Transforming the Delivery of Operative Anesthesia Services in Ontario

Transforming the Delivery of Operative Anesthesia Services in Ontario Report & Recommendations of the Operative Anesthesia Committee May 2006

TABLE OF CONTENTS SUMMARY OF RECOMMENDATIONS... 1 EXECUTIVE SUMMARY... 3 BACKGROUND AND CONTEXT... 4 OPERATIVE ANESTHESIA COMMITTEE... 6 UPDATE ON ACADEMIC ANESTHESIA SERVICES IN ONTARIO... 8 ANESTHESIA CARE TEAM... 10 Context...10 Description of ACT Model...10 Anesthesia Assistants...12 Benefits of the ACT Model...13 Challenges with the ACT Model...14 NEXT STEPS... 19 APPENDIX 1 - STATUS REPORT ON ANESTHESIA SERVICES AT ONTARIO S ACADEMIC HEALTH SCIENCE CENTRES... 20 Report & Recommendations of the Operative Anesthesia Committee

SUMMARY OF RECOMMENDATIONS The 2004 Physician Services Agreement provided for the formation of the Operative Anesthesia Committee (OAC) in recognition of the pressures facing operative anesthesia in Ontario s hospitals. The OAC is to provide recommendations to support stable and adequate access to anesthesia services in Ontario hospitals. The Agreement provides $5 million in new funding to support operative anesthesia, based on the Committee s recommendations. After considerable deliberation and wide ranging consultation, including the OMA Anesthesia Section meeting in September 2005, the OAC: 1) Asked Dr. Marshall to update his 2003 review of anesthesia services at Ontario s AHSCs and to gain an understanding of the current use of, support for and the potential of the Anesthesia Care Team (ACT) concept to address the anesthesia shortage. 2) Defined the ACT model, outlining roles, responsibilities and training requirements. In addition, the OAC identified the benefits and challenges associated with this new approach to providing anesthesia services. 3) Established a costing sub-committee to explore current funding of operative anesthesia, estimate the impact of investments in the 2004 Physician Services Agreement and evaluate additional options to better support operative anesthesia. Based on the work outlined above, a paper entitled Transforming the Delivery of Operative Anesthesia Services in Ontario was developed by the OAC. This document recommends: #1 Formal introduction of the ACT model Establish ACT demonstration sites in Academic Health Sciences Centres (AHSCs) and community hospitals. Evaluate the demonstration sites, modify the model and set minimum requirements for viability and expected outcomes. Explore different funding models for ACTs (e.g. APP, AFP, fee-for-service). Roll out the ACT model across the province. #2 Widespread training and use of anesthesia assistants in the delivery of anesthesia services in a variety of practice settings (e.g. AHSCs and community hospitals) Bring together a group of stakeholders to develop a common definition of anesthesia assistant, define their roles and responsibilities and agree on training requirements. Introduce and/or expand training opportunities across Ontario. #3 Changes to the Schedule of Benefits, which will allow the use of supervision in a fee-for-service practice environment and encourage the provision of operative anesthesia services Replace the anesthesia fee (base & time units) with a supervisory payment when someone other than an anesthesiologist provides anesthesia care. Reinvest the savings achieved through this change to the Schedule of Benefits in other anesthesia services. Report & Recommendations of the Operative Anesthesia Committee Page 1 of 101

Further support the provision of operative anesthesia services through other specified investments. The Committee agreed that the above-noted recommendations must be considered in their entirety and not as a collection of stand-alone recommendations. The Committee is now focused on costing the proposed recommendations: ACT model demonstration sites for AHSCs and community hospitals Supervisory payments Schedule of Benefit changes (e.g. triple time units for intra-operative anesthesia) The OAC plans to finalize all documents and recommendations for submission to the Physician Services Committee by June 2006. Report & Recommendations of the Operative Anesthesia Committee Page 2 of 101

EXECUTIVE SUMMARY For several years the Canadian anesthesiology community has been concerned about a growing shortage of anesthesia personnel. This national shortfall was made particularly relevant to Ontario in light of the provincial government s announcement of its Wait List Initiative in the Fall of 2003. Even though anesthesiologists sacrificed academic activity to ensure the provision of clinical services, surgical wait times continued to grow, operating rooms were closed and surgeries cancelled. Despite recent efforts to address the situation, including increasing medical school enrollment and anesthesia residency training positions and investing in academic anesthesia services, the anesthesia shortfall continued to grow. The Ontario Medical Association (OMA) and the Ministry of Health and Long-Term Care (MOHLTC) recognized that immediate action was required and called for the establishment of the Operative Anesthesia Committee (OAC) in the most recent Physician Services Agreement. To support stable and adequate access to anesthesia services in Ontario hospitals, the OAC is calling for the formal introduction of Anesthesia Care Teams (ACTs). The ACT is an innovative model of care which calls for a significant change to the way anesthesia services are currently provided. Specially trained other health professionals assist in the provision of anesthesia services under the direct supervision of an anesthesiologist. This model of care will provide better access to anesthesia services in a more efficient and cost cost-effective manner. It will also allow all ACT team members to fully utilize their skills and experience in the provision of anesthesia services, a key component in transforming the provision of health care. Outlined below are the Committee s 3 major recommendations. The steps suggested to implement these recommendations are detailed in the report: #1 Formal introduction of the ACT model Establish ACT demonstration sites in Academic Health Sciences Centres (AHSCs) and community hospitals. Evaluate the demonstration sites, modify the model and set minimum requirements for viability and expected outcomes. Explore different funding models for ACTs (e.g. APP, AFP, fee-for-service). Roll out the ACT model across the province. #2 Widespread training and use of anesthesia assistants in the delivery of anesthesia services in a variety of practice settings (e.g. Academic Health Sciences Centres and community hospitals) Bring together a group of stakeholders to develop a common definition of anesthesia assistant, define their roles and responsibilities and agree on training requirements. Introduce and/or expand training opportunities across Ontario. #3 Changes to the Schedule of Benefits, which will allow the use of supervision in a feefor-service practice environment and encourage the provision of operative anesthesia services Replace the anesthesia fee (base & time units) with a supervisory payment when someone other than an anesthesiologist provides anesthesia care. Reinvest the savings achieved through this change to the Schedule of Benefits in other anesthesia services. Further support the provision of operative anesthesia services through other specified investments. Report & Recommendations of the Operative Anesthesia Committee Page 3 of 101

