Basic Standards for Preanesthesia Care
Standards for Basic Anesthetic Monitoring
Minimal Safety Standards: Dep of Anaesthesia, Basel
Standards for Postanesthesia Care
Basic Standards for Preanesthesia Care
Standards for Basic Anesthetic Monitoring
Minimal Safety Standards: Dep of Anaesthesia, Basel
Standards for Postanesthesia Care
Guidelines for Perioperative Transesophageal Echocardiography
Guidelines for Blood Component Therapy
Guidelines for Ambulatory Surgical Facilities
Guidelines for a Minimally Acceptable Program of Any Continuing Education Requirement
Guidelines for Critical Care in Anesthesiology
Guidelines for Delineation of Clinical Priveleges in Anesthesiology
Ethical Guidelines for the Care of Patients with DNR Orders or Directives That Limit Treatment
Guidelines for the Ethical Practice of Anesthesiology
Guidelines for Expert Witness Qualifications and Testimony
Guidelines for Delegation of Technical Anesthesia Functions to Nonphysician Personnel
Guidelines for Nonoperating Room Anesthetizing Locations
Guidelines for Regional Anesthesia in Obstetrics
Guidelines for Patient Care in Anesthesiology
Statement of Policy
The Anesthesia Care Team
Anesthesia Consultation Program
Statement on Conflict of Interest
Documentation of Anesthesia Care
Statement on Physicians DRGS
Statement on Economic Credentialing
Statement on Invasive Monitoring in Anesthesiology
Position on Monitored Anesthesia Care
ASA Policy for the Reimbursement of Monitored Anesthesia Care
The Organization of an Anesthesia Department
Statement on Regional Anesthesia
Statement Regarding Respiratory Care Practitioneer Credentialing
Statement on Routine Preoperative Laboratory and Diagnostic Screening
Protocol for Supporting a Member's Right to Practice
kaufmannm@ubaclu.unibas.ch 1996
Practice parameters are developed to demonstrate indications and/or
methods for diagnosis, management and treatment of specific clinical
problems.
Practice Parameters include standards, guidelines and other strategies.
Standards are rules; e.g., minimum requirements for sound practice.
They are generally accepted principles for patient management.
Guidelines are recommendations for patient management that may
identify a particular management strategy or a range of management
strategies.
Variances from practice parameters may be acceptable based on
the judgment of the responsible anesthesiologist. Practice parameters
are intended to encourage quality patient care, but cannot guarantee
any specific patient outcome. They are subject to revision from
time to time as warranted by the evolution of technology and practice.
Practice parameters are recommended to the ASA Board of Directors
and House of Delegates. Committees which develop practice parameters
are not empowered to define interpretations for specific institutions,
organizations or practices.
Members of the Society are responsible for interpreting and applying
practice parameters to their own institutions and practices. The
practice parameters adopted by ASA are not necessarily the only
evidence of appropriate care. An individual physician should have
the opportunity to show that the care rendered, even if departing
from the parameters in some respects, satisfies the physician's
duty to the patient under all the facts and circumstances.
In addition to standards and guidelines, the ASA House of Delegates
has approved a number of documents variously titled Statements,
Positions or Protocols. These documents represent expressions
of view by the House on a variety of subjects, but have not necessarily
been subjected to the same level of formal scientific review as
Standards or Guidelines. Variances from the terms of these documents
may also be acceptable based on sound judgment of the responsible
anesthesiologist.
Appearing on the following pages are the Standards, Guidelines,
Practice Parameters, Positions and Protocols.
STANDARDS OF THE AMERICAN SOCIETY
OF ANESTHESIOLOGISTS
As defined in the Policy Statement on Practice Parameters,
Standards are rules; e.g., minimum requirements for sound practice.
They are generally accepted principles for patient management.
Appearing on the following pages are the standards listed below:
Basic Standards for Preanesthesia Care
Standards for Basic Anesthetic Monitoring
Standards for Postanesthesia Care
(Approved by House of Delegates on October 14, 1987)
These standards apply to all patients who receive anesthesia or
monitored anesthesia care. Under unusual circumstances, e.g.,
extreme emergencies, these standards may be modified. When this
is the case, the circumstances shall be documented in the patient's
record.
Standard I: An anesthesiologist shall be responsible for determining
the medical status of the patient, developing a plan of anesthesia
care and acquainting the patient or the responsible adult with
the proposed plan.
The development of an appropriate plan of anesthesia care is based
upon:
1. Reviewing the medical record.
2. Interviewing and examining the patient to:
a. Discuss the medical history, previous anesthetic experiences
and drug therapy.
b. Assess those aspects of the physical condition that might affect
decisions regarding perioperative risk and management.
3. Obtaining and/or reviewing tests and consultations necessary
to the conduct of anesthesia.
4. Determining the appropriate prescription of preoperative medications
as necessary to the conduct of anesthesia.
The responsible anesthesiologist shall verify that the above has
been properly performed and documented in the patient's record.
(Approved by House of Delegates on October 21, 1986 and last amended
on October 25, 1995)
These standards apply to all anesthesia care although, in emergency
circumstances, appropriate life support measures take precedence.
These standards may be exceeded at any time based on the judgment
of the responsible anesthesiologist. They are intended to encourage
quality patient care, but observing them cannot guarantee any
specific patient outcome. They are subject to revision from time
to time, as warranted by the evolution of technology and practice.
They apply to all general anesthetics, regional anesthetics and
monitored anesthesia care. This set of standards addresses only
the issue of basic anesthetic monitoring, which is one component
of anesthesia care. In certain rare or unusual circumstances,
1) some of these methods of monitoring may be clinically impractical,
and 2) appropriate use of the described monitoring methods may
fail to detect untoward clinical developments. Brief interruptions
of continual monitoring may be unavoidable. Under extenuating
circumstances, the responsible anesthesiologist may waive the
requirements marked with an asterisk (*); it is recommended that
when this is done, it should be so stated (including the reasons)
in a note in the patient's medical record. These standards are
not intended for application to the care of the obstetrical patient
in labor or in the conduct of pain management.
Note that "continual" is defined as "repeated regularly
and frequently in steady rapid succession" whereas "continuous"
means "prolonged without any interruption at any time."
STANDARD I
Qualified anesthesia personnel shall be present in the room throughout
the conduct of all general anesthetics, regional anesthetics and
monitored anesthesia care.
OBJECTIVE
Because of the rapid changes in patient status during anesthesia,
qualified anesthesia personnel shall be continuously present to
monitor the patient and provide anesthesia care. In the event
there is a direct known hazard, e.g., radiation, to the anesthesia
personnel which might require intermittent remote observation
of the patient, some provision for monitoring the patient must
be made. In the event that an emergency requires the temporary
absence of the person primarily responsible for the anesthetic,
the best judgment of the anesthesiologist will be exercised in
comparing the emergency with the anesthetized patient's condition
and in the selection of the person left responsible for the anesthetic
during the temporary absence.
STANDARD II
During all anesthetics, the patient's oxygenation, ventilation,
circulation and temperature shall be continually evaluated.
OXYGENATION
OBJECTIVE
To ensure adequate oxygen concentration in the inspired gas and
the blood during all anesthetics.
METHODS
l) Inspired gas: During every administration of general anesthesia
using an anesthesia machine, the concentration of oxygen in the
patient breathing system shall be measured by an oxygen analyzer
with a low oxygen concentration limit alarm in use.*
2) Blood oxygenation: During all anesthetics, a quantitative method
of assessing oxygenation such as pulse oximetry shall be employed.*
Adequate illumination and exposure of the patient are necessary
to assess color.*
VENTILATION
OBJECTIVE
To ensure adequate ventilation of the patient during all anesthetics.
METHODS
l) Every patient receiving general anesthesia shall have the adequacy
of ventilation continually evaluated. While qualitative clinical
signs such as chest excursion, observation of the reservoir breathing
bag and auscultation of breath sounds may be adequate, quantitative
monitoring of the carbon dioxide content and/or volume of expired
gas is encouraged.
2) When an endotracheal tube is inserted, its correct presence
in the trachea must be verified by clinical assessment and by
identification of carbon dioxide in the expired gas. Continual
end-tidal carbon dioxide analysis, in use from the time of endotracheal
tube placement, until extubation or transfer to a postoperative
care location, shall be performed using a quantitative method
such as capnography, capnometry or mass spectroscopy.*
3) When ventilation is controlled by a mechanical ventilator,
there shall be in continuous use a device that is capable of detecting
disconnection of components of the breathing system. The device
must give an audible signal when its alarm threshold is exceeded.
4) During regional anesthesia and monitored anesthesia care, the
adequacy of ventilation shall be evaluated, at least, by continual
observation of qualitative clinical signs.
CIRCULATION
OBJECTIVE
To ensure the adequacy of the patient's circulatory function during
all anesthetics.
METHODS
1) Every patient receiving anesthesia shall have the electrocardiogram
continuously displayed from the beginning of anesthesia until
preparing to leave the anesthetizing location.*
2) Every patient receiving anesthesia shall have arterial blood
pressure and heart rate determined and evaluated at least every
five minutes.*
3) Every patient receiving general anesthesia shall have, in addition
to the above, circulatory function continually evaluated by at
least one of the following: palpation of a pulse, auscultation
of heart sounds, monitoring of a tracing of intra-arterial pressure,
ultrasound peripheral pulse monitoring, or pulse plethysmography
or oximetry.
BODY TEMPERATURE
OBJECTIVE
To aid in the maintenance of appropriate body temperature during
all anesthetics.
METHODS
There shall be readily available a means to continuously measure
the patient's temperature. When changes in body temperature are
intended, anticipated or suspected, the temperature shall be measured.
In den letzten Jahrzehnten hat sich die Anästhesie von einer Kunst zu einer wissenschaftlich orientierten Spezialität gewandelt. Während man früher mit dem Finger am Puls unter Beobachtung von Atmung und Reflexzeichen mit einfachen Mitteln Patienten narkotisierte, so kann man heute mit einer Vielzahl von Methoden und Techniken den Patienten situationsgerecht anästhesieren und dabei wichtige physiologische Parameter gleichzeitig überwachen. Verschiedene Faktoren haben dazu beigetragen, dass in dieser Zeit die Anästhesie sicherer geworden ist. Musste man in den 50-er Jahren noch mit einer anästhesiebedingten Mortalität von 1:2'000 rechnen, so liegt die Zahl von schweren Zwischenfällen heute je nach Institution zwischen 1:10'000 bis 1:200'000. Die Anästhesie hat sich in dieser Zeit zum führenden Fach in Bezug auf Risiko-Management und Patientensicherheit entwickelt. An der Harvard Medical School wurden vor 5 Jahren erstmals Minimal Safety Standards eingeführt, eine Initiative, die in der Folge praktisch alle wichtigen Fachgesellschaften auf Ihre Art nachvollzogen haben.
