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Anaesthesia Clinical Indicator User Manual 2011

1. CLINICAL 2. SUPPORT1.3 Appropriate care and services areprovided to consumers / patients.1.3.1 Health care and services areappropriate and delivered in the mostappropriate setting.1.4 The organisation provides careand services that achieve expectedoutcomes.1.4.1 Care and services are planned,developed and delivered based on thebest available evidence and in the mosteffective way.1.5 The organisation provides safecare and services.1.5.1 Medications are managed toensure safe and effective consumer /patient outcomes.1.5.2 The infection control systemsupports safe practice and ensures asafe environment for consumers /patients and healthcare workers.1.5.3 The incidence and impact ofbreaks in skin integrity, pressure ulcersand other non-surgical wounds areminimised through wound preventionand management programs.1.5.4 The incidence of falls and fallinjuries is minimised through a fallsmanagement program.1.5.5 The system to manage samplecollection, blood, blood components /blood products and patient bloodmanagement ensures safe andappropriate practice.1.5.6 The organisation ensures that thecorrect consumer / patient receives thecorrect procedure on the correct site.1.5.7 The organisation ensures that thenutritional needs of consumers /patients are met.1.6 The governing body is committedto consumer participation.1.6.1 Consumers / patients, carers andthe community participate in theplanning, delivery and evaluation of thehealth service.1.6.2 Consumers / patients are informedof their rights and responsibilities.1.6.3 The organisation meets the needsof the consumers / patients and carerswith diverse needs and from diversebackgrounds.Anaesthesia Clinical Indicators Version 5.12.3.1 Health records management systemssupport the collection of information and meetthe consumer / patient and organisation‟s needs.2.3.2 Corporate records management systemssupport the collection of information and meetthe organisation‟s needs2.3.3 Data and information are collected, storedand used for strategic, operational and serviceimprovement purposes.2.3.4 The organisation has an integratedapproach to the planning, use and managementof information and communication technology(I&CT).2.4 The organisation promotes the health ofthe population.2.4.1 Better health and wellbeing is promoted bythe organisation for consumers / patients, staffand the wider community.2.5 The organisation encourages andadequately governs the conduct of healthand medical research to improve the safetyand quality of health care.2.5.1 The organisation‟s research programdevelops the body of knowledge, protects staffand consumers / patients and has processes toappropriately manage the organisational risksassociated with research.Key:Mandatory CriteriaACHS Clinical Indicator User Manual 2011 7

INDICATOR AREA 1: PRE-ANAESTHESIA PERIODIndicator TopicAdequate pre-anaesthesia assessment of the surgical patient.Anaesthesia Clinical Indicators Version 5.1RationaleConsultation by an anaesthetist is essential for the medical assessment of a patient prior toanaesthesia for surgery or other procedure to ensure that the patient is in the optimal statefor anaesthesia and surgery.The consultation must take place at an appropriate time and place prior to anaesthesia andsurgery in order to allow for adequate consideration of all factors.Pre-anaesthesia consultation facilities must include appropriate equipment and space toallow for a consultation and clinical examination in privacy. An appropriately equippedconsulting room or single bed hospital room is most appropriate.Type of IndicatorThis is a comparative rate based indicator addressing the process of patient care.Desired Rate1.1 – HighDefinition of TermsFor the purpose of Indicator 1.1The pre-anaesthesia consultation refers to Recommendation on the Pre-AnaesthesiaConsultation Review PS7 (2008) (Appendix 5).The visit should preferably be conducted by the attending anaesthetist but may beconducted by one of the medical members of the same anaesthetic department or group.Note: This indicator applies to emergency as well as elective procedures; Patients for non-elective surgery (including emergency patients) who undergo aprocedure on the day of admission should be included as well as patients for nonelectivesurgery who undergo a procedure on any subsequent day; Diagnostic and therapeutic procedures such as E.R.C.P, radiological interventions,cardioversion, and gastroenterology endoscopy patients should be included.ACHS Clinical Indicator User Manual 2011 8

Anaesthesia Clinical Indicators Version 5.1INDICATORCI 1.1 NumeratorDenominatorTotal number of patients with a documented pre-anaesthesiaassessment completed by an anaesthetist prior to transfer to theoperating theatre or procedure room, during the time period understudy.Total number of patients who undergo a procedure with ananaesthetist in attendance, during the time period under study.This indicator can be used to support the following EQuIP5 criteria:1.1.1 Assessment1.1.2 Care Planning and Delivery1.1.4 Evaluation of Care1.1.6 Ongoing Care1.1.8 Health Care Documentation1.3.1 Appropriateness of Care1.4.1 Effectiveness of CareACHS Clinical Indicator User Manual 2011 9

INDICATOR AREA 1: PRE-ANAESTHESIA PERIODAnaesthesia Clinical Indicators Version 5.1Indicator TopicProphylactic anti-emetic treatment in patients with a documented history of post-operativenausea and vomiting (PONV).RationalePONV is a frequent and distressing consequence of many surgical procedures. There is awealth of literature highlighting known risk factors, and international consensus guidelines forprophylaxis.Type of IndicatorThis is a comparative rate based indicator addressing the process of patient care.Desired Rate1.3 – HighSuggested Data Collection Period4–8 weeks (depending on throughput).INDICATORCI 1.3NumeratorDenominatorTotal number of patients with a history of PONV to whom aprophylactic anti-emetic has been administered, during the timeperiod under studyTotal number of patients receiving anaesthesia care who have ahistory of PONV, during the time period under studyThis indicator can be used to support the following EQuIP5 criteria:1.1.2 Care Planning and Delivery1.1.4 Evaluation of Care1.3.1 Appropriateness of Care1.4.1 Effectiveness of CareACHS Clinical Indicator User Manual 2011 11

INDICATOR AREA 2: INTRA-OPERATIVE PERIODIndicator TopicPresence of a trained assistant.Anaesthesia Clinical Indicators Version 5RationaleThe presence of a trained assistant for the anaesthetist during the conduct of anaesthesia isa major contributory factor to safe patient management.Type of IndicatorThis is a comparative rate based indicator addressing structure.Desired Rate2.1– HighDefinitions of TermsFor the purpose of Indicator 2.1Trained assistant must have undertaken appropriate training in order to provide effectivesupport to the anaesthetist. Please refer to Recommendations on the Assistant for theAnaesthetist Review PS8 (2008) (Appendix 7).Suggested Data Collection PeriodContinuous collectionNote: Diagnostic and therapeutic procedures such as E.R.C.P, radiological interventions,cardioversion, and gastroenterology endoscopy patients should be INCLUDED. Please refer to Guidelines on Sedation and/or Analgesia for Diagnostic and InterventionalMedical or Surgical Procedures Review PS9 (2008) (Appendix 8).INDICATORPresence of a trained assistantCI 2.1NumeratorDenominatorTotal number of patients who undergo a procedure with ananaesthetist in attendance, where there is a trained assistant tothe anaesthetist, during the time period under studyTotal number of patients who undergo a procedure with ananaesthetist in attendance during the time period under studyThis indicator can be used to support the following EQuIP5 criteria:1.1.2 Care Planning and Delivery1.1.4 Evaluation of Care1.3.1 Appropriateness of Care1.4.1 Effectiveness of CareACHS Clinical Indicator User Manual 2011 12

INDICATOR AREA 2: INTRA-OPERATIVE PERIODAnaesthesia Clinical Indicators Version 5Indicator TopicCompliance of anaesthesia records with ANZCA minimum requirements for anaesthesiainformation.RationaleAn adequate anaesthesia record is an essential part of the patient‟s medical record andshould chart all aspects of management relevant to the anaesthetic.Type of IndicatorThis is a comparative rate based indicator addressing the process of patient care.Desired Rate2.2– HighDefinitions of TermsFor the purpose of Indicator 2.2ANZCA stands for The Australian and New Zealand College of AnaesthetistsSubstantially complies can be interpreted as implying there is sufficient information in thepatient record to identify the patient and understand the treatment provided, Please refer toRecommendations on the Recording of an Episode of Anaesthesia Care ANZCA PS6 (2006)(Appendix 9).Suggested Data Collection Period4–8 weeks (depending on throughput).INDICATORCI 2.2NumeratorDenominatorTotal number of patients who undergo a procedure with ananaesthetist in attendance, where the anaesthesia recordssubstantially complies with the ANZCA requirements for theanaesthetic record, during the time period under studyTotal number of patients who undergo a procedure with ananaesthetist in attendance, during the time period under studyThis indicator can be used to support the following EQuIP5 criteria:1.1.2 Care Planning and Delivery1.1.4 Evaluation of Care1.1.8 Health record documentation1.3.1 Appropriateness of Care1.4.1 Effectiveness of CareACHS Clinical Indicator User Manual 2011 13

INDICATOR AREA 3: PATIENT RECOVERY PERIODIndicator TopicOccurrence of defined clinical events during the recovery period.Anaesthesia Clinical Indicators Version 5.1RationaleThe occurrence of a „clinical event‟ may indicate less than optimal performance inanaesthesia. These indicators should encourage recovery room staff to report any significantdeparture from the usual recovery process.Type of IndicatorThese are comparative rate based indicators addressing the outcomes of patient care.Desired Rate3.1 – Low3.2 – Low3.3 – Low3.4 – Low3.5 – LowDefinitions of TermsFor the purpose of Indicator 3.1 – 3.5Recovery period is the time the patient spends in the recovery room until transfer toanother area of the facility.For the purpose of Indicators 3.2 and 3.4Written protocols for patient management in recovery should be established. Please refer toRecommendations for the Post-Anaesthesia Recovery Room Review PS4 (2006) (Appendix10).For the purpose of Indicators 3.4Severe pain is defined as a pain intensity score at 7 to 10 based on 10 point numericalrating scale (NRS).Suggested Data Collection PeriodContinuous collection.ACHS Clinical Indicator User Manual 2011 14

