The Physicians Assistants Anaesthesia Project

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The Physicians Assistants Anaesthesia Project

• Dr HMRobb
• Lead clinician for NES
• Consultant in Anaesthesia Critical Care FVHB

Ms S Lang Project Lead for NES E-Tutor,
University of Edinburgh
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Why did you change the name?
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Why change the name?

• SEHD have opted to develop the roles of Physician
  Assistant
• Introducing multiple new roles is confusing to
  the Public
• The term Anaesthesia Practitioner suggests a
  fully independent role

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Why change the name?

• Clarity for the public
• The term Physicians Assistant defines an
  individual trained to a specific level of
  competence
• The addendum (Anaesthesia) simply defines the
  role

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...support for the project has been withdrawn in
England!
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Anaesthesia Practitioners Supplement to
previous position statements Feb 2007

• In September 2006 the College and Association of
  Anaesthetists published a supplement to its
  earlier joint statement on the Anaesthesia
  Practitioner (AP) project. Those statements
  confirmed both bodies support for the programme
  as it had been developed under the guidance of
  the National Stakeholder Board for Anaesthesia
  Practitioners.
• The AP project, set up to expand the workforce,
  was part of the National Practitioner Programme
  that also included specialties other than
  anaesthesia. The curriculum for the AP project
  was developed by the College in partnership with
  the Association and the Universities of
  Birmingham, Hertfordshire, Hull and was later
  adopted by the University of Edinburgh.
• We have recently learnt from the National
  Practitioner Programme Implementation Group
  (NPPIG) that the funding stream for England and
  Wales will be cut-off from 1st April 2007 in
  Scotland support for a programme assessing the
  Physicians Assistant Anaesthesia (the term
  used in Scotland for the AP role) will continue
  until at least 2009. It has been recognised by
  the NPPIG that the consequences of the loss of
  funding in England and Wales will be that the
  route to recognition of the title Anaesthesia
  Practitioner and formal registration with a UK
  regulating body, such as the Health Professions
  Council, will now be lost together with the
  national forum determining standards, education
  and safe practice. This may encourage departments
  to recognise, and individuals to identify
  themselves as, 'anaesthesia practitioners',
  regardless of training or competence, and will
  exacerbate the current confused situation for
  patients, employers and healthcare colleagues.
• The risk that alternative approaches may be
  considered by some employers, such as locally
  developed roles and the employment of
  overseas-trained staff such as nurse
  anaesthetists is now a real threat. With the loss
  of the AP programme, there will therefore be no
  method for the robust assessment of the role
  neither as a whole, nor of any individual AP, nor
  of accreditation. It is only through continued
  support, including funding, for the existing
  nationally recognised AP programme that
  appropriate training, assessment and employment,
  consistent with patient safety, can be assured.
• Patient safety has been of paramount importance
  in all stages of development of the AP programme
  and any deviation from the agreed and recognised
  training may endanger that principle. We only
  support the training or employment of APs, from
  those within the nationally approved AP programme
  and validated by the Universities of Birmingham,
  Hertfordshire, Hull and Edinburgh.
• For the avoidance of confusion the College and
  the Association do not support any alternative
  strategies, and advise all fellows, members and
  employers against being involved in any such
  initiatives.
• If anyone requires any further advice on this
  issue please contact either body.
• Dr Judith Hulf, President, The Royal College of
  AnaesthetistsDr David Whitaker, President, The
  Association of Anaesthetists of Great Britain and
  Ireland

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But

• we only support the training or employment of
  APs, from those within the nationally approved AP
  programme and validated by the Universities of
  Birmingham, Hertfordshire, Hull and Edinburgh.
• For the avoidance of confusion the College and
  the Association do not support any alternative
  strategies, and advise all fellows, members and
  employers against being involved in any such
  initiatives.

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Additional Concerns Raised April supplementary
statement

• Statutory Regulation
• White Paper Trust, Assurance and Safety The
  Regulation of Health Professionals in the 21st
  Century
• RCoA believe National Curriculum being delivered
  by the 4 HEIs meets the criteria laid down.
• Funding
• Recruitment, education and examination will
  continue to be funded by sponsoring bodies
• Additional
• Affiliates
• RCoA will continue to offer this

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What is happening in Scotland?
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Time line - 2006
Site selection
Student selection
Netherlands
Workforce Planning
Awareness
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2 2
0 - 2
2 2
2 0
4 2
2 2
0 - 1
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2 2
12 11
0 - 2
2 2
2 0
4 2
2 2
0 - 1
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2 2
120 110
0 - 2
2 2
2 0
4 2
2 2
0 - 1
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Time line - 2006
Site selection
Student selection
Netherlands
Workforce Planning
Awareness
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Evaluation of the project

• Has the training package delivered PAAs capable
  of delivering the roles envisioned?
• Is there appropriate awareness and understanding
  of the role by other health care professionals as
  well as the public?
• Can aspects of the surgical service within the
  Scottish NHS can be suitably reconfigured to
  allow PAAs to effectively contribute to the
  service e.g. by servicing lists running
  concurrently, supervised by a single medically
  qualified anaesthetist?

