Developed By: Committee on Anesthesia Care Team
Last Amended: October 17, 2018 (original approval: October 26, 1982)
Anesthesiology is the practice of medicine including, but not limited to, patient care before, during, and after surgery and other diagnostic and therapeutic procedures, and the management of systems and personnel that support these activities. The practice of anesthesiology includes the evaluation and optimization of preexisting medical conditions, the perioperative management of coexisting disease, the delivery of anesthesia and sedation, the management of postanesthetic recovery, the prevention and management of periprocedural complications, the practice of acute and chronic pain medicine, and the practice of critical care medicine. This care is personally provided, directed, and/or supervised by the physician anesthesiologist.
In the interests of patient safety and quality of care, the American Society of Anesthesiologists (ASA) believes that all patients deserve the involvement of a physician anesthesiologist in their perioperative care. In the U.S. today, most anesthesia care either is provided personally by a physician anesthesiologist, or is provided by a non-physician anesthesia practitioner directed by a physician anesthesiologist within the Anesthesia Care Team (ACT) model. The practice of anesthesiology includes the delegation of monitoring and appropriate tasks by the physician to non-physicians. Such delegation is defined specifically by the physician anesthesiologist and must be consistent with state law, state regulations, and medical staff policy. 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.
Core Members of the Anesthesia Care Team
The ACT includes physicians and non-physicians. All members of the team have an obligation to identify themselves and other team members accurately to patients and families. Physician anesthesiologists should not permit the misrepresentation of non-physician personnel as resident physicians or practicing physicians. The nomenclature below is appropriate terminology for this purpose.
ANESTHESIOLOGIST: Director of the Anesthesia Care Team; a physician licensed to practice medicine who has successfully completed a training program in anesthesiology accredited by the ACGME, the American Osteopathic Association or equivalent organizations.
ANESTHESIOLOGY FELLOW: An anesthesiologist enrolled in a training program to obtain additional education in one of the subdisciplines of anesthesiology.
ANESTHESIOLOGY RESIDENT: A physician enrolled in an accredited anesthesiology residency program.
ANESTHETIST: A nurse anesthetist or anesthesiologist assistant, as each is defined below. (Note: In some countries where non-physicians do not participate in the administration of anesthesia, a physician who practices anesthesiology is known as an “anaesthetist” or “anesthetist”)
NURSE ANESTHETIST: A registered nurse who has satisfactorily completed an accredited nurse anesthesia training program and certifying examination (also, “CRNA”).
ANESTHESIOLOGIST ASSISTANT: A health professional who has satisfactorily completed an accredited anesthesiologist assistant training program and certifying examination (also, “CAA”).
STUDENT NURSE ANESTHETIST: A registered nurse who is enrolled in an accredited nurse anesthesia training program (also, “SRNA”).
ANESTHESIOLOGIST ASSISTANT STUDENT: A health profession graduate student who has satisfied all prerequisite undergraduate coursework typically required for entry into an accredited school of medicine, and is enrolled in an accredited anesthesiologist assistant training program.
NON-PHYSICIAN ANESTHESIA STUDENT: Student nurse anesthetists, anesthesiologist assistant students, dental anesthesia students and others who are enrolled in accredited anesthesia training programs.
OTHERS: Although not considered core members of the ACT, other health care professionals make important contributions to the perioperative care of the patient (see Addendum A).
ANESTHESIA CARE TEAM: Care is led by a physician anesthesiologist who directs or supervises care of qualified anesthesia personnel and meets the ASA Guidelines for the Ethical Practice of Anesthesiology.
QUALIFIED ANESTHESIA PERSONNEL OR PRACTITIONERS: Physician anesthesiologists, anesthesiology fellows, physician residents, anesthesiologist assistants, and nurse anesthetists.
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 provide pre-anesthesia evaluation and care and appropriate post-anesthesia care.
