TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING
BOARD OF MEDICINE
Agency Decision
Title of Regulation: 18VAC85-20. Regulations Governing the Practice of Medicine, Osteopathic Medicine, Podiatry, and Chiropractic.
Statutory Authority: § 54.1-2400 of the Code of Virginia.
Name of Petitioner: Michael Jurgensen for the Medical Society of Virginia.
Nature of Petitioner's Request:
Part VIII. Office-Based Anesthesia.
18VAC85-20-320. General provisions.
A. Applicability of requirements for office-based anesthesia.
1. The administration of topical anesthesia, local anesthesia, minor conductive blocks, or minimal sedation/anxiolysis, not involving a drug-induced alteration of consciousness other than minimal preoperative tranquilization, is not subject to the requirements for office-based anesthesia. A health care practitioner administering such agents shall adhere to an accepted standard of care as appropriate to the level of anesthesia or sedation, including evaluation, drug selection, administration and management of complications.
2. The administration of moderate sedation/conscious sedation, deep sedation, general anesthesia, or regional anesthesia consisting of a major conductive block are subject to these requirements for office-based anesthesia. The administration of 300 or more milligrams of lidocaine or equivalent doses of local anesthetics shall be deemed to be subject to these requirements for office-based anesthesia.
3. Levels of anesthesia or sedation referred to in this chapter shall relate to the level of anesthesia or sedation intended and documented by the practitioner in the pre-operative anesthesia plan.
B. A doctor of medicine, osteopathic medicine, or podiatry administering office-based anesthesia or supervising such administration shall:
1. Perform a preanesthetic evaluation and examination or ensure that it has been performed;
2. Develop the anesthesia plan or ensure that it has been developed;
3. Ensure that the anesthesia plan has been discussed with the patient or responsible party pre-operatively and informed consent obtained;
4. Ensure patient assessment and monitoring through the pre-, peri-, and post-procedure phases, addressing not only physical and functional status, but also physiological and cognitive status;
5. Ensure provision of indicated post-anesthesia care; and
6. Remain physically present or immediately available, as appropriate, to manage complications and emergencies until discharge criteria have been met, and
7. Document any complications occurring during surgery or during recovery in the medical record.
C. All written policies, procedures and protocols required for office-based anesthesia shall be maintained and available for inspection at the facility.
18VAC85-20-340. Procedure/anesthesia selection and patient evaluation.
A. A written protocol shall be developed and followed for procedure selection to include but not be limited to:
1. The doctor providing or supervising the anesthesia shall ensure that the procedure to be undertaken is within the scope of practice of the health care practitioners and the capabilities of the facility.
2. The procedure or combined procedures shall be of a duration and degree of complexity that shall not exceed eight hours and that will permit the patient to recover and be discharged from the facility in less than 24 hours.
3. The level of anesthesia used shall be appropriate for the patient, the surgical procedure, the clinical setting, the education and training of the personnel, and the equipment available. The choice of specific anesthesia agents and techniques shall focus on providing an anesthetic that will be effective, appropriate and will address the specific needs of patients while also ensuring rapid recovery to normal function with maximum efforts to control post-operative pain, nausea or other side effects.
B. A written protocol shall be developed for patient evaluation to include but not be limited to:
1. The preoperative anesthesia evaluation of a patient shall be performed by the health care practitioner administering the anesthesia or supervising the administration of anesthesia. It shall consist of performing an appropriate history and physical examination, determining the patient's physical status classification, developing a plan of anesthesia care, acquainting the patient or the responsible individual with the proposed plan and discussing the risks and benefits.
2. The condition of the patient, specific morbidities that complicate anesthetic management, the specific intrinsic risks involved, and the nature of the planned procedure shall be considered in evaluating a patient for office-based anesthesia.
3. Patients who have pre-existing medical or other conditions that may be of particular risk for complications shall be referred to a facility appropriate for the procedure and administration of anesthesia. Nothing relieves the licensed health care practitioner of the responsibility to make a medical determination of the appropriate surgical facility or setting.
C. Office-based anesthesia shall only be provided for patients in physical status classifications for Classes I, II and III. Patients in Classes IV and V shall not be provided anesthesia in an office-based setting.
18VAC85-20-350. Informed consent.
1. Prior to administration, the anesthesia plan shall be discussed with the patient or responsible party by the health care practitioner administering the anesthesia or supervising the administration of anesthesia. Informed consent for the nature and objectives of the anesthesia planned shall be in writing and obtained from the patient or responsible party before the procedure is performed. Such consent shall include a discussion of discharge planning and what care or assistance the patient is expected to require after discharge. Informed consent shall only be obtained after a discussion of the risks, benefits, and alternatives, contain the name of the anesthesia provider and be documented in the medical record.
2. The surgical consent forms shall be executed by the patient or the responsible party and shall contain a statement that the doctor performing the surgery is board certified or board eligible by one of the ABMS boards and list which board or contain a statement that the doctor performing the surgery is not board certified or board eligible.
3. The surgical consent forms shall indicate whether the surgery is elective, medically necessary, or if a consent is obtained in an emergency, the nature of the emergency.
18VAC85-20-370. Emergency and transfer protocols.
A. There shall be written protocols for handling emergency situations, including medical emergencies and internal and external disasters. All personnel shall be appropriately trained in and regularly review the protocols and the equipment and procedures for handling emergencies.
B. There shall be written protocols for the timely and safe transfer of patients to a prespecified hospital or hospitals within a reasonable proximity. For purposes of this section "reasonable proximity" shall mean a licensed general hospital capable of providing necessary services within 30 minutes notice to the hospital. There shall be a written or electronic transfer agreement with such hospital or hospitals.
