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Interpretive Guidance for Standard 1-A-3

Inconsistencies in the application of standard 1-A-3 have been identified. Interpretive Guidance for this standard has been developed to assist facilities in determining the most appropriate facility class for the types of anesthesia provided.

Surveyors have identified a concerning trend in which higher doses or combinations of medications are being administered to patients in facilities accredited under the Class A standards that result in much more than minimal sedation or anxiolysis. The American Society of Anesthesiologist's (ASA’s) definition of minimal sedation/anxiolysis is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Facility Class A: a single dose of the same medication, either an analgesic or anxiolytic, is to be administered to the patient pre-operatively and post-operatively in doses that only result in minimal sedation. The administration of additional doses of either an analgesic or anxiolytic is no longer considered minimal sedation. A facility accredited under the Class A standards may put a patient at significant risk when additional doses are administered because Class A accreditation standards do not require the necessary monitoring equipment and rescue drugs as the facility Class B or higher accreditation standards.

In certain doses, drugs such as Diazepam, Midazolam, Tramadol, and MKO Melt® (a combination of the medications Midazolam, Ketamine, and Ondansetron) can induce more than minimal sedation; therefore, falling outside the intended guidelines of standard 1-A-3. If the dose or drug combination goes beyond anxiolysis or minimal sedation, the facility must be evaluated under the accreditation standards for facility Class B.   The minimum monitoring requirement for facility Class A cases is continuous pulse oximetry which correlates to the ASA standards of practice. However, for moderate sedation, provided in Class B facilities, the patient will require additional monitoring.

An ophthalmology facility accredited under facility Class A standards is permitted to perform procedures using topical anesthetic eye drops in conjunction with oral medication, which provides minimal sedation. However, if the facility performs procedures under a peribulbar or retrobulbar block, this requires the facility to be accredited under the Class B standards.

Utilizing nerve blocks (interscalene, supraclavicular, femoral, etc.) or field blocks (e.g., retrobulbar, digital, Bier, etc.) with oral medications is considered a facility Class B practice and must comply with all Class B accreditation standards. The use of field or nerve blocks with local anesthetic placed around a nerve has the potential to enter the bloodstream and could cause lidocaine toxicity.

We appreciate your commitment to patient safety. Please ensure your facility practice follows the standards. If you have any questions, feel free to reach out to your accreditation specialist.

Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.