Anaesthesia Practitioners

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Anaesthesia Practitioners
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The first nurse anaesthetist was probably
Catherine Lawrence during the civil war
1862 This is not her!
A surgeon about to amputate under open drop ether
anaesthesia at Gettysburg
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Nurse Alice Magaw administered ether by open drop
method in 14,000 cases without a death between
1895 and 1906. She worked with Robert Mayo at the
Mayo Clinic, Rochester Minnesota and earned the
epithet Mother of Anaesthesia
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Nurse Helen Lamb providing anaesthesia for the
first successful pneumonectomy in 1929
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Cleveland Lakeside Hospital 1915 Nurse Agatha
Hodkins administers anaesthesia with the Teter
gas oxygen apparatus.
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MASH
THE SCENE Capt. Walter Kosciusko "Painless Pole"
Waldowski - the best equipped dentist in the army
- has decided his womanizing is merely a cover-up
for homosexuality. Feeling he has nothing to live
for, he can see only one way out suicide.
Painless seeks out his surgical friends for a
quick and easy method. "Black capsule!" says
Trapper John. Painless wonders if it will really
work but is assured by Trapper, "It worked for
Hitler and Eva Braun."
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Anaesthesia in Britain and Ireland A Physician
Only ServiceAAGBI March 1996
The role of non-medical staff in the delivery of
anaesthesia services Report of visits to the USA,
The Netherlands and Sweden From The Royal College
of Anaesthetists and The Changing Workforce
Programme, NHS Modernisation Agency July 2003
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The role of non-medical staff in the delivery of
anaesthesia services Report of visits to the USA,
The Netherlands and Sweden From The Royal College
of Anaesthetists and The Changing Workforce
Programme, NHS Modernisation Agency July 2003
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Why? Because you want to work in teams
Operating Department Practitioner
Anaesthesia Practitioner
Pain Team Nurse
Specialist Registrar or SHO Anaesthetist
Recovery Nurse
Consultant Anaesthetist or SAS Anaesthetist
Anaesthetic Nurse
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Why not extended roles?

• Bad experience with extended roles of nurses
• Lack of uniformity no national model
• Piecemeal learning

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Why a new profession?

• To ensure uniform and high standards
• To permit recruitment from outside the existing
  professions of nurse and ODP

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Maintaining Uniform Practice
Variation is the engine of evolution
lx  prob. of survival from birth to age x 
(cumulative) survivorship probability of
survival to age x1 from age x      mx
fecundity ( offspring) at age x
                 L      then      (lx)(mx)
exp(-rx)    1  (in a stable population,
x1                                      where L
life expectancy)        
So why is the RCoA opposed to it?
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The Safety of anaesthesia depends on
standardisation
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RCA Functions

• College Practitioner Committee
• In-Service Curriculum
• Organising practice assessment (OSCE etc)
• Moderating National MCQ
• Recommending accreditation Affiliate of Royal
  College of Anaesthetists
• Holding Voluntary Register - Equivalence

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RCA AAGBI Strategy
There is competition with anaesthesia medical
training so training sites must

• Demonstrate there is enough teaching material
• Demonstrate a full and stable complement of
  consultant anaesthetists
• A clean bill of health at RCoA visits

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RCA AAGBI Strategy

• The RCoA proposes to
• Moderate national exams
• Coordinate training standards in the workplace
• Affiliate the trainees
• With AAGBI give working practice guidance

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The Workforce Issues

• 2001 A Specialist Workforce
• 8500 Consultants or equivalent with CCST by 2015
• We only have trainees to provide consultants
• Realistic maximum trainees 500 per year for ten
  years

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Target specialist workforce
30 of procedures by trainees
8000
Number of Consultants
Number of Trainees
3000
1990
2000
2010
2020
A Specialist Workforce
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Target specialist workforce
30 of procedures by trainees
8000
3000
1990
2000
2010
2020
A Specialist Workforce
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Has something gone wrong with the calculations?

• Has government lost the desire for a specialist
  workforce?
• Loss of existing work to new providers
• Extending existing contracts to 13 sessions is
  cheaper than more consultants
• Post retirement workers in the new sector

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Does it make a difference?

• Not really we never thought that APs would
  replace consultants, we thought they would
  replace trainees.

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Are they safe?
Smith AF, Kane M, Milne R. Comparative
effectiveness and safety of physician and nurse
anaesthetists A narrative and systematic review.
British Journal of Anaesthesia 2004 93 540-5
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Whats the job?Should we develop..

• a problem solver with insight
• rather than.
• an extended role machine-minder?

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We decided to go for A PROBLEM SOLVER WITH
INSIGHT
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• Its not reasonable to dumb down the role because
  we are scared of their possible independence.
• They will be on their own with a patient they
  have got to be good.
• Is the project worthwhile as a means of letting
  medical anaesthetists get long coffee breaks!

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Setting the role at this high level creates
problems

• Nurse and ODP entrants do not understand
  sufficient pharmacology and physiology.
• At present only anaesthetists can teach the
  practice AND the contextualised science.
• Convincing people who dont understand
  anaesthesia of these facts is not easy

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A Training Partnership

• Royal College
• NHSU/Universities

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This project is not just about a new grade of
professional it is also about significant
change in theatre work practices
Firstly a department must want to work in teams
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Is your department ready to run a group of
theatres as a team?It breaks the one to one
surgeon to anaesthetist connection.It breaks
the one to one anaesthetist to patient connection
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Is your department ready to run a group of
theatres as a team?The consultants must be
flexible and willing to experiment.The clinical
director must be good and command confidence and
respect!!!!!!
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The outstanding issues for the RCoA?

• The partnership with Universities
• Maintaining uniform practice
• Regulation
• Equivalence
• Countering disinformation

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Partnership with universities

• To guarantee uniform clinical input
• To ensure uniform standards
• To prevent diversification of roles

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Partnership with universities

• This is a new type of partnership
• There is no standard machinery for agreement

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The examinations

• MCQ
• OSCE

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Diversification

• Of Courses within the project
• Of similar roles

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• I had to unfortunately refuse the job offer my
  main reasons
• There is no guarantee of a job for at the end of
  the two and a half years training.
• If a job was available, long term career
  progression was limited.
• Mathew Williams ex AP applicant writing in
  Anaesthesia News

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Threats and Encouragements

• Greatest Threat The inflexibility of Consultant
  Anaesthetists
• Greatest Encouragement The Students

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RCA AAGBI Strategy
There is competition with anaesthesia medical
training so training sites must

• Demonstrate there is enough teaching material
• Demonstrate a full and stable complement of
  consultant anaesthetists
• A clean bill of health at RCoA visits

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RCA AAGBI Strategy

• A standardised, transferable high quality, new
  medical profession
• Developed by and managed by anaesthetists not
  the theatre manager
• Within the RCA

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A Leap of Faith