Manitoba/CAS Perspective
CAS 2015 Position Paper on AA

Manitoba Perspective

Introduction

The ability to offer a distinct and comprehensive training program for professionals interested in an Anesthesia physician extender role has long been desired by Anesthesiologists as a way to enhance system efficiencies, improve job satisfaction, promote patient safety and bring added consistency to Anesthetic care of the patient. The Anesthesiologist-led, Anesthesia care team model is an emerging concept, gaining momentum because it increases the flexibility and responsiveness of care and expands the ability to provide a broader and timelier range of services.

As the national Anesthesia Clinical Assistant (ACA) dialogue/debate unfolds, it is in the interest of Anesthesiology as a profession and Anesthesiologists as individuals to aim for a coherent national vision, with consistent prerequisites, congruent training and matching educational endorsements.

ACA programs should attract mature professionals (RN, IMG, PA, RT) with several years experience in high dependency clinical areas.

Anesthesia providers

University Departments of Anesthesia in Canada already train two Anesthesia providers, Family Practitioners (FP) and Specialists (FRCPC). Presently, FP’s provide Anesthesia services (limited to ASA I & II categories) in ghfrural areas. They take a one-year program of study after successful completion of a FP residency and following established practice in the clinical arena. FP Anesthetists tend to be under-utilized in non-rural settings. Improving funding to the FP Anesthesia sector to create more FP Anesthesia training positions would more expeditiously ease the specialist Anesthesiologist shortage than training yet another independent provider (as in the United States). At the same time this would honor the Canadian conviction that the safe practice of Anesthesia requires a degree in medicine and subsequent specialty training.

Physician Extenders

Many specialties, including Anesthesia, are dealing with workloads that are not sustainable. It is a credit to regional health authorities and Ministries of Health that this predicament is being recognized and funding for ACA positions and program development is forthcoming.

The schooling requisite to perform the duties of an Anesthesia Clinical Assistant is radically different from training required to become a Physician Assistant or Nurse Practitioner practicing in an office/clinic/ward setting. These latter two mid-level providers address the huge service needs in primary health care and staffing requirements for new models of primary and urgent care delivery. PA training also provides opportunities for foreign graduates to receive education and preceptorship within the Canadian system.

Comparison of Physician assistant, Nurse practitioner and ACA professional roles in the Health Care System

PA’s conduct physical examinations, diagnose illness, order tests and interpret test results, prescribe medication, advise patients on health care issues, and assist with procedures in an integrated practice relationship with physicians. They are educated in a medical model that prepares non-specialty graduates to work predominantly in clinic and ward settings (medical, surgical, psychiatric, emergency, primary care and/or pediatric, including remote settings). Further post-basic training is required to enable work in sub-specialty medical/surgical disciplines. Currently PA training is available through the Canadian military and an MSc program offered by The University of Manitoba. Upon completion of training, PA’s are eligible to sit a national certifying examination conducted by the Canadian Association of Physician Assistants (CAPA). Licensing of this health care provider role became possible in Manitoba with the addition of regulation CCSM.c.M90 to the province’s Medical Act. PA’s are listed on the medical register and fulfill the annual licensing requirements of the CPSM. They report directly to the physician(s) they assist.

NP’s have a similar role to physician assistants. Their training differs from the medical model in that they continue their post-graduate education in an independent nursing model. Upon graduation some choose to practice collaboratively with physicians. As a profession they are regulated by the College of Nurses, as a professional body they are unionized.

ACA’s work as physician extender members of the Anesthesia care team. They are educated in a post-graduate, vocational/occupational-specific model, acquiring knowledge and developing skills and judgment relevant to the practice of Anesthesia. This includes:

  1. Expertise in equipment, monitors, machines, airway management devices, vascular access and regional block procedures
  2. Pre-emptive, resuscitative and maintenance interventions, and drugs necessary for safe conduct of a general or regional anesthetic
  3. Sufficient familiarity with the maintenance phase of anesthesia to be left in charge of the care of the patient for various periods of time deemed appropriate by the attending physician.
  4. Algorithmic resuscitative interventions for unexpected catastrophic events occurring during the provision of anesthesia
  5. Assessment and care of patients in Pre & Post Anesthesia settings, Off-site locations, Acute/chronic pain service settings, Labor wards, ICU’s under the direct supervision of the attending physician.
  6. Patient transport
  7. Delegated administrative duties such as data collection for QA and research activities

Additional training, specific to the emerging and complex field of pain management, would position ACA’s to assume a greater role in the delivery of acute and chronic pain services. However pre-operative assessment (excluding low risk triage), particularly of high risk patients or patients undergoing high risk procedures, an area that brings together ALL of the Anesthesiologists knowledge, skill and judgment regarding risk reduction and optimization, should NOT be decanted to mid-level providers.

ACA learning is suited to a curriculum offered as an extension of a pre-existing health care professional degree, following a minimum of two years hands-on work experience in an acute care setting. Essential academic information is presented and clinical exposure obtained in a one-year program of study after a rigorous admission process.

Licensing of this health care provider role became possible in Manitoba because of The Medical Act regulation CCSM.c.M90. ACA’s are listed on the medical register and fulfill the annual licensing requirements of the CPSM. Their positions are non-union and they report directly to the physician(s) they assist.

