Anaesthesia Practitioners Report from Phase 1 pilot sites

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Anaesthesia PractitionersReport from Phase 1
pilot sites

• Dr Iain Wilson
• Royal Devon and Exeter Hospital

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Anaesthesia Practitioners

• Pilot Sites
• Why did we start in Exeter?
• Roles for APs?
• The future are they practical?
• Threat or Opportunity?

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Workforce Principles - NHS

• Anaesthesia is, and will remain, a medical
  specialty led by consultants
• Trainees entering anaesthesia must be certain
  that consultant jobs will be available
• Any changes must be safe for patients
• Lag phase for change

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Anaesthesia 2005

• Elderly patients undergoing major procedures
• Slower lists, more complex anaesthesia
• Major cases longer in recovery
• Admission during list more common
• Regional GA common
• Increasing day surgery rates

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The Role of Non-medical Staff in theDelivery of
Anaesthesia Services2002REPORT OF VISITS TO
THE USA, THE NETHERLANDS AND SWEDENP SimpsonG
SmithP HuttonJ MooreN McKellar G BennettP
Shuttleworth
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Conclusions
    Non-medically qualified staff are employed
successfully in other countries as part of a team
in the delivery of anaesthesia services, with
good outcomes.  The use of non-medically
qualified staff in the UK is only one of only
several strategies, which may be considered
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If the decision were taken by the DoH to
implement the use of non-medically qualified
staff in the provision of anaesthesia services,
the Royal College of Anaesthetists would wish to
collaborate and play a major role in setting the
standards of training and supervision of such
staff.   www.rcoa.ac.uk
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DoH and RCoA believe

• Potential shortage of Anaesthesia manpower in NHS
• Disastrous for patient care
• Some Trusts will be vulnerable

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Solutions to workforce shortage

• Major expansion of consultants trainees
  (remember every specialty has a problem!)
• Remove anaesthesia trainees from ICU and / or
  obstetric units
• Change how anaesthetists work - the anaesthesia
  team approach
• Import doctors

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NHS Changes Affecting RDE

• NHS payment by results (efficiency)
• Foundation Trust
• Competition from private sector ITCs
• EWTD 2009
• Pension reforms 2014

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Future Working Patterns of Consultants - RCoA

• By 2008 ratio of trainees to consultants will be
  half that of today
• Much out of hours work will be consultant based
• Our jobs will change (on call)
• D Saunders RCA Bulletin 2004

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Future Working Patterns for Consultant
Anaesthetists

• Fewer trainees on our lists consultant provided
  service
• MMC - will there be trainees at small DGHs?
• More out of hours work
• Department expansion do you want to?
• Careers will change ISTCs / Chambers
• Short term contracts?

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How did Exeter get involved?

• Rumour of Non-physician Anaesthetists via
  Modernisation Agency concerned me
• Would rather influence change from the start
• Clinical Lead Dr Paul Thomas

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RDE Developing Practitioners in

• Emergency Dept
• Critical Care
• Preop assessment
• Pain
• Why not Anaesthesia?

• Ophthalmology
• Neonates
• Venous access
• Cardioversion

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Role Adaptation
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Applied to Develop Student APs

• Successful pilot application with CWP MA
• Internal advertisement Dec 03
• Invited staff to apply for role with unknown
  future, no curriculum, no qualification and no
  guarantees
• 2 excellent candidates
• Hayley Critical Care Nurse
• David ODP

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Other Pilot Sites

• Birmingham, Salford - Trainee APs
• Morecombe Bay, Northumbria qualified Swiss
  Anaesthesia Nurses

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Strategy of Pilots

• 11 Could APs improve
• Throughput
• Teaching, training, supervision
• 21 Could APs could be trained to
• allow one consultant to run 2 lists

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First Year

• Decision to train to be capable of maintaining
  anaesthesia
• Wish to train Problem solver with insight
  rather than machine minder
• This is a NEW role not an extended role
• Concentrated on anaesthesia skills
• 2 tutorials/week basic sciences one dedicated
  to AP, other with SHOs
• Restricted consultant trainers

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Early Lessons

• ODPs well adapted to theatre role
• Considerable change for ICU nurse
• Loss of comfort zone for both
• Technical skills
• Academically a real challenge
• Change of focus on decision making and role

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Student Profile Initial Observations
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What sort of roles?

