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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:
POLICY STATEMENT ON PRACTICE
PARAMETERS
Basic Standards for Preanesthesia Care
Standards for Basic Anesthetic Monitoring
Standards for Postanesthesia Care
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.
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.
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.
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