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Facts About AAs
Basic Definitions & Information
Education & Certification
Practice Management of AAs
Basic Definitions & Information
Anesthesiologist Assistants (AAs) are highly skilled health professionals who work under the direction of licensed anesthesiologists to implement anesthesia care plans. AAs work exclusively within the anesthesia care team environment as described by the American Society of Anesthesiologists (ASA). All AAs possess a premedical background, a baccalaureate degree, and also complete a comprehensive didactic and clinical program at the graduate school level. AAs are trained extensively in the delivery and maintenance of quality anesthesia care as well as advanced patient monitoring techniques. The goal of AA education is to guide the transformation of qualified student applicants into competent health care practitioners who aspire to practice in the anesthesia care team.
Anesthesiologist Assistants and certified registered nurse anesthetists are both defined as "non-physician anesthetists" within the Centers for Medicare & Medicaid Services section of the Code of Federal Regulations.
In the 1960s, three anesthesiologists, Joachim S. Gravenstein, John E. Steinhaus, and Perry P. Volpitto, were concerned with the shortage of anesthesiologists in the country. These academic department chairs analyzed the spectrum of tasks required during anesthesia care. The tasks were individually evaluated based on the level of professional responsibility, required education and necessary technical skill. The result of this anesthesia workforce analysis was to introduce the concept of team care and to define a new mid-level anesthesia practitioner linked to a supervising anesthesiologist. This new professional - the Anesthesiologist Assistant or AA - had the potential to at least partially alleviate the shortage of anesthesiologists.
The new type of anesthetist would function in the same role as the nurse anesthetist under anesthesiologist direction. An innovative educational paradigm for anesthetists was created that built on a pre-med background during college and led to a Master's degree. This pathway placed AAs on an anesthesia "career ladder". Some AAs have leveraged their premed background, Master's degree and clinical experience to successfully apply to medical school. A few have returned to anesthesia to become the physician leader of the care team that launched their professional career.
The chairmen's vision became reality in 1969 when the first AA training programs began accepting students at Emory University in Atlanta, Georgia, and at Case Western Reserve University in Cleveland, Ohio.
Although AAs and physician assistants (PAs) both function as physician extenders, they do not perform the same functions. Each has its own separate educational curriculum, standards for accreditation, and its own agency for certification. PAs receive a generalist education and may practice in many different fields under the supervision of a physician who is qualified and credentialed in that field.
An AA may not practice outside of the field of anesthesia or apart from the supervision of an anesthesiologist. An AA may not practice as a physician.s assistant unless the AA has also completed a PA training program and passed the National Commission for the Certification of Physician Assistants (NCCPA) exam.
Likewise a PA may not identify him- or herself as an AA unless he or she has completed an accredited AA program and passed the National Commission for the Certification of Anesthesiologist Assistants (NCCAA) exam. If also certified as an AA, such a dual-credentialed PA would be required to practice as an anesthetist only as an extender for an anesthesiologist and could not provide anesthesia care at the direction of a physician of any other specialty.
Although both are considered to be equivalent clinical non-physician anesthesia providers and may serve as physician extenders in the delivery of anesthesia, AAs and NAs are very different with regard to their educational background, training pathway and certification process.
The professional organization for AAs is the American Academy of Anesthesiologist Assistants (AAAA). AAAA was founded in 1975 and serves the various educational, advocacy and national organizational needs of the AA profession. Their website may be found at: www.anesthetist.org.
AAs and AA students, as well as NAs and NA students, are eligible for ASA membership. They join under the category of "Educational Members" and are entitled to all of the educational benefits of ASA memberships, including free registration at the ASA Annual Meeting and a subscription to Anesthesiology.
Educational members are nonvoting members and cannot run for office. However at the invitation of the President, AAs can and do serve on committees and attend Reference Committee and House of Delegates meetings. Dues for Educational Members are currently the same as for Affiliate Members. Applications for membership may be obtained from the ASA website.
Education & Certification
As of January, 2008, there are 8 accredited AA educational programs.
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.
The Commission on Accreditation of Allied Health Education Programs (CAAHEP) accredits AA training programs. ASA is a CAAHEP member and participates in the accreditation processes for three health professions - anesthesiologist assistant, respiratory therapy and emergency medical technician-paramedic. CAAHEP is the largest accreditor in the health sciences field. In collaboration with its Committees on Accreditation, CAAHEP reviews and accredits over 2000 educational programs in nineteen (19) health science occupations. CAAHEP is recognized by the Council for Higher Education Accreditation (CHEA).
