RWANDA ALLIED HEALTH PROFESSIONS COUNCIL
NON-PHYSICIAN ANAESTHETISTS IN RWANDA
Scope of Practice
RAHPC © December 2017 Office of the Registrar
Table of Contents Abbreviations …………………………………………………………………………………….2 1. Introduction ……………………………………………………………………………….. 3 2. Purpose……………………………………………………………………………………..4 3. Structure of Anaesthesia Care Services in Rwanda (see separate page)…………..5 4. Categories of Non-Physician Anaesthetists ……………………………………………6 5. Scope of Practice Non-Physician Anaesthetists ……………………………………….8 1. Scope of SCOA …………………………………………………………………………………………………8 2. Scope of COA …………………………………………………………………………………………………..9 3. Scope of ACOA ………………………………………………………………………………………………11 6. Education of Non Physician Anaesthetists (NPA): ………………….…….…………12 7. Privileges ………………………………………………………………….….…………..13 1. Definition …………………………………………………………………….……………13 2. Interpretive statement ……………………………………………….…………………..13 8. Licensure …………………………………………………………………………………14 9. Code of Ethics ……………………………………………………………………………14 10. Annexes ……………………………………………………………………………….15 1. ASA CLASSIFICATION SYSTEM ……………………………………………….……………15 2. Description of ASA classifications …………………………………………….……………….16 3. Procedure for new credentialing and privileging of NPA …………………..……………………………..17 3.1. Purpose ………………………………………………………………………..…………………….………….17 3.2. Procedure of privileging …………………………………………………………………….………………….17 6.1. Privileging request form ……………………………………………………………………………………….18 REFERENCES ………………………………………………………………………………19
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Abbreviations
ACLS: Advanced Cardiac Life Support
ACOA: Assistant Clinical Officer Anesthetist
ASA: American Society of Anesthesiologist
AT: Anaesthetic Technician
BLS: Basic Life Support
Bsc: Bachelors of Science
COA: Clinical Officer Anesthetist
CRNA: Certified Registered Nurse Anesthetist
EMT: Emergency Medical Team.
Msc: Master of Science
NA: Nurse Anesthetist
NPA: Non Physician Anesthetists
PACU: Post Anaesthesia Care Unit
RAHPC: Rwanda Allied Health Profession Council
RNA: Registered Nurse Anesthetist
SCOA: Specialist Clinical Officer Anesthetist
MoH: Ministry of Health
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1. Introduction
Non Physician Anaesthetists are members of the anaesthetic care team, trained both in the underlying scientific and medical knowledge pertinent to anaesthesia, and in the skills of administering anaesthesia. Their core responsibility is to provide anaesthetic services to patients requiring anaesthesia, respiratory care, cardiopulmonary resuscitation and/or other emergency, life sustaining services within the anaesthesia and wider theatre and critical care environments.
Non Physician Anaesthetists are categorized according to education levels; they are Specialists Clinical Officer Anesthetists, Clinical Officer Anesthetists, Assistant Clinical Officer, Certified Registered Nurse Anaesthetists, Registered Nurse Anaesthetists, Nurse Anaesthetists and Anaesthetic Technicians.
The range of practice of Non Physician Anaesthetists extends from preoperative assessment to postoperative anaesthetic care; however, the role is primarily defined by the scope of work undertaken in the operating theatre where in an independent or supervised capacity, participate in induction, maintenance and reversal of anaesthesia using skills and knowledge that are based on an in-depth understanding and application of physiology and pharmacology.
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2. Purpose
The purpose of this document is to define the Scope of Practice for Non Physician Anaesthetists.
Professionals and to specify their role as members of the health care team, acting in the best interest of the patient. The scope of practice is a "living" document that will evolve as techniques and technology expand.
The scope of practice defined here and the areas specifically set forth describe the breadth of professional practice offered within the profession. Levels of education, experience, skill, and proficiency with respect to the activities identified within this scope of practice vary among individual providers.
Individuals may only practice in areas in which they are competent based on their education, training, and experience.
Certain situations may necessitate that the Non Physician Anaesthetists pursue additional education or training to expand their personal scope of practice.
