Facts About AAs

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The Practicing AA

Members of the medically directed anesthesia care team may include anesthesiology residents as well as non-physicians such as anesthesiologist assistants and nurse anesthetists. The ASA Anesthesia Care Team statement may be read in its entirety by clicking here.

What is the scope of AA clinical practice?

The scope of AA clinical practice is generally the same as that of nurse anesthetists on the Anesthesia Care Team. The ASA statement on the Recommended Scope of Practice of Nurse Anesthetists and Anesthesiologist Assistants may be found at: http://www.asahq.org/For-Members/Advocacy/Federal-Legislative-and-Regulatory-Activities/Position-Papers/Recommended-Scope-of-Practice-of-Nurse-Anesthetists-and-Anesthesiologist-Assistants.aspx

Specifically, the local scope of practice of AAs is usually defined by

• the medically directing anesthesiologist,
• the hospital credentialing body,
• the state's board of medicine
• any applicable state statute or regulation.

States may also require a practice agreement between the sponsoring anesthesiologist and the AAs who are medically directed.

What is the typical job description for AAs?

Under the direction of a qualified anesthesiologist, in agreement with the ASA Statement on the Anesthesia Care Team (ACT) and in accordance with the AAAA Statement on the ACT, the Anesthesiologist Assistant's functions include, but are not limited to, the following:

• Obtain an appropriate and accurate preanesthetic health history; perform an appropriate physical examination and record pertinent data in an organized and legible manner.
• Conduct diagnostic laboratory and related studies as appropriate, such as drawing arterial and venous blood samples.
• Establish non-invasive and invasive routine monitoring modalities, as delegated by the supervising anesthesiologist.
• Administer induction agents, maintain and alter anesthesia levels, administer adjunctive treatment and provide continuity of anesthetic care into and during the post-operative recovery period.
• Apply and interpret advanced monitoring techniques, such as pulmonary artery catheterization, electroencephalographic spectral analysis, echocardiography, and evoked potentials.
• Use advanced life support techniques, such as high frequency ventilation and intraarterial cardiovascular assist devices.
• Make post-anesthesia patient rounds by recording patient progress notes, compiling and recording case summaries, and by transcribing standing and specific orders.
• Evaluate and treat life-threatening situations, such as cardiopulmonary resuscitation, on the basis of established protocols (BLS, ACLS, and PALS).
• Perform duties in intensive care units, pain clinics, and other settings, as appropriate.
• Train and supervise personnel in the calibration, troubleshooting, and use of patient monitors.
• Delegate administrative duties in an anesthesiology practice or anesthesiology department in such functions as the management of personnel, supplies and devices.
• Participate in the clinical instruction of others.
• Perform and monitor regional anesthesia to include, but not limited to, spinal, epidural, IV regional, and other special techniques such as local infiltration and nerve blocks.

Can AAs perform regional anesthesia and place invasive monitors?

AAs are permitted to perform regional anesthesia techniques and place invasive monitors. These aspects of AA practice depend on the discretion of the supervising anesthesiologist, policies and procedures of the Department of Anesthesiology, standards set by the facility credentialing committee, and applicable state law. As always, performance of any such patient care task is under the medical direction of an anesthesiologist.

What is the legal authority for AAs to practice?

Anesthesiologist assistants may be either licensed as AAs or practice under the license of an anesthesiologist under the principle of delegation. Anesthesiologists may delegate those tasks or duties involved in the practice of anesthesiology to qualified individuals such as AAs as long as the anesthesiologist is immediately available and the anesthesiologist retains ultimate responsibility for the care of the patient. The exact details regarding delegation and licensing of AAs are different from state to state, and an anesthesiologist seeking to employ AAs should consult the board of medicine of the state in which he or she practices.

Where do AAs practice?

Anesthesiology practices in many states presently employ AAs. Inclusion of AAs in anesthesia care team practices across the country is a dynamic and evolving situation. For a complete list of states click here.

What is the difference between delegatory authority and licensure?

Licensure for AAs is created by legislation that is enacted and codified into state law or through regulation adopted by the board of medicine.

Delegatory authority may take the form of either recognition and action by the board of medicine or expressed in a delegation enabling statute such as the state's medical practice act. It is well accepted in various medical specialties, including anesthesiology, that the board of medicine may grant a physician the authority to delegate tasks or duties related to the practice of medicine to qualified individuals so long as the physician: 1) remains ultimately responsible to the patient and 2) assures that the individual performing the tasks is qualified to do so. An anesthesiologist seeking to employ AAs under the principle of delegatory authority should seek input from the board of medicine of their specific state.

Licensure for AA practice, although sometimes more difficult to achieve, better defines and anchors the practice of AAs in a state than does the simpler delegatory authority.

In all states AA practice falls under the auspices of the board of medicine. In contrast, nurse anesthetists' practice is regulated by state boards of nursing.

Hiring an AA

Can I hire an AA to work in my practice?

