Standards, Guidelines, and Statements


Policy Statement on Practice Parameters

Standards

Basic Standards for Preanesthesia Care
Standards for Basic Anesthetic Monitoring
Minimal Safety Standards: Dep of Anaesthesia, Basel
Standards for Postanesthesia Care

Guidelines

Guidelines for Perioperative Transesophageal Echocardiography
Guidelines for Blood Component Therapy
Guidelines for Ambulatory Surgical Facilities
Guidelines for a Minimally Acceptable Program of Any Continuing Education Requirement
Guidelines for Critical Care in Anesthesiology
Guidelines for Delineation of Clinical Priveleges in Anesthesiology
Ethical Guidelines for the Care of Patients with DNR Orders or Directives That Limit Treatment
Guidelines for the Ethical Practice of Anesthesiology
Guidelines for Expert Witness Qualifications and Testimony
Guidelines for Delegation of Technical Anesthesia Functions to Nonphysician Personnel
Guidelines for Nonoperating Room Anesthetizing Locations
Guidelines for Regional Anesthesia in Obstetrics
Guidelines for Patient Care in Anesthesiology

Statements, Positions and Protocols

Statement of Policy
The Anesthesia Care Team
Anesthesia Consultation Program
Statement on Conflict of Interest
Documentation of Anesthesia Care
Statement on Physicians DRGS
Statement on Economic Credentialing
Statement on Invasive Monitoring in Anesthesiology
Position on Monitored Anesthesia Care
ASA Policy for the Reimbursement of Monitored Anesthesia Care
The Organization of an Anesthesia Department
Statement on Regional Anesthesia
Statement Regarding Respiratory Care Practitioneer Credentialing
Statement on Routine Preoperative Laboratory and Diagnostic Screening
Protocol for Supporting a Member's Right to Practice


kaufmannm@ubaclu.unibas.ch 1996





















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.

MINIMAL SAFETY STANDARDS

in der Anästhesie
(english translation to follow)

In den letzten Jahrzehnten hat sich die Anästhesie von einer Kunst zu einer wissenschaftlich orientierten Spezialität gewandelt. Während man früher mit dem Finger am Puls unter Beobachtung von Atmung und Reflexzeichen mit einfachen Mitteln Patienten narkotisierte, so kann man heute mit einer Vielzahl von Methoden und Techniken den Patienten situationsgerecht anästhesieren und dabei wichtige physiologische Parameter gleichzeitig überwachen. Verschiedene Faktoren haben dazu beigetragen, dass in dieser Zeit die Anästhesie sicherer geworden ist. Musste man in den 50-er Jahren noch mit einer anästhesiebedingten Mortalität von 1:2'000 rechnen, so liegt die Zahl von schweren Zwischenfällen heute je nach Institution zwischen 1:10'000 bis 1:200'000. Die Anästhesie hat sich in dieser Zeit zum führenden Fach in Bezug auf Risiko-Management und Patientensicherheit entwickelt. An der Harvard Medical School wurden vor 5 Jahren erstmals Minimal Safety Standards eingeführt, eine Initiative, die in der Folge praktisch alle wichtigen Fachgesellschaften auf Ihre Art nachvollzogen haben.

Wie lassen sich nun die bereits publizierten, häufig sehr allgemein gefassten Standards (schweizerische fehlen ...) auf konkrete, einfache und durchsetzbare Vorschriften reduzieren.


Beispiel: MINIMAL SAFETY STANDARDS

Departement Anästhesie (DA), Universitäts-Kliniken, Basel

ALLGEMEIN

  1. Diese Standards gehlten für alle Bereiche und Kliniken des DA
  2. Arzt und Pflegeperson sind gemeinsam für das Einhalten dieser Vorschriften verantwortlich
  3. Checklisten und emergency procedures stellen eine Ergänzung dieser Vorschriften dar
  4. Ein temporärer Mangel an Personal oder Material ist kein Grund für das Nicht-Einhalten
    dieser Vorschriften

PRÄSENZ

AUSRÜSTUNG / MONITORING

Vor jeder Anästhesie (auch Maske / Regionalanästhesie / StandBy) werden folgende Systeme explizit geprüft und "in Betrieb" gesetzt:

Nur bei Intubations-Anästhesie:

Vor Einleitung :

Nach Intubation:

MEDIKAMENTE / ZUGÄNGE

SPEZIELLES


DISKUSSION

Den Hauptfaktor einer sicheren Anästhesie stellt nicht das Monitoring, sondern der Anästhesist dar. Eine integrale Erhöhung der Anästhesie-Sicherheit ist durch folgende Massnahmen erreichbar:


