Chapter 22 - Anesthesia Programs Within Indian Health Service Hospitals

Title	Section
Introduction	3-22.1
Purpose	3-22.1A
Background	3-22.1B
Responsibilities	3-22.1C
Staffing for the Delivery of Anesthesia Care	3-22.2A
Preanesthetic Preparation and Evaluation of the Patient	3-22.3
Anesthesia Equipment Checkout Requirements	3-22.4
The Anesthesia Record	3-22.5
Monitoring of Patients Undergoing Anesthesia	3-22.6
Post-Anesthetic Recovery of the Patient	3-22.7
Anesthesia Safety and Infection Control	3-22.8
Quality/Performance Improvement	3-22.9
Reports and Requirements of the Federal Managers' Financial Integrity Act	3-22.10

Appendix	Description
3-22-A	Anesthesia Equipment Checkout Requirements

3-22.1  INTRODUCTION

1. Purpose.  This section sets forth the basic Indian Health Service (IHS) policy for anesthesia care within IHS hospitals where surgical and/or full service obstetrical services are available.  These policies are based upon standards for anesthesia services published in:  the Accreditation Manual for Hospitals, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); Peer Review in Anesthesiology, the American Society of Anesthesiology (ASA), and Guidelines and Standards for Nurse Anesthesia Practice, the American Association of Nurse Anesthetists (AANA).
2. Background.  Of the forty-nine hospitals operated by the IHS and tribes, anesthesia services are provided in only twenty.  Each of these twenty hospitals provides surgical and/or obstetrical-gynecological services.  The policies of this chapter apply specifically to the IHS-operated hospitals with anesthesia services.  Facilities that do not have anesthesia services should apply these policies where applicable. The specialty of anesthesiology has the lead in the implementation of practice guidelines and in quality/performance improvement.  This Chapter adopts the JCAHO standards for anesthesia and the several guidelines and standards of the ASA and the AANA.
3. Responsibilities.
   1. Service Units.  The Clinical Director (CD) or other appropriate authority at IHS facilities that provide anesthesia services must designate a Chief of Anesthesia.  He/she must be a full-time physician member of the medical staff with appropriate clinical privileges and administrative experience to direct anesthesia services.  The Chief should be certified by an appropriate specialty board, or should affirmatively establish, through the privileges delineation process, that he/she possesses comparable competence.  Whenever possible, this physician should be an anesthesiologist.  The Chief of Anesthesia has the following responsibilities:
      1. Recommending to the medical staff, privileges for all individuals who have responsibility for providing anesthesia services.
      2. Establishing with the medical staff the types of anesthesia cases which can safely be handled at the facility.
      3. Recommending the number of anesthesia personnel required to provide the anesthesia services for the daily surgical schedule as well as for 24-hour call-back availability.
      4. Providing for anesthesiology consultant services as needed if an anesthesiologist is not a full time member of the medical staff.
      5. Recommending on an annual basis to the administration and medical staff the type and amount of equipment necessary for administering safe anesthesia.
      6. Establishing an ongoing quality/performance improvement program that monitors and evaluates anesthesia care and then takes appropriate actions based on the findings.
      7. Establishing a program of continuing education for all individuals with clinical anesthesia privileges, part of which program shall consist of in-service training as indicated by the results of the ongoing evaluation of anesthesia care.
      8. Developing policies and procedures to ensure anesthetic safety.
      9. Participating in the development of policies that relate to the function of anesthetists and the administration of anesthesia in any department of the hospital.
      10. Participating in the hospital's program of cardiopulmonary resuscitation.
      11. Ensuring that, where appropriate, a representative of the anesthesia service participates as an instructor in the hospital's program of continuing education.

   The service unit must maintain a description of the anesthesia department/service, including all policies and procedures applicable to its personnel.  The service unit shall compile them 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 Indian Heath Manual, and applicable laws and regulations.

