Anaesthetic Capability Framework
Draft for consultation
October 2019
Anaesthetic Capability Framework
Draft for consultation – October 2019
Contents
Contents
About this document ...... 7 Capability frameworks in Victoria ...... 7 The anaesthetic capability framework ...... 8 Figure 1. Continuum of anaesthetic services ...... 9 Next steps ...... 11
Level 1 Anaesthetic Service ...... 12 Service Description ...... 12 Service requirements ...... 12 Clinical Workforce ...... 12 Clinical support services ...... 13 Equipment and infrastructure ...... 13 Clinical Governance ...... 13
Level 2 Anaesthetic Service ...... 15 Service Description ...... 15 Service Requirements ...... 16 Clinical Workforce ...... 16 Clinical support services ...... 16 Equipment and infrastructure ...... 17 Clinical Governance ...... 17
Level 3 Anaesthetic Service ...... 19 Service Description ...... 19 Service Requirements ...... 20 Clinical Workforce: ...... 20 Clinical support services ...... 20 Equipment and infrastructure ...... 21 Clinical Governance ...... 21
Level 4 Anaesthetic Service ...... 22 Service Description ...... 22 Service requirements ...... 23 Clinical workforce ...... 23 Clinical support services ...... 23 Equipment and infrastructure ...... 24 Clinical Governance ...... 24
Level 5 Anaesthetic Service ...... 25 Service Description ...... 25 Service requirements ...... 26 Clinical workforce ...... 26 Clinical support services ...... 26 Equipment and infrastructure ...... 27 Clinical Governance ...... 27
Level 6 Anaesthetics ...... 28 Service Description ...... 28 Service Requirements ...... 29 Clinical workforce ...... 29 Clinical support services ...... 29 Equipment and infrastructure ...... 29 Clinical Governance ...... 30
Appendix 1 Anaesthetic risk, physical status, surgical complexity, and resource requirements...... 31 Table 1: ASA (American Society of Anesthesiology) Physical Status Classification System .. 31
Appendix 2: Procedure complexity ...... 33 Table 2 : Complexity of adult surgical procedures ...... 33
Appendix 3: References and Relevant ANZCA Position Statements ...... 35
About this document
Capability frameworks in Victoria Findings and recommendations from Targeting zero: report of the Review of Hospital Safety and Quality Assurance in Victoria (Duckett 2016) emphasise safety and quality improvement as a core goal for the Department of Health and Human Services (the department). The staged introduction of a role delineation framework for the Victorian health system, underpinned by a suite of capability frameworks, is a key action of the Statewide design, service and infrastructure plan for Victoria’s health system 2017–2037 (Department of Health and Human Services 2017c). This inaugural capability framework for anaesthetic services in Victoria is one of several capability frameworks being developed and implemented by the Department of Health and Human Services. Compliance with these capability frameworks will be mandatory for all public and private health services. Once implemented, all health services will have a service level designation determined and agreed by the department that they will be required to comply with. Further, health services will be required to notify the department of any changes to their capability. Access to safe, high-quality care is a core right of all Victorians and a key principle underpinning all capability frameworks. All Victorians have a right to expect the same high standard of care no matter where they live or which health service they attend. These capability frameworks will help deliver greater consistency in quality and safety across the Victorian health system by describing the minimum clinical standards required to care for patients of particular complexity at a given site. They also provide a transparent approach to planning and service development at the local, regional and system levels. Within each capability framework, there are six levels that define the complexity of care that a health service can provide. Capability across the continuum of care is outlined at each level. The clinical workforce, infrastructure, equipment, clinical support services and governance requirements are also described and must be met at all times to maintain service capability. Each capability framework may also refer to other capability framework levels when describing the support services required. In these instances, the capability frameworks must be read together to determine the relevant requirements. The frameworks do not replace or amend current legislation, mandatory standards or accreditation processes. The document assumes that health services provide care in accordance with: Delivering high-quality healthcare – Victorian clinical governance framework
Anaesthetics: Draft for Internal Consultation Only
• Victorian Government: Rural procedural services 2009, www.health.vic.gov.au/ • Joint Consultative Committee on Anaesthesia (JCCA), www.racgp.org.au/yourracgp/organisation/committees/joint-consultative-committees/jcca/
The anaesthetic capability framework The capability framework for anaesthetic care will define minimum standards for health services and associated anaesthetic and pain management services, informed by the types of surgical and interventional procedures undertaken within the health service. Services must be able to manage complex and unstable patients of different ages with comorbidities and/or complicated therapeutic needs as appropriate to their capability. As patient and procedural complexity and the inherent risks associated with anaesthesia increases, the range and number of patients who require specialist anaesthetic expertise increases. The framework also provides a mechanism for services to increase their capability in a planned way with direction from the department. Anaesthesia for children is an area of practice which requires specific training and experience.1 All care provided to children should be underpinned by the principal of providing the highest quality treatment for the child appropriate for their age, condition, and local health capability at the closest institution to their home.2 It is also expected that at all levels health services endeavour to provide care in an environment that is safe and appropriate for the age and stage of development of the child or adolescent. Where ever possible it is preferable to provide facilities for children and adolescents in areas of the health service where they are cared for, utilising equipment that is specifically designed to meet their needs, size and developmental age. It is also expected that children and adolescents are cared for by staff specifically trained to meet their physical, psychosocial, developmental, communication and cultural needs. 3 It is recognised that the initial treatment of paediatric emergencies may be necessary in facilities and under circumstances where paediatric care is not normally provided.4 For planned care, across the continuum, there should be adequate governance, clinical skill, equipment and an appropriate environment to ensure high quality care to children is provided. The core capability framework for anaesthetics is based on the following continuum of care (Figure 1). This continuum recognises that the levels of anaesthetic services provided by a health facility reflect the clinical case mix, surgical complexity and the number of acutely ill patients treated at that facility. It is recognised that in many cases anaesthetic services can be supplied by different medical and nursing professionals depending on the complexity of care and available workforce. For very low level complexity and low levels of patient risk, medical proceduralists, general practitioners with anaesthetic qualification and in some cases nursing staff may safely provide the appropriate anaesthetic. This is an appropriate service model for levels 1-2 and in some cases level 3 for a general practitioner. Where anaesthetic care is provided for children the medical practitioner should be credentialed at the health service for that scope of practice. Health facilities with very high patient acuity, and where a rapid response is required, should ensure that anaesthetic services are available on-site 24 hours 7 days a week. Trauma, emergency, surgery, oncology and critical care volumes are key variables in the level of anaesthetic service required, due to the frequency of urgent procedures, and the complexity of pain management requirements. Access to expert anaesthetic input for complex surgical procedures and pain management is a key requirement for higher capability level services.
