Document No.
GDH/POL/06
Dr. Gagandeep Version / 01/00
Hospital Revision
Policy On Anesthesia Date of Issue 01 JULY 2025
Page No. Page 1 of 8
Administration
POLICY ON
anaesthesia
administration
DR. GAGANDEEP HOSPITAL,
LUDHIANA
PREPARED AND ISSUED BY: Quality Manager, Ms. Nidhi Vijan APPROVED BY: MD, Dr. Gagandeep
Document No. GDH/POL/06
Dr. Gagandeep Version / 01/00
Hospital Revision
Policy On Anesthesia Date of Issue 01 JULY 2025
Page No. Page 2 of 8
Administration
Dr. Gagandeep Hospital,
Ludhiana
Policy on Anaesthesia Administration
This policy document is prepared for internal use of Dr. Gagandeep Hospital only.
Unauthorized publishing and disclosure of this document is prohibited.
Document Name Policy on Anaesthesia Administration
Document No. GDH/POL/06
No. of pages 7
Date of Issue 01 JULY 2025
Date of Implementation 01 JULY 2025
Date of Revision 01 JULY 2027
PREPARED AND ISSUED BY: Quality Manager, Ms. Nidhi Vijan APPROVED BY: MD, Dr. Gagandeep
Document No. GDH/POL/06
Dr. Gagandeep Version / 01/00
Hospital Revision
Policy On Anesthesia Date of Issue 01 JULY 2025
Page No. Page 3 of 8
Administration
Amendments
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PREPARED AND ISSUED BY: Quality Manager, Ms. Nidhi Vijan APPROVED BY: MD, Dr. Gagandeep
Document No. GDH/POL/06
Dr. Gagandeep Version / 01/00
Hospital Revision
Policy On Anesthesia Date of Issue 01 JULY 2025
Page No. Page 4 of 8
Administration
Policy on Anaesthesia Administration
1. PURPOSE
To ensure safe, standardized, and effective administration of anaesthesia at Dr. Gagandeep Hospital in compliance with
NABH 3rd Edition SHCO standards, thereby minimizing risks and ensuring patient safety before, during, and after
anaesthesia.
2. SCOPE
This policy applies to all patients undergoing procedures requiring anaesthesia (general, regional, local, or sedation) and to
all healthcare professionals involved in anaesthesia care, including anaesthesiologists, surgeons, nursing staff, and
operation theatre personnel.
3. POLICY STATEMENT
Dr. Gagandeep Hospital shall ensure that:
Anesthesia is administered only by qualified and credentialed anesthesiologists.
A pre-anesthesia assessment is conducted for every patient.
Appropriate monitoring and documentation are maintained throughout the peri-anesthetic period.
Patient safety and comfort are prioritized at all times.
4. DEFINITIONS
Anesthesia: Use of drugs and techniques to induce loss of sensation, pain relief, muscle relaxation, or
unconsciousness.
Types of Anesthesia: General anesthesia, regional anesthesia, local anesthesia, and monitored anesthesia
care/sedation.
ASA Classification: American Society of Anesthesiologists physical status classification system.
5. RESPONSIBILITIES
5.1 Medical Superintendent
Overall responsibility for implementation and compliance with the policy.
5.2 Anaesthesiologist
Conducting pre-anaesthesia evaluation and risk assessment.
Explaining anaesthesia plan and obtaining informed consent.
PREPARED AND ISSUED BY: Quality Manager, Ms. Nidhi Vijan APPROVED BY: MD, Dr. Gagandeep
Document No. GDH/POL/06
Dr. Gagandeep Version / 01/00
Hospital Revision
Policy On Anesthesia Date of Issue 01 JULY 2025
Page No. Page 5 of 8
Administration
Safe administration and monitoring of anaesthesia.
Post-anaesthesia care and management of complications.
5.3 Surgeon / Treating Consultant
Coordinating with anesthesiologist regarding surgical plan and patient condition.
5.4 Nursing & OT Staff
Preparing the patient, equipment, and drugs.
Assisting during anesthesia and monitoring.
Maintaining accurate records.
5.3 Blood Bank / Laboratory Services
Ensuring screening, cross-matching, labeling, storage, and transport of blood products.
Maintaining traceability and records.
6. PROCEDURE
6.1 Pre-Anaesthesia Assessment
A documented pre-anaesthesia evaluation shall be performed for every patient.
