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Legislative Research CommissionChapter 1Chapter 1The Anesthesiologist Assistant ProfessionIntroductionHealth care providers known as anesthesiologist assistants are asmall but growing group whose profession has fairly recentorigins. These practitioners are available in several jurisdictions asan option for an anesthesia care team. The majority of states do notcurrently allow anesthesiologist assistant practice. Some consideranesthesiologist assistants to be highly skilled and highly trainedpractitioners who are qualified to administer anesthesia under thesupervision of an anesthesiologist. Others view anesthesiologistassistants as not having the required educational or otherbackground to safely administer anesthesia care.This chapter provides an overview of the anesthesiologist assistantprofession by exploring what it is, its history, and its current issues.Also, qualifications of anesthesiologist assistants are reviewed bylooking at anesthesiologist assistant training and education,certification and licensure requirements, and scope of practice.Finally, Chapter 1 investigates the impact of anesthesiologistassistants on patient safety and access to care.History and Description of Anesthesiologist AssistantsThe first anesthesiologist assistantprograms began at EmoryUniversity and Case WesternReserve University in 1969.The first anesthesiologist assistant programs were started at EmoryUniversity and Case Western Reserve University in 1969. Theimpetus of the education program and profession was the physicianshortage faced by the field of anesthesiology in the mid-1960s, theshortage of nurses in anesthesia, and the increasing technologicaldemands of the field. In response, three anesthesiologists proposedthe concept of an "anesthesia technologist" who would be amember of the anesthesia team and be considered an "appliedphysiologist" (Gravenstein 356).It was envisioned that this new anesthesia professional would havea bachelor's degree in science with premedical training and beawarded a master's degree that allowed for both vertical mobilitytoward a medical degree and lateral mobility into other areasrequiring training in biomedical equipment and physiologicmeasurement. The anesthesiologist assistant would remain under1

Chapter 1Legislative Research Commissionthe supervision of the anesthesiologist as "responsibility andimmediate care of the patient must remain within the province ofthe anesthesiologist; consequently, personnel could not workindependently but only under the immediate direction of theanesthesiologist. An advantage in manpower for theanesthesiologist would result, as he could provide attention toseveral patients with the proper employment of the anesthesiateam, as described above" (Gravenstein 357).A small number ofanesthesiologist assistantspractice compared to other similarprofessions, and the practice hasremained largely regionalized.Since its inception, the anesthesiologist assistant profession hasgrown but remains a largely regionalized profession due to thesmall number of programs, which until recently numbered onlytwo; and the limited number of jurisdictions, 16, whereanesthesiologist assistants are authorized to practice. In 1989, theNational Commission for Certification of AnesthesiologistAssistants was formed to establish a national certification process.Today, the American Society of Anesthesiologists considersanesthesiologist assistants to be mid-level anesthesia providerswho work under the direction of an anesthesiologist and participatein the provision of anesthesia, performing such tasks asadministering drugs, obtaining vascular access, applying andinterpreting monitors, establishing and maintaining patient airway,and assisting with preoperative assessment (Emory).Current Issues Relating to Anesthesiologist AssistantsFlorida Anesthesiologist AssistantsFlorida began discussing the anesthesiologist assistant professionin 2001. Anesthesia physicians wanted a new type of anesthesiaprovider to alleviate the shortage of help for anesthesia teams.Also, those physicians felt that using only nurse anesthetistsdrained the already small pool of nurses available for moregeneralized work (Lundine).In 2004, anesthesiologist assistantlicensing was implemented inFlorida.In 2004, Florida enacted Senate Bill 626, which established theanesthesiologist assistant profession in that state. The bill requiredthat anesthesiologist assistants be directly supervised by ananesthesiologist, work pursuant to a written protocol filed with themedical board, and practice in accordance with the scope ofpractice defined in the legislation and as further defined by themedical board. The debate on the issue was intense. The FloridaAssociation of Nurse Anesthetists (FANA) opposed the FloridaSociety of Anesthesiologists (FSA) to try to preventanesthesiologist assistants from practicing in Florida. FANA stated2