Wie lassen sich nun die bereits publizierten, häufig
sehr allgemein gefassten Standards (schweizerische fehlen ...)
auf konkrete, einfache und durchsetzbare Vorschriften reduzieren.
ALLGEMEIN
PRÄSENZ
AUSRÜSTUNG / MONITORING
Vor jeder Anästhesie (auch Maske / Regionalanästhesie / StandBy) werden folgende Systeme explizit geprüft und "in Betrieb" gesetzt:
Nur bei Intubations-Anästhesie:
Vor Einleitung :
Nach Intubation:
MEDIKAMENTE / ZUGÄNGE
SPEZIELLES
DISKUSSION
Den Hauptfaktor einer sicheren Anästhesie stellt nicht das Monitoring, sondern der Anästhesist dar. Eine integrale Erhöhung der Anästhesie-Sicherheit ist durch folgende Massnahmen erreichbar:
Obwohl der Beweis aussteht, dass Safety Standards
den Hauptgrund für die Reduktion des Anästhesie-Risikos
darstellten, ist ihr Anteil an der Erhöhung der Patienten-Sicherheit
unbestritten.
Die häufigste Ursache von schweren Zwischenfällen
sind Probleme mit der Ventilation. Die Bedeutung des Monitorings
wird dadurch unterstrichen, dass Kapnographie und Pulsoxymetrie
die Mehrzahl gerade dieser Probleme vor dem Eintreten von irreversiblen
Folgeschäden aufzeigen können.
Es ist wichtig, dass wir unsere minimalen Safety
Standards selber definieren, bevor sie uns von aussen vorgeschrieben
werden. Da die Kosten eines derartigen minimalen Standards SFr
10.- pro Anästhesie nicht überschreiten, dürfen
im Interesse unserer Patienten auch materielle Einwände keinen
Grund mehr gegen die Einführung derartiger, minimaler Sicherheitsvorschriften
darstellen.
Bibliographie:
Beecher HK, Todd DP: A
study of the deaths associated with anesthesia and surgery. Ann
Surg 140:2,1954
Eichhorn JH, Cooper JB, Cullen DJ, et al:
Standards for patient monitoring during anesthesia at Harvard
Medical School. JAMA 256:1017-20,1986
Eichhorn JH: Prevention
of intraoperative anesthesia accidents and related severe injury
through safety monitoring. Anesthesiology 70:572-7,1989
Gaba DM, Maxwell A, DeAnda A:
Anesthetic mishaps: Breaking the chain of accident evolution.
Anesthesiology 66:670-6,1987
Lunn JN, Devlin HB: Lessons
from the confidential enquiry into perioperative deaths in three
NHS regions. Lancet ii:1384-5,1987
These Standards apply to postanesthesia care in all locations.
These Standards may be exceeded based on the judgment of the responsible
anesthesiologist. They are intended to encourage quality patient
care, but cannot guarantee any specific patient outcome. They
are subject to revision from time to time as warranted by the
evolution of technology and practice. Under extenuating circumstances,
the responsible anesthesiologist may waive the requirements marked
with an asterisk (*); it is recommended that when this is done,
it should be so stated (including the reasons) in a note in the
patient's medical record
STANDARD I
ALL PATIENTS WHO HAVE RECEIVED GENERAL ANESTHESIA, REGIONAL ANESTHESIA
OR MONITORED ANESTHESIA CARE SHALL RECEIVE APPROPRIATE POSTANESTHESIA
MANAGEMENT. 1
1. A Postanesthesia Care Unit (PACU) or an area which provides
equivalent postanesthesia care shall be available to receive patients
after anesthesia care. All patients who receive anesthesia care
shall be admitted to the PACU or its equivalent except by specific
order of the anesthesiologist responsible for the patient's care.
2. The medical aspects of care in the PACU shall be governed by
policies and procedures which have been reviewed and approved
by the Department of Anesthesiology.
3. The design, equipment and staffing of the PACU shall meet requirements
of the facility's accrediting and licensing bodies.
STANDARD II
A PATIENT TRANSPORTED TO THE PACU SHALL BE ACCOMPANIED BY A MEMBER
OF THE ANESTHESIA CARE TEAM WHO IS KNOWLEDGEABLE ABOUT THE PATIENT'S
CONDITION. THE PATIENT SHALL BE CONTINUALLY EVALUATED AND TREATED
DURING TRANSPORT WITH MONITORING AND SUPPORT APPROPRIATE TO THE
PATIENT'S CONDITION.
STANDARD III
UPON ARRIVAL IN THE PACU, THE PATIENT SHALL BE RE-EVALUATED AND
A VERBAL REPORT PROVIDED TO THE RESPONSIBLE PACU NURSE BY THE
MEMBER OF THE ANESTHESIA CARE TEAM WHO ACCOMPANIES THE PATIENT.
1. The patient's status on arrival in the PACU shall be documented.
2. Information concerning the preoperative condition and the surgical/anesthetic
course shall be transmitted to the PACU nurse.
3. The member of the Anesthesia Care Team shall remain in the
PACU until the PACU nurse accepts responsibility for the nursing
care of the patient.
STANDARD IV
THE PATIENT'S CONDITION SHALL BE EVALUATED CONTINUALLY IN THE
PACU.
1. The patient shall be observed and monitored by methods appropriate
to the patient's medical condition. Particular attention should
be given to monitoring oxygenation, ventilation, circulation and
temperature. During recovery from all anesthetics, a quantitative
method of assessing oxygenation such as pulse oximetry shall be
employed in the initial phase of recovery.* This is not intended
for application during the recovery of the obstetrical patient
in whom regional anesthesia was used for labor and vaginal delivery.
2. An accurate written report of the PACU period shall be maintained.
Use of an appropriate PACU scoring system is encouraged for each
patient on admission, at appropriate intervals prior to discharge
and at the time of discharge.
3. General medical supervision and coordination of patient care
in the PACU should be the responsibility of an anesthesiologist.
4. There shall be a policy to assure the availability in the facility
of a physician capable of managing complications and providing
cardiopulmonary resuscitation for patients in the PACU.
STANDARD V
A PHYSICIAN IS RESPONSIBLE FOR THE DISCHARGE OF THE PATIENT FROM
THE POSTANESTHESIA CARE UNIT.
1. When discharge criteria are used, they must be approved by
the Department of Anesthesiology and the medical staff. They may
vary depending upon whether the patient is discharged to a hospital
room, to the Intensive Care Unit, to a short stay unit or home.
2. In the absence of the physician responsible for the discharge,
the PACU nurse shall determine that the patient meets the discharge
criteria. The name of the physician accepting responsibility for
discharge shall be noted on the record.
1Refer to Standards of Post Anesthesia Nursing Practice 1992 published
by ASPAN, for issues of nursing care.
As defined in the Policy Statement on Practice Parameters, guidelines
are recommendations that may identify a particular management
strategy or a range of management strategies.
Appearing on the following pages are the guidelines listed below:
Guidelines for Ambulatory Surgical Facilities
Guidelines for a Minimally Acceptable Program of Any Continuing Education Requirement
Guidelines for Critical Care in Anesthesiology
Guidelines for Delineation of Clinical Priveleges in Anesthesiology
Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders or Other Directives That Limit Treatment
Guidelines for the Ethical Practice of Anesthesiology
Guidelines for Expert Witness Qualifications and Testimony
Guidelines for Delegation of Technical Anesthesia Functions to Nonphysician Personnel
Guidelines for Nonoperating Room Anesthetizing Locations
Guidelines for Regional Anesthesia in Obstetrics
Guidelines for Patient Care in Anesthesiology
In addition to these guidelines, ASA has published practice parameters
in the following areas:
Acute Pain Management; Perioperative Blood Transfusion; Cancer
Pain Management; Management of the Difficult Airway; Pulmonary
Artery Catheterization; Sedation and Analgesia by Nonanesthesiologists;
Transesophogeal Echocardiography
Copies of these practice parameters can be obtained from the ASA
Executive Office, 520 N. Northwest Highway, Park Ridge, IL 60068-2573.
ASA endorses and supports the concept of Ambulatory Surgery and
Anesthesia and encourages the anesthesiologist to play a role
of leadership in both the hospital and freestanding setting.
I. An ambulatory surgical facility may be hospital affiliated
or freestanding. The facility is established, equipped and operated
primarily for the purpose of performing outpatient surgical procedures.
II. ASA Standards, Guidelines and Policies should be adhered to
in all areas except where they are not applicable to outpatient
care.
III. A licensed physician, preferably an anesthesiologist, must
be in attendance in the facility at all times during patient treatment,
recovery and until medically discharged.
IV. The facility must be established, equipped, constructed and
operated in accordance with applicable local, state and federal
laws.
V. Staff shall be adequate to meet patient and facility needs,
and consist of:
A. Professional Staff
1. Physicians and other practitioners who are duly licensed and
qualified.
2. Nurses who are duly licensed and qualified.
B. Administration Staff
C. Housekeeping and Maintenance Staff
VI. Physicians providing medical care in the facility should be
organized into a Medical Staff which assumes responsibility for
credentials review, delineation of privileges, quality assurance
and peer review.
VII. Personnel and equipment shall be on hand to manage emergencies.
The facility must have an established policy and procedure concerning
unanticipated patient transfer to an acute care hospital.
VIII. Minimal patient care shall include:
A. Preoperative instructions and preparation.
B. An appropriate history and physical exam by a physician prior
to anesthesia and surgery.
C. Preoperative studies as medically indicated.
D. Anesthesia shall be administered by anesthesiologists, other
qualified physicians or medically directed nonphysician anesthetists.
F. Discharge of the patient is a physician responsibility.
F. Patients who receive other than unsupplemented local anesthesia
must be discharged to the company of a responsible adult.
G. Written postoperative and follow-up care instructions.
H. Accurate, confidential and current medical records.
(Approved by House of Delegates on October 4, 1972 and last amended
on October 18, 1989)
I. The program should consist of a minimum of 150 hours of approved
postgraduate education every three years.
II. Approved postgraduate educational experience should include
the following:
CATEGORY I (Minimum 60 hours)
The Society believes that 60 hours is the minimum time which should
be spent in Category I efforts.
We recognize that hours of credit suggested for the subcategories
below are quite appropriately subject to some degree of variation
from one program to another.
A. An ACGME accredited transitional year, residency or fellowship
should be credited at 50 credit hours per year for full-time training.
No credit for training prior to the three-year period under consideration
should be allowed.
B. Fifty credit hours should be allowed for each full academic
year of education leading to an advanced degree other than the
M.D. degree in a medical field or medically related science.
Education must occur within the three-year period under consideration.
C. Continuing medical education courses should be credited on
an hour-for-hour basis for the number of hours of course attendance.
Approved courses should include:
1. Any formally constituted meeting, program or course taught
or sponsored by a medical school accredited by the LCME.
2. Any formally constituted meeting, program or course sponsored
by an institution or hospital accredited by the AMA or State Medical
Society.
3. Any formally constituted meeting, program or course offered
nationally or locally by any of the specialty societies recognized
by the AMA. This would include programs sponsored by the ASA or
its component societies.
