Physician (including retired)
[January 17, 2023 2:00 PM]
My apologies on the late response.

1) Our clinic only offers cosmetic mole removal. I don’t think having stretcher access would be helpful to our clinic
2) Suction equipment is probably not appropriate as we would only use local anaesthetic. I would be more concerned that infrequent use would lead to accidentally causing an airway event.
3) As an Emergency Physician, I do not feel the use of intralipid would be appropriate in a level 1 clinic setting. This is an uncommonly used medication and would only really be safely used in conjunction with the ICU physicians and pharmacy service even in our ER.
3) Similarly for our local anaesthetic mole removal, the use of IV diphenhydramine, and hydrocortisone would be inappropriate and potentially delay IM epinephrine and EMS request. These are rarely used even in the ER for anaphylaxis (epinephrine IM is most important)
4) Cardiac events beyond initiating CPR/BLS are likely inappropriate for our low risk, level one and could potentially slow the request for EMS while staff attempts to execute more complex ICU/ER level resuscitation with medications like amiodarone, esmolol etc
5) Dantrolene should not be stocked in a level one facility like ours
6) Many physicians who can provide mole removal appropriate for a level 1 facility would not be qualified to use advanced airway equipment. Rapid use of the EMS service would be safer and more appropriate and attempting a rarely used technique/ECG monitoring equipment.

Thanks very much.
Organization
[January 13, 2023 9:22 PM]
Ontario Association of Gastroenterology (OAG) & Ontario Association of Clinic Endoscopists (OACE)
Response in PDF format.
Member of the public
[January 06, 2023 10:03 AM]
Good Morning,

As an interested, mature member of the public, and on the email list for consultations, having read the draft and the discussion comments, I appreciate this proposed medical service, OHP, is much more complex than I had thought.

Previously, I was aware of the October 2021 and February 2022 OMA documents on the website, offering OHIP covered out of hospital services for a list of minor or out patient surgical procedures and reference to the proposed pillars. My early impression was favourable.

In early 2023, the current prolonged COVID-19 pandemic, the limited health care professionals available to be recruited and trained, the federal versus provincial health care funding question, the reality of supply chain gaps for basic drugs, medical supplies, major medical equipment, building & renovation costs, this is very ambitious.

The most I would suggest is to consider a pilot program in up to three major cities, London, Hamilton, Toronto, or other major medical centre and in collaboration with a nearby hospital in an outreach role. Start with some but not all procedures to ensure patient safety and professional staff early experience before going further.

I noted much discussion about offering abortion. I am not sure why so many comments and not also on other potential common procedures, cataracts, cosmetic, others.

Living in [redacted] and as a patient in a Family Health Team for almost 20 years, my health care needs have been met including during the pandemic. In addition, the local public health unit, led by Dr. [redacted], has been excellent in being prepared for the pandemic with online appointments and drug freezer capacity prior to 2020 and with communication for the public by access to the website for comprehensive information about pandemic resources, updates, scheduling vaccines and more.
Physician (including retired)
[January 04, 2023 11:45 AM]
The effort to simplify ("modernize") the guidelines is an understandable goal; however, it has added complexity as outlined by the many comments above.

Assuming patient safety is the primary goal, guidelines should be consistent for OHP performing procedures using only local anesthetic, regardless of procedural intent - medically-indicated or cosmetic. Grouping local anesthetic procedures along with procedures requiring sedation creates significant and unnecessary financial and administrative burdens for solo practitioners providing services under local anesthetic exclusively.

Creating protocols for IV sedation and purchasing equipment/supplies (and repurchasing after expiry) only to serve accreditation standards, neither of which will ever be used, is wasteful and not something that a regulatory body should be imposing. This will not achieve any intended safety benefit.

A defined set of standards for OHP performing only local anesthetic procedures would address a wide spectrum of concerns already raised in previous comments. If the committee wishes to continue to distinguish local anesthetic procedures that are medically indicated and those which are cosmetic, then an OHP category for facilities performing only local anesthetic cosmetic procedures (no sedation) is needed in the guidelines.
Physician (including retired)
[January 03, 2023 10:14 PM]
Note: Some content has been edited in accordance with our posting guidelines.
Upon reading the CPSO OHP draft, I have concerns about its impact on abortion access in our province. As medical director at [redacted], where we have a hospital based surgical abortion service, I am aware of the important role free standing abortion clinics have in Ontario, and not including an abortion addendum as in previous standards would decrease the ability of many patients to access this important service at these OHP clinics.
 
Our hospital based abortion services are important for many patients who need the resources of in-hospital care, but most surgical abortions are in young healthy patients who are able to be safely and more efficiently cared for in free standing clinics where available. These clinics have been operating safely for decades with current standards. The single visit, the less time needed, the ability to be discharged without escort, are among the important aspects which need to be preserved for our population needing to access this important and essential health service. Many patients, especially the more vulnerable, need to access these services without needing visits over several days and without being able to tell anyone, otherwise being at risk of reproductive coercion or from intimate partner violence upon discovery of their attendance or wish to attend an abortion clinic. Many are very socially isolated due to their abuser and would have no one else to turn to as an escort.
 
Further restrictions on OHP abortion clinics would also place a burden on our hospitals, which could not service the increased number of patients without increasing available abortion OR time at the expense of other surgeries. As in-hospital abortion care requires an increased number of visits and an increased time commitment for patients, this could also increase barriers.
 
The goal of all is to ensure safe access to abortion care, however, the current draft without an abortion addendum will likely increase the number of patients who will not be able to access the most timely and safest care. Careful consideration is required to ensure that the new guidelines improve safe delivery of care rather than unintentionally having the opposite effect.
Member of the public
[January 03, 2023 4:19 PM]
Note: Some content has been edited in accordance with our posting guidelines.
The feedback I am providing flows from my role [redacted] at a Toronto-based abortion clinic from 2010 through 2019. My knowledge is further enhanced by my time [redacted] at Action Canada for Sexual Health and Rights (formally the Planned Parenthood Federation of Canada) and as a member of the former Federal Government Advisory Council on Gender-Based Violence.
 
I am disheartened to see that the revised OHPIP Standards do not include an addendum document specific to induced abortion care. Abortion is a low-risk medical procedure that comes with high-risk personal and social consequences for many. In particular, there are patients who are unable to safely disclose that they have terminated a pregnancy, especially patients with abusive intimate partners or family members. This impacts their capacity to safely seek discharge accompaniment. The former addendum document, “Applying the OHPIP Standards in Induced Abortion Care Premises and Independent Health Facilities,” recognized this reality and established that physicians weigh the decision to discharge a patient without accompaniment carefully, with patient safety being the primary consideration. If physicians are unable to exercise their professional judgement in this regard, vulnerable people seeking abortions will either continue with an unwanted pregnancy, be at risk of violence, or attempt to seek services at a hospital that is likely past capacity.
 
I further note that there is a wealth of evidence-based research and best practices pertaining to abortion care that counter the proposed OHPIP Standards regarding some medications and equipment. Examples of unnecessary medications include IV antihypertensives, IV calcium, IV agents for SVT, IV amiodarone, IV pressors, IV sodium bicarbonate, intralipid. Examples of unnecessary equipment include ACLS-compatible defibrillator (rather than an AED), intubation tray with blades/endotracheal tubes, capnography.
 
I encourage the CPSO to examine and incorporate the evidence-backed guidelines established by the National Abortion Federation (NAF), the Society for Family Planning (SFP), and the Society of Obsetrics and Gynecology of Canada (SOGC) when contemplating the application of OHPIP Standards to abortion provision. In closing, I strongly advocate that the OHPIP Standards continue to include the addendum document (or its equivalent), “Applying the OHPIP Standards in Induced Abortion Care Premises and Independent Health Facilities”. These guidelines reflect the best global evidence in procedural abortion care.
Organization
[January 03, 2023 3:30 PM]
Canadian Dermatology Association
Response in PDF format.
Physician (including retired)
[January 03, 2023 3:01 PM]
The draft guidelines are timely and in many ways there are not major changes from the original Guidelines. I was on the original advisory board that was involved in the Guidelines for the Pain Clinics in Ontario. I was also an expert advisor on subsequent revisions. I believe the Guidelines served the purpose and continue to ensure high standards and safety as evidenced by the stellar record of safety and patient satisfaction. The Change of Scope of Practice designation that was required by ALL physicians practicing interventional pain medicine became a model that was the best program in the country and emulated by other Provinces.
I have a few comments on the Guidelines. I will address my comments as they relate to pain clinics.
It should be clarified that pain interventions involving local anesthetics are the treatments in and of themselves. It is the analgesic affect from the deposition of local anesthesia using much lower volumes than used for Regional Anesthesia. This is not regional anesthesia but regional analgesia. It should be clarified that any physician doing these procedures fall into the category of using "local anesthetics" and will require the Change of Scope of Practice in Pain Medicine that is the Standard in Ontario and granted by the CPSO as acceptable for continuing to practice Interventional Pain Medicine in Ontario.

I am concerned that Medical Directors should be responsible for the "knowledge skill and judgement" of physicians. Of course we should be aware if there are any issues with a physician but we should be able to trust the College in assessing the qualifications of a physician after all we cannot have a physician join a clinic until the College agrees and they have their Change of Scope.

In summary the Guidelines continue to Guide the Practice of interventional Pain Medicine and the Addendum and Guidebook that accompanies the present Guideline should be part of the present draft and be included for clarification in any new update.
Other health care professional (including retired)
[January 03, 2023 1:48 PM]
As a registered nurse who works within gender-based violence and abortion care, these new regulations are greatly troubling. As many of my fellow HCPs above have mentioned, the risk of creating further restrictions on abortion care access is life-threatening and inequitable in many ways.
- the impact of delaying surgical abortion care can lead to social, emotional and physical health consequences that can be deadly. Including the risk of continuing a pregnancy despite medical advise indicating major health risks, emotional risks of increased anxiety, depression and possible suicidality, and the risk of attachment within a domestic violence situation where pregnant people are more than 7 times more likely to experience increased violence (including possible homicide).
- the impact of forcing/requiring patients to pursue a medication abortion when they would otherwise prefer surgical management can lead to financial and familial strains with clients requiring more time off of work, disempowerment with being unable to decide their own medical procedures, and lack of privacy to have a successful abortion without family presence.
- the impact of requiring accompaniment upon discharge which ultimately means that privacy and confidentiality cannot be maintained. This can also result in increased domestic violence risk.
Within the current climate (and fear) of abortion care restrictions, it is an injustice to folks seeking abortion care to experience greater barriers to an already restrictive form of healthcare. To require individuals with hyperemesis gravidum to fast, to require individuals to seek social support to have rides home that can jeopardize their social safety or require costly transport home (via ride-shares or taxis) and to further delay peoples care by requiring hospital procedures in a violation of equitable, just care and our duty to delay or not cause harm.
Finally, to expect that abortion care be deferred to hospital care in otherwise healthy individuals based on BMI standards and restrictive sedation requirements, amongst other concerns mentioned by fellow HCPs above places an immense strain on an already collapsing healthcare system and dismisses the knowledge, judgment, and expertise that abortion providers have in providing this form of care on a daily basis.
Abortion providers must be heard on this matter. We should have a seat at the table on how these updated OHP standards impacts our clients. In the spirit of advocacy, it is essential that the “Applying the OHPIP Standards in Induced Abortion Care Premises and Independent Health Facilities” (2015) abortion care companion document be reviewed and included in these standard updates with abortion provider guidance.