   2. Area Offices.  The facility governing body is responsible for a planned, systematic, and ongoing process for monitoring, evaluating, and improving performance and quality of care, including that of the anesthesia service.  The Area must assist the service unit in meeting anesthesia standards established by the JCAHO, IHS, or other recognized accrediting bodies and in correcting identified deficiencies.
   3. Headquarters.  The Office of Health Programs (OHP), in consultation with IHS anesthesia providers and Area Chief Medical Officers, establishes broad anesthesia program policies including the responsibilities of Area Offices and service units in assuring quality in the anesthesia program.

3-22.2  STAFFING FOR THE DELIVERY OF ANESTHESIA CARE.

1. Anesthesiologists and certified registered nurse anesthetists (CRNA) provide anesthesia care as necessary for surgical, obstetrical, medical, and pediatric patients.  Anesthesia staff will be available in the hospital during scheduled work days to cover routine and emergency procedures.  During evenings, nights, weekends, and holidays, qualified personnel will provide anesthesia care on call back.  (Hereafter anesthesia provider will refer to anesthesiologist or nurse anesthetist.  If specific roles are described, they will refer to the actual title.)
2. OPERATIONAL.  The anesthesia program is staffed to provide services for anesthesia based upon the surgical and obstetrical workload.
   1. Anesthesia providers who staff the anesthesia service shall be qualified to perform all the services usually required in the practice of anesthesia care, including the ability to:
      1. Apply accepted procedures commonly used to render the patient insensible to pain during the performance of surgical, obstetrical, and other pain-producing clinical maneuvers, and to relieve pain-associated medical syndromes.
      2. Support life functions during the administration of anesthesia, including induction and intubation procedures.
      3. Provide appropriate pre-anesthesia and post-anesthesia management of the patient.
      4. Provide consultation relating to other forms of patient care, such as respiratory therapy, cardiopulmonary resuscitation, and special problems in pain relief.
      5. If the anesthesia care required is beyond the qualifications of the anesthesia provider, the patient shall be referred to another anesthesia provider or facility.
   2. The on-call anesthesia staff shall be able to respond to a page for the operating room and other emergencies within a reasonable time as determined by hospital policy.
   3. Anesthesia Service CRNAs are under the aegis of the medical staff and will be granted clinical privileges by the usual medical staff mechanism according to their training and experience.  Those CRNAs who are licensed and permitted by the facility to function as independent practitioners are eligible, at the discretion of the local medical staff and its governing body, to be members of the active medical staff.
3. CRNA Scope of Practice.  The scope of practice of the CRNA encompasses the professional functions and responsibilities associated with nurse anesthesia practice.  Nurse anesthetists provide anesthesia services in collaboration with and at the specific request of a surgeon, obstetrician-gynecologist, or other physician responsible for the patient.
   1. The scope of practice, to include the specific use of medications, will be embodied in the CRNA's clinical privileges and reflect the individual's training and clinical experience.
   2. Prescription privileges should be granted on the basis of classes of pharmaceutical within the CRNA's scope of practice.  They may include pre-anesthetic medications, anesthetic agents, and other medications used during the anesthetic procedure; specific drugs within a class which are not authorized should be identified.  Prescription of controlled substances may only be granted if the CRNA is authorized to do so by a State in which he/she is licensed, certified or registered.  Substitution or institution of medication to treat disease processes, when added to the pre-anesthetic order must be co-signed by a physician with appropriate privileges.  Continuation of medications by the CRNA may be included in pre-anesthetic orders without countersignature.
   3. Anesthesia staff credentials and privileges are reviewed at least every two years.

3-22.3  PRE-ANESTHETIC PREPARATION AND EVALUATION OF THE PATIENT.

1. Purpose.  To establish guidelines for the pre-anesthesia preparation of the patient.
2. Policy.  A thorough evaluation of the patient by an anesthesia provider is mandatory prior to the administration of anesthesia.  In addition to a review of systems and a records review, the evaluation should contain personal communications, physical assessment, when indicated, and evidence that informed consent for the anesthetic has been obtained.
3. Procedure.
   1. The following is required of all pre-anesthesia patients:
      1. A pertinent written history and physical examination per hospital policy.  It should include at least the following:
         • Anesthetic history, patient and family
         • Medical history
         • Drug history
         • Drug allergies
         • Food and fluid status
         • Physical examination
         • Review of relevant laboratory data
         • Determination of physical status
         • Formulation of an anesthetic plan
         • Indication of informed consent

         The above evaluation must be documented on the anesthetic record which will be signed, dated, and timed by the interviewer.