The scope of practice statement does not supersede existing state licensure laws or affect the interpretation or implementation of such laws. It may serve, however, as a model for the development or modification of licensure laws.
Non Physician Anaesthetists is a dynamic and continuously evolving group of profession; listing specific areas within the scope of practice does not exclude emerging areas of practice In addition to this, Non Physician Anesthetists may be called on to perform services beyond theatre anesthetic tasks. These include, “multi skilling” in a health care setting, collaborative service delivery in schools and any other area such as critical care, emergency medicine including pre-hospital emergencies, hospital management, disaster management and any other task that is within NPA clinical and managerial competencies. In such instances it is both ethically and legally binding for professionals to exercise the tasks that they have the knowledge and skills.
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3. Structure of Anaesthesia Care Services in Rwanda (see separate page)
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4. Categories of Non-Physician Anaesthetists
1. Specialist Clinical Officer Anesthetist (SCOA) - is a skilled person qualified by academic and clinical education in anaesthesia who have acquired a Master’s Degree or its equivalent in anaesthesia from a recognized higher learning institution. He/She is usually not a physician though he/she possess essential knowledge of anaesthesia. They are qualified to make independent judgments concerning all aspects of anesthesia care based on their education, licensure, and certification.
2. Clinical Officer Anesthetist (COA) - is a skilled person qualified by academic and clinical education in anaesthesia who have acquired a Bachelors’ Degree or its equivalent in anaesthesia from a recognized higher learning institution. He/She is usually not a physician though he/she possess essential knowledge of anaesthesia. They are qualified to make independent judgments concerning all aspects of anesthesia care based on their education, licensure, and certification.
3. Assistant Clinical Officer Anaesthetist (ACOA) – is a skilled person qualified by academic and clinical education in anaesthesia who have acquired advanced Diploma or its equivalent in anaesthesia from a recognized higher learning institution. He/She is usually not a physician though he he/she possesses essential knowledge of anaesthesia. They are qualified to make independent judgments concerning all aspects of anaesthesia care based on their education, licensure and certification.
4. Certified Registered Nurse Anesthetist (CRNA) – is aregistered nurse who has qualified by academic and clinical education in anesthesia who have acquired a Master’s Degree or its equivalent in anaesthesia from a recognized higher learning institution. They are qualified to make independent judgments concerning all aspects of anesthesia care based on their education, licensure, and certification.
5. Registered Nurse Anesthetist (RNA) – is aregistered nurse who has qualified by academic and clinical education in anesthesia whohave acquired abachelors’ Degree or its equivalent in anaesthesia from a recognized higher learning institution. They are qualified to make independent judgments concerning all aspects of anesthesia care based on their education, licensure, and certification.
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6. Nurse Anesthetist (NA) - is an enrolled nurse who has qualified by academic and clinical education in anesthesia whohave acquired anadvanced Diploma or its equivalent in anaesthesia from a recognized higher learning institution. They are qualified to make independent judgments concerning all aspects of anesthesia care based on their education, licensure, and certification.
7. Anaesthetic Technician (AT) - is an individual with formal education whose primary responsibilities are to clean, sterilize, test, calibrate and troubleshoot anesthesia equipment, as well as keeping records of equipment inspections. He/she does not give anaesthesia, therefore registration and licensures for clinicians are not required to practice.
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5. Scope of Practice Non-Physician Anaesthetists
The scope of practice of non-physician anesthetists includes, but not limited to the following:
1. Scope of SCOA This scope applies to the CRNA with appropriate and equivalent qualification in nurse anaesthesia. 1. Performing and documenting a pre anesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, and administering pre anesthetic medications and fluids; and obtaining informed consent for anesthesia.
2. Developing and implementing an anesthetic plan.
3. Initiating the anesthetic technique which may include: general, regional, local, and sedation.
4. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring modalities for continuous evaluation of the patient’s physical status.
5. Selecting, obtaining, and administering the anesthetics, adjuvant and accessory drugs, and fluids necessary to manage the anesthetic.
6. Managing a patient’s airway and pulmonary status using current practice modalities.
7. Facilitating emergence and recovery from anesthesia by selecting, obtaining, ordering, and administering medications, fluids, and ventilatory support.
