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More from the March 2009 Joint Commission Changes: Anesthesia

Accreditation Monthly, July 14, 2009

Many of the published March 2009 changes were made to align with CMS' Conditions of Participation (CoP). However, when looking at the CMS definition of anesthesia, it does not include sedation. The Joint Commission standard (PC.03.01.01) states, "The standards for sedation and anesthesia care" which then goes on to specify "general, spinal, region, deep, and moderate sedation." Therefore, it is assumed that the following standards will include sedation, but as is often the case, uncertainty remains.

PC.03.01.03 states that a pre-anesthesia evaluation must be completed within 48 hours prior to the procedure requiring anesthesia.

PC.03.01.07 states that a post-anesthesia evaluation must be completed and documented no later than 48 hours following a procedure requiring anesthesia.

Points to remember:

• Both evaluations must be performed by an individual with privileges to administer anesthesia
• There is no specification in the standard as to how soon after the procedure the post-anesthesia evaluation can be performed

To achieve compliance, we recommend that you:

• Build pre- and post-anesthesia evaluations into your documentation process
• Design an anesthesia evaluation form that includes the pre- and post-anesthesia evaluations
• Educate your anesthesia providers and monitor compliance with the standard

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