Organisation of Anaesthesia Services: Duties of an Anaesthesia Provider
Organisation of anaesthesia services Duties of an anaesthesia provider Anaesthesia providers Organisation of anaesthesia services In medicine, including anaesthesia, teamwork is emphasised. A proposed ideal surgical team would include: Surgeons Surgeon assistants Anaesthesiologists Anaesthesia assistants Nursing personnel (including a scrub nurse and floor nurse) Clinical technicians Clinical ana
Organisation of anaesthesia services
Duties of an anaesthesia provider
Anaesthesia providers
Organisation of anaesthesia services
In medicine, including anaesthesia, teamwork is emphasised. A proposed ideal surgical team would include:
- Surgeons
- Surgeon assistants
- Anaesthesiologists
- Anaesthesia assistants
- Nursing personnel (including a scrub nurse and floor nurse)
- Clinical technicians
- Clinical anaesthesia technologists
- Cleaners
- Theatre administration
- Porters
In addition, ward personnel and allied professionals such as dieticians, physiotherapists and occupational therapists may form part of the team. This team may function as different compositions in different situations.
Duties of an anaesthesia provider
The practice of anaesthesia is unique in the provision of healthcare services in that:
- Providers are often not based at one facility and commute between different facilities.
- Providers are service providers and have little control over their daily bookings.
- Providers, as a group, may be faced with more urgent and emergent situations.
- Providers may have less time to establish rapport with the patient preoperatively.
- Anaesthesia is procedure-associated.
- Providers usually do not make the primary diagnosis.
The duties of the anaesthesia provider include:
- Maintaining personal knowledge and skills
- Providing anaesthesia services or supervising trainees who provide anaesthesia services.
- Anaesthetists may be directly responsible for only one anaesthesia at any specific time unless acting in a supervisory capacity.
- Carrying out a preoperative risk assessment and management for all types of patients and surgery.
- Delegating responsibility for patient supervision to a suitably trained substitute when a local anaesthetic technique is used for pain relief without concomitant surgery, e.g., labour epidural.
- Supervising the recovery room activities.
- Participating in postoperative management where appropriate.
- Managing or supervising the management of patients in the intensive care unit (ICU).
- Providing services related to the management of acute pain.
- Providing services related to resuscitation and advanced airway management in adults and children.
- Taking responsibility for supervising the maintenance of anaesthesia, monitoring, and other life-support equipment relevant to anaesthesiology and critical care. This must occur in conjunction with a suitable technical or biomedical engineering service.
- Taking responsibility for the safe use of anaesthetic drugs.
- Providing anaesthesia services that relate to obstetrics, including pain relief in labour.
- Providing monitored anaesthesia care services in and out of the hospital.
- Keeping complete documentation and records of the anaesthesia administered to patients.
- Obtaining informed consent to all invasive procedures, including those performed under local anaesthesia, spinal- or epidural anaesthesia, monitored anaesthesia care or general anaesthesia, and specific non-anaesthesia interventions such as blood transfusion or HIV testing.
- Maintaining personal and professional wellbeing.
Further duties may include:
- Providing services related to chronic pain management and consulting in pain clinics.
- Providing consultative anaesthesia and ancillary services.
- Carrying out administrative, educational, and managerial duties locally or regionally.
- Providing information and training on methods of handling mass casualties, trauma, and basic life support techniques to:
- paramedical staff,
- interested community groups (particularly basic life support), and
- contributing to the activities of professional associations
- Auditing and reviewing the quality of care and participating in hospital-based, regional and/or national efforts to improve patient safety.
- Participating in theatre complex management.
- Involvement in the conduct and/or supervision of research on drugs, equipment, clinical management methods, and physiological and pharmacological matters relevant to anesthesiology and intensive care and keeping up to date with such research.
- Providing and/or taking part in advisory services to hospital committees, health commissions and other organisations to improve health care services.
- Encouraging and supervising research.
- South African adapted CANmeds competencies in training a medical expert include being a medical expert, communicator, collaborator, leader, health advocate, scholar and professional.
