Medical Direction & Temporary Relief
CRNAs/AAs providing anesthesia services under the medical direction of an anesthesiologist
must have uninterrupted immediate availability of an anesthesiologist at all times. When a
medically directing anesthesiologist provides temporary relief to another anesthesia provider, the
need for uninterrupted immediate availability may be met by any of the following strategies:
• A second anesthesiologist, not medically directing more than three concurrent procedures,
may assume temporary medical direction responsibility for the relieving anesthesiologist. The
transfer of responsibility from one physician to another should be documented in the medical
• Policy and procedure may require that the relieved provider remain in the immediate area
and be available to immediately return to his/her case in the event the relieving
anesthesiologist is required elsewhere. Adequate mechanisms for communication among staff
must be in place.
• Policy and procedure requires that a specified anesthesiologist (e.g., O.R. Director) remain
available at all times to provide substitute medical direction services for anesthesiologist(s)
providing relief to anesthesia providers. This individual must not personally have ongoing
medical direction responsibilities that would preclude temporarily assuming responsibility
for additional case(s).
The following criterion applies to anesthesia services personally performed:
• The physician personally performed the entire anesthesia service alone;
• The physician is a teaching physician and is involved with one anesthesia case with a
• The physician is continuously involved in a single case involving a student nurse anesthetist;
• The physician and the non medically directed CRNA (or Anesthesiologist Assistant) are
involved in one anesthesia case and the services of each are found to be medically necessary.
Medical direction occurs if the physician medically directs qualified individuals in two, three, or
four concurrent cases and the physician performs the following activities:
• Performs a pre-anesthesia examination and evaluation;
• Prescribes the anesthesia plan;
• Personally participates in the most demanding procedures of the anesthesia plan, including
induction and emergence, if applicable;
• Ensures that any procedures in the anesthesia plan that he/she does not perform are
performed by a qualified anesthetist;
• Monitors the course of anesthesia administration at frequent intervals;
• Remains physically present and available for immediate diagnosis and treatment of
• Provides indicated post-anesthesia care.
The physician can medically direct two, three, or four concurrent procedures involving qualified
individuals, all of whom could be CRNAs, AAs, interns, residents or combinations of
individuals. The medical direction rules apply to cases involving student nurse anesthetists if the
physician directs two concurrent cases, each of which involves a student nurse anesthetist, or the
physician directs one case involving a student nurse anesthetist and another involving a CRNA,
AA, intern or resident.
For medical direction services, the physician must document in the medical record that he or she
performed the pre-anesthetic exam and evaluation. Physicians must also document that they
provided indicated post-anesthesia care, were present during some portion of the anesthesia
monitoring, and were present during the most demanding procedures, including induction and
emergence, if applicable.