Guideline text:
(Rev. 59, Issued: 05-21-10, Effective/Implementation: 05-21-10)

## §482.52(b) Standard:  Delivery of Services

Anesthesia services must be consistent with needs and resources.  Policies on anesthesia procedures must include the delineation of preanesthesia and postanesthesia responsibilities.  The policies must ensure that the following are provided for each patient:

## Interpretive Guidelines §482.52(b)

Anesthesia services must be delivered in a manner that is consistent with the needs and the resources of the hospital.  Anesthesia policies at a minimum must address:

- How the hospital's anesthesia services needs will be met;
- Delivery of anesthesia services consistent with recognized standards for anesthesia care.  A well-designed anesthesia services policy would address issues such as:
- o Patient consent;
- o Infection control measures;
- o Safety practices in all anesthetizing areas;
- o Protocol for supportive life functions, e.g., cardiac and respiratory emergencies;
- o Reporting requirements;
- o Documentation requirements;
- o Equipment requirements, as well as the monitoring, inspection, testing, and maintenance of anesthesia equipment in the hospital's biomedical equipment program.
- o Delineation of pre- and post-anesthesia staff responsibilities

## Survey Procedures §482.52(b)

Review the policies developed on anesthesia procedures.  Determine whether the anesthesia service policies for delivery of care address the issues identified in interpretive guidelines.

A-1003

(Rev. 74, Issued: 12-02-11, Effective: 12-02-11, Implementation: 12-02-11)

[The policies must ensure that the following are provided for each patient:]

§482.52(b) (1) - A pre-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, performed within 48 hours prior to surgery or a procedure requiring anesthesia services.

## Interpretive Guidelines §482.52(b)(1)

A pre-anesthesia evaluation must be performed for each patient who receives general, regional or monitored anesthesia.  While current practice dictates that the patient receiving moderate sedation be monitored and evaluated before, during, and after the procedure by trained practitioners, a pre-anesthesia evaluation performed by someone qualified to administer anesthesia as specified in §482.52(a) is not required because moderate sedation is not considered to be 'anesthesia', and thus is not subject to that requirement under this regulation.

The evaluation must be performed by someone qualified to administer anesthesia as specified in §482.52(a), i.e., only by:

- A qualified anesthesiologist;
- A doctor of medicine or osteopathy (other than an anesthesiologist);
- A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under State law;
- A certified registered nurse anesthetist (CRNA), who, unless exempted in accordance with paragraph (c) of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or
- An anesthesiologist's assistant who is under the supervision of an anesthesiologist who is immediately available if needed.

Although §482.12 (c)(1)(i) generally provides broad authority to physicians to delegate tasks to other qualified medical personnel, the more stringent requirements at §482.52(b)(1) do not permit delegation of the pre-anesthesia evaluation to practitioners who are not qualified to administer anesthesia.

The pre-anesthesia evaluation must be completed and documented within 48 hours immediately prior to any inpatient or outpatient surgery or procedure requiring anesthesia services.  The delivery of the first dose of medication(s) for the purpose of inducing anesthesia, as defined above, marks the end of the 48 hour time frame.

In accordance with current standards of anesthesia care, some of the individual elements contributing to the pre-anesthesia evaluation may be performed prior to the 48-hour timeframe.  However, under no circumstances may these elements be performed more than 30 days prior to surgery or a procedure requiring anesthesia services.  Review of these elements must be conducted, and any appropriate updates documented, within the 48-hour timeframe.

The pre-anesthesia evaluation of the patient includes, at a minimum:

Elements that must be performed within the 48-hour timeframe:

- Review of the medical history, including anesthesia, drug and allergy history; and
- Interview, if possible given the patient's condition, and examination of the patient.

Elements that must be reviewed and updated as necessary within 48 hours, but which may also have been performed during or within 30 days prior to the 48-hour time period, in preparation for the procedure:

- Notation of anesthesia risk according to established standards of practice (e.g., ASA classification of risk);
- Identification of potential anesthesia problems, particularly those that may suggest potential complications or contraindications to the planned procedure (e.g., difficult airway, ongoing infection, limited intravascular access);
- Additional pre-anesthesia data or information, if applicable and as required in accordance with standard practice prior to administering anesthesia (e.g., stress tests, additional specialist consultation);
- Development of the plan for the patient's anesthesia care, including the type of medications for induction, maintenance and post-operative care and discussion with the patient (or patient's representative) of the risks and benefits of the delivery of anesthesia.

## Survey Procedures §482.52(b)(1)

- Review a sample of inpatient and outpatient medical records for patients who had surgery or a procedure requiring administration of anesthesia.
- Determine whether each patient had a pre-anesthesia evaluation by a practitioner qualified to administer anesthesia.
- Determine whether each patient's pre-anesthesia evaluation included at least the elements described above.
- Determine that the pre-anesthesia evaluation was updated, completed and documented within 48 hours prior to the delivery of the first dose of medication(s) given for the purpose of inducing anesthesia for the surgery or a procedure requiring anesthesia services.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"anchor": "pre-anesthesia evaluation", "max_delay_minutes": 2880, "target": "surgery or a procedure requiring anesthesia services"}, "rule_type": "temporal", "scope_tags": ["clinical", "legal"]}