ANAESTHESIA, PAIN & INTENSIVE CARE

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EDITORIAL VIEW

Anesthesia Clinical Services

Accreditation by Royal College of
Anaesthetists UK: An example to follow
Zahid Sheikh

ABSTRACT
Consultant Anesthesiologist, There has been an increasing awareness about the need of a system of quality assurance
Royal Derby Hospitals NHS in the healthcare services throughout the world. Many of the advanced countries have
Foundation Trust, Derby (UK) developed meticulous guidelines and checklists to assure quality and safety, and
prevent medical errors at every step of the healthcare and minimise the iatrogenic
Correspondence: mortality and morbidity, and have introduced accreditation systems to offer incentives
Dr Zahid Sheikh, to the best of the institutions. A system of awarding a certificate of ‘Anesthesia Clinical
Consultant Anesthesiologist Services Accreditation’ (ACSA) has been evolved by Royal College of Anaesthetists UK
Royal Derby Hospitals NHS
(RCoA) to be awarded to the suitable healthcare institutions. This editorial offers an
Foundation Trust
outline of this system to introduce the need of such a system in every country with the
Uttoxeter Road
aim of enhancing quality of the care being provided by the healthcare institutions.
Derby DE22 3NE, (UK)
E-mail: [email protected]; Key words: Accreditation; Anesthesia; Medical Errors/prevention & control; Safety
[email protected] Management/standards; Quality Improvement

Received: 6 Sep 2018

Citation: Sheikh Z. Anesthesia Clinical Services Accreditation by Royal College of
Reviewed: 21 Sep 2018
Anaesthetists UK: An example to follow. Anaesth Pain & Intensive Care 2018;22(3):297-
Corrected & Accepted:
23 Sep 2018 300

Royal College of Anaesthetists UK (RCoA) has a accreditation laid down by the RCoA. The standards
system of awarding a certificate of Anesthesia Clinical committee visited the hospital every year to monitor
Services Accreditation (ACSA) to the suitable the progress in improving the standards of care and
healthcare institutions, who apply for this certificate. the measures taken by the anesthetic department to
At the time of writing this editorial, there have been fulfil the mandatory requirements. The accreditation
only 20 departments of anesthesiology in UK, which was awarded only after the whole process of the
were judged eligible to obtain this prestigious award. setting of the standards and demonstration of the
As part of the process, the applicant department is successful implications of all domains recommended
required to demonstrate to the RCOA, that it meets all by the College were completed and the standards
of the 155-quality standards within 5- main domains committee was fully satisfied.
being tested, including patient safety training
A summary of the 51-page comprehensive document
and teaching. The quality control teams of RCOA
for accreditation by the Royal College and the
visit the hospital every year to monitor progress in
salient points of the process to fulfil the criteria for a
the improvement of anesthetic services as per the
successful accreditation is presented here.
standards of ACSA.
The process of Anaesthesia Clinical Services
Most recently the anesthetic department of The
Accreditation (ACSA) has five main Domains:
Royal Derby Hospital in the East Midlands UK has
been granted the RCoA accreditation in anesthesia 1- The Care Pathway
services. The application for the accreditation had 2- Equipment, Facilities and Staffing
been submitted four years back and the accreditation 3- Patient Experience
process was completed according to the standards of 4- Clinical Governance

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anesthesia clinical services accreditation