Anaesthesia Clinical Indicators Version 5.1INDICATORCI 3.1CI 3.2CI 3.3CI 3.4CI 3.5NumeratorDenominatorNumeratorDenominatorNumeratorDenominatorNumeratorDenominatorNumeratorDenominatorTotal number of patients undergoing a procedure who requiretracheal intubation or insertion of a laryngeal mask (orequivalent) to relieve respiratory distress, in the recovery period,during the time period under studyTotal number of patients receiving post-anaesthesia care whoare admitted to the post anaesthesia recovery room during thetime period under studyTotal number of patients undergoing treatment for postoperative nausea and vomiting in the post anaesthesiarecovery room according to a hospital-approved protocol,during the time period under studyTotal number of patients receiving post-anaesthesia care whoare admitted to the post anaesthesia recovery room, during thetime period under studyTotal number of patients admitted to the post anaesthesiarecovery room with a temperature recorded in the recoveryperiod of less than 36 degrees 0 C., during the time periodunder studyTotal number of patients receiving post-anaesthesia care whoare admitted to the post anaesthesia recovery room, during thetime period under studyTotal number of patients undergoing a procedure who arereviewed by an anaesthetist to manage severe pain NOTresponding to the post anaesthesia recovery room painprotocol, in the recovery period, during the time period understudyTotal number of patients receiving post-anaesthesia care whoare admitted to the post anaesthesia recovery room, during thetime period under studyTotal number of patients undergoing a procedure with ananaesthetist in attendance who have an unplanned stay in thepost anaesthesia recovery room for longer than 2 hours formedical reasons, during the time period under studyTotal number of patients receiving post-anaesthesia care whoare admitted to the post anaesthesia recovery room, during thetime period under studyACHS Clinical Indicator User Manual 2011 15

Anaesthesia Clinical Indicators Version 5.1These indicators can be used to support the following EQuIP5 criteria:INDICATORS3.1 3.2 3.3 3.4 3.5CRITERION 1.1.1 Assessment 1.1.2 Care Planning and Delivery 1.1.4 Evaluation of Care 1.3.1 Appropriateness of Care 1.4.1 Effectiveness of CareACHS Clinical Indicator User Manual 2011 16

INDICATOR AREA 4: POST-OPERATIVE PERIODAnaesthesia Clinical Indicators Version 5.1Indicator TopicUnplanned patient admission to an intensive care unit within 24 hours of a procedure.RationaleUnplanned admission to an intensive care unit may be due to an avoidable incident inanaesthesia.Type of IndicatorThis is a comparative rate based indicator addressing the outcome of patient care.Desired Rate4.1 – LowDefinitions of TermsFor the purpose of Indicator 4.1The definition of an Intensive Care Unit will vary between organisations, however, it isanticipated that the level of intensive care available would support the delineated role of theparticular organisation. Please refer to Minimum Standards for Intensive Care Units ReviewIC-1 (2003) (Appendix 11).Unplanned admission refers to the necessity for an unexpected admission to the intensivecare unit (ICU) for treatment of a complication related to a previous procedure with ananaesthetist in attendance.Suggested Data Collection PeriodContinuous collection.Note: This indicator relates to any procedure requiring an anaesthetist to be in attendance; Unplanned admissions to high dependency units (HDUs) are EXCLUDEDINDICATORCI 4.1NumeratorDenominatorTotal number of patients having an unplanned admission to anintensive care unit within 24 hours of a procedure with ananaesthetist in attendance, during the time period under studyTotal number of patients receiving anaesthesia care, during thetime period under studyThis indicator can be used to support the following EQuIP5 criteria:1.1.2 Care Planning and Delivery1.1.4 Evaluation of Care1.3.1 Appropriateness of Care1.4.1 Effectiveness of CareACHS Clinical Indicator User Manual 2011 17

INDICATOR AREA 5: MANAGEMENT OF ACUTE PAINIndicator TopicEffective management of acute, post-operative painAnaesthesia Clinical Indicators Version 5.1RationaleAnalgesic efficacy and the occurrence of „clinical events‟ are an essential component of anacute pain audit. Continuous collection of information regarding „major adverse events‟ mayallow a more accurate estimation of the prevalence of rare events over time.Type of IndicatorThese are comparative rate based indicators addressing the process and outcomes ofpatient care.Desired Rate5.1 – High5.2 – HighDefinitions of TermsFor the purpose of Indicators 5.1 and 5.2Analgesic efficacy can be measured in many ways. Assessment of effective analgesiarequires ongoing review. Analgesia may vary with movement, equipment malfunction or for avariety of other reasons. The most appropriate measure varies with the clinical scenario andneeds to be determined by the clinicians involved.For the purpose of Indicator 5.2Post-operative epidural analgesia refers to continuing postprocedural epidurals.Optimising epidural analgesic efficacy while limiting unwanted side effects of this analgesictechnique requires regular patient review.While the risk of permanent neurological damage in association with epidural analgesia isvery low the incidence is higher when there is a delay in diagnosing epidural hamatoma orabcess.Please refer to Guidelines for the Management of Major Regional Analgesia Review PS3(2003) (Appendix 12).Note: New epidurals initiated at a date/time after the surgical procedure are EXCLUDED.Suggested Data Collection Period1–3 months (depending on throughput)Other Measurement ToolsA random survey could be undertaken examining education generally or specific topics forexample, use of PCA pumps, care of patients with epidurals etc.ACHS Clinical Indicator User Manual 2011 18

Anaesthesia Clinical Indicators Version 5.1INDICATORCI 5.1CI 5.2NumeratorDenominatorNumeratorDenominatorTotal number of surgical patients staying at least one night, withpain intensity scores regularly recorded by nursing staff, duringthe time period under studyTotal number of surgical patients staying at least one night whoreceive acute pain management, during the time period understudyTotal number of patients receiving post-operative epiduralanalgesia that are reviewed at least daily by an anaesthetistuntil removal of catheter, during the time period under studyTotal number of patients receiving post-operative epiduralanalgesia, during the time period under studyThese indicators can be used to support the following EQuIP5 criteria:INDICATORS5.1 5.2CRITERION 1.1.1 Assessment 1.1.2 Care Planning and Delivery 1.1.4 Evaluation of Care 1.1.8 Health record documentation 1.3.1 Appropriateness of Care 1.4.1 Effectiveness of CareACHS Clinical Indicator User Manual 2011 19

Anaesthesia Clinical Indicators Version 5.1INDICATORCI 6.1CI 6.2CI 6.3NumeratorDenominatorNumeratorDenominatorNumeratorDenominatorTotal number of obstetric patients who experience a post-duralpuncture headache, during the time period under study.Total number of obstetric patients receiving epidural/spinalanalgesia, during the time period under studyTotal number of patients who commence surgery within 30minutes of request for immediate lower segment cesariansection (LSCS), during the time period under studyTotal number of patients requiring immediate lower segmentcesarian section (LSCS), during the time period under studyTotal number of obstetric patients who have documentation ofrisks and benefits of spinal analgesia/epidural, during the timeperiod under study.Total number of obstetric patients receiving epidural/spinalanalgesia, during the time period under studyThese indicators can be used to support the following EQuIP5 criteria:INDICATORS6.1 6.2 6.3CRITERION 1.1.1 Assessment 1.1.2 Care Planning and Delivery 1.1.3 Informed consent 1.1.4 Evaluation of Care 1.1.8 Health record documentation 1.3.1 Appropriateness of Care 1.4.1 Effectiveness of CareACHS Clinical Indicator User Manual 2011 21

Area: 1 Pre-anaesthesia PeriodAnaesthesia Indicators Version 5First Half 2011Topic: Adequate pre-anaesthesia consultation of the surgical patient.1.1 Adequate pre-anaesthesia assessment of the surgical patient.Numerator From: To:Total number of patients with a documented pre-anaesthesia assessment completed by ananaesthetist prior to transfer to the operating theatre or procedure room, during the timeperiod under study.DenominatorTotal number of patients who undergo a procedure with an anaesthetist in attendance,during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 1

Area: 1 Pre-anaesthesia PeriodAnaesthesia Indicators Version 5First Half 2011Topic: Provision of patient information regarding risks and benefits of the anaesthetic procedure(s).1.2 Documentation of risks and benefits of anaesthesia.Numerator From: To:Total number of patients who have documentation of risks and benefits of the anaestheticprocedure(s) during the time period under study.DenominatorTotal number of patients receiving anaesthesia care, during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 2

Area: 1 Pre-anaesthesia PeriodAnaesthesia Indicators Version 5First Half 2011Topic: Prophylactic anti-emetic treatment in patients with a documented history of post-operativenausea and vomiting (PONV).1.3 Prophylactic anti-emetic treatment in patients with a documented history ofpost-operative nausea and vomiting.Numerator From: To:Total number of patients with a history of PONV to whom a prophylactic anti-emetic hasbeen administered, during the time period under study.DenominatorTotal number of patients receiving anaesthesia care who have a history of PONV, duringthe time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 3

Area: 2 Intra-operative PeriodTopic: Presence of a trained assistant.2.1 Presence of a trained assistant.Anaesthesia Indicators Version 5First Half 2011Numerator From: To:Total number of patients who undergo a procedure with an anaesthetist in attendance,where there is a trained assistant to the anaesthetist, during the time period under study.DenominatorTotal number of patients who undergo a procedure with an anaesthetist in attendanceduring the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 4

Area: 2 Intra-operative PeriodAnaesthesia Indicators Version 5First Half 2011Topic: Compliance of anaesthesia records with ANZCA minimum requirements for anaesthesiainformation.2.2 Compliance of anaesthesia records with ANZCA minimum requirements for anaesthesiainformation.Numerator From: To:Total number of patients who undergo a procedure with an anaesthetist in attendance,where the anaesthesia records substantially complies with the ANZCA requirements for theanaesthetic record, during the time period under study.DenominatorTotal number of patients who undergo a procedure with an anaesthetist in attendance,during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 5

Area: 3 Patient Recovery PeriodAnaesthesia Indicators Version 5First Half 2011Topic: Occurrence of defined clinical events during the recovery period.3.1 Avoiding severe respiratory distress in the recovery room.Numerator From: To:Total number of patients undergoing a procedure who require tracheal intubation orinsertion of a laryngeal mask (or equivalent) to relieve respiratory distress, in the recoveryperiod, during the time period under study.DenominatorTotal number of patients receiving post-anaesthesia care who are admitted to the postanaesthesia recovery room during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo3.2 Established protocol for treatment for post operative nausea and vomiting in the postanaesthesia recovery room.Numerator From: To:Total number of patients undergoing treatment for post operative nausea and vomiting inthe post anaesthesia recovery room according to a hospital-approved protocol, during thetime period under study.DenominatorTotal number of patients receiving post-anaesthesia care who are admitted to the postanaesthesia recovery room, during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 6

Area: 3 Patient Recovery PeriodAnaesthesia Indicators Version 5First Half 2011Topic: Occurrence of defined clinical events during the recovery period.3.3 Inadvertent hypothermia after surgery.Numerator From: To:Total number of patients admitted to the post anaesthesia recovery room with atemperature recorded in the recovery period of less than 36 degrees 0C., during the timeperiod under study.DenominatorTotal number of patients receiving post-anaesthesia care who are admitted to the postanaesthesia recovery room, during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo3.4 Manage severe pain not responding to the post anaesthesia recovery room painprotocol.Numerator From: To:Total number of patients undergoing a procedure who are reviewed by an anaesthetist tomanage severe pain NOT responding to the post anaesthesia recovery room pain protocol,in the recovery period, during the time period under study.DenominatorTotal number of patients receiving post-anaesthesia care who are admitted to the postanaesthesia recovery room, during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 7

