Who Can Administer Anesthesia?
on 2/21/2017 10:00:00 AM
A surveyor was looking at the medical record of a 21 year old male who presented to a hospital's Emergency Department with a dislocated shoulder. The patient underwent a shoulder reduction under deep sedation. The care rendered was appropriate and thoroughly documented. The problem, however, was a Registered Nurse administered the deep sedation. The hospital was promptly cited. So who exactly can administer anesthesia (deep sedation is considered monitored anesthesia care)? The interpretive guidance in Appendix A of the State Operations Manual at §482.52 form the basis for this discussion.
WHAT DOESN'T APPLY
The first thing to understand is what exactly is covered under the regulation by CMS. Regulations addressing who may administer anesthesia do not apply to the administration of topical or local anesthetics, minimal sedation or moderate sedation. However, your hospital must have policies and procedures, consistent with State law and scope of practice, that govern the provision of these types of anesthesia services. Basically, the decision as to who is permitted to administer the continuum from topical anesthetics to moderate sedation is made by your hospital consistent with State law and a disciplines professional scope of practice.
WHO CAN ADMINISTER ANESTHESIA
The CMS regulations address general anesthesia, regional anesthesia and monitored anesthesia, including deep sedation/analgesia. This continuum of anesthesia may only be administered by the following individuals:
- A qualified anesthesiologist;
- An MD or DO (other than an anesthesiologist);
- A dentist, oral surgeon or podiatrist who is qualified to administer anesthesia under State law;
- A CRNA who is supervised by the operating practitioner or by an anesthesiologist who is immediately available if needed; or
- An anesthesiologist's assistant under the supervision of an anesthesiologist who is immediately available if needed.
Administration by an MD/DO, Dentist, Oral Surgeon, Podiatrist
"Your hospital's anesthesia service policies must address the circumstances under which an MD or DO who is not an anesthesiologist, a dentist, oral surgeon or podiatrist is permitted to administer anesthesia. In the case of a dentist, oral surgeon or podiatrist, administration of anesthesia must be permissible under State law and comply with all State requirements concerning qualifications."
CMS will look to see that your hospital has conformed to generally accepted standards of anesthesia care when establishing policies governing anesthesia administration by these types of practitioners. For example, the American Society of Anesthesiologists have issued position statements on the qualifications and standards of practice for individuals who administer anesthesia but are not anesthesiologists. Adherence to these position statements would be one way of demonstrating that your hospital conforms to accepted standards of care.
Administration by a CRNA
Unless your hospital is located in a State that has chosen to opt out of the CRNA supervision requirements, a CRNA administering general, regional and monitored anesthesia must be supervised either by the person who is performing the procedure or by an anesthesiologist who is immediately available. According to CMS, an anesthesiologist is considered "immediately available" only if he/she is physically located within the same area as the CRNA (e.g., in the same operative/procedural suite or in the same labor and delivery unit and not otherwise occupied in a way that prevents him/her from immediately conducting hands-on intervention if needed).
In smaller mostly rural hospitals, it is not unusual to have anesthesia administered only by a CRNA. There is no anesthesiologist on staff. In this case, supervision falls to the surgeon or other MD/DO. It's a good idea to make sure these practitioners understand their responsibility to supervise the CRNA.
If the hospital is located in a State that has chosen to opt out of the supervision requirement then a CRNA may be permitted to administer anesthesia without supervision. A list of states that have opted out of the supervision requirement may be found at http://www.cms.hhs.gov/CFCsAndCoPs/02_Spotlight.asp
Administration by an Anesthesiologist's Assistant
Not all States have anesthesiologist assistants. If your State does, then they must be supervised similar to a CRNA. The big difference is that only an anesthesiologist can perform the supervision; no other practitioner (e.g. surgeon) may do so. In addition, there is no opt out process for a State for anesthesiology assistants. Therefore, if your hospital employs anesthesiology assistants, they must be supervised by an anesthesiologist.
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About the Author
Traci Burgkwist RCP, HACP
Traci Burgkwist is the Executive Director of Survey Operations for CIHQ. Traci has more than 15 years of experience in hospital survey preparation.
Traci's past positions include Chief Quality Officer for a multi-hospital community based health system where she was responsible for accreditation and regulatory compliance. Prior to joining CIHQ, Traci served as the Executive Director of Quality for a large regional medical center, providing executive management oversight in the areas of quality, risk, medical staff credentialing, and patient relations.
Traci received her degree in education from Pima in Tucson Arizona. She is nationally certified in healthcare accreditation, and serves on the Board of Examiners for the Healthcare Accreditation Certification Program.