Thank you.
Organization
[January 03, 2023 8:31 AM]
Ontario Trial Lawyers Association (OTLA)
Response in PDF format.
Physician (including retired)
[January 03, 2023 5:02 AM]
This proposed guideline ignores the previously created OHP addendum for interventional pain procedures and would negatively impact pain patients, which some studies put as high as 29% of Ontario being in some form of chronic pain. Does CPSO want to ignore them? Do they want to be in the Toronto Star for ignoring that segment of the population? As CPSO and OHP have seen with backlash from pain patients in the past with proposals that would adversely impact them, this is a segment of the population that is very vulnerable, but their needle-based interventions/procedures can hardly be grouped in with invasive surgical procedures otherwise governed by OHP. Hence, the previous OHP addendum for chronic pain/interventional pain, which was good for pain patients.

Action required: OHP addendum needed (either keep the previous or modify it), especially since most procedures are with local anesthetic only (note: local anesthetic administered into a tissue is NOT "regional anesthesia," which is the numbing of a nerve that provides feeling to another region on which one might operate). Pain procedures tend to be local to the patient's site of symptoms.

Another example: OHP pain addendum modified the requirement for a full surgical safety checklist as this checklist asks for things that do not apply to chronic pain needle-based injections like "specimens" referencing tissue being removed, "blood loss" which is always nil, "urine output" not measured, "fluids in" no fluids given, "incision" no incisions are made, etc
Physician (including retired)
[January 03, 2023 4:48 AM]
Highly agree.
OHP pain addendum required.
Example issue: surgical checklist does not apply. No incisions made in pain management procedures. No fluid loss. No blood loss. etc
Physician (including retired)
[January 03, 2023 4:45 AM]
Agreed, but taking this one step further: Is CPSO really advocating for a negative public health impact by further burdening the hospitals with minor cases rather than allowing for ASA 3 cases to be done in OHPs? ASA 4 has been mandated to hospital in the past, rightfully so, but the majority of >55 year-old patients have enough minor comorbidities to be classified as ASA 3. Does the CPSO really want to restrict care to 50% of Ontario? Would it be happy if that was published in the Toronto Star? Let's be reasonable.

ASA 3 (like all ASA classes) was created almost 100 years ago now for billing purposes (I'm an anesthesiologist). It is a generic and simplified system that cannot be used to algorithmically assign which patients need to be burdened with an extra appointment (pre-op consultation) or not. Specific criteria, either governed by CPSO or just by normal physician clinical assessment on a patient-by-patient basis, but a crude tool the the ASA classification should not be the one of choice, at least not alone.
Physician (including retired)
[January 03, 2023 12:48 AM]
1. The new Draft needs to clarify that nerve blocks done for Intervention pain mgt and not for operations, are not and should not be classed under regional anesthesia.

2. I recommend that the guidelines from the pain addendum in the existing policy should be worked in and included in this new draft guideline.
Physician (including retired)
[January 02, 2023 5:40 PM]
I have been the Medical Director for a community pain organization comprising a number of clinics providing interventional pain procedures. I have been in this position long before the inception of the OHP program. Overall I applaud the CPSO for attempting to simplify this document to make it all inclusive. However I believe that there is enough difference between interventional pain clinics and other OHPs to merit either a separate explanation document, or at least some exception statements.
I agree completely with others that the definition of "regional anesthesia" is different depending on the intent and outcome (surgical anesthesia vs. pain management). This distinction should be clearly defined in the main document, or referral made to a secondary specific document on Interventional Pain Medicine as is currently the case. This would also extend to other related issues such as qualifications, patient selection, required precautions, equipment and medications required and discharge considerations.
The Standard threatens consequences for an OHP if the Medical Director does not provide information in the format and timeframe requested by OHPIP. This format requirement is problematic as many of the OHPIP processes currently mandate use of the Portal, which was dysfunctional from its launch. For example, in the inspection documentation, there is a limitation in the size of files that can be uploaded. Data which would be logically organized in a table or spreadsheet, cannot be uploaded, but rather has to be entered by hand. Any pdf documents sent out for completion are not in an editable format. I suggest that the CPSO consider holding some virtual user group meetings to get specific feedback to make the Portal more useful before imposing data format requirements.
The Standard makes an arbitrary requirement for the Medical Director to be onsite at a OHP clinic at least monthly. This may be fine for a one-clinic operation but can become onerous if there are multiple clinics in an organization. An alternative could be that another skilled professional (a nurse, for example) in an organization could be appointed to carry out elements of this role instead. Since assessment of infection control is one of the primary outcomes of such a visit, I have found that nurses are generally much more skilled at assessing this than most doctors.
The Standard requires at least 2 meetings per year at each OHP to discuss quality improvement. Our organization has a monthly Medical Advisory Committee meeting of key personnel representing all the clinics in our organization that discusses QI and Adverse Events among other issues. This should be an alternative for OHPs consisting of multiple clinics.
Finally, I would like to applaud the improved definition of reportable adverse events suggested in the document, namely those adverse events logically related to a treatment provided at the OHP. Previously a lot of time was spent recording and reporting things such as a death in a house fire or a cat bite within 10 days of a treatment at an OHP. I agree with previous comments that the monitoring period after a treatment should be 5 days rather than 10 days - unless the CPSO has data suggesting that many AEs occur between 5 - 10 days. OHP should be required to collate and provide annual AE statistics for the Province as a QI initiative.
Organization
[January 02, 2023 5:00 PM]
National Chronic Pain Society
Response in PDF format.
Organization
[January 01, 2023 10:27 AM]
OMA Section on Plastic Surgery
The OMA Section on Plastic Surgery is grateful for the opportunity to provide its opinions and suggestions with respect to the CPSO draft updates of the ‘OHP Standards’ policy and the accompanying ‘Advice to the Profession’ documents.
 
The OMA Section on Plastic Surgery appreciates the College’s efforts to ensure that safe, high-quality care is being provided in the Out-of-Hospital premises setting. Overall, we are in support of the majority of the changes that have been made to the OHP Standards document. However, there are some important clarifications we would require before this becomes an updated Standards policy that we feel comfortable fully supporting.
 
Hospital Transfer Agreement 
One major issue is in the “Adverse Event Standard” under “Preparing for Adverse Events” (Document Page 47). In this document, there is a statement that Medical Directors must “ensure there is a formalized transfer agreement with a local hospital”. We believe that this is not only impractical, but it is likely impossible to achieve. First, the Hospitals have no incentive or reason to enter into a transfer agreement with any OHP/Medical Director. The CPSO has no jurisdiction to force hospitals to enter into these agreements, so suddenly OHPs may be forced to shut down if their local hospital doesn’t want to enter into one of these agreements. We also do not want this to become a ‘pay-to-play’ setup wherein Medical Directors are forced to may payouts to hospitals to set-up one of these agreements on the off chance that a patient needs to be transferred. Second, in the rare situation that a patient does require transfer directly from an OHP to a hospital, we as physicians (and therefore as Medical Directors) have no authority or say in where patients are sent, this is up to the EMS/Ambulance team. So even if one of these transfer agreements were to be agreed upon, what happens if their ER is on bypass at the time (which has become increasingly common) and the patient must be sent to another hospital where there is no transfer agreement? This stipulation makes the transfer process much more complex and frankly is untenable.
 
If the spirit of this regulation is to prevent surgeons/physicians with no hospital affiliations from operating and then sending their complications elsewhere to be dealt with, we agree that this situation is not ideal and should be avoided. The College could consider requiring that Medical Directors (or the operating surgeon) either a) have privileges at a local/regional hospital or b) an agreement with a physician/surgeon at a local/regional hospital to accept patients in transfer. This does not solve the issue that EMS may not take the patient to the site where the Medical Director/surgeon has privileges. This must be taken into consideration if changes are made to the Standards document. Unless the CPSO/province want to consider ‘universal privileging’, this whole idea of a formal transfer agreement should either be removed from the document or thoughtfully and carefully reworked
 
Injectables
Another major issue with the OHP Standards document is how they define procedures captured by the policy (Document Page 1). The major issue we have relates to non-surgical injectable products such as temporary hyaluronic acid soft-tissue fillers. In the document, the CPSO states that the regulation applies to “any procedure performed with local anaesthetic […] that is a cosmetic procedure, where a substance for material (including tissue from the patient’s own body i.e. autologous tissue) is injected or inserted into a patient”.
 
This is very problematic for a few reasons. First, many of the new temporary hyaluronic acid soft tissue fillers now come pre-mixed with lidocaine for patient comfort during injection. This local anesthetic cannot be removed from the filler product as it is already mixed in. So, even though local anesthesia is not ‘required’ to perform the procedure, and even though the physician may not be administering any additional local anesthetic into the patient, according to the current wording of the document the injection of these fillers would not be permitted outside of the OHP setting. This is a major issue. Many (if not the vast majority of) physicians perform these temporary soft tissue filler injections in the office setting alongside neuromodulators like Botox® (which is specifically exempted from the oversights of this regulation; Document Page 2). Unless the CPSO is planning to now consider all physician offices OHPs, and thereby inspect all these facilities and hold them to OHP standards, this is not a practical limitation. This has much wider ranging effects however, as if we take away the ability of physicians to perform these procedures in the office/non-OHP setting, it will regulate MDs out of the injectables space while allowing Nurse injectors (in many cases with a remote Medical Director) to inject whatever they want, wherever they want. If you think about it, in theory, an RN injecting out of their basement could call the CPSO to complain about a physician injecting the exact same product in their office, and the physician would be in violation of CPSO policy while the RN (likely with no on-site supervision) could continue to inject away. This is not good for patients and, in fact, is the exact opposite of what we should be trying to do. We need physicians in this space to keep patients safe.
 
If the College is concerned about the potential for local anesthetic toxicity with these products, that is highly unlikely. The concentration of local anesthetic in these fillers is extremely low (e.g. Juvederm Voluma XC is 0.3% lidocaine or 3mg of lidocaine per 1 cc syringe; https://www.accessdata.fda.gov/cdrh_docs/pdf11/p110033c.pdf). Most patients receive 1-4 syringes of filler in one visit. A patient receiving 10+ syringes in one sitting is very rare. Even so, for a 60 kg patient, the safe limit for lidocaine would be 300 mg (5 mg/kg x 60 kg) and therefore the patient would have to be treated 100 syringes of product in one sitting to achieve this dose, an amount of product that is frankly unheard of.
 
We think that non-permanent soft tissue fillers should be included as “minor cosmetic procedures that do not require local anesthesia” (Document Page 2) because in earnest, no additional local anesthetic (beyond what is pre-mixed into the product) is typically being administered.
 
Furthermore, we did cross-reference the prior (current) version of the OHP Standards document. In the prior version, there was reference to “permanent filler” which is very different than the temporary soft tissue fillers that are used today. Removing the reference to permanent fillers broadens the rules imposed by this new Draft Standards beyond where we feel is should. If the purpose is to prevent the injection of permanent fillers (including fat grafting) in non-OHP settings that is one thing, but to prevent the use of temporary fillers as the new OHP Standards imply, is where our issue lies.
 
Two additional points that we would point out here:
  • First, in the list of examples of “minor cosmetic procedures that do not require local anesthesia” (Document Page 2), the College specifies “Botox”. However, Botox is the brand name for the botulinum toxin product from Allergan/Abbvie. This should instead state 'botulinum toxin/neuromodulators’ to ensure that other brands of botulinum toxins (e.g. Xeomin, Dysport) are not excluded from this stipulation as they are also approved for use by Health Canada.
  • Second, the CPSO should amend the definition of tumescent anesthesia on Document Page 1. While some physicians use tumescent fluid as the CPSO defines it (dilute local anesthetic + epinephrine + sodium bicarbonate), any of these ingredients could be left out of the mixture (or additional products mixed in) which could be seen as a work-around to think that this clause does not apply to them even though this is still (essentially) the same product being used for the same purpose. The use of the terms “firm and tense” is also subjective. For example, when using the ‘wet’ liposuction technique, 200-300cc of infiltration fluid is injected to a body-area, which does not necessarily make the tissue firm and tense. They College could change this definition of tumescent anesthesia to something like to "the practice of injecting a very dilute solution of local anesthetic (+/- epinephrine and/or sodium bicarbonate) into tissues to perform a procedure”.
 
