Post-Anesthesia Evaluation: Using a Systems Based Team Approach to Achieve Compliance with CMS Interpretive Guidelines

Abstract

Introduction: In December of 2009 the Center for Medicare and Medicaid Services (CMS) issued Revised Anesthesia Services Interpretive Guidelines. The revised post-anesthesia evaluation rules require assessment and documentation within 48 hours from the time the patient is moved into the recovery area for patients (includes outpatients prior to discharge as well as all inpatients). It applies to all patients who have had monitored anesthesia services, regional or general anesthesia. It must be performed and documented by a practitioner who is qualified to administer anesthesia and can be completed at any time and location as long as the patient has recovered sufficiently from anesthesia to answer the key questions related to the evaluation. Required key elements include assessment of mental status, pain, nausea and vomiting, temperature, hydration, respiratory and cardiovascular status. We describe the systems based team approach we used to achieve compliance with the 93% or higher post-anesthesia evaluation set by CMS and The Joint Commission. Background: UMass Memorial is a multi-campus medical center (A: Ambulatory Surgery Center (ASC), C: Tertiary University site, B: Memorial).Annually we provide anesthesia coverage for approximately 37,000 patients at 43 anesthetizing locations (44% inpatients and 56% outpatient procedures). The spread of Anesthesiology resources over three sites and the resident work hour restrictions posed a challenge to ensure compliance with CMS requirements for post-anesthesia evaluation and documentation. Methods: With input from the Anesthesiologists at all three sites we designed a template form that captured the required elements of the post-anesthesia evaluation and became part of the patient medical record (figure 1). We also modified the discharge process from the Post Anesthesia Care Unit (PACU). Previously our patients were discharged when the Alderete criteria were met using a standardized post-anesthesia order set. We modified this post-anesthesia order set to add post-anesthesia evaluation and documentation to the discharge criteria (figure 2). The Peri-anesthesia staff (PACU and Surgical Admission unit) was educated about these changes. We implemented a visual clue by the patient stretcher in the PACU when the patient was discharge ready. A member of the Anesthesia team completed the evaluation and documentation prior to patient discharge from the PACU. Patients who were admitted directly to the ICU or were not seen in the PACU were seen the following day by a member of the group. We used a systems based team approach with the help of the Anesthesiology staff and Peri-anesthesia nursing to implement this process across all three campuses. Random monthly chart audits were performed by our Quality department to assess our compliance with these CMS revised guidelines (20 charts at each site per month). Conclusion: We were able to achieve an average compliance rate of 82 to 93% across the medical center (figure 3).