1 Australian and New Zealand College of Anaesthetists. 2008 Statement on anaesthesia care of children in healthcare facilities without dedicated paediatric facilities. 2 Royal Australian College of Surgeons (2017) Position Paper Surgery in Children. Melbourne, accessed at https://www.surgeons.org/about-racs/position-papers 3 Royal Australian College of Physicians (2008) Standards for the Care of Children and Adolescents in Health Services. Sydney accessed at: https://www.racp.edu.au//docs/default-source/advocacy-library/standards-for-the-care-of-children-and-adolescents-in- health-service.pdf?sfvrsn=28a12f1a_8 4 Australian and New Zealand College of Anaesthetists. 2008 Statement on anaesthesia care of children in healthcare facilities without dedicated paediatric facilities.
Anaesthetic capability framework
There is no specific reference to obstetric anaesthetic services in this framework. This is a specialist areas and is defined in the Maternity Capability Framework. It is recognised that a service may have a different capability for the anaesthetic service it can provide to adults compared to children due to its clinical skill mix, equipment and facilities.
Figure 1. Continuum of anaesthetic services The capability framework for anaesthetic services and its relationship with surgery and procedural complexity is based on the following continuum of care.
Level Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
Anaesthetic Local Procedural General General Full Full services analgesia sedation anaesthesia in anaesthesia anaesthetic anaesthetic provided by conscious low - moderate in moderate capability in capability in nurse led sedation and risk patients risk patients all patients all patients service deep and relevant and all sedation in specialities specialities low risk patients
Patient risk All patients ASA 1 and 2 ASA 1, 2 and 3 ASA 1 and 2 ASA 3, 4 and All patients ceiling requiring who are patients for patients 5 patients for all local undergoing intermediate undergoing undergoing complexity of analgesia minor complexity major surgical interventions surgical diagnostic or procedures, or procedures of high procedures interventional ASA 4 for minor ASA 3 and 4 surgical/proce procedures procedures patients dural undergoing complexity medium ASA 1 and 2 surgical/proced patients ural complexity undergoing selected major complex surgical procedures
Procedural Low risk, Low risk Medium medium High High risk / minor minor complexity, low surgical/proced surgical/proce surgical/proce example procedure: procedures: risk ural dural dural procedures: complexity: complexity complexity
Paediatric All patients ASA 1 and 2 ASA 1, 2 ASA 3 patients ASA 3, 4 and Specialist service requiring who are patients for undergoing 5 patients paediatric capability* local undergoing medium medium undergoing service analgesia minor complexity complexity interventions capable of diagnostic or procedures, procedures of high providing interventional surgical/proce service to all procedures dural patients for in complexity scope ASA 1 and 2 procedures patients undergoing selected major complex surgical procedures
Pain NA NA NA Nurse based HMO led Consultant Management service service led service service
* The paediatric service response may be a different capability level to the adult service due to clinical skill mix, facilities and governance arrangements. This will need to be clearly articulated during the
Anaesthetics: Draft for Internal Consultation Only
assessment and monitoring process with the Department and importantly communicated within the hospital.
The Core Capability framework for anaesthetic services (the framework) will help facilitate the development and delivery of a more efficient, integrated, coordinated anaesthetic and pain management system based on the following principles: • Timely, accurate anaesthetic and pain management services are available to all Victorians. • All patients receive the same high quality and safe care, regardless of where they access services. • The needs of vulnerable patient groups are met, and services are delivered safely and respectfully to diverse communities. • Services are integrated with the broader health system, with a clear role and linkages to other services. • Health services recognise roles and responsibilities within a coordinated system of care. • All anaesthetic services operate a high-quality service appropriate to the functions of their respective organisations. • Designated services have a key role in ensuring access to specialist anaesthetic services for patients from across Victoria who require higher complexity care and provide clinical leadership across the system The anaesthetic and pain management framework: • describes the complexity of care that a service can and should safely provide, and communicates this clearly to the local community • assists health services to make informed decisions about the resources, partnerships and protocols required to manage the different complexities of care • enables a transparent approach to planning and service development at a local level, taking into account community need • supports health service regions and the department to plan for and manage the anaesthetic, surgery and procedural services required to support their health care system.
It is important to be aware of the relationships between the different capability frameworks, and the minimum requirements across different capability frameworks. Tables 1 and 2 describe the minimum anaesthetic and pain management level configuration requirements for surgery and procedural services, and critical and intensive care services. For example Table 1: Minimum configuration requirements for surgery and procedural and anaesthetic services
Surgery and procedural service Minimum anaesthetic level of care level 6 6
5 5
4 3
Table 2: Minimum configuration requirements for critical care and intensive care and anaesthetics
critical and intensive care Minimum anaesthetic level of care service level 6 6
Anaesthetic capability framework
critical and intensive care Minimum anaesthetic level of care service level 5 5
4 4
The department is also developing capability frameworks for the other core services of diagnostic imaging, pathology, pharmacy and medicines management, and critical care and intensive care. The department will ensure there is consistency between the core capability frameworks and the clinical stream capability frameworks. It is recognised that capability frameworks must remain relevant and current and incorporate changing clinical practice where this is applicable. This will be achieved through regular review and updating of this framework led by the department.
