The Washington Medical Commission (WMC) currently regulates licenses for physician assistants, physicians, and surgeons in Washington State. WMC establishes, monitors, and enforces qualifications for licensure, consistent standards of practice and continuing competency.
 
All health professions are subject to the Uniform Disciplinary Act (UDA). Under the UDA, WMC may take disciplinary action against a licensed health professional for unprofessional conduct. Disciplining actions include fines, license revocations, and practice restrictions.
 
Anesthesiologist assistants are individuals qualified to provide anesthetic care under the direction and supervision of an anesthesiologist as part of an anesthesia care team. Anesthesiologist assistants cannot work in Washington because the scope of practice requires a health care license to perform. In December 2021, the Department of Health (DOH) issued a sunrise review related to a proposal to license anesthesiologist assistants. In the review, DOH found the proposal to meet the sunrise criteria to demonstrate it protects the public from harm, ensures adequate education and training, and is the most cost-effective option. DOH recommended in favor of the proposal if the suggested changes to increase patient safety are addressed. DOH recommended the following changes:

• clarify the definition of supervision to ensure the supervising anesthesiologist is present during induction or emergence from general anesthesia and is readily available for emergencies;
• narrow the scope of practice to match other states that license anesthesiologist assistants;
• replace language regarding the supervision ratio and instead require WMC to work with stakeholders to set the supervision ratio limitation; and
• remove the advisory committee because WMC already has mechanisms in place and the expertise to regulate this profession.

A license is created for anesthesiologist assistants in Washington and establishes it as a new health profession to be regulated by WMC.

To receive a license as an anesthesiologist assistant, an applicant must:

• pay a fee;
• file an application detailing their education, training, and experience;
• have completed an anesthesiologist assistant program accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP), or successor organization; and within one year of completing the program, pass an examination administered by the National Commission for the Certification of Anesthesiologist Assistants (NCCAA), or other examination approved by WMC; and
• be physically and mentally capable of practicing as an anesthesiologist assistant with reasonable skill and safety.

Anesthesiologist assistants may practice medicine and assist in developing and implementing anesthesia care plans for patients under the supervision of an anesthesiologist or group of anesthesiologists approved by WMC to supervise such assistants.

"Supervision" means the immediate availability of the medically directing anesthesiologist for consultation and direction of the activities of the anesthesiologist assistant.  A medically directing anesthesiologist is 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.
 
Duties and Responsibilities.  Anesthesiologist assistants may perform certain duties and responsibilities delegated by the supervising anesthesiologist.  Those duties include, but are not limited to:

• assisting with preoperative anesthetic evaluations, postoperative anesthetic evaluations, and patient progress notes, all to be cosigned by the supervising physician within 24 hours;
• administering and assisting with preoperative consultations;
• under the supervising physician's consultation and direction, order perioperative pharmaceutical agents, medications, fluids, oxygen therapy, to be used only at the facility where ordered, including, but not limited to, controlled substances, which may be administered prior to the supervising physician's cosignature;
• changing or discontinuing a medical treatment plan after consultation with the supervising physician;
• obtaining informed consent for anesthesia or related procedures;
• calibrating anesthesia delivery systems and obtaining and interpreting information from the systems and monitors, in consultation with an anesthesiologist;
• assisting the supervising anesthesiologist with the implementation of medically accepted monitoring techniques;
• assisting with the basic and advanced airway interventions including, but not limited to, endotracheal intubation, laryngeal mask insertion, and other advanced airways techniques;
• establishing peripheral intravenous lines as well as radial and dorsalis pedis arterial lines and central lines;
• assisting with general anesthesia, which includes induction, maintenance, emergence, and procedures associated with general anesthesia such as, but not limited to, gastric intubation;
• administering intermittent vasoactive drugs and starting and titrating vasoactive infusions for the treatment of patient responses to anesthesia;
• assisting with epidural, spinal, and intravenous regional anesthesia;
• maintaining and managing established neuraxial and regional anesthesia;
• assisting with monitored anesthesia care;
• evaluating and managing patient controlled analgesia, epidural catheters, and peripheral nerve catheters;
• obtaining venous and arterial blood samples;
• assisting with, ordering and interpreting appropriate preoperative, point of care, intraoperative, or postoperative diagnostic tests or procedures as authorized by the supervising anesthesiologist;
• obtaining and administering perioperative anesthesia and related pharmaceutical agents, including intravenous fluids and blood products;
• participating in management of the patient while in the preoperative suite and recovery area;
• providing assistance to a cardiopulmonary resuscitation team in response to a life-threatening situation;
• participating in administrative, research, and clinical teaching activities authorized by the supervising anesthesiologist; and
• assisting with other tasks not prohibited by law under the supervision of a licensed anesthesiologist that an anesthesiologist assistant has been trained and is proficient to assist with.

 
An anesthesiologist assistant may sign and attest to any certificates, cards, forms, or other required documentation that the anesthesiologist assistant's supervising anesthesiologist may sign, if it is within the anesthesiologist assistant's scope of practice.
 
A person may not practice as an anesthesiologist assistant or use the title certified anesthesiologist assistant (CAA) or anesthesiologist assistant (AA), if the person does not have a license granted by WMC.
 
Anesthesiologist assistants are subject to the UDA. WMC must consult with the board of osteopathic medicine and surgery when investigating allegations of unprofessional conduct against a licensee who has a supervising anesthesiologist.
 
Washington Medical Commission.  WMC must set:

• qualifications, educational, and training requirements for licensure, which includes completion of an anesthesiologist assistant program accredited by CAAHEP, or successor organization, and, within one year, passing the NCCAA examination or other examination approved by WMC;
• requirements for temporary licensure, which cannot be issued for longer than one year, for any applicant who successfully completes an anesthesiologist assistant program accredited by CAAHEP, but has not passed certification examination;
• requirements and limitations on the practice by and supervision of anesthesiologist assistants, including the number of anesthesiologist assistants an anesthesiologist may supervise concurrently, as a physician may not concurrently supervise more than four specific, individual anesthesiologist assistants at any one time; and
• rules for the arrangement of other anesthesiologists to serve as backup or on-call supervising anesthesiologist for multiple anesthesiologist assistants.

Supervising Anesthesiologists.  No anesthesiologist who supervises a licensed anesthesiologist assistant is considered aiding and abetting an unlicensed person to practice medicine in accordance with and within the terms of any permission granted by WMC.  The supervising anesthesiologist and anesthesiologist assistant shall retain professional and personal responsibility for any act which constitutes the practice of medicine when performed by the anesthesiologist assistant.

PRO: Anesthesiologist assistants in the state have to travel to other states to practice. This bill keeps jobs in Washington with qualified providers in Washington. This bill would offer a solution for limited hospital capacity by adding health care professionals into the workforce. Recognizing anesthesiologist assistants as a health profession in Washington would also not impair the CRNA practice in Washington, as CRNAs and anesthesiologist assistants can practice interchangeably.

CON: CRNAs are eager to address the perceived workforce concerns and are able to practice independently. The cost of care goes up for anesthesia care team model, and there is a delay in care because anesthesiologist assistants must be supervised.

OTHER: This bill could bring a competitive and disruptive culture between culture of anesthesiologist assistants and CRNAs working in the same environment.