Practice area 412

CLINICAL PRIVILEGE WHITE PAPER

Anesthesiologist assistant

Background

Anesthesiologist assistants (AA) are AHPs who practice under the supervision of
licensed anesthesiologists to develop and implement anesthesia care plans. They are
trained extensively in the delivery and maintenance of quality anesthesia care as well
as in advanced patient monitoring techniques. They work exclusively within the anes-
thesia care team environment, which is directed by a licensed anesthesiologist and
may also include anesthesiology residents and nonphysicians (e.g., AAs and certified
registered nurse anesthetists [CRNA]).

To qualify for practice, AAs must complete an educational program accredited by the
Commission on Accreditation of Allied Health Education Programs (CAAHEP). AA
programs are based on the master’s-degree model and require at least two full academic
years. Programs are required to be codirected by board-certified anesthesiologists.

AA programs accept students who have prior education in the sciences that would
qualify them to pursue careers in medicine, dentistry, or one of the basic medical
sciences. Students are taught course work that enhances their basic science knowledge
in physiology, pharmacology, anatomy, and biochemistry with special emphasis on the
cardiovascular, respiratory, renal, nervous, and neuromuscular systems.

Upon graduation from an accredited program, AAs must pass a national certifying ex-
amination administered by the National Commission for Certification of Anesthesiologist
Assistants (NCCAA). To maintain certification, AAs must submit documentation to the
NCCAA stating that they have completed 40 hours of continuing medical education
(CME) every two years. In addition, they must pass the Examination for Continued
Demonstration of Qualifications every six years. Failure to meet the CME or examination
requirements results in withdrawal of certification for the AA.

AAs may be licensed or practice under the license of an anesthesiologist who can dele-
gate tasks or duties involved in the practice of anesthesiology to qualified individuals
(e.g., AAs) as long as the anesthesiologist is immediately available in the operating
room area. The licensed anesthesiologist retains ultimate responsibility for the care
of the patient.

The exact details regarding delegation and licensing of AAs differ by state, so a health-
care facility or an anesthesiologist seeking to employ AAs should consult the board of
medicine of the state in which the practice is located.

A supplement to Briefings on Credentialing 781/639-1872 05/06

Anesthesiologist assistant Practice area 412

For more information, see Clinical Privilege White Paper Anesthesiology, Practice area 125
and Clinical Privilege White Paper Certified registered nurse anesthetist, Practice area 170.

Involved specialties Anesthesiologists, CRNAs, and AAs

Positions of societies The American Academy of Anesthesiologist Assistants (AAAA)

and academies is a nonprofit association of graduates from accredited AA train-
AAAA ing programs specializing in the science and clinical practice of
anesthesiology. According to the AAAA, there are currently four
established AA programs in the United States.

The programs, which graduate AAs with master’s degrees in

science, are located at

§ Emory University in Atlanta

§ Case Western Reserve University in Cleveland
§ South University in Savannah, GA, which is conducted in
conjunction with the Mercer University School of Medicine
in Macon, GA
§ Nova Southeastern University in Fort Lauderdale, FL

In the AA programs, students complete 2,000 hours of hands-

on clinical training. Admission requirements to the programs
include the following:

§ Baccalaureate degree
§ Premedical curriculum
§ Grade point average of at least 3.0
§ Completion of a Medical College Admissions Test
or Graduate Record Examination

The states in which AAs work by license, regulation, or certifi-

cation are Alabama, Florida, Georgia, Kentucky, Missouri, New
Mexico (in university hospital settings), Ohio, South Carolina,
Vermont, and the District of Columbia.

The states in which AAs are granted practice privileges through

physician delegation are Colorado, Michigan, New Hampshire,
Texas, West Virginia, and Wisconsin.

Positions of other The NCCAA provides the certification process for AAs in the
interested parties United States. The NCCAA charter includes assuring the public

2 A supplement to Briefings on Credentialing 781/639-1872 05/06

Anesthesiologist assistant Practice area 412

NCCAA that a certified AA meets basic standards related to fund of

knowledge and application of that knowledge to the duties of
practicing as an AA.