Next steps The implementation of this framework will be led by the Department of Health and Human Services commencing in early 2020. Full implementation is expected to take 12 months, beginning with a stocktake of where each service’s capability currently sits against the framework. More information on the implementation process will be available from March 2020.
Anaesthetics: Draft for Internal Consultation Only
Level 1 Anaesthetic Service
Service Description
Service Description Complexity of Care / A level 1 service provides: service role • local infiltration analgesia5 to healthy patients undergoing low risk, minor description procedures in an acute health service or multi purpose service6 . • Includes procedures done by registered health practitioners under service agreements with public health services • Planned and unplanned services Excludes sedation and other anaesthesia including regional blocks. Service has clear escalation processes to stabilise and transfer patient to appropriate medical care in the unlikely event that the need arises5 Note: Local anaesthetic and procedure generally done by one practitioner. Pre-admission • Provides procedures on demand service • Assessment of suitability for treatment is undertaken by the proceduralist against health service’s policy’s and the proceduralist’s credentialing Anaesthetic and pain • Use of local infiltration analgesia only management • Ensures patient has discharge advice about pain management in the capability community when required.
Recovery • Relevant referral/follow up arranged in the community to be provided by GP or other primary care provider if required.
Service requirements
Clinical Workforce
Service Requirements Proceduralist Procedures and local anaesthesia are undertaken by registered medical practitioner or other qualified registered health practitioner, credentialed at the health service for minor procedures including local anaesthetic/regional blocks. Proceduralist has demonstrated competence in: • infection control procedures outlined in ANZCA PS28: Guidelines on Infection Control in Anaesthesia and • local anaesthetic procedures and management including toxicity, allergic reactions.
5 ANZCA PS37: Guidelines for Health Practitioners Administering Local Anaesthesia 2013 6 List of agencies by region. https://www2.health.vic.gov.au/Api/downloadmedia/%7B0D2F8920-B568-4D0D-8C91- 0CD0827E7F9A%7D accessed 7/8/2019
Anaesthetic capability framework
Clinical support services
Service Requirements Emergency response Recognition7 and response system89, including rapid response (for example, ‘respond blue’), and designated roles on-site during service operating hours to respond immediately to medical and procedural emergencies for adult and paediatric patients across the facility in line with health service clinical protocols. • Registered health practitioner with demonstrated competency in advanced life support (adult and paediatrics, if paediatric procedures are in scope) available during service operating hours. • Registered nurse with demonstrated competency in advanced life support on-site during service operating hours to administer medicines under protocols 10 Able to respond to adverse reactions of local analgesia via referral to registered medical specialist (RACGP, ACRRM) or calling 000 Pathology and Core service capability framework – pathology: Level 1 blood/blood products Pharmacy Core service capability framework – pharmacy Level 1 Access to local anaesthetic agents on site for unplanned procedures
Language services Guidelines for access to language services in accordance with the Department of Health and Human Services Language services policy.
Equipment and infrastructure
Area Requirements Equipment Minimum recommendations for provision of local analgesia
Procedure rooms Procedures are undertaken in patient areas that meet the requirements of the Australasian Facility Guidelines – 0155 Ambulatory Care Unit. And Part D: Infection Prevention and Control
Clinical Governance
Area Requirements Service guidelines • Protocols in place to define appropriate levels of service and capability. • Protocols in place for escalation of care and patient transfer as required. • Partnership Care • Policies and processes are in place to support service delivery via telehealth.
7 https://www.safetyandquality.gov.au/standards/nsqhs-standards/recognising-and-responding-acute-deterioration-standard 8 Australian Standard 4083-2010, AS3745 planning for emergencies in facilities 9 Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to acute physiological deterioration second edition. Sydney, ACSQHC. 2017 10 Regulation 8 - Schedule 4: Drugs, Poisons and Controlled Substances Regulations 2017, accessed at https://www2.health.vic.gov.au/public-health/drugs-and-poisons/drugs-poisons-legislation/secretary-approvals.
Anaesthetics: Draft for Internal Consultation Only
• Protocols between proceduralists and the health service on assessing clinical risk and procedure types to be undertaken. • Protocols for post-procedure care in the community and information for patients about care at home and escalation. Consultation, referral • Designated pathways to consult with a higher level service and arrange and transfer transfer of deteriorating patients (e.g. through ARV)
Competence and • Credentialing processes for medical staff providing anaesthetic care11 Credentialing • Process to assess competency of staff in ALS.
