Part of what the anesthesia provider is paid for—as reflected by the anesthesia code appearing on the claim form—is performing an assessment and indicated care after the surgical case has concluded. In other words, there is some level of post-surgery involvement that is both bundled and expected as part of the overall anesthesia service package. And, yes, there are authoritative sources that provide specific and extensive guidelines for performing this post-anesthesia evaluation.
Society Standards
Just as the American Society of Anesthesiologists (ASA) produced a position statement on pre-anesthesia assessments, it also has an official guide when it comes to the post-anesthesia evaluation. Originally approved in 2004 by the ASA’s Committee on Standards and Practice Parameters, the “Standards for Post-anesthesia Care” were last amended just one year ago. The standards are meant to apply to all post-anesthesia care locations and include several requirements, as outlined below.
Standard I. All patients who have received general anesthesia, regional anesthesia or monitored anesthesia care shall receive appropriate post-anesthesia management. 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.
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 nurse by the member of the anesthesia care team who accompanies the patient. The patient’s status on arrival in the PACU shall be documented. Information concerning the preoperative condition and the surgical/anesthetic course shall be transmitted to the receiving nurse. A member of the anesthesia care team shall remain with the patient until the receiving nurse accepts responsibility for the nursing care of the patient.
Standard IV. The patient’s condition shall be evaluated continually in the PACU. Particular attention should be given to monitoring oxygenation, ventilation, circulation, level of consciousness 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. A written report of the recovery period shall be maintained. General medical supervision and coordination of patient care in the PACU should be the responsibility of an anesthesiologist.
Standard V. A physician is responsible for the discharge of the patient from the PACU. 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.
Medicare Mandates
According to the Interpretive Guidelines (IGs), as found in the Medicare State Operations Manual that deal with the Medicare conditions of participation (CoPs), a post-anesthesia evaluation must be completed and documented no later than 48 hours after a procedure requiring anesthesia services. The evaluation must be completed and documented by any practitioner who is qualified to administer anesthesia. It shouldnot begin until the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation (e.g., answer questions appropriately, perform simple tasks, etc.).
While the evaluation should begin in the PACU/ICU or other designated recovery location, it may be completed after the patient is moved to another inpatient location or, for same day surgeries, if State law and hospital policy permits, after the patient is discharged, so long as it is completed within 48 hours. Individual patient risk factors may dictate that the evaluation be completed and documented sooner than 48 hours. This should be addressed by hospital policies and procedures.
For those patients who are unable to participate in the post-anesthesia evaluation, the evaluation should be completed and documented within 48 hours with notation that the patient was unable to participate. This documentation should include the reason for the patient’s inability to participate as well as expectations for recovery time.
The elements of an adequate post-anesthesia evaluation should be clearly documented and conform to current standards of anesthesia care, including:
- Respiratory function, including respiratory rate, airway patency and oxygen saturation
- Cardiovascular function, including pulse rate and blood pressure
- Mental status
- Temperature
- Pain
- Nausea and vomiting
- Postoperative hydration
Depending on the specific surgery or procedure performed, additional types of monitoring and assessment may be necessary.
Anesthesia providers are reminded that these IGs are meant as instructions to surveying organizations, such as the Joint Commission, on what to look for when determining whether or not a facility should retain its participation status within the Medicare program. Accordingly, these IGs essentially become requirements that must be followed by anesthesiologists and anesthetists working in those facilities.