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Why the geographical differneces?
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Why the geographical differences?

• No engagement
• Perception that there are adequate trainees to
  continue current or reconfigured service
• Focus on developing the SAS role to replace
  trainees
• MMC 1st then PA-A
• Anaesthesia assistants
• Service changes as insurmountable

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Why the geographical differences?

• Engagement
• Perception that there will not be adequate
  trainee to continue the current method of service
  delivery
• Increasing SAS doctors is only part of the
  solution
• Replacing unrecognised trainee contributions to
  the service which are critical to efficiency and
  effectiveness
• Focus on team development and increasing
  flexibility

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... can they....?
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What is a Physician's Assistant - Anaesthesia?
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What is a Physician's Assistant - Anaesthesia?

• A new member of the anaesthesia team
• Ability to undertake the maintenance of
  anaesthesia under indirect supervision
• Contribute to pre-operative care
• e.g. pre-operative assessment etc
• Contribute to post-operative care
• e.g. recovery, post operative analgesia etc
• Offer advanced airway skills in emergency and
  other settings

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... can they....?
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What are the boundaries to the role?
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What are the boundaries to the role?

• A PA-A is not a trained anaesthetist
• Undergraduate 5 years
• Post-graduate 7 years

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What is a Physician's Assistant - Anaesthesia?

• Fully trained to the standards defined in the
  curriculum framework
• Work within the boundaries defined within the
  curriculum framework

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What are the limitations to the role?
Limitations to the role
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What are the limitations to the role?
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What are the limitations to the role?
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What are the limitations to the role?
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What are the limitations to the role?
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What are the limitations to the role?
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What are the limitations to the role?
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What are the limitations to the role?
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What are the limitations to the role?
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But

• Occasionally Council or the Anaesthesia
  Practitioner Committee will have to take
  decisions that may affect the immediate
  interpretation or application of specific topics
  in this section.

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But

• Occasionally Council or the Anaesthesia
  Practitioner Committee will have to take
  decisions that may affect the immediate
  interpretation or application of specific topics
  in this section
• Qualified practitioners may use only a limited
  range of these competences in their work, or
  their competences may be further extended in some
  areas by local training initiatives after they
  qualify

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General Medical Council

• 46. Delegation involves asking a nurse, doctor,
  medical student or other health care worker to
  provide treatment or care on your behalf. When
  you delegate care or treatment you must be sure
  that the person to whom you delegate is competent
  to carry out the procedure or provide the therapy
  involved. You must always pass on enough
  information about the patient and the treatment
  needed. You will still be responsible for the
  overall management of the patient.

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Responsibility accountability
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Potential developments

• Unsupervised No
• Regional anaesthesia No
• Obstetric anaesthesia No
• Paediatric anaesthesia No
• Extubation possibly
• Sedation possibly

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Role development ? facilities
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Reception Recovery
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4
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Patient safety?
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Risks

• Some patients are anaesthetised by trainee
  doctors in their first year in anaesthesia
  without direct supervision (Chapter 2). Is this
  more or less safe than being anaesthetised by an
  experienced and well-trained assistant who is
  under the supervision of a consultant immediately
  available within the theatre suite?
• Nurses monitor very ill patients who are being
  treated with multiple interventions in ICU how
  does this compare in risk to monitoring a healthy
  patient undergoing a minor operation?

Anaesthesia Under Examination 1997
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Risks

• Comparative effectiveness and safety of
  physician and nurse anaesthetists a narrative
  systematic review.
• Smith, AF et al. Br J Anaesth
  2004 93 540-5
• Maaløe R. Incidents in Relation to Anaesthesia.
  PhD Thesis. Copenhagen University of Copenhagen,
  2000
• Silber JH, Kennedy SK, Even-Shoshan O, et al.
  Anesthesiologist direction and patient outcomes.
  Anesthesiology 2000 93 15263.
• Hoffmann KK, Thompson GK, Burke BL, Derkay CS.
  Anesthetic complications of tympanostomy tube
  placement in children. Archives of Otolaryngology
  and Head and Neck Surgery 2002 128 10403.
• Pine M, Holt KD, Lou Y-B. Surgical mortality and
  type of anesthesia provider. American Association
  of Nurse Anesthetists Journal 2003 71 10916.

