Guidelines for the Anesthesia Services Condition of Participation

CMS Manual System

Department of Health &

Human Services (DHHS)

Pub. 100-07 State Operations

Provider Certification

Centers for Medicare &

Medicaid Services (CMS)

Transmittal 59

Date: May 21, 2010

SUBJECT: Clarification of the Interpretive Guidelines for the Anesthesia Services

Condition of Participation

I. SUMMARY OF CHANGES: Revisions to Appendix A, “Survey Protocol, Regulations and

Interpretive Guidelines for Hospitals.” This instruction updates and clarifies the guidance for the

Anesthesia Services Condition of Participation and related standards.

NEW/REVISED MATERIAL - EFFECTIVE DATE*: May 21, 2010

IMPLEMENTATION DATE: May 21, 2010

The revision date and transmittal number apply to the red italicized material only. Any other

material was previously published and remains unchanged.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual not updated.)

(R = REVISED, N = NEW, D = DELETED) – (Only One Per Row.)

R/N/D

CHAPTER/SECTION/SUBSECTION/TITLE

Appendix A/§482.52/Condition of Participation Anesthesia Services/

Tag A-1000

Appendix A/§482.52(a)/Standard: Organization and Staffing/Tag A-1001

Appendix A/§482.52(b)/Standard: Delivery of Services/Tag A-1002

Appendix A/§482.52(b)(1)/Standard: Pre-anesthesia Evaluation/Tag A-1003

Appendix A/§482.52(b)(2)/Standard: Intraoperative Anesthesia Record/Tag A

1004

Appendix A/§482.52(b)(3)/Standard: Post-anesthesia Evaluation/Tag A-1005

III. FUNDING: No additional funding will be provided by CMS; contractor activities are

to be carried out within their operating budgets.

IV. ATTACHMENTS:

Business Requirements

Manual Instruction

Confidential Requirements

One-Time Notification

One-Time Notification -Confidential

Recurring Update Notification

*Unless otherwise specified, the effective date is the date of service.

A-1000

(Rev.59, Issued: 05-21-10, Effective/Implementation: 05-21-10)

§482.52 Condition of Participation: Anesthesia Services

If the hospital furnishes anesthesia services, they must be provided in a well-organized

manner under the direction of a qualified doctor of medicine or osteopathy. The service is

responsible for all anesthesia administered in the hospital.

Interpretive Guidelines §482.52

The provision of anesthesia services is an optional hospital service. However, if a hospital

provides any degree of anesthesia service to its patients, the hospital must comply with all the

requirements of this Condition of Participation (CoP).

“Anesthesia” involves the administration of a medication to produce a blunting or loss of:

• pain perception (analgesia);

• voluntary and involuntary movements;

• autonomic function; and

• memory and/or consciousness,

depending on where along the central neuraxial (brain and spinal cord) the medication is

delivered.

In contrast, “analgesia” involves the use of a medication to provide relief of pain through the

blocking of pain receptors in the peripheral and/or central nervous system. The patient does not

lose consciousness, but does not perceive pain to the extent that may otherwise prevail.

The additional definitions below illustrate differences among the various types of anesthesia

services. Not all of the definitions are considered “anesthesia.” The definitions are generally

based on American Society of Anesthesiologists definitions found in its most recent set of

practice guidelines (Anesthesiology 2002; 96:1004-17). In addition, a visual representation of

these terms is displayed on the next page.

“Anesthesia services” in a hospital subject to the anesthesia administration requirements at 42

CFR 482.52(a):

• General Anesthesia: a drug-induced loss of consciousness during which patients are not

arousable, even by painful stimulation. The ability to independently maintain ventilatory

support is often impaired. Patients often require assistance in maintaining a patent airway,

and positive pressure ventilation may be required because of depressed spontaneous

ventilation or drug-induced depression of neuromuscular function. Cardiovascular function

may be impaired. For example, a patient undergoing major abdominal surgery involving the

Hospital

Anesthesia Services

Anesthesia

• General

• Regional

• MAC

• Deep Sedation

Analgesia/Sedation

• Topical

• Local

• Minimal

• Moderate

To be administered

by appropriately

trained medical

practitioner within

scope of practice

To be administered

by anesthesiologist,

qualified physician,

CRNA or anesthesia

assistant as specified

§482.52(a)

Rescue Capacity

Opt-Out State?

