ANESTHESIA ASSISTANT (Approved by the College of Physicians and Surgeons of Manitoba, July 2006)

Transcription

1 ANESTHESIA ASSISTANT (Approved by the College of Physicians and Surgeons of Manitoba, July 2006) Description of the Position Anesthesia Assistants are allied heath professionals, qualified by advanced academic and clinical education to provide anesthetic care under the immediate supervision of a fellowship-trained Anesthesiologist or a physician trained in Anesthesiology and credentialed to practice the specialty in a WHRA facility. The AA executes complementary and supplementary therapeutic interventions and monitoring tasks that allow the physician Anesthesiologist to use his or her own skills more efficiently and effectively. The role of the AA within any given anesthesia service will be: Dependent on the nature of the services that the hospital/facility provides, Defined by the job description approved by the CPSM and, Consistent with the vision and position of the Canadian Anesthesiologists Society Job description The scope of practice of the AA is defined by the scope of practice of the supervising physician Anesthesiologist and includes those tasks & responsibilities that the Anesthesiologist is capable of performing and comfortable delegating, and the AA is competent to perform. An Anesthesia Assistant may, under medical direction from the attending Anesthesiologist: 1. Provide assessment of the patient s health status as it relates to the relative risks involved with anesthetic management of the patient during performance of the operative procedure, 2. Perform diagnostic laboratory and related studies as appropriate (i.e. draw venous blood samples, conduct spirometry testing, operate a rapid blood analyzer, record an ECG), 3. Establish peripheral venous access, 4. Institute non-invasive physiologic monitoring modalities, 5. Assist with/perform arterial puncture for the purpose of blood sampling and/or vessel cannulation, 6. Assist the attending Anesthesiologist with; i. Establishment of central venous access, ii. Institution of invasive physiologic monitoring modalities, iii. Application, manipulation, and interpretation of data from routine & advanced monitoring techniques, iv. Institution and maintenance of regional blocks and catheters, v. Elective/emergent complex airway management, vi. Acute/chronic pain management, 7. Assist the responsible Anesthesiologist with all aspects of the anesthesia care plan formulated for a particular patient (preanesthetic preparation, induction, maintenance, alteration of anesthesia levels, administration of adjunctive treatment, emergence & continuity of care into, and during, the post operative period), 8. Temporarily execute the maintenance phase of the anesthesia plan based on the health status of the patient (i.e., administer pharmacologic agents, manage the airway, monitor and record vital signs, support life functions, use mechanical support devices, manage fluid, electrolyte & blood component therapy), in consultation with the responsible Anesthesiologist (who remains immediately available and accountable for the anesthetic management of the patient), 9. Recognize and initiate appropriate corrective action to counteract problems that may develop during implementation of the anesthesia plan, in consultation with the responsible Anesthesiologist,