• Supervised
• In the anaesthesia team

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Standard Theatre Staffing
Theatre 1 Consultant ODP
Theatre 3 Consultant ODP
Theatre 2 Consultant ODP
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Tuesday 22 November 2005

• Colorectal list no trainee
• Bowel resection 56 years, obese
• Day case EUA arriving 0900
• AP resection 84 years
• Hernia 32 years
• Laparoscopy 75 years

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Wednesday 24 November

• Orthopaedic list no trainee
• Shoulder release, GA ISB
• Day case shoulder, GA ISB
• Day case shoulder, GA ISB
• Shoulder release, GA ISB
• Bankharts operation, GA ISB
• Shoulder replacement, GA ISB

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Improving Theatre Throughput(particularly GI,
ortho and regional)
Setting up complex anaesthesia Patients admitted
on day Troubleshooting recovery
Theatre Consultant AP ODP
(Theatre costs in Exeter 10/minute)
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Improving Theatre Teaching?Competency based
training
Theatre 1 Consultant SHO AP
Teaching - blocks - epidurals
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Improving Theatre Organisation
Theatre 1 Consultant AP ODP
Consultant of the Day
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Long Surgical Cases
Theatre 1 Consultant AP ODP
Rest breaks
Willoughby L, Morgan R. Neuroanaesthesthetists
workload isssues. Anaesthesia 200560151-4
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Theatre Staffing Options Trauma
Trauma Theatre Consultant AP ODP
Trauma Ward


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Theatre Staffing Options 2 Theatres
Consultant


Theatre 2 SHO ODP
Theatre 1 AP ODP
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Flexible AP for 2 Theatres
Theatre 2 Consultant ODP
Theatre 1 Consultant ODP
AP
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Theatre Staffing Options 2 Theatres
Consultant


Theatre 1 AP
Theatre 2 AP
ODP


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Non - theatre Roles for APs?

• Perioperative troubleshooting?
• Others - preoperative assessment, venous access,
  ophthalmic blocks, sedation, scanning, transfer
  etc

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If We Develop APs - Recruitment?

• Variety of sources
• ODPs?
• Nurses?
• Science graduates?
• Some staff group are already depleted
• Career development, retention and recruitment
  real issues for the NHS
• Ability at Diploma level and Clinical Skills will
  be important

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Making life easier 11 model

• Very effective
• Day case admissions during list
• Rest breaks
• Improve training of procedures etc
• Relax no training required!
• Long term colleague

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21 theatre working in NHS

• Could work if there is a staffing problem
• Attractive to profession?
• Effective? Would need considerable flexibility
  in theatre
• Pilots untested as only student APs
• Unlikely in near future??

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What are 2nd years doing in pilots?

• Exeter
• Biers block clinics
• Preoperative assessment for hip surgery
• Increase THR / day by one joint
• Sub-Tenons one list a funded AP
• 11 working
• Consultants 80 for 20 against
• Prefer increased flexibility

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Anaesthetic Practitioners

• Disadvantages
• Controversial not UK model.
• Viewed as introducing independent nurse
  anaesthetists by some Not True!
• Will not suit all Trusts, theatres, types of
  surgery or consultants.
• Probably not a cheaper alternative.
• Can we recruit and retain?
• Large numbers unlikely help not solve!

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Potential Problems

• Conflict with SHO / SpR training?
• Training capacity (RCoA)
• Consultant support
• Anaesthesia
• Surgery
• Support of ODP and Nurses

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Anaesthetic Practitioners

• Advantages (future)
• If you recruit the right person
• May be locally trained within 2 years
• Totally service orientated
• Flexible roles to suit your Trust
• Increase flexibility of Consultant working
• Potentially improve consultant working in the
  future

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Anaesthetic Practitioners - pilot sites views?

• Very early in project results not known
• Is workforce prediction robust?
• Can we recruit APs?
• Will we retain- career step?
• Sickness rate?
• Is NHS flexible enough to use them?
• Can 21 be effective?
• Can only be developed by the profession we are
  in control

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Anaesthetic Practitioners RDE Summary

• Alternative safe team based model of anaesthesia
• Practical for RDE
• Fully integrated into the anaesthetic team
• Must be nationally registered with clear role
• Need input by all members of the team, and
  organisation of theatres, to be safe

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Thank You for Listening