Maintaining Compliance with Anesthesia Evaluations
Anesthesia care consists of pre-operative evaluation, preparation and monitoring services, administration of anesthesia, and post-anesthesia recovery care. Anesthesiologists may personally perform anesthesia services or may supervise anesthesia services performed by a certified registered nurse anesthetist (CRNA) or anesthesiologist’s assistant (AA).
A CRNA may perform anesthesia services under the supervision of an anesthesiologist or operating practitioner or may perform the work independently if allowed by state law. An AA always performs anesthesia services under the direction of an anesthesiologist. The hospital’s governing body must approve the specific anesthesia service privileges for each practitioner who furnishes anesthesia, addressing the type of supervision, if any, required, according to §482. 22(c)(6).
Pre- and post-anesthesia evaluations for each patient who receives general, regional, or monitored anesthesia is important to ensure safe care will be provided. A frequent deficiency for Acute Care Hospitals (ACHs) is related to maintaining compliance with timely documentation of pre- and post-anesthesia assessments.
The Centers for Medicare & Medicaid Services (CMS) and ACH Manual from Accreditation Commission for Health Care (ACHC) have standards, provided below, that relate to defining current practice and describe how to effectively evaluate it.
Pre-Anesthesia Evaluation
In the pre-anesthesia period, an essential part of the anesthesia provider’s responsibility is to perform a pre-anesthesia evaluation to assess risk and develop the anesthesia plan. This evaluation includes a sufficient history and physical examination so the risk of adverse reactions can be minimized, alternative approaches to anesthesia can be planned, and all questions regarding the anesthesia procedure from the patient or family can be answered.
18.00.05 Pre-Anesthesia Evaluation
A pre-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of 42 CFR 482.52, performed within 48 hours prior to any inpatient or outpatient surgery or a procedure requiring anesthesia services.
Pre-anesthesia evaluations must be performed by:
- A qualified anesthesiologist.
- A doctor of medicine or doctor of osteopathic medicine (other than an anesthesiologist).
- A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under state law.
- A certified registered nurse anesthetist (CRNA) who is under the supervision of the operating practitioner or an anesthesiologist who is immediately available, unless exempted by the state for supervision of CRNAs.
- An anesthesiologist’s assistant who is under the supervision of an anesthesiologist who is immediately available.
Elements of the pre-anesthesia evaluation that must be performed within 48 hours and documented in the medical record include:
- Review of medical history, including previous anesthesia experiences, drug, and allergy history.
- Interview and focused examination of patient.
Elements that may be performed within the preceding 30 days but must be reviewed and updated within 48 hours and documented in the medical record include:
- Anesthesia risk according to established standards such as the American Society of Anesthesia Physical Classification System (ASA risk score) and Mallampati score.
- Potential anesthesia problems that may suggest potential complications or contraindications to planned procedure (e.g., difficult airway, ongoing infection, coagulopathy, limited intravascular access, family history of anesthesia complications).
- Ordering and reviewing pertinent available pre-anesthesia tests and information required by standard practice (e.g., stress tests, lab work, specialist consultation).
- Plan for patient’s anesthesia care, including type of anesthesia for induction, maintenance and post-operative care, and discussion with patient or representative of the risk and benefits of anesthesia.
While current practice dictates patients receiving Moderate Sedation are to be monitored before, during, and after the procedure by trained professionals, a pre-anesthesia evaluation by a qualified anesthesia provider is not required because Moderate Sedation is not considered anesthesia.
Post-Anesthesia Assessment
The anesthesia practitioner assumes responsibility for anesthesia and related care rendered in the post-anesthesia recovery period until the patient is released to the surgeon or another physician. The post-anesthesia assessment must be completed and documented by any practitioner who is qualified to administer anesthesia; this need not be the same practitioner who administered the anesthesia to the patient.
The ACH Manual from ACHC has standards related to defining current practice and how to effectively evaluate it as provided below.
18.00.07 Post-Anesthesia Assessment
A post-anesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with state law and with hospital policies and procedures that have been approved by the medical staff and that reflect current standards of anesthesia care. This evaluation is required any time general, regional, or monitored anesthesia has been administered.
The calculation of the 48-hour timeframe begins at the point the patient is moved into the designated recovery area. Accepted standards of anesthesia care indicate this evaluation should not begin until the patient is sufficiently recovered from acute anesthesia so they can participate by appropriately answering questions and perform simple tasks. While the post-anesthesia assessment is usually performed in the PACU or ICU, it may be completed after the patient has moved to the inpatient area or the same-day surgery area. If state law and hospital policy allow, the evaluation may be done after discharge so long as it is within 48 hours.
Elements of the post-anesthesia evaluation must be clearly documented and meet current standards of anesthesia care, including:
- Respiratory function, including respiratory rate, airway patency, and oxygen saturation.
- Cardiovascular function, including pulse rate and blood pressure.
- Mental status.
- Temperature.
- Pain assessment.
- Nausea and vomiting.
- Postoperative hydration.
Depending on the specific surgery performed, additional types of monitoring and assessment may be necessary.
The medical staff is responsible to establish one standard of care for assessment of all patients following anesthesia, including main operating room, outpatient surgery, ambulatory surgery centers, interventional radiology, nuclear medicine, obstetrics, cardiac catheterization lab, endoscopic services, and other procedure rooms in which general anesthesia, spinal anesthesia, regional anesthesia epidural, or monitored anesthesia is administered. The facility must establish a process for ensuring the post-anesthesia assessment is complete for patients within 48 hours.
While current practice dictates that the patient receiving moderate sedation be monitored and evaluated before, during, and after the procedure by trained practitioners, a post-anesthesia evaluation performed by someone qualified to administer anesthesia as specified in 42 CFR §482.52(a) is not required under this regulation.
Organizations have been successful in ensuring their compliance with the requirement for documentation of both pre- and post-anesthesia evaluations by using their Quality Assessment Performance Improvement (QAPI) programs to define practices that may require additional staff education and training for compliance. Ongoing chart auditing or monitoring of documentation for these essential aspects of the anesthesia provider’s responsibility does improve compliance rates and limits deficiencies in these standards.
Additional Resources
State Operations Manual Appendix, February 21, 2020. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_a_hospitals.pdf
“Guidelines, Statements, Clinical Resources,” American Society of Anesthesiologists, June 20, 2021. https://www.asahq.org/standards-and-guidelines/basic-standards-for-preanesthesia-care
Guidelines to the Practice of Anesthesia – Revised Edition 2021, January 4, 2021. https://pubmed.ncbi.nlm.nih.gov/33398771/
Post-Anesthesia Evaluation, American Society of Anesthesiologists, August 2014. https://www.asahg.org
“Distinguishing Between a Pre-Anesthesia Evaluation and a Separately Reportable Evaluation and Management Service,” American Society of Anesthesiologists, November 2020. https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
Staying Up to Date
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