No MD super-

vision required for

CRNA

MD supervision

required for

CRNA

Yes

Note: analgesia via

epidurals/spinals for Labor

& Delivery is permitted to

be administered by

CRNAs without MD

supervision.

removal of a portion or all of an organ would require general anesthesia in order to tolerate

such an extensive surgical procedure. General anesthesia is used for those procedures when

loss of consciousness is required for the safe and effective delivery of surgical services;

• Regional Anesthesia: the delivery of anesthetic medication at a specific level of the spinal

cord and/or to peripheral nerves, including epidurals and spinals and other central

neuraxial nerve blocks, is used when loss of consciousness is not desired but sufficient

analgesia and loss of voluntary and involuntary movement is required. Given the potential

for the conversion and extension of regional to general anesthesia in certain procedures, it is

necessary that the administration of regional and general anesthesia be delivered or

supervised by a practitioner as specified at 42 CFR 482.52(a).

The administration of medication via an epidural or spinal route for the purpose of

analgesia, during labor and delivery, is not considered anesthesia and therefore is not

subject to the anesthesia supervision requirements at 42 CFR 482.52(a). However, if the

obstetrician or other qualified physician attending to the patient determines that an operative

delivery (i.e., C-section) of the infant is necessary, it is likely that the subsequent

administration of medication is for anesthesia, as defined above, and the anesthesia

supervision requirements at 42 CFR 482.52(a) would apply.

• Monitored Anesthesia Care (MAC): anesthesia care that includes the monitoring of the

patient by a practitioner who is qualified to administer anesthesia as defined by the

regulations at §482.52(a). Indications for MAC depend on the nature of the procedure, the

patient’s clinical condition, and/or the potential need to convert to a general or regional

anesthetic. Deep sedation/analgesia is included in MAC.

- Deep sedation/analgesia: a drug-induced depression of consciousness during which

patients cannot be easily aroused but respond purposefully following repeated or

painful stimulation. The ability to independently maintain ventilatory function may

be impaired. Patients may require assistance in maintaining a patent airway, and

spontaneous ventilation may be inadequate. Cardiovascular function is usually

maintained. An example of deep sedation would be a screening colonoscopy when

there is a decision to use propofol, so as to decrease movement and improve

visualization for this type of invasive procedure. Because of the potential for the

inadvertent progression to general anesthesia in certain procedures, it is necessary

that the administration of deep sedation/analgesia be delivered or supervised by a

practitioner as specified in 42 CFR 482.52(a).

“Anesthesia services” in a hospital NOT subject to the anesthesia administration and

supervision requirements at 42 CFR 482.52(a):

• Topical or Local Anesthesia;

• Minimal Sedation: A drug-induced state during which patients respond normally to

verbal commands. Although cognitive function and coordination may be impaired,

ventilator and cardiovascular functions are unaffected. For example, a patient

undergoing an MRI or CT scan may receive minimal sedation with an oral

medication to decrease the anxiety while undergoing these types of radiologic

examinations;

• Moderate Sedation/Analgesia: (“Conscious Sedation”): A drug-induced depression

of consciousness during which patients respond purposefully to verbal commands,

either alone or accompanied by light tactile stimulation. No interventions are

required to maintain a patent airway, and spontaneous ventilation is adequate.

Cardiovascular function is usually maintained. For example, a patient undergoing

the reduction of a dislocated large joint (shoulder) may require this form of sedation

to tolerate the procedure.

• Rescue Capacity. Because sedation is a continuum, it is not always possible to

predict how an individual patient will respond. Hence, hospitals must ensure that

procedures are in place to rescue patients whose level of sedation becomes deeper

than initially intended, for example, patients who inadvertently enter a state of Deep

Sedation/Analgesia when moderate sedation was intended. “Rescue” from a deeper

level of sedation than intended requires an intervention by a practitioner with

expertise in airway management and advanced life support. The qualified

practitioner corrects the adverse physiologic consequences of the deeper-than-

intended level of sedation and returns the patient to the originally intended level of

sedation.

Anesthesia services throughout the hospital (including all departments in all campuses and off-

site locations where anesthesia services are provided) must be organized into one anesthesia

service, under the direction of a qualified doctor of medicine (MD) or doctor of osteopathy

(DO). Areas where anesthesia services are furnished may include (but are not limited to):

• Operating room suite(s), both inpatient and outpatient;

• Obstetrical suite(s);

• Radiology department;

• Clinics;

• Emergency department;

• Psychiatry department;

• Outpatient surgery areas; and

• Special procedures area (e.g., endoscopy suite, pain management clinic, etc.).

The hospital’s medical staff establishes criteria for the qualifications for the director of the

anesthesia services in accordance with State laws and acceptable standards of practice. The

anesthesia service is responsible for developing policies and procedures governing the provision

of all categories of anesthesia services, including specifying the minimum qualifications for each

category of practitioner who is permitted to provide anesthesia services that are not subject to

the anesthesia administration requirements at 42 CFR 482.52(a).

A well-organized anesthesia service must be integrated into the hospital’s required Quality

Assessment/Performance Improvement program, in order to assure the provision of safe care to

patients.

Survey Procedures §482.52

• Request a copy of the organizational chart for anesthesia services.

• Determine that a doctor of medicine or osteopathy has the authority and responsibility for

directing the administration of all anesthesia throughout the hospital.

• Look for evidence of the director’s appointment. Review the position description.

Confirm that the director’s responsibilities include at least the following:

- Planning, directing, and supervising all activities of the service;

- Establishing staffing schedules;

- Evaluating the quality and appropriateness of the anesthesia patient care;

• Review the hospital’s anesthesia policies and procedures.

- Do they address who may provide anesthesia services in each setting where such

services are furnished, and are these policies in compliance with the regulations?

- Do they apply in all hospital locations where anesthesia services are provided?

______________________________________________________________________________

A-1001

(Rev.59, Issued: 05-21-10, Effective/Implementation: 05-21-10)

§482.52(a) Standard: Organization and Staffing

The organization of anesthesia services must be appropriate to the scope of the services

offered. Anesthesia must be administered only by --

(1) A qualified anesthesiologist;

(2) A doctor of medicine or osteopathy (other than an anesthesiologist);

(3) A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia

under State law;

(4) A certified registered nurse anesthetist (CRNA), as defined in §410.69(b) of this

chapter, who, unless exempted in accordance with paragraph (c) of this section, is

under the supervision of the operating practitioner or of an anesthesiologist who is

immediately available if needed; or

(5) An anesthesiologist’s assistant, as defined in Sec. 410.69(b) of this chapter, who is

under the supervision of an anesthesiologist who is immediately available if

needed.

§482.52(c) Standard: State Exemption

(1) A hospital may be exempted from the requirement for MD/DO supervision of

CRNAs as described in paragraph (a)(4) of this section, if the State in which the

hospital is located submits a letter to CMS signed by the Governor, following

consultation with the State’s Boards of Medicine and Nursing, requesting

exemption from MD/DO supervision of CRNAs. The letter from the Governor

must attest that he or she has consulted with State Boards of Medicine and

Nursing about issues related to access to and the quality of anesthesia services in

the State and has concluded that it is in the best interests of the State’s citizens to

opt-out of the current MD/DO supervision requirement, and that the opt-out is

consistent with State law.

(2) The request for exemption and recognition of State laws, and the withdrawal of

the request may be submitted at any time, and are effective upon submission.