Equipment
In the “Co-operation with the Out-of-Hospital Premises Inspection Program Standard” section under point 11 (Document Page 7) the CPSO is asking for 2 week’s notice prior to changes to the OHP, including equipment. In the case of equipment malfunction in the OHP setting, this is not possible. For example, if a cautery machine breaks down and needs to be fixed/serviced, in some cases this may take weeks (or months). Sometimes, a replacement machine will be provided on loan from the manufacturer as a temporary replacement product. It does not make sense to force an OHP to shut down for 2 weeks to inform the College of a temporary replacement for a piece of equipment that has malfunctioned. This would limit the provision of care to a lot of patients for no reason. This is very different than when a clinic purchases a new piece of equipment or technology, and we agree that this regulation should be in place for that purpose. However, we would like to see a change to the wording in the Document (or clarification in the advice to the profession document) that accounts for both temporary equipment to replace broken/damaged equipment and like-for-like replacement (i.e. buying the same machine to replace one that may have broken/failed). At the very least, the College should account for these scenarios in some way (e.g. expedited same day review process) so that whenever a piece of technology/equipment breaks/fails, the OHP and Medical Director are not in contravention of OHP Standards by replacing the equipment without notifying the College and shutting down the provision of care for 2 weeks.
 
Thank you for the opportunity to participate in this Consultation. Please do not hesitate to contact us if any further information or clarification is required.
Physician (including retired)
[December 30, 2022 9:57 PM]
Surgeon with over 10 years experience in Hospitals and OHPs.

Comments I hope will one day be included.

1. Facilities need to be upkept to some form of modern standards.
Patient care is highly compromised when obtaining care at a severely outdated facilities simply because they are grandfathered. Facilities which are not meeting basic standards need to be upkept or unfortunately shut down. They are not hospitals they do not have immediate access to emergent care and are dangerous.
Unfortunately despite understanding the significant need I also disagree that many non emergent minor procedures should be allowed in all primary care practices without adequate sterilization equipment or disposables simply due to need. Unfortunately this leads to complications such as infections and is a poor approach to care. More funding for OHPs need to be created or renumeneration for such cases in outpatient facilities for primary care physicians of all types so that they can invest in proper equipment and follow adequate standards.

2. Funding for NEW physician run OHPs (either through new IHF licenses or other form of licenses) need to be instituted immediately as this will greatly improve ambulatory care efficiencies and access to surgical care.
Proper new facilities cannot be build or maintained without some form of new funding to perform minor procedures (Sutures, Staffing, Sterilization costs etc). Community physicians and surgeons without pre-existing IHF licences at least need a method to recoup those costs should they be willing to put in the considerable effort to build these facilities and maintain them for Ontario.

IHF licenses need to be opened up again for all applicants and SHOULD NOT be grandfathered as they continue to reward old facilities based on nepotism who stifling competition rather than new facilities run by potentially willing physicians and surgeons based on merit.

Grandfathered IHF facilities are also completely unfair to physicians and surgeons without access to these facilities who may be able to produce the highest qualities of care and to patients without options. This needs to be immediately recognized and corrected and not used as a method to preserve funding and benefiting only preexisting licenses from almost 2 decades ago.

Any Modern OHP Facility should be able to qualify for an IHF License. Funding should be commensurate on the quality and efficiency of care being provided, and Level of OHP standard met.

3. OHPs that meet OHP Standards should also be provided licenses to a certified EMR for operating room facilities such as EPIC. Paper charting is simply outdated and not a way forward and we should begin to assist these facilities transition to the modern world. EPIC or similar EMR currently are only available to hospitals and should be funded for credentialled facilities with their use hightly encouraged. In this way patient care standards can be more easily implemented monitored and enforced and statistics should OHPs desire to participate in alleviating surgical backlogs or offloading ambulatory care be monitored in addition to case costs. (Again such EMRs should not only be available to pre-exising IHFs as this would further not be fair and stiffle competition which will bring about the most positive change)

Finally and Off topic I believe EPIC should be made available to all physicians in Ontario free of charge. There should be unified medical record system across our province unifying patient care across our province and for all for those willing to embrace and utilize it. It could improve our outcomes, assist with our data of all forms, billing, access problems etc. Shouldering the costs of such a system would be a win win.
Physician (including retired)
[December 29, 2022 9:36 PM]
Hello there,

I would like to agree that the drafted policy is very thorough and comprehensive. However, as some physicians have already mentioned, the proposed revised OHP standards are significantly changing from the current standards in interventional pain management OHPs. It has usually been the case that interventional pain clinics are having their own standard, separately from other OHPs. I have read the letter from the OMA Section on Chronic Pain and agree with their concerns and proposed solutions.
There are two main issues.1) The draft standards should be changed to clarify that nerve blocks done for interventional pain medicine are not nerve blocks done for regional anesthesia. 2) Incorporating the current addendum "Applying Out-of-Hospital premises inspection program standards in interventional pain premises" in the draft guidelines.
The main issue today is to provide the best possible care to our patients. The current waiting time at our clinic is about 3 months. The situation in GTA is relatively good but staffing is still a serious problem. There are not enough doctors, nurses, and technicians. Patients are coming from remote areas, such as Windsor, Sudbury, Ottawa, Northern Ontario, and other provinces, where the waiting time is already one year! If the drafted version is implemented it would end up with most community pain clinics' closure. The waiting time will grow from months to years. This would certainly affect the care of our chronic pain patients. I would put an accent on a doctor's education and training.
Please consider changing the proposed standards with regard to interventional pain clinics according to the current standards in pain management.
Physician (including retired)
[December 29, 2022 3:05 PM]
Hi there,

I am a full-time practising interventional pain management physician with a 20+ year background as an ER physician as well. I have been practicing interventional pain management now for close to 20. As such, I have been through multiple iterations and various frameworks as pertaining to 'Change of Scope' practice over the years since its very inception, both within the OHP framework and the model which predated it. I must say that this most recent proposal in the new Draft Guidelines to lump together all OHP practices such as pain management, abortion clinics, as well as scope and surgical procedure facilities seems extremely poorly thought through, and frankly, absent of much logic.

The notion that in performing peripheral nerve blocks - and even image-guided neuraxial blocks done flouroscopically, which I also do - the 'recovery room' requirement should be the same as for a clinic performing open surgical procedures and liposuction, or that of an abortion clinic, is just not based on the demonstrable risks and facts of interventional pain practice. Whether this was a deliberate and intentional effort to simply curtail or castrate pain practices I do not know (but, if I were a cynic...).

For instance, the proposed requirement that "the size of the recovery must area accommodate the number of patients for two hours of operating room [sic] time" be applied to interventional pain clinics is simply nonsensical, and frankly, would render even the most responsible such practices financially non-viable.

If feel that abandoning a tailored and nuanced approach to the OHP regime in favour of a one-size-fits-all (read: no one) approach would be disastrous. And I see many similar concerns voiced throughout the comments and response thread.

I would strongly urge that the Committee seriously reconsider this approach, and keep in place more nuanced guidelines specific to each of the applicable OHP categories. This does not mean that there is no room for improvements or modification to current standards. For instance, I would fully support the mandate of image-guidance being a requirement for all neuraxial procedures.
Physician (including retired)
[December 28, 2022 11:57 PM]
Thank you for providing this discussion board. I appreciate the diversity of postings from respondents' interaction with the CPSO regulation as it applies to their specialty practice.

It seems wise for the CPSO to acknowledge the different levels of risk (anesthesia risk particularly) and styles of practice encountered at different surgical centers.

In September 29, 2022 eDialogue, the CPSO representative, Laurie Reid, is quoted as stating:
"Physicians will note that the new draft streamlines and simplifies expectations by setting out principled expectations and pointing to existing clinical practice guidelines where they exist, including the CAS Guidelines, Peri-Anesthesia Nursing Standards and the Surgical Safety Checklist”.

Does the CPSO, by only referencing outside guidelines, anticipate a change in how OHP premises will be regulated or assessed?
How strictly will guidelines referenced by the CPSO now need to be followed?
Does it seem reasonable to fear that, during OHP inspections, the interpretation of how these outside guidelines are followed will now mostly become the prerogative of the individual assessor?
Does this risk creating different interpretations and application of the OHP Standards amongst OHPs that provide the same specialty care?

Certainly, existing professional guidelines should inform our college's standards, and the CPSO should rely on them. The new draft standards seem to simply deflect to outside organizations' statements, rather than reflect on how these statements can inform its own standards and regulation of premises. Given the diversity of procedures, and anesthesias administered in its OHPs, the CPSO should, after reflection and consultation, provide guidance on what its expectations are when it comes to interpretation and compliance of outside standards. This will provide clarity when clinics are inspected or physicians observed.

The previous "Applying the Out-of-Hospital Premises Inspection Program (OHPIP) Standards in Endoscopy/Colonoscopy Premises" that acknowledged that a “time-out” or “surgical pause” is not required for endoscopy/colonoscopy premises", is an example of this type of guidance of expectations.
Physician (including retired)
[December 27, 2022 1:49 PM]
Note: Some content has been edited in accordance with our posting guidelines.
I would like to give my opinion about the OHP rules about local anaesthetics in aesthetic procedures outside of an OHP facility. I am an academic Plastic Surgeon at [redacted] and I educate and run courses on aesthetics for our residents and other staff. I think this is not a good rule and an over regulation that has profound effects on patient care and education of residents and practitioners. Giving a local anaesthetic is a basic skill for any physician, let alone a plastic surgeon. Every plastic surgeon gives local anaesthetics countless times in their work day and complications are exceedingly rare. On the contrary, much of what we do could not be done without giving local anaesthetics. For a plastic surgeon, it is safe, effective and good care. In my professional opinion, it is not a technique that needs to be done in an OR setting. In fact, it seldom, if ever, is. I have been involved in creating the standards for plastic surgery residency training programs and this is actually a very basic skill set. Giving a local anaesthetic helps patients tolerate any topical treatment better and more comfortably. I am engaged in the creation of a laser training program and this is skill I believe everyone should use when lasering. Making this a part of an OHP facility denies the majority of practitioners the ability to give this basic treatment when trying to make patients more comfortable. It is important to note that the vast majority of aesthetic practitioners do not have access to an OR or OHP facility. Making local anaesthetics an OHP procedure disproportionately affects the majority of practitioners and makes patient comfort very difficult to manage during lasers or injectable procedures. This is also one of the most important skills I want to teach our residents and practitioners in our courses. It allows patients to have a better experience and not have to be managed in an OR for simple treatments. Without that, simple, safe, and basic treatments will be unavailable to patients and the vast majority of practitioners in Ontario. I would ask that I be involved with the committee making these policies to give my experience and opinion about this. Thank you for considering.
Physician (including retired)
[December 27, 2022 12:23 PM]
Note: Some content has been edited in accordance with our posting guidelines.
During the consultation period, we received three responses from individual physicians containing the following:
Response in PDF format.
Physician (including retired)
[December 26, 2022 3:33 PM]
With respect to the injection of temporary fillers for minor cosmetic procedures:

1) Temporary fillers should be included in the exemptions for minor cosmetic procedures like Botox and sclerotherapy just like it was in the previous OHP standard.