Anaesthesia providers
This section attempts to categorise physician anaesthesia providers based on training and experience. Given the risks involved in providing anaesthesia services and the possibility of simple errors that result in severe adverse outcomes, the scope of practice for the various classes of medical practitioners is defined. The scope of practice should not vary according to the facility level of care. Health Professions Council of South Africa (HPCSA) regulations regarding training and accreditation are only restated to provide context or when alternative recommendations are made. The two main groups of relevance are supervised practice and independent practice.
Supervised practice
Medical practitioners from countries that do not meet local requirements/equivalence for anaesthetic training must practice under supervision. These may be, for example, non-South African doctors who have not completed the South African two-month anaesthesia intern programme. It is recommended that medical interns receive direct supervision by a diplomate anaesthetist or, if not available, an anaesthetist designated as intern supervisor (see below).
Interns
- An intern is a doctor in training
- An intern relies on the undergraduate curriculum for training in anaesthesia at medical school. It is recommended that undergraduate teaching outcomes in anaesthesia at different training institutions across South Africa be standardised.
- Interns must receive a minimum of two months of supervised anaesthesia training (4–6 months is desirable). We emphasise here the HPCSA training requirements with regards to supervision:
“Adequate supervision: Constant supervision of the intern is of critical importance. The most acceptable form of “adequate” supervision is the presence of a specialist anaesthesiologist or a registrar in anaesthesiology. In the absence of a specialist, the supervisor should preferably possess the Diploma in Anaesthetics (DA) of the College of Medicine of South Africa (CMSA), or at a minimum, have three (3) years full-time experience of administering anaesthesia as a medical officer.” Irrespective of the qualification, the constant presence of the senior physician on a one-to-one basis is strongly recommended.
- It is considered mandatory that interns are trained in the anaesthesia module of the Essential Steps in the Management of Obstetric Emergencies (ESMOE) training programme.
Community service medical officers
Community service doctors are often required to administer anaesthesia because no other trained medical practitioner is available. A community service doctor relies on both undergraduate and internship training in anaesthesia. Provision of anaesthesia must be supervised.
- It is recommended that supervision of community service doctors in a training institution is done by either an anaesthesiologist or a diplomate anaesthetist.
- It is recommended that a diplomate anaesthetist supervises at all other facility levels of care.
- It is recommended that the option for 6 months training in anaesthesia be available in institutions accredited for DA training.
- Even though the community service period is a period of service, and not of training, it is advisable that community service doctors keep a logbook of all supervised completed cases for these to be recognised toward qualifying to write the DA examination.
Independent practitioners/general practitioners
SASA recommends that general practitioners with less than three years experience and less than 75% working time spent in anaesthesia, and who have had no additional training in anaesthesia and rely on undergraduate, internship and community service training when performing anaesthesia services, should not be involved in the independent administration of anaesthesia. The only exception would be in a dire emergency, where a patient of the American Society of Anesthesiologists (ASA) class VE requires urgent anaesthesia, and no other clinician trained in anaesthesia is available. As soon as feasible, every effort should be made to transfer the patient to a centre where more specialised care is available.
To gain experience when there is no recourse to supervised training, a newly qualified general practitioner is advised to join SASA as an associate member to benefit from guidance and contact with diplomate anaesthetists and specialists and CPD activities in the local SASA branch and nationally.
It should be noted that proof of experience in anaesthesia care may be required in peer-review processes or medicolegal investigations. Therefore, SASA recommends keeping a professional portfolio, including a registered logbook of cases before and after being registered as an independent practitioner with the HPCSA.
Practitioners should inform patients of their level of experience and qualification during their first encounter with the patient.
Diplomate anaesthetists with less than three years of full-time anaesthesia practice or ‘experienced’ anaesthetists without DA
‘Experience’ for non-diplomate anaesthetists is defined as at least 3 years of anaesthesia practice and at least 75% of working time spent in anaesthesia. This experience may be limited to specific surgical categories or anaesthesia domains, e.g., obstetric anaesthesia, and this practice category is included here. It is highly recommended that evidence of CPD activities relating to anaesthesia practice be kept up to date.