D. Thirty credit hours should be allowed for each examination
in which a physician participates in the ASA Self-Evaluation Program
for a potential 60 credit hours per year.
CATEGORY II (Maximum 90 hours)
A. Up to 24 credit hours per year should be allowed for hours
of self-education by tapes such as those of the American College
of Physicians or Audio-Digest.
B. Up to 24 credit hours per year should be allowed for hours
of self-education through the study of medical literature related
to the specialty.
C. Up to 10 credit hours per year should be allowed for hours
spent teaching anesthesiology related sciences to medical students,
graduate physicians or allied health personnel.
D. Up to 10 credit hours per year should be allowed for hours
spent in the initial preparation and publication of scientific
papers.
E. Up to l0 credit hours per year should be allowed for presentation
of each paper, course or exhibit at meetings of any national,
regional or local medical group recognized by the AMA.
F. Hour-for-hour credit should be allowed for such educational
activities as attendance at:
1. Medical meetings, programs, courses or scheduled grand rounds
not included in previous categories.
2. Postmortems with a pathologist.
3. Journal clubs.
The Society and its Section on Education and Research will continue
to coordinate and promote the availability nationally, regionally
and locally of suitable continuing medical education activities.
The decision for the initiation of programs for required continuing
education shall remain a responsibility of the component societies.
Delivery of health care services for critically ill patients by
anesthesiologists can be defined as: 1) total management (anesthesiologist
as primary care physician); 2) cooperative (coordinated) care;
and 3) consultative care. These critical (intensive) care services
are distinct from intraoperative anesthesia care. Care must fulfill
the following guidelines:
I. TOTAL MANAGEMENT
In addition to satisfying locally accepted standards for primary
patient care, the anesthesiologist assuming responsibility for
total patient management must meet the following guidelines:
A. The anesthesiologist must personally review the history, examine
the patient and confirm initial diagnoses.
B. All activities shall be appropriately documented in the medical
record. Histories, physical examinations, progress notes and discharge
summaries must be countersigned by the attending anesthesiologist
if written by someone else.
C. The attending critical care anesthesiologist must ensure continuity
of care. Visits and procedures are to be performed as often as
required by patient needs. All activities are to be documented
in the medical record.
D. Appropriate consultative help should be sought where doubt
remains regarding diagnosis or therapy as required by local regulation
and when requested by the patient or family.
E. The attending anesthesiologist should be capable of providing
medical services outlined in section IV.
II. COOPERATIVE (COORDINATED) CARE
Most critically ill patients require the expertise of more than
one physician. The critical care anesthesiologist and other physicians
may cooperatively care for such patients with authority for some
or all medical services outlined in section IV assumed by the
critical care anesthesiologist. Guidelines for the anesthesiologist
involved in cooperative patient care include:
A. Medical responsibility for critical care is to be designated
by the Governing Body of the Medical Staff.
B. There will be provision for continuous coverage by physicians
experienced in critical care.
C. The anesthesiologist should be capable of assuming responsibility
for medical services outlined in section IV.
D. Visits and procedures are to be performed as often as required
by patient needs. All activities are to be documented in the medical
record.
E. Physicians involved in cooperative care must coordinate their
activities by frequent communication.
III. CONSULTATIVE INVOLVEMENT
Anesthesiologists possess knowledge and skills relevant to the
care of a broad range of problems encountered in critically ill
patients. Thus, anesthesiologists are consulted by other physicians
for their expertise.
A. The consultant anesthesiologist must provide for continuous
availability of consultative medical expertise (as described in
section IV) for critically ill patients.
B. The consultant anesthesiologist must review the history, examine
the patient, review other data and provide suggestions regarding
diagnosis, monitoring or therapy to the primary care physician.
C. Patients must be seen at intervals appropriate to the patient's
condition.
D. All findings, suggestions and procedures shall be documented
in the medical record.
IV. PATIENT CARE ACTIVITIES
The critical care anesthesiologist provides expertise in the following
areas, which may include, but not necessarily be limited to:
A. Diagnostic or therapeutic problems of the respiratory system.
B. Diagnostic or therapeutic problems of the cardiovascular system.
C. Fluid, electrolyte, nutrition and acid-base disorders.
D. Care of the unconscious patient, regardless of etiology.
E. Care of the patient with multiple systems organ failure, injury
or disease.
F. Care of patients requiring life support techniques.
G. Diagnostic and monitoring activities.Examples of specific diagnostic
and monitoring skills of critical care anesthesiologists include,
but are not limited to, bronchoscopy, invasive and noninvasive
hemodynamic and respiratory monitoring techniques, and metabolic
assessment methods.
H. Therapeutic activities.
Appropriate therapeutic techniques are to be instituted. Examples
of specific techniques performed by critical care anesthesiologists
include, but are not limited to, bronchoscopy, airway intubation,
institution of and weaning from mechanical ventilation, tube thoracostomy,
cardiopulmonary resuscitation, cardioversion, electrical cardiac
pacing, mechanical and pharmacologic support of the circulation,
parenteral and enteral nutrition, fluid, electrolyte and acid-base
support, management of extracorporeal membrane oxygenation, hyperbaric
therapy, intraaortic counterpulsation and prolonged pain relief.
V. ADMINISTRATIVE RESPONSIBILITY
Administrative responsibility for critical (intensive) care is
designated by the hospital administration. Examples of appropriate
activities include authority for admission to and discharge of
patients from intensive care units, triage of critical care services,
involvement in budgetary matters, and input into constructing,
remodeling, equipping, staffing and supplying intensive care units.
Vl. EDUCATIONAL RESPONSIBILITY
Teaching conferences for the regular critical (intensive) care
staff (including physicians, nurses, respiratory therapists, paramedical
personnel and respective trainees) are to be conducted or supervised.
These conferences should disseminate information relative to the
care of critically ill patients.
(Approved by House of Delegates on October 15, 1975 and last amended
on October 19, 1994)
The granting, reappraisal and revision of clinical privileges
shall be in accordance with medical staff bylaws, rules and regulations.
The granting of privileges to prescribe and personally administer
or medically direct or supervise provision of anesthesia care
shall be based upon verified information using, but not limited
to, the following criteria:
1. Current medical licensure and registration to practice;
2. Federal and, where applicable, state narcotics registration;
3. Relevant anesthesiology training and/or documented recent clinical
experience;
4. Documented current clinical competence based on peer review,
outcome studies and quality management data;
5. Appropriate mental and physical health status;
6. References and recommendations from credible sources.
Types of Privileges
LIMITED PRIVILEGES IN ANESTHESIOLOGY
These privileges are granted to physicians who are qualified to
perform specific anesthetic procedures, under specific conditions,
and/or to use parenteral sedation to a level at which a patient's
reflexes may be obtunded. Medical staffs may have provision for
recommending "Limited Privileges in Anesthesiology"
or its equivalent to physicians in other specialties at the request
of the service or department wherein the physician practices.
Physicians with these privileges must meet the same standards
as an anesthesiologist would for the same privileges. There cannot
be separate standards within the same facility. Examples of physicians
who might apply for limited privileges include, but are not limited
to Surgeons, Radiologists, Gastroenterologists, Intensivists,
Cardiologists and Emergency Physicians.
GENERAL PRIVILEGES IN ANESTHESIOLOGY
These privileges are granted to physicians who are qualified by
training to render patients insensible to pain and stress during
surgical, obstetrical and certain medical procedures using general
anesthesia, regional anesthesia and/or parenteral sedation to
a level at which a patient's protective reflexes may be obtunded.
The performance of preanesthetic, intraanesthetic and postanesthetic
evaluation and management, and appropriate measures to protect
life functions and vital organs, is required.*
At facilities where the scope and complexity of care provided
by physicians require specialized competence, clinical privileges
may be tailored to reflect these skills. Tailored privileges would
be appropriate for physicians with general privileges in anesthesiology
who possess additional skills for highly specialized care by virtue
of training and experience or demonstrated competence. Examples
might include, but not be limited to, anesthesia for premature
or high risk neonates, cardiac and transplant surgery, high risk
obstetrical procedures, certain neurosurgical procedures, provision
of critical care, and evaluation and treatment of acute and chronic
pain conditions.
Tailoring of privileges may also be appropriate in facilities
where technologically advanced or highly specialized invasive
and noninvasive techniques are utilized. Physicians performing
techniques or interpreting results that may affect patient safety
or well-being may have specific privileges granted on the basis
of training and experience or demonstrated competence. Examples
may include, but not be limited to, placement of central venous,
pulmonary or peripheral arterial catheters, EEG or evoked potential
monitoring, precordial or transesophageal echocardiography, transcutaneous
or transvenous cardiac pacing, and flexible fiberoptic laryngo/bronchoscopy.
* Non-physician personnel providing technical assistance with
anesthesia care must be certified by their own specific organization
and be medically directed or supervised by physicians who have
appropriate clinical privileges for the anesthesia care provided.
These guidelines apply to competent patients and also to incompetent
patients
who have previously expressed their preferences.
I. Given the diversity of published opinions and cultures within
our society, an essential element of preoperative preparation
and perioperative care for patients with Do-Not Resuscitate (DNR)
orders or other directives that limit treatment is communication
among involved parties. It is necessary to document relevant aspects
of this communication.
II. Policies automatically suspending DNR orders or other directives
that limit treatment prior to procedures involving anesthetic
care may not sufficiently address a patient's rights to self-determination
in a responsible and ethical manner. Such policies, if they exist,
should be reviewed and revised, as necessary, to reflect the content
of these guidelines.
III. Prior to procedures requiring anesthetic care, any changes
in existing directives that limit treatment should be documented
in the medical record. These include absolute injunctions as desired
by the patient (or the patient's legal representative). When appropriate,
the items that should be considered are:
A. Blood product transfusion
B. Tracheal intubation or instrumentation
C. Chest compressions and direct cardiac massage
D. Defibrillation
E. Cardiac pacing, internal or external
F. Invasive monitoring
G. Postoperative ventilatory support
H. Vasoactive drug administration
IV. When relevant, the anesthesiologist should describe and discuss
the appropriate use of therapeutic modalities to correct deviations
of hemodynamic and respiratory variables predictably resulting
from anesthetic agents and techniques.
V. Additional issues that may be relevant to discuss are perioperative
placement of naso/ orogastric tubes or urinary catheters, administration
of antibiotics? establishment of intravenous access, maintenance
of intravascular volume with nonblood products and treatment with
supplemental oxygen.
VI. It is important to discuss and document whether there are
to be any exceptions to the injunction(s) against intervention
should there occur a specific recognized complication of the surgery
or anesthesia.
VII. Concurrence on these issues by the primary physician (if
not the surgeon of record), the surgeon and the anesthesiologist
is desirable. If possible, these physicians should meet together
with the patient (or the patient's legal representative) when
these issues are discussed. This duty of the patient's physicians
is deemed to be of such importance that it should not be delegated.
