Chapter 9 – Anesthesia Services
Possible Survey Review Items
This list represents some of the items that an AAAHC surveyor may review during an on-site
survey.
Chapter 9 – Anesthesia Services
 Policy – education, training, and supervision of personnel
 Policy - responsibilities of non-physician anesthetists
 Policy – responsibilities of supervising physicians and dentists
 Policy – written with regards to assessment and management of acute pain
 Policy – written protocols concerning the treatment of malignant hyperthermia (if
organization has triggering agents)
o Education (initial, annual, and for new employees)
o Written protocol following national recommendations (such as MHAUS)
 Posted
o Dantrolene and other medications and cooling methods available
 Policy – written protocols addressing the safe and timely transfer of patients for
extended or emergency services
 Policy - written protocols explaining how deeper than intended sedation is handled for
non-physician anesthetists
 Policy – concerning levels of anesthesia provided
 Policy – informed consent
 Policy – regarding safe use of injectables and single use syringes and needles
 Policy – discharge of patients
 Policy – addressing staff levels/assignments
 Current CPR, BLS, ACLS, PALS training
 Appropriate monitoring for level of anesthesia with available resuscitative medications,
supplies and equipment
 Complete anesthesia worksheet
 Identification of individual credentialed to administer sedative, hypnotic, or anesthetic
drugs that do not have any antagonistic medication (propofol)
 Alternative power available, if needed
 General anesthesia
o End-tidal CO2 monitoring
o Means to measure body temperature
Updated 1.1.2015