8. Discharging the patient from a post anesthesia care area and providing post anesthesia follow-up evaluation and care.
9. Implementing acute and chronic pain management modalities.
10. Responding to emergency situations by providing airway management, administration of emergency fluids and drugs, and using basic or advanced cardiac life support techniques.
11. Administration/management: scheduling, material and supply management, development of policies and procedures, fiscal management, performance evaluations, preventative maintenance, billing, data management, and supervision of staff, students or ancillary personnel.
12. Quality assessment: data collection, reporting mechanism, trending, compliance, committee meetings, departmental review, problem-focused studies, problem solving, interventions, documents and process oversight.
13. Performs BLS, ACLS and where resuscitation committees exist shall be part of it.
14. Education: clinical and didactic teaching, BCLS/ACLS instruction, in-service commitment, EMT training, supervision of residents, and facility continuing education.
15. Research: conducting and participating in departmental, hospital-wide, and university-sponsored research projects.
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16. Interdepartmental liaison: interface with other departments such as nursing, surgery, obstetrics, post anesthesia care units (PACU), outpatient surgery, admissions, administration, laboratory, pharmacy, etc.
17. Clinical/administrative oversight of other departments: respiratory therapy, PACU, operating room, surgical intensive care unit, pain clinic, etc.
18. Works in collaboration indirectly or directly with anaesthesiologist who has been privileged to administer anaesthesia in the concerned hospital/institute/organization.
2. Scope of COA This scope applies to the RNA with appropriate and equivalent qualification in nurse anaesthesia. 1. Performing and documenting a pre anesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, and administering pre anesthetic medications and fluids; and obtaining informed consent for anesthesia.
2. Developing and implementing an anesthetic plan.
3. Initiating the anesthetic technique which may include: general, regional, local, and sedation.
4. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring modalities for continuous evaluation of the patient’s physical status.
5. Selecting, obtaining, and administering the anesthetics, adjuvant and accessory drugs, and fluids necessary to manage the anesthetic.
6. Managing a patient’s airway and pulmonary status using current practice modalities.
7. Facilitating emergence and recovery from anesthesia by selecting, obtaining, ordering, and administering medications, fluids, and ventilatory support.
8. Discharging the patient from a post anesthesia care area and providing post anesthesia follow-up evaluation and care.
9. Implementing acute and chronic pain management modalities.
10. Responding to emergency situations by providing airway management, administration of emergency fluids and drugs, and using basic or advanced cardiac life support techniques.
11. Performs BLS, ACLS and where resuscitation committee exists shall be part of it.
12. Administration/management: scheduling, material and supply management, development of policies and procedures, fiscal management, performance evaluations, preventative maintenance, billing, data management, and supervision of staff, students or ancillary personnel.
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13. Quality assessment: data collection, reporting mechanism, trending, compliance, committee meetings, departmental review, problem-focused studies, problem solving, interventions, documents and process oversight.
14. Research: conducting and participating in departmental, hospital-wide, and university-sponsored research projects.
15. Works in collaboration indirectly or directly with anaesthesiologist who has been privileged to administer anaesthesia in the concerned hospital/institute/organization.
16. Shall seek privileges to undertake the duties of SCOA and CRNA in case he/she works in a setting where she/he is the most senior anaesthesia provider
17. Except in the case of emergencies, and situations where transfer to higher institution is less likely to yield better patient outcome, the COA and RNA shall not provide anaesthesia to patients beyond ASA III classification and children under 1 year, Neurosurgery and cardiothoracic cases without being supervised/assisted by another senior anaesthesia provider such as SCOA, CRNA, and/or other superior anaesthesia staff.
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3. Scope of ACOA This scope applies to the Nurse Anaesthetist with appropriate and equivalent qualification in nurse anaesthesia.
1. Performing and documenting a pre anesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, and administering pre anesthetic medications and fluids; and obtaining informed consent for anesthesia.
2. Developing and implementing an anesthetic plan.
3. Initiating the anesthetic technique which may include: general, regional, local, and sedation.
4. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring modalities for continuous evaluation of the patient’s physical status.
