The line between doctors' and nurses'
jobs just got a little more blurred. Not all physicians
like the way the wind's blowing.
On March 17, the Ontario Ministry
of Health and Long-Term Care announced the creation
of anesthesia care teams. The linchpin of these teams
will be a new class of health provider called the anesthesia
assistant (AA). These AAs will be drawn from the ranks
of registered nurses (RNs) and respiratory therapists
who've received additional training. Other team members
will be nurse practioners (NPs) specialized in anesthesiology
and acute pain management. They'll both work alongside
the province's dwindling number of anesthetists to improve
efficiency and cost-effectiveness and reduce wait times,
according to health minister George Smitherman. Nine
pilot sites have been announced across the province.
"Lots of things affect wait times
— what we tried to do was find a longterm solution
to ensure anesthesiology could be taken off the list,"
says Dr Jack Kitts, chair of the Ontario Medical Association's
(OMA) Operative Anesthesia Committee (OAC), which recommended
the initiative. The Registered Nurses Association of
Ontario (RNAO) also applauds the plan.
But the nation's anesthetists aren't
joining in the cheering. "We feel strongly that anesthesia
is a complex area of medicine," says Dr Shane Sheppard,
president of the Canadian Anesthesiology Society (CAS).
"We believe we're safe and effective in that role and
we don't think that anesthesia can be practised by people
that have less training than we do."
STEPPING
ON TOES
If the argument sounds familiar, it should. When the
province announced plans to increase colorectal cancer
screening by introducing nurse endoscopists, gastroenterologists
expressed similar concerns (see "GI
dearth stalls CRC screening, June 15 2006, Vol 3,
No 11, page 7). Ontario has fully embraced the idea
of "innovative new healthcare roles" — surgical
and radiation assistants are also in the works. But
the approach is disillusioning many physicians, who
wonder "What's next?".
Dr Kitts sympathizes. "Of course
anesthetists are concerned — they're worried about
losing their jobs. We have to make it clear that this
needs to be a fully collaborative model, which is essential
to maintaining the extraordinarily high level of quality
and patient safety anesthetists have achieved in the
last few decades," he says.
TECHNICAL
SUPPORT
Proponents of the plan say each member of the new care
team will bring a unique set of skills to the table.
AAs will provide technical support primarily in the
OR, whereas NPs in anesthesia will play a major role
in pre- and post-op care.
The first cohort of AAs graduated
last fall from Toronto's Michener Institute of Applied
Health Sciences, which received a $1.35 million grant
from the ministry to set up the 22-week advanced program.
"They're trained to support the equipment, provide airway
management and monitor the patient's vitals during the
period of sedation," explains Paul Gamble, CEO of the
Michener Institute. "They're also able to provide conscious
sedation and administer anesthetic gases and medications
— under the direct supervision of the anesthetist
and with a specific directive to do so." Respiratory
therapists and RNs must have two years of critical care
or OR experience within the past four years to enrol.
AAs are well established internationally
and, to a limited extent, elsewhere in Canada. The US
has used them for 30 years, Quebec for 20; BC uses them,
though in a less formalized way than Ontario.
Even sceptical Dr Sheppard accepts
they fill an important gap in the delivery of anesthesia
care. "Our patients are getting older and the procedures
more complex and I think the technical support is justifiable.
But," he adds, "you don't see a lot of support for anybody
giving the anesthetic except the anesthetist."
GIVE
AN INCH
Dr Kitts says many of his colleagues are worried the
teams will impose a US-style model of care, where nurse
anesthetists administer up to 60% of all anesthetics
given each year. While anesthetists here appreciate
the need for AAs, NPs in anesthesia — a first in
Canadian healthcare — are more of a threat.
The Ministry is still working with
the University of Toronto and the RNAO to develop the
curriculum for NPs in anesthesia. Everyone admits their
role has not yet been clearly defined, which may be
contributing to physicians' unease.
"Anesthetists have established
very stringent regulations and standards, which is why
anesthesia has become so incredibly safe in the last
30 years. Anything that changes that will obviously
set off alarm bells," says Dr Kitts.
No NP, he insists, will be allowed
to give full general anesthetic alone in OR. "But we
do think that NPs could take over the bulk of the pre-op
assessment to free up anesthetists for the OR and look
after patients for acute pain management post-op as
well," he explains.
FOR
YOUR MUM?
As far as Dr Sheppard is concerned, there are better
ways to address the shortage of anesthetists. "Health
regions in other provinces have funded training spots
and the number of graduates — typically 70-80 per
year — is on the rise," he says. "In 2008, it will
be 125. What once looked like an impending manpower
disaster has already been addressed at many levels."
He adds that the shortage of anesthetists is only 5-8%
nationwide — far lower than many other specialities.
He too can appreciate that patients
get frustrated when a life-saving surgery is cancelled
because there's no anesthetist around to do the job.
"But," he says, "the question I ask around the table
is 'if it was your mother on the table, would you want
[a nurse] to put her under?'"
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