Introduction and definitions
Throughout my professional life, the topic of 'Nurse Anaesthetists' has been a source of disagreement between medical anaesthetists with personal experience of systems in which nurse anaesthetists have a degree of autonomy in the administration of general anaesthesia, and those who have always worked in anaesthesia systems entirely staffed by doctors. Often the debate has seemed like a dialogue between the deaf, with people opposing something which others were not actually proposing, and vice versa.
The United Kingdom is the archetypal example of a system in which the administration of all forms of anaesthesia has been restricted to qualified doctors but nevertheless employs trained anaesthetic assistants. Confusingly, these have, in some centres, been nurses who have undergone a 6-12-month specialist nursing course to become an anaesthetic nurse. Increasingly, however, assistance for anaesthetists has been provided by a cadre designated as Operating Department Practitioners, the majority of whom have not had formal nursing training but undergone a 2-year 'in-service' training after which they can specialize in assisting the anaesthetist or assisting the surgeon. The entry qualifications and training period of these two types of assistant are thus very different. Whilst an anaesthetic nurse can (and often does) act as an anaesthetic assistant, the reverse is not true.
Furthermore, both are much less comprehensively trained than the 'nurse anaesthetists' employed in some other European countries and in the USA. Like-wise, the tasks which the latter can perform are at a much higher level, particularly in monitoring and managing the maintenance of general anaesthesia. There should be no confusion over their roles in the two types of system.
In some parts of the developing world, such as much of sub-Saharan Africa, stark necessity continues to justify the continued use of non-physician anaesthetists (most of whom are Clinical Officers who have had 3 years of training) without whom even essential, life-saving surgery would not be possible. Parts of the USA, however, continue the system for economic reasons and the tension between nurse anesthetists and anesthesiologists remains active in many parts of the USA. The latest shot in this conflict is a statement by the American Medical Association 'that anesthesiology is the practice of medicine' and a Resolution 'to now seek legislation to establish the principle in federal and state law and regulation that anesthesia care requires the personal performance or supervision by an appropriately licensed and credentialed doctor of medicine, osteopathy or dentistry'.
In the context of this article, the key phrase in this is 'or supervision' which is not defined and could be interpreted strictly from its etymology (super + videre-to see) as requiring direct visual observation but, knowing the American scene, will be interpreted more in line with 'supervisor', all of whose dictionary definitions lack this specificity of direct observation.
To avoid at least one of the conceptual confusions I propose from here on to refer to anyone who has a measure of clinical autonomy in the management of anaesthesia but lacks a medical qualification as a non-physician anaesthetist and I will call a medically-qualified anaesthetist an 'anaesthesiologist' despite the non-acceptance of this as a defining term in the United Kingdom.
In Europe, the employment of nurses as non-physician anaesthetists in some countries was not originally economically driven and it certainly is not now. A study of three typical departments in Switzerland and Sweden, conducted by the author, was unable to detect that their overall salary costs were less than if they had relied solely on a suitable mix of doctors. This may seem surprising, considering the salary differential at an individual level. However, the need for medical supervision, the stricter limits on the hours of work and the inflexibility which results, ensures that it is not a matter of one-for-one substitution and the extra numbers make up the difference in overall costs.
The main pressure initially was a shortage of medical manpower and the belief that it was more beneficial overall to concentrate a limited resource into Intensive Care, Pain Management and pre- and post-operative care. As a consequence, as much surgery as possible was carried out under regional or local anaesthesia and the task of monitoring and managing general anaesthesia in suitable patients was delegated to a considerable extent to non-physician (nurse) anaesthetists who were trained in a limited repertoire of techniques.
When the European Academy was founded it was anticipated that this divergence of practice would be a source of division for a European academic body and it was tacitly concluded that it would not be possible to produce a universally acceptable 'Academy view' on the role (if any) of non-physician anaesthetists and nothing could be gained by attempting to produce one.
However, with the passage of time, these apparently fundamentally different systems have increasingly come to resemble each other within the countries represented in the Academy. In Sweden, for example, restrictions on what practice is appropriate for non-physician anaesthetists has led to forms of organization of practice which are not dissimilar to trends towards an 'anaesthesia team' approach promulgated by the American Society of Anesthesiologists and the Association of Anaesthetists of Great Britain and Ireland. As a generalization, the role of non-physician anaesthetists has been increasingly restricted whilst the role of the anaesthetic assistant has tended to expand.
