What might we be missing out on today that could help improve the delivery of modern day anesthesia? It is a very exciting time as many explore research insights that could reshape anesthesia care and our understanding of it moving forward.
Anesthesia use began over 175 years ago, first by Crawford Long and Jefferson Georgia, then William Morton and the Ether Dome. It started as a simple practice with some ether on a handkerchief or in a glass jar, but quickly became a worldwide phenomena with well researched standards of practice and ever-evolving approaches. Eventually, anesthesiologists developed complex ways to monitor sedated patients and precise ways to measure the proper dose of anesthesia.
Throughout the nearly two centuries of advances in anesthesia drugs, practice standards and patient safety, the mystery of exactly how anesthesia works the way it does has never really been unravelled. As Dr. Kathryn McGoldrick explains, “We understand some of the physiologic consequences in terms of circulation, blood pressure and respiration, but what it’s doing to the brain we still don’t know.”
That was until very recently. Now there is a growing body of research that is deciphering the code of anesthesia use and the human brain by monitoring electrical brain patterns. Dr. Emery Brown’s research with the use of the EEG has shown there are many different neurocircuits and avenues that drugs can intersect to cause unconsciousness. With so many circuits involved and different pathways to administer anesthesia, it becomes very complicated.
Studying the brain patterns of patients in states of sleep, coma and sedated, Dr. Brown has found these three states to be very different. He suggests using a neuroscience approach to administering anesthesia will provide more personalization for each patient. This will also help to identify the best role for the different anesthesia specialists.
Performing at Optimal Capacity
“It’s time to redesign anesthesia care delivery,” according to Karen Sibert, MD, FASA, UCLA Department of Anesthesiology and Perioperative Medicine. In a recent article she states, “We should be charting the course, not executing every change of sail. We should be performing the diagnostic and intellectual work of physicians all the time, not just some of the time. If we don’t, we shouldn’t be surprised if we continue to lose control over the future of our profession. It’s way too expensive to pay a physician to do the tasks of a nurse.”
Nurses argue that they can perform many hands-on tasks of anesthesia care just as well as physician anesthesiologists can. So, why are we still doing those tasks when other physicians don’t do likewise?
Let’s look all the way back to the second half of the 19th century, when the use of ether, chloroform, and nitrous oxide for surgical anesthesia spread rapidly. During the American Civil War, according to medical historian Shauna Devine, PhD, “Union records show that of more than 80,000 operations performed during the war, only 254 were done without some kind of anesthetic.” Most often, the anesthetic was chloroform. “The practice was for the operating physician’s assistant to place the chloroform on a piece of cotton or towel, which had been fashioned into a cone, and then placed over the patient’s nose and mouth, preferably in the open air.”
Outcomes were variable and sometimes tragic. In the early 20th century a true scientist, Ralph Waters, MD, devoted his career to anesthesiology, joined the faculty of the new medical school at the University of Wisconsin in 1927, and founded the first anesthesiology residency program. However, the model of anesthesia care delivery as the practice of nursing by then was well established in America. It took decades for academic anesthesiology programs to proliferate in the U.S., but the model in America continued to be one person at the bedside, giving medications and monitoring the patient – and that person could be either a physician or a nurse.
In an ASA Monitor article a few years ago, authors Marc Steurer, MD, DESA, and Michael Ganter, MD, DESA, examined differences in the delivery of anesthesia care in the U.S. compared with Europe. Among the chief disparities are that most European countries mandate two professionals to provide anesthesia (physician and assistant, e.g., certified registered anesthesia nurse) while in the U.S. the anesthesia physician may provide anesthesia alone without a trained assistant. Also, in most western European countries, the clinical anesthesiologist is more longitudinally involved in patient care. Not only do anesthesiologists govern the prehospital portion of emergency medicine, but also once the intrahospital care begins. Together with the primary team, an anesthesiologist is usually involved in the care of the most ill medical and surgical patients in the hospital. Also in those settings, the anesthesiologist stays with the patient for the entire critical period and provides a very helpful continuum of care. In Europe there is also a heavy involvement of anesthesiologists in both medical and surgical ICUs. Additionally, operation room (OR) management, preoperative and pain clinics as well as services for palliative care have been a mainstay for even small anesthesia departments for a long time. This contrasts to most U.S. practices, where anesthesiologists have predominantly focused on the intraoperative and critical care period. The broader and more longitudinal scope of practice positions European colleagues well for the development of the field.
These European anesthesiologists are actually functioning as physicians.
The ICU Model of Care
“We need to do a total restructure of procedural care to function along the same lines as ICU care, where physicians direct the care of multiple patients. Pharmacists and registered nurses – sedation nurses and critical care nurses – could be involved as part of a cost-effective bedside care team, flexing the composition of the team to the complexity of the case. Cardiologists, GI and ER physicians supervise RNs giving sedation; why don’t we?” states Dr. Sibert.
With today’s technologies, it’s possible to monitor multiple sites at the same time. You don’t have to stay tethered to your patient with a plastic earpiece and a length of IV tubing to listen for breath sounds. Physicians who specialize in anesthesiology can be freed up to do actual physician work, putting medical diagnostic skills to use and functioning as team leaders, not as pawns on the OR chessboard interchangeable with nurse anesthetists.
ACT vs. CAT Models of Care
The Anesthesia Care Team model (ACT) is a more compressed version of the ICU model.The ASA defines the ACT model as “care that is led by a physician anesthesiologist who directs or supervises care of qualified anesthesia personnel and meets the ASA Guidelines for the Ethical Practice of Anesthesiology.” The anesthesiologist may delegate monitoring and some appropriate tasks, but retains overall responsibility for the patient.
This practice of anesthesiology includes the evaluation and optimization of preexisting medical conditions, the perioperative management of coexisting disease, the delivery of anesthesia and sedation, the management of postanesthetic recovery, the prevention and management of periprocedural complications, the practice of acute and chronic pain medicine, and the practice of critical care medicine. This care is personally provided, directed, and/or supervised by the physician anesthesiologist.
The Collaborative Anesthesiology Team model (CAT) is local, optimal teams of CRNAs, physician anesthesiologists or both. It is the anesthesiology version of “the right provider, at the right time, for the right patient.”
The best mix of providers is based on the following factors:
- Resources (i.e., the characteristics of the local available providers)
- Needs of the patients and facility
- All anesthesia providers are licensed, but they’re not all the same. There are no care teams designed predominantly around licensure, they’re designed based on creating value for patients
Fundamentally, the CAT is based on the idea that if true professional collaboration is to exist, each needs to recognize the other’s autonomy, which includes statutory independence, followed by specific model decisions being made at the local level. This allows effective interprofessional collaboration to occur. Collaboration and autonomy are not mutually exclusive – in fact, they are both necessary if anesthesiology professionals are going to meet the challenges of the future.
The CAT is a model that respects both major professions in anesthesiology, CRNAs and physician anesthesiologists. They are not the same – they have different professional backgrounds and licenses. However, the professions do have significant overlap in the scope of services offered.
There continues to be an ongoing push for medical progress, not only for progress in our profession itself, but more importantly for the sake of future patients. The bottom line is that during and after COVID-19, the country needs all anesthesiology professionals to make their full contribution to patient care. That’s what maximizes value. Collaborative anesthesiology teams, whatever their makeup, are the future.
The Etherist: The Next Chapter of Anesthesia. anesthesiologynews.com
When, If Ever, Will We Redesign Our Work? apennedpoint.com
The Collaborative Anesthesiology Team Model of Care. anesthesiologynews.com