Interpretive Guidelines §482.52(a) and (c)

Who May Administer Anesthesia

Topical/local anesthetics, minimal sedation, moderate sedation

The requirements at §482.52(a) concerning who may administer anesthesia do not apply to the

administration of topical or local anesthetics, minimal sedation, or moderate sedation.

However, the hospital must have policies and procedures, consistent with State scope of practice

law, governing the provision of these types of anesthesia services. Further, hospitals must

assure that all anesthesia services are provided in a safe, well-organized manner by qualified

personnel.

General anesthesia, regional anesthesia and monitored anesthesia, including deep

sedation/analgesia, may only be administered by:

• A qualified anesthesiologist;

• An MD or DO (other than an anesthesiologist);

• A dentist, oral surgeon or podiatrist who is qualified to administer anesthesia under State

law;

• A CRNA who is supervised by the operating practitioner or by an anesthesiologist who is

immediately available if needed; or

• An anesthesiologist’s assistant under the supervision of an anesthesiologist who is

immediately available if needed.

Administration by an MD/DO/dentist/oral surgeon/podiatrist

The hospital’s anesthesia services policies must address the circumstances under which an MD

or DO who is not an anesthesiologist, a dentist, oral surgeon or podiatrist is permitted to

administer anesthesia. In the case of a dentist, oral surgeon or podiatrist, administration of

anesthesia must be permissible under State law and comply with all State requirements

concerning qualifications. Hospitals should conform to generally accepted standards of

anesthesia care when establishing policies governing anesthesia administration by these types of

practitioners as well as MDs or DOs who are not anesthesiologists.

Administration by a CRNA

Unless the hospital is located in a State that has chosen to opt out of the CRNA supervision

requirements, a CRNA administering general, regional and monitored anesthesia must be

supervised either by the operating practitioner who is performing the procedure, or by an

anesthesiologist who is immediately available.

Hospitals should conform to generally accepted standards of anesthesia care when establishing

policies for supervision by the operating practitioner. An anesthesiologist is considered

“immediately available” when needed by a CRNA under the anesthesiologist’s supervision only

if he/she is physically located within the same area as the CRNA, e.g., in the same operative/

procedural suite, or in the same labor and delivery unit, and not otherwise occupied in a way

that prevents him/her from immediately conducting hands-on intervention, if needed.

If the hospital is located in a State where the Governor has submitted a letter to CMS attesting

that he or she has consulted with State Boards of Medicine and Nursing about issues related to

access to and the quality of anesthesia services in the State and has concluded that it is in the

best interests of the State’s citizens to opt-out of the current physician supervision requirement,

and that the opt-out is consistent with State law, then a hospital may permit a CRNA to

administer anesthesia without operating practitioner or anesthesiologist supervision. (A list of

States that have opted out of the CRNA supervision requirement may be found at

http://www.cms.hhs.gov/CFCsAndCoPs/02_Spotlight.asp)

A CRNA is defined in §410.69(b) as a “registered nurse who:

(1) Is licensed as a registered professional nurse by the State in which the nurse

practices;

(2) Meets any licensure requirements the State imposes with respect to non-physician

anesthetists;

(3) Has graduated from a nurse anesthesia educational program that meets the

standards of the Council on Accreditation of Nurse Anesthesia Programs, or such

other accreditation organization as may be designated by the Secretary; and

(4) Meets the following criteria:

(i) Has passed a certification examination of the Council on Certification of

Nurse Anesthetists, the Council on Recertification of Nurse Anesthetists, or

any other certification organization that may be designated by the Secretary;

(ii) Is a graduate of a program described in paragraph (3) of this definition and

within 24 months after that graduation meets the requirements of paragraph

(4)(i) of this definition.”

Administration by an Anesthesiologist’s Assistant

An anesthesiologist’s assistant may administer anesthesia when under the supervision of an

anesthesiologist. The anesthesiologist must be immediately available if needed. An

anesthesiologist is considered “immediately available” to assist the anesthesiologist’s assistant

under the anesthesiologist’s supervision only if he/she is physically located within the same area

as the anesthesiologist’s assistant, e.g., in the same operative/procedural suite, or in the same

labor and delivery unit, and not otherwise occupied in a way that prevents him/her from

immediately conducting hands-on intervention, if needed.