18VAC85-20-380. Discharge policies and procedures.
A. There shall be written policies and procedures outlining discharge criteria. Such criteria shall include stable vital signs, responsiveness and orientation, ability to move voluntarily, controlled pain, and minimal nausea and vomiting.
B. Discharge from anesthesia care is the responsibility of the health care practitioner providing or the doctor supervising the anesthesia care and shall only occur when: (i) patients have met specific physician-defined criteria; and (ii) ordered by the health care practitioner providing or the doctor supervising the anesthetic care.
C. Written instructions and an emergency phone number shall be provided to the patient. Patients shall be discharged with a responsible individual who has been instructed with regard to the patient's care.
D. At least one person trained in advanced resuscitative techniques shall be immediately available until all patients are discharged.
Agency Decision: Request granted.
Statement of Reason for Decision: The intent of the board is to address the need for additional public protection in the administration of office-based anesthesia. Specific amendments recommended by the petitioner will be considered, as well as comments received on the petition and on the NOIRA.
Agency Contact: Elaine Yeatts, Agency Regulatory Coordinator, Department of Health Professions, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone (804) 367-4688, or email elaine.yeatts@dhp.virginia.gov.
VA.R. Doc. No. R15-01; Filed October 21, 2014, 8:37 a.m.
BOARD OF NURSING
Agency Decision
Title of Regulation: 18VAC90-20. Regulations Governing the Practice of Nursing.
Statutory Authority: § 54.1-2400 of the Code of Virginia.
Name of Petitioner: Patrick Sorensen.
Nature of Petitioner's Request: To accept paramedic hours of clinical experience towards the requirement of 500-hour requirement for licensure as a registered nurse, similar to the 150 hours of credit allowed for persons licensed as practical nurses.
Agency Decision: Request denied.
Statement of Reason for Decision: The Board of Nursing considered the request at its meeting on September 16, 2104, and after much discussion, declined to initiate rulemaking. While the board recognizes the excellent contributions of paramedics in emergency medical services, it does not feel that the training and experience provides a broad range of patient care in a variety of settings. Additionally, the educational curriculum of a licensed practical nurse includes rotations across the spectrum of the life cycle with various populations, so it would be difficult to equate the clinical experience.
Agency Contact: Elaine Yeatts, Agency Regulatory Coordinator, Department of Health Professions, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone (804) 367-4688, or email elaine.yeatts@dhp.virginia.gov.
VA.R. Doc. No. R14-37; Filed October 27, 2014, 1:28 p.m.
BOARD OF VETERINARY MEDICINE
Agency Decision
Title of Regulation: 18VAC150-20. Regulations Governing the Practice of Veterinary Medicine.
Statutory Authority: § 54.1-2400 of the Code of Virginia.
Name of Petitioner: Alysoun Ann Mahoney.
Nature of Petitioner's Request: To amend 18VAC150-20-121, Requirements for licensure by endorsement for veterinary technicians, to require completion of training in animal behavior through a certified applied animal behaviorist.
Agency Decision: Request denied.
Statement of Reason for Decision: At its meeting on October 22, 2014, the board considered all comments in favor of and in opposition to the request for amendment. Its conclusion was that the veterinary technician programs have adequate training in animal behavior, and the additional requirement for a formal training through a certified applied animal behaviorist would be burdensome. The board does not specify certain training or subject matter for licensure; it does require that educational programs be accredited. While the topic of animal behavior is certainly important to the practice of veterinary technicians, the board does not believe it is primary above all other subject matter and therefore necessary to be singled out as a requirement. Therefore, the board has denied the petition and will not initiate rulemaking.
Agency Contact: Elaine Yeatts, Agency Regulator Coordinator, Department of Health Professions, 9960 Mayland Drive, Richmond, VA 23233, telephone (804) 367-4688, or email elaine.yeatts@dhp.virginia.gov.
VA.R. Doc. No. R14-29; Filed October 23, 2014, 4:24 p.m.
Agency Decision
Title of Regulation: 18VAC150-20. Regulations Governing the Practice of Veterinary Medicine.
Statutory Authority: § 54.1-2400 of the Code of Virginia.
Name of Petitioner: Lee Henkel.
Nature of Petitioner's Request: The petitioner requests (i) an amendment to 18VAC150-20-10 to further define supervision as "direct," "immediate," or "indirect" for greater clarity to the public about the involvement of the supervising veterinarian; (ii) an amendment to 18VAC150-20-130 to require owner notification and consent for practice on an animal by a student, extern, preceptee, intern, or resident; and (iii) an amendment to 18VAC150-20-140 on unprofessional conduct to reflect changes in the supervision definition.
Agency Decision: Request denied.
Statement of Reason for Decision: At its meeting on October 22, 2014, the board considered all comments in favor of and in opposition to the request for amendments. Its conclusion was that additional study of issues relating to owner consent and notification and the levels of supervision was necessary before deciding whether regulations of the Board of Veterinary Medicine should be amended. Therefore, the board has denied the petition and will not initiate rulemaking at this time. The subject matter was referred to the Regulatory/Legislative Committee for further review and discussion.
Agency Contact: Elaine Yeatts, Agency Regulatory Coordinator, Department of Health Professions, 9960 Mayland Drive, Richmond, VA 23233, telephone (804) 367-4688, or email elaine.yeatts@dhp.virginia.gov.
VA.R. Doc. No. R14-41; Filed October 23, 2014, 4:25 p.m.