11 Safer Care Victoria 2018, Credentialing and scope of clinical practice for senior medical practitioners policy, State Government of Victoria, Melbourne, accessed at https://www.safercare.vic.gov.au/reports-and-publications/credentialing-and-scope-of-clinical- practice-for-senior-medical-practitioners-policy
Anaesthetic capability framework
Level 2 Anaesthetic Service
Service Description
Service Description Complexity of care/ A level 2 service provides: service role • Conscious sedation and/or analgesia12 for adult or paediatric patients description classified ASA 1, or 2 for low risk or minor medical, surgical, or and dental procedures • Referral for adults requiring deeper sedation and general anaesthetic, or higher anaesthetic risk to higher level services. • Referral for children requiring higher level of care (for example, above ASA 3, under 2 years of age) to a specialised paediatric unit.13 • Pre-operative assessment, anaesthesia and recovery care to day stay or overnight surgical or procedural services14 for planned (elective) and/or unplanned care. • Post procedure anaesthetic recovery care and observation in dedicated area or in the procedure room. Pre-procedure • Undertakes anaesthetic assessment of all patients in line with ANZCA Guidelines15 • Obtains informed consent prior to procedural sedation and/or analgesia16. • Refers patients with higher anaesthetic risk to a higher capability serviceError! Bookmark not defined.. Anaesthetic and pain • Manages patient’s intra-procedure care using local anaesthetic and/or management conscious sedation. capability • Manages and supervises patient’s post procedure analgesia/symptom control Recovery • Manages and supervises patient’s recovery in properly equipped and staffed area which may be : – The procedure room, or – Second stage recovery area17 (a “second stage” recovery area provided for observation of ambulant patients prior to discharge from the healthcare facility18) – The recovery area must have adequate staffing and facilities for managing patients who have become unconscious (first stage recovery) or who have suffered complications during the procedure.Error! Bookmark not defined.,19
12 ANZCA PS09: Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. 13 ANZCA PS29: Statement on Anaesthesia Care of Children in Healthcare Facilities Without Dedicated Paediatric Facilities, 2002. 14 ANZCA PS15: Guidelines for the Perioperative Care of Patients Selected for Day Stay Procedures Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. 2018 15 ANZCA PS37: Guidelines for Health Practitioners Administering Local Anaesthesia 2013 16 ANZCA PS14: Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. 2014 17 ANZCA PS04: Statement on the Post-Anaesthesia Care Unit. 2018
Anaesthetics: Draft for Internal Consultation Only
Service Requirements
Clinical Workforce
Service Requirements Proceduralist Where procedure & anaesthetic performed by same proceduralists: • Registered medical or dental practitioner proceduralists with airway and resuscitation skills, and demonstrated competency in conscious sedation and / or analgesia, credentialed at the health service, performs day stay procedures. • Proceduralist has demonstrated competence in: – infection control procedures outlined in ANZCA PS28: Guidelines on Infection Control in Anaesthesia and – local anaesthetic procedures and management including toxicity, allergic reactions. • Supported by a dedicated anaesthetic assistant for identified cases20 Medical Where anaesthesia performed by a separate anaesthetic provider: • Anaesthesia provided by a registered medical practitioner who has successfully completed JCCA-accredited training or equivalent, credentialed at the health service for anaesthetic care. • Supported by a dedicated anaesthetic assistant for identified cases21
Overnight/multiday care: • Registered medical practitioner available 24/7 for patients that are admitted overnight following conscious sedation and/or analgesia. Nursing • Nurse with demonstrated competency in post anaesthetic and recovery care available according to demand. 22 • For identified cases, anaesthetic assistant available in line with PS08: Statement on the Assistant for the Anaesthetist23. This may be a registered nurse. Allied Health • Anaesthetic technician available to support and maintain all equipment needs according to case load. Error! Bookmark not defined. • For identified cases, anaesthetic assistant available in line with PS08: Statement on the Assistant for the Anaesthetist24. This may be an anaesthetic technician, dental assistant or other health practitioner.Error! Bookmark not defined.
Clinical support services
Service Requirements Emergency As for level 1 response
Critical Care Core service capability framework – Critical Care and Intensive Care: Level 1
20 ANZCA PS08: Statement on the Assistant for the Anaesthetist 2016 21 ANZCA PS08: Statement on the Assistant for the Anaesthetist 2016 22 Australian College of Perioperative Nurses. Standards for Perioperative Nursing in Australia 15th Edition. Victoria Australia 23 ANZCA PS08: Statement on the Assistant for the Anaesthetist 2016 24 ANZCA PS08: Statement on the Assistant for the Anaesthetist 2016
Anaesthetic capability framework
Pathology and Core service capability framework – Pathology: Level 2 blood/blood Protocols for access to blood. On site O- is available, capable of formal blood products analysis for ordering specific blood stock.
Pharmacy Core service capability framework – Pharmacy and medicines management: Level 2 in hours, level 1 out-of-hours.
Language As for level 1 services
Equipment and infrastructure
Area Requirements Equipment As for level 1, in addition: • Facilities available as per ANZCA PS55 – Recommendations on Minimum Facilities for Safe Administration of Anaesthesia in Operating Suites and Other Anaesthetising Locations. • Anaesthesia delivery system in place, maintained and checked – in line with ANZCA PS31: Guidelines on Checking Anaesthesia Delivery Systems • Appropriate airway equipment in accordance with ANZCA PS56: Guidelines on Equipment to Manage a Difficult Airway During Anaesthesia. • Specialist anaesthetic equipment available according to demand Where children are in scope must have appropriate equipment for the needs of children including a range of sizes for procedural and monitoring equipment.25 Procedure As for level 1 rooms
Recovery Has a separate post anaesthetic care area Where in scope and within demand has appropriate facilities for the care of children and their parents in the perioperative, and post operative periods26
Clinical Governance
Area Requirements Service guidelines As for level 1, in addition: • Policies and procedures in place to ensure best practice with patient preparation, assessment and aftercare.Error! Bookmark not defined. • Monitoring in line with ANZCA PS09: Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. • Documentation of anaesthetic care provided in line with ANZCA PS06: The Anaesthesia Record. Recommendations on the Recording of an Episode of Anaesthesia Care.
25 Australian and New Zealand College of Anaesthetists. 2008 PS 29 Statement on anaesthesia care of children in healthcare facilities without dedicated paediatric facilities. 26 Australian and New Zealand College of Anaesthetists. PS29 (2008) Statement on anaesthesia care of children in healthcare facilities without dedicated paediatric facilities
Anaesthetics: Draft for Internal Consultation Only
• Policies must be in place for the care of children where the facility is not dedicated to paediatric care. This must detail criteria for management of anaesthesia, surgery and nursing care, as well as liaison with a specialist paediatric facility for advice and referral .27 • A clinical emergency response plan to manage potential clinical deterioration. • For all elective procedures there are selection guidelines to determine the suitability of patients for day procedure care • The hospital or health service nominate an executive officer28 to review and approve all current and new procedures to ensure they are within scope. • The health service has policies and procedures to identify patient risk factors and conditions that are likely to exclude a patient from treatment in that facility. Consultation, referral As for level 1 and transfer
Partnership Care As for level 2, in addition: • There are agreed protocols between the proceduralist and anaesthetist regarding clinical risk • There are clear lines of communication between proceduralist and clinician providing anaesthetic • There are agreed escalation/transfer protocols for patients deemed unsuitable for care at this level. Competence and As for level 1, in addition: Credentialing • Registered health practitioners carrying out sedation and/or analgesia should be subject to regular and effective audit of sedation administration complying with local jurisdictional requirementsError! Bookmark not defined.