Area: 3 Patient Recovery PeriodAnaesthesia Indicators Version 5First Half 2011Topic: Occurrence of defined clinical events during the recovery period.3.5 Unplanned recovery room stay of longer than 2 hours for medical reasons.Numerator From: To:Total number of patients undergoing a procedure with an anaesthetist in attendance whohave an unplanned stay in the post anaesthesia recovery room for longer than 2 hours formedical reasons, during the time period under study.DenominatorTotal number of patients receiving post-anaesthesia care who are admitted to the postanaesthesia recovery room, during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 8

Area: 4 Post-operative PeriodAnaesthesia Indicators Version 5First Half 2011Topic: Unplanned patient admission to an intensive care unit within 24 hours of a procedure.4.1 Unplanned patient admission to an intensive care unit within 24 hours of a procedure.Numerator From: To:Total number of patients having an unplanned admission to an intensive care unit within 24hours of a procedure with an anaesthetist in attendance, during the time period under study.DenominatorTotal number of patients receiving anaesthesia care, during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 9

Area: 5 Management of Acute PainAnaesthesia Indicators Version 5First Half 2011Topic: Effective management of acute, post-operative pain5.1 Measurement and documentation of pain intensity scores after major surgery.Numerator From: To:Total number of surgical patients staying at least one night, with pain intensity scoresregularly recorded by nursing staff, during the time period under study.DenominatorTotal number of surgical patients staying at least one night who receive acute painmanagement, during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo5.2 At least daily review by an anaesthetist of patients receiving postoperative epiduralanalgesia, until removal of catheter.Numerator From: To:Total number of patients receiving post-operative epidural analgesia that are reviewed atleast daily by an anaesthetist until removal of catheter, during the time period under study.DenominatorTotal number of patients receiving post-operative epidural analgesia, during the time periodunder study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 10

Area: 6 Obstetric Anaesthesia CareAnaesthesia Indicators Version 5First Half 2011Topic: Provision of anaesthesia care to obstetric patients6.1 Minimisation of post-dural puncture headache.Numerator From: To:Total number of obstetric patients who experience a post-dural puncture headache, duringthe time period under study.DenominatorTotal number of obstetric patients receiving epidural/spinal analgesia, during the time periodunder study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo6.2 Commencement of surgery within 30 minutes of a request for emergency caesareansection.Numerator From: To:Total number of patients who commence surgery within 30 minutes of request forimmediate lower segment cesarian section (LSCS), during the time period under studyDenominatorTotal number of patients requiring immediate lower segment cesarian section (LSCS),during the time period under study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 11

Area: 6 Obstetric Anaesthesia CareAnaesthesia Indicators Version 5First Half 2011Topic: Provision of anaesthesia care to obstetric patients6.3 Provision of patient information regarding risks and benefits of epidural / spinalanalgesia for labour.Numerator From: To:Total number of obstetric patients who have documentation of risks and benefits of spinalanalgesia/epidural, during the time period under study.DenominatorTotal number of obstetric patients receiving epidural/spinal analgesia, during the time periodunder study.In collecting and reporting the data for this indicator the definitions in theUsers Manual were followed preciselyComments:YesNo08-Feb-2011 14:10 12

Anaesthesia Clinical Indicators Version 5.1APPENDIX 2: ICD-10-AM Codes applicable to this indicator setINDICATOR AREA 3: PATIENT RECOVERY PERIODNumerator in ICD-10-AMCI Codes that may assist data collection: For consideration:3.13.23.3Any of the following disease codes:R06.0 DyspnoeaJ80Adult respiratory distresssyndromewith/withoutJ95.8 Other postproceduralrespiratory disordersR11Nausea and vomitingorK91.0 Vomiting followinggastrointestinal surgeryT88.5 Other complications ofanaesthesiawith/withoutT68HypothermiaRecord review required to: check whether interventionwas undertaken byanaesthetist check that clinical eventwas during the recoveryperiodRecord review required to: check whether interventionwas undertaken byanaesthetist check that clinical eventwas during the recoveryperiodRecord review required to: determine if type ofcomplication ishypothermia check whether interventionwas undertaken byanaesthetist check that clinical eventwas during the recoveryperiodIndicator Area 6: OBSTETRIC ANAESTHESIA CARENumerator in ICD-10-AMCI Codes that may assist data collection: For consideration:6.1O74.5 Spinal and epiduralanaesthesia-inducedheadache during labourand deliveryDenominator in ICD-10-AMCI Codes that may assist data collection: For consideration:6.1Either of the following procedure codes:92506-xx [1333] Neuraxial block duringlabour92507-xx [1333] Neuraxial block duringlabour and deliveryprocedureorAny procedure code from block:[1340] Caesarean sectionwith92508-xx [1909] Neuraxial blockACHS Clinical Indicator User Manual 2011 22

6.216520-03 [1340] Emergency lowersegment caesareansectionAnaesthesia Clinical Indicators Version 5.1Need to refer to RANZCOGstatement* (see definition ofterms) for those cases thatmeet the definition of„immediate‟* Royal Australian & New Zealand College of Obstetricians & Gynaecologists. CollegeStatement: Delivery Interval for Caesarean Section. C-Obs 14. East Melbourne; RANZCOG:July 2007. Accessed 12 December 2008 fromhttp://www.ranzcog.edu.au/publications/statements/C-obs14.pdfACHS Clinical Indicator User Manual 2011 23

Anaesthesia Clinical Indicators Version 5.1APPENDIX 3: Working Party MembershipTHE AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS (ANZCA)Dr Margie Cowling(Chairperson)Senior ConsultantDepartment of AnaesthesiaFlinders Medical CentreProfessor Paul MylesDr Tracey TayDirector, Department of Anaesthesia and PerioperativeMedicineAlfred Hospital and Monash UniversitySenior Staff SpecialistDepartment of AnaestheticsJohn Hunter HospitalClinical Lead, Innovation and ReformHunter New England Area Health ServiceMs Janney WaleMs Julie RustCONSUMER REPRESENTATIVEConsumers‟ Health Forum of AustraliaNATIONAL CENTRE FOR CLASSIFICATION IN HEALTHProject Officer, National Centre for Classification inHealth, Faculty of Health Sciences, University of SydneyDr Leon ClarkAUSTRALIAN PRIVATE HOSPITALS ASSOCIATIONCEO, Sydney Adventist Hospital, NSWMs Jennifer RabachROYAL COLLEGE OF NURSING, AUSTRALIALecturer in Acute Care, School of Nursing & Midwifery,Victoria UniversityA/Professor Bob GibberdHEALTH SERVICES RESEARCH GROUPDirector, Health Services Research Group, University ofNewcastleDr Chris MaxwellTHE AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDSClinical Director, ACHS Performance and OutcomesServiceMs Helen StarkCoordinator, Performance and Outcomes ServiceACHS Clinical Indicator User Manual 2011 24

Anaesthesia Clinical Indicators Version 5.1APPENDIX 4: PUBLISHED EVIDENCE FOR ANAESTHESIA INDICATORSCI 1.1CI 1.2CI 1.3CI 2.1CI 2.2Adequate pre-anaesthesiaassessment by ananaesthetist prior totransfer to the operatingtheatre or procedure room.Provision of patientinformation regarding risksand benefits of theanaesthetic procedure(s).Prophylactic anti-emetictreatment in patients witha documented history ofpost-operative nausea andvomitingPresence of a trainedassistant.Compliance ofanaesthesia records withANZCA minimum1. ANZCA. Safety of Anaesthesia in Australia: A Reviewof Anaesthesia Related Mortality, 1997 – 1999.Australian and New Zealand College of Anaesthetists.2. ANZCA. Safety of Anaesthesia in Australia: A Reviewof Anaesthesia Related Mortality, 2000-2002.Australian and New Zealand College of Anaesthetists.3. Buck N, Devlin HB, Lunn JN. The report of aconfidential enquiry into perioperative deaths.London: Nuffield Provincial Hospitals Trust, 1987.4. The 2002 Report of the National Confidential Enquiryinto Perioperative Deaths.www.ncepod.org.au/pdf/2002/02sum.pdf5. Professional Standards Document PS7 :Recommendations on The Pre-AnaesthesiaConsultation. Australian and New Zealand College ofAnaesthetists.www.anzca.edu.au/resources/professionaldocuments1. Hoehner PJ. Ethical aspects of informed consent inobstetric anesthesia - new challenges and solutions.J Clin Anesth 2003; 15(8):587-600.2. Hoehner PJ. Ethical decisions in perioperative eldercare. Anesthesiol Clin North America2000;18(1):159-81.3. Professional Standards Document PS26 : Guidelineson Consent for Anaesthesia or Sedation. Australianand New Zealand College of Anaesthetists.www.anzca.edu.au/resources/professionaldocuments1. Gan TJ, Meyer T, Apfel CC, et al. Society forAmbulatory Anesthesia Guidelines for themanagement of postoperative nausea and vomiting.Anesth Analg 2007; 105:1615-28.2. Tramèr MR. A rational approach to the control ofpostoperative nausea and vomiting: evidence fromsystematic reviews. Part II. Recommendations forprevention and treatment, and research agenda. ActaAnaesthesiol Scand 2001; 45(1):14-9.1. Professional Standards Document PS8: Guidelineson the Assistant for the Anaesthetist. Australian andNew Zealand College of Anaesthetists.www.anzca.edu.au/resources/professionaldocuments2. Professional Standards document PS9: Guidelines onSedation and /or Analgesia for Diagnostic andInterventional Medical or Surgical procedureswww.anzca.edu.au/resourses/professionaldocuments1. Professional Standards Document PS6 : TheAnaesthesia Record. Recommendations on theRecording of an Episode of Anaesthesia Care.ACHS Clinical Indicator User Manual 2011 25