2) There are only 3mg of lidocaine (without epinephrine) per syringe of temporary hyaluronic acid filler, which is well within the safe level for local lidocaine injection. For reference, the maximum dose of lidocaine without epinephrine is 4.5mg/kg (not to exceed 300mg). Furthermore, no sedation is required to administer these temporary fillers. Injecting with temporary filler remains a relatively low risk and should remain exempt as it was previously.

3) Nurses are injecting temporary filler without doctor supervision in their own clinics and often in home offices. As nurses would not be restricted under the OHP act, they would not have to make any changes to their offices, not have to close temporarily, revamp and recertify whereas physicians would be forced to, in order to continue injecting temporary filler to comply with the proposed OHP standard change.

While physicians would be unable to inject temporary filler during the period of time their clinics are becoming OHP certified, nurses would be allowed to with no restrictions, resulting in patients seeking out temporary filler injections from nurses only. The concern is that nurses often have limited medical knowledge and experience compared to physicians, and often have less safe practices, which may result in poorer patient care and outcomes with likely more complications.

Furthermore, while physicians would have to undertake significant additional costs to restructure their clinics for the OHP standards, physicians’ prices to patients would increase, whereas the nurses’ prices would not change. As a result, patients would be more likely to seek out filler treatments from nurses due to better prices, and this is concerning as nurses often have limited medical knowledge and experience compared to physicians, and often have less safe practices, which may result in poorer patient care and outcomes with likely more complications.

For these reasons, temporary filler should be included in the minor cosmetic procedures that are not captured by the OHP program, and should continue to be exempt, just as they were in the previous OHP standard.
Physician (including retired)
[December 25, 2022 1:14 PM]
OHPIP Program Overview

For future Drafts it would be helpful to have page and line numbers

An introduction to outline major changes from previous version (with some rationale to explain why the changes were made) would also help

Page 1 modify foot note for definition of tumescent (someone could omit bicarb and claim it doesn’t fall under the regulation)

Scope of Program

LA containing temporary fillers: - the old Standards specifically referred to ‘permanent fillers’ (temporary fillers were exempt). The new draft Standard is no longer referring to ‘permanent fillers’ and would thus capture all (widely used) temporary fillers. In addition, many fillers are now (by the manufacturer) premixed with LA (very low concentrations: for example, 0.3 % Lidocaine). This would make most physicians’ offices (i.e. where those fillers are injected) OHPs

‘Nurse inspectors provide OHP inspection reports to CPSO, and CPSO provides a copy of the report to the Medical Director.’ – to whom? To PIC?

Categorizing Premises Based on Levels (e.g., risk)
Risk Matrix: It seems that the ‘risk matrix’ from the original OHP Standards is no longer used. This risk matrix was created in order to assign the final ‘OHP level’ (with associated requirements) based on the highest of either anesthesia or procedure risk. The goal was to prevent higher risk procedures (liposuction over 1,000 mL) to fall into a lower level classification if they were done without general anesthesia. How is this (for example high volume liposuctions done under local / sedation) addressed in the new draft Standards?

Redesign: Layout and Format
Companion Documents: what happened to the companion documents (chronic pain, endoscopy and abortion)?

Cooperation with the OHPIO

Notify CPSO 2 weeks prior to structural changes to patient care (incl. equipment) – what if loaner for broken?

Medical Directors and physicians practising in the OHP must participate fully in the inspection process and comply with CPSO requests… providing the inspector with any requested records: the wording should be changed to ‘any records that are relevant to the inspection’.

Medical Director Standard

Staff qualification ‘recent experience (2 years): that would mean 1 case in the last two years – so maybe a more precise requirement should be listed?

Nurses working in OHPs will have training, certification, and appropriate experience as required for the procedures performed, including holding qualifications in accordance with those set out in the National Association PeriAnesthesia Nurses of Canada’s Standards for Practice, where applicable, as well as current ACLS if administering sedation to, monitoring or recovering patients (RNs only). Please see my comments about external standards (under Procedures)

Physicians practicing in the OHP

n/a

Physical Space Standards

Medical Directors must ensure:… air exchanges meet infection control standards2 for the type of procedure being performed; I believe this reference is not correct. Air exchanges are referenced in the CSA document for health care facilities, not in infection control.

Equipment necessary for emergency situations … is inspected on a weekly basis… - I would think that it should be inspected at the beginning of each day that clinical care is provided.

Where an OHP administers general anesthesia, regional anesthesia or sedation, Medical Directors must ensure: …An anesthetic machine and anesthetic cart with appropriate drugs3 and equipment is provided, where general anesthesia is being administered.- the wording of the CAS Standards was changed several years ago. An anesthesia machine is no longer required. What is more importantly missing here is 1. Age appropriate equipment and disposables 2. Difficult airway equipment

Drugs and Equipment

Medical Directors must ensure that, at minimum, the OHP has the following drugs immediately available: minimum amounts should be specified.

Lidocaine 2% pre-filled syringe why a prefilled syringe? Lidocaine comes also as a preservative free iv plastic vial.

Sodium bicarbonate IV – why? Unless part of the MH cart, I don’t think it is in the ACLS algorithm anymore

Patient Selection

International Anesthesia Research Society, vol. 133, no. 6, pp 1415-1430. Incorrect reference. It is called ‘Anesthesia Analgesia’ instead of ‘International Anesthesia Research Society’

What kind of comorbidities may make a patient inappropriate to perform a procedure on in an OHP? malignant hyperthermia.2 – I don’t believe there is any evidence to support his claim and I don’t think the reference supports this claim either.

Procedures

Reliance on external Guidelines and Standards Documents:
Who decides what part of the external Guideline documents applies and is enforced and which doesn’t?
Experience of the assessor is absolutely critical – lack of experience with checklist mentality (‘mark the rule’) could lead to many unreasonable nonsensical enforcements. This could decrease access to much needed care.
Draft Standards make reference to a number of documents that were created with a focus on hospital-based care, and which contain well intended, but onerous requirements that may not be practicable for all OHPs - and for which there is no evidence that they improve the care in the OHP setting. I can attest personally to the Canadian Anesthesiologists’ Guidelines as I sat on their committee for many years and tried to make them more applicable to OHPs. This was not successful and countered with the argument that provincial colleges had jurisdiction over the Standards in OHPs and that the Canadian Anesthesiologists’ Guidelines were only Guidelines and not Standards. If the CPSO’s nurse inspectors’ checklists (which will likely be revised, based on a new OHP Standards document and the referenced materials) adopt some of the requirements from those documents, it would lead to a number of unintended consequences and may further limit patients’ choice and access to health care services. For example, the reference to the PeriAnesthesia Nursing Standards (V 2014) would require two RNs in the phase I recovery. However, the scope of practice for RPNs is continuing to grow and many RPNs have the knowledge, skills and judgement (as well as the experience) to assist in OHPs. Many OHPs, especially further north and in rural and remote areas (and serving under-privileged patients) may simply not have access to get two RNs for phase I recovery (even hospitals often have difficulties to obtain RN coverage) and could be forced to cease operating. Likewise the CSA Standards are very detailed (CSA Z8000-18 has 600 pages, Z317.2-19 has 140 pages) and most of those are not practicable for OHPs.

Physicians administering anesthesia or sedation must do so in accordance with the Canadian Anesthesiologists’ Society Guidelines to the Practice of Anesthesia, including requirements for patient assessment, pre-procedural testing, fasting guidelines, patient monitoring, documentation of care in the patient record, and anesthesia support personnel. – see my comments above. Also: some other specialties have the skills knowledge and judgement to provide sedation, but their professional societies may have slightly different guidelines.
Where a physician is administering anesthesia or sedation to a pediatric patient they must do so in accordance with the Canadian Pediatric Society’s Recommendations for procedural sedation in infants, children, and adolescents. – see my comments above. This document was clearly written for hospitals and not for OHPs and does not lend itself to be references (for example it says: 1. Procedural sedation should only be performed … as part of a hospital program with active and engaged quality assurance and safety initiatives; 2. The vast majority of adverse events can be prevented when sedation is performed in hospitals adhering to guidelines. 3. Procedural sedation should only be performed within the context of a hospital program that participates in quality assurance through the reporting, monitoring, and review of adverse events. 4. Procedural sedation should only be performed in hospitals…)

The Medical Director must ensure that nursing staff comply with National Association of PeriAnesthesia Nurses of Canada Standards for Practice, including requirements for appropriate staffing, discharge of patients from recovery phases, documentation of care in the patient record and appropriate discharge instructions. Please see my comments about external standards (under Procedures)

discharge score using a verified discharge scoring system. – should this be ‘validated’ instead of ‘verified’?

Infection Control Standards

n/a

Adverse Events Standards

Transfer Agreement: The need for a written transfer agreement between OHPs and hospitals was considered during the drafting of the original OHP Standards. It was felt that most hospitals would not be prepared to sign a legal transfer agreement (the destination of most ambulance transfers is dictated by EMS in any case) and that such an agreement would actually serve little to improve the quality of care. That is the reason why the current Standards do not have a requirement for a transfer agreement. Over the last few years the pressures on hospitals have further increased and hospitals will now be no more likely to sign legal transfer agreements and this requirement may turn into a road block for the delivery of much needed care in OHPs.

treating all adverse events same will introduce large admin burden

Quality Insurance

Other

It will be very helpful to inform the members about the risks from the adverse events compiled by the CPSO - those are important learning opportunities that can help to improve patient care.

Prolonged Stay in OHP: We encountered several OHPs that had planned for prolonged procedures or encountered patients who required prolonged post-operative monitoring. For this reason, the program established requirements for care overnight and this is recognized in the draft document (page 39 #13). In view of the ongoing shortage of hospital beds and prolonged wait-times in emergency departments, I think patients will be well served in the future if more OHPs had capacity for arranging a prolonged stay for monitoring to ‘off-load’ hospitals. This is an opportunity for the CPSO to contribute to the current and future critical shortage by providing more detailed requirements for safe care. Staffing levels overnight and vital sign recordings, as well as protocols for care would help to define those patients who can safely remain in the OHP for several hours.
Physician (including retired)
[December 23, 2022 7:34 PM]
Seven years ago the MOH and CPSO agreed that there should be better oversight of fertility clinics. The draft standards are an improvement over the past standard in that they are better organized and offer greater clarity. They do nothing to advance the safety or quality of the services provided and do nothing to protect the patient from substandard or unethical practices.
No requirement of sub-speciality training in GREI for the medical director. No oversight of the gamete lab. No performance indicators. Quality assurance is what the medical director (or corporate HQ) says it is.
Physician (including retired)
[December 23, 2022 3:57 PM]
Response in PDF format.
Other health care professional (including retired)
[December 21, 2022 9:10 AM]
Note: Some content has been edited in accordance with our posting guidelines.
Hello,
 
My name is [redacted], I am a Public Health Nurse (RN) working [redacted], in [redacted], ON. I work in Healthy Sexuality, with a portion of my work invested in pregnancy options and counselling, which includes abortion care.
 
I am writing you to request a change to the regulation and oversite of Out of Hospital Premises in Ontario, of which abortion clinics fall under. Previously, the Out of Hospital regulations recognized the often unique and precarious situations that clients presenting for abortion faced through the inclusion of the 2015 Abortion Addendum “Applying the OHPIP Standards in Induced Abortion Care Premises and Independent Health Facilities”. With the new proposed draft, there is no mention of any recognition for abortion patients.
 
