1. (1) The purpose of this rule is to promote and establish consistent standards, continuing competency, and promote patient safety. The commission establishes the following rule for physicians licensed under this chapter who perform surgical procedures and use nitrous oxide in office-based settings. This section does not apply to facilities that hold accreditation or certification from an accrediting organization approved under WAC 246-919-601 (5)(a).

2. (2) The use of nitrous oxide is exempt from WAC 246-919-601 but is subject to the requirements of this section if the following conditions are met:

   1. (a) Nitrous oxide is administered at a concentration of 50 percent or less;
   2. (b) Nitrous oxide is used without another inhaled anesthetic, sedative, or opioid drug; and

   3. (c) The following safeguards are in place:

      1. (i) The physician performing the procedure must demonstrate competence by completing a continuing medical education course in nitrous oxide administration;
      2. (ii) At least one healthcare practitioner must be present who is certified in basic life support (BLS);
      3. (iii) The physician must be capable of resuscitating a patient from deeper sedation levels and ensure the patient's vital signs are monitored;
      4. (iv) The physician performing the procedure must not administer nitrous oxide or monitor the patient;
      5. (v) The health care practitioner administering the nitrous oxide must be different from the physician performing the procedure. The health care practitioner administering the nitrous oxide must be trained and competent in nitrous oxide administration and patient monitoring and acting within their scope of practice;
      6. (vi) The physician performing a procedure under this rule must ensure that the facility maintains a documented plan for transferring patients to a hospital in the event of complications, including arrangements for emergency medical services and appropriate escort of the patient to the hospital;

      7. (vii) The physician must maintain legible, complete, comprehensive, and accurate medical records including the following:

         1. (A) Identity of the patient;
         2. (B) History and physical, diagnosis and plan;
         3. (C) Appropriate lab, X-ray, or other diagnostic reports;
         4. (D) Documentation of nitrous oxide administered or dispensed; and
         5. (E) Documentation of vital signs during the nitrous oxide sedation, including respiratory rate, oxygen saturation, heart rate, and blood pressure;

      8. (viii) The following equipment must be available and include:

         1. (A) Suction equipment capable of aspirating gastric contents from the mouth and pharynx;
         2. (B) Portable oxygen delivery system including full face masks and a bag-valve-mask combination with appropriate connectors capable of delivery positive pressure, oxygen enriched ventilation to the patient;
         3. (C) Blood pressure cuff or sphygmomanometer of appropriate size; and
         4. (D) Pulse oximeter;

      9. (ix) Nitrous oxide must not be administered to any patient under three years of age. For pediatric patients older than three years, a discussion with the parent or guardian is required to address the specific risks associated with nitrous oxide use in cases where the patient is younger than six years old, has airway abnormalities, or has significant comorbidities.

         This discussion must include reasoning why the pediatric patient can safely receive nitrous oxide in an outpatient environment and any alternatives.

      10. (x) Excess nitrous oxide must be removed from the procedure room to protect staff via a scavenging system:

          1. (A) Except when nitrous oxide is delivered solely through demand-flow equipment. "Demand-flow delivery" means a nitrous oxide system in which gas is released only upon patient inhalation; or
          2. (B) Except when a facility monitors nitrous oxide exposure with dosimeters and can demonstrate that staff exposure remains within safe limits;
      11. (xi) Equipment used for monitoring patients must be calibrated or performance verified according to manufacturer's instructions; and
      12. (xii) Nitrous oxide must be stored securely and accessible only by authorized individuals.

3. (3) The physician shall assess patient responsiveness using preoperative values as normal guidelines and discharge the patient only when the following criteria are met, except when their prior baseline is below the noted criteria:

   1. (a) Vital signs including blood pressure, pulse rate, and respiratory rate are stable. Vital signs are not required when a pediatric patient is uncooperative or the emotional condition is such that obtaining vital signs is not possible;
   2. (b) The patient is alert and oriented to person, place, and time as appropriate to age and preoperative psychological status;
   3. (c) The patient can talk and respond coherently to verbal questioning as appropriate to age and preoperative psychological status;
   4. (d) The patient can sit up unassisted;
   5. (e) The patient can walk with minimal assistance;
   6. (f) The patient does not have uncontrollable nausea or vomiting and has minimal dizziness.

[Statutory Authority: RCW 18.71.017 and 18.130.050. WSR 26-11-022, s 246-919-603, filed 5/13/26, effective 6/13/26.]