Other members of the health care team who are (or will be) directly
involved with the patient's care during the planned procedure
should, if feasible, be included in this process.
VIII. Should conflicts arise, the following resolution processes
are recommended:
A. When an anesthesiologist finds the patient's or surgeon's limitations
of intervention decisions to be irreconcilable with one's own
moral views, then the anesthesiologist should withdraw in a nonjudgmental
fashion, providing an alternative for care in a timely fashion.
B. When an anesthesiologist finds the patient's or surgeon's limitation
of intervention decisions to be in conflict with generally accepted
standards of care, ethical practice or institutional policies,
then the anesthesiologist should voice such concerns and present
the situation to the appropriate institutional body.
C. If these alternatives are not feasible within the time frame
necessary to prevent further morbidity or suffering, then in accordance
with the American Medical Association's Principles of Medical
Ethics, care should proceed with reasonable adherence to the patient's
directives, being mindful of the patient's goals and values.
IX. A representative from the hospital's anesthesiology service
should establish a liaisonwith surgical and nursing services for
presentation, discussion and procedural application of these guidelines.
Hospital staff should be made aware of the proceedings of these
discussions and the motivations for them.
X. Modification of these guidelines may be appropriate when they
conflict with local standards or policies, and in those emergency
situations involving incompetent patients whose intentions have
not been previously expressed.
(Approved by House of Delegtes on October 3, 1967 and last amended
on October 13, 1993)
Preamble
Membership in the American Society of Anesthesiologists is a privilege
of physicians who are dedicated to the ethical provision of health
care. The Society recognizes the Principles of Medical Ethics
of the American Medical Association (AMA) as the basic guide to
the ethical conduct of its members.
AMA Principles of Medical Ethics
The medical profession has long subscribed to a body of ethical
statements developed primarily for the benefit of the patient.
As a member of this profession, a physician must recognize responsibility
not only to patients but also to society, to other health professionals
and to self. The following Principles adopted by the American
Medical Association are not laws but standards of conduct which
define the essentials of honorable behavior for the physician.
I. A physician shall be dedicated to providing competent medical
service with compassion and respect for human dignity.
II. A physician shall deal honestly with patients and colleagues
and strive to expose those physicians deficient in character or
competence, or who engage in fraud or deception.
III. A physician shall respect the law and also recognize a responsibility
to seek changes in those requirements which are contrary to the
best interests of the patient.
IV. A physician shall respect the rights of patients, of colleagues
and of other health professionals and shall safeguard patient
confidence within the constraints of the law.
V. A physician shall continue to study, apply and advance scientific
knowledge, make relevant information available to patients, colleagues
and the public, obtain consultation, and use the talents of other
health professionals when indicated.
VI. A physician shall, in the provision of appropriate patient
care except in emergencies, be free to choose whom to serve, with
whom to associate and the environment in which to provide medical
services.
VII. A physician shall recognize a responsibility to participate
in activities contributing to an improved community.
AMA, 1993
The practice of anesthesiology involves special problems relating
to the quality and standards of patient care. Therefore, the Society
requires its members to adhere to the AMA Principles of Medical
Ethics and
any other specific ethical guidelines adopted by this Society.
Definitions
Medical Direction: Anesthesia direction, management or instruction
provided by an anesthesiologist whose responsibilities include:
a. Preanesthetic evaluation of the patient.
b. Prescription of the anesthesia plan.
c. Personal participation in the most demanding procedures in
this plan, especially those of induction and emergence.
d. Following the course of anesthesia administration at frequent
intervals.
e. Remaining physically available for the immediate diagnosis
and treatment of emergencies.
f. Providing indicated postanesthesia care.
An anesthesiologist engaged in medical direction should not personally
be administering another anesthetic and should use sound judgment
in initiating other concurrent anesthetic and emergency procedures.
I. The Anesthesiologist's Relationship to Patients and Other Physicians.
A. Anesthesiology is the practice of medicine.
B. Anesthesiologists, like other physicians, should render service
only to those patients who have consented to their services.
C. An anesthesiologist must maintain the personal relationship
which exists between physician and patient and must not permit
any third party layperson or organization to interfere with the
rendering of service in accordance with the standards of sound
medical practice.
D. If an anesthesiologist, either expressly or by implication,
undertakes an obligation to a patient, that anesthesiologist must
discharge this responsibility. A member of this Society should
not remain in any relationship whereby personal responsibility
is diluted or abrogated. Anesthesiologists should remain continuously
and immediately available throughout the procedure for which responsibility
is accepted. If the member is to render only a portion of the
anesthesia care, either through medical direction or otherwise,
the arrangement must be clearly explained to and understood by
the patient. Patient deception is unethical, whether deliberate
or not.
E. An anesthesiologist may not delegate an accepted responsibility
to another physician without prior consent of the patient. Patients
should be informed that more than one physician may care for them.
When an anesthesiologist gives preoperative care, but a nonphysician
will administer the anesthetic without medical direction by the
anesthesiologist, all parties must understand that responsibility
for the professional anesthetic care of the patient during such
administration is assumed by the surgeon or other physician present.
F. Associations created merely for sharing expenses or for convenience
of operation must not be confused with true partnerships in which
the partners are legally and morally responsible for each other's
professional conduct.
II. The Anesthesiologist's Duties, Responsibilities and Relationship
to the Hospital.
A. Anesthesiologists should be accorded the same clinical rights,
limitations, responsibilities and privileges accorded to other
members of the medical staff in the hospital's clinical departments.
Anesthesiologists must be permitted to conduct their medical practice
with the same independence of medical judgment and responsibility
(including, but not limited to, responsibility for matters of
clinical privileges and standards for patient care) as the members
of the medical staff in the hospital's other clinical departments.
Departments of Anesthesiology should have similar autonomy to
that afforded other clinical departments of the hospital.
B. The hospital should provide the necessary equipment, drugs
and gases that a specialist in anesthesiology may require, in
the manner and to the extent that such items are furnished for
use by other physicians practicing in the hospital.
III. The Anesthesiologist's Relationship to Nurse Anesthetists
and Other Nonphysician Personnel.
A. The Society recognizes that the personal provision of anesthesia
care by the anesthesiologist must remain a desirable primary goal.
It also believes that a proper concern for its members is the
establishment of an acceptable environment within which medical
direction of the anesthesia care team may be carried out so as
to provide better anesthesia care for more patients.
B. Neither the patient nor attending physician should be led to
believe that an anesthesiologist will medically direct the administration
of the anesthesia unless medical direction as defined above exists.
C. Proper safeguards must be provided so that no exploitation
of the patient or of personnel whose activities are medically
directed by the anesthesiologist is permitted. It is emphasized
that the anesthesiologist should assume responsibility for the
medical direction of the anesthesia care team so that all patients,
to the extent possible, receive good quality care.
D. A professional service occurs when the anesthetic care is rendered
by the physician alone, or with other members of the anesthesia
care team under the anesthesiologist's medical direction. This
medical direction must be in such numerical and geographic relationship
as to make possible the continual exercise of the medical judgment
of the anesthesiologist throughout the administration of the anesthesia.
This relationship must directly reflect on the experience and
skill of the members of the team.
E. Where an anesthesiologist medically directs a nonphysician,
such services are regarded anesthesiologist's responsibilities
include:
1. Preanesthetic evaluation of the patient.
2. Prescription of the anesthesia plan.
3. Personal participation in the most demanding procedures in
this plan, especially those of induction and emergence.
4. Following the course of anesthesia administration at frequent
intervals.
5. Remaining physically available for the immediate diagnosis
and treatment of emergencies.
6. Providing indicated postanesthesia care.
PREAMBLE
The integrity of the civil litigation process in the United States
depends in part on the honest, unbiased testimony of expert witnesses.
Such testimony serves to clarify and explain technical concepts
and to articulate professional standards of care. The ASA supports
the concept that such expert testimony by anesthesiologists should
be readily available, objective and unbiased. To limit uninformed
and possibly misleading testimony, experts should be qualified
for their role and should follow a clear and consistent set of
ethical guidelines.
A. EXPERT WITNESS QUALIFICATIONS
1. The physician (expert witness) should have a current, valid
and unrestricted state license to practice medicine.
2. The physician should be board certified in anesthesiology or
hold an equivalent specialist qualification as recognized by the
American Board of Anesthesiology.
3. The physician should be familiar with the clinical practice
of anesthesiology at the time of the occurrence and should have
been actively involved in clinical practice at the time of the
event.
B. GUIDELINES FOR EXPERT TESTIMONY
1. The physician's review of the medical facts should be thorough
and impartial and should not exclude any relevant information
to create a view favoring either the plaintiff or the defendant.
The ultimate test for accuracy and impartiality is a willingness
to prepare testimony that could be presented unchanged for use
by either the plaintiff or defendant.
2. The physician's testimony should reflect an evaluation of performance
in light of generally accepted standards, neither condemning performance
that clearly falls within generally accepted practice standards
nor endorsing or condoning performance that clearly falls outside
accepted medical practice.
3. The physician should make a clear distinction between medical
malpractice and adverse outcomes not necessarily related to negligent
practice.
4. The physician should make every effort to assess the relationship
of the alleged substandard practice to the patient's outcome.
Deviation from a practice standard is not always causally related
to a poor outcome.
5. Fees for expert testimony should relate to the time spent and
in no circumstances should be contingent upon outcome of the claim.
6. The physician should be willing to submit such testimony for
peer review.
I. Anesthesiology is the practice of medicine. Anesthesia, in
all its forms, should be administered by a physician who is trained
in the administration of anesthesia, preferably an anesthesiologist,
a physician who has completed an approved residency in anesthesiology.
Accordingly, an anesthesiologist should be personally responsible
to each patient for all aspects of anesthesia care.
II. While optimal anesthesia care involves a onetoone relationship
between anesthesiologist and patient, a shortage of anesthesiologists
may necessitate the utilization of nonphysician personnel to perform
technical functions relating to the administration of anesthesia
under the personal direction of an anesthesiologist or other qualified
physician.
III. Delegation of functions to nonphysician personnel should
be based on specific criteria (i.e., the individual's education,
training and demonstrated skills) approved by the medical staff
on the recommendation of the physician responsible for anesthesia
care. Such criteria should include competence to follow the anesthesia
plan prescribed by the anesthesiologist and the technical ability
to:
A. Induce anesthesia under the direction of an anesthesiologist.
B. Maintain anesthesia at prescribed levels.
C. Monitor and support life functions during the perioperative
period.
D. Recognize and report to the anesthesiologist any abnormal patient
responses during anesthesia.
These guidelines apply to all anesthesia care involving anesthesiology
personnel for procedures intended to be performed in locations
outside an operating room. These are minimal guidelines which
may be exceeded at any time based on the judgment of the involved
anesthesia personnel. These guidelines encourage quality patient
care but observing them cannot guarantee any specific patient
outcome. These guidelines are subject to revision from time to
time, as warranted by the evolution of technology and practice.
l. There should be in each location a reliable source of oxygen
adequate for the length of the procedure. There should also be
a backup supply. Prior to administering any anesthetic, the anesthesiologist
should consider the capabilities, limitations and accessibility
of both the primary and backup oxygen sources. Oxygen piped from
a central source, meeting applicable codes, is strongly encouraged.