2 10. Assist members of the Anesthesia care team with the management of life-threatening situations (recognition, evaluation, response) as directed by the responsible Anesthesiologist, 11. Perform initial resuscitation in life-threatening situations according to established protocols (i.e. BCLS/ACLS, MH, NRP, PALS), while awaiting arrival of the responsible Anesthesiologist, 12. Setup, calibrate, maintain and troubleshoot machines, devices and physiologic monitors used in preanesthetic evaluation, pain management and anesthetic/resuscitative care, 13. Prepare and administer drugs commonly used in anesthetic practice by protocol and/or as directed by the responsible Anesthesiologist, 14. Assist in the performance of anesthesia-related duties in intensive care units, labor & delivery units, off-site anesthetizing locations, pain clinics, and other settings, as appropriate, 15. Provide for safe transport of a patient between acute care settings, 16. Assist in the orientation, education and clinical instruction of others, 17. Perform delegated administrative duties in an Anesthesiology Department such as data collection for quality assurance and clinical research activities, maintenance of computerized databases, evaluation, ordering and management of supplies & devices, 18. Adhere to all workplace health policies, safe practices and regulations, 19. Establish and maintain productive and cooperative working relationships, 20. Maintain registration with the CPSM and membership in the CAS, 21. Regularly undertake (and maintain a log of) continuing educational activities that enhance the professional AA role, 22. Demonstrate competence in an annual performance review of Knowledge, Clinical skills, Judgment, and Non-technical skills (Task management, Team work, Situation awareness, Decision making). Admission Requirements 1. Registered Respiratory Therapist (RRT) or Registered Nurse (RN) licensed to practice in Manitoba, or previously practicing (in country of origin) International Medical Graduate (IMG) with experience in Anesthesia/Emergency/Critical Care, graduated from a recognized and accredited university/college acceptable to the CPSM, 2. Two years critical care or anesthesia-related operating room experience within the past 5 years, 3. Three letters of recommendation, each addressing a different aspect of the applicant s suitability for study leading to a career as an AA; a. One from a physician who, by virtue of a close working relationship with the applicant in the acute care setting, can provide a detailed account of the applicant s aptitude in the non-technical skills of Task management, Team work, Situation awareness and Decision making (Appendix II), b. One from the applicant s present, or immediately previous, supervisor knowledgeable about the applicant s character, work habits, and professional conduct in connection with patients and interdisciplinary colleagues (Appendix III), c. One from someone familiar with the applicant s performance and performance potential, in terms of academic knowledge, technical/clinical skills, judgment, and response to teaching, 4. Evidence of manual skill with a computer; facility within the Microsoft office environment; ability to execute on-line computer search strategies; access to an Internet account, 5. Eligibility for registration with the CPSM as a non-certified Clinical Assistant (CA), 6. One page, typed letter outlining personal & professional reasons for wanting to become an AA,

3 7. Excellent written and verbal communication skills; Applicants for whom English is a second language must provide proof of proficiency in an English language assessment, including spoken and written medical terminology, 8. Successful completion of a pre-entrance assessment, the purpose of which is to review the applicant s baseline knowledge and skill level in order to determine if the curriculum as provided and the proposed duration of study (minimum 6 months [funded], maximum one year) would, in all likelihood, allow the applicant to acquire the appropriate knowledge/skills/judgment to pass an AA challenge exam (written, technical and nontechnical skills assessment) and fulfill all aspects of the AA role described above. 9. Willingness to accept the training period as probationary (performance evaluations conducted at 1, 3 and 6 months, + 9,12 months) and the offer of a permanent position in one or more of the WRHA hospitals Departments of Anesthesia as contingent upon successful completion of an AA challenge exam. Appendix I: Clinical Assistants in Anesthesia, Contract of Supervision Definitions The attending Anesthesiologist is: i. A physician, ii. Fellowship-trained to deliver anesthesia services as described by the Canadian Anesthesiologists Society (CAS) and the Royal College of Physicians and Surgeons of Canada (RCPSC) or, fully credentialed by the WRHA and currently practicing Anesthesia in an acute care facility operated by the WRHA, iii. Licensed, qualified and legally authorized to practice medicine as an Anesthesiologist. The Anesthesiologist Assistant is: i. An allied heath professional, ii. Qualified by advanced academic and clinical education to provide anesthetic care under the immediate supervision of a fellowship-trained Anesthesiologist. Responsibilities The attending Anesthesiologist engaged in medical direction of an AA remains responsible for: i. Pre anesthesia medical evaluation of the patient, ii. Formulation, prescription and implementation of the anesthesia care plan, iii. Personal participation in the most demanding procedures of the plan (i.e. performance of regional blocks/insertion of regional catheters, induction, emergence), iv. Monitoring the course of anesthesia administration at frequent intervals, v. Remaining physically available for consultation and immediate treatment of emergencies, vi. Providing indicated post anesthesia care, The Anesthesia Assistant: i. Executes complementary and supplementary therapeutic interventions and monitoring tasks that allow the physician Anesthesiologist to use his or her own skills more efficiently and effectively, ii. Works exclusively within the Anesthesia Care Team environment, iii. Reports directly to the attending Anesthesiologist. Appendix II: Evaluation of Performance Formative and summative evaluation of the academic, clinical and behavioral performance of Anesthesia Assistant trainees will be conducted on a recurrent basis with sufficient frequency to provide both the trainee and teaching faculty with valid and timely indications of the trainee s