27 PS29 (2008) Statement on anaesthesia care of children in healthcare facilities without dedicated paediatric facilities
28 An executive officer is ultimately accountable for the health service as to which procedures are appropriate to be performed at the assigned capability level. E.g. Director Medical Services
Anaesthetic capability framework
Level 3 Anaesthetic Service
Service Description
Service Description Complexity of care/ A level 3 service provides: service role • Pre-operative assessment, anaesthesia and recovery care to day stay or description overnight surgical or procedural services29 for planned (elective) care. • Local, regional and general anaesthetic to support the service’s surgical and procedural caseload for ASA 1, 2 and selected ASA 3 patients having low to medium complexity, low risk surgical procedures. • Conscious and deeper sedation for ASA 1, 2 and selected ASA 3 patients having common and medium complexity, low risk surgical procedures. • Anaesthesia for selected ASA 4 patients who are undergoing low risk, minor surgical procedures. • Elective anaesthetic services provided during business hours for scheduled lists and may include weekends or after hours. • Anaesthesia for selected paediatric patients (ASA 1-2) who are undergoing low risk, minor surgical procedures.30 • Post procedure anaesthetic recovery care and observation in dedicated area (s)
Where 24/7 emergency surgery is provided: • pre-operative assessment, anaesthesia and recovery care must also be available to provide anaesthetic services 24/7. Pre-procedure • Undertakes anaesthetic assessment of all patients in line with ANZCA Guideline PS0731 as part of a standardised pre-operative assessment. • Assesses patients with a BMI> 40 for suitability for care at the service32. • Refers patients with higher anaesthetic risk to a higher capability service4. Anaesthetic and pain • Manages patient’s intra-procedure care using local, regional and general management anaesthetic and/or sedation. capability • Manages and supervised patient’s post procedure analgesia/symptom control • Consideration should be given to patients with a BMI> 40 and if appropriate facilities, equipment and post-operative care is available. 33 Recovery • Cares for patients in recovery unit in line with ANZCA PS04 Recommendations for the Post-Anaesthesia Recovery Room.
29 ANZCA PS15: Guidelines for the Perioperative Care of Patients Selected for Day Stay Procedures Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. 2018 30 PS29 (2008) Statement on anaesthesia care of children in healthcare facilities without dedicated paediatric facilities 31 ANZCA PS07: Guidelines on Pre-Anaesthesia Consultation and Patient Preparation. 2017 32 State of Queensland (Queensland Health). Anaesthesia: Non-bariatric Surgery in Obese Patients Guideline. 2013
Anaesthetics: Draft for Internal Consultation Only
• Refers selected patients needing higher levels of post procedure monitoring34 to onsite close observation area for ongoing care post recovery. • Where required reviews selected patients on the ward.
Service Requirements
Clinical Workforce:
Service Requirements Medical As for level 2, in addition: • Registered medical specialist (JCCA-accredited training) or equivalent, credentialed at the health service for anaesthetic care, performs deeper sedation and general anaesthesia and available 24/7. • Registered medical specialist (ANZCA) or equivalent, credentialed at the health services for anaesthetic care, available within operating hours to provide anaesthetic care for ASA 3 patients where required. • For identified cases, a second registered medical practitioner available to assist with anaesthesia as per ANZCA PS08. • Registered medical specialist (ANZCA) or equivalent, accessible during service operating hours for consultation (may be through telehealth). If providing 24/7 emergency surgery services • Registered medical specialist (JCCA-accredited training) or equivalent available 24/7. If providing paediatric procedures requiring general anaesthesia: • Registered medical specialist (JCCA-accredited training) or equivalent OR registered medical specialist (ANZCA) or equivalent credentialed at the health service for paediatric anaesthetic care, is available to provide paediatric anaesthetic care. Nursing As for level 2, in addition: • Nurse(s) with demonstrated competency in post anaesthetic and recovery care available according to demand. Allied health As for level 2
Clinical support services
Service Requirements Emergency response Recognition35 and response system3637, including rapid response (for example, ‘respond blue’), and designated roles on-site 24/7 to respond immediately to
34 Core Capability Framework – Critical Care and Intensive Care 35 https://www.safetyandquality.gov.au/standards/nsqhs-standards/recognising-and-responding-acute-deterioration-standard 36 Australian Standard 4083-2010, AS3745 planning for emergencies in facilities 37 Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to acute physiological deterioration second edition. Sydney, ACSQHC. 2017
Anaesthetic capability framework
medical, surgical and procedural emergencies across the facility in line with health service clinical protocols. Registered health practitioner(s) with demonstrated competency in advanced life support (adult and paediatric, where paediatric services are scope) on-site 24/7. Critical Care Core service capability framework – Critical Care and Intensive Care: Level 2 Pathology and Core service capability framework – pathology: Level 3 in hours; level 2 out of blood/blood hours products
Medical imaging Core service capability framework – medical imaging: Level 3
Pharmacy Core service capability framework – pharmacy: Level 3 Language services As for level 2
Equipment and infrastructure
Area Requirements Equipment As for level 2, in addition: • Monitoring equipment is provided and used in line with ANZCA PS18: Guidelines on Monitoring During Anaesthesia. • Specific consideration made regarding needs of patients with BMI>40 and if appropriate facilities and equipment is available • Appropriate equipment for the needs of children for planned, in scope procedures
Clinical Governance
Area Requirements Service guidelines As for level 2, in addition: • Protocols for management of key anaesthetic complications for recovery care • Monitoring in line with ANZCA PS18: Guidelines on Monitoring During Anaesthesia. • Service protocols should be in place which give specific consideration to patients with BMI>40 and if appropriate facilities, equipment and post- operative care is available. Consultation, referral As for level 2 and transfer
Partnership Care As for level 2 Competence and As for level 2, in addition: Credentialing Processes for assessing ALS competence for nurses working in recovery38
38 Post Anaesthetic Care Unit (Pacu) Stage 1 Staffing. ACPAN Statement 1 (2018) https://acpan.edu.au/wp- content/uploads/2018/11/OCTOBER-2018-ACPAN-Statement-1.pdf
Anaesthetics: Draft for Internal Consultation Only
Level 4 Anaesthetic Service
Service Description
Service Description Complexity of Care / A level 4 service provides: service role • pre-operative assessment, anaesthesia and recovery care to day stay or description multiday surgical or procedural services39 for both planned (elective) and unplanned (emergency) care. • local, regional and general anaesthetic to support the service’s surgical and procedural caseload for ASA 1-4 patients undergoing low - medium surgical/procedural complexity. • anaesthesia for ASA 1 and 2 patients undergoing major surgical procedures • Anaesthesia for selected paediatric patients (ASA 1-3) who are undergoing medium complexity surgical procedures.40 • an acute pain service across the organisation • post procedure anaesthetic recovery care and observation in dedicated area (s) including those suitable for children and carers. The anaesthetic team is structured to provide anaesthetic service across ambulatory, diagnostic and operating suite, acute pain services.