A lot of the problem has lain in trying to define the various types of non-physician anaesthetist and anaesthetic assistant and assigning appropriate duties and responsibilities. The debate will not be advanced by now trying to define 'supervision'. The key is to agree on the extent to which non-physician anaesthetists have clinical autonomy. This is helped by reversing one's stance and defining the responsibilities of the physicians in the system and thus focusing on the requirement to clarify, in local circumstances, what is an acceptable degree of clinical autonomy for non-physicians.
Analyses of mortality and morbidity data and analyses of critical incident data strongly suggest that when things go wrong, human error is almost always involved [1,2]. A key component of many such errors is the lack of appropriate knowledge. In all walks of life, those more intensively trained and more comprehensively educated tend to perform better than the less well-trained or educated. For this reason, any academic body representing the speciality is bound to start with a presumption that the goal of its efforts must be a fully physician-led and physician-administered anaesthetic service.
The dramatic reductions in perioperative mortality related to anaesthesia, achieved over the last 10-20 years, suggests that a physician-administered anaesthesia service which creates no additional mortality and no serious morbidity is now achievable. For various practical reasons to do with changing practice over time, the difficulty of obtaining comparable samples and the numbers needed for statistical significance, it will be difficult, if not impossible, to prove the same with other systems. One must concede, nevertheless, that it is possible that systems in which non-physicians anaesthetists are employed may be as safe and effective provided that they contain mechanisms by which higher-risk patients and higher-risk episodes can all, in theory, be managed by anaesthesiologists, and that when an unpredicted complication arises, anaesthesiologist help is rapidly available. However, it seems inherently unlikely that systems which allow non-physician anaesthetists any significant degree of clinical autonomy can be as safe as is now possible. There is thus both a scientific and practical need to continue efforts to resolve doubts concerning the relative safety of alternative systems of anaesthesia service delivery.
Pressures to avoid change
Whether it is a matter of introducing non-physician anaesthetists where they do not exist or phasing them out where they do, there is great resistance to change, natural conservatism playing a big role. In the United Kingdom there is organizational resistance to the introduction of non-physician anaesthetists, despite several attempts by government agencies to move in that direction. Their introduction is perceived as a downgrading of the speciality, despite evidence that this is not the case in some systems where they function currently.
Where skilled non-physician anaesthetists exist, the anaesthesiologists do not wish to see the disappearance of a cadre which they regard as a useful adjunct in the delivery of the overall service. There is an additional fear that a sudden demand for extra physicians could not be met, at least in the medium term, with unfortunate consequences for the overall effectiveness of the service. Less often articulated is the view that sitting through uneventful general anaesthesia for long periods is not only professionally unsatisfying but devalues the skills of highly trained and expensive anaesthesiologists.
Pressures creating change
Incrementally, with each step almost unnoticed, the nature of the practice of general anaesthesia has significantly changed so that there are elements which can increasingly be seen to be appropriate for non-physicians. Furthermore, work in progress suggests that this will continue. The changes are particularly the introduction of safer, shorter-acting drugs, both inhalational and intravenous, which allow techniques which require only minor corrections of concentrations or infusion rates rather than boluses. Target-controlled infusions are making intravenous techniques as controllable as inhalational ones. Feedback control of the depth of anaesthesia will limit the need for yet one more of the skills of the administrator of the anaesthetic. This has been accompanied by a revolution in monitoring technology so that artefact-free monitoring has become generally available and will soon be supplemented by artefact-free automatic record-keeping and artefact-free alarms, all of which can be displayed simultaneously in more than one place.
These developments influence attitudes on both sides of the divide: one camp sees the value in retaining its non-physician anaesthetists to handle this element of routine work and the other camp sees the need to increase the quality of its less well-trained assistants. It is now regarded as appropriate in some centres to allow anaesthetic assistants to undertake technical manoeuvres such as venous cannulation of peripheral veins or passing an endotracheal tube and other tasks, such as monitoring and charting. It is a short step from this to allowing them to monitor drug infusions of relaxants and analgesics to a protocol laid down by a supervising physician. Those in favour point to the fact that nurses do so in intensive care units: those against point to the different circumstances, notably the absence of the unpredictable effects of concurrent surgery.
What degree of clinical autonomy is appropriate for non-physician anaesthetists?
Anaesthesiologists who have completed their training have unfettered clinical autonomy. Despite the constraints of local guidelines or protocols (which they voluntarily accept by virtue of accepting local employment conditions), they have a legal right to give medical care in any way acceptable to the patient. Non-medical anaesthetists, even when fully trained and with a great deal of experience, are constrained in any number of ways which will vary from place to place. They can be constrained by restrictions on what drugs they may give, the maximum dose and how frequently; they can be constrained by positive requirements such as frequency of observations and their recording; they can be constrained by clinical indicators for which they must seek assistance. But they can also be constrained in non-clinical ways. for example, the indications for calling for assistance and the methods by which assistance is obtained may depend on how long it takes for relevant assistance to arrive, at a defined level of probability.
