This program will cover the CMS hospital CoP standards for surgery, anesthesia, and PACU. Every hospital that accepts Medicare and Medicaid must follow these standards and they must be followed for all patients. This program will cover some of the important CMS memos that discuss medication management, IV, and safe opioid use. This will cover the changes to H&P that went into effect in November 2019 and February 2020.  Some of the changes include the options for hospitals to elect to do an assessment on healthy outpatients undergoing surgery or a procedure instead of an H&P.

This program will go over the number of reported CMS deficiencies and types received by hospitals. This has many important issues such as informed consent, H&Ps, safe opioid use, safe injection practices, compounding, and beyond use dates (BUDs).

This program will discuss the many standards required by the surgery department and anesthesia including required policies. Hospitals will need to make sure their policies and procedures reflect these requirements.

This program will cover the current CMS guidelines, including the current interpretive guidelines regarding pre-anesthesia evaluations, post-anesthesia evaluation, and anesthesia services. Hospitals are required to have many policies including one on specific clinic situations involving anesthesia or analgesia. This includes interpretive guidelines on moderate sedation and deep sedation. It impacts moderate and deep sedation done in other places like the emergency department and GI lab and patients who have ECTs.

The history and physical and informed consent form must be on the chart before surgery except in an emergency. An exception is made for young healthy outpatients if hospitals implement policies and follow the requirements.

 A study found that 66% of the time the consent was missing which resulted in a delay of 10% of surgical procedures. This costs the average hospital almost $600,000 a year. What surgical equipment is required? Come learn the answers to these questions and many more.

Objectives:-

• Recall that there are several policies and procedures required by CMS related to surgery and anesthesia services
• Describe that CMS has a section that addresses PACU requirements
• Recall that CMS has a list of things that must be included in the OR register
• Describe what information is required for informed consent and that it should be on the chart before surgery
• Discuss the 48-hour requirements for the post-anesthesia evaluation of both inpatients and outpatients

Outline:-

Surgery and PACU

• CMS deficiency report
• CMS current manual and new website
• CMS Certification and Survey Memos
  • Humidity in the OR
  • Safe injection practices
  • Infection control breaches memo
  • CMS worksheets with a section on safe injection practices
• What constitutes surgery?
• Infection control in ORs
• Equipment, temperature, humidity
• Supervision in the OR
• Scrub tech and circulators
• Surgical privileges
• Surgery policies required
• Preventing OR fires
• History and physical 2019 & 2020 changes  
• Informed consent
• OR register
• PACU standards
• Operative report requirements
• Surgery equipment required
• PACU standards
  • Monitoring of patients receiving opioids

Anesthesia

• Must comply if the hospital does any type of anesthesia
• Director of Anesthesia Services
• Anesthesia versus analgesia
• General, regional, MAC, topical, minimal sedation, moderate sedation
• Rescue capacity
• OR, Radiology, ED, Clinics, Psychiatry and other sites where anesthesia is   provided
• QAPI
• Director of Anesthesia responsibilities
• Who can administer anesthesia
• Scope of practice for CRNA and Anesthesia Assistants
• CRNA state exemption
• Anesthesia Policies required
• Criteria for privileges
• Pre-anesthesia assessment
• Post-anesthesia evaluations
• Consent, infection control, documentation, safety policies required
• Documentation requirements
• Intraoperative anesthesia record requirements

Who Should Attend?

• Director of the OR and OR nurses/staff
• PACU Nurse Manager/PACU nurses
• Chief of Anesthesia
• Anesthesiologist
• CRNAs
• Anesthesia Assistants
• Medical Credentialing Staff
• Patient Safety Officer
• Risk Manager
• Chief Nursing Officer (CNO)
• Chief Medical Officer (CMO)
• Chief Operating Officer (COO)
• Chief Executive Officer (CEO)
• OB Nurses and Nurse Director
• Joint Commission liaison
• Quality Improvement Director
• Regulation and Accreditation Director
• Nurse Educator
• PI Director
• Compliance Officer