An anesthesiologist’s assistant is defined at §410.69(b) as a “person who-

(1) Works under the direction of an anesthesiologist;

(2) Is in compliance with all applicable requirements of State law, including any

licensure requirements the State imposes on nonphysician anesthetists; and

(3) Is a graduate of a medical school-based anesthesiologist’s assistant education

program that –

(a) Is accredited by the Committee on Allied Health Education and Accreditation;

and

(b) Includes approximately two years of specialized basic science and clinical

education in anesthesia at a level that builds on a premedical undergraduate

science background.”

Anesthesia Services Policies

The medical staff bylaws or rules and regulations must include criteria for determining the

anesthesia service privileges to be granted to an individual practitioner and a procedure for

applying the criteria to individuals requesting privileges, as required by the regulations at §482.

22(c)(6) for any type of anesthesia services, including those not subject to the anesthesia

administration requirements at §482.52(a). The hospital’s governing body must approve the

specific anesthesia service privileges for each practitioner who furnishes anesthesia services,

addressing the type of supervision, if any, required. The privileges granted must be in

accordance with State law and hospital policy. The type and complexity of procedures for which

the practitioner may administer anesthesia must be specified in the privileges granted to the

individual practitioner. Deficiencies related to these requirements should be cited under §482.

22(c)(6).

When a hospital permits operating practitioners to supervise a CRNA administering anesthesia,

the medical staff bylaws or rules and regulations must specify for each category of operating

practitioner, the type and complexity of procedures that category of practitioner may supervise.

However, individual operating practitioners do not need to be granted specific privileges to

supervise a CRNA.

Survey Procedures §482.52(a) and (c)

• Review the qualifications of individuals authorized to administer general anesthesia,

regional anesthesia and monitored anesthesia, including deep sedation/analgesia to

determine if they satisfy the requirements at §482.52(a) and (c).

• Determine that there is documentation of current licensure and, as applicable, current

certification for all persons administering anesthesia.

• Determine if the state is an “opt-out state” and therefore permits CRNAs to administer

anesthesia without supervision in accordance with 482.52(c).

• Review the hospital’s policies and procedures governing supervision of CRNA’s and

anesthesiologist’s assistants, and determine whether they comply with the regulatory

requirements. and

• Review the qualifications of individuals authorized to furnish other anesthesia services,

to determine if they are consistent with the hospital’s anesthesia service policies.

_____________________________________________________________________________

A-1002

(Rev.59, Issued: 05-21-10, Effective/Implementation: 05-21-10)

§482.52(b) Standard: Delivery of Services

Anesthesia services must be consistent with needs and resources. Policies on anesthesia

procedures must include the delineation of preanesthesia and postanesthesia

responsibilities. The policies must ensure that the following are provided for each patient:

Interpretive Guidelines §482.52(b)

Anesthesia services must be delivered in a manner that is consistent with the needs and the

resources of the hospital. Anesthesia policies at a minimum must address:

• How the hospital’s anesthesia services needs will be met;

• Delivery of anesthesia services consistent with recognized standards for anesthesia care.

A well-designed anesthesia services policy would address issues such as:

• Patient consent;

• Infection control measures;

• Safety practices in all anesthetizing areas;

• Protocol for supportive life functions, e.g., cardiac and respiratory emergencies;

• Reporting requirements;

• Documentation requirements;

• Equipment requirements, as well as the monitoring, inspection, testing, and

maintenance of anesthesia equipment in the hospital’s biomedical equipment

program.

• Delineation of pre- and post-anesthesia staff responsibilities

Survey Procedures §482.52(b)

Review the policies developed on anesthesia procedures. Determine whether the anesthesia

service policies for delivery of care address the issues identified in interpretive guidelines.

