Dr. Vargo said he hoped that hospitals would use the evidence available in order to craft an appropriate anesthesia policy regarding propofol and other types of procedural sedation. He also observed that an evidence-based position paper on non-anesthesiologist administration of propofol for GI endoscopy was recently jointly published by the ASGE, American Association for the Study of Liver Disease, American College of Gastroenterology, and American Gastroenterological Association (Gastrointest. Endosc. 2009;70:1053-9).
Dr. Douglas K. Rex, a vocal opponent of the CMS’s position on propofol and director of endoscopy at Indiana University Hospital, Indianapolis, said the CMS guidelines still state that deep sedation is the domain of anesthesia specialists, a concept for which there is virtually no evidence and plenty of evidence that the policy is wrong and unnecessary.
"CMS’s handling of this process has been tragic," he said. "They stuck their noses in an issue they did not and still do not understand."
Dr. Alexander A. Hannenberg, ASA immediate past-president and associate chair of anesthesia at Newton-Wellesley Hospital in Newton, Mass., said the ASA met with CMS officials in April 2010 to contest its position that a labor epidural was not considered anesthesia, and therefore could be administered without physician supervision by certified registered nurse anesthetists (CRNAs).
Dr. Hannenberg said the CMS appeared not to understand the physiology of epidural pain relief, and that epidurals for labor, just as those used as anesthesia for surgery, produce a sympathetic block, or block the nerves that control circulation. He went on to say that the CMS’s previous position appeared to lower the standard of care for laboring women.
"I think they appreciated the physiology lesson, and went back and realized that the distinction was not as crisp or clear as they had originally thought, and removed the language that said it’s different and that the requirement for physician supervision is therefore different," he said.
CRNAs can still administer anesthesia if the hospital is located in one of 16 states that have elected to opt out of the CRNA physician supervision requirement. Ms. Dahl noted, however, that in theory, the updated guidance does not preclude a hospital in a non-opt-out state from choosing to make a determination that labor epidurals are not anesthesia, if it could point to support in nationally recognized guidelines when doing so, and as long as this would not be in violation of the state’s scope of practice law.
Dr. Hannenberg said the ASA also sought changes to the CMS pre- and postanesthesia evaluations. Preanesthesia evaluation must be completed within 48 hours prior to surgery or a procedure requiring anesthesia services, but the CMS clarified that some elements may be performed before then, as long as they are reviewed and appropriately updated within the 48-hour time frame. Dr. Hannenberg said the new wording recognizes that tests are often performed before the 48-hour time frame, and that it is standard of care for all elements of a case to be reassessed by anesthesiologists immediately before anesthesia administration.
The postanesthesia evaluation previously had to be completed before discharge, but may now be completed within 48 hours after a patient is moved to another inpatient location within the hospital or is discharged. This flexibility allows for a more complete evaluation of a patient because some things, such as adverse events, may not be fully knowable until after a patient is sent home, he said.
Ms. Dahl, Dr. Hannenberg, and Dr. Vargo reported no conflicts of interest. Dr. Rex reported consulting and advisory arrangements with American BioOptics, Avantis Medical Systems, CheckCap, Epigenomics, Given Imaging, and SoftScope. He receives grant support from Braintree Laboratories and Given Imaging, and a salary as well as speaking and teaching fees from Olympus America.