Europe is growing together increasingly quickly, giving rise to a need for harmonization and standardization of various structures that have developed historically in the different countries. One of the goals of the Union Européenne des Medécins Specialistes (UEMS) and of the European Academy of Anaesthesiology (EAA) has always been to encourage this process of harmonization, to ensure that anaesthesiologists are able to move freely within the European Union. One of the problems that has been addressed is the way in which specialist training in anaesthesia is organized . Another problem lies in geographical variations in the manpower available in the field of anaesthesiology in different parts of Europe .
One problem the EAA has not yet dealt with is the need to develop common guidelines for the provision of anaesthesia - addressing the question of who should deliver anaesthesia. In this issue of the European Journal of Anaesthesiology, M. D. Vickers, past president of the European Academy of Anaesthesiology, presents a very well-considered paper discussing all the different models of anaesthesia services that are used in Europe and concluding with proposed guidelines which are intended to serve as the starting-point for discussion and as a possible basis for developing a common approach in the future.
We are here concerned with the standards of education and training for those delivering anaesthesia, and the way in which anaesthesia services are organized. What are these issues? It's economics, doctor! Salaries and education costs for anaesthesiologists are higher than those for non-physician anaesthetists (e.g. the Certified Registered Nurse Anaesthetist in the United States), which again are higher than those of even less qualified anaesthesia assistants. As changing economic forces have made it impractical to believe that medical care should be provided without regard to cost, we are facing the challenge of how to provide as much value as possible at as low a cost as possible. Rationalizing anaesthesia services might suggest the use of mixed systems for anaesthesia provision, provided that outcomes are as good as those with an anaesthesiologist-only service.
In addition to cost issues, another potential argument in favour of a mixed system for anaesthesia provision is 'boredom and fatigue' [3,4]. Maintenance of anaesthesia in uncomplicated cases may be professionally unsatisfying for highly qualified anaesthesiologists. Some colleagues find it more satisfying to delegate less important aspects of anaesthesia to less qualified personnel and simply to supervise the process as a whole, being physically present only during the major phases and crisis situations.
An academic organization such as the EAA, and a professional one like the UEMS, must argue that the quality of a service will improve along with the education, training and experience of those who deliver it. Although this is hard to prove, it is plausible and can be regarded as common sense . It is therefore obligatory that all anaesthetic procedures should at least be supervised by an anaesthesiologist, and that an anaesthesiologist should always be immediately available to manage every crisis. Delivery of anaesthesia by non-anaesthetists is conceivable only under the constraints of severely restricted financial resources, as in the developing countries, or in cases of mass casualties .
Whether or not parts of the anaesthesia process can be delegated depends, among other things, on patient characteristics, type of surgery, type of anaesthetic procedure, and the qualifications of the nonphysician anaesthetist, as well as on the rules for collaboration with the anaesthesiologist, with whom the overall responsibility remains. In most anaesthesia services, this type of delegation to less qualified personnel is everyday practice - even in Great Britain, where the consultant supervises junior anaesthesia staff. As long as delegation does not result in any demonstrable reduction in the quality of care, there are no reasonable arguments against it.
H. Van Aken
Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Westfälischen Wilhelms-Universität Münster, Albert-Schweitzer-Str. 33, 48149 Münster, Germany
1 European Board of Anaesthesiology Training Guidelines. www.uems.be/
2 Rolly G, MacRoe WR, Blunnie WP, Dupont M, Scherpereel P. Anaesthesiological manpower in Europe. Eur J Anaesthesiol
3 Chappelow J. The psychology of safety. Baillière's Clin Anaesthesiol
4 Weinger MB, Englund CE. Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. Anesthesiology
5 Abenstein JP, Warner MA. Anesthesia providers, patient outcomes, and costs. Anesth Analg
6 Lopez SA. Perioperative nursing: the Jamaican perspective. Semin Perioper Nurs