CI 3.1CI 3.2CI 3.3CI 3.4CI 3.5requirements foranaesthesia information.Avoiding severerespiratory distress in therecovery roomEstablished protocol fortreatment for postoperative nausea andvomiting in the postanaesthesia recoveryroomInadvertent hypothermiaafter surgery.Established protocol fortreatment of severe pain inthe post anaesthesiarecovery roomUnplanned recovery roomstay of longer than 2 hoursAnaesthesia Clinical Indicators Version 5.1Australian and New Zealand College of Anaesthetists.www.anzca.edu.au/resources/professionaldocuments1. The 2002 Report of the National Confidential Enquiryinto Perioperative Deaths.www.ncepod.org.au/pdf/2002/02sum.pdf.2. Vimlati L, Gilsanz F, Goldik Z. Quality and safetyguidelines of postanaesthesia care: Working Party onPost Anaesthesia Care. Eur J Anaesthesiol 2009 Apr22.1. Gan TJ, Meyer T, Apfel CC, et al. Society forAmbulatory Anesthesia Guidelines for themanagement of postoperative nausea and vomiting.Anesth Analg 2007; 105:1615-28.2. Vimlati L, Gilsanz F, Goldik Z. Quality and safetyguidelines of postanaesthesia care: Working Party onPost Anaesthesia Care. Eur J Anaesthesiol 2009 Apr22.3. Professional Standards Document PS4Recommendations for the Post AnaesthesiaRecovery Room1. Kurz A, Sessler DI, Lenhardt R. Perioperativenormothermia to reduce the incidence of surgicalwound infection and shorten hospitalization. N Engl JMed 1996; 334:1209-15.2. Bock M, Muller J, Bach A, et al. Effects ofpreinduction and intraoperative warming during majorlaparotomy. Br J Anaesth 1998; 80:159-63.3. Schmied H, Kurz A, Sessler DI, et al. Mildintraoperative hypothermia increases blood loss andallogeneic transfusion requirements during total hiparthroplasty. Lancet 1996; 347:289-92.4. Schmied H, Schiferer A, Sessler D, Meznik C. Theeffects of red-cell scavenging, hemodilution andactive warming on allogenic blood requirements inpatients undergoing hip or knee arthroplasty. AnesthAnalg 1998; 86:387-915. Vimlati L, Gilsanz F, Goldik Z. Quality and safetyguidelines of postanaesthesia care: Working Party onPost Anaesthesia Care. Eur J Anaesthesiol 2009 Apr22.6. National Institute for Health and Clinical Excellence(NICE) Guidelines on management of inadvertentperioperative hypothermia in adults.www.nice.org.uk/CG651. NHMRC. Acute pain management: scientificevidence, 2 nd ed. 20052. Aubrun F, Monsel S, Langeron O, et al.Postoperative titration of intravenous morphine. Eur JAnaesthesiol 2001 ; 18 : 159-65.3. Macintyre PE, Ready LB. Acute pain management: apractical guide. 2 nd ed., London; 2001, WB Saunders.1. The 2002 Report of the National Confidential Enquiryinto Perioperative Deaths.ACHS Clinical Indicator User Manual 2011 26

Anaesthesia Clinical Indicators Version 5.1CI 4.1CI 5.1CI 5.2CI 6.1CI 6.2for medical reasonsUnplanned patientadmission to an intensivecare unit within 24 hoursof a procedure.Measurement anddocumentation of painintensity scores aftermajor surgery.At least daily review by ananaesthetist of patientsreceiving postoperativeepidural analgesia, untilremoval of catheter.Minimisation of post-duralpuncture headache.Commencement ofsurgery within 30 minutesof a request foremergency Caesareanwww.ncepod.org.au/pdf/2002/02sum.pdf2. Vimlati L, Gilsanz F, Goldik Z. Quality and safetyguidelines of postanaesthesia care: Working Party onPost Anaesthesia Care. Eur J Anaesthesiol 2009 Apr22.1. Haller G, Myles PS, Wolfe R, Weeks AM, StoelwinderJ, McNeil J. Validity of uplanned admission to anintensive care unit as a measure of patient safety insurgical patients. Anesthesiology 2005; 103:1121-1129.2. Haller G, Stoelwinder J, Myles PS, McNeil J. Qualityand safety indicators in anesthesia: a systematicreview. Anesthesiology 2009; 110:1058-75.1. NHMRC. Acute pain management: scientificevidence, 2 nd ed. 20052. Acute postoperative pain (APOP) project.http://www.health.vic.gov.au/qualitycouncil/downloads/acute/apop_project.pdf.3. Gould TH, Crosby DL, Harmer M, et al. Policy forcontrolling pain after surgery: effect of sequentialchanges in management. BMJ 2005; 305:1187-93.4. JCAHO & NPC. Pain: current understanding ofassessment, management and treatments. JointCommission on Accreditation of HealthcareOrganisations and the National PharmaceuticalCouncil, Inc.www.jcaho.org/news+room/health+care+issues/pm+monographs.htm1. Policy Document PS3: Guidelines for theManagement of Major Regional Analgesia. Australianand New Zealand College of Anaesthetists.www.anzca.edu.au/resources/professionaldocuments2. Horlocker TT, Wedel DJ, Benzon H, et al. Regionalanesthesia in the anticoagulated patient: defining therisks (the second ASRA Consensus Conference onNeuraxial Anesthesia and Anticoagulation). RegAnesth Pain Med 2003;28(3):172-97.3. Tryba M. European practice guidelines:thromboembolism prophylaxis and regionalanesthesia. Reg Anesth Pain Med 1998;23(6 Suppl2):178-82.1. Choi PT, Galinski SE, Takeuchi L, et al. PDPH is acommon complication of neuraxial blockade inparturients: a meta-analysis of obstetrical studies.Can J Anaesth 2003; 50(5):460-9.2. Halpern S, Preston R. Postdural puncture headacheand spinal needle design. Meta-analyses.Anesthesiology 1994; 81(6):1376-83.1. American College of Obstetricians and Gynecologists.Optimal goals for anesthesia care in obstetrics.ACOG Committee Opinion #256. Washington, DC:American College of Obstetricians and Gynecologists,ACHS Clinical Indicator User Manual 2011 27

CI 6.1CI 6.2CI 6.3Minimisation of post-duralpuncture headache.Commencement ofsurgery within 30 minutesof a request foremergency Caesareansection.Provision of patientinformation regarding risksand benefits of epidural /spinal analgesia forlabour.2):178-82.Anaesthesia Clinical Indicators Version 5.11. Choi PT, Galinski SE, Takeuchi L, et al. PDPH is acommon complication of neuraxial blockade inparturients: a meta-analysis of obstetrical studies.Can J Anaesth 2003; 50(5):460-9.2. Halpern S, Preston R. Postdural puncture headacheand spinal needle design. Meta-analyses.Anesthesiology 1994; 81(6):1376-83.1. American College of Obstetricians and Gynecologists.Optimal goals for anesthesia care in obstetrics.ACOG Committee Opinion #256. Washington, DC:American College of Obstetricians and Gynecologists,2001.2. James D. Caesarean section for fetal distress. BMJ2001;322:1316-7. WPI14 Position Statement on theProvision of Obstetric Anaesthesia and AnalgesiaServices 2007www.anzca.edu.au/resourses/professionaldocuments1. Ruppen W, Derry S, McQuay H, Moore RA.Incidence of epidural hematoma, infection, andneurologic injury in obstetric patients with epiduralanalgesia/anesthesia. Anesthesiology2006;105(2):394-9.2. Moore RA, Derry S, McQuay HJ, Paling J. What dowe know about communicating risk? A brief reviewand suggestion for contextualising serious, but rare,risk, and the example of cox-2 selective and nonselectiveNSAIDs. Arthritis Res Ther2008;10(1):R20. Epub 2008 Feb 73. Hoehner PJ. Ethical aspects of informed consent inobstetric anesthesia - new challenges and solutions.J Clin Anesth 2003;15(8):587-600.ACHS Clinical Indicator User Manual 2011 28

Review PS7 (2008)AUSTRALIAN AND NEW ZEALAND COLLEGEOF ANAESTHETISTSABN 82 055 042 852RECOMMENDATIONS FORTHE PRE-ANAESTHESIA CONSULTATION1. INTRODUCTIONThe terms “pre-anaesthesia consultation” and “anaesthesia” in this doumentrefer not only to situations pertinent to the administration of generalanaesthesia but also includes those related to regional anaesthesia/analgesiaand sedation. Although this document is primarily directed to Anaesthetists,these recommendations should be followed by any suitably trained practitionerresponsible for performing anaesthesia (see PS2 Statement on Credentiallingand Defining the Scope of Clinical Practice in Anaesthesia) which involvesthe administration of drugs and performing related procedures that have thepotential for alteration of a patient’s:• conscious state (including all levels of sedation through to anaesthesia)• normal homeostatic mechanisms (particularly cardio-respiratoryphysiology)Consultation by a medical practitioner is essential for the medical assessmentof a patient prior to anaesthesia (see TE6 Guidelines on the Duties of anAnaesthetist). This pre-anaesthesia consultation should:• ensure the patient’s state of health has been optimised• plan the anaesthesia (including pre- and post-) management• allow appropriate prior discussion with the patient and/or guardian• obtain informed consent for the anaesthesia and related procedures .Adequate pre-anaesthesia consultation has been identified as an importantfactor in patient safety. Medical practitioners must also be aware of patientautonomy and a patient’s rights to privacy as set out in the Privacy Act 1993(NZ), the Privacy Act 1998 (Cth) and the Privacy Amendment (Private Sector)Act 2000 (Cth). (see also ANZCA Code of Professional Conduct and PS26Guidelines on Consent for Anaesthesia or Sedation).These requirements are also reflected in the New Zealand Code of Rights forpatients issued by the New Zealand Health and Disability Commissioner, andthe soon to be introduced Australian Charter of Healthcare Rights,foreshadowed by the Australian Government.2. GENERAL PRINCIPLES

2.1 The process involved in delivering a safe and effective pre-anaesthesiaconsultation will vary with the type of practice and environment inwhich the medical practitioner responsible for the anaesthesia works.2.2 Even if a pre-anaesthesia consultation has been performed by someother person, the medical practitioner responsible for administering theanaesthesia must be satisfied that all elements of that consultation havebeen adequately addressed, and if necessary repeat any elements aboutwhich there may be doubt.2.3 The use of written or computer-generated questionnaires, screeningassessments, documented telephone consultations by medical ornursing staff as part of a pre-admission process may be used so long asthe requirement of 2.2 is followed.2.4 The consultation must take place at an appropriate time prior toanaesthesia and the planned procedure in order to allow for adequateconsideration of all factors. This is particularly important where:• there is significant patient co-morbidity,• major surgery is planned• there are specific anaesthesia concerns.2.5 The difficulties inherent in adequately assessing patients admitted onthe day of surgery or medical procedure must be recognised. Ideallysuch patients should be assessed prior to admission. Otherwiseadmission times, list planning and session times must accommodate theextra time required for pre-anaesthesia consultations. (see PS15Recommendations for the Perioperative Care of Patients Selected forDay Care Surgery).2.6 In some circumstances, early consultation will not be possible (e.g.emergency surgery, and in emergency and critical care departments)but the consultation must not be modified except when the overallwelfare of the patient is at risk.2.7 Pre-anaesthesia consultation facilities must include appropriateequipment, hand washing/disinfecting facilities (see PS28 Guidelineson Infection Control in Anaesthesia) and space to allow for aconsultation and clinical examination in privacy, as well as supportpeople if required by the patient. An appropriately equippedconsulting room or single bed hospital room is ideal. For electiveprocedures, it is not appropriate for this consultation to occur in theoperating theatre. It may be possible for such consultation to occur inthe holding/waiting bay, anaesthesia room or recovery area as long asissues regarding patient confidentiality, privacy, the presence ofsupport people if required, autonomy, religious and culturalsensitivities are adequately addressed. (see also PS26 Guidelines onConsent for Anaesthesia or Sedation and the Australian Society of