      2. Written hospital policy must specify the routine pre-operative lab work and testing needed by categories of patients or procedures and the mechanism by which they will be obtained.  There will be a mechanism for exemption from policy for emergencies.
      3. Written hospital policy must specify the routine pregnancy testing to be done for all females of reproductive age for non-obstetrical surgery.
   2. Written hospital policy must specify the procedure for nil per os (NPO) prior to surgery.  It is recommended that a specific procedure be developed for periodic patients.
   3. When anesthesia is to be conducted by a CRNA, a physician must sign the pre-operative side of SF-517 (or other institutional anesthetic record) unless the CRNA is licensed and permitted by the facility to function as an independent practitioner.
   4. Except in extreme emergencies, the pre-anesthesia evaluation must be performed before the patient is premeditated and before the patient is transferred to the operating suite.  Each facility will define within their hospital policies what situations constitute an extreme emergency for their institution.

3-22.4  ANESTHESIA EQUIPMENT CHECKOUT REQUIREMENTS.

1. Proper patient care requires inspection of anesthetic equipment by the anesthesia provider prior to administration of every anesthetic.  The checkout as outlined in Appendix A, or its equivalent, must be conducted before the administration of anesthesia.  These recommendations are only valid for an anesthesia system that conforms to current standards and includes an ascending bellows ventilator and at least the following monitors:  capnograph, pulse oximeter, oxygen analyzer, respiratory volume monitor (spirometer) and breathing system pressure monitor with high and low pressure alarms.
2. This is a 14 step guideline; users are encouraged to modify it to accommodate differences in equipment design and variations in local clinical practice.  Such local modifications should have appropriate peer review and be part of the anesthesia service policy and procedure manual.  Users should refer to the specific operator's manual for specific procedures and precautions.

3-22.5  THE ANESTHETIC RECORD.

1. Purpose.  Anesthesia personnel must maintain a contemporaneous record of patient vital signs, status, and therapeutic activities during each case.
2. Procedure.  The following must be noted and updated with any changes on the anesthetic record:
   1. Properly identified with the patient's name and chart number.
   2. The times of all significant events.
   3. Gas flows.
   4. Drugs used, along with the amount given and the time of administration.
   5. IV fluids infused by types and amounts.
   6. The fraction of inspired oxygen (FIO₂).
   7. Hemoglobin oxygen saturation (SpO₂).
   8. End tidal carbon dioxide when monitored.
   9. EKG rhythm.
   10. Temperature when monitored.
   11. Any unusual events during the anesthetic in the appropriate space on the anesthetic record.

3-22.6  MONITORING OF PATIENTS UDERGOING ANESTHSIA.

1. These standards apply for any administration of anesthesia involving anesthesia staff and specifically refer to preplanned anesthetics administered in designated anesthetizing locations (Specific exclusion:  administration of epidural analgesia for labor).  In emergency circumstances in any location, immediate life support measures come first.  Attention will turn to the measures described in these standards as soon as possible.  Anesthesia personnel may exceed these standards based on their judgment.  These standards encourage high quality patient care, but observing them cannot guarantee any specific patient outcome.
2. Procedure.
   1. Anesthetic providers.  For all anesthetics initiated by or involving a member of the anesthesia staff, an anesthesia provider will be present in the room throughout the conduct of all general anesthetics, regional anesthetics, or monitored anesthetic care.  An exception is made when there is a direct hazard to the anesthesia personnel, in which case some provision for monitoring the patient must be made.
   2. Ventilation.  Intubation of the trachea shall be confirmed by auscultation, chest excursion, and confirmation of carbon dioxide in the expired gas.  Controlled or assisted ventilation during the anesthetic shall be monitored continuously with an end-tidal carbon dioxide monitor.  Additionally, spirometry and ventilatory pressure monitors may also be used.

