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New CMS Anesthesia Guidelines Completely Rewrite Former Standards

 |  By mphillion@hcpro.com  
   April 13, 2010

A recent round of edits to the Centers for Medicare & Medicaid Services' (CMS) interpretive guidelines has caught the attention of experts in the field for its focus on anesthesia guidelines.

Any hospital that accepts Medicare and Medicaid reimbursement must follow these interpretive guidelines, explains Sue Dill Calloway, RN, MSN, JD, director of hospital risk management for The Doctor's Company, in Columbus, OH.

These guidelines must be followed for all patients in the hospital, such as commercial payer or no pay patients, and not just Medicare and Medicaid patients. The guidelines do not apply to critical access hospitals, which have their own manual.

The final memo was 17 pages long and completely rewrites the CMS anesthesia section standards. Every anesthesiologist, certified registered nurse anesthetist (CRNA), or anesthesiology assistant that practices in a hospital, including surgery, post-anesthesia care unit (PACU), outpatient department, and obstetrics, should be aware of these new guidelines along with all Prospective Payment System hospitals.

These standards are also of interest to places where moderate sedation may be given, says Dill Calloway, such as in the emergency department or endoscopy unit. It is important to note that deep sedation is anesthesia, which can only be done by an anesthesiologist, qualified physician, CRNA, or anesthesiology assistant.

A dentist, oral surgeon, or podiatrist, who is qualified under state law, may also administer anesthesia. The hospital's policy must address the circumstances under which a doctor, who is not an anesthesiologist, is permitted to administer anesthesia and hospitals must follow accepted standards of anesthesia care when establishing their policy and procedure. The American Society of Anesthesiology (ASA) has a number of position statement and guidelines.

Anesthesia tags

The anesthesia standards start at tag number 1000. The CMS hospital manual is 370 pages long and has 1,163 tag or section numbers. The new standards go into detail on the differences between anesthesia and analgesia.

In analgesia, the patient does not lose consciousness and is given medication for pain relief by blocking pain receptors. Anesthesia is the administration of a medication to produce blunting or loss of pain perception, voluntary and involuntary movement, autonomic function, and memory or consciousness.

The anesthesia standards apply to general anesthesia, regional, Monitored Anesthesia Care (MAC), and deep sedation can be done by an anesthesiologist, qualified physician, CRNA, or anesthesiology assistant.

Topicals, locals, minimal sedation, and moderate sedation can be done by an appropriately trained medical practitioner within their scope of practice, such as an emergency department physician or gastroenterologist. Also, these four services (minimal, local, minimal sedation, and moderate sedation) are not subject to the anesthesia administration and supervision requirement.

"Often these are administered by a RN," says Dill Calloway. "The hospital must have a policy detailing who can administer these that is consistent with the state scope of practice."

Supervision of anesthesiology assistants

The guidelines also include the supervision of anesthesiology assistants (AA) for those states that recognized this category of healthcare workers. Some states have opted out of the supervision requirement meaning that the CRNA does not need any physician supervision.

In states that have not opted out, the CRNA must be supervised by the operating physician or by an anesthesiologist who is immediately available.

Immediately available, explains Dill Calloway, means the anesthesiologist is within the same area, such as in the OR or the labor and delivery unit, and is not occupied. In other words, they should not be prevented from immediately conducting hands-on intervention, if needed.

If the hospital allows the operating surgeon to supervise the CRNA, there must be medical staff bylaws or rules and regulations that specify for each category of operating practitioner, the type and complexity of procedures that category of practitioner may supervise. However, individual operating surgeons do not need to be granted specific privileges to supervise a CRNA.

A pre-anesthesia evaluation must be done within 48 hours prior to surgery and documented in the medical record, Dill Calloway explains. This must be done by a qualified person, like a CRNA, AA, physician, or anesthesiologist for patients under going anesthesia such as a general, regional, or MAC. It must be done within 48 hours prior to the delivery of the first dose of medication given for the purpose of inducing anesthesia. CMS sets forth what should be documented as part of the pre-anesthesia evaluation as does The Joint Commission and ASA.

CMS now requires a few items to be documented as part of the intraoperative anesthesia record. This includes:

  • Name and hospital identification number of the patient

  • Name of practitioner who administered anesthesia, and as applicable, the name and profession of the supervising anesthesiologist or operating practitioner

  • Name, dosage, route, and time of administration of drugs and anesthesia agents

  • Techniques used and patient position, including the insertion/use of any intravascular or airway devices;
  • Name and amounts of IV fluids, including blood or blood products if applicable

  • Time-based documentation of vital signs as well as oxygenation and ventilation parameters

  • Any complications, adverse reactions, or problems occurring during anesthesia, including time and description of symptoms, vital signs, treatments rendered, and patient's response to treatment

Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals (AHAP).

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