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Anesthesiologist Direction and Patient Outcomes

• . to determine whether general and
  orthopedic surgical outcomes differ depending on
  whether the anesthesiologist is involved
  significantly in the delivery of anesthesia
  services to elderly..
• Silber JH, Anesthesiology 2000 93
  152-163

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Anesthesiologist Direction and Patient Outcomes

• . to determine whether general and orthopedic
  surgical outcomes differ depending on whether the
  anesthesiologist is involved significantly in the
  delivery of anesthesia services to elderly..
• Directed or Non-directed care
• 
  Silber JH, Anesthesiology 2000 93
  152-163

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Anesthesiologist Board Certification and Patient
Outcomes

• Same core data as 2000 study 217,000 patients
• the lack of board certification is associated
  with worse outcomes..
• may be a result of the hospitals in which they
  practice and not necessarily their manner of
  practice.
• Anesthesiology 2002 96 1044-52

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Anesthesia Providers, Patient Outcomes, and Costs

• Dramatic decrease in anaesthetic complications
• Anaesthesia Care Team offer best outcomes
• Abenstein JP. Anesth
  Analg 1996 82 1273-83

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..if things go wrong

• Will a Consultant Anaesthetists always be
  immediately available?

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.. if things go wrong

• 13 (and perhaps higher ratios are safe)
• 12 working ensure adequate Medically qualified
  Anaesthetists available to support critical
  events
• Safety requires flexibility within the
  Anaesthetic Workforce

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Safety ? facilities
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Reception Recovery
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4
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Do we need PA-A?
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DO WE ACTUALLY NEED APs?

• Workforce considerations
• Increasing production of medical graduates
• Increased numbers of medically trained
  anaesthetists
• UK trained
• European
• International Medical Graduates
• Will long term job opportunities exist for them?
• Peter Simpson
  Dunblane 2006

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Manpower planning

• Complex
• Limited thought about team working (e.g. HAN,
  CST) or extended roles (e.g. Nurse endoscopy)
• Medical workforce
• Students 30 in 5 years, 100 in 10 years
  (5000)
• Consultants 70 in 10 years to 2004
• GPs 12 in 10 years to 2004
• 2009 5,800 graduates 2,250 doctors retiring
• Appropriate
• Affordability

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Manpower planning

• Complex
• Limited thought about team working (e.g. HAN,
  CST) or extended roles (e.g. Nurse endoscopy)
• Medical workforce
• Students 30 in 5 years, 100 in 10 years
  (5000)
• Consultants 70 in 10 years to 2004
• GPs 12 in 10 years to 2004
• 2009 5,800 graduates 2,250 doctors retiring
• Appropriate
• Affordable

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Manpower planning

• Complex
• Limited thought about team working (e.g. HAN,
  CST) or extended roles (e.g. Nurse endoscopy)
• Medical workforce
• Students 30 in 5 years, 100 in 10 years
  (5000)
• Consultants 70 in 10 years to 2004
• GPs 12 in 10 years to 2004
• 2009 5,800 graduates 2,250 doctors retiring
• Appropriate
• Affordable

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Shape of the workforce - current
Trainees 50
SAS 16 Consultant 34
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Replace Trainees with SAS

• OoH 2000 to 0800
• 36 sessions including prospective cover
• Nominally require 4 SAS, realistically 8
• Reality 10
• Generates 36-50 elective sessions per rota
• Reduces consultant requirement by 5 7
  Consultants per rota

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Shape of the workforce
Trainees 50
SAS 16 Consultant 34
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How should the Anaesthesia Team look?
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What do the PA-A offer?
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What do the PA-A offer?