5- Subspecialties patients including emergencies, obstetric patients and

children. Early warning scores should be visible on
All domains are divided into subdomains;
patient observation charts. Arrangements are in place
The Care Pathway: for the multidisciplinary management of patients
Includes preoperative care. Preoperative assessment with significant comorbidities. Pediatrics early
clinics need to be run by appropriately trained staff, warning scores should be visible on all age-specific
trainee anesthesiologists with input from senior observation charts. Charts should be modified for the
anesthesiologists. Any investigations required and obstetric patients.
support provided by other medical specialities in Policies for children’s surgical services are formulated
preoptimization of the patients and for the post-op and reviewed by a multidisciplinary team- including
care of patients is ensured. leads from the following specialties; pediatrics,
Speciality specific anesthesiologists as appropriate anesthesia, surgery and nursing.
should be assigned elective surgical lists. All lists have There is a documented policy for the interdisciplinary
named anesthesiologists and the lists are compiled 24 management of critically ill children including short
hrs preop. term admission to a general ICU. There are clear
Post-op care of patient includes the provision of criteria and standards for pediatric day surgery with
adequate pain relief and risk stratification is discussed regards the children attending, discharge pathway
and documented clearly in the pre-op notes. Patients and also about the environment and staff where it
and their careers are given adequate information upon is delivered. When a child undergoes anesthesia, all
which to base their decision regarding anesthesia, staff (operating department / practitioners / assistants
post-operative care and pain relief / anesthetic nurses / recovery) have pediatric
competencies and experience, including basic as well
All patients should have a named and documented as advanced life support competency.
supervisory anesthesiologist who has overall
Where there are elective cesarean section lists, there
responsibility for the care of the patient. This should
needs to be dedicated obstetric, anesthesia, theatre
be visible on the anesthetic record, on the rota
and midwifery staff.
and on display in the department. Named senior
anesthesiologists supervising trainees in all areas of Arrangements are in place for the multidisciplinary
anesthetic services is documented and published on management of vulnerable older patients.
weekly working rota. There should be policies for the 24-hour cover of
There are policies and documentation for the emergency surgery, prioritization of emergency cases
handover of care of patients from one team to according to clinical urgency, and seniority of clinical
another throughout the perioperative pathway. A staff according to patient risk. The local arrangements
copy of policies and protocols should be provided. should be verbally relayed by staff members and
Handovers should be visible on the anesthetic record. clearly visible on duty charts.
A rolling audit of handover quality, would be useful There is a policy to address the airway management
to demonstrate compliance with this standard. of adults and children in the emergency department.
Current guidelines for the management of anesthetic Equipment, Facilities and Staffing levels:
emergencies are appropriately displayed and
immediately and reliably available in sites where All anesthetic equipment is checked before use
anesthesia and sedation is provided and include according to published guidelines and the checks are
guidelines for children. Copies of policies which are documented. These guidelines can be published by
required for emergencies that may occur (based on the local competent authority.
the services being provided) should be appropriately A copy of documented checks should be provided
displayed and immediately and reliably available. Equipment for monitoring including capnography,
There are policies for the management of acute pain ventilation and resuscitation including defibrillation
and post-operative nausea and vomiting, including must be available at all sites where patients are
for those with special requirements, e.g. chronic anesthetized or sedated and on the delivery suite.
pain, drug dependency. There is a policy for the In areas that treat children, this must include
management of morbidly obese patients. A copy of equipment specifically designed for children.
the policy should be provided.
Defibrillators, bag and masks and capnography
An appropriate early warning score is in use for all should be available, including in remote locations.

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anesthesia clinical services accreditation