My request is for the Abortion Addendum to be maintained, to ensure abortion care does not become inappropriately overregulated and restricted. Clients seeking abortion have unique needs, without recognition of these needs, these proposed changes will aid to restrict safe and accessible abortion care.
 
For example: A client seeking abortion with mild sedation should not be required to bring someone to their appt. This completely infringes on their safety and privacy concerns. It is important to note that most people accessing abortion services do not have the support of society, or of a personal support system often due to a highly stigmatized service, thus they should not be denied care due to such circumstance.
 
A client should not be restricted from having an abortion based on their weight alone. This is not evidence based, and many studies demonstrate the relative safety of providing first and second trimester surgical abortion to higher BMI people. This is discriminatory against people with larger bodies trying to seek abortion care.
 
Clients should not be required to follow strict fasting rules prior to their surgical procedure. Requesting this is not evidence based practice, therefore client comfort should be respected in this regard. The NAF does not advise restricting care for people who are non-fasting. Pregnant people feel more nauseated when asked to fast before their procedures, and this can also delay / prolong a clients recovery experiences in the clinic. Hunger can also negatively affect peoples coping abilities when dealing with potentially stressful experiences.
 
In public health, in order to achieve health equity it is important to understand the social determinants of health, and how they contribute to a clients unique circumstance.
 
Clients are already burdened by the social determinants of health that lead to their unique circumstances, as such by their income and social status, employment and working conditions, education and literacy level, social supports and coping mechanisms to name a few. Clients accessing abortion services already face additional barriers of stigma, difficulty locating clinics that offer abortion, difficulty obtaining access to such clinics based on their gestational age, difficulty making travel arrangements and allocating funds to access an appropriate clinic, and pressure to choose between medication vs surgical abortion based on accessibility not based on client preference.
 
There are negative impacts on clients and a society when you delay access to abortion care. Any day that you are pregnant, when you do not want to be pregnant, is a traumatic experience for a client. Clients have the right to achieve social justice. People should not be restricted with how and when they can have an abortion, they need to be in control of these decisions. We need to increase access to all abortion services, not further restrict abortion services.
 
Client centered care with consideration of the social determinants of health needs to be at the forefront of this decision.
 
Thank you.
Other health care professional (including retired)
[December 20, 2022 5:19 PM]
A few points need to be addressed:
ASA: What is considered "advanced age"? Most cataract patients are elderly but that should not impact their ability to have surgery in an OHP.
-Obesity is very vague, needs further clarification

Medications: Requirements for meds/emergency cart/supplies should be based on different levels of sedation (ie- IV/general/ regional). Clinics using Midazolam and fentanyl might not require as many medications/ equipment as hospitals using inhalation or general sedation.

Need to bring back the requirements for the different levels of sedation otherwise during these times of limited supplies/back orders it is a waste of time, money and resources to over stock one facility whilst leaving another facility short on necessary supplies.
Physician (including retired)
[December 20, 2022 11:07 AM]
I am a practicing anaesthesiologist in Ontario. I received your email for feedback about OHP Standards. I am aware that my colleagues providing abortion care have concerns about these Draft Standards. I echo their concerns that over regulating OHP abortion clinics can have the unintended consequence of limiting access to abortion, which actually puts patients in more harm if their care is delayed or is unavailable.

I understand that in 2015 the CPSO published a document about OHP Standards specific to abortion care. I recognize that many patients seeking abortion care are currently leaving the clinics unaccompanied for their own safety, privacy and confidentiality. I understand that previously the CPSO recognized the sensitive nature of abortion care, acknowledged that balancing the risks involved is necessary and therefore made it permissible to have patients leave unaccompanied from abortion clinics. I believe the CPSO should once again acknowledge this in the updated Standards, in order to maintain patient safety and abortion access.

Furthermore, I understand that patients are required to follow strict fasting rules before their procedure. However Appendix 6 of the Can Anaesthesiologist Guidelines states regarding fasting that “more liberal guidelines may be appropriate for minimal sedation”. I understand that OHP Abortion Clinics are only offering minimal sedation with midazolam and fentanyl. My colleagues providing abortion care have expressed to me that there is much literature to support the safety of avoiding fasting for abortions with minimal sedation. I think the CPSO should review this literature and make an evidence based decision about this requirement.

Finally, My colleagues have expressed concern about BMI >40 falling into ASA Class III classification and the implications of otherwise healthy patients with early pregnancies being restricted from accessing abortion care in an OHP. I understand that my colleagues providing abortion care make careful assessment of their patient’s medical comorbidities prior to offering procedural care in the OHP abortion clinics. I do not believe that BMI alone, in an otherwise healthy person, should preclude them from accessing abortion care at an OHP.

Thank you for taking the time to consider my input.
Other health care professional (including retired)
[December 19, 2022 11:14 AM]
I fully support the CPSO providing standards for clinics performing medical procedures outside of hospitals. However, I am troubled by the effects these new regulations will have on access to abortion care in Ontario. The nuance lost by discarding the companion abortion document is problematic.

As a Registered Nurse, I have concerns that requiring patients to have accompaniment at the time of discharge after having a surgical abortion (with mild sedation) jeopardizes their right to confidentiality and privacy, and can put them at increased risk of harm. I also know that using a patient's BMI alone as a potential limitation for accessing surgical abortion care in the community is not based in the evidence.

Losing access to safe, timely abortion does have detrimental physical and mental health consequences. It would be most responsible to reconsider these guidelines.
Physician (including retired)
[December 19, 2022 9:00 AM]
I have a concern about a subset of physicians providing deep sedation in endoscopy OHPs.
 
Traditionally, providing deep sedation has been the domain of anesthetists (FRCPC or FPA). This group of physician providers has the training, knowledge, and skill set to deliver this type of anesthetic safely and effectively.
 
I am concerned that either the CPSO has been misinterpreting the OHP standards and allowing physicians (non-anesthetists) to practise outside of their scope of practise OR the emergency physicians are practicing outside of their scope of practise in the OHPs.
 
Over the last ten years or so, the CPSO began approving physicians who work in the emergency department to provide deep sedation for OHPs. These emergency physicians could be FRCPC trained, CCFP(EM), or any physician who happens to work in any emergency department. They were required to apply for a change in scope of practise in order to do so, which might have required an airway course or demonstration of providing a certain number of cases under deep sedation. More recently, it seems as though there is no longer a change in scope required as some emergency physicians have begun applying (successfully) instead for an expanded scope of practise and receiving approval immediately. All of these emergency physicians are giving propofol in these OHP endoscopy clinics which according to OHP standards is deep sedation.
 
According to the OHP standards:
 
2.2 Moderate Sedation (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal 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. Note: Reflex withdrawal from painful stimulus is NOT considered a purposeful response.
2.3 Deep Sedation is 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. Note: Due to the potential for rapid and profound changes in sedative/anesthetic depth and the lack of antagonist medications, patients that receive potent intravenous induction agents (including, but not limited to Propofol, Ketamine, Etomidate, and Methohexital) must receive care that is consistent with deep sedation even if moderate sedation is intended. These medications must be administered by a physician qualified to provide deep sedation. Please see section 5.3.
 
The OHP standards further state that:
 
“ Physicians administering deep sedation must hold qualifications to administer general anesthesia (Section 5.3).”
 
Referencing Section 5.3,
5.3 Physicians Administering General Anesthesia
Physicians administering general anesthesia shall hold:
1) Valid CPSO certificate of registration
and
2) RCPSC designation as a specialist in anesthesia OR one of the following:
a) Completion of a 12-month rotation in a program accredited by the College of Family Physicians of Canada (CFPC) under the category of “Family Medicine Anesthesia”.
b) CPSO recognition as a specialist in anesthesia as confirmed by CPSO “Specialist Recognition Criteria in Ontario” policy.
c) Satisfactory completion of all CPSO requirements for a physician requesting a change in their scope of practice (based on CPSO policy, Changing Scope of Practice). This may include physicians who are currently engaged in a CPSO approved change in scope of practice process.
 
All practising anesthesiologists and the Canadian Anesthesiologists’ Society would agree that an emergency physician cannot be qualified to provide general anesthesia simply by applying for a change in scope of practise, as many have been doing successfully. And yet all emergency physicians have been providing deep sedation with propofol. According to the CPSO OHP Standards, only physicians who are qualified to provide general anesthesia are permitted to administer moderate or deep sedation. Emergency physicians ARE NOT qualified to provide general anesthesia and should not be administering moderate or deep sedation in the OHP setting. According to the OHP standards, emergency physicians should only be permitted to provide mild sedation only.
 
Furthermore, because emergency physicians have been providing deep sedation in the OHPs, they are under the (mistaken) impression that they are now permitted to provide anesthesia (deep sedation, perhaps general anesthesia) in dental and plastic surgery clinics as well. In fact, many have enquired about working in such facilities. To be clear, providing procedural sedation in the emergency department does not qualify one to be knowledgeable or skilled in the practise of anesthesia. From my own experience and from anesthesia colleagues, emergency physicians tend not to understand or appreciate NPO guidelines. They do not have the skills to avoid or treat laryngospasm which may occur particularly during gastroscopies. Finally, because all of their experience with sedation is in the emergency department, emergency physicians do not have a training or knowledge to properly assess patients and determine their risk and suitability for an elective anesthetic, a skill which is particularly important in the OHP setting.
 
In the interest of patient safety, I strongly feel that this needs to be addressed immediately and unequivocally.
 
Thank you for taking the time to address my concerns.
Physician (including retired)
[December 18, 2022 5:56 PM]
An area of this draft is contradictory.

When discussing the different levels of anesthesia, the draft states:

“ Due to the potential for rapid and profound changes in sedative/anesthetic depth and the lack of antagonist medications, patients that receive potent intravenous induction agents (including, but not limited to Propofol, Ketamine, Etomidate, and Methohexital) must receive care that is consistent with deep sedation even if moderate sedation is intended. These medications must be administered by a physician qualified to provide deep sedation.”

This implies that if physicians wish to provide moderate sedation, then they must be qualified to administer deep sedation.

However, in Appendix A - Staff Qualifications, there are two categories:

1) Physicians Administering General or Regional Anesthesia or Deep Sedation

2) Physicians Administering Minimal to Moderate Sedation

Because of the statement above,

The first category should read:

1) Physicians Administering General or Regional Anesthesia, Deep Sedation or Moderate Sedation

And the second group should be restricted to minimal sedation only as follows:

2)
Organization
[December 16, 2022 6:53 PM]
Action Canada for Sexual Health and Rights
Action Canada for Sexual Health and Rights welcomes the CPSO’s engagement of stakeholders in the review of their draft policies and we are pleased to submit the following recommendations in regard to the updating of the OHP Standards.
 
Abortion is a basic healthcare need for women, girls, and people who can get pregnant. In Canada, every year, close to half of the pregnancies are unintended and one person who can get pregnant in three will have an abortion in their lifetime.
 
While the need for abortion is common, access to safe and legal abortion services is far from guaranteed for those who may need it.
 
Action Canada runs a 24/7 hotline and text service where people with questions about their sexual and reproductive health can get support and referrals to service providers. Every year, we speak to thousands of Canadians. Concurrently, we manage a travel fund for anyone in Canada needing support to access abortion. Through our work responding to the public’s requests for information and referrals and for emergency financial assistance, we get to intimately know how barriers to abortion manifest.
 
This is why we must call attention to some of the proposed changes in the OHP standards as they may unnecessarily exacerbate or create barriers to abortion care in Ontario.
 