• The role of non-medical staff in the delivery of
  anaesthesia services. RCoA DoH
• New Ways of Working in Anaesthesia
• Hinchinbrooke
• Wansbeck
• Salford
• NES visit to Holland
• Amsterdam Medical Centre (AMC)
• Our Ladies Hospital

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What do the PA-A offer

• 11 working
• 12 working
• Other duties
• Out of hours contribution

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11 Working

• Freeing the Anaesthetist to-
• review day cases and those admitted under Day of
  Surgery Admission Policies
• undertake other activities e.g. research,
  teaching, management activities etc
• Enhance turnover through
• the PA-A managing the immediate recovery of
  patients in the Post Anaesthesia Recovery Unit (
  PACU)
• by freeing the Anaesthetist to site blocks or
  invasive monitoring. This may become critical to
  throughput as new services e.g. colonic screening
  increase the demand for major surgery and its
  associated anaesthetic time for epidurals,
  central lines etc.
• by siting cannula and arterial lines prior to
  theatre.
• by removing the need to stop for natural and
  other breaks
• Allow the opening of additional theatres at short
  notice (see 12 working)
• Potential switching to 12 to free an
  Anaesthetist for activities outside theatre or to
  allow flexibility due to shortage (e.g. sickness)

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12 Working

• Provide cover for appropriate lists on a regular
  basis to
• cover Consultant leave by allocating to
  appropriate lists and rescheduling Consultant
  Anaesthetists to more complex cases
• enhance the training experience of Trainees in a
  12 situation where the 2 is a Trainee
• Improve flexibility by using the 12 model to
  free anaesthetists e.g. to cover sick leave,
  attendance at meetings etc.

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Other duties

• Acute Pain Service
• Recovery
• Pre-operative assessment
• Contribution to cardiac arrest team (providing
  airway management)

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Out of hours

• For suitable cases 12 working to improve
  utilisation of theatres
• Support Anaesthetic and other staff OoH with
  specific tasks e.g. difficult cannulae, acute
  pain problems on the ward etc
• Review of surgical patients presenting for
  theatre (either directly or by freeing the
  medically qualified Anaesthetist for the task)
• Support for complex emergencies where two pairs
  of hands are required.
• Provide airway management in cardiac arrest and
  other emergency situations
• Support for medical staff within a large
  Critical Care Unit

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What do the PA-A offer

• 11 working
• 12 working
• Other duties
• Out of hours contribution

Replace the "old" trainee role
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Anaesthesia Team
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Do we need PA-A?

• Yes
• More efficient and more appropriate use of
  Consultant time
• Complex case
• Provide education
• Supervision (double tasking)
• Governance, service development etc
• Offers the opportunity to secure VFM from one of
  the NHSs most costly resources

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The Patients?

• Confidence in the service
• Information and involvement in their care
• The best treatment delivered by appropriately
  trained staff
• Good communication

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The way forward
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Time line - 2007
Site selection
Student selection
Workforce Planning
Hinchingbrooke
Awareness
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Time line - 2007
Site selection
Student selection
Workforce Planning
Hinchingbrooke
Awareness
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Way forward

• Secure additional funding for the project in
  Scotland
• Continue NES activity
• UoE course
• Project development and recruitment of additional
  Boards
• Focus on workforce planning and service
  development of the role

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• Training issues
• University considerations
• Board considerations
• Workforce issues
• What is the role?
• How do you introduce the role?
• Concerns
• Anaesthetists
• Anaesthetic Assistants
• Workforce planners

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Questions - Why do we need them?
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Questions - risks

• Emergencies can occur at any time (not just take
  off and landing)
• Supervising anaesthetist cannot be guaranteed to
  be immediately available

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Anesthesiologist Board Certification and Patient
Outcomes

• Same core data as 2000 study 217,000 patients
• the lack of board certification is associated
  with worse outcomes..
• may be a result of the hospitals in which they
  practice rand not necessarily their manner of
  practice.
• Anesthesiology 2002 96 1044-52

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• Analysis of the First Four Years' Referral Data
• 1772 cases
• Referral risk 1110 (excluding training grades)
  per year
• GMC involved in 19 ? 4
• Not related to the type of hospital
• Clinical (61) and behavioural (67) issues

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One year risk of referral ()
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Anaesthesia Providers, Patient Outcomes and Costs
Abenstein JP. Anesth Analg 1996 82 1273-83
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Risk 12 working

• 13 (and perhaps higher ratios are safe)
• 12 working ensure adequate Medically qualified
  Anaesthetists are available to support critical
  events
• Safety requires flexibility within the
  Anaesthetic Workforce

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What are the boundaries to the role?

• Not an Anaesthetic Assistant
• Part of the role in overseas models

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What is a Physician's Assistant - Anaesthesia?

• Physicians Assistant Anaesthesia (PA-A)
• Änesthesiemedewerker
• Anaesthesia Assistant

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What can a PA-A do?