BACKGROUND AND CONTEXT Shortage of Anesthesiologists The shortage of anesthesiologists is a growing concern across all jurisdictions in and outside of Canada. Many studies have examined the supply of anesthesiologists and have confirmed that there are insufficient numbers to meet current and predicted future demands. Two recent Canadian studies found the current supply of anesthesiologists to be inadequate and forecast an increasing deficit over time. While the magnitude of the problem varies from province to province and continues to worsen, Ontario appears to have the largest absolute shortfall of anesthesiologists in Canada. The Ryten Report, commissioned by the Association of Canadian University Departments of Anesthesia, identified an 8% shortfall of anesthesiologists in Canada (114 in Ontario) in 2000. This same study projected the deficit would grow to 656 anesthesiologists in Canada (459 in Ontario) by 2016. The 2002 Engen Study identified an immediate need for 228 full-time equivalent (FTE) anesthesiologists in Canada and suggested that by 2007 560 FTE anesthesiologists would be required. There are several factors associated with the increasing shortage of anesthesiologists in Canada: The 1991 Barer Stoddart report, Toward Integrated Medical Resource Policies for Canada, resulted in an 11.3% reduction in Canadian medical school enrollment over three years in the early 1990s. This was followed by a similar reduction in postgraduate positions in 1997. The opportunity for pursuing specialty training after becoming licensed as a physician in Ontario (re-entry) was closed with the introduction of the Regulated Health Professions Act in 1993. Prior to 1993, physicians could get a license to practice medicine in Ontario once they completed their 1-year rotating internship. Under this system, licensed physicians were able to access residency positions to complete specialty training and a significant number of residency spots were available for practicing physicians returning to training. The Act eliminated the 1-year rotating internship as a pathway to licensure and required that physicians complete either a 2-year family medicine program or a 4-5 year specialty training program in order to qualify for independent practice. In doing so, the informal pathway to reentry was closed. Effective July 1997, the Royal College of Physicians and Surgeons of Canada no longer recognized non-north American medical school training as meeting part of the requirements for its own specialty training programs thereby limiting the supply of International Medical Graduates. Impact on Operative Anesthesia The anesthesiologist shortage in Ontario has resulted in growing surgical wait times, cancelled surgeries, operating room closures and delays in diagnostic testing. The role of the anesthesiologist outside the operating room has also expanded over time and this has compounded the negative impact on operative anesthesia. The institution of same-day admission policies in the 1990s imposed the need for pre-anesthetic clinics to assess and evaluate patients before surgery. Simultaneously, the development of sophisticated post operative pain services has resulted in Report & Recommendations of the Operative Anesthesia Committee Page 4 of 101

multiple post-operative visits by anesthesiologists, further encouraged by fee-for-service remuneration. Recent Efforts to Address Ontario Shortfall Since the late 1990s, a number of steps have been taken to address the anesthesiologist shortage in Ontario. These efforts include: Ontario medical school enrollment has increased by 34%, growing from 526 positions in 1994 to 704 positions in 2004. Ontario anesthesia residency training positions have increased by 32%, growing from 140 positions in 1998 to 185 positions in 2004. International Medical Graduates (IMGs) are now recruited under academic certificates issued by the College of Physicians and Surgeons of Ontario. A formal re-entry program has been established beginning with 25 positions for both third year family medicine and specialties. In 2000, a further 15 spots were added bringing the total to 20 spots for family medicine and 20 spots for specialties. Physicians are required to return a maximum of two years in an under-serviced area in return for government funded training. $6 million annually was invested in academic anesthesia services beginning in 2003 resulting in the recruitment of 39 FTE anesthesiologists at Ontario s Academic Health Science Centres (AHSCs). Dr. John Marshall was asked to review anesthesia services, staffing, compensation and workload at Ontario s AHSCs and provide recommendations that led to this new investment. An Anesthesia Assistant Graduate Certificate Program was launched at the Michener Institute. This is a joint initiative involving the Michener Institute and the University of Toronto. The program, which originally offered basic or technical training, has recently expanded to include advanced or clinical training. Applicants skills and experience are assessed to determine their point of entry into the program. The Operative Anesthesia Committee was established in June 2005. Report & Recommendations of the Operative Anesthesia Committee Page 5 of 101

