Surgical Assistants also known as Assistants-at-surgery, who serve as members of surgical teams, perform tasks under the direction of surgeons and aid them in conducting operations. These tasks may include making initial incisions ("opening"), exposing the surgical site ("retracting"), stemming blood flow ("hemostasis"), surgically removing veins and arteries to be used as bypass grafts ("harvesting"), reconnecting tissue ("suturing"), and completing the operation and reconnecting external tissue ("closing"). Some of these tasks, like retraction, are relatively simple, while others, such as harvesting, are more complex. An assistant-at-surgery may perform one or more simple or complex tasks during an operation. In the United States the National Uniform Claim Committee (NUCC) was formally organized in May 1995. The NUCC is a diverse group of health care industry stakeholders representing providers, payers, designated standards maintenance organizations, public health organizations, and vendors. The mission of the NUCC, a national, multi-stakeholder committee, is to support and advocate for the development, maintenance, and adoption of uniform data content and standardized administrative transactions in the health care industry. As such, the NUCC is intended to have an authoritative voice regarding national standard data content and data definitions for professional (non-institutional) health care claims and/or related encounter data in the United States. The NUCC has definitions for surgical assistants and surgical technologist. A Surgical Assistant is defined as
a skilled practitioner who has undergone formalized education and training as a surgical assistant. The surgical assistant performs surgical functions that include, but are not limited to: retracting, manipulating, suturing, clamping, cauterizing, litigating, and tying tissue; suctioning, irrigating and sponging; positioning the patient; closure of body planes and skin; and participating in hemostasis and volume replacement. Surgical assistants are certified and registered or licensed by the state, or, in states without licensure, certified as surgical assistants by completing appropriate education and training.
A Surgical Technologist is defined as:
An allied health professionals, who are an integral part of the team of medical practitioners providing surgical care to patients. Surgical technologists work under the supervision of a surgeon to facilitate the safe and effective conduct of invasive surgical procedures, ensuring that the operating room environment is safe, that equipment functions properly, and that the operative procedure is conducted under conditions that maximize patient safety. Surgical technologists possess expertise in the theory and application of sterile and aseptic technique and combine the knowledge of human anatomy, surgical procedures, and implementation tools and technologies to facilitate a physician's performance of invasive therapeutic and diagnostic procedures.
In Australia the Royal Australian College of Surgeons position paper on surgical assistants states that the specific role of a surgical assistant may be primarily: to act as a facilitator, to act s facilitator and co-worker and to act as a facilitator and a consultant to the surgeon.
Surgical assistants thru out the world meet stringent surgical educational criteria, certification, registration and licensure requirements to practice as surgical assistants. The individuals practicing as a surgical assistant varies internationally and each country has legal requirements for the surgical assistant.
For example in Australia a "medical surgical assistant" is a qualified doctor who assists the surgeon during an operation.
In England the Royal College of Surgeons position statement on surgical assistants believes that the wide range of titles in use for practitioners who assist surgery, including for example surgical assistants, surgical care practitioners, medical care practitioners, surgeon's assistant, and advanced scrub patitioners, is a patient safety issue because it can cause confusion for patients and clinical staff.
In surgery team work is essential in the operating room and the team members are made up of surgeon, surgeon assistant, anesthesia provider, circulator nurse and surgical technologist. The surgeon and surgical assistant are the team members operating on the patient.
Teamwork is important in that it allows others to do the work of the surgeon so that the surgeon can focus on the indication for intervention, the procedure or operation, and preventing or managing complications. Most patients are satisfied with team care as long as the surgeon explains the concept and ensures trust in the team members by communicating that to the patient.
Community surgeons have always had some sort of assistance in performing their operations, if only on a purely informal basis. They may do the small operations on their own, but may seek assistance from a colleague, a family physician, or an OR nurse to do the larger and more complex procedures. Surgical assisting has been around for as long as surgical procedures in the OR. The majority of surgeons have spent most of their lives in the OR, largely assisting residents and fellows as they learn the finer points of being a good, gentle surgeon. In that respect, surgical assisting is almost a continuation of our surgical experience, expertise, and lifetime work.
