CMS Guidelines: Threat or Opportunity?

New guidelines have been released from Centers for Medicare & Medicaid Services related to “Anesthesia” services.  These guidelines have set off a firestorm of emails, letters, questions, and overall confusion to what they truly mean, what is their intention and how should these “interpretive” guidelines be interpreted.

The Society for Pediatric Sedation was one of many organizations that wrote to CMS, and expressed our opinion about the positives and negatives of these guidelines.  Our letter can be found here.

How has your institution approached these guidelines?

Has it been used as a threat to change your entire bylaws, sedation structure and deem “one physician” as the “controller” of  Anesthesia/Sedation? Has it been seen as “much ado about nothing” with no significant change seen based on your current structure? Has it brought specialties together or separated them further on this very important issue?

Overall, how do you feel it has or will impact patient care in your institution?

In my institution, it is yet to be determined.  Early on, I would readily admit that the confusion and difference of opinion led to some “tension” and mildly heated discourse.  Time will tell as the administration seeks to find clarity and answers to this dilemma.

The Opportunity

Overall, however, I see this as a great opportunity for improved sedation care.  Of course, this opportunity can only be seized if the anesthesia department and sedation service both feel that collaboration is truly what these guidelines are promoting.  The opportunity for anesthesia to provide oversight, input and collaboration is far different than an effort to take “control” or take back sedation care that they could not or did not want to provide many years ago thus allowing skilled expert sedation providers to fill this niche.

On the other hand, sedation services have an opportunity to promote very important dialogue with their anesthesia colleagues.  They should work to integrate care and not seen as a competitive services but rather a complementary one.

Our Hope

My feeling is that these guidelines can be interpreted very differently and “bias” clearly affects one’s vision.  However, if we are truly focused on “what is best for the patient” we can only hope that visions will clear, weapons will be dropped, and we will look back at these guidelines as an opportunity to promote multidisciplinary collaboration and improve sedation care.

High hopes perhaps, but perhaps a lofty goal that we as a society should strive for.

The SPS would appreciate your thoughts, opinions and experiences on this matter.  Please share via this Blog.  As a society we will continue to work to dialogue with Joint Commission, CMS and other agencies to meet our goals of improving sedation quality and safety.

Mick Connors MD

3 thoughts on “CMS Guidelines: Threat or Opportunity?

  1. Jessica Riggins

    I truly believe that I was the one individual most affected by the guidelines at my institution. Hired as the Nurse Practitioner for our Pediatric Sedation Service, I was given the “task” of starting the service. I collaborated with both Anesthesia and Intensivist services. I researched, questioned, traveled (Thank You to my hosts at Boston Children’s, Cincinnati Children’s, and Kosair) to observe and analyze what would be best practice in our institution with our resources and our patient population. I started a “Precedex MRI” service and we have served over 500 successful procedures in three years with a very high level of quality and safety. It took three years to get up and rolling with steam, and in a single memo, my role, my job was eliminated.
    I was honest about what level of sedation we provided. Deep. We are obtaining the child’s “physical consent” to complete the procedure. The child cannot be awakened to voice/noise (MRI) with or without light tactile stim. Safe. Yes, the child breathes on his or her own, but the guidelines we follow state the level is still Deep. According to the CMS guidelines, I cannot assess the patient (pre or post-sedation). I cannot consent the family of the patient. I cannot monitor. I cannot manage. I cannot determine the patient ready for discharge. I can possibly update a history and physical. There is no longer a role for me in Pediatric Sedation.
    My hope is that I developed a program with a strong foundation which will continue after I move on. I will be fine, but will the program continue? Will our patients continue to receive the high level of care I demanded, or will that become too time-consuming, too difficult for busy physicians who now have to add more responsibility and more jobs to their plates? Our program is more than pushing drugs and watching airways. We take kids’ pain and fear away. I do see that in some corners, much of the guidelines are needed and much that is positive will come from them, but when it comes down to it, there is much negative too. Not just for me, but for our patients. . .and those who wrote the “mandates” didn’t even consult the experts. . .I thank the society for acknowledging the missing RN and NP roles from the guidelines, but it doesn’t sound as if CMS is listening.

  2. Jud Barber

    This document has caused much hand wringing at our institution amongst people who are paid to worry about things. It remains to be seen what changes it will effect (if any) as we try to sort through it. I am hopeful the SPS will remain a voice of reason on this issue.

  3. Liz Edmundson

    I am curious if CMS has responded yet to the SPS letter from Feb 2010. My institution has a 17 year old nurse sedation service that is directed by anesthesiologists who work in a “sedationologist” role. They assess the pt, consent, write orders and are available for rescue. The nurse assess, educates, administers typically Fentanyl, Versed, Nembutal IV for generally Radiology procedures. We also work with non anesthesiologist for IP’s requiring chest tubes, abcess drains etc and clinic physicians for join injections, sexual abuse exams etc….
    As Jessica mentioned above, patients need deep sedation for MRI, without it the scans would be unsucessful. We have collected close to 50,000 nursing sedation outcomes over the past 17 years of which many of these are MRI. Not one sedation related death in 50,000 sedations. Strong program supported by our Dept of Anesthesia.

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