In the section on Procedure Standards and, more specifically, the draft instructions on Patient Discharge After General or Regional Anesthesia or Sedation, the CPSO calls for recovery area staff to ensure that patients are accompanied by an adult when leaving the OHP. Mandating requiring individuals to have accompaniment at the time of discharge after having a surgical abortion with mild sedation will have unintended consequences on abortion patients such as but not limited to violations of their right to privacy as well as higher risk of intimate partner violence and/or of reproductive coercion. In supporting hundreds of people accessing abortion care in Ontario and in the rest of Canada every year, we can assert that these are not theoretical risks. Because of the stigmatized nature of abortion, in cases of domestic violence, of reproductive coercion or when patients are under 18 and/or still live with parents or guardians, being required to have an escort can and will jeopardize people’s ability to get an abortion.
 
Delaying or restricting access to abortion has well-documented public health impacts. Creating barriers to surgical abortion care further narrows the window of opportunity for people to access abortion care as medical abortion is performed up to 10 weeks of gestation. Those who face the most barriers to abortion in Ontario are often from marginalized and/or vulnerable populations and so, it is of utmost importance that no additional barriers to care be introduced.
 
The above example of how the updated standards could inadvertently create barriers to abortion for people in Ontario demonstrates the critical importance of meaningfully engaging and seeking the feedback of Ontario-based abortion providers and of reproductive rights organizations on this policy as, in Ontario, a significant number of abortions are provided in out-of-hospital settings and has been for over 40 years. They will be able to speak to their patients’ profiles, needs, and circumstances and how those considerations must be reflected in the updated standards.
 
It is our opinion that it is critical to, not only seek this feedback but also to maintain the companion abortion document to the Standards, considering the unique services offered by abortion clinics and the consequences of delaying or compromising access to abortion.
 
We would be pleased to have further conversations if it is helpful.
Physician (including retired)
[December 16, 2022 4:46 PM]
The requirement for a transfer agreement in writing with a local hospital should be removed. There is no administrative authority to bind the hospital. Hospitals will refuse for liability reasons and also for political reasons unrelated to medical care of patients, it is also redundant because any emergency care of patients in hospitals is MANDATORY regardless of the circumstances.

Please remove this proposal
Physician (including retired)
[December 16, 2022 9:11 AM]
Note: Some content has been edited in accordance with our posting guidelines.
Dear Physician Colleagues and CPSO Members
 
My name is [redacted] and I’m a neurology resident in Toronto hoping to provide important input in regards to your ongoing consultation on the Draft OHP policy.
 
For over 40 years Ontario’s Abortion Clinics have been providing safe, timely and evidence based abortion care for patients in comfortable outpatient clinics. Despite previously acknowledging the established safety of abortion care by its 2015 standards companion document “Applying the OHPIP Standards in Induced Abortion Care Premises and Independent Health Facilities”, the CPSO has recently indicated that it will regulate abortion clinics as it does all other outpatient surgical centers whose services include more invasive surgeries that require deeper general anesthesia.
 
Without recognizing our patients’ unique needs, the CPSO changes will restrict safe and accessible outpatient abortion care in the very near future - in that:
 
Overly protective accompaniment requirements will make having a private abortion experience impossible; and
 
Overly restrictive patient selection requirements (such as on BMI alone), that do not recognize that abortion care patients are essentially young and healthy, will force patients to rely on hospital operating rooms to provide their care. We feel this will result in:
  1. delay of care;
  2. more complicated care associated with later gestation abortions;
  3. a greater burden on our already struggling hospitals.
I stand in solidarity with my local abortion clinics and feel that the Draft OHP Policy Standards should maintain the companion abortion document to the Standards. The CPSO should seek further input from community abortion providers in establishing appropriate Right Touch Regulation Standards.
 
Please strongly consider maintaining the companion abortion document or risk unduly burdening patients seeking abortion and our healthcare system. This is a vital health and feminist issue.
 
Thank you so much for your consideration, I look forward to hearing how this policy has changed.
Physician (including retired)
[December 16, 2022 8:00 AM]
Note: The attached response was submitted on behalf of eight OHP Medical Directors:
Response in PDF format.
Physician (including retired)
[December 15, 2022 1:37 PM]
The OHP draft is slightly too restrictive for ASA class.

1. Advanced age needs to be clarified. Almost all cataract patients are advanced age. Age itself should not be a factor excluding patients from care
2. Obesity needs to be clarified there is a huge difference between bmi of 30 and 49
3. Diabetes - was listed as an ASA III - It has to be clear that it is poorly controlled DM

The draft must differentiate between light and deep sedation as risk when it comes to ASA class.
Deep sedation on an ASA III has significant more risk than light sedation on an ASA III
Too restrictive guidelines will significantly impact elderly patients for cataracts who cannot afford to be in long waitlists for hospital spots.
Organization
[December 15, 2022 8:55 AM]
Ontario Association of Pain Management
As drafted, the proposed guidelines would negatively impact pain patients. Currently the standard for pain OHPs has been guided by the pain addendum. This has allowed pain patients to receive much needed pain care in a safe environment. This has been good for pain patients.
 
The proposed guidelines are a seismic shift from the current standard. We hope that this is unintentional. We do not see any reason to change the current standard so radically as we have not seen any systemic safety issues for patients.
 
We feel that the CPSO should change the proposed standards to fall in line with the current standards. The draft standards should be changed to clarify that nerve blocks done for interventional pain medicine are not regional anesthesia and the guidelines from the pain addendum should be worked into and included in the draft guidelines.
 
Changing the proposed standards to mirror the current standards would allow pain patients to get pain care safely.
Physician (including retired)
[December 14, 2022 10:48 PM]
These standards are completely excluding the sole practitioner, remote and rural general practice physician. In Ontario's remote north, we provide life and limb sustaining procedures in facilities that we do not control and that are not designed for regular and recurrent procedures. ORNGE services are limited by a lack of trained personnel, a lack of pilots, and a lack of planes. If we do not intervene then people die. There are no options to go to the local emergency department.
These standards are biased towards urban centres and are not considering the needs of rural practitioners and rural patients. There needs to be exclusions or caveats based on contexts where supply chains, access to other facilities, emergent/critical procedures versus elective, and specialist recommendations are considered.
The obvious choice would be to base expectations on the Ontario Governments Rurality Index and some common sense with a bit of compassion for rural patient's and their limitations of access to care.
Physician (including retired)
[December 14, 2022 8:04 PM]
The document is very complete. I would add that while its states difficult airway equipment should be available : Intubation tray with a variety of appropriately sized blades, endotracheal tubes, and oral airways-this is quite vague and as airway mishaps can be disastrous i would suggest this is more specific and in line with the CAS guidelines which state A ‘‘Difficult Airway Kit’’ for difficult or failed airway management is immediately available.As well it states:Airway management, particularly of the difficult airway, contributes to a significant proportion of anesthesia-related morbidity and mortality. The appropriate management of those patients who have an anticipated or unanticipated difficult tracheal intubation, a failed airway (completed best effort after 3 attempts), where bag-mask ventilation or supraglottic device placement may be difficult, in a ‘‘cannot ventilate, cannot oxygenate’’ (CVCO) scenario or who require an eFONA airway procedure is critical for patient safety. This includes, but need not be restricted to, adequate airway assessment, equipment (e.g., difficult airway kits, videolaryngoscopes, bronchoscopes, eFONA equipment), training and simulation, support personnel and the use of protocols and cognitive aids to optimize difficult
123
G. Dobson et al.

Guidelines to the Practice of Anesthesia – Revised Edition 2022
airway management. Equipment location and availability, local environment (e.g., remote locations) provider experience, teamwork and communication (e.g., team briefings) and psychological factors are all areas deserving of attention and optimization. It is essential to appreciate the non-technical human factors (individual, team and organizational) that may act as enablers or barriers to successful airway management. The CAS does not endorse any one specific guideline, algorithm or cognitive aid for difficult and failed airway management but strongly recommends that readers refer to Appendix 4 for up to date publications related to this topic.
Physician (including retired)
[December 14, 2022 4:47 PM]
There are many minor procedures that are not performed in hospital settings or registered facilities which allow timely care to patients. Any minor in office procedure requiring local anesthesia could be included however minor procedures Leigh as removal small lumps, bumps, moles could be affected by this. One procedure that stands out is newborn circumcision. Is this minor procedure of newborn circumcision considered part of this program? This procedure can be claimed to be clinically necessary vs cosmetic. Certainly parents wanting their newborn to have this procedure done would certainly be restricted with procedure to be done only in OHPs especially if they have been pleased with the care of previous similar procedures at same location with other children prior. Family doctors do perform many minor procedures and have done over many decades without problems and this program may restrict care that patients deserve to receive from their trusted physcian. Physicians need to follow guidelines in all they do including making sure their patients safety is always first.
Physician (including retired)
[December 14, 2022 1:08 PM]
It is good to see a succinct policy with clear guidelines. I feel that a number of clarifications are needed (some have been mentioned in other comments):

1. What is the reason why clinical removal of tissue will NOT be captured by the program, but cosmetic ones are? The performance of the procedure itself, not its intention, creates the risk.

“ Some procedures that are performed using local anesthesia are also captured by the Program. This includes any procedure performed with local anesthetic that is: • A procedure using tumescent anesthesia1 • A nerve block for chronic pain • A cosmetic procedure involving the alteration or removal of tissue or • A cosmetic procedure where a substance or material (including tissues from the patient’s own body i.e. autologous tissue) is injected or inserted into a patient.”

2. Procedures performed with tumescent anesthetic - EVLT and other varicose vein procedures use tumescent anesthesia, however they are not currently captured by the program. Is there a limit of the amount of anesthetic used or where do we draw the line?

3. Clarification required re: "sole or minimal use of oral anxiolysis for the purpose of premedication is not considered sedation". Does this mean the patient can take one milligram of Lorazepam?

4. I may have missed this, but where does use of nitrous oxide inhalation gas falls in? Midwives use it for home deliveries.

Many thanks
 
Physician (including retired)
[December 14, 2022 10:04 AM]
Note: During the consultation period, we received two responses from individual physicians containing the following:
The proposed revised OHP standards are a significant change from the present standards in interventional pain management OHPs. Years ago, it was recognized that interventional pain management procedures are unique in that they do not fall within the general 3 tiered structure of the OHP standards document. The pain medicine addendum was created to clarify these differences, and has been used effectively to ensure quality care for patients. The new proposed guidelines are a significant deviation from the current interventional pain standards.  If implemented as drafted, the proposed guidelines would force most community pain clinics to close. This would not be in the best interests of pain patients.
 
I have read the concerns from the OMA Section on Chronic Pain and agree with their concerns and proposed solutions.
 
There are two main issues.
  1. The draft standards should be changed to clarify that nerve blocks done for interventional pain medicine are not regional anesthesia.
  2. The guidelines from the pain addendum should be worked into and included in the draft guidelines.
Please consider changing the proposed standards to fall in line with the current pain standards.
Other health care professional (including retired)
[December 13, 2022 5:07 PM]
Regarding the statement in the Draft “ Some procedures that are performed using local anesthesia are also captured by the Program. This includes any procedure performed with local anesthetic that is: • A procedure using tumescent anesthesia1 • A nerve block for chronic pain • A cosmetic procedure involving the alteration or removal of tissue or • A cosmetic procedure where a substance or material (including tissues from the patient’s own body i.e. autologous tissue) is injected or inserted into a patient.”