Members of a wide range of health professions serve as assistants-at-surgery, including physicians, residents in training for licensure or board certification in a physician specialty, several different kinds of nurses, and members of several other health professions. Hospitals employ all the types of nonphysician health professionals who perform the role. Hospital employees likely serve as assistants-at-surgery for a majority of the procedures for which the American College of Surgeons says an assistant is “almost always” necessary.
The origins of the surgical assistant’s role in the United States can be traced back to the specialized surgical teams assembled by Michael DeBakey during World War II. “DeBakey and his colleagues conceived the idea of organizing mobile surgical teams, each comprising a well-trained chief surgeon, an assistant surgeon, an anesthesiologist, a surgical nurse and two technicians. The teams--initially called Auxiliary Surgical Groups--were assembled by surgical specialty (General, Thoracic, Orthopedic, etc.) The first teams were deployed to the Fifth Army in North Africa, Sicily and Italy in 1943. The careful records these teams kept demonstrated a dramatic increase in survival expectations and more teams were assembled as the Normandy invasion plans took shape. (The surgical groups were later renamed Mobile Auxiliary Surgical Hospital (MASH) units and became well known for their service in the Korean and Vietnam conflicts.)”
Since 1994, the American College of Surgeons, with other surgical specialty organizations, has conducted studies to determine which surgical procedures require physicians as assistants-at-surgery. These studies classify surgical procedures as "almost always," "sometimes," or "almost never" requiring an assistant-at-surgery. The 2002 study classifies approximately 5,000 surgical procedures, about 1,750 of which are designated as "almost always" requiring a physician to serve as an assistant-at-surgery.
American College of Surgeons (ACS) – Statement on Principles (excerpted), relating to Surgical Assistants;
The surgical assistant during a surgical operation should be a trained individual who is able to participate in and actively assist the surgeon in completing the operation safely and expeditiously by helping to provide exposure, maintain hemostasis, and serve other technical functions. The qualifications of the person in this role may vary with the nature of the operation, the surgical specialty, and the type of hospital or ambulatory surgical facility.
The American College of Surgeons supports the concept that, ideally, the surgical assistant at the operating table should be a qualified surgeon or a resident in an approved surgical education program. Residents at appropriate levels of training should be provided with opportunities to assist and participate in operations. If such surgical assistants are not available, other physicians who are experienced in assisting may participate.
It may be necessary to utilize nonphysicians as surgical assistants. Surgical Assistants (SA's) or Physician's Assistants (PA's) with additional surgical training should meet national standards and be credentialed by the appropriate local authority. These individuals are not authorized to operate independently. Formal application for appointment to a hospital as a Physician Assistant or Surgical Assistant should include:
There is no widely accepted set of standards for the education and experience required to serve as an assistant-at-surgery. The health care professions whose members provide assistant-at-surgery services have varying educational requirements. No state licenses all the types of health professionals who serve as assistants-at-surgery. And the licenses they issue typically attest to the completion of broad-based health care education, making them of limited value in determining which health professionals have the education and experience to serve as an assistant-at-surgery. Furthermore, the certification programs developed by the various nonphysician health professional groups whose members assist at surgery differ. We found that there was insufficient information about the quality of care provided by assistants-at-surgery--either generally or by members of specific health professions--to assess the adequacy of the requirements for a particular profession.