Thus the local forms of practice, the geography of the working environment, the level of technology and the ever evolving nature of anaesthetic practice all make it impossible to define boundaries acceptable to everyone for all time. Nevertheless, I believe it is now possible to formulate a statement of acceptable principles to which members in all European countries could agree. Furthermore, it is particularly opportune to do so since there is reason to believe that the authorities in some countries, notably France, plan to introduce non-physician anaesthetists by deliberately under-providing training posts for anaesthesiologists. Authorities in some Eastern European countries may well be thinking along similar lines.
Accordingly, I have formulated the following proposals and presented them to the Executive Committee for consideration. At their request they are published here for comment, either as Correspondence to the Editor of the European Journal of Anaesthesiology or to the Honorary Secretary of the Academy whose address is appended.
M. D. Vickers
Past President; Professor Emeritus, University of Wales College of Medicine, Cardiff, UK
1 Green R. The psychology of human error. In: Adams AP, Cashman JN, eds. Recent Advances in Anaesthesia and Analgesia,
19th edn. London, UK: Churchill Livingstone, 1995: 1-16.
2 Green R. The psychology of human error. Eur J Anaesth
Proposed Guidelines on the employment of non-physician anaesthetists within the Anaesthesia Team
Throughout the following text 'anaesthesiologist' means a physician with a medical qualification and specialist training (and ideally a postgraduate Diploma) in Anaesthesia.
1 All patients should be seen and assessed by an anaesthesiologist before being submitted to any form of anaesthesia. Consent to the mode of anaesthesia should be obtained by an anaesthesiologist able to explain the options available, who will be professionally responsible for its administration, even though elements may be delegated to a non-physician anaesthetist or anaesthetic assistant.
2 The mode of anaesthesia should be decided upon by the anaesthesiologist who will be responsible for its administration.
3 The induction of anaesthesia should be under the direct supervision of an anaesthesiologist, at least until the surgical incision.
4 At the end of operation, the patient should be handed over to a trained recovery or ITU nurse by the responsible anaesthesiologist.
5 The minute-by-minute observation and care of the patient may be delegated to an adequately trained assistant, at the discretion of the responsible anaesthesiologist, who nevertheless must retain personal and professional responsibility for the patient's welfare and be available at all times. Technical procedures such as cannulation and intubation should only be delegated to staff who have been assessed as competent in that procedure.
6 Local protocols should exist defining categories of patients which require the continuous presence of an anaesthesiologist. These might encompass those undergoing intrathoracic, intracranial or major vascular surgery, children below a defined age or weight, those above a defined age and those in fitness class ASA III or worse.
7 Local protocols should also define the monitoring which should be undertaken and the minimum frequency of recording of all relevant observations. Whenever technically feasible, repeater monitors should be installed in areas where they can be remotely observed by an anaesthesiologist.
8 Local protocols should also support any non-physician trusted to be the immediately responsible person by defining the circumstances under which help from an anaesthesiologist must be summoned, the immediately available source of that help, the maximum time which can elapse before that help must arrive, and what to do during that time. It is mandatory that the defined help is ALWAYS available within the time specified.
9 It is the duty of the chief of service to ensure that delegation is only entrusted to those able to sustain life and prevent physiological deterioration in a patient's condition for whatever time is set in paragraph 8 above.
10 The training of all non-medical assistants/anaesthetists allowed to undertake such delegated tasks must be the responsibility of the Chief of Service or his named deputy.
11 All non-medical assistants/anaesthetists should be included in programmes of continuing medical education and periodic revalidation of competence, no less rigorous than those undertaken by physicians.
12 The professional Societies of Anaesthesiologists in those countries which allow delegation of minute-to-minute care have a responsibility to encourage long-term mortality and morbidity studies so that the overall safety of the system can be assessed. The National Committee of Enquiry into Peri-Operative Deaths (NCEPOD) in the United Kingdom (c/o Royal College of Surgeons of England, 35-43, Lincoln's Inn Fields, London, WC2A 3PN) is commended as a suitable model.
Comments on these guidelines may be sent to the Editor or to the Secretary of the Academy, c/o The Permanent Administrative Secretariat, Mrs G Louw, P.O. Box 33, 3001 Heverlee 1, Belgium. Fax: +32-16-405151. E-mail: [email protected].