3. GUIDELINESAnaesthetists PS03 Minimum Facilities for PreanaesthesiaConsultations)The pre-anaesthesia consultation should include:3.1 Identification and introduction of the medical practitioner responsiblefor the anaesthesia to the patient.3.2 Confirmation with the patient of the patient’s identity, procedure (andside where appropriate) and the proceduralist involved.3.3 An appropriate medical assessment of the patient including medicalhistory (which may be assisted by a questionnaire and/or review ofavailable patient notes), clinical examination, review of anymedications, the results of any relevant investigations and arrangementfor any further investigations or therapeutic measures which areconsidered necessary. This medical assessment may lead to delay,postponement or even cancellation of the planned procedure.3.4 Consultation with professional colleagues if required.3.5 A discussion with the patient (and/or guardian) of those details of theanaesthetic management which are of significance to the patient. Thiswould usually include the conduct of the anaesthesia/sedation, painmanagement (see PS45 Statement on Patient’s Rights to PainManagement), the relevant potential complications and risks, andprovide the patient with an opportunity for questions and/or provisionof educational material. This educational material may be in the formof written pamphlets, video recordings or audiotapes but given to thepatient in a timely manner.3.6 Obtaining of informed consent for anaesthesia/sedation and relatedprocedures. This should include consent regarding the type ofanaesthesia, any invasive procedures, pain management and othermedication plan and, where appropriate, informed financial consent(see PS26 Guidelines on Consent for Anaesthesia and Sedation).3.7 The ordering of any medications considered necessary.3.8 Contemporaneous written notes documenting the consultation andinformed consent which should become part of the medical record ofthe patient. (see also ANZCA Code of Professional Conduct, PS6Recommendations on the Recording of an Episode of Anaesthesia Careand also PS 26 Guidelines on Consent for Anaesthesia or Sedation).

REFERENCESSafety of Anaesthesia in Australia: A Review of Anaesthesia Related Mortality 2000-2002 Gibbs N, Borton C (eds) 2006General Guidelines to Medical Practitioners on Providing Information to PatientsAustralian Govt Publishing Service 1993Consent and Anaesthetic Risk Jenkins K, Baker AB Anaesthesia 2003(58) 962-984Minimum Facilities for Pre-Australian Society of Anaesthetists Position Statementanaesthesia Consultation ASA PS03 (2004)Rovenstine Lecture: Patient Values, Hippocrates, Science, and technology: What We(physicians) Can do versus what We Should do for the Patient Hug CCAnesthesiology 2000: 93 (2); 556-564Australian Charter of Healthcare Rights developed by The Australian Commissionon Safety and Quality in Healthcare July 2008RELATED ANZCA DOCUMENTSTE6PS2PS3PS6PS9Guidelines on the Duties of an AnaesthetistStatement on Credentialling and Defining the Scope of Clinical Practice inAnaesthesiaGuidelines for the Management of Major Regional AnalgesiaRecommendations on the Recording of an Episode of Anaesthesia CareGuidelines on Sedation and/or Analgesia for Diagnostic and InterventionalMedical or Surgical ProceduresPS15 Recommendations for the Perioperative Care of Patients Selected for DayCare SurgeryPS26 Guidelines on Consent for Anaesthesia or SedationPS28 Guidelines on Infection Control in AnaesthesiaPS41 Guidelines on Acute Pain ManagementPS45 Statement on Patient’s Rights to Pain ManagementANZCA Code of Professional ConductCOLLEGE PROFESSIONAL DOCUMENTSCollege Professional Documents are progressively being coded as follows:TEEXPSTTraining and EducationalExaminationsProfessional StandardsTechnical

POLICY – defined as ‘a course of action adopted and pursued by theCollege’. These are matters coming within the authority and control of theCollege.RECOMMENDATIONS – defined as ‘advisable courses of action’.GUIDELINES – defined as ‘a document offering advice’. These may beclinical (in which case they will eventually be evidence-based), or nonclinical.STATEMENTS – defined as ‘a communication setting out information’.This document has been prepared having regard to general circumstances,and it is the responsibility of the practitioner to have express regard to theparticular circumstances of each case, and the application of this document ineach case.Professional documents are reviewed from time to time, and it is theresponsibility of the practitioner to ensure that the practitioner has obtainedthe current version. Professional documents have been prepared havingregard to the information available at the time of their preparation, and thepractitioner should therefore have regard to any information, research ormaterial which may have been published or become available subsequently.Whilst the College endeavours to ensure that professional documents are ascurrent as possible at the time of their preparation, it takes no responsibilityfor matters arising from changed circumstances or information or materialwhich may have become available subsequently.Promulgated: 1984Reviewed: 1989, 1992, 1998, 2003Date of current document: August 2008© This document is copyright and cannot be reproduced in whole or in part withoutprior permission.College Website: http://www.anzca.edu.au/

Review PS8 (2008)AUSTRALIAN AND NEW ZEALAND COLLEGE OFANAESTHETISTSABN 82 055 042 852RECOMMENDATIONS ON THE ASSISTANT FOR THEANAESTHETISTThe presence of a trained assistant for the anaesthetist during the conduct of anaesthesiais a major contributory factor to safe patient management. The assistant must haveundertaken appropriate training in order to provide effective support to the anaesthetist.The recommendations that follow establish both the practical and educationalresponsibilities of a competent assistant to the anaesthetist.1. PRINCIPLES1.1 These recommendations apply wherever general anaesthesia, regionalanaesthesia, local anaesthesia and/or sedation are administered by ananaesthetist. Henceforth, these activities are referred to as “anaesthesia”.1.2 The presence of a trained assistant for the anaesthetist is essential for thesafe and efficient conduct of anaesthesia:1.2.1 during preparation for and induction of anaesthesia. The assistantmust remain under the immediate direction of the anaesthetist untilinstructed that this level of assistance is no longer required.1.2.2 at short notice if required during the maintenance of anaesthesia.1.2.3 at the conclusion of anaesthesia.1.3 Facilities in which anaesthesia is administered must provide a servicewhich ensures that anaesthetic equipment is available, properlymaintained, checked before use and appropriately cleaned, as per CollegeProfessional Documents T1 (2006) Recommendations on MinimumFacilities for Safe Administration of Anaesthesia in Operating Suites andOther Anaesthetising Locations and PS31 (2003) Recommendations onChecking Anaesthesia Delivery Systems.1.4 Staff employed for these roles must be properly trained, as defined below.2. DEPLOYMENT OF ASSISTANTS2.1 The assistant to the anaesthetist is an essential member of the staffestablishment in all locations where anaesthesia is administered.

2.2 Management must ensure that staff establishments and rostering practicesallow the allocation of an assistant to the anaesthetist for every case whereanaesthesia is administered.2.3 The number and status of assistants in the staff establishment will bedetermined by the number and types of procedures undertaken by theanaesthesia service at each facility.2.4 The duties of the assistants in each location must be specified in anappropriate job description.2.5 Where a number of assistants are employed, an appropriately trained andexperienced senior member of the group should be designated as thesupervisor.2.6 Whilst assisting the anaesthetist, the assistant must be wholly andexclusively responsible to that anaesthetist.3. EDUCATIONAL REQUIREMENTS FOR ASSISTANTSAn adequately trained assistant to the anaesthetist must have completed a trainingcourse which has met, as a minimum, the following criteria:3.1 Eligibility3.1.1 Those without previous health sector experience must have theHigher School Certificate or its equivalent.3.1.2 Those with nursing experience must hold a certificate as aRegistered Nurse (Registered Nurse Division 1) or as an EnrolledNurse (Registered Nurse Division 2), or their equivalents.3.1.3 Registered Nurses, Division 1 or 2 or their equivalents, must be incurrent clinical employment or have been so employed within oneyear of acceptance into a training course.3.2 Course of InstructionThe course should be developed and administered by an appropriateinstitute of learning. Courses may include a distance learning componentwhere appropriate, and may be provided full-time, part-time or as acombination of full-time and part-time. There should be continuousemployment of trainee anaesthesia assistants during any part-timecomponents of the course.As a minimum, the course must include:3.2.1 A course of lectures of at least 150 hours duration.

3.2.3 Supervised practical experience in anaesthetising locations, whichshould be documented in a log book describing the type ofinstruction received and the competencies demonstrated.3.2.4 Successful completion of assignments appropriate to thecurriculum that are suitable for presentation to trainees andsupervisors.3.2.5 Successful completion of internal assessments, includingdemonstrated competencies and designated examinations.3.2.6 Input from anaesthestists in curriculum development, preparationand delivery of lectures, practical supervision and assessments. Theminimum curriculum content for courses is outlined in theAddendum.3.3 Duration of the Course3.3.1 Those without previous hospital experience must complete threeyears of full-time employment comprising study and work as atrainee anaesthesia assistant.3.3.2 Those with Registered Nurse Divison 2 qualifications or similarmust complete two years of full-time employment comprisingstudy and work as a trainee anaesthesia assistant.3.3.3 Those with Registered Nurse Division 1 qualifications mustcomplete one year of full-time employment comprising study andwork as a trainee anaesthesia assistant.4. CONTINUING EDUCATION OF ASSISTANTSAnaesthesia assistants must maintain and upgrade their knowledge and skills withregular continuing education activities. Management must ensure that staffestablishments and rostering practices allow for continuing education ofanaesthesia assistants.

