Though Centers for Medicare and Medicaid Services (CMS) expectations for anesthesia services have changed little over the years, these Conditions of Participation (CoPs) were recently revised and published in Transmittal 59 dated May 21, 2010. This four-part series outlines compliance challenges associated with the new CoPs and solutions to help hospitals assess vulnerabilities in anesthesia and sedation activities.
Defining Anesthesia and Related Services br>
The new changes clearly define both anesthesia and sedation, borrowing greatly from definitions found in the American Society of Anesthesiologists’ (ASA) most recent set of practice guidelines (Anesthesiology 2002; 96:1004-17), summarized here:
- Anesthesia involves the administration of a medication to produce a blunting or loss of pain, voluntary and involuntary movement, autonomic function, and memory and/or consciousness.
- Patients often require assistance in maintaining a patient airway, or correcting depressed spontaneous ventilation due to drug-induced depression of neuromuscular function.
- Cardiovascular function may be impaired.
- Anesthesia is used for those procedures when loss of consciousness is required for the safe and effective delivery of surgical services.
- Monitored Anesthesia Care (MAC) includes the monitoring of the patient by a practitioner who is qualified to administer anesthesia. Deep sedation/analgesia is included in MAC.
- The ability to independently maintain ventilatory function may be impaired.
- Patients may require assistance maintaining an airway, spontaneous ventilation may be inadequate.
- Cardiovascular function is usually maintained.
- Deep sedation/analgesia includes the use of propofol.
- Must be delivered or supervised by a practitioner as specified in 42 CFR 482.52(a).
- Regional Anesthesia is the delivery of anesthetic medication at a specific level of the spinal cord and/or to peripheral nerves used when loss of consciousness is not desired, but sufficient analgesia and loss of voluntary and involuntary movement is required.
- Regional anesthesia includes epidurals, spinals and other central neuraxial nerve blocks.
- Given the potential for the conversion and extension of regional to general anesthesia in certain procedures, administration of regional and general anesthesia must be delivered or supervised by a practitioner as specified in 42 CFR 482.52(a).
- Epidural or spinal route for the purpose of analgesia – during labor and delivery – is not considered anesthesia, and therefore it is not subject to the anesthesia supervision requirements.
- If C-section is necessary, anesthesia supervision requirements would apply (42 CFR 482.52(a)).
- In Deep Sedation/Analgesia, patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.
In contrast, the new CoPs also outline those services not subject to the anesthesia administration and supervision requirements (42 CFR 482.52(a)):
- Topical or Local Anesthesia
- Minimal Sedation in which:
- Patients respond normally to verbal commands.
- Although cognitive function and coordination may be impaired, ventilation and cardiovascular functions are unaffected.
- Moderate Sedation/Analgesia (“Conscious Sedation”) in which:
- Patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.
- No interventions are required to maintain a patient airway.
- Spontaneous ventilation is adequate.
- Cardiovascular function is usually maintained.
- Rescue Capacity
- Hospitals are required to ensure that procedures are in place to rescue patients whose level of sedation becomes deeper than initially intended.
- Intervention by a practitioner with expertise in airway management and advanced life support is required.
- The qualified practitioner corrects the adverse physiologic consequences of the deeper-than-intended level of sedation and returns the patient to the originally intended level of sedation.
Tips for Compliance
To comply with this section of the regulations, changes in policies and practices may be necessary. Assuring that all areas have been addressed is the only true way of avoiding violations on survey. Begin by assuring the following has been established in policy or practice:
- Align the definitions for anesthesia and sedation with those supported by CMS and ASA.
- Define where the different levels of anesthesia can occur and under what circumstances.
- Evaluate the level of compliance with the requirements at each location where anesthesia and sedation is administered.
This series of posts provides a guide to the most important aspects of the new regulations. When modifying your current practice, please refer to the full text of the regulations.
The next post in this series, “Take a Deep Breath: New CMS Anesthesia Regulations,” will tackle Anesthesia Administration and Privileging Practitioners. If you have questions about this series or any CMS regulation, please contact Cary D. Gutbezahl, MD, Chief Executive Officer of Compass Clinical Consulting at (513) 241.0142.