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Dichiarazioni, opinioni e protocolli 
della AMERICAN SOCIETY OF ANESTHESIOLOGISTS

Copyright (c)1996 American Society of Anesthesiologists. All rights reserved

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:

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.

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.

*Vedi anche Basic Standards for Preanesthesia Care
**Vedi anche 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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