1. Basic SciencesADDENDUMRECOMMENDED CONTENT OF TRAINING COURSESFOR THE ASSISTANT TO THE ANAESTHETISTInstruction must include appropriate elements of the following basic sciences as theyapply to anaesthesia:PhysicsChemistryPharmacologyAnatomyPhysiologyClinical MeasurementMicrobiology2. AnaesthesiaIn-depth understanding of the following topics is necessary and must be reinforced byappropriate practical experience obtained while providing assistance to anaesthetists.(a)Anaesthetic Equipment(i)The care, use and servicing of equipmentAnaesthesia delivery systems and ventilatorsMonitoring equipment including ultrasound devicesAirways devices including fiberoptic instrumentsIntravascular devices(ii)Cleaning and sterilisation of equipment(iii) Infection control issues for staff, equipment and patients(iv) Pollution prevention(b)SafetyElectrical safetyGas cylinders and pipelinesHazards in anaesthetising locationsPatient safetyStaff safety(c)Anaesthetic techniquesincluding all areas of perioperative practice (preparation, monitoring,induction, securing the airway, maintenance, recovery) in both theoretical andpractical terms.

(d) Invasive Techniquesincluding insertion of peripheral, central venous and pulmonary arterycatheters and arterial lines, as well as their ongoing management; intercostaltube drainage; red cell salvage, and endoscopy of the airways.(d)Regional and Local Anaesthesiaincluding all commonly used techniques for regional and local blockade.(e)Ultrasoundincluding use for nerve and vascular localisation.(f)Therapeuticsincluding the storage, preparation and use of all drugs, fluids and othertherapeutic substances administered during anaesthesia.(g)Emergency Careincluding knowledge of appropriate algorithms for crisis management,assistance to the anaesthetist, and provision and care of necessary equipmentfor:Cardiopulmonary resuscitationManagement of the difficult airway and failed intubationCardiac defibrillation and cardioversionMassive blood transfusionAnaphylaxisMalignant hyperthermia(h)Postoperative Painincluding management and equipment required.3. ManagementRosteringBudgetsAnaesthesia standards and protocolsIncident monitoringWorkplace, Occupational Health & Safety RegulationsCommunicationPrivacy ProtectionInterfaces with other healthcare workersLegal responsibilitiesHuman resources management

COLLEGE PROFESSIONAL DOCUMENTSCollege Professional Documents are progressively being coded as follows:TEEXPSTTraining and EducationalExaminationsProfessional StandardsTechnicalPOLICY - defined as ‘a course of action adopted and pursued by theCollege’. These are matters coming within the authority and control of theCollege.RECOMMENDATIONS – defined as ‘advisable courses of action’.GUIDELINES – defined as ‘a document offering advice’. These may beclinical (in which case they will eventually be evidence-based), or nonclinical.STATEMENTS – defined as ‘a communication setting out information’.This document is intended to apply wherever anaesthesia is administered.This document has been prepared having regard to general circumstances, and itis the responsibility of the practitioner to have express regard to the particularcircumstances of each case, and the application of this document in each case.Professional documents are reviewed from time to time, and it is the responsibilityof the practitioner to ensure that the practitioner has obtained the current version.Professional documents have been prepared having regard to the informationavailable at the time of their preparation, and the practitioner should thereforehave regard to any information, research or material which may have beenpublished or become available subsequently.Whilst the College endeavours to ensure that professional documents are ascurrent as possible at the time of their preparation, it takes no responsibility formatters arising from changed circumstances or information or material whichmay have become available subsequently.Promulgated: June 1989Reviewed: October 1993, 1998, 2003Date of Current Document: Apr 2008© This document is copyright and cannot be reproduced in whole or in part withoutprior permission.College Website: http://www.anzca.edu.au/

AUSTRALIAN AND NEW ZEALAND COLLEGE OFANAESTHETISTSABN 82 055 042 852Review PS9 (2008)GASTROENTEROLOGICAL SOCIETY OF AUSTRALIAABN 44 001 171 115ROYAL AUSTRALASIAN COLLEGE OF SURGEONSABN 29 004 167 766Guidelines on Sedation and/or Analgesia for Diagnostic andInterventional Medical or Surgical ProceduresThis document is intended to apply wherever procedural sedation and/or analgesiafor diagnostic and interventional medical and surgical procedures are administered,especially where sedation and/or analgesia may lead to general anaesthesia. TheAustralian and New Zealand College of Anaesthetists recognises that practitionerswith diverse qualifications and training are administering a variety of medications topatients to allow such procedures to be performed. This document addresses pertinentissues for all practitioners involved in such activities.1. DEFINITIONS1.1 Procedural sedation and/or analgesia implies that the patient is in a state ofdrug-induced permissiveness of uncomfortable or painful diagnostic orinterventional medical or surgical procedures. Lack of memory of distressingevents and/or analgesia are desired outcomes, but lack of response to painfulstimulation is not assured.1.1.1 Conscious Sedation is defined as a drug-induced depression ofconsciousness during which patients are able to respond purposefully toverbal commands or light tactile stimulation. No interventions are usuallyrequired to maintain a patent airway, spontaneous ventilation orcardiovascular function. Conscious sedation may be achieved by a widevariety of techniques including propofol, and may accompany localanaesthesia. All conscious sedation techniques should provide a margin ofsafety that is wide enough to render loss of consciousness unlikely.1.1.2 Deep levels of sedation, where consciousness is lost and patients onlyrespond to painful stimulation, are associated with loss of the ability tomaintain a patent airway, inadequate spontaneous ventilation and/orimpaired cardiovascular function. Deep levels of sedation may have similarrisks to general anaesthesia, and may require an equivalent level of care.1.1.3 Analgesia is reduction or elimination of pain perception, usually induced bydrugs which act locally (by interfering with nerve conduction) or generally(by depressing pain perception in the central nervous system).1

1.2 General Anaesthesia is a drug-induced state characterised by absence ofresponse to any stimulus, loss of protective airway reflexes, depression ofrespiration and disturbance of circulatory reflexes. General anaesthesia issometimes indicated during diagnostic or interventional medical or surgicalprocedures and requires the exclusive attention of an anaesthetist (see CollegeProfessional Document T1 – Recommendations on Minimum Facilities for SafeAdministration of Anaesthesia in Operating Suites and Other AnaesthetisingLocations)..2. AIMS AND RISKS OF PROCEDURAL SEDATION AND/OR ANALGESIAThe aims of procedural sedation and/or analgesia are to ensure patient safety andcomfort, and to facilitate completion of the planned procedure. In order to achievethese aims, a range of sedation options may be required during any one procedure,with a continuum from no medication, through conscious sedation and deepsedation, to general anaesthesia. While no sedation or conscious sedation withsmall doses of drugs such as benzodiazepines and opioids are options for somepatients and proceduralists, many patients and proceduralists want deep levels ofsedation or general anaesthesia to be an option during each procedure.Practitioners authorised or credentialled to administer procedural sedation and/oranalgesia should be aware that the transition from complete consciousnessthrough the various depths of sedation to general anaesthesia is a continuum andnot a set of discrete, well-defined stages. The margin of safety of drugs used toachieve sedation and/or analgesia varies widely between patients and loss ofconsciousness with its attendant risk of loss of protective reflexes may occurrapidly and unexpectedly. Therefore practitioners who administer sedative oranalgesic drugs that alter the conscious state of a patient must be prepared tomanage the following potential risks:2.1 Depression of protective airway reflexes and loss of airway patency.2.2 Depression of respiration.2.3 Depression of the cardiovascular system.2.4 Drug interactions or adverse reactions, including anaphylaxis.2.5 Individual variations in response to the drugs used, particularly in children,the elderly, and those with pre-existing medical disease.2.6 The possibility of deeper sedation or anaesthesia being used to compensatefor inadequate analgesia or local anaesthesia.2.7 Risks inherent in the wide variety of procedures performed under proceduralsedation and/or analgesia.2

2.8 Unexpected extreme sensitivity to the drugs used for procedural sedationand/or analgesia which may result in unintentional loss of consciousness,respiratory or cardiovascular depression.Over-sedation, airway obstruction, respiratory or cardiovascular complicationsmay occur at any time. Therefore, to ensure high standards of patient care, thefollowing guidelines are recommended.3. PATIENT PREPARATION3.1 The patient should be provided with written information which includesthe nature and risks of the procedure, preparation instructions (includingthe importance of fasting), and what to expect during the immediate andlonger term recovery period, including after discharge.3.2 Informed consent for sedation and/or analgesia and for the procedureshould be obtained (see College Professional Document PS26 –Guidelines on Consent for Anaesthesia or Sedation).4. PATIENT ASSESSMENT4.1 All patients should be assessed before procedural sedation and/oranalgesia. Assessment should include:4.1.1 Details of the current problem, co-existing and past medical andsurgical history, history of previous sedation and anaesthesia,current medications (including non-prescribed medications),allergies, fasting status, the presence of false, damaged or looseteeth, or other evidence of potential airway problems.4.1.2 Examination, including that relevant to the current problem, ofthe airway, respiratory and cardiovascular status, and othersystems as indicated by the history.4.1.3 Results of relevant investigations.4.2 This assessment should identify those patients at increased risk ofcardiovascular, respiratory or airway compromise during proceduralsedation and/or analgesia, as in such cases, an anaesthetist should bepresent to care for the patient. These patients include the elderly, thosewith severely limiting heart, cerebrovascular, lung, liver or renal disease,morbid obesity, significant obstructive sleep apnoea, or known orsuspected difficult endotracheal intubation, acute gastrointestinalbleeding with cardiovascular compromise or shock, severe anaemia, thepotential for aspiration of stomach contents (which may necessitateendotracheal intubation), previous adverse events due to sedation,analgesia or anaesthesia, and patients in ASA Grades P 4-5 (seeAppendix I). See also College Professional Document PS7 –Recommendations on the Pre-Anaesthesia Consultation.3

5. STAFFING5.1 There must be a minimum of three appropriately trained staff present: theproceduralist, the practitioner administering sedation and monitoring thepatient, and at least one additional staff member to provide assistance to theproceduralist and/or the practitioner providing sedation as required.5.2 The assistant to the practitioner administering sedation/anaesthesia must beexclusively available to the practitioner at induction of and emergence fromsedation/anaesthesia, and during the procedure as required. If generalanaesthesia is intended, and especially in emergency situations whereendotracheal intubation is planned, a fourth person to specifically assist thepractitioner throughout the procedure is required. (See College ProfessionalDocument PS8 Guidelines on the Assistant to the Anaesthetist)5.3 The practitioner administering procedural sedation and analgesia requiressufficient training to be able to:5.3.1 Understand the actions of the drugs being administered, and be ableto modify the technique appropriately in patients of different ages, orin the case of concurrent drug therapy or disease processes.5.3.2 Monitor the patient’s level of consciousness and cardiorespiratorystatus.5.3.3 Detect and manage appropriately any complications arising fromsedation.5.4 A medical practitioner who is skilled in airway management andcardiopulmonary resuscitation must be present whenever proceduralsedation and/or analgesia are administered.5.5 Techniques intended to produce deep sedation or general anaesthesia mustnot be used unless an anaesthetist is present (see College ProfessionalDocuments PS1 Recommendations on Essential Training for Rural GeneralPractitioners in Australia Proposing to Administer Anaesthesia, PS2Statement on Credentialling in Anaesthesia, PS8 Guidelines on the Assistantto the Anaesthetist, PS16 Statement on the Standards of Practice of aSpecialist Anaesthetist, TE3 Policy on Supervision of Clinical Experiencefor Trainees in Anaesthesia, T1 Recommendations on Minimum Facilitiesfor Safe Administration of Anaesthesia in Operating Suites and OtherAnaesthetising Locations).5.6 In situations other than those when an anaesthetist must be present (noted in4.2 and 5.5), administration of sedation and/or analgesia and monitoring ofthe patient should be performed by an appropriately trained medicalpractitioner other than the proceduralist.4

