​Statement on the Anesthesia Care Team

Developed By: Committee on Anesthesia Care Team
Last Amended: October 18, 2023 (original approval: October 26, 1982)

Anesthesiology is the practice of medicine. It includes, but is not limited to providing medical care to a patient before, during, and after a surgical, diagnostic, or therapeutic procedure which requires the administration of anesthetics and/or hemodynamic monitoring, regardless of patient or procedural complexity, as well as managing of systems and leading of clinicians that support these activities.¹ More specifically, anesthetic management includes the preoperative evaluation, diagnostic workup, optimization of preexisting medical conditions prior in preparation for surgery, the decision to proceed with surgery, the prescribing of anesthetic care plans, the perioperative management of coexisting disease, the delivery of anesthetics, determination and management of postoperative care requirements, the prevention and management of periprocedural complications, the practice of acute and chronic pain medicine, and the practice of critical care medicine. This care can only be personally provided, directed, or supervised by the physician anesthesiologist. Any anesthetic which is administered without physician anesthesiologist oversight as described in this document, falls outside of the Anesthesia Care Team model.

The American Society of Anesthesiologists (ASA) believes that all patients deserve their perioperative care to be led by a physician anesthesiologist. The World Health Organization and World Federation of Societies of Anaesthesiologists (WHO-WFSA) agree the physician anesthesiologist should lead all anesthetic care whenever and wherever possible.² Currently, most anesthesia care is provided either personally by a physician anesthesiologist or by a non-physician anesthesia clinician led by a physician anesthesiologist within the Anesthesia Care Team (ACT) model. Physician anesthesiologists are responsible for the determination and delegation of anesthesia delivery, monitoring, and appropriate tasks to qualified non-physician members of the ACT. Such delegation is determined specifically by the physician anesthesiologist and must be consistent with respective state law and regulations, institutional medical staff policy and bylaws. Although selected tasks may be delegated to qualified members of the ACT, overall responsibility for the team’s actions and patient safety ultimately rests with the physician anesthesiologist. For more information, please view the ASA Statement on Physician-Led Care.

Definitions

1. Composition and roles of the Anesthesia Care Team

   The composition of the Anesthesia Care Team may include physicians and non-physicians led by a physician anesthesiologist. All members of the ACT are expected to accurately represent and identify themselves to patients and their families. Misleading titles that misrepresent educational degree, licensure, certification, and expertise of clinicians must be avoided to ensure transparency with patients.  Physician anesthesiologists have a responsibility to ensure the adequate representation of the Anesthesia Care Team members.  The nomenclature below is appropriate terminology for this purpose.

   1. Physician Anesthesia Care Team members
      

      PHYSICIAN ANESTHESIOLOGIST: Director / Leader of the Anesthesia Care Team is the physician trained and licensed to practice medicine, and is subject matter expert in the practice of anesthesiology. The physician anesthesiologist has successfully completed a training program in anesthesiology accredited by the ACGME, the American Osteopathic Association or equivalent physician organizations.

      PHYSICIAN ANESTHESIOLOGIST FELLOW: A physician anesthesiologist enrolled in an approved anesthesiology fellowship subspecialty program, who has already completed a training program in anesthesiology accredited by the ACGME, the American Osteopathic Association or equivalent physician organizations.

      PHYSICIAN ANESTHESIOLOGIST RESIDENT: A physician enrolled in an ACGME accredited anesthesiology residency program.

   2. Non-physician Anesthesia Care Team members

      ANESTHETIST*: The name "anesthetist" in the U.S. refers to a nurse anesthetist or anesthesiologist assistant, as defined below. For further information, please refer to the ASA Statement on Comparing Certified Anesthesiologist Assistant and Certified Registered Nurse Anesthetist Education and Practice and ASA Statement on Students Involved in Anesthesia Care.  
      
      (Note: In some countries, a physician who practices anesthesiology is known as an “anaesthetist” or “anesthetist”.)

      NURSE ANESTHETIST: A registered nurse who has successfully completed an accredited nurse anesthesia training program, and graduated from an approved nursing school (also known as “CRNA”). 