      Breathing system disconnect monitor:  When the patient is ventilated by an automatic mechanical ventilator, the integrity of the breathing system shall be monitored by a device that is capable of detecting the disconnection of any component of the breathing system.  Such a device shall be equipped with an audible alarm which is activated when its limits are exceeded.

   3. Oxygenation.  Adequacy of patient oxygenation shall be monitored continuously with pulse oximetry.  In addition to pulse oximetry, oxygenation shall be also monitored by observations of skin color, the color of the blood in the surgical field, and arterial blood gas analysis when indicated.

      During general anesthesia, the oxygen concentration delivered by the anesthesia machine shall be monitored continuously with an oxygen analyzer with a low oxygen concentration limit alarm.  An oxygen supply failure alarm system shall be operational to warn of low oxygen pressure to the anesthesia machine.

   4. Circulation.  Blood pressure and heart rate shall be determined and recorded at least every 5 minutes.  The patient's electrocardiogram shall be monitored continuously throughout the course of the anesthetic.  Circulation also shall be assessed by at least one of the following measures: digital palpation of pulse, auscultation of heart sounds, continuous intra-arterial pressure monitoring, electronic pulse monitoring, or pulse oximetry.
   5. Body temperature.  Body temperature shall be monitored, intermittently or continuously, and recorded on all patients receiving general anesthesia with the possible exception of very brief procedures.  The means to monitor temperature shall be immediately available for use on all patients receiving local or regional anesthesia and used when indicated.
   6. Neuromuscular Function.  The means to evaluate the patient's neuromuscular function by the use of a nerve stimulator shall be available immediately when neuromuscular blocking drugs have been used.  When a nerve stimulator is used on a patient, it will be documented in the medical record.
   7. Anesthesia Equipment.  A complete equipment safety check shall be performed daily by the anesthesia provider and documented in a log.  The anesthesia machine check shall be performed in accordance with Section 3-22.4 of this chapter.  An abbreviated check of all equipment shall be performed before each anesthetic is administered in accordance with Section 3-22.4.  All anesthesia machines and monitoring equipment shall conform to the appropriate national and state standards.  An ongoing preventive maintenance program shall be established and enforced.
3. Waiver of Monitoring Requirements Under extenuating circumstances, the attending anesthesia provider may waive these requirements after stating the reason in the medical record.

3-22.7  POST ANESTHETIC RECOVERY OF THE PATIENT.

1. All patients receiving general anesthesia care should be transported to the post-anesthetic care unit (PACU) for immediate post-anesthesia recovery unless the operating surgeon and anesthesia provider agree that the patient should be transported directly to the intensive care unit.  Patients receiving other types of anesthesia care may be admitted to the PACU in accordance with departmental/hospital policy and based on the judgment of the anesthesia provider.
2. At the end of surgery, patients must be transported to the PACU by members of both the surgical and anesthesia team.
3. The post-operative status of the patient must be evaluated on admission to the PACU.  The anesthesia provider must document the patient's vital signs and level of consciousness on the anesthetic record.
4. The anesthesia provider responsible for administering anesthesia must remain with the patient as long as the patient's condition necessitates and until the PACU nurse accepts responsibility for the patient's care.
5. Discharge from the PACU.
   1. Patients shall be discharged from the PACU by (a) a written order of the anesthesia provider or (b) nursing personnel in accordance with medical staff-approved discharge criteria.
   2. The patient stay in the PACU may be curtailed or lengthened by the responsible physician or anesthesia provider, if so privileged, as the patient's condition dictates.
6. Post-anesthesia interview.
   1. A member of the anesthesia staff should interview all patients after release from the PACU but before discharge from the hospital.
   2. The anesthesia provider providing the anesthetic should perform the post-anesthesia visit.  If this is not feasible, he/she should arrange for another member of the anesthesia or surgical service to interview the patient.
   3. This interview should be performed the day following anesthesia if possible.  If the patient is going to be discharged before the next workday, the interview should be performed the same day that anesthesia is administered but after the patient has been released from the PACU.
   4. The anesthesia provider is responsible for documenting the post-anesthesia interview in the progress notes indicating the presence or lack of any anesthesia related complications as designated by departmental quality improvement program.  He/she should sign, date, and time the note.