4 progress toward attaining the requisite knowledge, skill and judgment to perform each of the tasks listed in the job description. Records of evaluations will be maintained in enough detail to document learning progress and achievements. Satisfactory completion of the Anesthesia Clinical Assistant program is dependent upon the trainee acquiring and demonstrating the following: 1. Basic scientific and clinical knowledge relevant to performance of the tasks listed in the job description 2. Technical proficiency in clinical skills 3. Acceptable/Good rating on Anesthesia Non-Technical Skills evaluations 4. Superior/satisfactory performance on the Professionalism & Humanism scale 5. Passing grade on the AA challenge examination Evaluations will continue at 3-month intervals for the first year of employment as an AA and yearly thereafter. The University of Manitoba, Department of Anesthesia reserves the right to terminate any trainee whose conduct, or academic or clinical performance is unacceptable to the Department; and, in this circumstance, to notify the College of Physicians and Surgeons of Manitoba to strike the trainee from the Medical Register. Evaluation tools Summative evaluation: Assessment of whether the performance is adequate to pass to a new level or deemed unacceptable necessitating either remedial training or dismissal. Formative evaluation: Constructive feedback to point out strengths, weaknesses and opportunities for improvement Specific tools 1. Multiple choice, short answer and essay-type tests to evaluate knowledge 2. ANTS system to evaluate behavioral markers 3. Professionalism & Humanism scale to evaluate values, characteristics, work habits, and professional conduct in connection with patients and colleagues 4. Procedural log book, ongoing CUSUM analysis to evaluate skill acquisition 5. Global rating scale of operative performance to evaluate procedural skills 6. Simulator sessions to evaluate performance in routine and emergency situations 7. Direct observation in the clinical setting to evaluate performance in routine and emergency situations 8. Comparative Self evaluation checklist Levels of competence have been developed for task-oriented procedures to serve as a guideline for expected performance in the clinical area. Individuals may proceed through various aspects of these levels at different rates throughout the training period; however, satisfactory performance at Level III or IV, depending on the task, is required at completion of the training period. Level I Level II Level III Level IV Level V Observes task execution in a variety of settings, gathers supplies and equipment, provides assistance when guided to do so Performs task capably with direct assistance Performs task safely and efficiently with direct supervision Performs task safely, efficiently and independently under routine conditions Performs task safely, efficiently and independently under exceptional circumstances Appendix III: Dismissal An Anesthesia Clinical Assistant will be dismissed prior to the termination of his/her contract under the following circumstances:

