CMS SOM App. A, Tag A-0957

care.

Interpretive Guidelines §482.51(b)(4)

Adequate provisions for immediate post-operative care means:

• Post-operative care must be provided to all surgical patients, including same-day surgery patients, in accordance with acceptable standards of practice.

• A post-operative care area, usually referred to as the post-anesthesia care unit

(PACU), is a separate area of the hospital. Access is limited to authorized

personnel.

• Policies and procedures specify transfer requirements to and from the PACU.

Depending on the type of anesthesia and length of surgery, the post-operative

check before transferring the patient from the PACU includes, but is not

limited to:

o Level of activity;

o Respirations;

o Blood pressure;

o Level of consciousness;

o Level of pain;

o Patient color; and

• If a patient is not transferred to the PACU, determine that provisions are made

for close observation until the patient has regained consciousness, e.g., direct

observation by a qualified RN.

Post-operative Monitoring

Hospitals are expected to develop and implement policies and procedures addressing the

minimum scope and frequency of patient monitoring in post-PACU care settings,

consistent with accepted standards of practice.

Patients receiving post-operative intravenous (IV) opioid medications are of particular

concern, due to the higher risk for oversedation and respiratory depression

7F

8. Once out of

the PACU, patients receiving IV opioid medication may be placed on units where vital

signs and other monitoring traditionally has not been done as frequently as in the PACU

or intensive care units, increasing the risk that patients may develop respiratory

compromise that is not immediately recognized and treated. (See the interpretive

guidelines at §482.23(c)(4)). When post-surgical patients are transferred out of the

PACU to another area of the hospital but continued on IV opioid medications, they need

vigilant monitoring, even if post-PACU care is not typically referred to as “immediate”

post-operative care. Opioid- induced respiratory compromise has resulted in inpatient

deaths that might have been prevented with appropriate assessment and vigilant

monitoring of respiration and sedation levels.

8F

9

Survey Procedures §482.51(b)(4)

• Verify that the hospital has provisions for post-operative care.

• Observe care provided to patients in a PACU to determine whether patients

See for example: 8 Institute for Safe Medication Practices (ISMP), Medication Safety Alert - High Alert

Medication Feature Reducing Patient Harm from Opiates. February 22, 2007.

9 Institute for Safe Medication Practices (ISMP), Medication Safety Alert – Fatal PCA Adverse Events

Continue to Happen…Better Patient Monitoring is Essential to Prevent Harm. May 30, 2013

are monitored and assessed appropriately prior to transfer or discharge (in the

case of same-day surgery patients) from the PACU.

• Does the hospital have a system for identifying and addressing the monitoring

needs of post-operative patients transferred from the PACU to other areas of

the hospital?

• Ask staff in the PACU and in units who receive patients from the PACU how

the needs of post-operative patients for vigilant monitoring is addressed when

the patients are transferred from the PACU to other areas of the hospital.