Assessment includes medical history, physical examination, ASA grading, investigations, and fasting status.
Any identified risks shall be communicated to the patient and surgical team.
6.2 Informed Consent
Written informed consent for anaesthesia shall be obtained separately or as part of surgical consent.
In emergencies, consent may be waived as per hospital policy and legal requirements.
6.3 Pre-Anaesthesia Preparation
Verification of patient identity, procedure, and site.
Availability and functionality of anaesthesia machine, monitors, drugs, and resuscitation equipment.
Compliance with WHO Surgical Safety Checklist.
6.4 Administration of Anaesthesia
Anaesthesia shall be administered as per standard clinical guidelines and patient condition.
Continuous monitoring of vital parameters including heart rate, blood pressure, oxygen saturation, and end-tidal
PREPARED AND ISSUED BY: Quality Manager, Ms. Nidhi Vijan APPROVED BY: MD, Dr. Gagandeep
Document No. GDH/POL/06
Dr. Gagandeep Version / 01/00
Hospital Revision
Policy On Anesthesia Date of Issue 01 JULY 2025
Page No. Page 6 of 8
Administration
CO₂ (where applicable).
PREPARED AND ISSUED BY: Quality Manager, Ms. Nidhi Vijan APPROVED BY: MD, Dr. Gagandeep
Document No. GDH/POL/06
Dr. Gagandeep Version / 01/00
Hospital Revision
Policy On Anesthesia Date of Issue 01 JULY 2025
Page No. Page 7 of 8
Administration
All drugs and doses administered shall be documented.
6.5 Intraoperative Monitoring
Monitoring shall continue throughout the procedure.
Any adverse events shall be promptly identified and managed.
6.6 Post-Anaesthesia Care
Patients shall be shifted to the Post-Anaesthesia Care Unit (PACU) or recovery area.
Monitoring of vital signs, pain, nausea, airway, and consciousness level.
Discharge from PACU shall be based on defined clinical criteria (e.g., Aldrete score).
7. MANAGEMENT OF ANESTHESIA-RELATED COMPLICATIONS
Any anaesthesia-related adverse event shall be immediately managed by the anaesthesiologist.
Events shall be documented and reported as per hospital incident reporting policy.
Root cause analysis shall be conducted for serious adverse events.
8. EQUIPMENT AND DRUG SAFETY
Anaesthesia equipment shall be regularly checked, calibrated, and maintained.
Emergency drugs and resuscitation equipment shall be readily available in OT and PACU.
Look-alike and sound-alike drugs shall be stored and labelled safely.
9. TRAINING AND COMPETENCY
All anaesthesia and OT staff shall receive periodic training in anaesthesia safety, airway management, and
basic/advanced life support.
Competency records shall be maintained.
10. QUALITY ASSURANCE AND AUDIT
Regular audits of anaesthesia records and outcomes shall be conducted.
Indicators such as anaesthesia complications, unplanned ICU admissions, and mortality shall be reviewed by
the quality committee.
11. STATUTORY AND REGULATORY COMPLIANCE
PREPARED AND ISSUED BY: Quality Manager, Ms. Nidhi Vijan APPROVED BY: MD, Dr. Gagandeep
Document No. GDH/POL/06
Dr. Gagandeep Version / 01/00
Hospital Revision
Policy On Anesthesia Date of Issue 01 JULY 2025
Page No. Page 8 of 8
Administration
This policy complies with NABH 3rd Edition SHCO standards, applicable national guidelines, and statutory
requirements.
12. RECORDS
Pre-anaesthesia assessment forms
Anaesthesia consent forms
Anaesthesia monitoring charts
PACU records
Incident reports
13. REVIEW AND REVISION
This policy shall be reviewed every three years or earlier if required due to changes in NABH standards or clinical
practice.
14. REFERENCES
NABH Standards for Small Healthcare Organizations (SHCO), 3rd Edition;
ISA Guidelines for Safe Anesthesia;
WHO Surgical Safety Checklist;
ASA Standards for Basic Anesthetic Monitoring;
Drugs & Cosmetics Act, 1940;
Biomedical Waste Management Rules, 2016;
Hospital Policies and Procedures.
PREPARED AND ISSUED BY: Quality Manager, Ms. Nidhi Vijan APPROVED BY: MD, Dr. Gagandeep