By Stephen F. Knoll, CRNA, MA
The induction, maintenance and reversal of sedation to patients is one of the highest risk elements in all of health care. While numerous patient safety requirements related to anesthesia are located within The Joint Commission’s standards found in our Comprehensive Accreditation Manual for Ambulatory Care (CAMAC), few are as important to individual patient safety as the required preoperative assessments.
Required preoperative physical assessments allow surgical teams to better plan for administering operative anesthesia. Physical assessments aim to meet the following goals:
- to reduce patients’ surgical and anesthetic perioperative mortality;
- to allow for necessary real time-adjustments during a case; and
- to return patients to pre-anesthesia functioning as quickly as possible.
Due to the crucial role that assessments play in providing safe patient care, they are required during multiple steps of each patient encounter. Physical assessments occur prior to, during and post-procedure.
Equally important is communication of assessment results to the rest of the care team, which may take place verbally and through documentation in the form of standardized processes such as time-outs and care hand offs. The goal of this communication is to ensure that all staff involved is updated with the most current patient status.
Joint Commission standards are not specific to required elements of these physical assessments, with the expectation that they are based on established or recommended professional practices. (Examples of professional organizations that provide guidance for clinical practice are the American Society of Anesthesiologists, American Association of Nurse Anesthetist, and American Dental Association.)
H&P Assessment
One of the most important assessments is the history and physical (H&P). A patient’s H&P is similar to their medical story communicated through verbalization as well as physical assessment. Together, the two components indicate whether a patient’s surgical needs are appropriate for an ASC setting. Centers must determine specific patient population and risk levels that their facilities can safely accommodate to ensure a robust process and strict adherence to guidelines.
Patients who fall into Category I and Category II are most often determined to be appropriate for outpatient settings. However, as technology and staff competency increases, some ASCs have added Category III patients as well, making thorough assessments even more important.
The H&P must be performed by an individual who is qualified to do so through their health care organization’s credentialing and privileging processes. Often, it is completed by a surgeon during a presurgical visit in a clinic rather than among the hustle and bustle of a busy surgical suite. An increasing number of pre-anesthesia assessment programs now require patients to complete their assessments prior to the day of surgery. This way, the H&P, the nursing assessment, and laboratory testing are performed with time to allow for additional testing, if required. These programs are designed to ensure that when a patient arrives for surgery the next day, both patient and surgical team are thoroughly equipped and ready to proceed safely.
Pre-Anesthesia Assessment
The pre-anesthesia assessment is conducted to confirm that there have been no changes in a patient’s status since the H&P was performed. This final re-evaluation occurs immediately prior to the initiation of moderate, deep, regional or general anesthesia.
An ASC determines both the elements which are required for this assessment as well as how it is captured within a patient’s medical record. This assessment is important as there may be hemodynamic changes in vital signs and in a patient’s overall condition since the previous assessments were completed.
Continuous Anesthesia Monitoring
Once the procedure has begun, continuous monitoring of a patient under anesthesia is critical as anesthesia can cause rapid changes in vital functions. Physiological parameters must continually be monitored including end tidal CO2 when required, by either select evidence-based guidelines, ASC policies and procedures, or state regulatory requirements. In addition to physiologic variables, anesthesia clinicians must also continuously monitor their equipment to detect and correct equipment malfunctions during all types of anesthesia. Patient monitoring equipment is used to assist in the titration of anesthetic medication, to detect physiologic perturbations, to ultimately allow for intervention before the patient suffers any harm.
Post-Anesthesia Assessment
Although the surgeon may have completed their procedure, the work of an anesthesia team continues. Quality care must continue to be provided post-surgery. Close monitoring of the final step in a safe patient journey is critical and should not be rushed or otherwise overlooked. These precautionary measures help prevent many post-discharge adverse events.
Conclusion
Thorough patient assessments are key to safe patient care. Better outcomes and safer delivery of care are achieved when assessments are performed, especially when related information is subsequently shared with an entire care team. Shared information from assessments provides the care team a collective mental model of the procedure, identified risks involved and helps establish a plan to mitigate those risks.
The Joint Commission is privileged to partner with our ASC customers on their journey to high reliability. We invite health care organizations to share their questions as well as best practices via our homepage at jointcommission.org.
– Stephen F. Knoll, CRNA, MA, is the associate director, Standards Interpretation Group, The Joint Commission.