American Medical Association (AMA) - Policy, H475.986 (full statement), Surgical Assistants other than Licensed Physicians;
Our AMA: (1) affirms that only licensed physicians with appropriate education, training, experience and demonstrated current competence should perform surgical procedures;
(2) recognizes that the responsible surgeon may delegate the performance of part of a given operation to surgical assistants, provided the surgeon is an active participant throughout the essential part of the operation. Given the nature of the surgical assistant's role and the potential of risk to the public, it is appropriate to ensure that qualified personnel accomplish this function;
(3) policy related to surgical assistants, consistent with the American College of Surgeons' Statements on Principles states: (a) The surgical assistant is limited to performing specific functions as defined in the medical staff bylaws, rules and regulations. These generally include the following tasks: aid in maintaining adequate exposure in the operating field, cutting suture materials, clamping and ligating bleeding vessels, and, in selected instances, actually performing designated parts of a procedure. (b) It is the surgeon's responsibility to designate the individual most appropriate for this purpose within the bylaws of the medical staff. The first assistant to the surgeon during a surgical operation should be a credentialed health care professional, preferably a physician, who is capable of participating in the operation, actively assisting the surgeon. (c) Practice privileges of individuals acting as surgical assistants should be based upon verified credentials and the supervising physician's capability and competence to supervise such an assistant. Such privileges should be reviewed and approved by the institution's medical staff credentialing committee and should be within the defined limits of state law. Specifically, surgical assistants must make formal application to the institution's medical staff to function as a surgical assistant under a surgeon's supervision. During the credentialing and privileging of surgical assistants, the medical staff will review and make decisions on the individual's qualifications, experience, credentials, licensure, liability coverage and current competence. (d) If a complex surgical procedure requires that the assistant have the skills of a surgeon, the surgical assistant must be a licensed surgeon fully qualified in the specialty area. If a complication requires the skills of a specialty surgeon, or the surgical first assistant is expected to take over the surgery, the surgical first assistant must be a licensed surgeon fully qualified in the specialty area. (e) Ideally, the first assistant to the surgeon at the operating table should be a qualified surgeon or resident in an education program that is accredited by the Accreditation Council for Graduate Medical Education (ACGME) and/or the American Osteopathic Association (AOA). Other appropriately credentialed physicians who are experienced in assisting the responsible surgeon may participate when a trained surgeon or a resident in an accredited program is not available. The AMA recognizes that attainment of this ideal in all surgical care settings may not be practicable. In some circumstances it is necessary to utilize appropriately trained and credentialed unlicensed physicians and non-physicians to serve as first assistants to qualified surgeons (emphasis added). (BOT Rep. 32, A-99; Reaffirmed: Res. 240, 708, and Reaffirmation A-00)
Certification programs for assistants-at-surgery generally require completion of a certain level of education or experience and passage of an examination.
Members of a wide range of health professions serve as assistants-at-surgery, including physicians, residents in training for licensure or board certification in a physician specialty, several different kinds of nurses, and members of several other health professions. Hospitals employ residents, international medical graduates, and all the types of nonphysician health professionals who perform the role. Hospital employees likely serve as assistants-at-surgery for a majority of the procedures for which the ACS says an assistant is "almost always" necessary.
Most assistants are employed by hospitals; however, a growing number are employed by physician groups, private SFA practices, medical travel agencies, or are self-employed. According to the National Surgical Assistant Association (NSAA), the average annual salary for the non-physician surgical first assistant in 2005 ranged from $50,000 (entry level) to $150,000 annually for full-time practitioners, with top wages reaching $200,000 yearly. The American Medical Association lists the average as $75,000 yearly.
Hospitals employ the gamut of health professionals who serve as assistants-at-surgery to perform the role. Some hospitals tend to hire assistants-at-surgery from a particular health profession, sometimes offering training courses in assistant services for that profession, to ensure that the hospital has a sufficient number of assistants. To encourage surgeons to use their operating rooms, hospitals may (1) employ assistants-at-surgery, eliminating the need for the surgeons to hire their own assistants, or (2) arrange for health professionals in independent practice to serve as assistants.
There is no widely accepted set of uniform requirements for experience and education that the health professionals who serve as assistants-at-surgery are required to meet. The health professions whose members provide assistant-at-surgery services have varying educational requirements. No state licenses all the health professionals who serve as assistants-at-surgery. Furthermore, the certification programs developed by the various nonphysician health professional groups whose members assist at surgery differ.
Physician Assistants who work as surgical assistants can complete a surgical physician assistant residency program to specialize as surgical physician assistants. Nursing graduates filling the role of surgical assistants must have completed the registered nurse first assistant program and be certified as RNFA's. Foreign Medical Graduates must have surgical training and hold a nationally recognized surgical assistant certificate.