There is no overlap in job function between PA and ACA. The nomenclature needs to be clarified because potential exists for confusion with providers of anesthesia care in team models in the United States and Europe.

PA, NP and ACA training programs should lead to certification designations. A national ACA examination and credential would necessarily await creation of a national ACA body. Is there a role for the RCPS to regulate physician assistants given their legislative authority to scrutinize educational programs? Are other provincial Colleges of Physicians and Surgeons considering PA/CA legislation? What is the role of the Federation of Medical Licensing Authorities of Canada (FMLAC)?

Value of ACA’s: The Anesthesia Care Team model (Manitoba situation)

The inaugural class of ACA’s graduated in December 2007. The second class finishes in January 2009 and a third class begins in March. Over the next few years, as we approach a full complement of staff in this provider role, we imagine many benefits, including:

1.    Resource Redistribution

It is reasonable to reclaim several hours per week in a busy tertiary hospital like the Health Sciences Centre (with a full complement of ACA’s). These daytime hours already staffed with OR personnel can be used to clear cases awaiting surgery, thus improving the management of service delivery to patients and accelerating inpatient throughput. This is achievable because ACA’s are in a position to monitor and titrate anesthesia for stable patients in the operating room for time periods of sufficient length to permit the significant benefit of freeing their attending Anesthesiologist to conduct “out of OR” activities in an expeditious way. For example:

  • Discharge a complex patient from the PACU who has been awaiting Anesthesiologist review
  • Conduct an emergency consult in order to optimize a patient’s condition prior to transport to the operating room
  • Triage existing emergency cases into available slots on surgical lists
  • See and evaluate the next patient on an elective list while the ACA transports the previous stable patient to the PACU
  • Deal with postoperative intractable acute pain or inadequate regional analgesia
  • Provide relief necessary for lunch and bathroom breaks, avoiding the need to break between cases

ACA’s serve as the primary educators for allied health personnel (OSP’s = Ophthalmic Sedation Professionals) trained to provide conscious sedation to stable patients undergoing ophthalmologic procedures. The care model utilizes one Anesthesiologist to cover the activities in three operating theatres and one to cover a complex sedation theatre manned by an ACA, while at the same time seeing high risk consults in the pre-op clinic.

Likewise, patient throughput on elective OR lists is facilitated when the next patient arrives in the induction room early to undergo planned procedures such as airway topicalization, insertion of invasive monitors or placement of regional block catheters. The ACA remains with the patient in the OR while the Anesthesiologist attends the patient in the induction room provided the attending or an alternate, designated Anesthesiologist be able to return immediately to the OR if summoned. Introducing the anesthesia pre-induction activities in parallel permits greater utilization of the operating theatre for surgical activity.

ACA’s are able to set-up and prepare an operating theatre appropriately, for any level of case (ASA I-V physical classification and E status), elective or emergent, with equipment, monitors, machines, devices, carts, drugs and drug infusions independently, a process that can take up to 30 minutes. This is especially critical in E1 cases. The Anesthesiologist is freed to leave the OR, assess/resuscitate the patient, and then proceed with transport to the OR.

2.    Facilitating Anesthesia Research

ACA’s achieve each of the five competency standards for “Information Literate” students designed by the Association of College and Academic Librarians during their training. As a result, they are adequately prepared to assist the Anesthesiologist with the conduct of literature searches, evaluation of web-based information and execution of clinical trials.

3.    Enhancing Patient Safety

Perhaps most importantly from the patients’ perspective, ACA’s provide expert assistance to the Anesthesiologist during the management of unforeseen intra-operative emergencies such as cardiac arrest, malignant arrhythmia, life-threatening hemorrhage, management of the unrecognized difficult airway, inability to intubate/ventilate scenarios and malignant hyperthermia crisis.

Whereas the Biomedical Engineering Department currently serves as the primary resource for preventative maintenance and equipment trouble-shooting and repair, the ACA’s share that role and serve as a resource for the evaluation and introduction of new equipment into the clinical arena. They also liaise with sales personnel. A component of the job description includes receiving and disseminating health device and drug alerts to members of the Department.

4.    Faculty of Medicine/Department of Anesthesia teaching & learning

ACA’s assist with, and teach basic knowledge and skills in the introductory-level anesthesia curriculum such as intravenous access and anesthesia machine check-out, topics germane to medical students who rotate through our specialty and to junior residents ACA’s assist with provision of simulator sessions, OSCE’s and in the airway lab.

Elements of the curriculum content of the ACA program traverses disciplines and has been shared with other educational programs within the Faculty of Medicine.

Summary

Manitoba supports the creation of a national curriculum for ACA’s. These programs should exist in harmony with PA and NP programs, as all advance the mandate of the Ministries of Health and address the present physician manpower crisis.
Collaborating to create uniformity in ACA training programs across the country will encourage the establishment of national standards/guidelines for practice and ensure the necessary rigor is applied to the educational process to make national accreditation a possibility.

Prepared by:

Dr. Judith Littleford MD, BSc, FRCPC
Department of Anesthesia, University of Manitoba