Pre-procedure As per level 3, in addition: • Anaesthetic assessment as part of a pre-admission clinic Anaesthetic and pain As per level 3, in addition: management • Coordinates an acute pain service to review patients including those using capability patient-controlled analgesia units41, 42 • May have a role in wider services pain management service e.g. in ED Recovery As per level 3, in addition: • Has specific protocols for assessment and recognition of risks associated with special populations (obstetric, paediatric, gerontological, bariatric and cognitively impaired patients)
39 ANZCA PS15: Guidelines for the Perioperative Care of Patients Selected for Day Stay Procedures Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. 2018
40 PS29 (2008) Statement on anaesthesia care of children in healthcare facilities without dedicated paediatric facilities
41 Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute pain management: scientific evidence. Fourth edition. 2015 Melbourne: Australia 42 ANZCA PS41: Guidelines on Acute Pain Management. 2013
Anaesthetic capability framework
Service requirements
Clinical workforce
Service Requirements Medical • Registered medical specialist (ANZCA) or equivalent, credentialed at the health service for anaesthetic care, as lead clinician and responsible for clinical governance of service (may be in partnership arrangement within region). • Registered medical specialist(s) (ANZCA) or equivalent, credentialed at the health service for anaesthetic care, available 24/7. • For identified cases, a second registered medical practitioner available to assist with anaesthesia as per ANZCA PS08. May be an accredited registrar on the ANZCA training program. • Registered medical practitioner with demonstrated competency in the management of peri-operative patients, on-site 24/7. For paediatric anaesthesia: • Registered medical specialist (ANZCA) or equivalent credentialed at the health service for paediatric anaesthetic care, available 24/7.
Note: at this level, most of the surgical anaesthetic services are provided by Registered medical specialist (ANZCA) or equivalent. Nursing As for level 3, in addition: • Nurse(s) with demonstrated competency in post anaesthetic and recovery care available 24/7. • Advanced and extended practice nurses with demonstrated competency in provision of pain management services available according to demand • Nurse practitioners, advanced and extended practice nurses working within their scope of practice may be able to administer sedation for minor procedures and investigations providing ALS capability available. • Nursing staff with demonstrated competence in the assessment and management of acute pain available to support the Acute Pain Service in business hours. Allied health As for level 3, in addition: • Anaesthetic technician to support and maintain all equipment needs available during service operating hours
Clinical support services
Service Requirements Emergency As for level 3 Response
Critical Care Core service capability framework – Critical Care and Intensive Care: Level 4 access to ICU
Anaesthetics: Draft for Internal Consultation Only
Pathology and • Core service capability framework – pathology: Level 3 in hours; level 2 blood/blood out of hours products • Supply and provision of blood and blood products in accordance with the service requirements outlined in Victoria’s Pathology Capability Framework.
Pharmacy Core service capability framework – pharmacy: Level 4 Specialist services Are there additional specialists at this level that are required for the anaesthetic team to do their roles successfully and safely e.g. physician or cardiologists etc
Language services As for level 2
Equipment and infrastructure
Area Requirements Equipment As for level 3 in addition; • Sufficient patient-controlled analgesia machines for post-operative volumes/activity.
Clinical Governance
Area Requirements Service guidelines As for level 3 in addition: • Guidelines for the acute pain service in placeError! Bookmark not defined.. Consultation, referral As for level 3 and transfer
Partnership Care As for level 3 Competence and As for level 3 Credentialing
Anaesthetic capability framework
Level 5 Anaesthetic Service
Service Description
Service Description Complexity of Care / A level 5 service provides: service role • pre-operative assessment, anaesthesia and recovery care to day stay or description multiday surgical or procedural services43 for both planned (elective) and unplanned (emergency) care. • local, regional and general anaesthetic to support the service’s surgical and procedural caseload for ASA 1-5 patients undergoing low, medium or high surgical/procedural complexity and or higher risk of intra-and post-operative complications. • anaesthetic support to endoscopy, imaging and other areas of the acute service on a planned and unplanned basis • an acute pain service across the organisation • post procedure anaesthetic recovery care and observation in dedicated area (s). • a dedicated service to paediatric patients from clinicians with demonstrated competency in the care of children • timely telehealth clinical decision support for lower level services 24/7 The anaesthetic team is structured to provide anaesthetic services across ambulatory, diagnostic and operating suites, endoscopy units, day surgery units and acute pain services. It will also provide dedicated services for paediatric patients.
Pre-procedure As per level 4 Anaesthetic and pain As per level 4 in addition; management • Provides anaesthesia for patients with ASA 3, 4 and 5 capability • Daily HMO round to review patients referred for pain management Recovery As per level 4 in addition: • Cares for patients in dedicated recovery unit in line with ANZCA PS04 Recommendations for the Post-Anaesthesia Recovery Room. • Refers selected patients needing higher levels of post procedure monitoring or interventions 44 to onsite intensive care for ongoing care post recovery.