5.7 If an appropriately trained medical practitioner is not present solely toadminister sedation and/or analgesia and monitor the patient, there must bean assistant to the proceduralist present during the procedure, who isappropriately trained in observation and monitoring of sedated patients, andin resuscitation, and whose sole duty is to monitor the level ofconsciousness and cardiorespiratory status of the patient. This person may,if appropriately trained, administer sedative and/or analgesic drugs underthe direct supervision of the proceduralist, who must have advanced lifesupport skills and training (see 5.4). If loss of consciousness, airwayobstruction or cardiorespiratory insufficiency occur at any time, all staffmust devote their entire attention to monitoring and treating the patient untilrecovery, or until such time as another medical practitioner becomesavailable to take responsibility for the patient’s care.6. FACILITIES AND EQUIPMENTThe procedure must be performed in a location which is adequate in size, andstaffed and equipped to deal with a cardiopulmonary emergency. This mustinclude:6.1 Adequate room to perform resuscitation should this prove necessary.6.2 Appropriate lighting.6.3 An operating table, trolley or chair which can be tilted head down readily.6.4 An adequate suction source, catheters and handpiece.6.5 A supply of oxygen and suitable devices for the administration of oxygen toa spontaneously breathing patient.6.6 A means of inflating the lungs with oxygen (e.g. a self-inflating bag)together with a range of equipment for advanced airway management (e.g.masks, oropharyngeal airways, laryngeal mask airways, laryngoscopes,endotracheal tubes).6.7 Appropriate drugs for cardiopulmonary resuscitation and a range ofintravenous equipment and fluids (See Appendix II).6.8 Drugs for reversal of benzodiazepines and opioids.6.9 A pulse oximeter.6.10 A sphygmomanometer, or other device for measuring blood pressure.6.11 Ready access to an ECG and a defibrillator.6.12 A means of summoning emergency assistance.5

6.13 Within the facility there should be access to devices for measuring expiredcarbon dioxide.(See College Professional Documents T1 Recommendations on MinimumFacilities for Safe Administration of Anaesthesia in Operating Suites and OtherAnaesthetising Locations, PS15 Recommendations for the Perioperative Care ofPatients Selected for Day Care Surgery.)7. TECHNIQUE AND MONITORING7.1 Reliable venous access should be in place for all procedures whenprocedural sedation and/or analgesia are used.7.2 As most complications of sedation are cardiorespiratory, doses of sedativeand analgesic drugs should be kept to the minimum required for patientcomfort, particularly for those patients at increased risk.7.3 Monitoring of the patient’s response to verbal commands must be routine.Loss of patient response to verbal commands indicates that loss of airwayreflexes, respiratory and/or cardiovascular depression are likely.7.4 All patients undergoing procedural sedation and/or analgesia must bemonitored continuously with pulse oximetry and this equipment must alarmwhen appropriate limits are transgressed.7.5 There must be regular recording of pulse rate, oxygen saturation and bloodpressure throughout the procedure in all patients.7.6 According to the clinical status of the patient, other monitors such as ECGor capnography may be required (see College Professional Document PS18Recommendations on Monitoring During Anaesthesia).8. OXYGENATIONHypoxaemia may occur during procedural sedation and/or analgesia withoutoxygen supplementation. Oxygen administration diminishes hypoxaemia duringprocedures carried out under sedation /or analgesia, and must be used in allpatients. Pulse oximetry enables the degree of tissue oxygenation to be monitoredand must be used in all patients during procedural sedation and/or analgesia.9. MEDICATIONSA variety of drugs and techniques are available for procedural sedation and/oranalgesia. The most common intravenous agents used are benzodiazepines (suchas midazolam) for sedation and opioids (such as fentanyl) for analgesia. Evensmall doses of these drugs may result in loss of consciousness in some patients.Special care is required when local anaesthesia of the larynx and/or pharynx hasbeen administered to facilitate the procedure.6

Intravenous anaesthetic agents such as propofol must only be used by asecond medical practitioner trained in their use because of the risk ofunintentional loss of consciousness. These agents must not be administeredby the proceduralist.10. DOCUMENTATIONThe clinical record should include the names of staff performing sedation and/oranalgesia, with documentation of the history, examination and investigationfindings. A written record of the dosages of drugs and the timing of theiradministration must be kept as a part of the patient's records. Such entries shouldbe made as near the time of administration of the drugs as possible. This recordshould also note the regular readings from the monitored variables, includingthose in the recovery phase, and should contain other information as indicated inthe College Professional Document PS6 Recommendations on the Recording ofan Episode of Anaesthesia Care.11. RECOVERY AND DISCHARGE11.1 Recovery should take place under appropriate supervision in a properlyequipped and staffed area (see College Professional Document PS4Recommendations for the Post-Anaesthesia Recovery Room).11.2 Adequate staffing and facilities must be available in the recovery area formanaging patients who have become unconscious or who have sufferedcomplications during the procedure.11.3 Discharge of the patient should be authorised by the practitioner whoadministered the drugs, or another appropriately qualified practitioner. Thepatient should be discharged into the care of a responsible adult to whomwritten instructions should be given, including advice about eating anddrinking, pain relief, and resumption of normal activities, as well as aboutmaking legally-binding decisions, driving, or operating machinery.11.4 A system should be in place to enable safe transfer of the patient toappropriate medical care should the need arise.12. TRAINING IN PROCEDURAL SEDATION AND/OR ANALGESIA FORNON-ANAESTHETIST MEDICAL PRACTITIONERSIt is recommended that non-anaesthetist medical practitioners wishing to provideprocedural sedation/analgesia should have received a minimum of 3 months fulltime equivalent supervised training in procedural sedation and/or analgesia andanaesthesia. They should participate in a process of In-Training and CompetencyAssessment. Training should include completion of a crisis resourcemanagement simulation centre course.It is recognised that there will be non-anaesthetist medical practitioners whohave had many years experience in procedural sedation and/or analgesia, butwho may not have had a period of formal supervised training as described. Such7

longstanding clinical experience may be deemed equivalent to a formal period oftraining as described.Credentialling, training and clinical support of such medical practitioners shouldreceive close cooperation from nominated anaesthetists in the hospital or centre.Annual certification in advanced cardiac and life support, and evidence ofrelevant Continuing Professional Development, are required for credentialling.13. REFERENCESThe following references provide evidence to support the recommendations madein this document.AGA Institute (Cohen LB et al.). AGA Institute review of endoscopic sedation.Gastroenterology 2007; 133: 675-701American College of Radiology (Towbin et al.). ACR practice guideline for adultsedation/analgesia. 2005American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists (Gross JB et al.). Practice guidelines for sedation and analgesia bynon-anesthesiologists. Anesthesiology 2002; 96: 1004-1017American Society of Anesthesiologists. Statement on granting privileges foradministration of moderate sedation to practitioners who are non anaesthesiaprofessionals. 2006American Society for Gastrointestinal Endoscopy (Chutkan R et al.). Trainingguideline for use of propofol in gastrointestinal endoscopy. Gastrointestinal Endoscopy2004; 60: 167-172American Society for Gastrointestinal Endoscopy (Vargo JJ et al.). Training in patientmonitoring and sedation and analgesia. Gastrointestinal Endoscopy 2007; 66: 7-10Clarke AC, Chiragakis L, Hillman LC, Kaye GL. Sedation for endoscopy: the safe useof propofol by general practitioner sedationists. Medical Journal of Australia 2002;176: 159-162Faigel DO, Pike IM, et al. Quality indicators for gastrointestinal endoscopicprocedures: an introduction. Gastrointestinal Endoscopy 2006; 63 (4 Suppl.): S3-S9Qadeer MA, Vargo JJ, Khandwala F, Lopez R, Zuccaro G. Propofol versus traditionalsedative agents for gastrointestinal endoscopy: a meta-analysis. ClinicalGastroenterology & Hepatology 2005; 3: 1049-1056Rex DK Review article: moderate sedation for endoscopy: sedation regimens for nonanaesthesiologists.Alimentary Pharmacology & Therapeutics 2006; 24: 163-1718

All College Professional Documents must be complied with, but particular noteshould be taken of the following:PS1 Recommendations on Essential Training for Rural General Practitioners inAustralia Proposing to Administer AnaesthesiaPS2 Statement on Credentialling in AnaesthesiaPS4 Recommendations for the Post-Anaesthesia Recovery RoomPS6 The Anaesthesia Record. Recommendations on the Recording of an Episodeof Anaesthesia CarePS7 Recommendations on the Pre-Anaesthesia ConsultationPS8 Guidelines on the Assistant to the AnaesthetistPS15 Recommendations for the Perioperative Care of Patients Selected for DayCare SurgeryPS16 Statement on the Standards of Practice of a Specialist AnaesthetistPS18 Recommendations on Monitoring During AnaesthesiaPS26 Guidelines on Consent for Anaesthesia or SedationT1Recommendations on Minimum Facilities for Safe Administration ofAnaesthesia in Operating Suites and Other Anaesthetising LocationsTE3 Policy on Supervision of Clinical Experience for Vocational Trainees inAnaesthesia9

APPENDIX IThe American Society of Anesthesiologists’ classification of physical status:P 1P 2P 3P 4P 5P 6EA normal healthy patientA patient with mild systemic diseaseA patient with severe systemic diseaseA patient with severe systemic disease that is a constant threat to lifeA moribund patient who is not expected to survive without the operationA declared brain-dead patient whose organs are being removed for donorpurposesPatient requires emergency procedureExcerpted from American Society of Anesthesiologists Manual for Anesthesia Department Organizationand Management 2003-04. A copy of the full text can be obtained from ASA, 520 N Northwest Highway,Park Ridge, Illinois 60068-2573APPENDIX IIEmergency drugs should include at least the following:adrenalineatropinedextrose 50%lignocainenaloxoneflumazenilportable emergency O 2 supply10

