(a) If a facility furnishes anesthesia services, the facility shall provide these services in a well-organized manner under the medical direction of a physician approved by the governing body and qualified in accordance with Texas Occupations Code Title 3, Subtitle B (relating to Physicians) and Texas Occupations Code Chapter 301 (relating to Nurses), as appropriate.     
      (b) A facility that furnishes anesthesia services shall comply with Texas Occupations Code Chapter 162, Subchapter C (relating to Anesthesia in Outpatient Setting), unless the facility is exempt under Texas Occupations Code §162.103 (relating to Applicability).     
      (c) A facility is responsible for and shall document all anesthesia services administered in the facility.     
      (d) Anesthesia services provided in the facility shall be limited to those that are recommended by the medical staff and approved by the governing body, which may include the following.      
        (1) Topical anesthesia--An anesthetic agent applied directly or by spray to the skin or mucous membranes, intended to produce transient and reversible loss of sensation to the circumscribed area.       
        (2) Local anesthesia--Administering an agent that produces a transient and reversible loss of sensation to a circumscribed portion of the body.       
        (3) Regional anesthesia--Anesthetic injected around a single nerve, a network of nerves, or vein that serves the area involved in a surgical procedure to block pain.       
        (4) Minimal sedation (anxiolysis)--A drug-induced state during which patients respond normally to oral commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.       
        (5) Moderate sedation or analgesia ("conscious sedation")--A drug-induced depression of consciousness during which patients respond purposefully to oral commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. (Reflex withdrawal from a painful stimulus is not considered a purposeful response.)       
        (6) Deep sedation or analgesia--A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. (Reflex withdrawal from a painful stimulus is not considered a purposeful response.)       
      (e) The medical staff shall develop written policies and practice guidelines for the anesthesia service, which the governing body shall adopt, implement, and enforce. The policies and guidelines shall include consideration of the applicable practice standards and guidelines of the American Society of Anesthesiologists, the American Association of Nurse Anesthetists, and the licensing rules and standards applicable to those categories of licensed professionals qualified to administer anesthesia.     
      (f) Only personnel who have been approved by the facility to provide anesthesia services shall administer anesthesia. All approvals or delegations of anesthesia services as authorized by law shall be documented and include the training, experience, and qualifications of the person who provided the service. On the order of a physician, podiatrist, dentist, or other practitioner practicing within the scope of their license and education, a qualified registered nurse (RN) who is not a certified registered nurse anesthetist (CRNA) may administer topical anesthesia, local anesthesia, minimal sedation and moderate sedation, in accordance with all applicable rules, polices, directives, and guidelines issued by the Texas Board of Nursing. When an RN who is not a CRNA administers sedation, as permitted in this paragraph, the facility shall:      
        (1) verify the RN has the requisite training, education, and experience;       
        (2) maintain documentation to support that the RN has demonstrated competency in administering sedation;       
        (3) with input from the facility's qualified anesthesia providers, develop, implement, and enforce detailed written policies and procedures to guide the RN; and       
        (4) ensure that, when administering sedation during a procedure, the RN has no other duties except to monitor the patient.       
      (g) Anesthesia shall not be administered unless the physician has evaluated the patient immediately before the procedure to assess the risk of the anesthesia and of the procedure to be performed.     
      (h) A patient who has received anesthesia shall be evaluated for proper anesthesia recovery by the physician, or the person administering the anesthesia, before discharge using criteria approved by the medical staff.     
      (i) A patient shall be evaluated immediately before leaving the facility by a physician, the person administering the anesthesia, or an RN acting in accordance with physician's orders and written policies, procedures, and criteria developed by the medical staff.     
      (j) Emergency equipment and supplies appropriate for the type of anesthesia services provided shall always be maintained and accessible to staff.     
      (k) All facilities shall provide at least the following functioning equipment and supplies:      
        (1) suctioning equipment, including a source of suction and suction catheters in appropriate sizes for the population being served;       
        (2) a source of compressed oxygen;       
        (3) basic airway management equipment, including oral and nasal airways, face masks, and self-inflating breathing bag valve set;       
        (4) blood pressure monitoring equipment; and       
        (5) emergency medications specified by the medical staff and appropriate to the type of procedures and anesthesia services provided by the facility.       
      (l) In addition to the equipment and supplies required under subsection (k) of this section, a facility that provides moderate sedation/analgesia, deep sedation/analgesia, or regional analgesia shall provide:      
        (1) intravenous equipment, including catheters, tubing, fluids, dressing supplies, and appropriately sized needles and syringes;       
        (2) advanced airway management equipment, including laryngoscopes and an assortment of blades, endotracheal tubes, and stylets in appropriate sizes for the population being served;       
        (3) a mechanism for monitoring blood oxygenation, such as pulse oximetry;       
        (4) electrocardiographic monitoring equipment;       
        (5) cardiac defibrillator; and       
        (6) pharmacologic antagonists, as specified by the medical staff and appropriate to the type of anesthesia services provided.       
     Source Note:        The provisions of this §509.48 adopted to be effective December 4, 2023, 48 TexReg 7064