The backup system should include the equivalent of at least a
full E cylinder.
2. There should be in each location an adequate and reliable source
of suction. Suction apparatus that meets operating room standards
is strongly encouraged.
3. In any location in which inhalation anesthetics are administered,
there should be an adequate and reliable system for scavenging
waste anesthetic gases.
4. There should be in each location: (a) a selfinflating hand
resuscitator bag capable of administering at least 90 percent
oxygen as a means to deliver positive pressure ventilation; (b)
adequate anesthesia drugs, supplies and equipment for the intended
anesthesia care; and (c) adequate monitoring equipment to allow
adherence to the "Standards for Basic Anesthetic Monitoring."
In any location in which inhalation anesthesia is to be administered,
there should be an anesthesia machine equivalent in function to
that employed in operating rooms and maintained to current operating
room standards.
5. There should be in each location, sufficient electrical outlets
to satisfy anesthesia machine and monitoring equipment requirements,
including clearly labeled outlets connected to an emergency power
supply. In any anesthetizing location determined by the health
care facility to be a "wet location" (e.g., for cystoscopy
or arthroscopy or a birthing room in labor and delivery), either
isolated electric power or electric circuits with ground fault
circuit interrupters should be provided.*
6. There should be in each location, provision for adequate illumination
of the patient, anesthesia machine (when present) and monitoring
equipment. In addition, a form of battery-powered illumination
other than a laryngoscope should be immediately available.
7. There should be in each location, sufficient space to accommodate
necessary equipment and personnel and to allow expeditious access
to the patient, anesthesia machine (when present) and monitoring
equipment.
8. There should be immediately available in each location, an
emergency cart with a defibrillator, emergency drugs and other
equipment adequate to provide cardiopulmonary resuscitation.
9. There should be immediately available in each location, a reliable
means of two-way communication to request assistance.
10. For each location, all applicable building and safety codes
and facility standards, where they exist, should be observed.
*See National Fire Protection Association. Health Care Facilities
Code 99; Quincy, MA: NFPA, 1993.
These guidelines apply to the use of regional anesthesia or analgesia
in which local anesthetics are administered to the parturient
during labor and delivery. They are intended to encourage quality
patient care but cannot guarantee any specific patient outcome.
Because the availability of anesthesia resources may vary, members
are responsible for interpreting and establishing the guidelines
for their own institutions and practices. These guidelines are
subject to revision from time to time as warranted by the evolution
of technology and practice.
GUIDELINE I
REGIONAL ANESTHESIA SHOULD BE INITIATED AND MAINTAINED ONLY IN
LOCATIONS IN WHICH APPROPRIATE RESUSCITATION EQUIPMENT AND DRUGS
ARE IMMEDIATELY AVAILABLE TO MANAGE PROCEDURALLY RELATED PROBLEMS.
Resuscitation equipment should include, but is not limited to:
sources of oxygen and suction, equipment to maintain an airway
and perform endotracheal intubation, a means to provide positive
pressure ventilation, and drugs and equipment for cardiopulmonary
resuscitation.
GUIDELINE II
REGIONAL ANESTHESIA SHOULD BE INITIATED BY A PHYSICIAN WITH APPROPRIATE
PRIVILEGES AND MAINTAINED BY OR UNDER THE MEDICAL DIRECTION1 OF
SUCH AN INDIVIDUAL.
Physicians should be approved through the institutional credentialing
process to initiate and direct the maintenance of obstetric anesthesia
and to manage procedurally related complications.
GUIDELINE III
REGIONAL ANESTHESIA SHOULD NOT BE ADMINISTERED UNTIL: I ) THE
PATIENT HAS BEEN EXAMINED BY A QUALIFIED INDIVIDUAL2; AND 2) THE
MATERNAL AND FETAL STATUS AND PROGRESS OF LABOR HAVE BEEN EVALUATED
BY A PHYSICIAN WITH PRIVILEGES IN OBSTETRICS WHO IS READILY AVAILABLE
TO SUPERVISE THE LABOR AND MANAGE ANY OBSTETRIC COMPLICATIONS
THAT MAY ARISE.
Under circumstances defined by department protocol, qualified
personnel may perform the initial pelvic examination. The physician
responsible for the patient's obstetrical care should be informed
of her status so that a decision can be made regarding present
risk and further management.2
GUIDELINE IV
AN INTRAVENOUS INFUSION SHOULD BE ESTABLISHED BEFORE THE INITIATION
OF REGIONAL ANESTHESIA AND MAINTAINED THROUGHOUT THE DURATION
OF THE REGIONAL ANESTHETIC.
GUIDELINE V
REGIONAL ANESTHESIA FOR LABOR AND/OR VAGINAL DELIVERY REQUIRES
THAT THE PARTURIENT'S VITAL SIGNS AND THE FETAL HEART RATE BE
MONITORED AND DOCUMENTED BY A QUALIFIED INDIVIDUAL. ADDITIONAL
MONITORING APPROPRIATE TO THE CLINICAL CONDITION OF THE PARTURIENT
AND THE FETUS SHOULD BE EMPLOYED WHEN INDICATED. WHEN EXTENSIVE
REGIONAL BLOCKADE IS ADMINISTERED FOR COMPLICATED VAGINAL DELIVERY,
THE STANDARDS FOR BASIC ANESTHETIC MONITORING3 SHOULD BE APPLIED.
GUIDELINE VI
REGIONAL ANESTHESIA FOR CESAREAN DELIVERY REQUIRES THAT THE STANDARDS
FOR BASIC ANESTHETIC MONITORING3 BE APPLIED AND THAT A PHYSICIAN
WITH PRIVILEGES IN OBSTETRICS BE IMMEDIATELY AVAILABLE.
GUIDELINE VII
QUALIFIED PERSONNEL, OTHER THAN THE ANESTHESIOLOGIST ATTENDING
THE MOTHER, SHOULD BE IMMEDIATELY AVAILABLE TO ASSUME RESPONSIBILITY
FOR RESUSCITATION OF THE NEWBORN.3
The primary responsibility of the anesthesiologist is to provide
care to the mother. If the anesthesiologist is also requested
to provide brief assistance in the-care of the newborn, the benefit
to the child must be compared to the risk to the mother.
GUIDELINE VIII
A PHYSICIAN WITH APPROPRIATE PRIVILEGES SHOULD REMAIN READILY
AVAILABLE DURING THE REGIONAL ANESTHETIC TO MANAGE ANESTHETIC
COMPLICATIONS UNTIL THE PATIENT'S POSTANESTHESIA CONDITION IS
SATISFACTORY AND STABLE.
GUIDELINE IX
ALL PATIENTS RECOVERING FROM REGIONAL ANESTHESIA SHOULD RECEIVE
APPROPRIATE POSTANESTHESIA CARE. FOLLOWING CESAREAN DELIVERY AND/OR
EXTENSIVE REGIONAL BLOCKADE, THE STANDARDS FOR POSTANESTHESIA
CARE4 SHOULD BE APPLIED.
l. A postanesthesia care unit (PACU) should be available to receive
patients. The design, equipment and staffing should meet requirements
of the facility's accrediting and licensing bodies.
2. When a site other than the PACU is used, equivalent postanesthesia
care should be provided.
GUIDELINE X
THERE SHOULD BE A POLICY TO ASSURE THE AVAILABILITY IN THE FACILITY
OF A PHYSICIAN TO MANAGE COMPLICATIONS AND TO PROVIDE CARDIOPULMONARY
RESUSCITATION FOR PATIENTS RECEIVING POSTANESTHESIA CARE.
1The Anesthesia Care Team (Approved by ASA House of Delegates
10/26/82 and last amended 10/21/92).
2 Guidelines for Perinatal Care (American Academy of Pediatrics
and American College of Obstetricians and Gynecologists, 1988).
3 Standards for Basic Anesthetic Monitoring (Approved by ASA House
of Delegates 10/21/86 and last amended 10/25/95).
4 Standards for Postanesthesia Care (Approved by ASA House of
Delegates 10/12/88 and last amended 10/19/94).
(Approved by House of Delegates on October 3, 1967 and last amended
on October 16, 1985)
I. Definition of Anesthesiology:
Anesthesiology is a discipline within the practice of medicine
specializing in:
A. The medical management of patients who are rendered unconscious
and/or insensible to pain and emotional stress during surgical,
obstetrical and certain other medical procedures (involves preoperative,
intraoperative and postoperative evaluation and treatment of these
patients);
B. The protection of life functions and vital organs (e.g., brain,
heart, lungs, kidneys, liver) under the stress of anesthetic,
surgical and other medical procedures;
C. The management of problems in pain relief;
D. The management of cardiopulmonary resuscitation;
E. The management of problems in pulmonary care;
F. The management of critically ill patients in special care units.
II. Anesthesiologist's Responsibilities:
Anesthesiologists are physicians who, after college, have graduated
from an accredited medical school and have successfully completed
an approved residency in anesthesiology. Anesthesiologists' responsibilities
to patients should include:
A. Preanesthetic evaluation and treatment;
B. Medical management of patients and their anesthetic procedures;
C. Postanesthetic evaluation and treatment;
D. On-site medical direction of any nonphysician who assists in
the technical aspects of anesthesia care to the patient.
III. Guidelines for Anesthesia Care:
A. The same quality of anesthetic care should be available for
all patients:
1. 24 hours a day, seven days a week;
2. Emergency as well as elective patients;
3. Obstetrical, medical and surgical patients.
B. Preanesthetic evaluation and preparation means that the responsible
anesthesiologist:
1. Reviews the chart.
2. Interviews the patient to:
a. Discuss medical history, including anesthetic experiences and
drug therapy.
b. Perform any examinations that would provide information that
might assist in decisions regarding risk and management.
3. Orders necessary tests and medications essential to the conduct
of anesthesia.
4. Obtains consultations as necessary.
5. Records impressions on the patient's chart.
C. Perianesthetic care means:
1 . Re-evaluation of patient immediately prior to induction.
2. Preparation and check of equipment, drugs, fluids and gas supplies.
3. Appropriate monitoring of the patient.
4. Selection and administration of anesthetic agents to render
the patient insensible to pain during the procedure.
5. Support of life functions under the stress of anesthetic, surgical
and obstetrical manipulations.
6. Recording the events of the procedure.
D. Postanesthetic care means:
1. The individual responsible for administering anesthesia remains
with the patient as long as necessary.
2. Availability of adequate nursing personnel and equipment necessary
for safe postanesthetic care.
3. Informing personnel caring for patients in the immediate postanesthetic
period of any specific problems presented by each patient.
4. Assurance that the patient is discharged in accordance with
policies established by the Department of Anesthesiology.
