Physicians Assistants in Anaesthesia. Inventing a new type of advanced practitioner

Transcription

1 Physicians Assistants in Anaesthesia Inventing a new type of advanced practitioner

2 Beer Mat Manpower Planning 2001 IF Anaesthesia continues to grow at the current rate AND IF EWTD is fully implemented -50% of service provided by trainees -24/7 cover of ICU and Obstetrics by Consultant Anaesthetists AND IF all the anaesthetists who were appointed in the 1970s retire as expected

3 Beer Mat Manpower Planning 2001 THEN BY 2020 EVERY SINGLE MEDICAL GRADUATE IN THE UK WILL HAVE TO BECOME AN ANAESTHETIST

4 Thinking the Unthinkable UK anaesthesia may have to be provided by non medical anaesthetists

5 Are Medical Anaesthetists the Norm?

6 Some of the Commonwealth

7 and the ex-iron Curtain Block

8 Non Medical Anaesthetists are used in Most of Western Europe United States of America The developing world

9 Models of non-medical Anaesthetic Provision Anaesthetic Nurse Europe CRNA USA Work in the presence of a doctor e.g. surgeon Anaesthetic Assistant USA Nurse 1 year course Directed by Anaesthetist 2:1 working Nurse 3 year post ICU Course Work in the presence of a doctor e.g. surgeon Graduate 3 year course Directed by Anaesthetist 2:1 working

10 Models of non-medical Anaesthetic Provision Anaesthetic Nurse Sweden Holland CRNA USA Work in the presence of a doctor e.g. surgeon Anaesthetic Practitioner USA Nurse 1 year course Directed by Anaesthetist 2:1 working Nurse 3 year post ICU Course Work in the presence of a doctor e.g. surgeon Graduate 3 year course Directed by Anaesthetist 2:1 working

11 The Anaesthetic Practitioner (AP) Consistent with New Ways of Working in Anaesthesia Did not poach valuable skilled staff from other parts of the NHS Biomedical Science Graduate NHS employee trained to degree level 27 month PG Diploma/MSc Universities of Birmingham Edinburgh Hull

12 The Advanced Practitioner in Anaesthesia (APA) Consistent with New Ways of Working in Anaesthesia Did not poach valuable skilled staff from other parts of the NHS Biomedical Science Graduate NHS employee trained to degree level 27 month PG Diploma/MSc Universities of Birmingham Edinburgh Hull

13 The Physician s Assistant in Anaesthesia (PA(A)) Consistent with New Ways of Working in Anaesthesia Did not poach valuable skilled staff from other parts of the NHS Biomedical Science Graduate NHS employee trained to degree level 27 month PG Diploma/MSc Universities of Birmingham Edinburgh Hull

14 Implementing the AP/APA/PA(A) Role European Nurse Anaesthetists recruited 2005 Training started Initial Tranche of 50 The Rest will be History..

15 Operating theatres are expensive and inefficient per minute ( per hour)

16 The patient journey Patient A A R Theatre Recovery Patient B Patient C Coffee Room

17 Anaesthetist Anaesthetic Room THEATRE Recovery

18 The Anaesthetist Patient A Patient B Patient C

19 Theatre Team Setting up Theatre Potential break Cleaning

20 The Theatre Team Patient A Patient B Patient C

21 Surgeon? THEATRE Note Writing

22 Surgeon Patient A Patient B Patient C

23 Normal Theatre Practice Inefficient Too much empty table time Failure to make efficient use of the surgeon Rate limited by speed of anaesthetist outside theatre Speed of surgeon inside theatre Imbalance of resource Not enough anaesthesia Inefficient use of rooms

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27 Patient A Patient B Patient C

28 Effect of a second anaesthetist Patient A Patient B Limiting factor is now the speed of the theatre team Patient C Patient D

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30 STH Cardiothoracic Theatre Facilitate Turnaround No stops for lunch Overruns reduced Monitor patient during complex procedure Trans-Oesophageal Echocardiography CSF drain

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32 2 to 1 Working Widely practised Lincoln Exeter Efficient Enjoyable Good use of Consultant skills

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34 Problems with 1 to 2 working Only works for lists with the same sort of cases Lists start out of sync (Theatre 2 starts 30 mins later than Th 1) Lists stay out of sync

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36 Sheffield Microsystems Coaching Academy Information about microsystems work in Sheffield Case studies Principles of microsystems approach

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39 Problems and Developments in the PA(A) Role

40 A New Profession Where do PA(A)s fit in? Who pays for them? Who regulates their practice? Need for Register Need for Regulator? A threat to Anaesthetists?

41 Where do PA(A)s fit in? Part of the Anaesthetic Team Department of Anaesthesia BUT Hospitals with anaesthetic vacancies Cancelled lists Service deficit Limb block Sedation for vascular angiography Anaesthetic Departments have no money for training

42 Who pays the PA(A)s? Medical Budget (locum payments) Service Development Nursing Budget Often an attempt to make PA(A)s fit a nursing model Preconceptions about AfC banding

43 Who Regulates PA(A) Practice? PA(A)s are not regulated Managed Voluntary Register Regulation refused by HPC GMC RCoA Perfusionists have regulated themselves for 50 years Register is effective Dismissal from Trust = Erasure from Register

44 What Limits PA(A) Practice Scope of Practice 2008 RCoA AAGBI No Extubation No Local Blocks

45 What Limits PA(A) Practice RCoA Scope of Practice 2010 Acceptance of extended roles Appropriate Governance arrangements

46 Extended Roles Emergence and Extubation Spinal Anaesthesia Limb Blocks Insertion of invasive monitoring lines Arterial CVP Sedation for radiological procedures

47 Drug Handling Not Prescribers Administering drugs on the orders of a doctor e.g. parent administering IV drugs to child Perfusionist giving drugs on bypass

48 Patient Specific Directive Anaesthetist directs what drugs are given What doses For what PA(A) follows directive In practice this means producing indication, dosage and frequency protocols for standard anaesthetic drugs.

49 A threat to Anaesthetists? The AAGBI says not

50 What can PA(A)s do for The NHS?

51 What PA(A)s can do for patients? Improve the quality of admission on the day of surgery Staggered admission times The anaesthetist can be freed from the list to assess patients No early morning scrum on the admissions ward By improving throughput there is the potential to Reduce waiting times Reduce on day cancellations

52 What can PA(A)s offer Anaesthetists? Increased output More money for the Trust More money for the directorate Workforce stability Reduced need for locums No more recruiting expeditions to Eastern Europe Resilience Work continues despite consultant up in the night Flexibility Happy Consultants Coffee, Comfort & Meal breaks AT EXTRA COST BUT PROFITABLY OVERALL

53 What PA(A)s do not offer Paediatric & Obstetric Cover Standalone anaesthesia Reduction in Salary costs Band 7/8a Support worker An immediate solution to manpower problems 27months training is a long time

54 Challenges and threats Lack of funds for training NHS employees 50-60k Biomedical Science graduates 40k Lack of national strategy to manage changing medical workforce Emphasis on General Practice means fewer Hospital Doctors

55 Physician s Assistants in Anaesthesia Have the skills to improve theatre efficiency and increase income Can extend their skills to cater for local needs May be the only long term option for keeping theatres running at all Have yet to find their feet as an independent profession Threatened by lack of training resource.