________________________________________________________________________

A-1003

(Rev.59, Issued: 05-21-10, Effective/Implementation: 05-21-10)

[The policies must ensure that the following are provided for each patient:]

§482.52(b) (1) - A pre-anesthesia evaluation completed and documented by an individual

qualified to administer anesthesia, as specified in paragraph (a) of this section, performed

within 48 hours prior to surgery or a procedure requiring anesthesia services.

Interpretive Guidelines §482.52(b)(1)

A pre-anesthesia evaluation must be performed for each patient who receives general, regional

or monitored anesthesia. While current practice dictates that the patient receiving moderate

sedation be monitored and evaluated before, during, and after the procedure by trained

practitioners, a pre-anesthesia evaluation is not required because moderate sedation is not

considered to be “anesthesia”, and thus is not subject to this requirement.

The evaluation must be performed by someone qualified to administer anesthesia as specified in

§482.52(a), i.e., only by:

• A qualified anesthesiologist;

• A doctor of medicine or osteopathy (other than an anesthesiologist);

• A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under

State law;

• A certified registered nurse anesthetist (CRNA), who, unless exempted in accordance

with paragraph (c) of this section, is under the supervision of the operating practitioner

or of an anesthesiologist who is immediately available if needed; or

• An anesthesiologist’s assistant who is under the supervision of an anesthesiologist who is

immediately available if needed.

Although §482.12 (c)(1)(i) provides broad authority to physicians to delegate tasks to other

qualified medical personnel, the more stringent requirements at §482.52(b)(1) do not permit

delegation of the pre-anesthesia evaluation to practitioners who are not qualified to administer

anesthesia.

The pre-anesthesia evaluation must be performed within 48 hours prior to any inpatient or

outpatient surgery or procedure requiring anesthesia services. The delivery of the first dose of

medication(s) for the purpose of inducing anesthesia, as defined above, marks the end of the 48

hour time frame.

In accordance with current standards of anesthesia care, the pre-anesthesia evaluation of the

patient includes, at a minimum:

• Review of the medical history, including anesthesia, drug and allergy history;

• Interview and examination of the patient;

• Notation of anesthesia risk according to established standards of practice (e.g., ASA

classification of risk);

• Identification of potential anesthesia problems, particularly those that may suggest

potential complications or contraindications to the planned procedure (e.g., difficult

airway, ongoing infection, limited intravascular access);

• Additional pre-anesthesia evaluation, if applicable and as required in accordance with

standard practice prior to administering anesthesia (e.g., stress tests, additional

specialist consultation);

• Development of the plan for the patient’s anesthesia care, including the type of

medications for induction, maintenance and post-operative care and discussion with the

patient (or patient’s representative) of the risks and benefits of the delivery of anesthesia.

Survey Procedures §482.52(b)(1)

• Review a sample of inpatient and outpatient medical records for patients who had surgery

or a procedure requiring administration of anesthesia.

• Determine whether each patient had a pre-anesthesia evaluation by a practitioner

qualified to administer anesthesia.

• Determine whether each patient’s pre-anesthesia evaluation included at least the

elements described above.

• Determine that the pre-anesthesia evaluation was performed within 48 hours prior to the

delivery of the first dose of medication(s) given for the purpose of inducing anesthesia for

the surgery or a procedure requiring anesthesia services.

_____________________________________________________________________________

A-1004

(Rev.59, Issued: 05-21-10, Effective/Implementation: 05-21-10)

[The policies must ensure that the following are provided for each patient:]

§482.52(b)(2) - An intraoperative anesthesia record.

Interpretive Guidelines §482.52(b)(2)

There must be an intraoperative anesthesia record or report for each patient who receives

general, regional or monitored anesthesia. While current practice dictates that the patient

receiving moderate sedation be monitored and evaluated before, during, and after the procedure

by trained practitioners, an intraoperative anesthesia report is not required because, as

explained above , moderate sedation is not “anesthesia”. Current standard of care stipulates

that an intraoperative anesthesia record, at a minimum, includes:

• Name and hospital identification number of the patient;

• Name(s) of practitioner(s) who administered anesthesia, and as applicable, the name and

profession of the supervising anesthesiologist or operating practitioner;

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

• Techniques(s) used and patient position(s), including the insertion/use of any

intravascular or airway devices;

• Name and amounts of IV fluids, including blood or blood products if applicable;

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

parameters; and

• Any complications, adverse reactions, or problems occurring during anesthesia,

including time and description of symptoms, vital signs, treatments rendered, and

patient’s response to treatment.