43 ANZCA PS15: Guidelines for the Perioperative Care of Patients Selected for Day Stay Procedures Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. 2018 44 Core Capability Framework – Critical Care and Intensive Care
Anaesthetics: Draft for Internal Consultation Only
Service requirements
Clinical workforce
Service Requirements Medical • Registered medical specialist (ANZCA) or equivalent, credentialed at the health service for anaesthetic care, as lead clinician and responsible for clinical governance of service (may be in partnership arrangement within region). Registered medical specialist(s) (ANZCA) or equivalent, credentialed at the health service for adult and paediatric anaesthetic care, available 24/7. • Registered medical practitioner with appropriate experience in anaesthetics, credentialed to initiate adult and paediatric anaesthetic management for emergencies (beyond ANZCA supervision level 1), available 24/7. May be an accredited registrar on the ANZCA training program. • Second registered medical practitioner available to assist with anaesthesia as per ANZCA PS0845,46. May be an accredited registrar on the ANZCA training program. • Registered medical practitioner(s) with demonstrated competency in the management of adult and paediatric peri-operative patients on-site 24/7. • Designated member of anaesthetic team to review patients referred for pain management daily Nursing As for level 4 Allied health As for level 4
Clinical support services
Service Requirements
47 4849 Emergency Recognition and response system , including rapid response (for example, response ‘respond blue’), and designated team on-site 24/7 to respond immediately to deteriorating patients and medical emergencies across the facility in line with health service clinical protocols. • Registered health practitioners(s) from intensive care workforce support organisation wide rapid response team 50. Critical Care Core service capability framework – Critical Care and Intensive Care: Level 5
Emergency As for level 4, in addition: Theatre Services Operating suites available during extended business hours with on call access after-hours. Paediatric Care If within scope: • Dedicated ward and team for post-operative management of paediatric patients.
45 ANZCA PS37 Guidelines for Health Practitioners Administering Local Anaesthesia page 2 46 ANZCA PS08: Statement on the Assistant for the Anaesthetist 2016 47 https://www.safetyandquality.gov.au/standards/nsqhs-standards/recognising-and-responding-acute-deterioration-standard 48 Australian Standard 4083-2010, AS3745 planning for emergencies in facilities 49 Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to acute physiological deterioration second edition. Sydney, ACSQHC. 2017 50 College of Intensive Care Medicine. Minimum standards for intensive care unit based rapid response systems. 2017
Anaesthetic capability framework
Pathology and • Core service capability framework – pathology Level 5: blood/blood products
Pharmacy Core service capability framework – pharmacy: Level 5 Specialist Are there additional specialists at this level that are required for the anaesthetic services team to do their roles successfully and safely e.g. Toxicologists drugs and positions state advice service etc
Equipment and infrastructure
Area Requirements Equipment As for level 4 in addition Dedicated paediatric facilities for perioperative and post-operative care
Clinical Governance
Area Requirements Service guidelines As for level 4 Consultation, referral As for level 4 and transfer Partnership Care As for level 4
Competence and As for level 4 Credentialing
Anaesthetics: Draft for Internal Consultation Only
Level 6 Anaesthetics
Service Description
Service Description Complexity of Care / A level 6 service provides: service role • pre-operative assessment, anaesthesia and recovery care to day stay or description multiday surgical or procedural services51 for both planned (elective) and unplanned (emergency) care. • local, regional and general anaesthetic to support the service’s surgical and procedural caseload for all patients • services for patients with the highest level of anaesthetic risk in a range of specialties in conjunction with the most complex surgical and medical presentations. These patients may have a high level of complexity, magnitude or risk to patients with an extensive range of comorbidities requiring specialist staff. • Provide anaesthesia for all levels of ASA patient risk undergoing major complex surgical procedures including subspecialties • anaesthetic support to endoscopy, imaging and other areas of the acute service on a planned and unplanned basis • an acute pain service across the organisation • post procedure anaesthetic recovery care and observation in dedicated area(s). • provides timely telehealth clinical decision support for lower level services 24/7 The anaesthetic team is structured to provide anaesthetic services (including anaesthetic services for sub-specialty surgical and diagnostic services) across ambulatory, diagnostic and operating suites, endoscopy units, day surgery units and acute pain services.
Pre-procedure As for level 5, in addition: • Reviews patients referred from pre-admission services for anaesthetic risk assessment including subspecialties • Refers patients to speciality hospitals for specialist or statewide service provision Anaesthetic and pain As for level 5, in addition: management • Provides planned and unplanned services to theatre, procedure suites, capability imaging areas of the service • Coordinates a consultant led acute pain service to review patients 52, 53 • Provides full complement of anaesthetic services to all speciality and subspecialty patients
51 ANZCA PS15: Guidelines for the Perioperative Care of Patients Selected for Day Stay Procedures Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. 2018 52 Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute pain management: scientific evidence. Fourth edition. 2015 Melbourne: Australia 53 ANZCA PS41: Guidelines on Acute Pain Management. 2013
Anaesthetic capability framework
Recovery • As for level 5
Service Requirements
Clinical workforce
Service Requirements Medical As for level 5, in addition: • Registered medical specialists (ANZCA) or equivalent with qualifications and demonstrated competency in sub- specialist anaesthetic care available during service operating hours and accessible 24/7 (such as neonatal anaesthesia, complex anaesthesia and anaesthesia for super specialty procedures). • Registered medical practitioner with appropriate experience in anaesthetics, credentialed to initiate anaesthetic management for emergencies (beyond ANZCA supervision level 1), on-site 24/7. May be an accredited registrar on the ANZCA training program. • Registered medical specialist led anaesthetic round to respond to pain management referrals operates daily
Nursing As for level 3
Allied health As for level 3
Clinical support services
Service Requirements Emergency Response As for level 5 Critical Care Core service capacity framework – Critical Care and Intensive Care: Level 6 Pathology and blood/blood Core service capacity framework – pathology Level 6: products
Pharmacy Core service capacity framework – pharmacy: Level 6 Specialist services As for 5
Equipment and infrastructure
Area Requirements Equipment As for level 5 plus: • Specialist anaesthetic equipment available for surgical subspecialties within scope
Anaesthetics: Draft for Internal Consultation Only
Clinical Governance
Area Requirements Service guidelines As for level 5
Consultation, referral As for level 5 and transfer
Partnership Care As for level 5
Competence and As for level 5 Credentialing
Anaesthetic capability framework
Appendix 1 Anaesthetic risk, physical status, surgical complexity, and resource requirements.