CAAHEP re-approved the "Standards and Guidelines for Anesthesiologist Assistant Education" most recently in 2009. These standards are composed and submitted by the Accreditation Review Committee on Education for the Anesthesiologist Assistant (ARC-AA). ARC-AA in turn is composed of representatives from the American Academy of Anesthesiologist Assistants (AAAA), and the American Society of Anesthesiologists (ASA). Anesthesiologists from ASA work along with AA representatives from AAAA to define the educational process that produces a competent AA graduate. This partnership of professional organizations has ensured an integral role for anesthesiologists in AA education. This in turn echoes the anesthesiologist / AA relationship in the anesthesia care team.
Additional information on accreditation may be found at the CAAHEP website. www.caahep.org/arc-aa
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.
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:
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.
The National Commission for Certification of Anesthesiologist Assistants (NCCAA) was founded in July 1989 to develop and administer the certification process for AAs in the United States. The NCCAA consists of Commissioners representing ASA, AAAA, and at-large physician and AA members.
Graduates or senior students in their last semester in an AA educational program that has been accredited by CAAHEP may apply for initial certification. Initial certification is awarded to an AA who has successfully completed the Certifying Examination for Anesthesiologist Assistants administered by NCCAA in collaboration with the National Board of Medical Examiners (NBME). Certified AAs are permitted to use the designation AA-C to indicate that they are currently certified.
The content for the Certifying Examination for Anesthesiologist Assistants is based on knowledge and skills required for anesthetist practice. NCCAA has contracted with NBME to serve as a consultant for the development and ongoing administration of the Certifying Examination. A Test Committee of anesthesiologists and AAs is responsible for writing and evaluating test questions for the examinations. The first Certifying Examination was administered in 1992.
NCCAA maintains a database of Anesthesiologist Assistants-Certified from which certification of individual practitioners can be verified. Hospitals, practice groups, state boards, and others can verify an AA.s certification, including a printed verification statement, by going to the Verify Certification page of NCCAA's web site, www.aa-nccaa.org.
The web site also contains additional information about the National Commission and about the certification process.
AAs are granted a time-limited certificate after passing the initial examination. The ongoing process or recertification requires that AAs submit documentation to NCCAA every two years that they have completed 40 hours of continuing medical education (CME). In addition, every six years they must pass the Examination for Continued Demonstration of Qualifications (CDQ). This ongoing certification cycle is depicted below.
NCCAA Certification Process
The CDQ Examination was first administered in 1998, making AAs the first anesthesia profession to require passage of a written examination as part of the recertification process. Failure to meet any of the above CME or examination requirements results in withdrawal of certification for the AA.
According to the ASA statement on the Anesthesia Care Team, anesthesia care personally performed or medically directed by an anesthesiologist constitutes the practice of medicine. Certain aspects of anesthesia care may be delegated to other properly trained and credentialed professionals. These professionals, medically directed by the anesthesiologist, comprise the Anesthesia Care Team.
The Care Team statement (last amended on October 21,2009) says,
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 at: www.asahq.org/publicationsAndServices/standards/16.html.
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: www.asahq.org/clinical/crnaaascope.pdf
Specifically, the local scope of practice of AAs is usually defined by
States may also require a practice agreement between the sponsoring anesthesiologist and the AAs who are medically directed.
The specific job descriptions and duties of AAs may differ according to local practice. State law or board of medicine regulations or guidelines may further define the job descriptions of AAs. The constant ingredient no matter what the local variation is that AAs always practice under the medical direction of a qualified anesthesiologist.
As part of defining the educational goal of AA training programs, the CAAHEP accreditation Standards include a template AA job description. The excerpt is included below. Wherever the term 'assisting' occurs, it is understood that such assistance may be actual performance of the stated task by the AA as part of duties directed by the supervising anesthesiologist.
The complete Standards for Accreditation of Anesthesiologist Assistant Education is available from CAAHEP at AA Standards.
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.
ASA policy on the performance of regional anesthesia by non-physicians is found in the ASA Statement on Regional Anesthesia and can be read in its entirety at: www.asahq.org/publicationsAndServices/standards/26.pdf
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.
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. To get the latest and most accurate information, please contact your state board of medicine or the ASA Washington Office for any questions on the licensure and practice locations of AAs.
Another excellent resource is maintained by the American Academy of Anesthesiologist Assistants (AAAA). A list of states where AAs currently practice may be obtained by contacting AAAA at their website.
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.
Practice Management of AAs
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.
Also, the American Academy of Anesthesiologist Assistants is a valuable resource on suggested methods of licensing and establishing practice of AAs drawn from various states. You can contact AAAA at: www.anesthetist.org
Finally, you can also contact the educational programs directly as listed in FAQ #7 above.
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.
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)
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.
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