Health Professions. Health professions are registered, certified, or licensed by various disciplining authorities.  Some professions have their own boards and commissions as their disciplining authorities, such as the Washington Medical Commission (Commission) and the Board of Osteopathic Medicine and Surgery.  The disciplining authority for the remaining professions is the Department of Health (DOH).

All health professions are subject to the Uniform Disciplinary Act (UDA). Under the UDA, DOH or a professional board or commission investigates unprofessional conduct claims and may take disciplinary action against a licensed health care provider. Disciplining actions include fines, license revocations, and restrictions on practice.

Anesthesiologist Assistants. Anesthesiologist assistants (AAs) are authorized to practice under the direction and supervision of a licensed anesthesiologist within an Anesthesia Care Team Model. AAs are currently practicing in at least 15 states and throughout the country by working for the federal government. The U.S. Department of Veterans Affairs and the Department of Defense hires AAs to practice under the TRICARE program.

Sunrise Review. In 2021, DOH issued a sunrise review related to a proposal for AA licensure in Washington State and to assess if the licensure meets the sunrise criteria for creating a new regulated health profession. In the review, DOH found the proposal, with the recommended changes, meets the sunrise criteria to demonstrate it protects the public from harm, ensures adequate education and training, and is the most cost-effective option for this credential.

A license is created for AAs in the state and establishes AA as a new health profession in the state. An AA is a person who is licensed by the Commission to assist in developing and implementing anesthesia care plans for patients under the supervision of an anesthesiologist or group of anesthesiologists approved by the Commission to supervise such assistant.

AA Licensure Requirements. The Commission governs the licenses and registrations issued for AAs.  The Commission may approve, deny, or take other disciplinary action upon the application for a license. The Commission shall adopt rules fixing the qualifications and the education and training requirements for AA licensure that include:

• completion of an AA program accredited by the Commission on Accreditation of Allied Health Education Programs, or successor organization; and  
• within one year, successfully taking and passing a Commission-approved certification exam administered by the National Commission for the Certification of AAs or another Commission-approved exam.    

The Commission shall adopt rules for the issuance of a temporary AA license to any person who has completed the AA program but has not passed the certification exam. The temporary license issued may not exceed a one-year period and is subject to conditions determined by the Commission in rule.

To receive a license as an AA, an applicant must: file an application; pay a fee; complete an approved and accredited AA program and be eligible to take the examination; and be physically and mentally capable of practicing as an AA with reasonable skill and safety.

The UDA governs the issuance and denial of AA licenses and the discipline of AA licensees. The Commission shall consult with the board of Osteopathic Medicine and Surgery when investigating allegations of unprofessional conduct against a licensee who has a supervising licensed anesthesiologist.

No person shall practice as an AA or represent they are a certified anesthesiologist assistant, anesthesiologist assistant, C.A.A., or A.A. without licenses granted by the Commission.

Supervision of Anesthesiologist Assistants. The Commission shall adopt rules establishing the requirements and limitations on the practice by and supervision of AAs, including the number of AAs an anesthesiologist may supervise concurrently. Unless approved by the Commission, a physician may not concurrently supervise more than four specific, individual AAs at any one time.

The Commission may adopt rules for the arrangement of other anesthesiologists to serve as backup or on-call supervising anesthesiologists for multiple AAs.

No anesthesiologist who supervises a licensed AA in accordance with and within the terms permitted by the Commission is considered aiding and abetting an unlicensed person to practice medicine. The supervising anesthesiologist and AA retains professional and personal responsibility for any act that constitute as the practice of medicine when performed by the AA.

Supervision means the immediate availability of the medically directing anesthesiologist for consultation and direction of the activities of the AA. 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. An AA may assist with those duties and responsibilities delegated to them by the supervising anesthesiologist, and for which they are competent to assist with based on their education, training, and experience. 

Assists means the AA personally performs those duties and responsibilities delegated by the anesthesiologist. Delegated services must be consistent with the delegating physician's education, training, experience, and active practice. Delegated services must be of the type a reasonable and prudent physician would find within the scope of sound medical judgment to delegate.

An AA may sign and attest to any certificates, cards, forms, or other required documentation the AA's supervising anesthesiologist may sign, if it is within the AA's scope of practice.

Duties which an anesthesiologist may delegate to an AA 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, and respiratory therapy, to be used only at the facility where ordered, including but not limited to controlled substances, which may be administered prior to the cosignature of the supervising physician. The supervising physician may review and if required by the facility or institutional policy must cosign these orders in a timely manner;
• 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 basic and advanced airway interventions, including but not limited to endotracheal intubation, laryngeal mask insertion, and other advanced airways techniques;
• establishing peripheral intravenous lines, including subcutaneous lidocaine use;
• establishing radial and dorsalis pedis arterial lines and central lines;
• assisting with general anesthesia, including induction, maintenance, and emergence;
• assisting with 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 as authorized by the supervising anesthesiologist; and
• assisting with such 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.

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. 

PRO: Carolyn Logue, WA Academy of Anesthiologist Assistants; Sarah Brown, Certified Anesthesiology Assistant/President WA Academy of Anesthesiologist Assistants; Grier James, Certified Anesthesiologist Assistant; Cassie Gabriel, WSSA; Scott Wolf, WSSA; Erik Condon, WSSA; Amy Brackenbury, WSSA & WSMA; Stephanie Mason, Washington Medical Commission.

CON: Kelli Camp, Washington Association of Nurse Anesthetists; Adrianna Silva, Washington Association of Nurse Anesthetists; Ashley Fedan, Washington Association of Nurse Anesthetists; Brad Hemingway, Washington Association of Nurse Anesthetists; Robert Conroy, MD.

OTHER: Jonathan Alvarado, Nursing Care Quality Assurance Commission.

PRO: Mike Cioffi; Richard Evans, American Academy of Anesthesiologist Assistants; Shane Angus, Chair, Anesthesiologist Assistant Education Programs; Deborah Rusy, American Society of Anesthesilogists Rep to AAAA; Michael Robinson.

OTHER: Sherry Thomas, AVAILABLE FOR QUESTIONS Washington State Department of Health.

PRO: The need for Anesthesia providers is so great that many approaches will be needed and this is only one of them. There is not enough anesthesiologist to provide anesthesia services. Washington needs to do everything it can to attract all types of anesthesia providers to the state. This bill is narrowly about AA licensure. Certified AAs may be new to Washington but they've been licensed in the US since the 1970s. AAs are safe and qualified medical professionals that deliver compassionate, safe, and cost-effective anesthesia, while working with a physician anesthesiologist. AAs do not take away anesthesia provider jobs from other professions and they do not take away jobs from current residents. AAs fill a gap when patients are unable to receive what they need in a timely fashion because operating rooms are unable able to run due to staffing shortages. There are precious few healthcare resources, both human and dollars and it is incumbent upon legislators to make sure that both are allocated as wisely as possible. There is a need to collaborate with all anesthesia providers, including AAs. In other states, AAs work with anesthesiologists and CRNAs as a single care team to provide the best care for the patient and the community. This bill allows trained AAs to move to the state and help hospitals and surgery centers in the state to mitigate anesthesia workforce shortages. There are areas of this state where people who do not have access to some elective surgeries, which is an important part of healthcare. Hospitals use elective procedures to support other necessary work that they must do, and the staffing shortages limit the money that hospitals must have to be able to provide healthcare. This bill does not require the hiring of certified AAs but this gives hospitals an opportunity to hire from a currently unavailable pool of candidates. There is a need for all types of anesthesia providers and in the sunrise review, DOH recommended licensure and the review ensures that the state is maximizing resources available to ensure the best patient care. This bill is a right first step towards addressing anesthesia care workforce needs and bringing the maximum number of providers into the state. 

CON: There are two types of providers who provide safe anesthesia services in the state and both are licensed independent providers. The increase of a dependent provider would not decrease the delay of surgical care and it might be disruptive to the state's cohesive anesthesia workforce. This bill will not increase access to care and does not address the anesthesia workforce in a comprehensive way, which could be done with a workforce study. A more comprehensive bill is needed to also include an expansion and incentives for the nurse anesthetists education programs. Washington?s only nurse anesthesia program is limited to only 20 students due to restrictions limiting residents in training sites. This bill will reduce the training spots for nurse anesthesia residents. Since AAs are required supervision throughout their careers, the training spots would be better utilized to train independent providers like anesthesiology residents or nurse anesthesia residents. AA licensure without addressing more clinical sites for nurse anesthesia residents will create a bigger bottleneck in the anesthesia workforce. Different hospitals have different care models and AAs can only be used in the medical directed care model, where there is a limit on the number of people that a physician can supervise. Under this model, a physician anesthesiologist supervises the nurse anesthetist, which limits scope of practice for the nurse anesthetist. If CRNAs are allowed to operate at the height of their scope, more hospital operating rooms would open and more anesthesia could be completed overnight without AAs. To effectively address the anesthesia work force shortage, there is a need to leverage all the providers and increase efficiency and access to all practice care models. Since CRNAs cannot supervise AAs, there are health care settings where AAs cannot be used such as rural areas, other health clinics, and healthcare settings where a nurse anesthetist may be the only anesthesia provider in the surgery center. The bill limits access in the state by only having one supervising provider. It also allows AAs to perform invasive procedures that they may not be adequately educated to do under the current training. The bill should align with the scope of other states and remove the highly invasive procedures. 

OTHER: This is not currently included in the Governor's budget. The Commission is supportive of the bill and believes that the bill can be implemented as written. This bill is a result of a sunrise review that the Commission engaged in extensively and appreciates the changes that were incorporated during the review. The Commission does not have any patient safety concerns with the creation of a regulatory structure as proposed and this model would benefit the patient. At a time when healthcare procedures are being delayed and anesthesiologist overtime is mandated in many settings due to a shortage, this can be a solution for patients and add to the healthcare workforce in a specialized field. 

PRO: Senator Ann Rivers, Prime Sponsor; Patrick Hession, CAA; Truc-Anh Tran, CAA; Christy Kohlsaat, Certified Anesthesiologist Assistant; Carolyn Logue, WA Academy of Anesthesiologist Assistants; Charlie Chase, Certified Anesthesiologist Assistant; Tim Clement, Washington State Society of Anesthesiologists; Cassie Gabriel, Washington State Society of Anesthesiologists.

PRO: Amy Brackenbury, Washington State Society of Anesthesiologists; Anna Nguyen; Shane Angus, Association of Anesthesiologist Assistant Education Programs.