5 1. Non-performance of contractual duty, examples include; Absence without leave from assigned duty, refusing specific assignments, habitual tardiness, engaging in unapproved outside employment, lack of skill or judgment, unprofessional behavior, medical or psychiatric illness for which treatment is refused or ineffective and which impairs patient welfare, failure to maintain valid professional licensure with the CPSM 2. Substantially substandard performance 3. Inability of the University Department of Anesthesia to perform its contractual duty due to circumstances beyond its control. Appendix IV: AA Formulary The AA may administer, on direct order by the supervising Anesthesiologist, those medications the supervising Anesthesiologist is competent to prescribe/prepare/administer. After completion of formal and informal educational training and documented competency, the AA will progress to: Preparation and labeling of the medications listed below, without direct supervision, Adjustment of anesthetic depth, without direct Anesthesiologist supervision, according to the anesthetic care plan formulated by the attending Anesthesiologist, Administration of specific medications (atropine, glycopyrolate, lidocaine, epinephrine, ephedrine, phenylephrine, syntocinon, labetolol, nitroglycerin SL, 50% dextrose, naloxone, flumazenil, oxygen, vaponephrine, salbutamol) in a life-threatening emergency while awaiting direction from the supervising Anesthesiologist, Set-up, maintenance and adjustment of medication infusion pumps, without direct Anesthesiologist supervision, to fulfill the goals of the anesthetic care plan, Administration of sedation for procedures (midazolam, lorazepam, propofol, fentanyl, sufentanil, morphine, ketamine), as approved by the attending Anesthesiologist, Infiltration of local anesthetic for the purpose of establishing intravenous/intra-arterial access or preparing the scalp for the placement of head tongs, Titration of analgesia by local anesthetic and/or narcotic administration per epidural or plexus catheter, application of a transcutaneous nerve stimulation device or application of topical analgesia products (i.e. diclofenac drops, EMLA cream, drug-eluting patch) Programming of spinal cord stimulators Refilling the drug reservoirs of implantable (intrathecal, subcutaneous) infusion pumps. The AA will not independently prescribe either scheduled or PRN medications. The AA may document verbal medication orders given by the attending Anesthesiologist on the Physician s order sheet and any forms/requisitions/records specific to the Pre Anesthesia Clinic, Operating Room, consultation for off site Anesthesia calls (Emergency, ICU, Radiology, Wards), Labor & Delivery, Pain Service and the Post Anesthesia Care Unit. 1. Analgesia (acetaminophen, aspirin, other NSAID s [eg. ketorolac, naprosyn,diclofenac, indomethacin], opioids, opioid agonist-antagonists, tramadol, gabapentin, pregabalin, amytriptilene, capsaicin 2. Induction (propofol, thiopental, ketamine, sedation, analgesia); Maintenance (inhaled agents [nitrous oxide, oxygen, helium, desflurane, sevoflurane, isoflurane], analgesics, neuromuscular blocking agents, TIVA); Emergence (antiemetics, analgesics, reversal of neuromuscular blockade) 3. Emergency a. Alpha & beta agonists, sympathomimetics (clonidine, phenylephrine, ephedrine, noradrenaline, epinephrine, dopamine, dobutamine, milrinone) b. Peripheral vasodilators (hydralazine, nitroprusside, nitroglycerin)

6 c. Anticholinergics (atropine, glycopyrolate, scopolamine) d. Beta blockers (labetolol, metoprolol, atenolol, propranolol) e. Antihypertensives & Antiarrythmics (enalapril, diltiazem, verapamil, amiodarone, digitalis) 4. Adjunctive treatment a. Special conditions (mannitol, phenytoin, heparin, protamine, nitric oxide, steroids, insulin, diuretics (furosemide, spironolactone), B vitamins, calcium, magnesium, bicarbonate, syntocinon, antibiotics [penicillin, vancomycin, clindamycin, gentamicin, metronidazole, cefazolin, cefuroxime, cephalexin, cloxacillin], dantrolene, iron, vitamin K, low molecular weight heparin, erythropoetin) b. Antifibrinolytics (aprotinin, tranexamic acid, e-aminocaproic acid) c. Antiemetics (dimenhydrinate, diphenhydramine, droperidol, phenergan, granisetron, dexamethasone, metoclopramide, prochlorperazine) d. Anti-reflux prophylaxis (ranitidine, metoclopramide, domperidone, omeprazole) e. Inhaled bronchodilators (salbutamol, atrovent, vaponephrine) f. Airway topicalization (cetacaine, lidocaine, cocaine, nasal decongestant) g. Epidural, plexus sheath & peripheral nerve catheter local anesthetics (lidocaine, bupivacaine, ropivacaine) and narcotics (fentanyl, sufentanil, hydromorphone) h. Blinded study medications as part of approved clinical trials i. Immunosuppressive agents as part of transplant protocols j. Agents used during the diagnosis and treatment of pain syndromes (IV contrast dye, bretylium, guanethedine, phenol, absolute alcohol) 5. Blood components (prbc, plasma, platelets, cryoprecipitate, coagulation factors, albumin) 6. Intravenous fluids (NaCl, Ringers, Dextrose & H 2 O, Pentaspan) July 12 th, 2006