Obwohl der Beweis aussteht, dass Safety Standards den Hauptgrund für die Reduktion des Anästhesie-Risikos darstellten, ist ihr Anteil an der Erhöhung der Patienten-Sicherheit unbestritten.
Die häufigste Ursache von schweren Zwischenfällen sind Probleme mit der Ventilation. Die Bedeutung des Monitorings wird dadurch unterstrichen, dass Kapnographie und Pulsoxymetrie die Mehrzahl gerade dieser Probleme vor dem Eintreten von irreversiblen Folgeschäden aufzeigen können.
Es ist wichtig, dass wir unsere minimalen Safety Standards selber definieren, bevor sie uns von aussen vorgeschrieben werden. Da die Kosten eines derartigen minimalen Standards SFr 10.- pro Anästhesie nicht überschreiten, dürfen im Interesse unserer Patienten auch materielle Einwände keinen Grund mehr gegen die Einführung derartiger, minimaler Sicherheitsvorschriften darstellen.

Bibliographie:

Beecher HK, Todd DP: A study of the deaths associated with anesthesia and surgery. Ann Surg 140:2,1954
Eichhorn JH, Cooper JB, Cullen DJ, et al: Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA 256:1017-20,1986
Eichhorn JH: Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 70:572-7,1989
Gaba DM, Maxwell A, DeAnda A: Anesthetic mishaps: Breaking the chain of accident evolution. Anesthesiology 66:670-6,1987
Lunn JN, Devlin HB: Lessons from the confidential enquiry into perioperative deaths in three NHS regions. Lancet ii:1384-5,1987

STANDARDS FOR POSTANESTHESIA CARE
(Approved by House of Delegates on October 12, 1988 and last amended on October 19, 1994)

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.

GUIDELINES FOR AMBULATORY SURGICAL FACILITIES
(Approved by House of Delegates on October 11, 1973 and last amended on October 12, 1988)

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.

GUIDELINES FOR CRITICAL CARE IN ANESTHESIOLOGY
(Approved by House of Delegates on October 16, 1974 and last amended on October 21, 1986)

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.

ETHICAL GUIDELINES FOR THE ANESTHESIA CARE OF PATIENTS
WITH DO-NOT-RESUSCITATE ORDERS OR OTHER DIRECTIVES
THAT LIMIT TREATMEN
T
(Approved by House of Delegates on October 13, 1993)

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.

GUIDELINES FOR EXPERT WITNESS QUALIFICATIONS AND TESTIMONY
(Approved by House of Delegates on October 14, 1987 and last amended on October 23, 1990)

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.

GUIDELINES FOR DELEGATION OF TECHNICAL ANESTHESIA FUNCTIONS TO NONPHYSICIAN PERSONNEL
(Approved by House of Delegates on October 17, 1984)

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.

GUIDELINES FOR NONOPERATING ROOM ANESTHETIZING LOCATIONS
(Approved by House of Delegates on October 19, 1994)

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.

GUIDELINES FOR REGIONAL ANESTHESIA IN OBSTETRICS
(Approved by House of Delegates on October 12, 1988 and last amended on October 30, 1991)

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

STATEMENT OF POLICY
(Approved by House of Delegates on November 8, 1950 and last amended on October 19, 1994)

The American Society of Anesthesiologists is a nonprofit association of reputable Doctors of Medicine or Osteopathy engaged in the practice of or otherwise especially interested in anesthesiology.
As provided in the Bylaws, the Society holds to the following purposes:
To advance the science and art of anesthesiology, and
To stimulate interest and promote progress in the scientific, cultural and economic aspects of the specialty of anesthesiology.
It is the official policy of the American Society of Anesthesiologists that all anesthesiologists are free to choose whatever arrangement they prefer for compensation of their professional services. The Society does not consider the compensation arrangement so chosen to be a matter of professional ethics. In addition, anesthesiologists' compensation arrangements shall not affect their eligibility to attain or retain membership in this Society or any of its Component Societies.
The Society advocates the following principles and believes that its members should be specifically cognizant thereof:
I. The practice of anesthesiology is the practice of medicine and is not an institutional "service."
II. No contract or other practice arrangement should:
A. Restrict a patient's access to quality anesthesiology care.
B. Restrict ultimate physician control of the delivery of that care, as for example, the use of provisions coupling termination of privileges with the termination of the contract.
C. Impede contractual or other legal rights to offer or deliver anesthesiology care.
III. No person or entity should create an artificial shortage of anesthesiologists in order to justify a supervisory arrangement.
IV. The professional income of a member of this Society should be derived from those medical services rendered to the patient by the member or under the member's direct, personal and continual medical direction. A stipend may properly be accepted as compensation for administrative or educational responsibilities.
V. Exploitation of anesthesiologists by other anesthesiologists is improper. For example, in group practice, after a reasonable trial period to determine acceptability, each anesthesiologist should generally receive income that is relatively proportionate to the service rendered for the group.
This Statement of Policy contains principles formally adopted by and strongly advocated by this Society.
Neither acceptance of nor adherence to this Statement of Policy is a condition of any privilege of membership in the Society, and the adoption and publication of this Statement of Policy is not intended to interfere with any member's exercise of independent judgment. Each member of the Society, however, is urged to consider the principles stated herein as they apply to the member's own medical practice.

