This saturday weekend evening, I finish a post on one of the six (6) standards for Anaesthesia Care found in the Joint Commission International Accreditation Standards For Hospitals, 4th Edition that requires documentation in the medical record. I have two (2) more remaining standards to write about under Anaesthesia Care. This post is about patient monitoring during anaesthesia.

The overall monitoring during anaesthesia is a continuous process (“continuous” meaning, prolonged without any interruption at any time) mandated by accreditation requirements for example, by the Joint Commission International (JCI) Standard ASC.5.3, as one of the JCI standards that guide the quality improvement program in anaesthesia that apply to all general anaesthetics, regional anaesthetics, and monitored anaesthesia care. JCI Standard ASC.5.3  evaluates the quality of care by attention to the process of monitoring of the patient during anaesthesia. Adequate monitoring is a key factor (Ronald & Manuel, 2011) in the prevention of patient injury related to anaesthesia

Monitoring and maintenance of normal physiology during the perioperioperative period of anaesthetised patients is designed to collect data that reflect the patient’s ongoing physiologic conditions and any responses that may result from therapeutic interventions. Monitoring allows the anaesthesiologist to react to adverse physiologic changes or trends before they result in irreversible damage. Monitoring is deemed (Ronald & Manuel, 2011) to serve to further enhance the vigilance of the anaesthesiologist and decrease the role of human error in anaesthetic morbidity and mortality.

Monitoring methods depend on the patient’s preanaesthesia status, anaesthesia choice, and complexity of the surgical or other procedure performed during anaesthesia.

The vigilance of the anaesthesiologist is enhanced by the use of a monitoring equipment such as the anaesthesia workstation (previously recognised as the anaesthesia machine) which has evolved (Ronald & Manuel, 2011) from a simple pneumatic device to a complex integrated computer controlled multicomponent workstation that includes physiologic monitoring systems (electrocardiogram, arterial blood pressure, temperature, pulse oximeter, and inhaled and exhaled concentrations of oxygen, carbon dioxide, anaesthetic gases, and vapors). The anaesthesia workstation provides objective data to the anaesthesiologist’s own subjective observations.

From my experiences, it is commonly viewed that anaesthesia standards are applicable in whatever setting anaesthesia and/or moderate or deep sedation are used because of the (JCI, 2011) common and complex processes of the administration of anaesthesia during which the patient’s protective reflexes needed for ventilatory functions are at risk.

In the prevention of patient injury related to anaesthesia,  JCI Standard ASC.5.3 or in all cases when the use of  (JCI, 2011) anaesthesia, sedation, and surgical interventions are common at settings which include hospital operating theatres, day surgery or day hospital units, dental and other outpatient clinics, emergency services, intensive care areas, or elsewhere must have a hospital policy and standard operating procedures which address the following issues for anaesthetised patients:

1. the basic anaesthetic monitoring standards adopted for example from Standards for Basic Anaesthetic Monitoring  by the American Society of Anaesthesiologists, that mandate (Ronald & Manuel, 2011) the use of pulse oximetry, capnography, an oxygen analyzer, disconnect alarms, body temperature measurements, and a visual display of an electrocardiogram (ECG) during the intra-operative period in all patients undergoing anaesthesia.
2. the minimum frequency, for example systemic blood pressure and heart rate must be evaluated every 5 minutes
3. the choice of intra-operative monitoring during anaesthesia depends on the patient’s medical condition and the complexity of the intra-operative procedure
4. the type of anaesthesia is uniform for similar patients receiving similar anaesthesia wherever anaesthesia is provided
5. the patient’s physiological status assessed immediately after recovery from anaesthesia

The JCI Standard ASC.5.3 requires documentation of monitoring of the patient during administration of anaesthesia. An anaesthesia record is required and must be maintained when a patient receives an anaesthetic other than a local anaesthetic to document patient monitoring during administration of anaesthetic agents and other activities related to the surgical episode (intra-operative anesthesia).

Documentation regarding monitoring of the patient during administration of anaesthesia  in the anaesthesia record includes (Michelle & Mary, 2011) the following records:

1. anaesthetic agents administered, including amount, technique(s) used, effect on patient, and duration
2. patient’s vital signs (e.g., temperature, pulse, blood pressure) enhanced by the use of a monitoring equipment such as the anaesthesia workstation
3. other activities related to the surgical episode like any blood loss, transfusions administered, including dosage and duration, IV fluids administered, including dosage and duration
4. the patient’s physiological status immediately after recovery from anaesthesia

If your hospital shows the (a) existence of a policy and procedures that address the standards required for the (i) minimum frequency of monitoring, (ii) type of monitoring,  (iii) process of monitoring of the physiological status during the administration of anaesthesia and immediately after recovery from anaesthesia is uniform for similar patients receiving similar anesthesia wherever anesthesia is provided, and when (b) all the results of monitoring during anaesthesia are written into the patient’s anaesthesia record, I think it is safe to conclude that your hospital fully meets the JCI Standard ASC.5.3 and its three (3) Measurable Elements requirements for documentation of monitoring of the patient during administration of anaesthesia.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

Ronald, DM & Manuel, CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA