Policy Statement on Practice Parameters
Basic Standards for Preanesthesia
Care
Standards for Basic Anesthetic
Monitoring
Standards for Postanesthesia Care
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
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
POLICY STATEMENT ON
PRACTICE PARAMETERS
(Approved by House of Delegates on October 13, 1993)
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
BASIC STANDARDS FOR PREANESTHESIA 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.
STANDARDS FOR BASIC ANESTHETIC MONITORING
(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.
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.
GUIDELINES OF THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
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.
GUIDELINES FOR A MINIMALLY ACCEPTABLE PROGRAM OF ANY CONTINUING EDUCATION REQUIREMENT
(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.
GUIDELINES FOR DELINEATION OF CLINICAL PRIVILEGES IN ANESTHESIOLOGY
(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.
GUIDELINES FOR THE ETHICAL PRACTICE OF ANESTHESIOLOGY
(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).
GUIDELINES FOR PATIENT CARE IN ANESTHESIOLOGY
(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.
STATEMENTS,
POSITIONS AND PROTOCOLS
OF THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
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.
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 individuals. This group of people,
medically directed by the anesthesiologist, comprises 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 does not intend that its recognition of the
Anesthesia Care Team concept shall limit the availability of
anesthesia care personally delivered by an anesthesiologist. The
Society strongly encourages practice arrangements that provide
patient access to the direct care of an anesthesiologist.
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
that anesthesiologist's medical direction should be fully
disclosed to all concerned.
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.
STATEMENT ON
CONFLICT OF INTEREST
(Approved by House of Delegates on October 13, 1993)
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 OF
ANESTHESIA CARE
(Approved by House of Delegates on October 12, 1988)
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
STATEMENT ON
PHYSICIANS DRGS
(Approved by House of Delegates on October 17, 1984)
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.
STATEMENT ON
ECONOMIC CREDENTIALING
(Approved by House of Delegates on October 13, 1993)
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.
POSITION ON
MONITORED ANESTHESIA CARE
(Approved by House of Delegates on October 21, 1986)
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.
ASA POLICY FOR THE REIMBURSEMENT OF MONITORED ANESTHESIA CARE
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.
STATEMENT ON
REGIONAL ANESTHESIA
(Approved by House of Delegates on October 12, 1983)
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.
STATEMENT ON ROUTINE PREOPERATIVE LABORATORY AND DIAGNOSTIC SCREENING
(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.