are to be provided to infants and children, the required equipment, medication and resuscitative capabilities should be appropriately sized for a pediatric population. 

Emergencies and Transfers

• All facility personnel should be appropriately trained in and regularly review the facility’s written emergency protocols. 
• There should be written protocols for cardiopulmonary emergencies and other internal and external disasters such as fire. 
• The facility should have medications, equipment and written protocols available to treat malignant hyperthermia when triggering agents are on site. 
• The process for activation of emergency services should be determined and made clear to all concerned parties prior to starting services in an office setting. 
• Mock code drills or procedure-specific simulations are strongly recommended to identify gaps in personnel, equipment, and logistics before an actual emergency arises.
• The facility should have a written protocol in place for the safe and timely transfer of patients to a prespecified alternate care facility when extended or emergency services are needed to protect the health or well-being of the patient.

* defined herein as physicians, dentists, and podiatrists