Legislative Research CommissionChapter 1that anesthesiologist assistants were not adequately educated andtrained, and FSA argued that they were adequately educated andtrained. After much media attention and debate, the bill passed andwas signed into law by Governor Jeb Bush (Turpin). The Governorstated that he recognized that there are "differences in trainingbetween nurse anesthetists and anesthesiologist assistants, but thedifference does not equate to inferiority" (Maine Nurse).Nova Southeastern University in Ft. Lauderdale, Florida,established a Master of Health Science Anesthesiologist AssistantProgram in 2005. This program will graduate anesthesiologistassistant students within the next few years.Training and EducationCAAHEP Accreditation of ProgramsThere are four accreditedanesthesiologist assistant schoolsin the U.S. Accreditation isgranted by the Commission onAccreditation of Allied HealthEducation Programs (CAAHEP).Anesthesiologist assistants graduate from one of four accreditededucational programs in the U.S. The programs are located atEmory University in Atlanta, Georgia; Case Western ReserveUniversity in Cleveland, Ohio; Nova Southeastern University inFort Lauderdale, Florida; and South University in Savannah,Georgia. These programs are accredited by the Commission onAccreditation of Allied Health Education Programs (CAAHEP).CAAHEP is the largest programmatic accreditor in the healthsciences field. Through its Committees on Accreditation,CAAHEP reviews and accredits more than 2,000 educationalprograms in 19 health science occupations and is recognized by theCouncil for Higher Education Accreditation (Commission. Home).The four schools of medicine associated with these programs areaccredited by the Liaison Committee on Medical Education.Additionally, the programs meet the criteria for accreditation bythe Accreditation Council for Graduate Medical Education foranesthesia residency training programs (Commission. Standards2).The education requirements are similar among the programs. TheStandards and Guidelines of CAAHEP requires that theanesthesiologist assistant program build on a pre-professionalstudy of the sciences that would allow a student to pursue anadvanced degree program in medical science (6). A bachelor'sdegree with specific prerequisite courses in science, math, andEnglish are required for entrance into an anesthesiologist assistantprogram. An entrance exam is also required for admittance(American Society. Frequently). Emory, Nova Southeastern, and3

Chapter 1Legislative Research CommissionSouth Universities accept entrance exam scores from the GraduateRecord Examination (GRE) or the Medical College AdmissionTest (MCAT). Case Western Reserve University only acceptsentrance exam scores from the MCAT.Table 1.1Anesthesiologist Assistant Education ProgramsLocationEntranceExamRequired ForProgram*Term ofProgramNumber ofClinicalHours inProgramCurriculumHours inProgramCAAHEPCertifiedEmory UniversitySchool of MedicineMaster of MedicalScience Program inAnesthesiologyAtlanta,GAGRE orMCAT24 months(6 semesters)2,500 hours78 hoursYesCase WesternReserve UniversityMaster of Sciencein AnesthesiaProgramCleveland,OHMCAT24 months(6 semesters)2,000 hours63 hoursYesFt.Lauderdale,FLGRE orMCAT27 months(7 semesters)2,592 hours132 hoursYesSavannah,GAGRE orMCAT28 months(9 quarters)2,718 hours158 hoursYesName ofAnesthesiologistAssistant ProgramNova SoutheasternUniversity Masterof Health ScienceAnesthesiologistAssistant ProgramSouth UniversityMaster of MedicalScienceAnesthesiologistAssistant Program*Other admission requirements for all four schools include a bachelor's degree with some specificprerequisite course work in science, math, and English.Source: Staff research of all four institutions.The 16 jurisdictions where anesthesiologist assistants work bylicense, regulation, certification, or physician delegation all requirethrough statute or regulation that anesthesiologist assistants havegraduated from an accredited anesthesiologist assistant program.Beyond this requirement, passing the national certifying exam andparticipating in continuing education sessions, staff research4

