n 1960, the ASA Committee on Anesthesia Care Team (CACT) was born from the vision of then ASA President John J. Bonica, M.D. He conceptualized the need for a focused group of representatives to address issues involving nonanesthesiologists who participate in the care of our patients. As the “care team” mode of delivery has matured to include not only nurse anesthetists but also anesthesiologist assistants (AAs), his astuteness has stood the test of time! Years later, in its annual report to the 1982 ASA House of Delegates (HOD), the CACT said, “There appear to be questions among both ASA members and others about what an Anesthesia Care Team (ACT) is, what it is supposed to do, and why the concept has worth.” Along with that report, they submitted the first statement on the ACT aimed at addressing these matters. As a specialty, we continue to suffer from that same lack of understanding and awareness not only among those outside of our specialty but regrettably also among ourselves. While our practice climate has changed dramatically, the original 1982 statement on the ACT changed little — until now. Previous committee Chair Arthur M. Boudreaux, M.D., provided leadership to initiate the two years of diligent work required to achieve HOD approval of this significantly revised statement.

The potential audience of this crucial communication tool is broad-based and includes anesthesiologists, physician residents and fellows, AAs, nurse anesthetists, patients, payers, policymakers, regulators, legislators, the media and the general public. Careful consideration of this diverse audience guided both the content and wording of the new statement. The goal was to draft a declaration that would successfully impart to others who anesthesiologists are and how we currently practice, particularly our scientific and clinical leadership of the ACT.

The new statement defines the medical specialty of anesthesiology, what constitutes the practice of medicine within the ACT, anesthesia care team practice, to whom care may be delegated and specific duties of a medically directing anesthesiologist. The statement especially addresses particular areas of confusion such as exceptions to the ACT and the distinction between the billing terms “medical direction” and “supervision.” In anticipation of confusion caused by other relevant groups, we included the shared obligation of all anesthesia providers to accurately disclose and convey to patients their title and level of training.

Several items generated very lively debate during the development of the new document. Payer rules were moved from the main body of the statement to an addendum in order to avoid the implication that payers’ rules somehow define quality care. Immediately following the payer rules, an important paragraph was added to address the inaccurate interpretation that failure of an anesthesiologist to comply at all times with common payer rules equates to substandard medical care. That paragraph conveys the fact that anesthesiologists must consider collectively all patients simultaneously under their care and prioritize concurrent care needs in order to provide the highest quality of care and greatest safety, as opposed to blind adherence to predetermined actions that does not take into consideration an infinite number of rapidly changing clinical situations. The new language clearly states that an anesthesiologist practicing in the care team may, in uncommon circumstances, actually improve the overall quality of care delivered by not complying with all payer rules at a particular point in time. While misunderstood by both commercial and governmental payers, it is critical that we communicate and elucidate this concept if we intend to help redesign payer rules that make sense in the real world and that support sound clinical practice.

Another contentious yet important item was the inclusion of a paragraph addressing the provision of anesthesia care in the absence of an anesthesiologist. To more clearly define the ACT, we also included what situations are not the ACT. While anesthesia provision without an anesthesiologist is not the ACT, failure to address the issue in this document would ignore a great opportunity to improve understanding about anesthesia practice in the minds of those within our intended audience. Supporting surgeon assumption of medical responsibilities in the absence of an anesthesiologist, we outline why caution should be exercised in our absence. Addressing surgeon supervision in a manner that points out its shortcomings while also clearly stating its benefits will aid in the ASA’s ongoing challenges in this era of opt-outs. Several state societies fighting opt-out battles confirmed the potential value of this section of the statement.

The most challenging question raised was how to define “qualified anesthesia personnel.” ASA already has a published monitoring standard stating, but not defining, that “qualified anesthesia personnel must remain in the O.R. throughout every anesthetic.” The committee’s proposed definition was eventually deleted from the statement because testimony in the reference committee revealed the complexity of the issue, the diversity of opinion and the need for broad input in order to achieve consensus. Superficially it seems easy to define, but realize that this definition has far-reaching implications when considering who should and should not be left alone in the operating room (O.R.) to monitor patients during anesthetics. The heart of the controversy is whether nonphysician students (AA, nurse anesthetist and medical students) and perfusionists may be left alone in the O.R. during anesthetics. Aware that patient safety, staffing, training, finances and politics within and outside of ASA are all facets of this issue worthy of meticulous consideration, the CACT is soliciting nationwide input prior to drafting a HOD-requested stand-alone statement focused on the topic. If you are interested in offering your opinions on this topic, contact your state component society leaders immediately and make your views known.

The members of the CACT deserve recognition and thanks for their contributions to the newly revised “Statement on the Anesthesia Care Team.” All ASA members are encouraged to read the statement in its entirety, which is located at www.ASAhq.org/publicationsAndServices/ standards/16.pdf.

Jeffrey S. Plagenhoef, M.D., is ASA Director for Alabama, and President, Medical Staff, Southeast Alabama Medical Center, Dothan, Alabama.