An anesthesiologist assistant is an advanced non-physician provider who provides anesthesia under the medical direction of a physician anesthesiologist. In the United States, such providers are termed certified anesthesiologist assistants or CAAs and are known professionally as anesthesists.
Anesthesiologist assistants are qualified by advanced graduate medical education and clinical training to work in collaboration with an anesthesiologist in developing and implementing the anesthesia care plan. The anesthesiologist assistant works under the medical direction of an anesthesiologist as an anesthesist and is an integral member of the anesthesia care team. Anesthesiologist assistants obtain pre-anesthetic health histories, perform preoperative physical exams, order and interpret laboratory and radiological studies, order preoperative medications prior to surgery, establish non-invasive and invasive monitors, use advanced airway skills to intubate patients, administer medications, IV fluids and blood products, evaluate and treat life-threatening situations, and execute general, local, and regional anesthetic techniques, as delegated by the anesthesiologist.
Anesthesiologist assistants generally work in the hospital setting but can work at any location where they can be medically directed by anesthesiologists such as pain clinics, dental offices, and outpatient surgical centers. Anesthesiologist assistants work in all facets of surgical environments such as cardiac surgery, neurosurgery, transplant surgery, and trauma surgery centers. The incorporation of anesthesiologist assistants into anesthesia care teams across the country is a dynamic process, and currently there are sixteen states, as well as Washington D.C. and the Veteran’s Affairs Medical System where CAAs practice. In each of these states, the anesthesiologist assistant falls under the regulatory authority and licensing of the State Board of Medicine.
As of 2017[update] there are twelve anesthesiologist assistant training programs in the United States all of which offer degrees at the Master’s level. Approximately 97% of currently practicing anesthesiologist assistants hold a Master’s degree (some early anesthesiologist assistant graduates held Bachelor’s degrees). All newly credentialed and future anesthesiologist assistants must complete an accredited Master’s program for anesthesiologist assistants. Upon completion of the educational program, graduates must sit for a credentialing exam that is co-validated by the National Board of Medical Examiners and National Commission for Certification of Anesthesiologist Assistants. All anesthesiologist assistant programs are credentialed by the Commission on Accreditation of Allied Health Educational Programs (CAAHEP).
History of the profession
In the mid-1960s, the United States faced a shortage of qualified anesthesia professionals. This shortage prompted Doctors Joachim S. Gravenstein, John E. Steinhaus, and Perry P. Volpitto to evaluate the educational pathways of both anesthesiologists and nurse anesthetists. After their study was completed, a new educational track was designed to train a new type of non-physician anesthesia provider, who would be called an anesthesiologist assistant. The physicians hoped to achieve two goals that would make their new educational paradigm unique from what already existed in the field of anesthesia. First, they wanted to train a non-physician anesthesia provider with a premedical background, so that the individual would be readily eligible for upward mobility into medical school later in their career. Second, the new anesthesia professional would always remain under the supervision of an anesthesiologist. The physicians’ plans came to fruition when the first AA training programs formed at Emory University in 1969. Today these goals are still upheld: 10% of AAs choose to later go to medical school and 100% of practicing AAs still work under the medical direction of an anesthesiologist.
A master’s level education is required to train anesthesiologist assistants to collect patient data, assist in the evaluation of patients’ physical and mental status, document the surgical procedures planned, and administer the therapeutic plan for patient care that has been formulated with the anesthesiologist. There are eleven programs available for the Anesthesiologist Assistant Master Degree in the United States. All programs are accredited by the Commission on Accreditation of Allied Health Education (CAAHEP).
- Emory University in Atlanta, GA (Est. 1969)
- Case Western Reserve University in Cleveland, OH (Est. 1970)
- South University in Savannah, GA (Est. 2004)
- Nova Southeastern University in Fort Lauderdale, FL (Est. 2005)
- University of Missouri–Kansas City in Kansas City, MO (Est. 2008)
- Nova Southeastern University in Tampa, FL (Est. 2009)
- Case Western Reserve University in Houston, TX (Est. 2010)
- Case Western Reserve University in Washington, D.C. (Est. 2012)
- University of Colorado in Denver, Colorado (Est. 2013)
- Quinnipiac University in Hamden, Connecticut
- Medical College of Wisconsin in Milwaukee, Wi (Est. 2016)
- Indiana University School of Medicine in Indianapolis, IN (Est. 2017)
To enroll in an AA program, candidates must complete a bachelor’s degree and obtain a minimum of eight hours of documented anesthesia exposure by observation in the operating room though absolutely no clinical background is required. Additionally, some of these programs require premedical coursework and an entrance exam (either GRE or MCAT, MCAT preferred).