THE ANESTHESIA CARE TEAM
The Anesthesia Care Team

(Approved by House of Delegates on October 26, 1982, and last amended on October 25, 1995)

Anesthesiology is a recognized specialty of medicine. Anesthesia care personally performed or medically directed by an anesthesiologist, a physician who has completed an approved residency in anesthesiology, constitutes the practice of medicine. Certain aspects of anesthesia care may be delegated to other properly trained professionals. These professionals, medically directed by the anesthesiologist, comprise the Anesthesia Care Team.

Such delegation and direction should be specifically defined by the anesthesiologist director of the Anesthesia Care Team and approved by the hospital medical staff. Although selected functions of overall anesthesia care may be delegated to appropriate members of the Anesthesia Care Team, responsibility and direction of the Anesthesia Care Team rest with the anesthesiologist.

The Society believes that the involvement of an anesthesiologist in the care of every patient undergoing anesthesia is essential. This may be accomplished through personal provision of anesthesia care or by medical direction of the Anesthesia Care Team.

Members of the medically directed Anesthesia Care Team may include physicians and nonphysician personnel.

A. Those who assist in providing direct patient care during the perioperative period, for example:

ANESTHESIOLOGY RESIDENT -- a physician who is presently in an approved anesthesiology residency program.

NURSE ANESTHETIST -- a registered nurse who has satisfactorily completed an approved nurse anesthesia training program.

ANESTHESIOLOGIST'S ASSISTANT -- a graduate physician's assistant who has satisfactorily completed an approved anesthesiologist's assistant training program.

B. Others who have patient care functions during the perioperative period include:

POSTANESTHESIA NURSE -- a nurse who cares for patients recovering from anesthesia.

CRITICAL CARE NURSE -- a nurse who cares for patients in a special care area such as the intensive care unit.

RESPIRATORY THERAPIST -- an allied health professional who provides respiratory care to patients.

C. Support personnel whose efforts deal with technical expertise, supply and maintenance, for example:

Anesthesia technologists and technicians

Anesthesia aides

Blood gas technicians

Respiratory technicians

Monitoring technicians

In order to apply the Anesthesia Care Team concept in a manner consistent with the highest standards of patient care, the following essentials should be observed:

1. Medical Direction: Anesthesia direction, management or instruction provided by an anesthesiologist whose responsibilities include:

a. Preanesthetic evaluation of the patient.

b. Prescription of the anesthesia plan.

c. Personal participation in the most demanding procedures in this plan, especially those of induction and emergence.

d. Following the course of anesthesia administration at frequent intervals.

e. Remaining physically available for the immediate diagnosis and treatment of emergencies.

f. Providing indicated postanesthesia care.

An anesthesiologist engaged in medical direction should not personally be administering another anesthetic and should use sound judgment in initiating other concurrent anesthetic and emergency procedures.

2. Delegation of any part of anesthesia care by an anesthesiologist to a member of the Anesthesia Care Team under the medical direction of the anesthesiologist should be fully disclosed.

3. Exploitation of patients, institutions, Anesthesia Care Team members, colleagues or payers is unethical. .


ANESTHESIA CONSULTATION PROGRAM
(Approved by House of Delegates on October 17, 1984 and last amended on October 18, 1989)

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.

STATEMENT ON INVASIVE MONITORING IN ANESTHESIOLOGY
(Approved by House of Delegates on October 17, 1984)

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.

THE ORGANIZATION OF AN ANESTHESIA DEPARTMENT
(Approved by House of Delegates on October 26, 1982 and last amended on October 19, 1994)

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.

STATEMENT REGARDING RESPIRATORY CARE PRACTITIONER CREDENTIALING
(Approved by House of Delegates on October 16,1985 and last amended on October 21, 1992)

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.

PROTOCOL FOR SUPPORTING A MEMBER'S RIGHT TO PRACTICE
(Approved by House of Delegates on October 19, 1994)

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.


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