Anesthesia is the use of medicines to prevent patients from feeling pain during health care procedures such as dental procedures, some screening and diagnostic procedures, and surgery. The medicines, known as anesthetics, may be administered by injection, inhalation, topical lotion, spray, eye drops, or skin patch. Anesthesia may be local anesthesia for a small part of the body, regional anesthesia for larger areas of the body where the patient may either be awake or sedated during the procedure, or general anesthesia which affects the whole body and the patient is unconscious and unable to move.
According to a Department of Health sunrise review from 2021, there are three primary health professions in Washington that may perform anesthesia on a general basis within their scopes of practice: physicians, advanced registered nurse practitioners, and physician assistants. For each of these professions, additional certifications and training may be required to perform certain types of anesthesia. In addition, in the context of dental procedures, dentists and dental anesthesia assistants may perform anesthesia within the limits of rules adopted by the Dental Quality Assurance Commission.
The sunrise review analyzed a proposal to license anesthesiologist assistants as a new health profession in Washington. The sunrise review found that the unregulated practice of anesthesiology can harm the public, the public can benefit from an assurance of professional ability, and the public cannot be protected by other, more cost-beneficial means, and, therefore, recommended in favor of the proposal with recommendations to assure public safety.
Anesthesiologist assistants are established as a new health profession licensed by the Washington Medical Commission (Commission). The requirements to become an anesthesiologist assistant include: (1) completing an anesthesiologist assistant program accredited by the Commission on Accreditation of Allied Health Education Programs; (2) successfully completing an examination within one year of completing the education program; (3) submitting proof of physical and mental capacity to practice, and (4) paying any required fees.
Anesthesiologist assistants may assist in developing and implementing anesthesia care plans for patients under the supervision of anesthesiologists who have been approved by the Commission to supervise an anesthesiologist assistant. The term "assist" is defined as performing responsibilities delegated by the anesthesiologist. The term "supervision" means the immediate availability of the medically directing anesthesiologist for consultation and direction of the anesthesiologist assistant's activities. Medically directing anesthesiologists are considered to be immediately available if they are in physical proximity that allows the anesthesiologist to reestablish direct contact with the patient to meet medical needs and any urgent or emergent clinical problems, and personally participating in the most demanding procedures, including inductions and emergence.
An anesthesiologist assistant may provide assistance according to responsibilities delegated by a supervising anesthesiologist as consistent with the anesthesiologist assistant's education, training, and experience. An anesthesiologist assistant may not exceed the scope of the supervising anesthesiologist's practice. Anesthesiologist assistants may access and obtain drugs as directed by the supervising anesthesiologist. Anesthesiologist assistants may not prescribe, order, compound, or dispense drugs, medications, or devices. These responsibilities may include:
The Commission must adopt rules regarding the practice by and supervision of anesthesiologist assistants, including the number of anesthesiologist assistants that an anesthesiologist may supervise. Unless the Commission approves, a physician may not supervise more than four specific, individual anesthesiologist assistants at any one time.
The supervising anesthesiologist and anesthesiologist assistant are responsible for actions that constitute the practice of medicine. Anesthesiologist assistants are subject to the Uniform Disciplinary Act and the Commission is the disciplining authority in any case of unprofessional conduct.
The amended bill requires the medically directing anesthesiologist to personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence. The responsibilities of supervision may be met through coordination among anesthesiologists of the same group or department.
The amended bill adds to the definition of an "anesthesiologist" that they must be an actively practicing, board-eligible physician.
The amended bill eliminates the issuance of a temporary license for persons who have completed an anesthesiologist assistant program, but not passed a certification examination.
The amended bill prohibits anesthesiologist assistants from exceeding the scope of the supervising anesthesiologist's practice. An anesthesiologist assistant's authority to order oxygen therapy and respiratory therapy is removed. An anesthesiologist assistant's authority to obtain informed consent for anesthesia and related procedures is removed. Anesthesiologist assistants may maintain and manage neuraxial epidurals, rather than assist with epidurals. An anesthesiologist assistant's authority to establish central lines is removed. Anesthesiologist assistants are prohibited from prescribing, ordering, compounding, or dispensing drugs, medications, or devices.
The amended bill corrects references to physicians, so they apply to anesthesiologists. Statutes are updated to reflect changes made in the previous legislative session.
(In support) The anesthesia shortage is well documented in Washington and across the country and anesthesiologist assistants are safely and cost-effectively working to address this shortage in 22 other jurisdictions. The data show exceptionally long vacancies for nurse anesthesia positions in hospitals. This shortage is causing the cancellation of elective procedures, some of which can become necessary procedures unless they are addressed early. This bill attempts to make sure that constituents can get the care that they need when they need it. Licensing anesthesiologist assistants would be a win for patients by expanding the health care workforce with proven, trained anesthesia providers that can fill these open positions for which there are not enough certified registered nurse anesthetists. Anesthesiologist assistants in Washington must travel out-of-state in order to work even though there are many open positions in-state and this affects patients in Washington who face increased wait times for surgery.
There have not been any data showing an impact on certified registered nurse anesthetists if anesthesiologist assistants are licensed. The five states with most certified registered nurse anesthetists also license anesthesiologist assistants. Approving this bill will not force a practice or hospital to hire a particular provider but give them an opportunity to tap into this currently unavailable pool, so it will not take jobs away from current residents. The sunrise review recommended licensure and the recommended changes were discussed and accommodated in this bill.
(Opposed) There are many safety concerns with the recommendations in the sunrise review. This bill does not follow the recommendation to narrow the scope of practice to match other states regarding ordering medications, assisting rather than performing invasive regional techniques, performing procedures to place lines into large arteries and veins, and respiratory therapy and oxygen. The bill allows anesthesiologist assistants to practice for an entire year before passing their certifying examination or showing basic competency.
This bill does not solve the access issue, especially in rural areas where certified registered nurse anesthetists are the sole providers and are unable to supervise anesthesiologist assistants. The introduction of anesthesiologist assistants has decreased access to care. The trend in states where anesthesiologist assistants have been introduced shows a swift decline in physician anesthesiologists, followed by anesthesiologist assistants' decline because they must be supervised by physicians. This is not a sustainable model. Adding anesthesiologist assistants does not increase a team's numbers, but exchanges providers which leads to costly anesthesia models and anticompetitive markets. In sites where anesthesiologist assistants are used, certified registered nurse anesthetists (CRNA) feel like they have been pushed out. The solution to anesthesia care is CRNAs, but the barriers to clinical sites and training for CRNAs are so significant that not enough independent providers are ready to fill the gaps. Certified registered nurse anesthetists provide interventional pain management and anesthesiologist assistants cannot work in these settings.
(Other) This is not included in the Governor's budget, but the Washington Medical Commission is capable of implementing this new license without concerns. The proposal accurately reflects the Department of Health's sunrise review recommendations. There are no safety concerns with the bill. The potential for increased service access and market competition is a benefit to patients. In a time of shortage, the creation of a profession should not be delayed for a multiyear study.
This proposal will not increase access to rural services without the completion of a thorough workforce study. The addition of a dependent provider alone will not address surgical delays, nor increase access to rural areas. Certified registered nurse anesthetists provide 88 percent of anesthesia services in rural critical access hospitals. The introduction of anesthesiologist assistants would not add to these services since they cannot work independently of an anesthesiologist.
(In support) Senator Ann Rivers, prime sponsor; Tim Clement and Amy Brackenbury, Washington State Society of Anesthesiologists; Carolyn Logue, Washington Academy of Anesthesiologist Assistants; Patrick Hession; and Sarah Brown.
None.