Trained anesthetic assistance / nurse should be escalation plans. A system by which anesthesiologists
present to help anesthesiologist where patients are can be called at any time for advice should be relayed
being anesthetized. Staff should be proficient in verbally by any member of staff, including nursing
using the available equipment models and frequently staff, for adults and children. There is a dedicated
asked if they encounter any difficulties with acute pain nurse specialist service which also covers
equipment in any sites; specifically at all situations the needs of children.
where a patient will be intubated, including the ward. There is a trained resuscitation team for adults,
Equipment must be available to administer oxygen including pregnant women, children and neonates as
to all patients undergoing procedures under sedation appropriate.
by an anesthesiologist. There must be the ability to
monitor continuous CO2 output. There are anesthetic clinical leads with responsibility
in the following areas: pre-operative assessment,
Devices for monitoring and maintaining or raising emergency anesthesia, remote sites, pediatrics,
the temperature of the patient should be available obstetrics, day surgery, acute pain management,
throughout the perioperative pathway including perioperative medicine, resuscitation, ICM, anesthetic
control of theatre temperature. equipment, governance, simulation/human factors
There is either a fully equipped obstetric theatre in training, research, airway management, and safety
the delivery suite or an adjacent theatre that is always and others as appropriate. This list is not exhaustive.
available for this purpose PSA must work with the higher authorities to start
fellowship programs of adequate duration in these
After general or regional anesthesia, or sedation, all
disciplines at well-suited centers of excellence.
patients recover in a specially designated recovery
areas equipped with appropriate monitoring facilities Trainees have specific training and demonstrated
/ emergency drugs and intubating equipment. The competence in relevant areas before working with or
recovery area should have oxygen delivery system without distant supervision. They have unimpeded
and suction. The recovery room staff must be access to a nominated consultant for advice and
appropriately trained in all relevant aspects of post- supervision at all times.
operative care. A written policy should be provided A duty anesthesiologist is available for the obstetric
describing which members of staff, based on their unit 24 hours a day, where there is a 24-hour epidural
qualifications, should be present in recovery for service, the anesthesiologist is immediately available
each of the procedures being undertaken. Until to the delivery suite.
patients can maintain their airway, breathing and
circulation they are cared for on a one-to-one basis Patient Experience:
by an appropriately trained member of staff, with Evidence be provided for appropriate pre-op
an additional member of staff available at all times. assessment times and clinics. Anesthetic notes
Critically ill patients in the recovery area are cared for must include the explanation of anesthesia, risk
by appropriately trained staff and have appropriate stratification and the anesthesia including the
monitoring and support provision of post-op pain relief discussed and
recorded clearly in pre-operative notes.
A written policy should be provided and this should
be seen in the recovery area. The patients given the choice between the general
and regional anesthesia as appropriate and informed
There is a recognized process in place for the referral
consent obtained from the patient.
of patients requiring critical care, including pediatric
and obstetric patients, to an appropriate facility. Any support needed for patients with individual or
A written policy should be provided for adults and special requirements including children must be
children. mentioned in the records.
There are agreed criteria for discharge from recovery. Information given to patients and/or advocates
After these criteria have been met, an appropriately includes what to expect in the anesthetic room,
trained member of staff accompanies patients during operating theatre and recovery room and obstetrics
transfer department, as appropriate
A written policy should be provided for adults and Copies of written information should be provided.
children. Procedure specific leaflets that cover a variety of ages
Specialist acute pain management advice and and levels of understanding appropriate to the patient
intervention is available at all times including are produced by the administration and provided in

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the pre-op period. monitored and reviewed and is used to plan future
demand. Rolling audit data should be available.
Clinical Governance:
Continuity of high quality of anesthesia care and
Accurate, contemporaneous, clear and complete
safety for patients is demonstrated in the specialized
information about operating lists is printed and
surgical services supported by audits / studies with
displayed and any changes to lists are agreed by all
measurable outcomes.
relevant parties.
An understanding and review of the information
Written documentation should be provided and
regarding this accreditation can be helpful towards
displayed
standardisation of services and to improve quality of
The whole theatre team engage in the use of the WHO care of the anaesthetic services in other countries as
surgical check list including team brief and debrief in well.
all settings where anesthesia is administered.
The guidelines and the requirements can be
Patient’s identification including the surgical process modified as appropriate to best fit for the local
and surgical site marked checked and confirmed with anaesthesia services in other countries. It is suggested
patient and the published list. “Stop before Block “is that a steering group be formed by 6/8 senior
carried out in order to avoid wrong side block. anesthesiologists, who could review the standards
Where relevant there must be adequate number and put together a document akin to the one used
of doctors available to simultaneously cover by the RCOA. This document can be used to guide
commitments in obstetrics, critical care and the anesthetic departments in the country who would
emergency theatres. wish to apply for the accreditation.

There is a formal handover process between shifts, A Quality control teams comprising of 10/12 senior
multidisciplinary where appropriate. anesthesiologists could be formed. They are prepared
to visit the anesthesia departments striving to achieve
There is a system in place to allow reporting and accreditation. The quality control team monitors the
regular presentation of: audit projects, complaints, improvement in anesthesia services and provides
critical incidents and other untoward incidents feedback on the drawbacks and areas of services that
and near misses, with demonstrated learning and needed enhancement. A certificate of accreditation
improved outcomes. The department has evidence is awarded to the department that successfully
of engagement with, and implementation of national demonstrates and fulfils all criteria of standards of
audit projects and quality improvement programs, care.
including obstetrics.
Conflict of interest: None declared by the author.
Continuous measurements of the outcome of elective
Acknowledgement: The author is grateful to RCoA for making
and emergency anesthesia is undertaken.
the document, which prompted us to write this editorial, freely
The emergency surgery workload is continually available on their website.

REFERENCES
1. Royal college of Anaesthetists UK, aesthesia Clinical Services Accredita- rcoa.ac.uk/acsa/acsa-standards
Documents on application for The An- tion (ACSA). Available at https://www.

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