APPENDIX IIIPersonnel for Procedural Sedation and AnalgesiaScenario 1: Three practitioners – Sedation by Proceduralist• Medical practitioner proceduralist with airwayand resuscitation skills, and training in sedation• Practitioner with training in monitoring sedation• Assistant to assist both• Conscious sedation in ASA P 1-2 patients• Propofol, thiopentone and other intravenousanaesthetic agents must not be usedScenario 2: Three practitioners – Sedation by Medical Practitioner• Proceduralist• Medical practitioner with airway andresuscitation skills, and training in sedation• Assistant to assist both• Conscious sedation in ASA P 1-2 patients• Propofol, thiopentone and other intravenousanaesthetic agents may only be used by a medicalpractitioner trained in their useScenario 3: Four practitioners – Sedation by Medical Practitioner• Proceduralist• Medical practitioner with airway andresuscitation skills, and training in sedation• Assistant to assist each*• Conscious sedation in ASA P 1-3 patients #• Propofol, thiopentone and other intravenousanaesthetic agents may only be used by amedical practitioner trained in their useScenario 4: Three practitioners – Sedation by Anaesthetist• Proceduralist• Anaesthetist• Assistant to assist both• Conscious, deep sedation or general anaesthesiain all patients• All approved anaesthetic drugs may be usedScenario 5: Four practitioners – Sedation by Anaesthetist• Proceduralist• Anaesthetist• Assistant to assist each*• Conscious sedation, deep sedation or generalanaesthesia in all patients• All approved anaesthetic drugs may be used* Recommended if assistance is likely to be required for the majority of the case (e.g. complex oremergency patients)# Please refer to Section 4.211

COLLEGE PROFESSIONAL DOCUMENTSCollege Professional Documents are progressively being coded as follows:TEEXPSTTraining and EducationalExaminationsProfessional StandardsTechnicalPOLICY – defined as ‘a course of action adopted and pursued by theCollege’. These are matters coming within the authority and control of theCollege.RECOMMENDATIONS – defined as ‘advisable courses of action’.GUIDELINES – defined as ‘a document offering advice’. These may beclinical (in which case they will eventually be evidence-based), or nonclinical.STATEMENTS – defined as ‘a communication setting out information’.This document has been prepared having regard to general circumstances, andit is the responsibility of the practitioner to have express regard to the particularcircumstances of each case, and the application of this document in each case.Professional documents are reviewed from time to time, and it is theresponsibility of the practitioner to ensure that the practitioner has obtained thecurrent version. Professional documents have been prepared having regard tothe information available at the time of their preparation, and the practitionershould therefore have regard to any information, research or material whichmay have been published or become available subsequently.Whilst the College endeavours to ensure that professional documents are ascurrent as possible at the time of their preparation, it takes no responsibility formatters arising from changed circumstances or information or material whichmay have become available subsequently.Promulgated (as P9): 1986Reviewed: 1991, 1996, 2001, 2005Date of current document: April 2008© This document is copyright and cannot be reproduced in whole or in part withoutprior permission.College Website: http://www.anzca.edu.au/12

Review PS4 (2006)AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTSABN 82 055 042 852RECOMMENDATIONS FORTHE POST-ANAESTHESIA RECOVERY ROOM1. INTRODUCTIONA well-planned, well-equipped, well-staffed and well-managed post-anaesthesiarecovery area is essential for the safe early management of patients who have recentlyundergone a surgical or other procedure, irrespective of the type of anaesthesia orsedation used.2. GENERAL PRINCIPLES2.1 Recovery from anaesthesia should take place under supervision in an areadesignated for the purpose.2.2 This area should be close to where the anaesthesia or sedation wasadministered.2.3 The staff working in this area must be trained for their role and able to contactsupervising medical staff promptly when the need arises.2.4 In some situations (for example, paediatric hospitals) minor variations in theserecommendations may be appropriate.3. DESIGN FEATURES FOR THE RECOVERY AREA3.1 The area should be part of the operating or procedural suite with easy accessfor management of emergencies by both theatre medical staff and staff in streetclothes from outside the theatre suite. Provision should be made for rapidevacuation of patients from the area in an emergency.3.2 Ventilation of the area should be of operating theatre standard.3.3 Space allocated per bed/trolley should be at least 9 square metres. There mustbe easy access to the patient’s head.3.4 The number of bed/trolley spaces must be sufficient for expected peak loadsand there should be at least 1.5 spaces available per operating room.3.5 The layout of bed spaces should allow staff to have an uninterrupted view ofseveral patients at once.1

3.6 Each bed space must be provided with:3.6.1 an oxygen outlet3.6.2 medical suction complying with relevant national standards3.6.3 two general power outlets3.6.4 appropriate lighting and wall colour to allow accurate assessment ofskin colour3.6.5 emergency lighting3.6.6 appropriate facilities for mounting and operating any necessaryequipment and for the patient’s chart3.7 Space must be provided for a nursing station, utility room and storage fordrugs, equipment and linen.3.8 There must be appropriate facilities for scrubbing up for procedures.3.9 There should be a wall clock with a sweep second hand or analogue displayclearly visible from each bed space.3.10 Communication facilities should include:3.10.1 an emergency call system to areas where specialist staff areavailable3.10.2 a telephone with access to the hospital paging system3.11 There must be access for portable X-Ray equipment. Appropriate poweroutlets and viewing box must be available.3.12 An emergency power supply must be available in the area.4. EQUIPMENT AND DRUGS4.1 Each bed space should be provided with:4.1.1 oxygen flowmeter and patient oxygen delivery systems4.1.2 suction equipment including a receiver, appropriate hand pieces anda range of suction catheters4.1.3 pulse oximeter4.1.4 facilities for blood pressure measurement including cuffs suitablefor all patients4.1.5 stethoscope4.1.6 means of measuring body temperature4.2 Within the recovery area there must be:2

4.2.1 means for manual ventilation with oxygen in a ratio of one unit pertwo bed spaces, but with a minimum of two such devices4.2.2 equipment and drugs for airway management and endotrachealintubation4.2.3 emergency and other drugs4.2.4 a range of intravenous equipment and fluids and a means ofwarming those fluids4.2.5 drugs for acute pain management4.2.6 a range of syringes and needles4.2.7 patient warming devices4.2.8 devices for measuring expired carbon dioxide4.3 There should be easy access to:4.3.1 12 lead electrocardiograph4.3.2 defibrillator4.3.3 neuromuscular function monitor4.3.4 chest drains4.3.5 warming cupboard4.3.6 refrigerator for drugs and blood4.3.7 procedure light4.3.8 basic surgical tray4.3.9 blood gas and electrolyte measurement4.3.10 diagnostic imaging services4.3.11 apparatus for mechanical ventilation of the lungs4.3.12 monitors for direct arterial and venous pressure monitoring4.4 The recovery trolley/bed must:4.4.1 have a firm base and mattress4.4.2 tilt from one or both ends both head up and head down at least 15degrees4.4.3 be easy to manoeuvre4.4.4 have efficient and accessible brakes4.4.5 provide for sitting the patient up4.4.6 have secure side rails which must be able to be dropped below thebase or be easily removed4.4.7 have an I.V. pole3

4.4.8 have provision for mounting monitoring equipment, apparatus fordelivering oxygen, patient ventilation equipment, underwater sealdrains and suction apparatus during transport of patients5. STAFFING5.1 Staff trained in the care of patients recovering from anaesthesia must bepresent at all times.5.2 A registered nurse trained in recovery area care should be in charge.5.3 Trainee nurses and registered nurses who are not experienced in the care ofpatients recovering from anaesthesia must be supervised.5.4 The ratio of registered nurses to patients needs to be flexible so as to provideno less than one nurse to three patients, and one nurse to each patient who hasnot recovered protective reflexes or consciousness.6. MANAGEMENT AND SUPERVISION6.1 Written protocols for management should be established. The Director ofAnaesthesia should be responsible for the medical aspects of these policies.6.2 A written routine for checking the equipment and drugs must be established.6.3 When an anaesthetised patient is being transferred from one trolley/bed toanother, a minimum of three people must assist with lifting. An anaesthetistmust be present to have prime responsibility for the patient’s head, neck andairway.6.4 A designated anaesthetist should be contactable in the event that theresponsible anaesthetist is unavailable. In larger hospitals, recovery dutiesshould be the designated anaesthetist’s primary duty6.5 Observations should be recorded at appropriate intervals and should includestate of consciousness, oxygen saturation, respiratory rate, pulse rate, bloodpressure and temperature.6.6 All patients should remain until they are considered safe to be discharged fromthe recovery area according to established criteria.6.7 The anaesthetist responsible for the patient should:6.7.1 accompany the patient until transfer to recovery area staff iscompleted6.7.2 provide written and verbal instructions to the recovery area staff4

6.7.3 specify the type of apparatus and the flow rate to be used foroxygen therapy6.7.4 remain in the vicinity until the patient is safe to be left in the care ofrecovery area staff6.7.5 supervise the recovery period and authorise the patient's dischargefrom the recovery area. It is recognised that in some circumstancesit may be necessary for the anaesthetist previously responsible forthe patient to delegate these duties to a trained recovery area nurseor to another anaesthetist who should be fully informed of theclinical state of the patient6.8 The practitioner responsible for the patient’s overall care should be availableto consult with the anaesthetist in the recovery period if necessary and, inappropriate circumstances, authorise the discharge of the patient.COLLEGE PROFESSIONAL DOCUMENTSCollege Professional Documents are progressively being coded as follows:TEEXPSTTraining and EducationalExaminationsProfessional StandardsTechnicalPOLICY – defined as ‘a course of action adopted and pursued by the College’.These are matters coming within the authority and control of the College.RECOMMENDATIONS – defined as ‘advisable courses of action’.GUIDELINES – defined as ‘a document offering advice’. These may be clinical(in which case they will eventually be evidence-based), or non-clinical.STATEMENTS – defined as ‘a communication setting out information’.This document has been prepared having regard to general circumstances, and it isthe responsibility of the practitioner to have express regard to the particularcircumstances of each case, and the application of this document in each case.Professional documents are reviewed from time to time, and it is the responsibility ofthe practitioner to ensure that the practitioner has obtained the current version.Professional documents have been prepared having regard to the informationavailable at the time of their preparation, and the practitioner should therefore haveregard to any information, research or material which may have been published orbecome available subsequently.5

Whilst the College endeavours to ensure that professional documents are as currentas possible at the time of their preparation, it takes no responsibility for mattersarising from changed circumstances or information or material which may havebecome available subsequently.College Website: http://www.anzca.edu.au/Promulgated: 1989Reviewed: 1994, 1995, 2000Date of current document: Aug 20066