1. (a) Organization and staffing.

   1. (1) Anesthesia services shall be provided in a well-organized manner under the direction of a qualified physician.
   2. (2) The service is responsible for all anesthesia administered.

2. (b)

   1. (1) Those administering anesthesia shall be:

      1. (A) Credentialed by medical staff; and
      2. (B) Approved by the governing body.
   2. (2) A current roster with delineation of privileges for those administering anesthesia shall be maintained and readily available.

3. (c) Anesthesia shall be administered by the following:

   1. (1) Anesthesiologist;
   2. (2) Physician qualified to administer anesthesia; or
   3. (3) Certified registered nurse anesthetist (CRNA) in consultation with a physician.

4. (d)

   1. (1) Written policies and procedures specific to anesthesia services shall have evidence of ongoing review and/or revision.

   2. (2) The first page of the manual shall have the:

      1. (A) Annual review date; and
      2. (B) Signature of the department supervisor and/or person or persons conducting the review.

5. (e) Policies and procedures shall include:

   1. (1) Preanesthesia evaluation;
   2. (2) Approved anesthesia agents;
   3. (3) Methods of delivery of anesthesia;
   4. (4) Intraoperative anesthesia record;
   5. (5) Postanesthesia follow-up report;
   6. (6) Mechanism for routine checking and maintenance of anesthesia machines and equipment for safe use;

   7. (7)

      1. (A) Medication accountability.
      2. (B) See:

6. (i) 20 CAR § 41-110, patient care service;

   1. (ii) 20 CAR § 41-111, medications; and

      1. (iii) 20 CAR § 41-115, pharmacy;

   2. (8)

      1. (A) Responsibilities in the discharge of patients from the postanesthesia care unit.
      2. (B) See 20 CAR § 41-126, postanesthesia care unit; and
   3. (9) Infection prevention and control measures.

7. (f)

   1. (1) All medications and anesthesic agents administered to the patient shall be ordered by the prescriber and/or anesthesia provider.
   2. (2) This includes preoperative as well as intraoperative and postoperative medications.
8. (g) There shall be an ongoing QA/PI program that is specific to the patient care administered.

Codification Notes: “QA/PI” means quality assurance/performance improvement.