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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:
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 TREATMENT
(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.
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