5. The period of postanesthetic surveillance is determined by
the status of the patient and the judgment of the anesthesiologist.
(Ordinarily, when a patient remains in the hospital postoperatively
for 48 hours or longer, one or more notes should appear in addition
to the discharge note from the postanesthesia care unit.)
IV. Additional Areas of Expertise:
A. Resuscitation procedures.
B. Pulmonary care.
C. Critical (intensive) care.
D. Diagnosis and management of pain.
E. Trauma and emergency care.
V. Quality Assurance:
The anesthesiologist should participate in a planned program for
evaluation of quality and appropriateness of patient care and
resolving identified problems.
In addition to standards and guidelines, the ASA House of Delegates
has approved a number of documents variously titled statements,
positions or protocols.
Appearing on the following pages are the statements, positions
and protocols listed below:
Statement of Policy
The Anesthesia Care Team
Anesthesia Consultation Program
Statement on Conflict of Interest
Documentation of Anesthesia Care
Statement on Physicians DRGS
Statement on Economic Credentialing
Statement on Invasive Monitoring in Anesthesiology
Position on Monitored Anesthesia Care
ASA Policy for the Reimbursement of Monitored Anesthesia Care
The Organization of an Anesthesia Department
Statement on Regional Anesthesia
Statement Regarding Respiratory Care Practitioneer Credentialing
Statement on Routine Preoperative Laboratory and Diagnostic Screening
Protocol for Supporting a Member's Right to Practice
The American Society of Anesthesiologists is a nonprofit association
of reputable Doctors of Medicine or Osteopathy engaged in the
practice of or otherwise especially interested in anesthesiology.
As provided in the Bylaws, the Society holds to the following
purposes:
To advance the science and art of anesthesiology, and
To stimulate interest and promote progress in the scientific,
cultural and economic aspects of the specialty of anesthesiology.
It is the official policy of the American Society of Anesthesiologists
that all anesthesiologists are free to choose whatever arrangement
they prefer for compensation of their professional services. The
Society does not consider the compensation arrangement so chosen
to be a matter of professional ethics. In addition, anesthesiologists'
compensation arrangements shall not affect their eligibility to
attain or retain membership in this Society or any of its Component
Societies.
The Society advocates the following principles and believes that
its members should be specifically cognizant thereof:
I. The practice of anesthesiology is the practice of medicine
and is not an institutional "service."
II. No contract or other practice arrangement should:
A. Restrict a patient's access to quality anesthesiology care.
B. Restrict ultimate physician control of the delivery of that
care, as for example, the use of provisions coupling termination
of privileges with the termination of the contract.
C. Impede contractual or other legal rights to offer or deliver
anesthesiology care.
III. No person or entity should create an artificial shortage
of anesthesiologists in order to justify a supervisory arrangement.
IV. The professional income of a member of this Society should
be derived from those medical services rendered to the patient
by the member or under the member's direct, personal and continual
medical direction. A stipend may properly be accepted as compensation
for administrative or educational responsibilities.
V. Exploitation of anesthesiologists by other anesthesiologists
is improper. For example, in group practice, after a reasonable
trial period to determine acceptability, each anesthesiologist
should generally receive income that is relatively proportionate
to the service rendered for the group.
This Statement of Policy contains principles formally adopted
by and strongly advocated by this Society.
Neither acceptance of nor adherence to this Statement of Policy
is a condition of any privilege of membership in the Society,
and the adoption and publication of this Statement of Policy is
not intended to interfere with any member's exercise of independent
judgment. Each member of the Society, however, is urged to consider
the principles stated herein as they apply to the member's own
medical practice.
THE ANESTHESIA CARE TEAM
The Anesthesia Care Team
(Approved by House of Delegates on October 26, 1982, and last amended on October 25, 1995)
Anesthesiology is a recognized specialty of medicine. Anesthesia care personally performed or medically directed by an anesthesiologist, a physician who has completed an approved residency in anesthesiology, constitutes the practice of medicine. Certain aspects of anesthesia care may be delegated to other properly trained professionals. These professionals, medically directed by the anesthesiologist, comprise the Anesthesia Care Team.
Such delegation and direction should be specifically defined by the anesthesiologist director of the Anesthesia Care Team and approved by the hospital medical staff. Although selected functions of overall anesthesia care may be delegated to appropriate members of the Anesthesia Care Team, responsibility and direction of the Anesthesia Care Team rest with the anesthesiologist.
The Society believes that the involvement of an anesthesiologist in the care of every patient undergoing anesthesia is essential. This may be accomplished through personal provision of anesthesia care or by medical direction of the Anesthesia Care Team.
Members of the medically directed Anesthesia Care Team may include physicians and nonphysician personnel.
A. Those who assist in providing direct patient care during the perioperative period, for example:
ANESTHESIOLOGY RESIDENT -- a physician who is presently in an approved anesthesiology residency program.
NURSE ANESTHETIST -- a registered nurse who has satisfactorily completed an approved nurse anesthesia training program.
ANESTHESIOLOGIST'S ASSISTANT -- a graduate physician's assistant who has satisfactorily completed an approved anesthesiologist's assistant training program.
B. Others who have patient care functions during the perioperative period include:
POSTANESTHESIA NURSE -- a nurse who cares for patients recovering from anesthesia.
CRITICAL CARE NURSE -- a nurse who cares for patients in a special care area such as the intensive care unit.
RESPIRATORY THERAPIST -- an allied health professional who provides respiratory care to patients.
C. Support personnel whose efforts deal with technical expertise, supply and maintenance, for example:
Anesthesia technologists and technicians
Anesthesia aides
Blood gas technicians
Respiratory technicians
Monitoring technicians
In order to apply the Anesthesia Care Team concept in a manner consistent with the highest standards of patient care, the following essentials should be observed:
1. Medical Direction: Anesthesia direction, management or instruction provided by an anesthesiologist whose responsibilities include:
a. Preanesthetic evaluation of the patient.
b. Prescription of the anesthesia plan.
c. Personal participation in the most demanding procedures in this plan, especially those of induction and emergence.
d. Following the course of anesthesia administration at frequent intervals.
e. Remaining physically available for the immediate diagnosis and treatment of emergencies.
f. Providing indicated postanesthesia care.
An anesthesiologist engaged in medical direction should not personally be administering another anesthetic and should use sound judgment in initiating other concurrent anesthetic and emergency procedures.
2. Delegation of any part of anesthesia care by an anesthesiologist to a member of the Anesthesia Care Team under the medical direction of the anesthesiologist should be fully disclosed.
3. Exploitation of patients, institutions, Anesthesia Care Team members, colleagues or payers is unethical. .
The American Society of Anesthesiologists believes that patient
care in anesthesiology will be enhanced through careful, unbiased
and objective evaluation of anesthesia practice and assessment
of quality. The Society urges its members to take an active role
in peer review at the local, regional and national level. As an
aid to peer review, quality and risk management, the ASA Committee
on Quality Improvement and Practice Management has developed the
following procedures for responding to requests to evaluate the
quality of anesthesia care and for recommending improvements where
indicated.
I. A request for consultation may be made by an anesthesiologist,
chief of medical staff, chief executive officer or hospital governing
body. In all instances, there must be an expression of agreement
to such consultative services by BOTH the hospital chief executive
officer and either the director of anesthesiology or the chief
of the medical staff.
II. The request may be made through the ASA Executive Office at
520 N. Northwest Highway, Park Ridge, Illinois 60068-2573. The
request will be forwarded to the Chair of the Committee on Quality
Improvement and Practice Management (or designee) who will appoint
an ad hoc subcommittee consisting of qualified ASA members. No
member shall serve on the subcommittee when such person's service
would involve a conflict of interest.
III. The consultation consists of a site visit by the ad hoc subcommittee.
The subcommittee will prepare a detailed written analysis of the
quality of anesthesia care and the strengths and weaknesses ofthe
department and its practices. The consultation consists of the
following:
A. Interviews with appropriate members of the medical, nursing
and administrative staffs;
B. Inspection of hospital charts, anesthesia records and other
documents;
C. Concurrent review (observation of practice);
D. Quality improvement and practice management based on the principles
contained in the latest edition of the ASA publication: "Manual
for Anesthesia Department Organization and Management."
A confidential formal report shall be sent to the requesting parties
by the Chair of the Committee on Quality Improvement and Practice
Management. This report will state the results of the consultation
and may, if appropriate, contain recommendations.
IV. In exceptional circumstances when an informational, educational
or diagnostic consultation regarding a specified concern of anesthesiology
practice (e.g., department organization, implementation of a quality
assessment program, etc.) is requested, the Chair of the Committee
will appoint a qualified ASA member for the site visit. A verbal
analysis of the specified concern will be provided to the organization
at the conclusion of the site visit. (Should more than one consultant
or a written analysis be desired, the consultation will proceed
as in item III.
V. Within a year after the site visit, the Chair of the Committee
on Quality Improvement and Practice Management shall request from
the requesting parties an evaluation of the results of the consultation.
VI. Prior to the conduct of any consultative visit, the Chair
of the Committee on Quality Improvement and Practice Management
and the requesting parties shall enter into an agreement which
provides for the payment of consultation fees and expenses covering
such other items as legal counsel for the ASA shall deem appropriate
and advisable.
Members of ASA are encouraged to serve the interests of the specialty
and its practitioners by participating in activities of the Society.
Participation includes, but is not limited to serving as a member
of an ASA committee, as an ASA representative to another organization
or as one of the Society's directors or officers. All of these
represent positions of trust and require the exercise of independent
personal judgment.
When ASA members agree to serve in any of these capacities, they
are expected to avoid involving themselves in conflicts, or apparent
conflicts, between their duties to the Society and personal interests
or duties they may have to other organizations. A conflict of
interest may not disqualify an individual from rendering service
to ASA, but may necessitate an alteration in the member's duties
or disclosure of the conflict or apparent conflict so that the
words or deeds of the member can be evaluated by others.
It is not possible to define all circumstances in which such a
conflict of interest may arise. A conflict of interest can be
assumed to exist when an ASA member or someone in the member's
immediate family is involved in a relationship or arrangement,
the terms of which may be inconsistent with, or appear to be inconsistent
with performance of the member's duties or exercise of judgment
on the Society's behalf. A conflict may also involve exploitation
of a member's position with the Society for the purpose of contemporaneous
financial gain.
To avoid such conflicts or apparent conflicts and to avoid exploitation
of an office, the Society maintains a mechanism by which members
nominated for or holding ASA positions, or serving on the executive
staff, are required to provide the Society with information which
may bear upon the member's capacity to perform contemplated duties
and exercise independent judgment on the Society's behalf. The
Society also requires that lecturers at ASA-sponsored scientific
meetings disclose arrangements which could be viewed as affecting
the objectivity of the lecturer's presentation.
Avoidance of conflicts requires constant sensitivity to the issue
by all members and a willingness to disclose potential conflicts
for review and appropriate resolution.