      ANESTHESIOLOGIST ASSISTANT: A health professional who has successfully completed an accredited anesthesiologist assistant master’s degree training program, after graduation from an approved baccalaureate degree program with completion of all premedical coursework required for admission to an AAMC approved medical school (also known as “CAA”). (For further information, please refer to the ASA Statement on Certified Anesthesiologist Assistants (CAAs): Description and Practice. 



2. Additional Terms
   

   ANESTHESIA CARE TEAM: Physician anesthesiologists are responsible for leading anesthesia care administered by qualified members of the ACT. Such delegation must be consistent with local, state, and federal laws, regulations, policies, and bylaws and meet the ASA Guidelines for the Ethical Practice of Anesthesiology. Ultimate responsibility for the team’s actions and patient's safety rests with the physician anesthesiologist.

   DIRECTING VS. SUPERVISING CARE. In the ACT, the physician anesthesiologist’s involvement in the care varies when the physician anesthesiologist “directs'' or “supervises” care. When he/she directs care, the physician anesthesiologist has substantially more direct involvement with the care provided than when supervising. At a minimum, to meet the ASA Guidelines for the Ethical Practice of Anesthesiology, in both situations, a physician anesthesiologist must perform the pre-anesthesia evaluation, medical determination for patient to proceed with procedure, prescribing of anesthetic plan for periprocedural care, and manage post-anesthesia care.

   ANESTHETIZING SITE: An operating room or other location where a surgical, diagnostic, or therapeutic procedure is performed under anesthesia care.

   IMMEDIATELY AVAILABLE: Wherever it appears in this document, the phrase “immediately available” is used as defined in the ASA Statement on Definition of Immediately Available When Medically Directing.

Safe Conduct of the Anesthesia Care Team
The physician anesthesiologist who directs the ACT is responsible for the following:

1. Preanesthetic evaluation, work up, optimization, and decision to proceed: A preanesthetic evaluation considers a patient’s current condition, co-existing diseases, risks associated with undergoing anesthesia for the procedure, need for optimization, and postoperative care requirements. Although non-physicians may contribute to the preoperative collection and documentation of patient data, the physician anesthesiologist is ultimately responsible for the results of the preoperative evaluation including, but not limited to, determining the need for further diagnostic testing and workup, and deciding whether to proceed with the scheduled procedure.
2. Prescribing the anesthetic plan: The physician anesthesiologist is responsible for prescribing an anesthetic plan designed for the greatest safety and highest quality of care for each patient. The physician anesthesiologist discusses with the patient or guardian, as appropriate, the anesthetic risks, benefits and alternatives, and obtains informed consent. When part of the anesthetic care will be performed by another qualified anesthesia practitioner, the physician anesthesiologist informs the patient or guardian that delegation of anesthetic duties is included in care provided by the ACT.
3. Management of the anesthetic: The management of a prescribed anesthetic plan is dependent on many factors including the current medical condition of the patient, their comorbidities, associated risk factors, and the risk of the procedure being performed. Physician anesthesiologists are responsible for delegating periprocedural tasks, if any, to qualified members of the ACT. If delegating, the physician anesthesiologist must ensure that quality of care and patient safety are not compromised, participate in critical parts of the anesthetic, and remain immediately available for management of emergencies. 
4. Post anesthesia care: Physician anesthesiologists determine, coordinate, and oversee the postoperative care requirements for patients undergoing procedures requiring anesthesia.  Any acute postoperative events or complications which occur in the post-anesthesia recovery-care unit are medically supervised by the physician anesthesiologist. 
5. Anesthesiology consultation: Comparable to other forms of medical consultation, the anesthesiology consultation is the practice of medicine and may not be delegated to non-physicians.
6. Management of personnel: Physician anesthesiologists ensure the assignment and delegation of tasks of clinicians for each patient and procedure.

References:

1. https://www.theaba.org/wp-content/uploads/pdfs/Policy_Book.pdf
2. Gelb, A.W., Morriss, W.W., Johnson, W. et al. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Can J Anesth/J Can Anesth 65, 698–708 (2018). https://doi.org/10.1007/s12630-018-1111-5

APPENDIX A:

What is NOT the Anesthesia Care Team model?