To be eligible to apply for the initial certifying examination, a

candidate must be

§ 21 years of age
§ a graduate of a CAAHEP-accredited educational program
for AAs
§ practicing as an AA or eligible to practice as an AA in at least
one of the 50 U.S. states, or
§ a student in good standing in an accredited program who
will graduate from that program within 180 days of the
certifying examination

JCAHO The JCAHO has adopted the following American Society of

Anesthesiology (ASA) sedation and anesthesia definitions:

§ Minimal sedation (anxiolysis) is a drug-induced state during

which patients respond normally to verbal commands.
§ Moderate sedation/analgesia (conscious sedation) is a drug-
induced depression of consciousness during which patients
respond purposefully to verbal commands, either alone or
accompanied by light tactile stimulation.
§ Deep sedation/analgesia is a drug-induced depression of con-
sciousness during which patients cannot be easily aroused
but respond purposefully to repeated or painful stimulation.
§ Anesthesia consists of general anesthesia and spinal or major
regional anesthesia. It does not include local anesthesia.
General anesthesia is a drug-induced loss of consciousness
during which patients are not arousable, even by painful
stimulation.

In the past, the JCAHO allowed healthcare organizations to

consider conscious sedation (or moderate sedation, which is
the term that the JCAHO uses) as a nonanesthesia procedure.
As a result of adopting the ASA definitions, the JCAHO now
treats moderate sedation/analgesia (conscious sedation) as a
continuum rather than as two separate things.

The JCAHO revised its anesthesia care standards (TX2–TX2.4.1)

so they now apply to conscious sedation. These standards are
published in the JCAHO’s Comprehensive Accreditation Manual
for Hospitals.

A supplement to Briefings on Credentialing 781/639-1872 05/06 3

Anesthesiologist assistant Practice area 412

To comply with these revisions, healthcare organizations may

have to update their sedation/anesthesia policies and review
their privileging criteria for practitioners who provide sedation/
anesthesia care.

The JCAHO has no formal position on the delineation of privi-

leges for AAs. However, in regard to qualifications for AAs,
hospitals must comply with the following human resources
(HR) and leadership (LD) standards from the Comprehensive
Accreditation Manual for Hospitals:

§ LD.3.70—The leaders define the required qualifications and

competence of those staff who provide care, treatment, and
services and recommend a sufficient number of qualified and
competent staff to provide care, treatment, and services
§ HR.1.10—The organization provides an adequate number and
mix of staff consistent with the organization’s staffing plan
§ HR.1.20—The organization has a process to ensure that a
person’s qualifications are consistent with his or her job
responsibilities
§ HR.2.10—Orientation provides initial job training and
information
§ HR.2.20—Staff, licensed independent practitioners, students,
and volunteers can describe or demonstrate their roles and
responsibilities based on specific job duties or responsibilities,
relative to safety
§ HR.2.30—Ongoing education, including inservices, training,
and other activities, maintains and improves competence
§ HR.3.10—Competence to perform job responsibilities is
assessed, demonstrated, and maintained
§ HR.3.20—The organization periodically conducts perform-
ance evaluations

CRC draft criteria When a hospital receives a request from an AA to become a

staff membe, it should not be the first time that the hospital
considers whether this type of practitioner should be granted
privileges or specified duties.

The policy covering AAs should be drafted in advance by the

board and resolve any liability, peer review, and reimbursement
issues. In addition, the board should review federal and state
laws and state and local licensing requirements. The advice of
the medical staff, needs of the community, and hospital’s mis-
sion and strategic plan should also be considered.

4 A supplement to Briefings on Credentialing 781/639-1872 05/06

Anesthesiologist assistant Practice area 412

Criteria should be in place covering the qualifications, scope of

practice, and physician supervisory requirements. The policy
should be reviewed to ensure that it is in line with the JCAHO’s
revised anesthesia standards, particularly in regard to conscious/
moderate sedation.

All provision of services should be in accordance with the writ-

ten policies and protocols governing AHPs and developed and
approved by the relevant medical staff department, medical
executive committee, and governing board of the hospital.