Legislative Research CommissionChapter 1indicates no other specific educational requirements in any of thejurisdictions.A potential fifth anesthesiologistassistant school, located inKansas City, Missouri, is currentlyseeking accreditation.In Missouri, a fifth school has requested accreditation. TheUniversity of Missouri Board of Curators approved in July 2006the creation of a Master of Science in Anesthesia program to beoffered at the University of Missouri-Kansas City's School ofMedicine. The program is now seeking accreditation fromCAAHEP and hopes to begin accepting prospectiveanesthesiologist assistant students in the summer of 2007 (Corey).Curriculum and Clinical HoursCAAHEP has created guidelineson curriculum and clinical hoursfor anesthesiologist assistantschool programs.The Standards and Guidelines of CAAHEP establish basicguidelines for the curriculum of an anesthesiologist assistantprogram. CAAHEP states that "the curriculum should be designedon an advanced degree model and require a minimum of two fullacademic years. The curriculum should provide an earlyintegration of clinical and didactic instruction with supervisedclinical practice”(Commission. Standards 5). Further, CAAHEPindicates that “Clinical rotations should afford students a variety ofpatient care experiences as well as a consistency of learningopportunities among individual students. External rotations ataffiliated sites should be planned based on the desired educationaloutcomes set by the program" (5).CAAHEP requires the basic science curriculum to includeappropriate content in anatomy, biochemistry, physiology, andpharmacology, with particular emphasis on the cardiovascular,respiratory, renal, nervous, and neuromuscular systems.Appropriate study components of other basic medical sciences arecompulsory, including microbiology, pathology, and immunology.Medical biophysics appropriate to anesthesia practice is alsorequired, and it includes and emphasizes the principles underlyingthe function of the devices used in anesthesia delivery systems, inlife support systems such as ventilators, and in basic and advancedpatient monitors. Also required are the principles of medicalinstrumentation that emphasize the design, function, operation, andcalibration of patient monitoring devices. CAAHEP mandatestraining in the function, calibration, and use of the equipment inassociated clinical laboratories (e.g., blood gas analyzers). Anotheressential condition of anesthesiologist assistant program curriculais that instruction be provided on the concepts of data analysis asrelated to collecting, processing, and presenting basic science andclinical data in medical literature, emphasizing methods thatsupport an understanding of clinical decision making. Instruction is5

Chapter 1Legislative Research Commissionrequired on patient assessment, including techniques ofinterviewing to elicit a health history and performing a physicalexamination at the level appropriate for preoperative,intraoperative, and postoperative anesthetic evaluations. Anotherprerequisite is extensive instruction in the clinical practice ofanesthesia and patient monitoring, principally in an operating roomsetting but also in preoperative areas, postoperative recovery areas,intensive care units, pain clinics, affiliated clinical laboratories,and other supporting services. Also, curricula must discuss clinicalquality assurance conferences and literature reviews (5-6).Anesthesiologist assistantprograms consist of master'sdegree training in anesthesialasting between 24 and 28consecutive months. The fourprograms require between 2,000and 2,700 clinical hours andbetween 63 and 158 curriculumhours.The four current anesthesiologist assistant programs requirebetween 24 and 28 consecutive months to complete master'sdegree training in anesthesia. The programs mandate that studentscomplete between 2,000 and 2,700 clinical hours of training andbetween 63 and 158 curriculum hours before a degree will beawarded.Certification and Licensure RequirementsAll 16 jurisdictions whereanesthesiologist assistantspractice require individualcertification by the NationalCommission for Certification ofAnesthesiologist Assistants(NCCAA).Currently, 16 jurisdictions allow anesthesiologist assistants topractice. Of those 16, 10 (including Kentucky) allow practicethrough direct licensure of the anesthesiologist assistant. The othersix jurisdictions allow anesthesiologist assistants to practice underthe concept of "physician delegation." (See Chapter 2 for moredetail on the jurisdictions and distinctions.) Regardless of thepractice scheme chosen, all of these jurisdictions require that eachanesthesiologist assistant receive certification by the NationalCommission for Certification of Anesthesiologist Assistants(NCCAA).NCCAA certifies anesthesiologist assistants through a three-stageprocess. First, NCCAA administers a general "certifying"examination for initial applicants. This examination must bepassed in order to practice in any jurisdiction as an anesthesiologistassistant. Second, anesthesiologist assistants are required toregister credit for continuing medical education (CME) taken intwo-year cycles. In each two-year period, the anesthesiologistassistant must complete at least 40 hours of CME classes approvedby NCCAA. Third, anesthesiologist assistants must successfullycomplete an Examination for Continued Demonstration ofQualifications (CDQ) every six years, beginning six years afterinitial certification. The anesthesiologist assistant must still meetCME requirements during the year when the CDQ exam is taken(National Commission. Certification).6

Legislative Research CommissionChapter 1NCCAA Certificate and ExaminationTo receive initial certification,

of anesthesiologist assistant practice to that of other anesthesia care providers. In the . of the anesthesiologist assistant degree program varies from 63 to 158 hours of course work and from 2,000 to about 2,700 clinical hours. As part of their training,