In the ASA Statement on the Anesthesia Care Team (ACT), the anesthesiologist must perform specific activities in order to meet the definitions of providing physician-led anesthesia care in an Anesthesia Care Team model. When the anesthesiologist is not able to perform these activities, then the anesthesia care is not being provided in an Anesthesia Care Team model or acceptable under the ASA Guidelines for Ethical Practice of Anesthesiology. 

Despite this explicit understanding, proponents of alternative anesthesia staffing models have used terminology, e.g., “Anesthesia Team” or “Collaborative Anesthesia Team (CAT)”, to confound how anesthesia care is provided. For this reason, some examples of what is NOT Anesthesia Care Team model are provided to illustrate how these models do not meet the definition. The following is not an exhaustive list. 

1. Physician Anesthesiologist does not perform pre-anesthesia evaluation and plan. If the staffing model results in the physician anesthesiologist unable to see, evaluate, and facilitate the informed decision-making, then the staffing model is not Anesthesia Care Team. This may be a result of the physician anesthesiologist being assigned to a high number of anesthetizing sites and/or the physician anesthesiologist is not physically available to do the evaluation due to other duties. 
2. Physician Anesthesiologist is not able to participate in critical parts of the anesthetic nor immediately available. If staffing model is created where the physician anesthesiologist is not able to fulfill both these duties to the patient undergoing anesthesia care, then the staffing model is not Anesthesia Care Team. This may occur when the “responsible anesthesiologist” is not present in the facility or is simultaneously assigned to personally provide anesthesia care. 
3. Physician Anesthesiologist’s only duty to the patient is to “rescue” the nurse anesthetist in emergencies. In this staffing model, the physician anesthesiologist is a “rescue-ologist” and does not perform a pre-anesthesia evaluation and/or does not participate in critical portions of the anesthesia care. 
4. Physician Anesthesiologist is supervising anesthesia students without any other qualified anesthesia clinician with the student. Physician anesthesiologists who teach non-physician anesthesia students are dedicated to their education and to providing optimal safety and quality of care to every patient. The ASA Standards for Basic Anesthetic Monitoring define the minimum conditions necessary for the safe conduct of anesthesia. The first standard states, “Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care.” By definition, non-physician anesthesia students are not yet fully “qualified anesthesia personnel”, and must be supervised to a greater degree than fully credentialed anesthesiologist assistants or nurse anesthetists. Therefore, the use of students in place of qualified personnel or practitioners is inappropriate as well as inconsistent with the ASA Guidelines for the Ethical Practice of Anesthesiology. Please see Statement on Students Involved in Anesthesia Care.
5. A non-Anesthesiologist Physician supervising anesthesia care by a nurse anesthetist. By definition, Anesthesia Care Team requires a physician anesthesiologist leading the care, so this type of staffing is not Anesthesia Care Team. All types of anesthesia carry risks. Non-anesthesiologist physicians lack the expertise that uniquely qualifies and enables physician anesthesiologists to manage the challenging airway and other complications that could occur during the perioperative period. While some surgical training programs (such as oral and maxillofacial surgery) provide anesthesia-specific education, non-anesthesiology programs cannot prepare their graduates to provide a board-certified physician anesthesiologist’s level of expertise.
   
   Medical, anesthetic, and surgical complications may arise unexpectedly and require immediate medical diagnosis and treatment. In the circumstance when a physician anesthesiologist is not part of the care team, the proceduralist (surgeon, obstetrician, gastroenterologist, or cardiologist, for example) may be the only physician on site. In such cases, the physician, as the most highly trained medical professional, should direct patient care, including nurse anesthesia care. Careful consideration is required whenever a non-anesthesiologist physician will be the only physician available, as in some small hospitals, freestanding surgery centers, and offices. In the event of an emergency, lack of immediate support from other physicians trained in the management of critical events may reduce the likelihood of successful resuscitation.