OPERATIVE ANESTHESIA COMMITTEE 2004 Physician Services Agreement The 2004 Physician Services Agreement provided for the formation of the OAC in recognition of the pressures facing operative anesthesia in Ontario s hospitals. According to Section 27.3 of the 2004 MOHLTC-OMA Physician Services Agreement: The Parties agree that there is an urgent need to address the challenges facing operative anesthesia in Ontario s hospitals. Accordingly, the Parties agree to establish a committee with representation from the OMA and MOHLTC to develop recommendations for addressing this issue in a timely fashion including opportunities for Schedule of Benefits redefinition, other physician payment strategies and the use of anaesthesia extenders. This committee will consult with the OHA as appropriate. The MOHLTC agrees to provide physician funding beginning October 1, 2005. The Agreement also provides over $52 million in annual funding for anesthesia services including increases to unit fees and base units ($26 M+), targeted fee increases ($7M+), increased and expanded hospital on-call coverage payments ($13 M) as well as new funding to support operative anesthesia ($5M). Use of funding to support operative anesthesia is to be based on the recommendations of the OAC OAC Terms of Reference The OAC is to provide recommendations to support stable and adequate access to anesthesia services in Ontario hospitals. Areas of focus include: Understanding current and anticipated service demands and workforce issues Short and longer term strategies to support the use of anesthesia assistants Applicability of various funding approaches Consideration of changes to fee-for-service payment program Discussion of longer term alternate funding approaches Impact of short and long term recommendations on the Wait Time Strategy Other longer term recruitment and retention strategies for anesthesia Potential impact on anesthesia requirements in the Local Health Integration Network environment The OAC consists of five members appointed by each of the OMA and MOHLTC (see table below for details). The Chair, Dr. Jack Kitts, was appointed jointly by the OMA and MOHLTC. Dr. David Bevan Dr. Steve Brown Dr. John Cain Dr. Geraint Lewis Operative Anesthesia Committee Membership Chair/Facilitator Dr. Jack Kitts OMA MOHLTC Support Ms. Bernita Drenth Ms. Susan Fitzpatrick Dr. Alan Hudson Mr. Hugh MacLeod Dr. John Marshall Ms. Danielle Claus, Consultant Ms. Honorata Bittner, PSC Secretariat Mr. David Mackey, PSC Secretariat Mr. Jim Simpson, OMA Ms. Peggy Taillon, The Ottawa Hospital Report & Recommendations of the Operative Anesthesia Committee Page 6 of 101

Committee Focus The OAC has closely examined current and planned initiatives to address the anesthesiologist shortage. While encouraging, it is clear that significant additional effort is required, effort that looks beyond existing service and funding models in order to better meet current and future service demands. After considerable deliberation and wide ranging consultation, including the OMA Anesthesia Section meeting in September 2005, the OAC: 1) Asked Dr. Marshall to update his 2003 review of anesthesia services at Ontario s AHSCs and to gain an understanding of the current use of, support for and the potential of the ACT concept to address the anesthesia shortage. 2) Clearly defined the ACT model, outlining roles, responsibilities and training requirements. In addition, the OAC identified the benefits and challenges associated with this new approach to providing anesthesia services. 3) Established a costing sub-committee to explore current funding of operative anesthesia estimate the impact of investments in the 2004 Physician Services Agreement and evaluate additional options to better support operative anesthesia. This report focuses on the ACT model. A separate paper, which deals with the funding of operative anesthesia, is currently under development. Report & Recommendations of the Operative Anesthesia Committee Page 7 of 101

UPDATE ON ACADEMIC ANESTHESIA SERVICES IN ONTARIO Methodology Questionnaires were sent to the Chiefs of Anesthesiology and to the Directors or Managers of Perioperative Services at each of the AHSC institutions. Following the return of the questionnaires, Dr. Marshall conducted telephone interviews with each Anesthesiology Chief and Peri-Operative Services Manager. The interviews at the two children s hospital were conducted in person, as these sites were not included in the original report. The purpose of the interviews was two-fold. First, confirm the data submitted in the returned questionnaires and clarify any ambiguity. Second, obtain an understanding as to how specific services were delivered at each site with particular focus on the roles played by anesthesia assistants and nurses in supporting anesthesia activities at each stage of the peri-operative process. Findings A summary of Dr. Marshall s findings is outlined in the chart below. There are two points of particular interest. First, it appears the anesthesiologist shortfall across Ontario AHSCs has not changed significantly between February 2003 and November 2005. This is due to an almost parallel increase in the volume of services (expressed as Daily Anesthetic Locations) and the general increase in FTE anesthesiologists, 35 and 42 respectively. This reflects the pent up demand for services met by the increasing staff complement. In the absence of the $6 million investment annually, which assisted in the recruitment of the 42 FTE anesthesiologists, the situation at AHSC would be profoundly worse. Staffing Formula Components Feb.2003 Nov.2005 Difference % Change Daily Anesthetic Locations 323.5 358.2 34.7 10.7% Required Anesthesia FTE 398.7 446.2 47.6 11.9% Actual Anesthesiologist FTE 333.7 375.4 41.7 12.5% Actual Assistant/RN Equivalent 5.9 15.6 9.7 163.6% Anesthesiologist FTE Shortfall FTE 59.1 55.3-3.8-6.4% Second, the use of other health professionals to assist in the provision of anesthesia services has grown significantly in the last two to three years. In February 2003, these individuals represented approximately 6 anesthesia FTEs, while in November 2005, they represented almost 16 FTEs, a growth of 164%. These individuals contributed significantly to reducing the anesthesia shortfall. Without anesthesia assistants and registered nurses (RNs), the anesthesiology shortage would have been 65 FTE instead of the 55 FTE. Report & Recommendations of the Operative Anesthesia Committee Page 8 of 101