Would this indicate that Cosmetic filler with hyaluronic acid and lidocaine, would need to be injected in an OHP?
Organization
[December 12, 2022 12:23 PM]
Ontario Medical Association (OMA) Section on Chronic Pain
Response in PDF format.
Medical student
[December 08, 2022 2:13 PM]
this!!!
Medical student
[December 08, 2022 2:12 PM]
Hello! I am a medical student at a leading medical university in ontario and I do not believe that this policy is comprehensive for at-risk patients. some patients do not want a support person there with them because they want privacy or because of fear of abuse from their partner at the time. if we introduce these policies, this may restrict patients further from being able to receive the care that they need.
Physician (including retired)
[December 03, 2022 11:09 AM]
The new draft standards take a step backwards for reproductive justice in Ontario. The 2015 exemption for abortion clinics should be re-approved to protect access for abortion in Canada. Patients are often unable to bring a support person with them to a surgical abortion as they don’t feel comfortable sharing with another person that they are having an abortion. After light sedation in a healthy young person, we should not require constant supervision once the patient is well enough to leave the clinic.
Other health care professional (including retired)
[November 30, 2022 4:14 PM]
Hi, there. I am a nurse working at one of the abortion clinic in Ontario. I heard there will be new Draft OHP Policy draft for Out-Of-Hospital standards. I appreciate your work to be updated and effort to provide the safest procedure to the public. However, there are few things I want to share with you.
-New draft suggests to have a accompany with patient for next 24 hours. At least 50% of our patients do not want to let anybody know why they are at the clinic, even to their spouse. If they need to have someone with them, they have to let their accompany know why they are at the clinic. We only use midazolam and fentanyl for anxiety not Propofol, and they don't need to have accompany on their discharge.
-New draft suggests more patient should be accessible to hospital than clinic. Most of patients who we see are young (usually younger than 50) and healthy. Since hospitals require 2-3 appointments for procedure, it is not convenient for the patients. And it will not give them enough privacy as well. If they need more resource than clinic setting, we assess them and refer them to proper setting. This will be good enough resource for them.
-New draft suggests to have rescue drugs like AED, IV antihypertensive, IV agents for SVT and etc. Since clinic only uses Midazolam and fentanyl, we don't need to have so many medications and equipment like hospitals where use Propofol.
-New draft suggests nurses to have ACLS. I understand it is good to have, but RPN are not allowed to push IV medication by their own, they shouldn't have ACLS training.
-New draft suggests only RN can take care of patient at recovery room. When patients are discharged from OR and transferred to recovery room, they are already stable enough to ambulate by themselves and respond to order. The most "unstable" situation we encounter is vomiting after procedure. As it mentioned, patients are mostly young and healthy, we don't encounter "unstable" situation. RPN should be more than enough to take care of patients with RN support.
-New draft suggests to be more strict to fasting and BMI. Patients are pregnant and they are more nauseated when they are fasting. If they are fasting for more than 6 hours, they tend to be more anxious and nauseated. We've never haven aspiration incidents during procedure because they didn't fast enough. Also selecting patient only by BMI is not fair for patients who has high BMI but without any underlying medical problem.
Physician (including retired)
[November 29, 2022 8:41 PM]
The guidelines are clear but in my opinion are not enough to define the level of facility equipment that should be present for patients requiring general anesthesia.
1.I believe the facility that provides general anesthesia requires the presence of modern anesthesia machines (spelled out clearly- modern machine with the capability of providing supportive ventilation modes, closed system, proper scavenging). They should minimize the use of volatile anesthetics that contribute to green house gases (desflurane and N20). There should be the ability to run air/oxygen.
2. The facility should have a powerful central suction, and a battery pack up suction.
3. There should be difficult airway equipment present including videolaryngoscopy, and front of the neck access (scapel/bougie).
4. There should a modern infusion pump incase there is a requirement for conversion to TIVA.
5. Succinylcholine should be required to treat laryngospasm, and hence Dantrolene should be present.
6. Modern nerve stimulator should be present to monitor neuromuscular function when muscle relaxants are required.
Physician (including retired)
[November 29, 2022 11:33 AM]
I agree that the CPSO needs to recognize the minimally invasive nature of abortion care and the relatively good health of patients having abortions. Healthy patients (mostly under the age of 40) are given anxiolytic doses of midazolam and fentanyl for a procedure that often takes less than 5 minutes. How can an OHP setting where patients pass through to Recovery Phase II before even leaving the procedure room be forced to fall under the same regulation (staffing, drugs, equipment, discharge criteria) and scrutiny as centres that are designed to provide deeper sedation/anesthesia and surgeries that require overnight stays?
Physician (including retired)
[November 27, 2022 6:45 PM]
As a physician providing abortion care in this province, I believe that the failure to include the abortion care addendum put out in 2015, is a step backwards. Under the new standards, devoid of the abortion addendum, patients will be re-routed to the already overburdened hospital system. This will place them at greater risk from adverse outcomes from the larger gestational ages which will be the result from weeks of waiting to be seen in hospital. It is weeks now, it could be months if the hospitals are further burdened than they are currently. For decades, abortion clinics have been safely providing the vast majority of abortions to the people of this province. Many of the requirements of the current standards do not apply to the care and medication level provided in abortion clinics. Bring back to abortion addendum. It only hurts patient access and patient safety if it is not brought back.
Physician (including retired)
[November 26, 2022 9:35 PM]
As the famous adage goes, "Everything should be made as simple as possible, but no simpler".

These Standards by eliminating levels of facilities based on anaesthesia used, and getting rid of addendum documents that clarify requirements for specific facilities such as Abortion facilities, are a case of making things too simple.

As a physician providing abortion care in several OHP facilities as well as hospital-based clinics, these draft guidelines fail to account for the long track record of safety of community abortion clinics and would require us to turn away a significant subset of our patients. I know the hospital clinics do not have the capacity to see this redirected volume, if the patients could even get to a hospital facility.

For example, the proposed Draft standards would require patients with elevated BMI, or patients without an adult to pick them up from the clinic, to be redirected to a hospital facility. Or to delay a procedure when our pregnant patient, trying to combat her morning sickness, had a light meal the day of her procedure.

We see such patients daily, and they have their abortions safely, and are discharged home, safely. The evidence does not support a need for fasting, or accompanied discharge, or hospital care for obese people (which is a subset of the population that is increasing).

A final thought - which patients will have the greatest difficulty accessing care with these increased restrictions on OHP abortion facilities? Those who are already marginalized, and already have the least social and financial capital.

I urge the CPSO to look at the ramifications of this elimination of nuance and its potential devastating impact on patients in Ontario, and maintain the standards for abortion facilities already in place as outlined in the current Abortion Addendum to the OHP standards.
Physician (including retired)
[November 26, 2022 7:36 PM]
As a physician working at multiple OHPs providing abortion care, I am concerned about these standards that will restrict access to safe and timely abortion care for a subset of my patients. Specifically, I would like standards such as BMI restrictions, NPO restrictions, and leaving unaccompanied restrictions to be evidence based to IMPROVE care and DECREASE risk. As I understand it, the literature does NOT support these restrictions and in fact by imposing such broad standards, we INCREASE risk to patients who then may not be able to access timely abortion care. We know that delaying care actually then INCREASES their risk, not just medically, but also within the context of physical safety (domestic violence, financial and housing stability, self-administered unsafe abortion attempts, etcetera). The Turnaway Study, a multicentre prospective longitudinal study examining the impact of unwanted pregnancy on pregnant people’s lives, shows that receiving an abortion does NOT harm the health and wellbeing of these individuals, but in fact, being DENIED abortion results in worse financial, health, and family outcomes. Again, I emphasize that these restrictions, if to be implemented, should be evidence-based to actually improve care and decrease harm in the setting of minimally sedated surgical abortions.

Further, I urge the CPSO to consider an equity-based, inclusive, and intersectional lens which acknowledges the far reaching implications of restricting equitable and timely access to abortion care, which has been safety delivered in an outpatient setting in Ontario for 40 years. To not do so would be an extreme disservice to the population. We do not need to look far for examples of non-evidence based, non-science based policy decisions surrounding reproductive healthcare that have far reaching negative implications for society at large (see: US). We need to care for these patients appropriately and an Abortion specific Addendum must be included in these new standards if we are to ensure that Ontario patients are well protected from unnecessary harm inflicted by the healthcare system.
Physician (including retired)
[November 26, 2022 11:06 AM]
The Draft document seems to be an effort to consolidate the oversight of a wide variety of medical practices, of widely different risk and complexity, and widely different health and safety requirements, into a single, overarching document. The goal is laudable, but in this document, necessary specificity is lost. The document is easy to present, easy to digest, but without the relevant specificity in many areas, will be difficult to comply with, or to enforce.

The document is not organized hierarchically, or by numeric sections, making it difficult to refer to specific standards for either review, or enforcement. One should be able to refer to sectionX, subsection Y, etc. This is the way statues are written, and for good reason. It makes it clear which recommendations apply to which areas or concepts within the document.

In two areas, the CPSO has mandated agreements between OHPs and third parties - Medical device maintenance providers, and hospitals for transfer of patients. CPSO has authority over its members, but not over third parties. It cannot mandate agreements between CPSO members, and those other parties - nor can it punish CPSO members because third parties refuse to enter in to agreements with them - (for that behaviour is beyond the control of the OHP). Lastly, such agreements are pointless - an agreement between OHP and biomedical firm would not in any way force the biomedical firm to service the OHP, nor would it force the OHP to use the biomedical firm, if the OHP decided to use another firm. In the case of OHP-hospital agreement, again, any such document would not force a hospital to accept OHP transfers if they were on redirect, or if EMS conditions locally dictated that the patient would be best served by transfer to another facility. It would neither force the OHP to transfer patients to that hospital, as the final destination of the patient is not in the control of the OHP, but local EMS providers. Both sections requiring agreements should be struck.

This standards document is a good template, and covers all relevant areas of practice. An experienced Assessor, with knowledge of the medical area being assessed, could come away with a reasonable idea of what was going on in the OHP. However, there is much ambiguity in the many of the standards regarding physical space, necessary drugs, etc that have wildly different requirements depending on whether the OHP is non-sterile procedures, or gastric bypass surgery in medically complex patients, under general anaesthetic. The idea of a single set of requirements for physical plant, infection control, etc for all OHPs is misguided. It could result in nonsensical standards for some OHPs performing minor procedures, and dangerous ambiguity for those performing complex sterile procedures.

A good example of this problem is the approach to Adverse Events. In the current document, all adverse events are treated equally in terms of their reporting requirement (within 5 days) and the required response by the OHP and The Medical director. The requirements for all adverse events are clearly stated in non-permissive language (ie MUST, SHALL, WILL, rather than MAY, COULD). In the DRAFT document, for each adverse event the Medical Director MUST undertake a new investigation of that adverse event, MUST develop recommendations relating to that adverse event, and MUST communicate the results of the investigation, and the new recommendations arising from it to OHP staff. Additionally, at the end of each year, the Medical Director MUST review every adverse event 'critically', MUST evaluate the effectiveness of the OHPs response, MUST document that review process, and MUST communicate that review to the OHP staff. For events such as wrong site surgery, or a death in the premises, this is an appropriate requirement. However, in this draft, CPSO has erased the distinctions between minor and major adverse events. Adverse events can include incisional infections, post-procedure bleeding, and examples of excellent care where , for example, patients are discovered to be in rapid atrial fibrillation, stabilized, treated, and subsequently transferred to hospital. For each of these minor adverse events, the process that is mandated, in non-permissive language, is unnecessary. It will result in under-reporting of adverse events - OHPs will not go through this mandated process unless they feel CPSO will likely become aware of the event through other avenues (complaints, coroner). The previous tiered system of adverse events was meant to distinguish between minor, common adverse events that should be logged and reviewed for quality assurance on a yearly basis (like infection rates, etc) and those that should be treated more seriously, reported every time they occur, and might represent a deeper functional problem in the OHP (like wrong side surgery, or a death). The approach taken in this document is akin to putting out a house fire, and a match, with a fire hose. It is appropriate for a guideline, but inappropriate for a non-permissive standard.

