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Sedation and Anesthesia - Understanding the Assessment Requirements

What are the assessment requirements organizations need to understand?

Any examples are for illustrative purposes only.

Moderate sedation - A drug-induced depression of consciousness during which patients respond to purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful stimulus is not considered a purposeful response. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Deep sedation/analgesia - A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance and maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
Anesthesia - Consists of general anesthesia and spinal or major regional anesthesia, does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arouse a ball even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuro-muscular function. Cardiovascular function may be impaired.
While each level shares some common accreditation requirements, deep sedation and general and regional anesthesia assessments/administration require an anesthesia provider or a Licensed Independent Practitioner (LIP) with Medical Staff privileges in accordance with hospital's policy and state scope-of-practice laws. 

Irrespective of the medications administered, the level of sedation/anesthesia achieved determines the applicability of the accreditation requirements as discussed in this FAQ.

Pre-sedation or pre-anesthesia (deep sedation, regional or general anesthesia): 
  • The Joint Commission is not specific as to the required elements of the assessment, the expectation is that the assessment is 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, American Dental Association.) Typically, the assessment includes, vital signs, status of the airway and response to any pre-procedure medications.
  • Moderate Sedation: The organization determines who is qualified to perform the assessment consistent with competencies of staff, scope of practice, rules and regulation and State. 
  • Deep Sedation/Regional Blocks/General Anesthesia: must be performed by an anesthesia provider or LIP with medical staff privileges to administer deep sedation, regional or general anesthesia in accordance with hospital policy and state scope of practice laws.  This assessment may not be delegated to a non-privileged individual.   
Immediate pre-sedation, anesthesia assessments
  • The purpose is to confirm that there have been no changes in the patient's status since the initial assessment. This re-evaluation occurs immediately prior to (meaning without delay) the initiation of the moderate, deep or general anesthesia.  The organization determines the required elements and documentation format. (Examples may include vital signs, status of the airway and response to any pre-procedure medications.) This assessment is most often the first entry on the procedure or anesthesia record. 
  • Moderate Sedation: the organization may determine who can perform this assessment based on staff competencies scope of practice and law and regulation.
  • Deep Sedation, Regional anesthesia and Anesthesia: assessments must be performed by a qualified individual and consistent with state law and regulation.
Post anesthesia (deep sedation, regional and general anesthesia) assessments
  • In deemed(^^) organizations, completion of the post- anesthesia assessment for both inpatient and outpatient must be completed within 48 hours by an anesthesia practitioner or credentialed LIP. This assessment may not be delegated
  • The calculation of the 48-hour timeframe begins at the point the patient is moved into the designated recovery area. The evaluation generally should not be performed immediately at the point of movement from the operative area to the recovery area. The assessment should not begin until the patient is sufficiently recovered from the administration of the anesthesia so as to participate in the evaluation, e.g., answer questions appropriately, perform simple tasks, etc. 
  • Components of the evaluation may include, but are not limited to: respiratory function, including respiratory rate, airway patency and oxygen saturation; cardiovascular function, including pulse rate and blood pressure; mental status; temperature; presence of nausea and/or vomiting; pain' and post-operative hydration. Depending on the specific surgery or procedure performed, additional types of monitoring and assessment may be necessary.
  • In non-deemed organization post-anesthesia assessments for patients receiving moderate, deep, regional and general anesthesia care are evaluated by criteria established by the medical staff based on State law and professional organizations recommended practices. e.g. American Society of Anesthesiologists.
Discharge assessments
  • Discharge assessments are completed by a LIP, or the patient may be discharged upon a LIP's order based on criteria established by the medical staff. 
^The definitions are also published in the glossary of the accreditation manual.
^^ Deemed Status:  Status conferred by the Centers for Medicare & Medicaid Services (CMS) on an organization whose standards and survey process are determined by CMS to be equivalent to those of the Medicare program or other federal laws, such as the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88). Accreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement. 

Manual: Ambulatory
Chapter: Provision of Care Treatment and Services PC
Last reviewed by Standards Interpretation: October 19, 2021 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on November 22, 2021 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.

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