5. Selecting, obtaining, and administering the anesthetics, adjuvant and accessory drugs, and fluids necessary to manage the anesthetic.
6. Managing a patient’s airway and pulmonary status using current practice modalities.
7. Facilitating emergence and recovery from anesthesia by selecting, obtaining, ordering, and administering medications, fluids, and ventilatory support.
8. Discharging the patient from a post anesthesia care area and providing post anesthesia follow-up evaluation and care.
9. Implementing acute pain management modalities.
10. Responding to emergency situations by providing airway management, administration of emergency fluids and drugs, and using basic or advanced cardiac life support techniques.
11. Performs BLS in all settings as required, if trained in ACLS shall deliver required ACLS services and where resuscitation committee exist shall be part of it.
12. Shall seek privileges to undertake the duties of COA and RNA in case he/she works in a setting where she/he is the most senior anaesthesia provider.
13. Except in the case of emergencies, and situations where transfer to higher institution is less likely to yield better patient outcome, the ACOA and NA shall not provide anaesthesia to patients beyond ASA II classification and children under 3 year, Neurosurgery and cardiothoracic cases without being supervised/assisted by another SCOA,CRNA, and or anaesthesiologist.
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6. Education of Non Physician Anaesthetists (NPA): 1. Advanced diploma or equivalent. 2. BSc. in anaesthesia or its equivalent. 3. MSc. in anaesthesia or its equivalent.
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7. Privileges
1. Definition This is a special right, immunity, or exemption granted to non-physician Anaesthetists to free them from certain obligations or liabilities.
2. Interpretive statement: 1.1. Because of the significant risks that patients who receive anaesthesia may go through, privileges to administer anaesthesia should be granted to all NPA practitioners who are qualified to administer anaesthetic care in RWANDA.
1.2. The process of privileging NPA may differ from hospital to hospital, but as a general rule, all NPA must have relevant qualifications and competencies to provide anaesthetic care, henceforth, they must be registered and licensed to do so by their regulatory body.
1.3. The credentialing and privileging process shall be granted by the RAHPC after examining the application from the concerned hospital/other health institute or organization; the procedure to follow is explained in details in annex II.
1.4. The privileging and appointment of all categories of the NPA shall directly or indirectly be in line with the labor code, other ministry of health policies and individual hospital prescripts such as employment contracts, professional registration, credentialing and recruitment, selection and appointment policies.
1.5. Non Physician Anaesthetist may perform duties which belong to one level higher above his/hers; only if there is an agreement written on the new privilege(s)/service in which the dual parties have signed prior to rendering the concerned service (s)
1.6. The NPA may be privileged to work in another departments with similarities to anaesthesia professions such as a quality assurance officer, risk management officer, fire fighting officer, safety and health management officer or any other deemed important by the concerned institution.
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8. Licensure
Acquiring and renewal of the license to practice as NPA in Rwanda shall follow the processes laid down by the RAHPC.
Member of the NPA must submit official documents as stringent as those established and as required by RAHPC for acquiring or renewing the license to practice as NPA in Rwanda in accordance to the law.
9. Code of Ethics
Non Physician Anaesthetists practice provides anesthesia and anesthesia related services. They accept the responsibility conferred upon them by the government of RWANDA, the profession, and society. The RAHPC has adopted this Code of Ethics to guide its registrants in fulfilling their obligation as professionals. Each member of NPA has a personal responsibility to uphold and adhere to these ethical standards. The code of conduct guiding NPA is directly in line with RWANDA Ethical code of conduct for allied health professionals as established under the pursuant of the Constitution of the Republic of Rwanda and law No. 46/2012 of 14/01/2013 establishing Rwanda Allied Health Professions Council.
