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Who are Canadian Anesthesia Assistants?

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    Posted: 09 Sep 2009 at 9:04am
Who are Canadian Anesthesia Assistants?

Implications of the Recent Changes to the CAS Guidelines

The February Board meeting accepted changes to the CAS Guidelines to the Practice of Anesthesia as recommended by the Standards Committee relating to the scope of practice by anesthesia assistants. These changes have been in the works for a considerable amount of time, allowing both the Standards Committee sufficient time to review all aspects and the Board members to consult broadly with the membership.

What do these changes mean, and what are their implications? This question can be answered from several different perspectives. First, and perhaps most importantly, it reaffirms our commitment to the fundamental principle that a patient receiving anesthetic is best served by having an anesthesiologist dedicated to his and only his care. In other words: "one patient, one anesthesiologist." These new changes do not alter this concept in any way. As a Society we remain firmly convinced that this provides the safest and most efficacious care for our patients.

These changes do demonstrate the recognition for the increasing need for trained individuals to "help" in the delivery of safe and efficient anesthesia services. We are defining the Canadian version of the Anesthesia Care Team. The first significant change occurs in the statement on providing ancillary care. Instead of stating "available where appropriate," which could mean different things to different individuals, such as administration/managers, the new statement states "as determined by the department of anesthesia." This is a very significant step forward, as now the responsibility for determining what ancillary help is necessary lies appropriately with anesthesiology departments. Who better to decide what is necessary to provide safe anesthesia than anesthesiologists?

Formal introduction of the term anesthesia assistant has a number of implications. First, it clearly identifies an individual whose responsibility is to assist the anesthesiologist in the administration of anesthesia. There is a requirement for this individual to have appropriate training and a well-defined scope of practice. The current changes do not address these issues specifically, but place this responsibility on individual anesthesia departments and hospitals. Obviously, there is a need for further national direction, and the CAS Allied Health Professions Committee, including its stakeholder organizations, has been addressing this issue over the past several years. These guideline changes will give the committee new enthusiasm and breathe new life into the project. We need a nationally approved training program with formal certification of successful candidates, including a well-defined scope of practice for anesthesia assistants.

The most significant change now "allows" an anesthesiologist to temporarily leave the OR and delegate the care to an anesthesia assistant. A key statement is "to an anesthesia assistant," not to just anyone. The practice of using well-trained individuals in this manner has been in common use in many jurisdictions throughout Canada. It has been proven to be safe and also to have some significant benefits. Thus, our guidelines will be reflecting what is already happening in much of Canada. However, now it will be formally recognized, and this will allow the practice to be appropriately structured and monitored.

There are several significant benefits that can arise, many related to improved patient safety. First, it raises the awareness of an increased need for well-trained individuals to assist anesthesiologists. Next, as an example, we have all been involved in long cases in which we become hungry, thirsty and need to use the washroom. It is impossible to remain highly vigilant with these distractions. Now it will be possible to take a short break to deal with these issues, knowing that the patient is being monitored by a well-trained individual who will be in immediate communication with you as necessary. Thus, many would say that overall monitoring (Vigilance) is improved in this scenario.

Another benefit is the ability to leave the OR and to directly, in person, evaluate/treat a patient in PACU rather than via a telephone conversation or relying on a friendly colleague who is free. A similar advantage can be seen in allowing an earlier pre-op evaluation and preparation of the next patient in the holding area. With the extensive use of "same-day surgery," this additional time for evaluation and preparation could be very useful. In the majority of situations, this is the attending anesthesiologist's first contact with the patient. This is a dramatic change from several years ago, when the majority of patients were admitted the night before, and this was the time of initial contact. Thus, improved OR efficiency could easily result from the appropriate use of anesthesia assistants.

Indeed, Canadian Medical Forum Task Force II has been examining a number of different models using alternate health care providers to deliver health care across all areas of medicine. The appropriate use of anesthesia assistants will improve OR efficiency and, while certainly not the solution to the worsening physician shortages in anesthesia, at least it will help alleviate the problem and demonstrate that the CAS has been proactive in this area. Perhaps the necessary funding to allow the CAS Allied Health Professions Committee to complete the necessary work on anesthesia assistants will come as a result of the work of Task Force II.