If your state does not presently provide the legislative or delegatory option of AA practice, consultation should take place with the board of medicine or other governing body to explore the specific legal implications of AA practice in your state. General information on the steps to establish AA practice is available from the ASA's Office of Governmental and Legal Affairs. You may also inquire of other state societies as to their local advocacy and procedural steps that have led to gaining the option to hire AAs.

What is the anesthesiologist supervision ratio for AAs?

In addition to the practical issues that limit how many anesthetists may be supervised by an anesthesiologist at any one time, ratios are also often specified as contract requirements from payors. For instance in order to meet CMS requirements for medical direction, no more than 4 anesthetists (AAs or NAs) may be concurrently directed by an anesthesiologist.

The supervision ratio may also be defined in state law or Board of Medicine guidelines and is usually between 2:1 and 4:1. Check the regulations in your state for the applicable standard. It is important to note that in states where statutes specify a supervision ratio of AAs to anesthesiologists at less than 4:1, the anesthesiologist may also concurrently supervise NAs up to a total combined ratio of 4:1 for both non-physician anesthetists.

How is AA practice reimbursed by CMS and third-party payers?

CMS recognizes both CRNAs and AAs as non-physician anesthesia providers. Similarly, commercial insurance payors make no distinction between the two anesthetist types with regard to payments for services provided under medical direction by an anesthesiologist.

According to the United States Code of Federal Regulations (42 C.F.R. § 482.52 Condition of participation: Anesthesia services)

"If the hospital furnishes anesthesia services, they must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital.

Standard: Organization and staffing. The organization of anesthesia services must be appropriate to the scope of the services offered. Anesthesia must be administered by only

• A qualified anesthesiologist;
• A doctor of medicine or osteopathy (other than an anesthesiologist);
• A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under State law;
• A certified registered nurse anesthetist (CRNA), as defined in § 410.69(b) of the Federal Register, who is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or
• An anesthesiologist's assistant, as defined in § 410.69(b) of the Federal Register, who is under the supervision of an anesthesiologist who is immediately available if needed."

How do AA and NA salaries compare?

When employed within the same department and when possessing the same job description and experience level within the anesthesia care team, AAs and NAs are compensated with identical salary and benefit packages.

States with Licensure

AAs currently work in eighteen (18) states.

The states in which AAs work by a license, regulation, and/or certification are:
Alabama
District of Columbia
Florida
Georgia
Kentucky
Missouri
New Mexico (university hospital settings)
Ohio
Oklahoma
South Carolina
Vermont
North Carolina

The states in which AAs are granted practice privilege through physician delegation (meaning the anesthesiologist can delegate specific anesthesia tasks to an AA):
Colorado
Michigan
New Hampshire
Texas
West Virginia
Wisconsin

The federal government recognizes and uses AAs.
Both the Department of Defense and the Department of Veterans Affairs authorize the use of anesthesiologist assistants to practice under the TRICARE insurance program.

Articles of Interest

• Anesthesiologist Assistants vs. Nurse Anesthetists ... What Are the Differences?



• Analysis of Manpower in Anesthesiology (Used by permission of Lippincott, Williams, Wilkins;Steinhaus, et.al et.al Analysis of Manpower in Anesthesiology. Anesthesiology 1970 Sept;33(3):350-356)

Media Outlets Covering AA Issues

• American College of Surgeons
• American Society for Healthcare Human Resources Administration
• Anesthesiology News
• Centers for Medicare and Medicaid Services
• Florida Medical Business

Recent Articles

• AA Students Go West!

  This new article in Missouri Medicine, the publication of the Missouri State Medical Association, describes how a new AA program is getting underway in Kansas City. It will mean more choice for those considering the AA profession out west, and eventually more AAs to solve the shortage of anesthesia providers, as they are doing in other states.

  Click here to read the article

  Reprinted with permission from Missouri Medicine 2008 Jan/Feb; 105(1) pgs 27-29, Copyright © 2008 Missouri State Medical Association.




• How to Hire an Anesthesiologist Assistant

  By Al Rothstein

  (Panama City, Fl) - Shane Angus had visions of living near the water, taking him back to his California roots.  But his chosen profession, the Anesthesiologist Assistant, is not licensed to work in his home state.
  
  "I wanted to be in a state where there was an ocean culture," he says.
  
  Things began to fall into place when the legislature for another state known for its ocean culture, Florida, licensed AAs in 2004.  His wife was considering law schools there, making the Sunshine State an ideal choice for the couple.  Shane was well-qualified, having graduated from the AA program at Case Western Reserve University in Cleveland, Ohio.
  
  Politics Stood in the Way
  
  But Shane didn't realize the job search would take months.  Even though AAs were licensed, no one had been hired yet, and there was a lot of hesitation among anesthesia groups to do so.  In fact, there was pressure NOT to hire AAs.

  Read more...