This draft also relies heavily on outside standards, such IPAC infection control standards, CSA standards for physical plant issues such as electrical standards, or ventilation standards, and MHAUS for standards relating to malignant hyperthermia prevention and treatment. This is appropriate, as CPSO has neither the expertise or the authority to say that these standards are wrong, and should be different. However, there is a tension between using and overusing/relying on these outside standards. Many standards are relevant to the subject, but not relevant to the environment or purpose - having been developed for an environment or purpose very different from which they are being applied. Transport Canada and Occupational Health and Safety Canada have standards for the transport, storage, use and disposal of acetone and isopropyl alcohol, for instance, that are irrelevant to people who wish to remove their nail polish, or disinfect household surfaces. Those standards should not be applied in that environment, or for that purpose. This draft uses relevant outside standards, but fails to qualify or appropriately limit the application of those standards. Again, CPSO is not changing or contravening these standards, but offering guidance as to how they apply in this particular environment. That guidance and detail will be different for different OHPs, and those distinctions and that guidance are absent from this draft.

The OHP Standards required updating, unquestionably. For instance, the requirement for OHPs to have sodium bicarbonate was more than a decade out of date - it having added in 2008 as part of ACLS drug protocol, but having been removed from ACLS protocol 10 years ago. This draft is in large part, an effective framework for oversight and regulation, but requires re-organization, editing, and a greater effort to furnish granular, relevant advice to a wide variety of OHP practices.
Physician (including retired)
[November 25, 2022 4:41 PM]
I have been part of accreditation process as a medical director or member of staff at a facility in Ontario and other provinces. I applauded CPSO for the 2015 Guidelines that separated out facilities were abortion care (and uterine aspiration for retained POC or miscarriage) was provided. This current update does not separate out the unique needs of those facilities. The listing of appropriate emergency equipment and medications in that situation includes those needed for adverse drug reaction but also for hemorrhage which is the more likely, albeit very rare, complication. Addition of supplies and medication for adverse cardiac events, such as IV antihypertensives, amiodarone, calcium, intralipid- are not required in other provinces, and were exempt medications in the 2015 version. These are not medications that clinicians in these facilities every use. Addition of capnography is also not justified when only minimal doses of fentanyl and midazolam are used for sedation in a patient that is usually talking, not using a mask, and for a procedure of 5 minutes duration. Suggested increased professional staffing levels in the recovery is also not justifiable in abortion care, as patients usually walk from procedure room to recovery, with Aldrete scores of 8 or 9 even before recovery.
Member of the public
[November 25, 2022 10:11 AM]
Note: During the consultation period, we received 337 responses from individual members of the public and physicians, containing some variation of the attached sentiments, with varying levels of personal content or information included. While each individual response is not being published here in full, these responses are all being read and considered as part of the public consultation.
Response in PDF format.
Physician (including retired)
[November 24, 2022 10:46 AM]
As a physician working at two different OHP clinics providing abortion services, I have significant concerns that the proposed OHP policy will not improve the safety of patient care. Instead, we will see decreased access to care for patients who are already vulnerable, and may be facing significant risks from stigma, domestic violence, etc. Current standard practice in Ontario, which is similar to that elsewhere in Canada and the US, has been used for years and on millions of procedures with excellent safety data. Specifically, the safety of providing mild to moderate sedation in an outpatient setting (fentanyl and midazolam) is well documented and evidence-based. The modified guidelines relating to this degree of sedation were addressed in the 2015 addendum of the CPSO on the provision of care in abortion clinics. I strongly urge the CPSO to ensure that the alterations included in this document will remain in place for the current OHP guidelines.
Physician (including retired)
[November 23, 2022 6:51 PM]
Note: Some content has been edited in accordance with our posting guidelines.
I am writing as a physician and OHP medical director of [redacted] Clinic to request that the modified OHP protocol for abortion providers put out by the CPSO in 2015 be part and parcel of the current draft update. In thanks, [redacted]
Physician (including retired)
[November 23, 2022 6:50 PM]
Note: Some content has been edited in accordance with our posting guidelines.
I am writing as a physician and OHP medical director of [redacted] Clinic to request that the modified OHP protocol for abortion providers put out by the CPSO in 2015 be part and parcel of the current draft update. I am attaching it for your convenience.
Physician (including retired)
[November 18, 2022 9:00 AM]
Hello, I have concerns about the infection control part. Family doctors do some very minor procedures. For example, suture removal, punch biopsies, incision and drainage of a boil, removal of an IUD. Public health is requiring very expensive autoclaves for even small family doctor's offices. Disposable tools are clumsy and expensive or not available. So even minor procedures are going to Emergency Departments. Is there a middle ground?
Physician (including retired)
[November 18, 2022 8:29 AM]
It is not clear from the Standards what procedures are allowed OUTSIDE an OHP facility, ie what procedures must be performed in an OHP. One example is vein work, which can range from minor Sclerotherapy of skin spider veins to Laser ablation of the Greater Saphenous Vein. This needs clarification.
Organization
[November 01, 2022 1:37 PM]
Professional Association of Residents of Ontario (PARO)
We have reviewed these guidelines and believe them to be quite comprehensive, clear and reasonable.
 
One issue with regards to the OHPIP standards relates to administration of sedation and performance of a procedure by the same physician. The CAS (Canadian Anesthesiologist Society) guidelines are fairly clear about the following:
 
"It is unacceptable for a single physician to administer an anesthetic, including deep procedural sedation, and simultaneously perform a diagnostic or therapeutic procedure, except for procedures done with only infiltration of local anesthetic and/or minimal sedation" (section 5.3 2022 guidelines- this likely refers to Level 1 facilities)
 
We found the OHPIP document to provide less clarity around this. In Section 6.8 of the OHPIP it states that the patient should be monitored during these procedures, but it can be delegated to an individual who is trained to attend to sedation or regional anesthesia (which could include an RN/AA). It was not clear to us what the standard is as per CPSO regarding whether it is acceptable to do a procedure and administer sedation at the same time and in what circumstances.
 
We wonder if it is worth clarifying within the document what CAS states about not being able to administer anesthesia and perform a procedure simultaneously and make it explicit. Perhaps also include references to the CAS guidelines to the practice of anesthesia may help provide guidance to physicians looking to figure out what the standard should be.
 
We once again appreciate being included in the CPSO's consultative process.
Physician (including retired)
[October 23, 2022 10:02 AM]
As a practicing physiatrist I do not work in a OHP facility but after reading this OHP Standards Document up for consultation I do have some concerns.
I am frequently referred patients for interventional steroid injections for the following problems:
  1. Cubital Tunnel Syndrome
  2. Tarsal Tunnel Syndrome
  3. Carpal Tunnel Syndrome
Technically these procedures could be considered 'nerve blocks for chronic pain' as the intended target for the injections are the involved nerves which get hydrodissected and blocked to treat chronic pain.
Reading the standard as its worded,

"Some procedures that are performed using local anesthesia are also captured by the Program.
This includes any procedure performed with local anesthetic that is:
• A nerve block for chronic pain"

Is the intended interpretation of the OHP standard to mean that these previously mentioned procedures are required to be done in an OHP facility only which if done elsewhere would be in violation of the college proposed standard for these procedures. This wording and interpretation of the standard needs to be more explicit for practicing physicians to be able to interpret.
Physician (including retired)
[October 23, 2022 9:49 AM]
Based on the current wording of the OHP Standards document the following procedures are required to be done in an OHP "This includes any procedure performed with local anesthetic that is:
• A nerve block for chronic pain"

Does this mean that all the minor nerve blocks such as occipital nerve blocks for headaches that are currently being done in doctor's office all across the province are in violation of this standard because they are not being done in accredited OHP facilities. Are all practicing physician's (ie. Neurologists) aware of this? Is this the intended practical application of this standard?
Physician (including retired)
[October 23, 2022 9:41 AM]
Hello, I would like to make a few comments regarding the current OHP Standard Policy document up for consultation;
1) With regards to Adverse Event Standard and requirements for reporting. The wording states that an adverse event related to the procedure being performed in the OHP needs to be reported including ADR's such as death within 10 days of a procedure or unscheduled treatment of a patient in a hospital within 10 days of a procedure.
I find the wording regarding the reporting of these types of events somewhat arbitrary and confusing.

If a clinician is made aware of a death of one of their patients that had a procedure within the 10 day timeframe from their procedure or had to go to the hospital for an unscheduled treatment but the clinician feels the cause was unrelated to the procedure performed, does this still need to be reported to the college?
Is the decision to report at the discretion of the clinician performing the procedure or the OHP medical director or is just that all deaths and unscheduled hospital treatment within 10 days of a procedure at an OHP need to be reported.
I know the example was given in the document that a patient having an unrelated injury within 10 days of procedure that resulted in a hospital stay does not need to be reported but what about a death...say 9 days after a procedure as a result of stroke or car accident etc. that clinician feels is unrelated to the procedure they performed 9 days prior. How are these situations handled in the standard. Or perhaps a patient had a procedure for back pain and then develops a cholecystitis requiring a hospital visit and surgery. Is this related or unrelated to the procedure and again at who's discretions. 10 days is a long period of time for unscheduled health related matters requiring treatment in a hospital including death to occur in the population being treated at OHP premises. Who's responsibility is it for deciding whether these events are or are not related to the procedure the patient received within the 10 days reporting time frame and at who's discretion is it to make a report to the college. This needs to be better clarified in the OHP Standard document
Physician (including retired)
[October 02, 2022 4:59 PM]
What would be an example of removing tissues / altering tissue using local anesthetic for Cosmetic / non cosmetic reasons ?
A list of procedures / examples would be highly appreciated to clarify this.
Physician (including retired)
[October 01, 2022 4:56 PM]
Hello, I have been a medical director of an OHP sincie the program’s inception in 2011. I have reviewed the most recent policy and find it clear and comprehensive. I have a few comments upon review.
• There is commentary relating that physicians should only perform procedures that are relevant to their level of training and specialty certification. I believe that this should be further clarified, rather than being left to the interpretation of the individual physician. For example, plastic surgeons should only perform procedures which are part of the lexicon of their surgical training, etc. family doctors are not trained in surgical procedures and should not perform surgery unless certification from the royal college is obtained for such procedures. Specialty committees have determined the extent of what comprises a competent surgeon for each of our respective disciplines (competency by design) and these should set the standard proceudres of what a physician should be able to perform. In general I would like to see the college take a more definite role in enforcement of these competencies, and perhaps a metric that may be used for the OHP program is that a physician should not perform procedures in an OHP that would not be granted should that physician request privileges from an accredited hospital for the same procedure.
• Specifically what training is required for a non-anesthetist physician to safely administer sedation? Suggest highlighting specific criteria and level of training, as above for surgical procedures.
• I did not note definition of levels of acuity and standards in the document, ie. Levels 1, 2, and 3, with differing requirements for each level. Has this been discarded? Would propose that the level of designation should reflect the acuity of the procedure, and the level of anesthesia administered, rather than the intent of the procedure. As an example, a facial nevus removed for cosmetic purposes is designated as a level 2 act, whereas removal of that same nevus for diagnostic purposes is a level 1 act.
• Lastly, would be helpful to provide a framework to build policy and procedure manuals in a standardized format acceptable to the college, allowing uniformity and clarity throughout the program.