(Approved by the ASA Committee on Quality Management and Departmental Administration on May 19, 2011, and last amended on October 8, 2014)
On January 14, 2011, the Centers for Medicare and Medicaid Services (CMS) issued revised Interpretive Guidelines (IGs) pertaining to the hospital Conditions of Participation. To help its members implement the many changes in these IGs, ASA has prepared a set of policy templates and forms. Language that is quoted from the IGs is in blue color in these documents, as well as the source reference e.g. (§482.52).
In the IGs, CMS reaffirmed its many-year definition of “anesthesia,” to mean general anesthesia, regional anesthesia, deep sedation/analgesia or monitored anesthesia care. “Analgesia/sedation” is defined as local/topical anesthesia, minimal sedation, and moderate sedation/analgesia (“conscious sedation”).
Only qualified anesthesia professionals are permitted to administer “anesthesia” as defined above. CMS defines these individuals as qualified anesthesiologists; non-anesthesiologist M.D./D.O.s; dentists, oral surgeons or podiatrists qualified under State law; nurse anesthetists (CRNAs); and anesthesiologist assistants (AAs). CMS now more clearly acknowledges that the boundary between ‘anesthesia’ and ‘analgesia’ is a continuum. Since there are certain CMS requirements that apply only when “anesthesia” is administered, each hospital must establish policies and procedures, based on nationally recognized guidelines, which address whether specific clinical situations involve "anesthesia" versus "analgesia." New in this revision is a hospital requirement to monitor quality and safety indicators for all "anesthesia" and "analgesia" services. (§482.52)
See policy template "Scope of Anesthesia Services
CMS has affirmed that “all services along the continuum of anesthesia services provided in a hospital must be organized under a single anesthesia service, which must be directed by a qualified physician. The Director has the authority and responsibility for directing the administration of all anesthesia throughout the hospital “including all departments in all campuses and off-site locations where anesthesia services are provided,” as well as for the quality and appropriateness of anesthesia care. The Director must be appointed using qualification criteria approved by the hospital’s governing body.
See policy template "Director of Anesthesia Services: Job Description
The service and its Director are also responsible for planning, directing and supervising all activities of the anesthesia service. This responsibility includes establishing criteria for granting privileges to all providers, from topical/local anesthesia through all levels of sedation to general anesthesia.
See policy template “Policies and Procedures Governing Anesthesia Privileging in Hospitals
The updated IGs also provide more detail on the requirements for pre- and post-anesthesia evaluations. These evaluations must be performed whenever general anesthesia, regional anesthesia, deep sedation/analgesia or monitored anesthesia care is administered, and can be completed only by a qualified anesthesia professional. However, this need not be the same practitioner who administered the anesthesia to the patient.
The pre-anesthesia medical history review as well as patient interview and examination must be completed within 48 hours prior to the first dose of medication for anesthesia induction. The IGs now clarify that the other specified components of the pre-anesthesia evaluation may be performed within 30 days before the procedure, needing review and update within the 48-hour window.
See policy templates for "Preanesthesia Evaluation" and for the "Preanesthesia Evaluation
The postanesthesia evaluation must be completed within 48 hours from the time the patient is moved to the designated recovery area (e.g., same day surgery recovery, PACU or ICU). The postanesthesia evaluation should not begin until the patient has recovered sufficiently from the anesthesia to appropriately participate in the assessment, unless the plan is continued sedation.
See policy templates for "Postanesthesia Evaluation" and for the "Postanesthesia Evaluation Note
Current practice dictates that the patient receiving moderate sedation be monitored and evaluated before, during, and after the procedure by trained practitioners. However, pre- and postanesthesia evaluations are not required for moderate sedation for the purposes of complying with the hospital Conditions of Participation, because moderate sedation is not considered by CMS to be “anesthesia” and thus is not subject to this requirement. Nevertheless, the director of anesthesia services should define what are the minimum requirements for pre- and post-sedation evaluations.
The IGs also provide guidance on the minimum elements required under the current standard of care for an anesthesia intra-operative report or record.
See policy template “Intraoperative Anesthesia Record
It is important that anesthesiologists proactively work with their facility's Medical Executive Committee, or its local equivalent. The authority given by CMS to the director of anesthesia services gives anesthesiologists the opportunity and the authority to promote safety throughout our hospitals for all aspects, levels and providers of anesthesia care.
In addition to the minimum requirements set forth in the CMS regulations and described in these Policy Templates and Resources, ASA has issued Standards, Guidelines, Statements and Other Documents,
the Manual for Anesthesia Department Organization and Management and other resources available at www.asahq.org.
Finally, the policy templates and resources are not intended to be, nor should they be interpreted as, legal advice. All anesthesia departments and hospitals should review these templates and resources with appropriate legal counsel and make their own determinations as to relevance to their particular hospital setting and compliance with State and federal laws and regulations.
Beverly K. Philip, M.D.
This committee work product has not been reviewed or approved by ASA’s Board of Directors or House of Delegates and does not represent an ASA Policy, Statement, or Guideline.