• Outpatient Surgery

  ANESTHESIOLOGIST ASSISTANTS ARE NOW LICENSED to work in Washington, D.C., surgical facilities. AAs are also licensed to work in nine other states and allowed to practice in six more if facilities or physician anesthesiologists specifically request them. The licensing has been a long time in coming: in 2002, the D.C. Board of Medicine issued AA guidelines; the district's council passed a law creating licensure in 2004; the council wrote the licensure regulations last year; and licensing was finally approved on Tuesday. "We have had a shortage of anesthesia providers for a while," says Frederick Finelli, MD, president of the medical staff of Washington Hospital Center and chairman of the D.C. Board of Medicine. "AAs are helping to alleviate that shortage." Seven AAs now work in the capital.

  From Outpatient Surgery (www.outpatientsurgery.net/newsletter), 2-27-06 issue, News and Notes section.




• Considering a Career as an Anesthesiologist Assistant

  Making a Difference in Health Care -
  Considering a Career as an Anesthesiologist Assistant
  
  36-year old Richard Bassi was a navy pilot for ten years and absolutely loved it. But he was unsure what he would do after his military career.
  
  “The one thing I did know is that I didn’t want to sit behind a desk,” says Bassi.

  Read more...




• TRICARE Recognizes AAs


• Patient Safety Remains Intact


• Good Working Environment

AA Education and Program Application Process

Admission Requirements

In order to be admitted to an AA program, the applicant must have achieved a bachelor's degree with prescribed prerequisites typical of premedical course work. Specific requirements include general and organic chemistry, advanced college math, general and advanced biology, and physics. Applicants must then take either the (MCAT) or the (GRE). Although many applicants who are from allied health backgrounds such as respiratory therapy and emergency medical technology may have years of clinical experience, a clinical background is not an absolute requirement. Nurses who meet the premed coursework prerequisites have been admitted to AA programs.

Individual program requirements

Educational Programs

AA training programs must include a minimum of 24 months in a Master's level program accredited by the Commission for the Accreditation of Allied Health Educational Programs (CAAHEP). The programs must be based at, or in collaboration with, a university that has a medical school and academic anesthesiologist physician faculty. Each AA program must have at least one director that is a licensed, board-certified anesthesiologist. Main clinical sites must be academic medical centers. An average of 600 hours of classroom/laboratory education, 2600 hours of clinical anesthesia education, and more than 600 anesthetics administered, including all types of surgery, are typically required to successfully complete AA training.

What are the requirements for sponsoring an AA program?

According to the latest standards established by the Commission on Accreditation of Allied Health Education Programs (CAAHEP), accredited Anesthesiologist Assistant educational program must be supported by an anesthesiology department of a medical school that is accredited by the Liaison Committee on Medical Education or its equivalent. The anesthesiology department must have the educational resources internally or through educational affiliates that would qualify it to meet the criteria of the Accreditation Council for Graduate Medical Education (ACGME), or its equivalent for sponsorship of an anesthesiology residency program. CAAHEP rules also allow for consortium sponsorship utilizing the combined resources of an academic anesthesiology department and an accredited college with appropriate allied health faculty and degrees.

Although the standards recognize the importance of a basic science education within a clinically oriented academic setting, it is also recognized that some of the supervised clinical practice components of the curriculum may be carried out in affiliated community hospitals that have the appropriate affiliation agreements specifying the requisite teaching faculty and staffing ratios for the clinical experience.

What is the length of the AA education program?

According to CAAHEP standards for AA programs, the depth and duration of the total program, and particularly the clinical experience, shall be sufficient to assure the potential employer that the newly graduated AA will be able to perform entry-level functions. The number, content and length of courses shall be appropriate to the training of an assistant to the anesthesiologist. The AA curriculum is based on an advanced graduate degree model, and at least two full academic years are required. The current programs are 24 to 28 months long. Graduates from all AA educational programs earn a masters-level degree.

What types of students enter AA education programs?

Qualified student applicants must possess a baccalaureate degree and complete all of the premedical course work required by the typical American medical school.

Though minor differences between programs may exist, generalized admission requirements for students seeking entrance into an AA program include:

• Bachelor's degree from an accredited institution with a premedical sciences track
• Two semesters of biology with laboratory
• Two semesters of vertebrate anatomy and physiology (or other advanced biology) with laboratory
• Two semesters of general chemistry; 1 semester of organic chemistry; a second semester of organic chemistry or biochemistry with laboratory
• Two semesters of general physics with laboratory
• Two semesters of advanced college mathematics including calculus
• Either the Medical College Admissions Test (MCAT) or the Graduate Records Admission Test (GRE)

Who are the faculty of AA programs?

According to CAAHEP standards, the program must include faculty who are qualified through academic preparation and experience to teach assigned subjects. Faculty members for the basic sciences are university-based professors and instructors. Faculty for the supervised clinical practice portion of the educational program must include physicians and AAs based within the department of anesthesiology, but also may include other health professionals who are experienced in their disciplines. Faculty members may possess clinical appointments within the affiliated medical school. Although anesthesiology residents and fellows may be involved in AA training, they should not play a predominant role. For a list of programs, click here.