Re: "Dueling Over Propofol" (October, page 32). As president of the Society of Gastroenterology Nurses and Associates, I was pleased to see our position statement (Statement of the Use of Sedation and Analgesia in the Gastrointestinal Endoscopy Setting) referenced in your article. While I understand that space constraints necessitate using excerpts and synopses rather than the full text of a position statement, I am concerned that your use of the following language - without further clarification - could be misleading:

"The Society of Gastroenterology Nurses and Associates, Inc., supports the position that registered nurses trained and experienced in gastroenterology nursing and endoscopy can administer and maintain moderate sedation and analgesia (conscious sedation) by the order of a physician, as well and monitor and assess the patient."

We believe this synopsis does not capture the key elements of our position statement, including full details of the role of the RN during conscious sedation, the RN's required level of education and experience, as well as the role of the physician during the procedure. Additionally, no mention was made of our stance regarding the recommended additional training - with emphasis on advanced airway management and treatment of cardiorespiratory complications - for RNs and physicians involved in the admission of deep sedation.

As GI nurses, patient safety is our first concern, and we believe it is very important that patients and other medical professionals have a clear understanding of our commitment to quality care.

Nancy R. DeNiro, RN, CGRN
SGNA President
Rocky Mountain Gastroenterology Associates
Lakewood, Colo.
writeMail("[email protected]")

"Behind Closed Doors" Too Bawdy
Re: "Behind Closed Doors" by Paula Watkins, RN, CNOR. I'm certainly no prude and have what I believe is a good sense of humor. However, I feel this column repeatedly oversteps the boundaries with overtly sexual tones that, in the centers I work in, would earn an immediate visit to the risk management attorney for code of conduct violations. I don't see the use of this type of humor in a professional journal, if that is what you strive to be.

Michael A. Kellams, DO
Northside Anesthesia Services, LLC
Carmel, Ind.
writeMail("[email protected]")

Behind Closed Doors Tells It Like It Is
As a CNOR whose primary role is on a consultative basis versus daily practical application, Paula Watkins' column in Outpatient Surgery Magazine is refreshing, educational and entertaining, as it provides me with a realistic reminder of the perioperative nursing role on a daily basis. Keep the realistic viewpoint - it is appreciated and valuable.

Susan Fausett, RN, CNOR, MBA
Vice President of Operations
ASCOA
Norwell, Mass
writeMail("[email protected]")

Financial Arrangements with Anesthesia
Re: "Understanding the Business of Anesthesia" (Manager's Guide to New Surgical Construction, January, page 20). In the employee model or locum tenens model, who is billing the patients? My assumption is that the ASC is doing the billing with permission from the anesthesia provider. In the independent contractor or hospital group model, is it necessary or prudent to rent space and supplies to the anesthesia provider (at fair market value)?

Brian K. Moser, MBA-HCM
Administrator
The Surgery & Laser Center at Professional Park
Clinton, S.C.
writeMail("[email protected]")

Adam F. Dorin, MD, MBA, replies: In the employee and locum tenens models, the anesthesia provider is included under the ASC contract (and business tax ID #) for the purpose of billing for services. In effect, the provider signs away his rights to bill for cases done at that facility.

Regarding the independent contractors and hospital group entities, be careful about renting space and supplies. It's not enough to set up contracts at fair market value since the mere presence of such an arrangement gives the appearance of a potential kickback. Federal offices reviewing such an arrangement would ask if there competitors for the right to provide anesthesia services at that location and if the payment of rent were a quid pro quo for such a right. The government wants to know that patients who are brought to a facility by a surgeon can have the peace of mind to know that the reason a particular anesthesia provider is giving them anesthesia is because of their competence - not because of some unseen business arrangement or kickback scheme. There are always exceptions. You could rent office space to an anesthesia group that's providing pain management services, but I'd run things by a healthcare lawyer.

As for having anesthesia providers pay for their supplies, this is universally seen as a big no-no - something that's just not done. The wording of the Medicare rules and those of other insurance providers clearly states that the facility fee is designed to capture all such procedural-related costs. Even settings involving exclusively cash-pay patients (office-based plastic surgical suites, for example) are not immune from issues of ethics, kickbacks and taxation.