Section 250.1410  Anesthesia Service

a)         The Anesthesia Service shall be organized under written policies and procedures regarding staff privileges, the administration of anesthetics, and the maintenance of strict safety controls. In hospitals where there is no organized Anesthesia Service, the Surgery Service shall assume the responsibility for establishing general policies and supervising the administration of anesthetics.  The Anesthesia Service is responsible for all anesthetics administered in the hospital.

b)         The Anesthesia Service shall be under the direction of a physician who has had specialized preparation and/or experience in the area or who has completed a residency in anesthesiology.  An anesthesiologist, Board certified or Board eligible, is recommended.

c)         A physician or registered professional nurse shall supervise the work of all nonmedical personnel working in the Anesthesia Service.

d)         Responsibility for regular inspection, maintenance, and repair of anesthesia equipment and supplies shall be established.

e)         The Anesthesia Service, hospital administration, and medical staff shall collaborate to establish policies and procedures for the control, storage, and safe use of combustible anesthetics, oxygen and other medicinal gases; types of anesthesia to be administered and procedures for each; personnel permitted to administer anesthesia; infection control and safety regulations to be followed.

f)          The hospital shall recognize the dangers of accidental ignition of anesthetic gases to patients and others and shall make provisions to minimize this hazard in accordance with National Fire Protection Association (NFPA) Standard No.99 (1993), "Health Care Facilities Code."

g)         Appropriate measures shall be taken to acquaint all personnel with the policies and procedures established and to assure enforcement.

h)         Anesthetic agents and medicinal gases shall be administered only on the order of a member of the medical staff and shall be administered only by persons qualified in the management of such materials. See subsection (e) of this Section.

i)          The use and storage of anesthetic gases shall be in accordance with NFPA Standard No.99 (1993), "Health Care Facilities Code." Areas for cleaning, testing, and storing anesthesia equipment shall be provided.

j)          An anesthetic record on special forms shall be made a part of the patient's chart.  Drugs used, vital signs and other relevant information shall be recorded at regular intervals during anesthesia.

1)         There shall be a history and physical examination by a physician within 48 hours prior to the surgery, with findings recorded in the patient's record. For dental surgery, the history and physical examination may be performed by a dentist who has been granted such privileges by the hospital medical staff.

2)         Except in emergency, no anesthetic shall be administered until the patient has had a history and physical examination, and a record made of the findings.

k)         Patients under or recovering from anesthesia and those who have received sedatives or analgesic shall remain under continuous, direct nursing supervision until vital signs have become stabilized.  Any nurse performing this duty shall have been instructed in the management of post-anesthetic patients, shall have no other clinical duties while supervising such patients, and shall have immediate recourse to the attending surgeon or anesthesiologist, or qualified substitute, present in the hospital.

l)          Post-anesthetic follow-up visits shall be made within 24 hours after the operation, by the anesthesiologist, nurse anesthetist or responsible physician, who shall note and record any postoperative abnormalities or complications from anesthesia.

(Source:  Amended at 19 Ill. Reg. 13355, effective September 15, 1995)