Survey Procedures §482.52(b)(2)

Review records to determine that each patient has an intraoperative anesthesia record that

includes the elements described above.

______________________________________________________________________

A-1005

(Rev.59, Issued: 05-21-10, Effective/Implementation: 05-21-10)

[The policies must ensure that the following are provided for each patient:]

482.52(b)(3) - A postanesthesia evaluation completed and documented by an individual

qualified to administer anesthesia, as specified in paragraph (a) of this section, no later

than 48 hours after surgery or a procedure requiring anesthesia services. The

postanesthesia evaluation for anesthesia recovery must be completed in accordance with

State law and with hospital policies and procedures that have been approved by the

medical staff and that reflect current standards of anesthesia care.

Interpretive Guidelines §482.52(b)(3)

A postanesthesia evaluation must be completed and documented no later than 48 hours after

surgery or a procedure requiring anesthesia services. The evaluation is required any time

general, regional, or monitored anesthesia has been administered to the patient. While current

practice dictates that the patient receiving moderate (conscious) sedation be monitored and

evaluated before, during, and after the procedure by trained practitioners, a postanesthesia

evaluation is not required (71 FR 68691)

The evaluation must be completed and documented by any practitioner who is qualified to

administer anesthesia. In accordance with §482.52(a), anesthesia must be administered only by:

• A qualified anesthesiologist;

• A doctor of medicine or osteopathy (other than an anesthesiologist);

• A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under

State law;

• A certified registered nurse anesthetist (CRNA), who, unless exempted in accordance

with paragraph (c) of this section, is under the supervision of the operating practitioner

or of an anesthesiologist who is immediately available if needed; or

• An anesthesiologist’s assistant who is under the supervision of an anesthesiologist who

is immediately available if needed.

Although §482.12(c)(1)(i) provides broad authority to physicians to delegate tasks to other

qualified medical personnel, the more stringent requirements of §482.52(b)(3) do not permit

delegation of the postanesthesia evaluation to practitioners who are not qualified to administer

anesthesia.

The calculation of the 48-hour time frame begins at the point the patient is moved into the

designated recovery area. Except in cases where post-operative sedation is necessary for the

optimum medical care of the patient (e.g., ICU), the evaluation generally would not be

performed immediately at the point of movement from the operative area to the designated

recovery area. Accepted standards of anesthesia care indicate that the evaluation may not begin

until the patient is sufficiently recovered from the acute administration of the anesthesia so as to

participate in the evaluation, e.g., answer questions appropriately, perform simple tasks, etc.

The evaluation can occur in the PACU/ICU or other designated recovery location. The elements

of an adequate post-anesthesia evaluation should be clearly documented and conform to current

standards of anesthesia care, including:

• Respiratory function, including respiratory rate, airway patency, and oxygen saturation;

• Cardiovascular function, including pulse rate and blood pressure;

• Mental status;

• Temperature;

• Pain;

• Nausea and vomiting; and

• Postoperative hydration.

Depending on the specific surgery or procedure performed, additional types of monitoring and

assessment may be necessary.

Survey Procedures §482.52(b)(3)

• Review a sample of medical records for patients who had surgery or a procedure

requiring general, regional or monitored anesthesia to determine whether a post

anesthesia evaluation was written for each patient.

• Determine whether the evaluation was conducted by a practitioner who is qualified to

administer anesthesia.

• Determine whether the evaluation was performed within 48 hours after the surgery or

procedure.

• Determine whether the appropriate elements of a post anesthesia evaluation are

documented in the medical record.