In 2002 the Medicare Payment Advisory Commission did an analysis for Medicare coverage of surgical technologists when functioning as first surgical assistants. The commission recommended that Congress should not expand the list of providers eligible to bill Medicare for first assistant services to include certified surgical technologists. The types of nonphysician practitioners who perform first assistant services vary in their education and training requirements. For example, clinical nurse specialists are licensed registered nurses with a master’s degree. Although some physician assistants are graduates of certificate or associate degree programs, most states require recent trainees to have a bachelor’s degree for licensure. In contrast, surgical technologists may have nine months to two years of additional education after high school; in order to be certified, they must document two years of first assisting experience (or complete a first assistant program) and at least 350 cases. In addition, the duties and scope of practice of first assistants vary and are dictated in part by the surgeon, the type of surgery, the hospital, and state law or regulations. This lack of a consistently defined list of duties and skills complicates Medicare’s job of determining qualified providers.
The educational requirements for certification, registration and licensure for surgical assistant vary greatly depending on the professional credential obtained by the practitioner. Surgical assistants come from diverse healthcare and medical backgrounds and include such professionals as medical doctors, surgical residents, certified surgical assistants, physician assistants, registered nurses, licensed surgical assistants and graduates of surgical first assistant training programs. Educational backgrounds for surgical assistants are: associate, bachelor or masters degrees plus surgical assistant educational program completion, physician assistant certification with surgical residency, nursing degree plus registered nurse first assistant program completion or foreign medical graduate with surgical assistant certification completion. In addition to educational degrees the surgical assistants must complete clinical surgical case requirements with surgeon recommendations to sit for a nationally recognized examination in order to be certified, registered or licensed.
For surgical assistants with an associate degree they can complete a CAAHEP program to sit for a nationally recognized surgical assistant examination. The Commission on Accreditation of Allied Health Education Programs (CAAHEP) has established and published guidelines for surgical assistants who want to be certified by completing a certified educational program. Programs which meet these criteria are able to be reviewed and obtain accreditation through CAAHEP. Currently, there are several schools in the United States which offer CAAHEP accredited surgical first assistant training programs. Additional programs are approved by the National Surgical Assistant Association (NSAA) and the American Board of Surgical Assistants]] (ABSA). These programs typically last between 12 and 24 months and lead to a Certificate of Completion or Associate of Science degree. There is one Master level educational programs for surgical assistants at East Virginia Medical School.
Regulation of Surgical Assistants is done through licensure, certification, or registration. Each of these regulations have different levels of educational and professional experience requirements. Licensure – applicants typically are required to pass a Board-approved professional education program and exam ◦ A Board-issued license is typically granted in order to practice (with possible exceptions for students and “grandfathered” providers). ` Certification – applicants may be required to pass a Board-approved professional education program and exam or to satisfy the requirements of a certifying body (and the Board may stipulate the certifying body or bodies that are approved) ◦ Unless certification to practice is mandatory, providers may be allowed to practice without having any certification. ` Registration – applicants typically are required to provide their names and practice locations only.
Surgical Assistants are credentialed as Surgical PA's, RNFA's and Surgical Assistants (SA). SA's are certified nationally by the American Board of Surgical Assistants (ABSA), the National Board of Surgical Technology and Surgical Assisting (NBSTSA), and the National Surgical Assistant Association (NSAA). Some states, such as Kentucky, Texas, Colorado, Illinois, and Washington DC have additional state registration and licensure requirements. When deciding which professional certification, registration or licensure to pursue, the surgical assistant practitioner should consider local legislation, facility policy, and regional practice as some credentials are preferred over others in different parts of the United States. Additionally, local laws and hospital policies may favor or require a specific credential to practice as a Surgical Assistant.
Only two states have laws that regulate this profession: Texas established a licensure program in 2001 for "licensed surgical assistants," and beginning July 1, 2004, surgical technologists are required to meet registration requirements to practice in Illinois (2003 Ill. Laws 93-0280, adding 225 Ill. Stat. 130/1 - 130/170). To be licensed as a surgical assistant the applicant must have completed educational degree, surgical clinical training and surgical cases in US under the supervision of a licensed surgeon. The Texas Medical Board grants surgical assistants licensure to become licensed surgical assistants (LSAs) once the following requirements have been met:
- Minimum education of an Associate's Degree from a 2 or 4-year institution or greater:
- One of the four educational pathways outlines below:
- Graduation from a CAAHEP accredited Surgical Assisting educational program
- Registered Nurse First Assisting program
- Surgical Physician Assistant program
- Full Medical School (and receipt of a Physician's Degree).