To summarize, the guideline changes maintain our high standard of care and can lead to improved patient safety, improved OR efficiency and to a healthier work environment for anesthesiologists, while staying true to our fundamental belief that a patient is best served by an anesthesiologist dedicated to a single patient only. Is it possible to abuse these new guidelines? The answer is obvious: of course it is. These are only guidelines, and it is the ultimate responsibility of every anesthesiology department, department Chair and individual anesthesiologist to conform to the "spirit" of the CAS Guidelines.

The following was approved by the CAS Board of Directors for amendment in the 2004 edition of the CAS Guidelines to the Practice of Anesthesia.

Ancillary Help

. . . .

The health care facility must ensure that ancillary personnel are available where appropriate as determined by the department of anesthesia. Qualified allied health professionals (herein called anesthesia assistants) may, with the approval of the governing body of the hospital, render certain ancillary assistance in providing anesthetic, resuscitative and intensive care services. These individuals must be properly trained and must have received accreditation by the appropriate authority where applicable. The tasks that they may perform must be clearly defined. An anesthesiologist must only delegate, or assign, to such personnel tasks for which they have approval or accreditation.

The Canadian Anesthesiologists' Society recognizes the formal job designation "Anesthesia Assistant." Anesthesia assistants must have undergone specific training in anesthesia assistance. The scope of practice for anesthesia assistants working in a specific institution must also be approved by the department of anesthesia, the local hospital administration and/or the Medical Advisory Committee (Council of Physicians). Furthermore, anesthesia assistants, like other hospital employed health professionals, must be covered by the hospital liability insurance. Duties and tasks delegated to anesthesia assistants must be consistent with existing governmental regulations, the policies and guidelines established by professional regulatory agencies, and the local hospital policies.

The Anesthetic Period

The anesthesiologist's primary responsibility is to the patient receiving care. The anesthesiologist or an anesthesia assistant supervised by the anesthesiologist shall remain with the patient at all times throughout the conduct of all general, major regional and monitored intravenous anesthetics until the patient has been transferred to the care of personnel in the post-anesthesia recovery (PAR) room or intensive care unit (ICU).

If the attending anesthesiologist leaves the operating room temporarily, he must delegate care of the patient to another anesthesiologist, to a resident in anesthesia, or to an anesthesia assistant. When the attending anesthesiologist delegates care to a resident in anesthesia or an anesthesia assistant, the attending anesthesiologist remains responsible for the anesthetic management of the patient. Before delegating care of the patient to an anesthesia assistant, the anesthesiologist must ensure that the anesthesia assistant is familiar with the operative procedure, the operating room environment and equipment, and that the patient's condition is stable. When care is delegated to an anesthesia assistant, the attending anesthesiologist must remain immediately available.

Only under the most exceptional circumstances, for example to provide life-saving emergency care to another patient, may an anesthesiologist briefly delegate routine care of a stable patient to a competent person who is not an anesthesia assistant, and that person's only responsibility is to monitor that patient during the anesthesiologist's absence and to keep the anesthesiologist informed until he returns. In this situation the anesthesiologist remains responsible for the care of the patient and must inform the surgeon.

Simultaneous administration of general, spinal, epidural or other major regional anesthesia by one anesthesiologist for concurrent diagnostic or therapeutic procedures on more than one patient is unacceptable. However, in an obstetric unit, it is acceptable to supervise more than one patient receiving regional analgesia for labour. Due care must be taken to ensure that each patient is adequately observed by a suitably trained person following an established protocol. When an anesthesiologist is providing anesthetic care for an obstetric delivery, a second appropriately trained person should be available to provide neonatal resuscitation.

Simultaneous administration of an anesthetic and performance of a diagnostic or therapeutic procedure by a single physician is unacceptable, except for procedures done with only infiltration of local anesthetic.

Patient Monitoring

The only indispensable monitor is the presence, at all times, of a physician or an anesthesia assistant, under the immediate supervision of an anesthesiologist, with appropriate training and experience. Mechanical and electronic monitors are, at best, aids to vigilance. Such devices assist the anesthesiologist to ensure the integrity of the vital organs and, in particular, the adequacy of tissue perfusion and oxygenation.

John Scovil, President, MD FRCPC
Daniel Chartrand, Standards Committee Chair, PhD MD FRCPC
Serge Lenis, Allied Health Professions Committee Chair, MD FRCPC

------------------------------------------------------------------------------------------------------------------- = Doctorate Of Nurse Anesthesia Practice


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