Documentation is a factor in the provision of quality care and
is the responsibility of an anesthesiologist. While anesthesia
care is a continuum, it is usually viewed as consisting of preanesthesia,
perianesthesia and postanesthesia components. Anesthesia care
should be documented to reflect these components and to facilitate
review.
The record should include documentation of:
I. Preanesthesia Evaluation*
A. Patient interview to review:
1. Medical history
2. Anesthesia history
3. Medication history
B. Appropriate physical examination.
C. Review of objective diagnostic data (e.g., laboratory, ECG,
Xray).
D. Assignment of ASA physical status.
E. Formulation and discussion of an anesthesia plan with the patient
and/or responsible adult.
II. Perianesthesia (time-based record of events)
A. Immediate review prior to initiation of anesthetic procedures:
1. Patient reevaluation
2. Check of equipment, drugs and gas supply vital signs).
B. Monitoring of the patient** (e.g., recording of vital signs.
C. Amounts of all drugs and agents used, and times given.
D. The type and amounts of all intravenous fluids used, including
blood and blood products, and times given.
E. The technique(s) used.
F. Unusual events during the anesthesia period.
G. The status of the patient at the conclusion of anesthesia.
III. Postanesthesia
A. Patient evaluation on admission and discharge from the postanesthesia
care unit.
B. A time-based record of vital signs and level of consciousness.
C. All drugs administered and their dosages.
D. Type and amounts of intravenous fluids administered, including
blood and blood products.
E. Any unusual events including postanesthesia or postprocedural
complications.
F. Postanesthesia visits.
*See Basic Standards for Preanesthesia Care
**See Standards for Basic Anesthetic Monitoring
Pursuant to Congressional mandate, the Health Care Financing Administration
is currently conducting studies to determine the feasibility of
reimbursing inpatient physician services to Medicare patients
by use of a "diagnosis-related group" (DRG) methodology.
In essence this methodology as applied to physicians would likely
involve the payment by HCFA of a single prospectively determined
amount for all physician services rendered in connection with
a particular inpatient medical procedure, and would require allocation
of such amount among the various participating physicians on a
basis determined by the hospital administrator, the hospital medical
staff or the primary care physician.
Over a period of many years, this Society has dedicated significant
resources to the development and acceptance of the relative value
guide methodology involving both procedure and time units as the
most appropriate basis, both from the point of view of the patient
and the anesthesiologist, for measuring the anesthesiolgist's
specific contribution to the patient's care. This methodology
also reflects the fact that the nature and complexity of anesthesia
care in a given procedure is essentially unrelated to the nature
and complexity of care rendered by other physicians participating
in that procedure.
In light of its historical and present commitment to the RVG methodology,
ASA opposed the development of any DRG payment scheme for physician
services to Medicare inpatients which does not permit anesthesiologists
to charge for their services on the basis of an RVG methodology
specifically designed to describe the particular services rendered
by anesthesiologists, as distinct from other physicians.
The American Society of Anesthesiologists believes that the granting,
renewal and termination of medical staff privileges should be
based upon quality of professional care considerations only, and
should occur pursuant to procedures set forth in the medical staff
bylaws. The Society condemns the practice known as "economic
credentialing," by which decisions related to medical staff
privileges are based on considerations unrelated to quality of
care.
Economic credentialing can take a variety of forms in addition
to economic profiling, including the conditioning of medical staff
privileges on the making of direct or indirect payments to the
hospital or its agents in amounts that exceed the fair market
value of facilities or services provided to the medical staff
member, or the conditioning of privileges on the requirement that
members of a particular department of the medical staff accept
less than fair market value for the provision of care to patients
in the hospital.
The Society believes that anesthesiologists should not, as a condition
of medical privileges, be compelled to purchase goods or services
at more than fair market value nor to provide their services at
less than fair market value. The Society also believes that quality
of care issues involved in the privileging process should be exclusively
dealt with by the medical staff, and that medical staff privileges
should be granted, renewed or terminated only upon recommendation
of the medical staff.
A major contribution to the current practice of medicine is made
by the galaxy of monitoring equipment and techniques developed
in the past two decades. They have played a vital role in improving
our ability to prevent and to recognize and treat many conditions
that previously contributed to morbidity and mortality.
These techniques, particularly those involving insertion of central
venous pressure (CVP) monitoring lines, intra-arterial catheters
(Alines) and Swan-Ganz catheters (PA lines), all carry with their
application some varying degree of risk to the patient.
This statement attempts to minimize such risk by outlining our
position on the provision of such procedures in the delivery of
anesthesia care by Anesthesia Care Team personnel:
A. The decision to use invasive monitoring is a medical judgment
and should, therefore, be made only by a qualified physician.
B. Invasive monitoring techniques should be prescribed by a physician.
Depending upon its risk, each should be applied only by a competent
and trained physician, or under the personal and immediate medical
direction of such a competent and responsible physician.
C. Training and credentialing of nonphysician members of the Anesthesia
Care Team who may perform invasive monitoring techniques should
be approved at the local medical staff level by the anesthesia
department and the active medical staff.
D. Some of the invasive monitoring tasks, namely the insertion
of CVP lines placed via the upper extremity and of arterial lines
(A-lines), may be delegated to properly trained and credentialed
members of an Anesthesia Care Team. Performance, however, sould
be under the immediate and personal medical direction of the leader
of the Team, preferably an anethesiologist.
E. Insertion of pulmonary artery catheters is a relatively hazardous
procedure and should only be done by a properly trained physician.
The phrase "Monitored Anesthesia Care" refers to instances
in which an anesthesiologist has been called upon to provide specific
anesthesia services to a particular patient undergoing a planned
procedure, in connection with which a patient receives local anesthesia
or, in some cases, no anesthesia at all. In such a case, the anesthesiologist
is providing specific services to the patient and is in control
of the patient's nonsurgical or nonobstetrical medical care, including
the responsibility of monitoring of the patient's vital signs,
and is available to administer anesthetics or provide other medical
care as appropriate.
The preamble to the Medicare TEFRA regulations specifically acknowledges
that "Standby Anesthesia" is, under these circumstances,
a physician service to the individual patient and thus reimbursable
under Medicare Part B. HCFA Transmittal No. 1001, amending the
Medicare Carriers Manual, advises carriers under these circumstances
to provide for reimbursement of Standby Anesthesia "the same
as for any other anesthesia procedure," that is (as also
provided in Transmittal No. 1001), on the basis of (a) procedure-specific
base unit values, and (b) additional units to take into account
time, risk and patient age. These provisions are to apply when
a physician is physically present in the operating suite monitoring
the patient's condition, making medical judgments regarding the
patient's anesthesia needs and ready to furnish anesthesia services
as necessary. There is no suggestion in either TEFRA regulations
or in Transmittal No. 1001 that this type of service is a "reduced
service" or should be the subject of reduced reimbursement,
either in terms of procedural or time units, or risk modifiers.
Unfortunately, use of the broad term "Standby" Anesthesia
has led some third-party payers mistakenly to conclude that reduced
services are somehow involved.
This misunderstanding has resulted in proposals for third-party
reimbursement at a level below that of the more classical anesthesia
services, namely, the provision of general or regional anesthesia
to provide pain relief during a surgical or obstetric procedure.
Such reduction has recently been made or proposed by a number
of Medicare carriers. To permit this pattern of reduced reimbursement
to prevail creates a potential for reduced availability of services
to Medicare patients as well as less than adequate care for many
such patients at risk, not only because of advanced age but because
of complicating medical problems.
The American Society of Anesthesiologists (ASA) believes the participation
of an anesthesiologist in the case of an individual patient under
circumstances such as those described in Transmittal No. 1001
is often critical to the provision of sound medical care and should
be subject to reimbursement at the same level as if a general
or regional anesthetic had in fact been administered. ASA also
recognizes, however, that this is an area which may involve the
provision of anesthesia care where it may not be necessary, given
the circumstances of an individual case. ASA believes that proper
resolution of this problem requires, not "across the board"
reduction in physician reimbursement, but rather a more precise
outline of the circumstances under which such care is medically
necessary and therefore fully reimbursable.
ASA would propose that the phrase "Monitored Anesthesia Care,"
as defined in ASA's policy below, be henceforth utilized so as
to eliminate any confusion or misunderstanding.
ASA would propose that anesthesiologists be as adequately reimbursed
as for any other anesthesia service when such "Monitored
Anesthesia Care" is provided to Medicare patients.
DEFINITION OF SERVICES
1. The service shall be requested by the attending physician and
be made known to the patient, in accordance with accepted procedures
of the institution.
2. The service shall include:
a. Performance of a preanesthetic examination and evaluation.
b. Prescription of the anesthesia care required.
c. Personal participation in, or medical direction of, the entire
plan of care.
d. Continuous physical presence of the anesthesiologist or, in
the case of medical direction, of the resident or nurse anesthetist
being medically directed.
e. Proximate presence or (in the case of medical direction) availability
of the anesthesiologist for diagnosis or treatment of emergencies.
3. All institutional regulations pertaining to anesthesia services
shall be observed, and all the usual services performed by the
anesthesiologist shall be furnished, including but not limited
to:
a. Usual noninvasive cardiocirculatory and respiratory monitoring.
b. Oxygen administration, when indicated.
c. Intravenous administration of sedatives tranquilizers, antiemetics,
narcotics, other analgesics, beta-blockers, vasopressors, bronchodilators,
antihypertensives or other pharmacologic therapy as may be required
in the judgment of the anesthesiologist.
REIMBURSEMENT OF SERVICES
1. In the event the foregoing services are performed, then full
reimbursement shall be made, as if general or regional anesthesia
had been administered.
2. Full reimbursement shall be deemed to include application of
the appropriate conversion factor to the proper procedural units,
time units, and age and risk modifier units, as if a general or
regional anesthetic had been administered, utilizing the current
Relative Value Guide.
It is the official policy of The American Society of Anesthesiologists,
Inc. that anesthesiologists are free to choose whatever arrangement
they prefer for compensation of their professional services. The
Society does not consider the compensation arrangement so chosen
to be a matter of professional ethics.
Experience has shown that anesthesiology has encountered problems
individual to it relating to the quality and standards of patient
care which are due in part to practice arrangements between hospitals
and anesthesiologists and between anesthesiologists themselves.
In response to these problems, the American Society of Anesthesiologists
has adopted a Statement of Policy which contains principles that
the Society urges its members to consider in structuring their
own individual medical practices.*
Provision of quality anesthesia care for the patient requires
that individual medical practices within the context of the individual
hospital be organized for administrative purposes into a functioning
entity, or department, which is managed and operated in a manner
that will facilitate the patient's access to quality anesthesia
care and promote the efficient fulfillment of the responsibilities
of individual physicians and the hospital's administration to
the patient and the community. Because of the diversity of local
conditions, no single framework for the organization and management
of a department of anesthesia that is suited to all situations
can be recommended. However, the organization of the department
of anesthesia should be consistent with the organization of the
hospital's other clinical departments and should assure the availability
of qualaity anesthesia care where and when needed in the hospital.