Other Health Professionals and the Provision of Anesthesia Services As part of the review of anesthesia services within Ontario s AHSCs, Dr. Marshall also learned about the current use of and interest in professionals in the provision of anesthesia services. A synopsis of his findings is as follows: Pre-operative Assessment Unit Most AHSCs support the concept of specially trained nurses in the clinic and agree that this role could reduce the anesthesiologist workload. Very few AHSCs currently use specially trained nurses to triage patients in the preoperative assessment unit. A small number of organizations disagree with this approach claiming that all patients should be seen by an anesthesiologist (based on physician and patient preference). Intra-Operative Care Almost all AHSCs use some model of anesthesia assistant to augment services specifically, RNs and registered respiratory therapists (RRTs) in cataract rooms. That said, there is significant variation in the role of the anesthesia assistant (RRTs and RNs) and the degree to which anesthesiologists can increase clinical services. In two pilot projects, anesthesia assistants assisted in hip and knee procedures. Once regional anesthesia was established, the procedure started and the patient stabilized, the patient was monitored by an anesthetic assistant while the anesthesiologist prepared the next patient. The use of anesthetic assistants resulted in a 33% increase in productivity allowing one additional joint procedure per day (from 3 to 4 cases). Only one AHSC is using anesthesia assistants to occasionally monitor stable long cases under general anesthetic. Those organizations and anesthesiologists currently using anesthesia assistants in a clinical role are more receptive to expanding the assistant role. In AHSCs, there is widespread use of anesthesia assistants to assist in room preparation and turn over and to be on hand at induction, particularly for the more complex cases. Some believe that significant increases in productivity can be achieved by this role. Post-Operative Care Acute Pain Service A number of AHSCs use specially trained nurses to augment the Acute Pain Service. Those organizations using specially trained nurses report significantly improved patient care and variable savings in anesthesiologist time. All AHSCs endorse the use of specially trained nurses in this role but opinions vary on the extent to which specially trained nurses could reduce anesthesiologist workload. All agree that patient safety and satisfaction would be improved. Across the AHSCs, there is a general willingness to introduce some components of the ACT. The enthusiasm for such an introduction varies considerably by site. In general, it could be said that in Centres where alternative approaches have been employed the greater the willingness to consider an expansion of assistant roles. Report & Recommendations of the Operative Anesthesia Committee Page 9 of 101

ANESTHESIA CARE TEAM Context Support for the ACT concept is well established. The Surgical Process Analysis and Improvement Expert Panel, established by the MOHLTC in October 2004 to improve surgical efficiencies in Ontario s hospitals, recommends expanding anesthesia resources by supporting: Advance practice roles that complement and expand anesthesia services currently provided by anesthesiologists such as GP anesthetists, anesthesia assistants and acute care nurse practitioners with special training in anesthesia. Teams to provide anesthesia services. The Canadian Anesthesiologists Society (CAS) is calling for a nationally approved training program for anesthesia assistants with formal certification of successful candidates including a well-defined scope of practice. The Canadian Society of Respiratory Therapists supports this concept and is currently drafting a scope of practice for consideration of its members. According to the Council of Academic Hospitals of Ontario and the Ontario Hospital Association, it is believed that anesthesia assistants can play a valuable role in the long-term sustainability of Ontario s health care system. While ACTs have existed informally at some of Ontario s AHSCs for several years, the ability and willingness to introduce or expand the concept has been limited by several factors. By formalizing the ACT model and clearly articulating roles, responsibilities and training requirements, many of the challenges of implementing the model could be addressed and the full potential of the team concept could be realized. Description of ACT Model The ACT consists of anesthesiologists and specially trained other health professionals, RNs and RRTs, working under the supervision of anesthesiologists for a specified set of anesthesia services. The chart below outlines the functions, staff components and reporting structures of the ACT model. This model calls for a change in current reporting relationship. In the ACT model, RNs and RRTs report directly to anesthesiologists. Anesthesia Care Team Pre-Operative Care Intra-Operative Care Pre-Operative Care Anesthesiologists Anesthesiologists Anesthesiologists Clerks Specially trained RNs Technicians Anesthesia Assistants (RNs and/or RRIs) Specially trained RNs Report & Recommendations of the Operative Anesthesia Committee Page 10 of 101