PROCEDURE ROOM: An operating room or other location where an operation or diagnostic/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 policy statement “Definition of ‘Immediately Available’ When Medically Directing” (see Addendum B).
Safe Conduct of the Anesthesia Care Team
The physician anesthesiologist who directs the ACT is responsible for the following:
- Management of personnel: Anesthesiologists should assure the assignment of appropriately skilled physician and/or non-physician personnel for each patient and procedure.
- Preanesthetic evaluation of the patient: A preanesthetic evaluation allows for the development of an anesthetic plan that considers the patient’s current condition, co-existing diseases, and postoperative care requirements. Although non-physicians may contribute to the preoperative collection and documentation of patient data, the physician anesthesiologist should provide preoperative evaluation and care.
- Prescribing the anesthetic plan: The physician anesthesiologist should prescribe an anesthesia 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.
- Management of the anesthetic: The management of an anesthetic is dependent on many factors including the medical conditions of individual patients and the procedures being performed. Physician anesthesiologists determine which periprocedural tasks, if any, may be delegated. The physician anesthesiologist, who may delegate specific tasks to qualified members of the ACT, ensures that quality of care and patient safety are not compromised, participates in critical parts of the anesthetic, and remains immediately available for management of emergencies (see Addendum B).
- Postanesthesia care: Routine postanesthesia care is coordinated by a physician anesthesiologist and delegated to postanesthesia nurses under the medical supervision of a physician anesthesiologist. The physician anesthesiologist should provide appropriate postanesthetic care for their patients.
- Anesthesia consultation:Comparable to other forms of medical consultation, the anesthesiology consultation is the practice of medicine and may not be delegated to non-physicians.
THE FOLLOWING ARE NOT ANESTHESIA CARE TEAM
Medical Supervision of Nurse Anesthetists by Non-Anesthesiologist Physicians
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. However, surgeons and other procedural physicians contribute to patient safety and quality of care by assuming medical responsibility for perioperative care when a physician anesthesiologist is not present.
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. These circumstances should be considered when deciding which procedures should be performed in settings without a physician anesthesiologist, and which patients are appropriate candidates.
Medical Supervision of Non-Physician Anesthesia Students
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.
Students are not qualified anesthesia personnel. Therefore, the use of students in place of qualified personnel is inappropriate as well as inconsistent with the ASA Guidelines for the Ethical Practice of Anesthesiology.
- Other personnel involved in perianesthetic care:
POSTANESTHESIA NURSE: A registered nurse who cares for patients recovering from anesthesia.
PERIOPERATIVE NURSE: A registered nurse who cares for the patient in the procedure room.
CRITICAL CARE NURSE: A registered nurse who cares for patients in a special care area such as an intensive care unit.
OBSTETRIC NURSE: A registered nurse who provides care to patients during labor and delivery.
NEONATAL NURSE: A registered nurse who provides cares to neonates in special care units.
RESPIRATORY THERAPIST: An allied health professional who provides respiratory care to patients.
CARDIOVASCULAR PERFUSIONIST: An allied health professional who operates cardiopulmonary bypass machines.
- Support personnel for technical procedures, equipment, supply and maintenance:
ANESTHESIA TECHNOLOGISTS AND TECHNICIANS
BLOOD GAS TECHNICIANS
Definition of “Immediately Available” When Medically Directing
The ASA has established the definition of “immediately available when medically directing”, updated most recently by the House of Delegates in 2014. This policy states:
“A medically directing anesthesiologist is immediately available if s/he is in physical proximity that allows the anesthesiologist to re-establish direct contact with the patient to meet medical needs and any urgent or emergent clinical problems. These responsibilities may also be met through coordination among anesthesiologists of the same group or department.
“Differences in the design and size of various facilities make it impossible to define a universally applicable specific time or distance for physical proximity. The physical layout of the operating room and other anesthetizing locations are important in determining how medically directing anesthesiologists can fulfill the requirement to be immediately available.”