In addition, the following suggestions should be considered in
addressing the practical problems of organizing and managing an
anesthesia department that has quality patient care as its primary
goal.
I. PHYSICIAN RESPONSIBILITIES FOR MEDICAL CARE
Since the quality of care in anesthesia depends in large measure
upon the role of the physician in rendering such care, the proper
definition of the responsibilities of individual physicians in
the provision of medical care is the starting point in the organization
of an anesthesia department. Such definition should take into
account the following principles.
A. Anesthesia care is the practice of medicine.An anesthesiologist
must be personally responsible to each patient for the provision
of anesthesia care.An anesthesiologist exercises the same independent
medical judgment on behalf of the patient as is exercised by other
physicians.
B. The anesthesiologist's responsibilities to the patient should
include responsibility for preanesthetic evaluation and care,
medical management of the anesthetic procedure and of the patient
during surgery, postanesthetic evaluation and care, and medical
direction of any nonphysician who assists in providing anesthesia
care to the patient. The anesthesiologist should fulfill these
responsibilities to the patient in accordance with the ASA Guidelines
for the Ethical Practice of Anesthesiology and Guidelines for
Patient Care in Anesthesiology.
C. As a member of the hospital medical staff, an anesthesiologist
is subject to and must observe, as well as be accorded the benefits
of, the medical staff bylaws, rules and regulations generally
applicable to all physicians granted privileges in the hospital.
Additional rights and responsibilities may arise from rules and
regulations specifically applicable to physicians in the department
of anesthesia.
D. An anesthesiologist with full staff privileges must share on
a fair and equitable basis in the responsibility for assuring
24-hour-a-day, 7day-a-week availability of anesthesia care.
II. MEDICO-ADMINISTRATIVE ORGANIZATION AND RESPONSIBILITIES
The department of anesthesia has the responsibility to promote
and ensure patient access to quality care in anesthesia and the
optimal utilization of hospital facilities. To fulfill this responsibility,
it is necessary to grant staff privileges to a sufficient number
of qualified physicians to assure the existence of patient access
to quality anesthesia care and optimal utilization of facilities.
Additionally, the anesthesia department must develop a practicable
system that will assure the constant personal availability of
a member of the department. The department must also monitor and
enforce adherence to standards of care, the medical staff bylaws
and the rules and regulations particularly applicable to the anesthesia
staff. The discharge of these administrative responsibilities
should be guided by the following principles:
A. The assumption and performance of medicoadministrative responsibilities,
though for the ultimate benefit of patients, are undertaken on
behalf of, and as the agent for, the hospital. The fact that a
physician has medicoadministrative responsibilities should not
affect that physician's, or any other physician's, individual
responsibilities to patients or the physician's rights under the
medical staff bylaws.
B. All members of the staff should share in the discharge of medico-administrative
responsibilities to the extent necessary or appropriate.
C. Administration of the anesthesia department should be directed
by a qualified anesthesiologist member of the medical staff. The
director should be elected or appointed in the same manner as
the directors of the other clinical departments in the hospital.
D. The director of the anesthesia department should be responsible
for the following medico-administrative functions in a manner
similar to directors of other clinical departments and should
be a permanent voting member of the Executive Committee.
1. Recommending clinical privileges for all individuals with primary
anesthesia responsibilities. Privileges should be processed through
established medical staff channels, be based solely on qualifications
and competence, and be conditioned upon observance of the medical
staff bylaws and the rules and regulations governing the anesthesia
department. Privileges should be delineated in accordance with
the ASA Guidelines for Delineation of Clinical Privileges in Anesthesiology
and the Guidelines for Delegation of Technical Anesthesia Functions
to Nonphysician Personnel.
2. Monitoring the quality of anesthesia care rendered throughout
the hospital, including surgical, obstetrical, emergency, outpatient,
psychiatric and special procedures areas.The ASA Documentation
of Anesthesia Care should be followed in order to provide the
factual basis for such monitoring.
3. Recommending to the hospital administration and medical staff
the type and amount of equipment and supplies necessary for administering
anesthesia and for resuscitation.
4. Developing regulations concerning anesthetic safety.
5. Ensuring evaluation of the quality of anesthesia care throughout
the hospital.
6. Establishing a program of continuing education for all personnel
having anesthesia privileges, such program to include in-service
training and to be based in part on the results of the evaluation
of anesthesia care. Such program should follow the ASA Guidelines
for a Minimally Acceptable Program of Any Continuing Education
Requirement.
7. Participating in the development of, and enforcing policies
and procedures relating to the functioning of anesthesia personnel
and the administration of anesthesia throughout the hospital.
8. Ensuring that qualified anesthesia personnel are available
for the daily surgical schedule and providing a schedule for 24-hour,
7-day-a-week availability of anesthesia care. Scheduling may be
coordinated by the director or may be accomplished directly by
scheduling between surgeons and anesthesiologists or indirectly
by surgeons through the person responsible for developing the
surgical schedule. Any scheduling mechanism should accommodate
patient requests for specific anesthesiologists.
E. A description of the details of the operation of the anesthesia
department, including all policies and procedures applicable to
personnel in the department, should be compiled in a single set
of rules and regulations or in a procedure and policy manual.
Such policies and procedures must be consistent with the medical
staff bylaws, the hospital charter and administrative regulations
and local law, and should be based upon the ASA Manual for Anesthesia
Department Organization and Management and other ASA guidelines
and suggestions, adapted to suit local conditions.
*It is the official policy of the Society that all anesthesiologists
are free to choose whatever arrangement they prefer for compensation
of their professional services. The Society does not consider
the compensation arrangement so chosen to be a matter of professional
ethics. In addition. anesthesiologists' compensation arrangements
shall not affect their eligibility to attain or retain membership
in this Society or any of its Component Societies.
In any event, the department of anesthesia must not be operated
in a manner which restricts the patient's access to quality care
or inhibits the development of the specialty of anesthesiology.
There has been an increased interest in the question of whether
nurse anesthetists and other nonphysicians should be trained and
permitted to perform spinal and other regional anesthesia procedures.
While the permissible scope of practice by nurses and other nonphysicians
is a matter to be determined by appropriate licensing and credentialing
authorities, the Committee on Anesthesia Care Team believes that
it is appropriate for the Society, as an organization of physicians
dedicated to enhancing the safety and quality of anesthesia care,
to state its views concerning the responsibilities of anesthesiologists
for patient care in anesthesia and the role of nonphysicians in
participating in such care. The Committee believes that these
views are well and adequately set forth in guidelines and policy
statements adopted by the House of Delegates.
These guidelines and policy statements emphasize that anesthesiology
is the practice of medicine and thatanesthesia, in all its forms,
should be administered by, or under the medical direction of,
a physician who is trained in the administration of anesthesia,
preferably an anesthesiologist. Accordingly, anesthesiologists
should assume responsibility for all aspects of anesthesia care,
including obstetrical anesthesia, outpatient anesthesia and anesthesia
for emergency surgery. Spinal and other regional anesthesia procedures
involve diagnostic assessment, indications, contraindications,
the prescription of drugs, and the institution of corrective measures
and treatment in response to complications, and are not merely
technical parts of patient care. In common with other medical
practices, these procedures require a sound basic science background
and experienced medical judgment.Regional anesthesia should be
performed only by an anesthesiologist or other physician trained
in the administration of anesthesia.
Anesthesiology is the practice of medicine which includes the
personal performance or medical direction of anesthesia and respiratory
care. Respiratory care practitioners (technicians and therapists)
should provide respiratory care only under the medical direction
of an anesthesiologist or other qualified physician. The American
Society of Anesthesiologists believes that all personnel providing
direct patient care must possess appropriate qualifications and
competence. To accomplish this, the Society enthusiastically supports
the efforts of the Joint Review Committee for Respiratory
Therapy Education and the National Board for Respiratory Care
to provide accredited educational programs and national credentials
for respiratory care practitioners.
Several states have enacted legislation, and more are considering
legislation which credentials respiratory care practitioners by
establishing a state licensing system. Any legislation relating
to the credentialing of respiratory care practitioners, whether
or not providing for formal licensure, should be consistent with
the following principles:
1. The scope of practice is defined.
2. The practice should be permitted only under medical direction
of an anesthesiologist or other qualified physician.
3. The minimum standards for education, training and competency
should be consistent and compatible with existing national standards
of nongovernment credentialing of these practitioners.
The American Society of Anesthesiologists supports state credentialing
systems that are based upon these principles. When called upon
to assist with proposed legislation involving the credentialing
of respiratory care practitioners, Component Societies of this
Society are urged to support through testimony and legislative
advocacy any proposed credentialing statute that is consistent
with the previously stated principles. The document titled "A
Model State Respiratory Care Practice Act," as approved by
the American Association for Respiratory Care Board of Directors
on April 18, 1986, is in conformity with this statement.
(Approved by House of Delegates on October 14,1987 and last amended
on October 13,1993)
Preanesthetic laboratory and diagnostic testing is often essential;
however, no routine* laboratory or diagnostic screening test is
necessary for the preanesthetic evaluation of patients. Appropriate
indications for ordering tests include the identification of specific
clinical indicators or risk factors (e.g., age, pre-existing disease,
magnitude of the surgical procedure). Anesthesiologists anesthesiology
departments or health care facilities should develop appropriate
guidelines for preanesthetic screening tests in selected populations
after considering the probable contribution of each test to patient
outcome. Individual anesthesiologists should order test(s) when,
in their judgment, the results may influence decisions regarding
risks and management of the anesthesia and surgery. Legal requirements
for laboratory testing where they exist should be observed. The
results of tests relevant to anesthetic management should be reviewed
prior to initiation of the anesthetic. Relevant abnormalities
should be noted and action taken, if appropriate.
* Routine refers to a policy of performing a test or tests without
regard to clinical indications in an individual patient.
Screening means efforts to detect disease in unselected populations
of asymptomatic patients.
In the event a member of the American Society of Anesthesiologists
believes that the member is being denied the opportunity to provide
anesthesia care in violation of contractual or other legal rights,
the member may seek, through the member's Component Society, the
assistance of the Society's legal counsel on such terms as the
ASA President in each case shall approve.
In normal circumstances, assistance by the Society's legal counsel
shall be limited to providing, at the Society's expense, technical
assistance to the attorney for the member in question, and such
assistance may be provided on approval of the President only.
In the event that it is proposed that more extensive assistance
be given, such as filing of an amicus cunae brief or actual participation
in the case, then such assistance will be given only on recommendation
of the pertinent Component Society and upon approval of the ASA
Administrative Council.
Subject to determination that no conflict of interest exists,
nothing herein shall be construed as preventing the Society's
legal counsel, on recommendation of the pertinent Component Society,
from providing assistance to such member at the member's expense
or at the expense of the Component Society.
Copyright (c)1996 American Society of Anesthesiologists. All
rights reserved.