Pre-operative Assessment Unit Specially trained nurses, under the supervision of an anesthesiologist, would conduct chart reviews, where indicated, initiate investigation using a series of protocols and algorithms and evaluate/assess patients. Technicians would collect blood work and conduct electrocardiograms. Anesthesiologists would oversee the clinic and provide consultation services as required. Staffing suggestions: 1 FTE specially trained RN for every 5000 clinic patients (Approximately 20 patients per day) 1 FTE anesthesiologist for every 3500 clinic patients who require a consultation (Approximately 10-15 patients per day) The assumption is that an anesthesiologist may need to see approximately 30% of all clinic patients, seen by the physician only. Note: there may be other flagged patients that the nurse asks the anesthesiologist to see. These flagged patient visits will be much shorter as the nurse has already seen the patient. Note: staff to patient ratios may vary depending on the acuity of the case mix Intra-Operative Care Specially trained anesthesia assistants (RNs and/or RRTs) would provide both technical and clinical assistance to anesthesiologists. The technical role would involve preparation of equipment, facilitating vascular access and insertion of regional nerve blocks as well as assisting with airway management. The clinical role would include assisting the anesthesiologist in the care of stable patients during anesthesia. Anesthesiologists would continue to provide a full range of services in the operating room. Staffing suggestions: 1 FTE anesthesia assistant for every 2 operating rooms The assumption is that this staffing ratio could result in a 20% increase in operating room efficiency and that this increase in efficiency could result in more operative cases Note: to fully utilize the ACT model, anesthesia assistants should be available 24 hours a day, seven days a week Post-operative Care - Acute Pain Service Specially trained nurses would provide patient monitoring and documentation and carry out therapeutic adjustments of both drugs and devices under agreed protocols. These RNs would also have a very active role in patient and unit staff education under the supervision of an anesthesiologist. Anesthesiologists would supervise the acute pain service and have a consultant role when conventional pain management fails. Staffing suggestions: 1 FTE specially trained RN for every 1500 post operative pain patients 0.5 FTE anesthesiologist for every 5000 post operative pain patients The assumption is that the majority of patients could be cared for by the nurse under the supervision of an anesthesiologist. This staffing approach could reduce the anesthesiologist workload by at least 60% Note: to fully utilize the ACT model, specially trained nurses should be available 24 hours a day, seven days a week. Report & Recommendations of the Operative Anesthesia Committee Page 11 of 101

Anesthesia Assistants The ACT model calls for the use of RNs and/or RRTs in extended roles for which they have appropriate training. As previously mentioned, it is necessary to achieve an agreed upon definition of anesthesia assistant, their roles and required training for these individuals. The OAC defines an anesthesia assistant as: A specially trained health professional that participates in the care of the surgical patient. Anesthesia assistants will not be a substitute for anesthesiologists nor will they be certified to work independently in environments without the direct supervision of a licensed anesthesiologist. Currently, there are only 2 post-graduate anesthesia assistant training programs in Canada: Caribou College (BC) Michener Institute (Ontario) An overview of the Michener program is provided below. For specific details, refer to the Michener web site www.michener.ca/ce/postdiploma/anesth_asst.php Admission requirements: RN or RRT 2 years critical care or operating room experience within the past 4 years Completion of basic level anesthesia assistant training program or equivalent Course competencies include: Evaluating the pre-, peri- and post-operative patient Advanced airway management Assisting with pharmacologic therapy Maintaining fluid therapy Assisting with the administration of peripheral nerve blocks, spinal anesthetics and epidural Assisting with the administration and maintenance of general anesthesia for stable patients Managing special anesthetic considerations Program Duration: For those individuals who have completed basic level training, the program is approximately 22 weeks in length (15 weeks coursework and 6 weeks clinical rotation). For those individuals who have not completed basic level training, the program is approximately 37 weeks in length (30 weeks coursework and 6 weeks clinical rotation). Report & Recommendations of the Operative Anesthesia Committee Page 12 of 101

Benefits of the ACT Model There are several benefits associated with this innovative model of care. They range from improved access to services to greater patient safety and include more cost-effective care. The ACT concept also provides a better work environment for all team members as physicians will have assistance and other health professionals will be given an opportunity to fully utilize their skills and experience. Listed below is a brief synopsis of the benefits: Access Access to service improves because other health professionals assist in the provision of anesthesia services thereby freeing up anesthesiologists to provide additional clinical and other services. Appropriateness In the ACT approach, anesthesiologists provide surgical services with the clinical and technical support of anesthesia assistants where deemed appropriate. Specially trained nurses provide routine services in pre and post-operative care under the supervision of an anesthesiologist. Capacity System capacity improves as a result of freeing up additional time for anesthesiologists, incorporating the use of assistants and making operative anesthesia more attractive to anesthesiologists. Cost Effectiveness This model is cost effective because it uses a mix of other health professional and anesthesiologists to provide anesthesia services. Patient Safety The addition of staff, trained for specific roles, in all three environments has the potential to increase patient safety. In the operating room, during preparation, induction of anesthesia and extubation, the assistant provides support to the anesthesiologist. On the acute pain service, the nurse under the supervision of the anesthesiologist becomes an important resource to the unit staff thus improving the quality of care. In the pre-anesthetic clinic, systematic review and patient preparation by specially trained nursing staff and anesthesiologists will continue to reduce the possibility of ill-prepared patients and operating room cancellations. Patient Satisfaction By using specially trained nurses in the pre-admission facility, patients could be seen in a timelier manner. Acute pain service nurses could see patients more promptly as the RNs would be dedicated to this service. Intra-operative anesthesia assistants would improve efficiency and turnover, resulting in fewer cancelled cases. Report & Recommendations of the Operative Anesthesia Committee Page 13 of 101