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10. Annexes
1. ASA CLASSIFICATION SYSTEM
1.1. Description 1.1.1. The ASA physical status classification system is a system for assessing the fitness of cases for anaesthesia before surgery. In 1963 the American Society of Anesthesiologists (ASA) adopted the five-category physical status classification system which is today being used almost all over the world (reference). 1.2. Interpretive statement 1.2.1. The purpose of the grading system is simply to assess the degree of a patient’s "sickness" or "physical state" prior to selecting the anesthetic or prior to performing surgery. Describing patients’ preoperative physical status is used for recordkeeping, for communicating between colleagues, and to create a uniform system for statistical analysis. The grading system isintended for use as a measure to predict anaesthesia risk. 1.2.2. Except in the case of emergencies, and situations where transfer to higher institution is less likely to yield better patient outcome, the COA and RNA shall not provide anaesthesia to patients beyond ASA III classification. 1.2.3. Except in the case of emergencies, and situations where transfer to higher institution is less likely to yield better patient outcome, the COA and RNA shall not provide anaesthesia to patients beyond ASA II classification.
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2. Description of ASA classifications:
ASA PRE OPERATIVE HEALTH DESCRIPTION OF THE PREBOPERATIVE HEALTH CLASSES: STATUS: STATUS:
ASA 1 Normal healthy patient No organic, physiologic, or psychiatric disturbance; excludes the very young and very old; healthy with good exercise tolerance
ASA 2 Patients with mild systemic disease No functional limitations; has a well-controlled disease of one body system; controlled hypertension or diabetes without systemic effects, cigarette smoking without chronic obstructive pulmonary disease (COPD); mild obesity, pregnancy
ASA 3 Patients with severe systemic Some functional limitation; has a controlled disease of more disease than one body system or one major system; no immediate danger of death; controlled congestive heart failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure; bronchospastic disease with intermittent symptoms ASA 4 Patients with severe systemic Has at least one severe disease that is poorly controlled or at disease that is a constant threat to end stage; possible risk of death; unstable angina, life symptomatic COPD, symptomatic CHF, hepatorenal failure
ASA 5 Moribund patients who are not Not expected to survive > 24 hours without surgery; imminent expected to survive without the risk of death; multiorgan failure, sepsis syndrome with operation hemodynamic instability, hypothermia, poorly controlled coagulopathy
ASA 6 A declared brain-dead patient who Since this category does not require conventional organs are being removed for donor anaesthesia, no organ donation and transplant done in purposes Rwanda, the description has been left for discussion in due time.
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3. Procedure for new credentialing and privileging of NPA
3.1. Purpose To establish a uniform process through which all NPA will go through to be credentialed and privileged in order to protect patient as well as staff safety at work thus avoiding legal implication.
3.2. Procedure of privileging 4. All requests to RAHPC for approval of a New Privilege for NPA shall be initiated by the appropriate hospital/other health institute or organization
5. The hospital/other health institute or organization shall be required to submit the request [Annex 11.2.3] to the RAHPC accompanied by at least the following:
5.1. A description of the New Privilege including location within the facility where the New Privilege would be done and any special equipment which may be necessary;
5.2. Position statements of relevant educational institutions, trade associations and specialty boards regarding the New Privilege and the recommendations and requirements of those organizations for demonstrating current competence (evidence base);
5.3. Recommendations(s) of the Department/Service/Discipline Head or any other relevant authority for minimum education, training and experience required for practitioner to demonstrate current competence in the New Privilege;
6. Upon receipt of the information specified in paragraph 2 above, the RAHPC may choose to appoint a multidisciplinary task Force (“Task Force”) to review and evaluate the request and supporting information. The RAHPC Task Force shall conduct such reviews and interviews as it deems appropriate, including interviews with the relevant Department/Service/Discipline Head/Lead, and grant or deny the approval of the new privilege.
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6.1. Privileging request form
Name of (New) Privilege ______Specialty: ______
Brief description of the (New) Privilege
Specialties (if any) who may perform the New Privilege
Service (s) in which the (New) Privilege would normally be/may be performed
Necessary equipment purchase or remodelling that would need to be done, including cost.
Is the New Privilege currently being done at your institute? If so by which specialty and in which Service(s).
Education level of applicant in anaesthesia.
Applicant license Number)
How much recent direct or indirect experiences in the New Privilege or in a related field (within immediately preceding 12-24 consecutive months) have the applicant demonstrated?
Referees
Other (please specify) relevant information.
Submitted By: ______Designation______
Signature:______Date______
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