Program lengths range from 24 to 28 months with didactic and clinical instruction. Didactic training includes courses such as physiology, pharmacology, airway management, simulation laboratory, Basic Life Support (BLS) certification, Pediatric Advanced Life Support (PALS) certification, Advanced Cardiac Life Support (ACLS) certification, anatomy, monitoring, and applied principles and practices. In addition to class work, programs include 2000 to 2700 clinical hours per student. Students gain preoperative, intra-operative and post-operative experience with a variety of patients in a variety of surgical settings. In addition, each program may have additional educational experiences; for example, Nova Southeastern University provides students with courses on scientific research and publishing. All programs must have at least one board-certified, licensed anesthesiologist serving as a director. Additionally, each AA program must be based at, or in collaboration with, a university that has a medical school.
Because in some cases a premedical undergraduate education is required for acceptance into an Anesthesiologist Assistant program, some AAs are readily eligible to apply to medical school. This facet of the AA educational pathway distinguishes AAs from other non-physician anesthesia providers such as nurse anesthesists who train under a nursing model of education as opposed to the medical model for the AA.
Graduates from an accredited educational program are eligible to take the initial certifying examination and can do so up to 6 months before graduating from the program. The certifying examination for anesthesiologist assistants is a written exam administered by the National Board of Medical Examiners (NBME), which is contracted by the National Commission for Certification of Anesthesiologist Assistants (NCCAA). Once successfully completed, the NCCAA will award a time-limited certificate to each candidate. In order to maintain certification, anesthesiologist assistants need to register for 40 hours of Continuing Medical Education (CME) every two years and successfully complete a Continued Demonstration of Qualifications (CDQ) examination every six years.
Scope of practice
Anesthesiologist assistants are highly trained medical professionals who work under the direction of licensed anesthesiologists as integral members of the Anesthesia Care Team (ACT) and are considered to have the same scope of practice and privileges as a nurse anesthesist. The following list is obtained from the American Academy of Anesthesiologist Assistants (AAAA), which states anesthesiologist assistant responsibilities may include but are not limited to:
- Obtaining an appropriate and accurate pre-anesthetic health history; conducting a physical examination and documentation of relevant information in the patient anesthesia records.
- Perform necessary diagnostic laboratory and radiological studies, such as drawing arterial and venous blood samples and ordering x-rays.
- Establishing non-invasive and/or invasive monitors.
- Implementing regional anesthesia techniques when appropriate.
- Administer induction drugs, maintain and adjust appropriate anesthetic depth, manage additional treatment and deliver continuous anesthesia care and monitoring into and during the postoperative recovery phase.
- Operate and analyze advanced monitoring methods, such as pulmonary artery catheterization, electroencephalographic spectral analysis, echocardiography etc.
- Apply advanced life support practices, such as high frequency ventilation and intra-arterial cardiovascular assist devices.
- Perform post-anesthesia rounds by documenting patient progress notes, collecting and recording case summaries, and by transcribing standing and specific orders.
- Evaluate life-threatening situations, such as cardiac arrest, and treat with protocols established within BLS, ACLS, and PALS.
- Perform anesthetic functions in intensive care units, pain clinics, and other settings.
- Train and supervise anesthesia personnel in the calibration, troubleshooting, and employment of patient monitors.
- Delegate administrative duties in an anesthesiology practice or anesthesiology department in such functions as the management of personnel, supplies, medications, and devices.
- Contribute in the clinical instruction of others.
The AA scope of practice may differ slightly in relation to local practice, and is usually defined by the medically directing anesthesiologist, the hospital's clinical protocol procedures, the state’s board of medicine, and state regulations.
The American Medical Association (AMA) states that "AAs are most commonly employed in larger facilities that perform procedures such as cardiac surgery, neurosurgery, transplant surgery, and trauma care." Studies by the AMA found entry-level salaries for 2006 Anesthesiologist Assistant graduates to be between $100,000 and $130,000 for the 40-hour work week plus benefits and consideration of on-call activity. They also found the high end of the salary range to be around $180,000 to $210,000 for experienced anesthesiologist assistants. Salaries vary by region and individual employer.
Anesthesiologist assistants are currently able to work in sixteen states plus Washington, D.C. and the US territory of Guam either by licensure or through physician delegation. AAs are recognized by the federal government and are authorized to work at all Veteran Affairs hospitals using the TRICARE insurance program.