Physician & Other Health Professional Satisfaction Anesthesia assistants will improve efficiency and reduce workload for the specialist anesthesiologist in the pre, intra and post operative domains. The anesthesiologist will have access to technical and clinical support resulting in better working conditions. Anesthesia assistants will also improve the working conditions of operating room nurses who, until now, have been supporting the anesthesiologist. Specially trained nurses on the Acute Pain Service will improve the working conditions of ward staff as there will be a dedicated resource to the pain service available 24 hours a day, 7 days a week. In addition to establishing a career path, the new positions created by this model provide other health professionals with an opportunity to fully utilize their skills and training. Productivity The throughput in some operating rooms could be increased if anesthesia assistants were used. Quality of Care In addition to protocols, care maps, and algorithms, anesthesiologists supervise the work of the other health professionals thereby ensuring quality of patient care. Sustainability This model does not eliminate the need for additional anesthesiologists but it does reduce the pressure on the system and helps the system manage more effectively with existing physician resources. Challenges with the ACT Model There are several significant challenges associated with the ACT model that must be addressed in considering widespread implementation. These challenges range from costing the model to understanding its potential impacts. Details are provided below. Perceptions of the ACT Model While there is broad support across AHSCs for components of the ACT model, the commitment to and interest in implementing all components varies significantly. The ability to implement core components of this model depends upon the culture of the hospital and the physicians practicing there. The extent to which the ACT model is supported depends on the degree to which other health professionals are currently being used. Recommendations: #1 Initiate a consultation process. Circulate the report to stakeholders, receive and review feedback. Report & Recommendations of the Operative Anesthesia Committee Page 14 of 101

Impact and Viability of the ACT Model There is also a wide range of opinions on the extent to which other health professionals can make anesthesiologists available to perform operative services. The precise potential of the ACT model, particularly in terms of cost effectiveness and increased system capacity, is unknown and there is significant variation in the estimates. There is, however, a fairly general belief that the quality of services would be greatly improved through standardizing and supporting this model. While this paper attempts to estimate the impact of the ACT model, it is only through implementing the ACT model at demonstration sites that the ability of the model to increase efficiency and productivity while maintaining and, indeed, enhancing the quality of care be better understood. Further, the minimum requirements for an ACT model to be viable are not understood. Is this model only viable in AHSCs? What about community hospitals, large and small, urban and rural? Do all three components of the ACT model have to be in place for the model to be of benefit or can one or two components stand alone. If so, which components are they? To better understand minimum requirements, components of the ACT model need to be tested in different practice settings (demonstration sites). Recommendations: #2 Establish an ACT Implementation & Evaluation Committee composed of stakeholders: Create minimum requirements for demonstration sites Develop an evaluation framework Select demonstration sites #3 Issue an Indication of Interest. Hospitals seeking consideration as an ACT demonstration site would submit a proposal (similar to the Family Health Team Strategy). #4 Create a coaching team(s) to support the development of ACT proposals and to assist with the implementation of the ACT model at the demonstration sites. #5 Choose demonstrations sites in AHSCs and community hospitals using a transparent selection process. #6 Develop contracts for the demonstration sites which contain accountability agreements that address productivity, quality, patient and staff satisfaction. #7 Staff demonstration sites on the basis of the assumptions outlined in the report. #8 Evaluate the demonstration sites using the framework developed by the Committee. #9 Set minimum requirements for ACT model viability and expected outcomes prior to rolling out the ACT model across the province, based on evaluation of demonstration sites. #10 Explore different funding models for ACTs (e.g. APP, AFP, fee-for-service). Report & Recommendations of the Operative Anesthesia Committee Page 15 of 101

Composition of the ACT Model (physician and other health professional) At present, there is no standard approach to staffing ACTs (physician/other health professional/patient ratios). If the model is to be introduced widely, a standard approach is required. Staffing suggestions, outlined in this report, are an attempt to address this issue. There is little evidence that further study will yield more appropriate standards. Evaluation of the demonstration sites can provide data to support the ratios recommended in the report or to suggest modifications to the model. Recommendations: #11 Modify the ACT model, if necessary, based on the evaluation of the demonstration sites. Anesthesia Assistants Currently, there is no minimum standard of training required for anesthesia assistants. Some organizations provide on-site programs while others require anesthesia assistant training while still others fund conscious sedation education in the United States. There is also no commonly recognized definition of the roles and responsibilities (clinical and/or technical) of an anesthesia assistant. While the College of Respiratory Therapists of Ontario believes the anesthesia assistant role falls within the scope of practice for RRTs, the College of Nurses of Ontario does not recognize the role of monitoring patients under general anesthesia. The CAS is calling for a nationally approved training program with formal certification of successful candidates including a well-defined scope of practice for anesthesia assistants. The Canadian Society of Respiratory Therapists supports this concept and is currently drafting a scope of practice for consideration of its members. The challenge will be reaching consensus on roles and responsibilities as the work of anesthesia assistant varies considerably within and across institutions and provinces. Furthermore, RRTs are only regulated in 4 provinces (Ontario, Quebec, Alberta and Manitoba). Recommendations: #12 Bring together a stakeholder group to: develop a common definition of anesthesia assistant define roles and responsibilities agree on the training requirements It would be important that this work not delay the implementation of demonstration sites. This work could be done in parallel. #13 Establish training requirements for anesthesia assistants. From this time on, individuals wishing to become anesthesia assistants must successfully complete an advanced level anesthesia assistant training program. #14 Assess the skills of those individuals currently performing anesthesia assistant functions to determine if additional training is required. Report & Recommendations of the Operative Anesthesia Committee Page 16 of 101