Minimum threshold criteria The following draft criteria are intended to serve solely as a
for requesting core AA starting point for the development of an institution’s policy
privileges or duties regarding this practice area:

Basic education and minimum formal training: Applicants must

be able to demonstrate successful completion of an AA educa-
tional program accredited by the CAAHEP. In addition, AAs
should meet the following requirements:

§ Successful completion of the national certifying examination

given by the NCCAA.
§ A current state license, if applicable.
§ Evidence of adequate professional liability insurance secured
either through the AA’s employer or held by the AA.
§ No physical or mental health problem that prevents him or
her from exercising the privileges granted. For more infor-
mation concerning this issue, refer to the Americans with
Disabilities Act of 1990.
§ Employment by or agreement with a licensed anesthesiolo-
gist currently appointed to the medical staff of the hospital
to supervise the AA’s practice in the hospital. According to
a written agreement, the licensed anesthesiologist must

- assume responsibility for supervision or monitoring of

the AA’s practice as stated in the appropriate hospital
or medical staff policy governing AAs
- be continuously available or provide an alternate to pro-
vide consultation when requested and intervene when
necessary
- assume total responsibility for the care of any patient
when requested by the AA or required by this policy
or in the interest of patient care
- cosign all orders entered by the AA on the medical
records of all patients seen or treated by the AA

A supplement to Briefings on Credentialing 781/639-1872 05/06 5

Anesthesiologist assistant Practice area 412

§ Hold current advanced cardiac life support (ACLS) and

cardiopulmonary resuscitation (CPR) certification.

Required previous experience: Applicants must be able to

demonstrate that they have successfully provided anesthesia
services for at least 350 patients during the past 12 months.

References A letter of reference must come from the director of the appli-
cant’s AA training program. Alternatively, a letter of reference
regarding competence should come from the applicant’s super-
vising licensed anesthesiologist at the institution where the
applicant most recently practiced.

Core privileges for AAs Core privileges for AAs include but are not limited to the following:

§ Pretest and calibrate anesthesia delivery systems and monitors

§ Take and record patient histories and other important
preoperative data
§ Establish plans for anesthetic care (e.g., ordering pre-
operative medicine and testing after consulting with the
anesthesiologist)
§ Insert any IV or arterial catheters and monitor the data from
these devices
§ Administer anesthesia under the supervision of an
anesthesiologist
§ Manage patient airways by using standard and advanced
techniques (e.g., intubation of the trachea)
§ Make appropriate anesthesia or vasocative drug adjustment
when necessary
§ Monitor patient status before, during, and after anesthesia is
administered
§ Adjust levels of anesthetic medication as needed
§ Provide recovery room care, including ventilatory support
and pain management
§ Give CPR during life-threatening situations or as directed by
a physician or anesthesiologist
§ Train staff in the use of monitoring and ventilating machinery

Physician oversight A physician oversight policy that is in accord with the organiza-
tion’s overall policies and with appropriate state laws and regula-
tions should be created by the organization. The policy should
define when he or she can work with limited oversight or when
the AA would be required to work under the direct supervision
of a licensed anesthesiologist. The policy should also define
areas such as

6 A supplement to Briefings on Credentialing 781/639-1872 05/06

Anesthesiologist assistant Practice area 412

§ general expectations for the supervising licensed anesthesiol-

ogist and the AA
§ how the supervising licensed anesthesiologist and AA work
together, which would include decisions about delegation
that are determined jointly
§ requirements that the supervising licensed anesthesiologist
has for the AA (e.g., specific patient problems that are always
referred to the supervising licensed anesthesiologist)
§ how supervision will be documented
§ specific lists of approved tasks

Note: State practice acts and licensure regulations must be used to define
the licensed-anesthesiologist-to-supervised-AA maximum ratio.

Special requests for AAs For each special request, threshold criteria (e.g., additional train-
ing or completion of a recognized course and required experi-
ence) must be established. Special requests for AAs include but
are not limited to procedures that were not a part of the appli-
cant’s AA training program.

Reappointment Reappointment should be based on unbiased, objective results

of care according to the organization’s existing quality assur-
ance mechanisms.