3-22.8  ANESTHESIA SAFETY AND INFECTION CONTROL.

1. The anesthesia service/department must develop and/or adopt anesthesia safety and infection control policies to assure the safe administration of anesthetics.
2. The following precautions must be taken to assure the safe administration of anesthetic agents:
   1. The five basic safety devices, oxygen analyzer, pressure and disconnect alarm, pin-indexing safety system, gas scavenging system, and oxygen pressure interlock system, shall be checked prior to the first case of the day by following the procedures on the anesthesia machine check list.  The provider checking the machine will initial the list.
   2. Only non-flammable agents shall be used for anesthesia.  All Anesthetizing locations shall be identified by prominently posted signs at all entrances and within the location indicating that only non-flammable anesthetic agents shall be employed:

      RESTRICTED TO NON-FLAMMABLE INHALATION ANESTHETIC AGENTS

   3. To minimize the risk of fire during surgery, fabric worn by personnel or used for draping patients will be restricted to materials that are not highly combustible.  Extreme care should be exercised when using cautery, lasers and electro-surgical devices during surgery.
   4. Preventive maintenance shall be performed by trained and qualified personnel at a frequency defined by the equipment manufacturer, but not less than every six months.  Clinical Engineering shall perform preventive maintenance on all operating room equipment, and shall maintain necessary records of such maintenance, notifying the anesthesia service of any significant abnormalities found.  The anesthesia machines preventive maintenance records shall be provided to the anesthesia staff.
   5. The anesthesia machines shall be checked for air leaks each morning and prior to each administration of anesthesia to a patient.  Appropriate function of the EKG monitor, blood pressure monitor and oxygen analyzer shall be checked similarly.  If an air leak or a malfunction is observed, the equipment will be replaced or repaired prior to the administration of anesthesia.
   6. A policy on the management of waste anesthetic gases shall be developed.  A resource for developing this policy is the AANA "White Paper", Management of Waste Anesthetic Gases, © 1992.  Occupational exposure to waste anesthetic gases shall be monitored using an approved method.  The records of such exposures shall be maintained in the employee medical record as defined in the Indian Health Manual, Part 1, Chapter 9, "Occupational Safety and Health Program."
   7. Standard precautions will be observed with gloves being worn for all contact with body fluids and secretions.  Eye protection is recommended.
   8. Disposable equipment (circuits, masks, endotracheal tubes) will be used as much as possible.  Laryngoscope blades will be washed and sterilized (gas or autoclave) or soaked in a disinfecting solution a minimum of 15 minutes between uses.
   9. Needle-less technique is encouraged through the use of stopcocks with the discarding of syringes between patients.

3-22.9  QUALITY/PERFORMANCE IMPROVEMENT (QPI) PROGRAM

The service unit must monitor and evaluate the quality and appropriateness of patient care provided by the anesthesia service.  Each IHS hospital with an anesthesia service must develop and implement a program that assures an ongoing, comprehensive, and systematic review of anesthesia care.  It shall resolve identified problems and implement program changes to improve anesthesia care.

The Director of Anesthesia shall appoint a member of the anesthesia staff to act as a QPI coordinator for gathering, documenting, and reporting data as required.  He/she shall monitor preoperative, intraoperative, and postoperative anesthesia care and any other appropriate aspects of anesthesia care.  The hospital anesthesia policy and procedure manual shall contain guidelines for monitoring.

3-22.10  REPORTS AND REQUIREMENTS OF THE FEDERAL MANAGERS FINANCIAL INTEGRITY ACT (FMFIA).

The JCAHO inspects all IHS hospitals at last every three years.  The results of these inspections are provided to the Office of Health Programs (OHP), IHS Headquarters.  The Health Care Administration Branch, OHP tracks the responses by IHS facilities to Type 1 findings and provides quarterly reports to the Associate Director, OHP.  This process represents an alternative management control review under the FMFIA.