There are only two anesthesia assistant training programs in Canada (Caribou College and the Michener Institute) at present. These programs have limited enrollment and takes several months to complete. Recommendations: #15 Introduce and/or expand anesthesia assistant training opportunities at other institutions across Ontario, using the standards established at the Michener Institute. CAS Guidelines to the Practice of Anesthesia While the CAS has identified the need for a nationally approved training program with formal certification of successful candidates, including a well-defined scope of practice for anesthesia assistants, the current CAS guidelines state that: Simultaneous administration of general, spinal, epidural or other major regional anesthesia by one anesthesiologist for concurrent diagnostic or therapeutic procedures on more than one patient is unacceptable. The CAS Other health Professions Committee is developing a draft document on the scope of practice for anesthesia assistants. This document will be presented to the Board for discussion at its February 2006 meeting. Recommendations: #16 Review the February 2006 Scope of Practice document being developed by the CAS Allied Health Professions Committee to see if it reflects core components of the ACT model. Currently, the CAS guidelines do not support some components of the ACT model wherein anesthesia assistants provide patient care and monitor stable patients during spinal, regional and general anesthesia allowing the supervising anesthesiologist to perform other duties. Potential Role of the ACT Model in Community Hospitals Further research is needed to assess the interest in and the applicability of the ACT Model in large urban community hospitals as well as rural and northern settings. Recommendations: #17 Conduct a survey of Ontario s community hospitals to determine: The extent to which the hospitals are using specially trained nurses and anesthesia assistants to assist in the provision of anesthesia services If RNs and anesthesia assistants are being utilized, how are they being used by the hospitals What kind of specialized training, if any, have the assistants and/or RNs received. If assistants have received training, what training and from where The receptivity to introducing specially trained nurses and anesthesia assistants to assist in the provision of anesthesia services Report & Recommendations of the Operative Anesthesia Committee Page 17 of 101

Schedule of Benefits Currently, the Schedule of Benefits does not include payment for supervision or delegation of services as envisaged in the ACT model. The Ontario Schedule of Benefits remunerates physician services provided in direct contact with the patient. The Schedule includes fee codes for physician supervision of the performance of a limited set of diagnostic and therapeutic procedures, the technical component of diagnostic procedures and simple office laboratory procedures. There is no payment for delegation of assessments, time-based services or major procedures. As well, there are strict limits on the circumstances where delegation is paid under the Ontario Health Insurance Plan (OHIP) for office-based services. Services in hospital are not included under the current Schedule s delegation scope and are not considered insured services when delegated, as the alternate provider is typically an employee of the hospital, not the physician. To facilitate the use of anesthesia assistants in a fee-for-service environment, changes are needed to the Schedule of Benefits to permit and remunerate physician supervision. Recommendations: #18 Replace the anesthesia fee (base & time units) with a supervisory payment when someone other than an anesthesiologist provides anesthesia care. #19 Reinvest the savings achieved through this change to the Schedule of Benefits in other anesthesia services. #20 Establish a Working Group to further examine the issue of supervision and delegation. #21 Further support the provision of operative anesthesia services through other specified investments. Report & Recommendations of the Operative Anesthesia Committee Page 18 of 101

NEXT STEPS 1. Following the circulation of the report to various stakeholder groups, an ACT Implementation and Evaluation Committee should be established to oversee the selection and evaluation of ACT demonstration sites. 2. Concurrently, changes should be made to the Schedule of Benefits to incent operative anesthesia and facilitate the implementation of the ACT model. 3. Anesthesia assistant training programs should be established to facilitate the roll-out of the ACT model across the province. 4. Once the demonstration sites have been evaluated and the model adjusted accordingly, the ACT model should be rolled-out across the province using the minimum requirements and expected outcomes set by the Committee. Report & Recommendations of the Operative Anesthesia Committee Page 19 of 101

APPENDIX 1 Status Report on Anesthesia Services at Ontario s Academic Health Science Centres Submitted to: Operative Anesthesia Committee, April 2006 Prepared by: Dr. John Marshall & Ms. Danielle Claus Report & Recommendations of the Operative Anesthesia Committee Page 20 of 101

