The Centers for Medicare & Medicaid Services (CMS), accreditation agencies and other reimbursement platforms will be requiring non–operating room anesthesia (NORA) practices to be written, recorded and measured for quality assurance purposes. Anesthesia providers should be more aware of the policies used to dictate standards and practice measures, according to a session on NORA policies at the 2016 joint meeting of the Society for Ambulatory Anesthesia and the American Society of Anesthesiologists.
“If we don’t write these policies ourselves, we end up following what others have written,” said Basem Abdelmalak, MD, associate professor of anesthesiology at the Cleveland Clinic Lerner College of Medicine, in Ohio, and Society for Ambulatory Anesthesia board director.
At the minimum, anesthesia providers should understand the differences between policies, procedures, directives, guidelines and care paths, and the weight that each carries. For instance, a policy is a mandatory requirement for the practice, such as the minimum qualification and supervision requirement for every category of providers allowed to provide anesthesia or moderate sedation, including the nonanesthesiologist proceduralists.
A procedure dictates the steps needed to accomplish a given policy, including pre- and postoperative patient care. A directive indicates the variance from an established policy for a target group of providers or patients and distinguishes what is different about this group, such as certain drugs administered for certain patient populations, such as pediatrics, or sedation types.
A guideline is a recommendation for certain situations. It is not mandatory, which allows for individualization during procedures. A care path is the guide that optimizes value of care by reducing variation in care among different practitioners. For example, it can help create group efficiency when providers follow the same care path for discharge or follow-up.
“Why do we need these? Simply put, CMS requires them,” Dr. Abdelmalak said. He suggested that clinicians should base their NORA policies on national guidelines and local and state regulations. The policies should address the qualifications of all personnel, including nurse anesthetists and procedural sedation registered nurses, as well as instructions for pre- and post-anesthesia care and discharge criteria.
Dr. Abdelmalak said providers should pay attention to definitions as they apply to early, intermediate and late recovery phases. Discharge criteria after sedation should be based on criteria and not time. Breathing, blood pressure, heart rate, surgical bleeding, pain, nausea and wakefulness are often the most important factors to consider. Postoperative urination, clear liquid consumption and overnight caregiver observation are not necessary factors to consider for discharge in selected patients. When in doubt, consult the American Society of Anesthesiologists’ guidelines for post-anesthetic care, he said.
These policies and procedures need to be updated regularly because guidelines can change based on new data.
“When somebody tells you about a new requirement, before you start implementing it, find out and verify the source of that information,” he said. “Nobody can force you to do something. You need to make these policies and guidelines your own.”
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