The training requirement for a diplomate anaesthetist is a minimum of 6 months of supervised practice in an accredited institution. The DA is awarded by the CMSA after the required training has been completed, and the candidate has successfully passed the DA(SA) examination.
The diplomate anaesthetist is eligible for the independent practice of general and regional anaesthesia in fit and healthy patients (ASA class I) and patients with controlled systemic disease (ASA class II). Patients with poorly controlled systemic disease or functional limitations should only be anaesthetised in consultation with a specialist anaesthesiologist (ASA class III), i.e., with a supervisor. The nature of the surgery must not be major.*
It is reasonable to expect the diplomate to provide safe anaesthesia for fit and healthy (ASA class I & II) paediatric patients over the age of two years, provided the practitioner has maintained the necessary skills and the nature of the intended surgery is minor and elective. If that is not the case, supervision or referral should be sought.
In an emergency, or where no alternative exists, the diplomate may administer anaesthesia to patients with severe systemic disease (ASA class IV and V) in consultation with a specialist anaesthesiologist. This constitutes supervised practice.
*Surgical severity or grading is done according to the definitions used in large international and national studies on surgical outcomes (i.e., not facility or outcome specific):
Minor surgery includes procedures lasting less than 30 minutes that are performed in a dedicated operating room, which would often involve extremities or body surface, or brief diagnostic and therapeutic procedures, e.g., arthroscopy without intervention, removal of a small cutaneous tumour, diagnostic proctology, biopsy of small lesions, etc.
Intermediate procedures are more prolonged or complex and may pose the risk of significant complications or tissue injury. Examples include laparoscopic cholecystectomy, arthroscopy with intervention, bilateral varicose vein removal, tonsillectomy, inguinal hernia repair, breast lump resection, haemorrhoidectomy, appendicectomy, partial thyroidectomy, cataract surgery, uvuloplasty, minimally invasive repair of vaginal prolapse, vaginal hysterectomy, tendon repair of hand, fixation of mandibular fracture, etc.
Major surgical procedures are expected to last more than 90 minutes. They include major gut resection, major joint replacement, mastectomy, extensive head and neck tumour resection, abdominal aortic aneurysm repair, major vascular bypass procedure, procedures involving free flap to repair tissue defects, amputation, total thyroidectomy, cystectomy, transurethral resection of the prostate, resection of liver tumour, carotid endarterectomy, nephrectomy, total abdominal hysterectomy, spinal discectomy, etc.
Experienced diplomate anaesthetists
Experienced diplomate anaesthetists may have extensive experience in specific surgical categories or types but not in others. If experienced and spending at least 75% of their time providing anaesthesia care, the diplomate may be responsible for ASA III patients or patients undergoing major surgery. The provider must realise that peer review for this practice will be assessed at a specialist level.
Family physicians
The family physician practitioner has an invaluable role in the perioperative care of patients, especially at the district level. We recognise that due to the diverse background of training, experience, and competence, they might be in different categories above, e.g., experienced without a diploma or experienced with a diploma. Therefore, we cannot make specific recommendations about family physicians.
Specialist trainees (registrars)
The anaesthetic registrar is permitted to administer anaesthesia under specialist supervision. Although the revised recommended ratio by the HPCSA ratio is set at 4:1, i.e., four registrars to each specialist for elective procedures, SASA recommends that a ratio of 2:1, i.e., two registrars to one specialist, is preferable. In circumstances where the anaesthesia is classified as “high risk”, the ratio may be reduced to 1:1.
Specialist anaesthetists (anaesthesiologists)
The specialist anaesthetist can be expected to provide anaesthesia services independently to all patients, irrespective of the state of health or co-existing disease (ASA classes I, II, III, IV, V and VI). It behoves the individual practitioner to confine their practice to those areas where they have maintained the necessary advanced skills. This applies particularly to cardiac, thoracic, neuro- and paediatric anaesthesia sub-specialities.
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South African Society of Anaesthesiologists (SASA) Practice Guidelines_2022_Reviewed by: E Cloete