Table of Contents TABLE OF CONTENTS EXECUTIVE SUMMARY... 22 BACKGROUND... 26 SECTION 1: ANESTHESIA SERVICES AT AHSCS... 28 SECTION 2: PERCEPTIONS OF ACT MODEL AT ONTARIO AHSCS... 30 SECTION 3: SECTION 4: CURRENT USE OF OTHER HEALTH PROFESSIONALS IN SUPPORT OF ANESTHESIA SERVICES... 33 OPPORTUNITIES FOR INTRODUCING AND/OR EXPANDING THE ACT MODEL AT AHSCS IN ONTARIO... 36 SECTION 5: CONSIDERATIONS ON PRODUCTIVITY AND ACCOUNTABILITY. 40 SECTION 6: INTRODUCING THE ACT MODEL... 44 Appendix 1 Questionnaires...46 Appendix 3 DAL Calculation...51 Appendix 4 Overview of Anesthesia Services at AHSCs by Site...53 Appendix 5 Overview of Anesthesia Services at AHSCs by Site...54 Appendix 6 Hospital Specific Information...55 Children s Hospital of Eastern Ontario...56 Hamilton Health Sciences...60 Hamilton St. Joseph s Health Care...64 Hospital for Sick Children...68 Kingston Health Sciences Centre...72 London Health Sciences Centre...76 St. Michael s Hospital...80 Sunnybrook & Women s College Health Sciences Centre...84 The Ottawa Hospital...88 University Health Network & Mount Sinai Hospital...92 University of Ottawa Heart Institute...96 Report & Recommendations of the Operative Anesthesia Committee Page 21 of 101

Executive Summary The purpose of this report is two-fold. First, update the 2003 review of anesthesia services at Ontario s Academic Health Sciences Centres (AHSCs). Second, gain an understanding of the current use of, support for and the potential of the anesthesia care team (ACT) concept to address the anesthesia shortage. To fully address these complex and multi-faceted issues, the report has been organized into the following sections: A picture of the current supply of and demand for anesthesia services at Ontario s AHSCs An overview of the perceptions of the ACT model, as well as a description of the perceived barriers to ACT implementation A summary of the current use of Other Health Professionals in support of anesthesia services in AHSCs An assessment of the opportunities for introducing ACTs at the AHSCs An examination of productivity and accountability measures that could be utilized in the delivery of perioperative anesthesia services A summary of the steps required to introduce the ACT model in AHSCs Anesthesia Services at Ontario s AHSCs As seen in the table below, the overall supply of anesthesia services has increased considerably since the original 2003 review, from 323.5 to 358.2 daily anesthetic locations (DALs). During the same period, the actual number of anesthesiologists grew from 333.7 full time equivalents (FTEs) to 375.4 FTEs. Despite the addition of almost 42 anesthesiologist FTEs, the shortfall has remained the same because the demand for services has kept pace with the supply of anesthesiologists. Staffing Formula Components Feb.2003 Nov.2005 Difference % change Daily Anesthetic Locations (DALs) 323.5 358.2 34.7 10.7% Required Anesthesia FTE 398.7 440.9 42.2 10.6% Actual Anesthesiologist FTE 333.7 375.4 41.7 12.5% Shortfall FTE 65.0 65.5 0.5 0.8% Report & Recommendations of the Operative Anesthesia Committee Page 22 of 101

The use of other health professionals in the provision of anesthesia services has also increased significantly during this period. In February 2003, registered nurses and anesthesia assistants provided the services of almost 6 FTE anesthesiologists and in November 2005, the work of these other health professionals represented almost 16 FTE anesthesiologists. By employing other health professionals in anesthesia service delivery, the anesthesia shortfall is reduced from 65 to 55 anesthesiologist FTEs. Staffing Formula Components Feb.2003 Nov.2005 Difference % change Daily Anesthetic Locations (DALs) 323.5 358.2 34.7 10.7% Required Anesthesia FTE 398.7 446.2 47.6 11.9% Actual Anesthesiologist FTE 333.7 375.4 41.7 12.5% Actual Assistant/RN Equivalent Anesthesiologist FTE 5.9 15.6 9.7 163.6% Shortfall FTE 59.1 55.3-3.8-6.4% Perceptions of the ACT Model The Chiefs of Anesthesia at the AHSCs were interviewed and their views were sought on the level of acceptance of the concepts inherent in the ACT model for the delivery of anesthesia services. They were asked to express both their own opinions and to indicate how these opinions aligned with others in their department. To summarize, there was a universal willingness to consider introducing of the ACT model. The enthusiasm for such an introduction varied considerably by site and, in general, it could be said that the more the concepts inherent in the model had been already introduced to a site, the greater the willingness of that site to consider expanding the assistant roles. Use of Allied Health Professionals in the Delivery of Anesthesia Services The current use of anesthesia assistants and nurses to support the delivery of anesthesia service at Ontario s AHSCs is relatively modest. As seen in the table below, there is significant variation between sites in both the number of other health professionals supporting anesthesia service delivery and the roles these individuals play. Hospital Pre-Operative Intra-Operative Post-Operative Total Hamilton Health Sciences 2 1.2 2 5.2 Hamilton St. Joseph's Health Care 0 0 1 1 Kingston 1 3.6 1 5.6 London Health Sciences Centre 3 0 2.5 5.5 Ottawa Heart Institute 0 0 0 0 St. Michael's Hospital 0 2 3 5 Sunnybrook & Women's 0 6 3 9 The Ottawa Hospital 0 2 2 4 UHN/MSH 3 5 7 15 Children's Hospital of Eastern Ontario 0 4.6 0 4.6 Hospital for Sick Children 1 0 1.5 2.5 Total 10 24.4 23 57.4 Report & Recommendations of the Operative Anesthesia Committee Page 23 of 101