- Worked 2000 hours within the last 3 years as a Surgical Assistant.
- Taken and passed one of the three national certifying exams.
- Have a current national Board Certification.
- Have never been convicted of a felony or crime of moral turpitude.
- 100% honest and forthcoming on the application.
All of the above are requirements to become licensed as a Surgical Assistant in Texas.
The surgical assistant is a critically important participant in the majority of surgical procedures performed in the US. The patient’s time spent under anesthesia is reduced when the surgeon and surgical assistant are working in unison, sharing surgical tasks during the procedure. The surgical assistant’s vast knowledge, honed technical skills, and in-depth experience assisting with surgical procedures have a positive impact on the time-efficiency of the surgery, and ultimately on the patient’s recovery process.
- "Medicare: Payment Changes are Needed for Assistants-at-Surgery. Report to Congressional Committees. GAO-04-97.". U.S. General Accounting Office. (Not copyrighted). Retrieved 25 October 2014.
- National Uniform Claim Committee
- Royal Australian College of Surgeons surgical assistant position paper http://www.surgeons.org/media/304233/pos_2012-08-31_surgical_assistants.pdf
- Australian Association of Medical Surgical Assistants http://www.aamsa.org.au/index.php
- Royal College of Surgeons https://www.rcseng.ac.uk/publications/docs/rcs-position-statement-surgical-assistants 2011
- "The Evolution of Surgery The Story of 'Two Poems'". Journal of the American Medical Association. Retrieved 25 October 2014.
- Ein, Sigmund H.; Amurawaiye, Emmanuel; Ein, Arlene. "Recycling the retired surgeon: Surgical assisting—A Canadian’s perspective". American College Of Surgeons. Retrieved 25 October 2014.
- "Allied Health: Surgical Assistant". American Medical Association. Retrieved 16 June 2011.
- "Surgical Assisting". Association of Surgical Assistants. Retrieved June 5, 2011.
- "Allied Health: Surgical Assistant". American Medical Association. Retrieved 16 June 2011.
- "NSAA Salary Survey Letter". National Surgical Assistant Association. Retrieved June 5, 2011.
- Medicare Payment Advisory Commission 2002 analysis for Medicare coverage of surgical technologists when functioning as first surgical assistants. http://www.medpac.gov/search-results?WordQuery=surgical+assistants
- "Surgical Assistant Programs". Surgical Assistant Resource. Retrieved 16 June 2011.
Links to US surgical assistant certification requirements
- ABSA grants the Surgical Assistant-Certified (SA-C) credential to candidates who meet these criteria:
- NBSTSA is the only professional credential accredited by the National Commission for Certifying Agencies (NCCA) and grants the Certified Surgical First Assistant (CSFA, formally CFA) credential to candidates who meet these criteria:
- NSAA is the oldest professional certification agency for SFAs and grants the Certified Surgical Assistant (CSA) credential to candidates who meet these criteria.
Surgical Assistants Analysis http://www.gao.gov/products/GAO-04-97
Eastern Virginia Medical School http://www.evms.edu/education/masters_programs/surgical_assistant_program/
Surgical Assistant Billing Practices http://www.naot.org/sections/pdfs/an12/an12satbrout3bartczak.pdf
American College of Surgeons http://bulletin.facs.org/2012/04/a-canadians-perspective/
Journal American Medical Association http://jama.jamanetwork.com/article.aspx?articleID=1918827
Royal College of Surgeons https://www.rcseng.ac.uk/publications/docs/rcs-position-statement-surgical-assistants
Royal Australian College of Surgeons http://www.surgeons.org/media/304233/pos_2012-08-31_surgical_assistants.pdf
Australian Association of Medical Surgical Assistants http://www.aamsa.org.au/index.php
National Uniform Claim Committee http://www.nucc.org/index.php?option=com_content&view=featured&Itemid=101