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

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

The Use of Ultrasound to Measure the Depth of Thoracic Epidural Space

Introduction: The use of ultrasound to aid in regional blocks has increased in recent years as a result of improvement in ultrasound technology. There have been many studies to evaluate the use of ultrasound to measure the depth of the epidural space in the lumbar region1-9,10,11,12. Studies have shown a strong correlation between the depth of the lumbar epidural space measured by ultrasound and the distance of the needle from the skin after establishing the loss of resistance in the epidural space3,6,7. This study looked at the epidural space in the thoracic space to evaluate the possibility to visualize the thoracic spine anatomy and the possibility to measure the depth of the epidural space and it\u27s correlation with the actual depth by the loss of resistance technique. This study was also designed to assess the ability of the ultrasound to define the best needle insertion point and limit the number of needle skin puncture attempts. Methods: After approval of the IRB at the UMass Medical School and written consent was obtained, 29 patients were enrolled in the study. Exclusion criteria included pregnancy, prisoners, and patients with an absolute contra-indication to thoracic epidural. Ultrasound scan technique: We used a curvilinear 2-5 MHz probe. Both longitudinal para-median and transverse scan were done before the placement of the epidural catheter. The transducer was stabilized at the the best image of intra-laminal space and a mark was placed at the midpoints of the transducer. The puncture point was determined by the intersection of those two lines. The depth of the epidural space was measured using the built-in calipers. The ultrasound depth (UD) was also measured in the transverse view. The epidural catheter was placed using the standard technique at the UMass Memorial Medical Center. Assessment of the catheter function was based on the technique, response to test dose and pain control on post operative day number one. Statistical analysis included the distributional characteristics of the measures, Pearson’s correlation analysis and general linear model. Difference by gender groups were evaluated using Student’s t-test. Results: Mean ultrasound distance (UD) values were 4.22cm ± 0.82 and actual distance (AD) values were 5.59 cm ± 1.29 with Pearson’s correlation coefficient between AD and ultrasound longitudinal (USL) and ultrasound short axis (USS) values were 0.637 and 0.566 respectively, The mean number of attempts were 1.96 ± 1. The number of attempts were defined as the number of skin puncture points by a single provider or the number of providers attempting in the same insertion point. The use of ultrasound was able to identify the depth of the thoracic epidural space in 24/29 cases (83 %) of the cases. The catheter was considered at least partially functioning in 26/29 patients (20 functioning, 6 partially functioning (89.65 %)). Conclusion: Ultrasound scanning can be used to measure the depth of the thoracic epidural space with good correlation

Ultrasound-guided epidural blood patch

Presents a case where an epidural injection was performed under real-time ultrasound guidance

Prediction of the development of sigmoid ischemia on the day of aortic operations. Indirect measurements of intramural pH in the colon

A deviation in an indirect measurement of intramural pH below the limits of normality (6.86) was used as a diagnostic test for sigmoid ischemia in 25 high-risk patients undergoing abdominal aortic operations. The clinical diagnosis of ischemic colitis was made by the attending physicians in only two of the 25, on the day after operation in one and three months after operation in another. In neither was the ischemic colitis considered to have been a causative factor in their subsequent deaths. In contrast, six patients developed pH evidence of ischemia on the day of operation. All six subsequently developed a transient episode of guaiac-positive diarrhea, four developed physical signs consistent with ischemic colitis, and four died. Of 19 who did not develop pH evidence of ischemia, none developed guaiac-positive diarrhea, none developed any signs of ischemic colitis, and none died. Stepwise logistic regression showed the duration of pH evidence of ischemia on the day of operation to be the best predictor for the symptoms and signs of ischemic colitis and for death after operation