When the treatment of a patient requires medical equipment, an essential step is to ensure each piece of equipment is functioning correctly. An anesthesia machine requires a thorough check to determine it is in working order prior to each case.

To ensure patient safety during operative procedures, each component of the anesthesia machine needs to be checked for appropriate functioning. Failure to perform this check may lead to near-misses or patient injury and increases the risk of severe morbidity and mortality.

National organizations recommend performing a machine check at the beginning of each day or whenever an anesthesia machine may have been moved or serviced or its vaporizers have been changed. In addition, the machine must be checked before each operative procedure.

Accreditation Commission for Health Care (ACHC) Standards address the requirements for maintenance of anesthesia machines used at Ambulatory Surgery Centers.

ACHC Standards

Standard: Adequate Anesthesia Equipment and Supplies (11.04.01, deemed and non-deemed)

The organization leadership has a policy approved by the professional staff that:

• Establishes sufficient quantities and types of anesthesia supplies and equipment, such as appropriate periodic automatic replenishment (PAR) levels of equipment.
• Addresses the requirement for anesthesia supplies and equipment to be stored so that movement is minimized during cases.
• Addresses the expectations for processed supplies to be protected from surface/airborne contamination.
• Establishes the process to periodically use staff input to evaluate the quantity and quality of anesthesia equipment available to meet the needs of the patients.

Standard: Maintenance of Anesthesia Equipment (11.04.02, deemed and non-deemed)

All anesthesia equipment must be maintained in compliance with all applicable requirements (e.g., Safe Medical Device Act and Food and Drug Administration requirements).

Anesthesia machines and related equipment undergo documented, routine preventive maintenance in accordance with manufacturer specifications or nationally recognized standards and guidelines.

Required Elements/Additional Information

The Ambulatory Surgery Center has written policies to address these requirements.

The patient records include documentation of:

• Safety checks completed before each patient use.
• Anesthesia machine number. This documentation is necessary in the event of patient injury or any equipment recall.

Standard: Generator Inspection (16.05.03, deemed and non-deemed)

Where general anesthesia or life support equipment is used, each ASC must be provided with an essential electrical system (i.e., emergency power generator) in accordance with NFPA 99, Standard for Health Care Facilities (2012 edition), and NFPA 110, Standard for Emergency and Standby Power Systems (2010 edition).

Tips for Compliance

• Label each anesthesia machine with a unique identifying number, and document that number in the patient’s medical record.
• Develop a maintenance calendar to service the equipment following manufacturer requirements.
• Maintain service logs for each piece of equipment, and identify each machine by its unique identifying number.
• Develop a spot in the medical record to record the anesthesia machine number and equipment check conducted prior to each procedure.
• Provide education to the appropriate individuals on the elements required to be evaluated during the safety checks and to document all maintenance of the equipment, along with daily and pre-procedure safety checks.
• Audit medical records to ensure compliance with documentation requirements for anesthesia machine numbers and safety checks performed before procedures.

Here to Help

To access the most recent ACHC Accreditation Standards Manual, contact your Account Advisor or email us at [email protected].