Licensure defines the practice of AAs and is achieved through state law or by approval of the individual state board of medicine. Physician delegation is achieved through recognition of AAs by the state board of medicine or through statutes included in the state's medical practice act. The board of medicine affords Anesthesiologist's the right to delegate the responsibilities of their realm of practice to qualified individuals. Delegating authority requires that the physician remain ultimately responsible for the patient. In all states, the practice of anesthesiologist assistants is guided by the board of medicine. Any attempt to employ AAs under delegating authority should be made through the individual state's board of medicine.
States where AAs practice through license and certification:
- District of Columbia
- New Mexico
- North Carolina
- South Carolina
States where AAs practice through physician delegation:
In the U.S. federal government
Anesthesiologist Assistants are employed at Veteran Affairs (VA) and Department of Defense facilities under the TRICARE health system since Dec 22, 2006.
The Veterans Health Administration Handbook 1123 on Anesthesia Service, includes the profession of anesthesiologist assistant as an allied health professional. Information in regards to required qualifications, coverage criteria, billing, and payment for Medicare services under the TRICARE program for anesthesiologist assistants is published by the Department of Health and Human Services.
- Anesthesia provision in the US, a brief description of the different anesthesia providers in the US.
- Physicians' assistant (anaesthesia)
- "What is an Anesthesiologist Assistant?". The AA Profession. American Academy of Anesthesiologist Assistants. Retrieved 26 April 2012.
- "Facts About AAs". American Academy of Anesthesiologist Assistants. Archived from the original on 13 April 2012. Retrieved 26 April 2012.
- "AA Educational Programs". American Academy of Anesthesiologist Assistants. Retrieved 8 March 2017.
- "Anesthesiologist Assistant" (PDF). Health Care Careers Directory 2008-2009. American Medical Association. Retrieved 26 April 2012.
- "Human Resources Management Letter No. 05-06-12: Qualification Guidelines for the Position of Anesthesiologist Assistant" (PDF). Department of Veterans Affairs. Retrieved 26 April 2012.
- Gravenstein, J.S.; J.E. Steinhaus (March 2003). "The origin of the Anesthesiologist Assistant". ASA Newsletter. 67. Archived from the original on 2012-07-14. Retrieved 26 April 2012.
- "Standards and Guidelines for the Accreditation of Educational Programs in Anesthesiologist Assistant" (PDF). CAAHEP. Retrieved 26 April 2012.
- "Accreditation Review Committee for the Anesthesiologist Assistant". Commission on Accreditation of Allied Health Education Programs. Retrieved 26 April 2012.
- "Anesthesiologist Assistants Program". Nova Southeastern University. Retrieved 26 April 2012.
- "Master of Science in Anesthesia Program". Case Western Reserve University. Retrieved 26 April 2012.
- "Master of Medical Science Program in Anesthesiology". Emory University. Retrieved 26 April 2012.
- Amburgey, B.; M. Fordham; B. Payne; M. Trebelhorn (February 2007). "A Study of Anesthesiologist Assistants: Research Report No. 337" (PDF). Frankfort, KY: Kentucky Legislative Research Commission. Retrieved 26 April 2012.
- "Certification Process". American Academy of Anesthesiologist Assistants. Archived from the original on 3 August 2012. Retrieved 26 April 2012.
- "National Commission for Certification of Anesthesiologist Assistants". NCCAA. Retrieved 26 April 2012.
- "Types of Careers in Anesthesiology". Careers in Healthcare. American Society of Anesthesiologists. Archived from the original on 18 April 2012. Retrieved 26 April 2012.
- "Health care income ranges". Careers in Health Care. American Medical Association. Archived from the original on April 26, 2012. Retrieved 27 April 2012.
- "States with Licensure" (PDF). Facts About AAs. AAAA. Archived from the original (PDF) on 17 April 2012. Retrieved 26 April 2012.
- "Medicare Information for Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants" (PDF). Centers for Medicare and Medicaid Services. Department of Health and Human Services. September 2011. Retrieved 27 April 2012.
- Handbook of Occupational Groups and Families (PDF). US Office of Personnel Management. 2009.
- American Academy of Anesthesiologist Assistants (AAAA)
- National Commission for Certification of Anesthesiologist Assistants (NCCAA)
- Commission on Accreditation of Allied Health Education Programs (ARC-AA)
- A Study of Anesthesiologist Assistants by the Kentucky Legislative Research Commission
- Anesthesiologist Assistants: Qualified Members of the Anesthesia Care Team
- Comparison of AAs and CRNAs
- Anesthesiologist Assistants: Being a (Care) Team Player
- Federal Government: Anesthesiologist Assistants
- VAs and AAs