The main factor affecting service levels is the interaction between anaesthetic risk (i.e. a patient’s physical status) and procedural / surgical complexity. The American Society of Anesthesiologists (ASA) has a scale accepted as both a universal means of determining a patient’s physical status, and a proxy for risk.54 When these two indicators are used, they provide a level of service enabling a particular type of patient to undergo a particular complexity of procedure safely. Management of risk relative to procedure and patient will also determine staffing and type of sedation provided. The ANZCA provides recommendations regarding staffing profiles for medical personnel and anaesthetic assistants according to the complexity of the sedation and patient risk according to the ASA.Error! Bookmark not defined. Table 1: ASA (American Society of Anesthesiology) Physical Status Classification System54:
ASA PS Examples, including, but not limited to: Definition Classification
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 disease Some functional limitation; has a controlled disease of more 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, chronic renal failure; bronchospastic disease with intermittent symptoms.
54 Joint Consultative Committee on Anaesthesia Curriculum statement in anaesthesia for advanced rural skills and advanced specialised training, Fourth edition, 2010
Anaesthetics: Draft for Internal Consultation Only
ASA 4 Patients with severe systemic disease that Has at least one severe disease that is poorly controlled or at end stage; possible is a constant threat to life risk of death; unstable angina, symptomatic COPD, symptomatic CHF, hepatorenal failure
ASA 5 Moribund patients who are not expected to Not expected to survive > 24 hours without surgery; imminent risk of death, survive without the operation multiorgan failure, sepsis syndrome with hemodynamic instability, hypothermia, poorly controlled coagulopathy
Note: The ASA also includes a level 6 patient defined as A declared brain-dead patient whose organs are being removed for donor. These patients are not included in this framework.
Anaesthetic capability framework
Appendix 2: Procedure complexity
Procedure complexity is influenced by the type of anaesthesia required, necessary clinical expertise, potential for perioperative complications and expected convalescence period.
Table 2 : Complexity of adult surgical procedures
Complexity Description Minor This level of surgical complexity: procedure • Requires local anaesthesia or peripheral nerve block and possibly some level of sedation, but not general anaesthesia. • Most procedures can be undertaken in an ambulatory, day-stay or emergency department setting. • Examples may include: skin biopsy; subcutaneous tumour excision; drainage of abscess; minor debridement; tooth extraction, gastroscopy and colonoscopy.
Intermediate This level of surgical complexity: procedure • Usually requires general anaesthesia and/or a regional, epidural or spinal block • May be a day procedure, overnight or multiday stay case. A post-surgery intensive care admission would be an unexpected event. • Examples may include: Varicose vein surgery, herniorrhaphy, mastectomy, tonsillectomy, uncomplicated hip/knee replacement and lower-segment caesarean section.
Major This level of surgical complexity: procedure • Usually requires general anaesthesia and/or a regional, epidural or spinal block • Has potential for perioperative complications • Examples may include: exploratory laparotomy; diaphragmatic hernia repair; prostatectomy; extensive or complicated skin graft and cerebral shunting.
Complex This level of surgical complexity: procedure • Includes surgery with the highest potential for intra-and post-operative complications
Anaesthetics: Draft for Internal Consultation Only
• Examples may include: interventional endoscopy; pancreatic resection; lung resection; cystectomy; spinal cord injury surgery and skull base surgery.
*Adapted from NSW Role Delineation Framework, developed by NSW in consultation with the Royal Australian College of Surgeons.
Anaesthetic capability framework
Appendix 3: References and Relevant ANZCA Position Statements55: PS06: The Anaesthesia Record. Recommendations on the Recording of an Episode of Anaesthesia Care. PS08: Statement on the Assistant for the Anaesthetist PS09: Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures PS18: Guidelines on Monitoring During Anaesthesia PS28: Guidelines on Infection Control in Anaesthesia PS29 Statement on anaesthesia care of children in healthcare facilities without dedicated paediatric facilities PS31: Guidelines on Checking Anaesthesia Delivery Systems PS42: Statement on Staffing of Accredited Departments of Anaesthesia PS55: Recommendations on Minimum Facilities for Safe Administration of Anaesthesia in Operating Suites and Other Anaesthetising Locations PS56: Guidelines on Equipment to Manage a Difficult Airway During Anaesthesia Further resources Australian and New Zealand College of Anaesthetists (ANZCA), Guidelines, Standards and Safety & Quality, www.anzca.edu.au/ Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/consultative- councils/council-anaesthetic-mortality Victorian Government: Rural procedural services 2009, www.health.vic.gov.au/ NSQHS Standards, www.safetyandquality.gov.au/our-work/accreditation-and-the-nsqhs-standards Joint Consultative Committee on Anaesthesia (JCCA), www.racgp.org.au/yourracgp/organisation/committees/joint-consultative-committees/jcca/ Australian Society of Anaesthetists, position statements and professional standards, www.asa.org.au/ AIWH National definitions for elective surgery urgency categories, https://www.aihw.gov.au/reports/hospitals/national-definitions-for-elective-surgery- urgency/contents/table-of-contents NSW Health, www.health.nsw.gov.au/services/Publications/guide-role-delineation-health-services.pdf Australian Commission for Safety and Quality in Healthcare 2017, 'National consensus statement: Essential elements for recognising and responding to acute physiological deterioration', Second Edition.
55 Accessible at http://www.anzca.edu.au/resources/professional-documents
Core Capability Frameworks Page 35