Applicants must be able to demonstrate that they have main-

tained competence by documenting that they have successfully
provided anesthesia services for at least 350 patients annually
during the reappointment cycle.

In addition, continuing education related to anesthesiology

should be required.

For more information For more information regarding this practice area, contact

American Academy of Anesthesiologist Assistants

P.O. Box 13978
Tallahassee, FL 32317
Telephone: 850/656-8848
Fax: 850/656-3038
Web site: www.anesthetist.org

A supplement to Briefings on Credentialing 781/639-1872 05/06 7

Anesthesiologist assistant Practice area 412

Joint Commission on Accreditation

of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Telephone: 630/792-5000
Fax: 630/792-5005
Web site: www.jcaho.org

National Commission for Certification

of Anesthesiologist Assistants
P.O. Box 15519
Atlanta, GA 30333-0519
Telephone: No telephone or voice mail
Fax: 404/687-9978
Web site: aa-nccaa.org

8 A supplement to Briefings on Credentialing 781/639-1872 05/06

Anesthesiologist assistant Practice area 412

Privilege request form

Anesthesiologist assistant
To be eligible to request clinical privileges as an AA, an applicant must meet the follow-
ing minimum threshold criteria:

§ Basic education and minimum formal training: Applicants must be able to demonstrate
successful completion of an AA educational program accredited by the CAAHEP or a program
that offers equivalent training. In addition, AAs should meet the following requirements:

-Successful completion of the national certifying examination given by the NCCAA.

- A current state license, if applicable.
- Evidence of adequate professional liability insurance either secured through the AA’s
employer or held by the AA.
- No physical or mental health problem that prevents him or her from exercising the privi-
leges granted. For more information concerning this issue, refer to the Americans with
Disabilities Act of 1990.
- Employment by or agreement with a licensed anesthesiologist currently appointed to the
medical staff of the hospital to supervise the AA’s practice in the hospital. According to a
written agreement, the licensed anesthesiologist must

§ assume responsibility for supervision or monitoring of the AA’s practice as stated in

the appropriate hospital or medical staff policy governing that AAs be continuous-
ly available or provide an alternate to provide consultation when requested and
intervene when necessary
§ assume total responsibility for the care of any patient when requested by the AA
or required by this policy or when in the interest of patient care
§ cosign all orders entered by the AA on the medical records of all patients seen or
treated by the AA

- Hold current ACLS and CPR certification.

§ Required previous experience: Applicants must be able to demonstrate that they have
successfully provided anesthesia services for at least 350 patients during the past 12 months.

§ References: A letter of reference must come from the director of the applicant’s AA training
program. Alternatively, a letter of reference regarding competence should come from the appli-
cant’s supervising licensed anesthesiologist at the institution where the applicant most recently
practiced.

A supplement to Briefings on Credentialing 781/639-1872 05/06 9

Anesthesiologist assistant Practice area 412

§ Core privileges: Core privileges for AAs include but are not limited to the following:

- Pretest and calibrate anesthesia delivery systems and monitors

- Take and record patient histories and other important preoperative data
- Establish plans for anesthetic care (e.g., ordering preoperative medicine and testing
after consulting with the anesthesiologist)
- Insert any IV or arterial catheters and monitor the data from these devices
- Administer anesthesia under the supervision of an anesthesiologist
- Manage patient airways by using standard and advanced techniques (e.g., intubation
of the trachea)
- Make appropriate anesthesia or vasocative drug adjustment when necessary
- Monitor patient status before, during, and after anesthesia is administered
- Adjust levels of anesthetic medication as needed
- Provide recovery room care, including ventilatory support and pain management
- Give cardiopulmonary resuscitation during life-threatening situations or as directed
by a physician or anesthesiologist
- Train staff in the use of monitoring and ventilating machinery

§ Physician oversight: A physician oversight policy should be created by the organization,

which is in accord with the organization’s overall policies and appropriate state law and regu-
lation. The policy should define when the AA can work with limited oversight or when he or
she would be required to work under the direct supervision of a licensed anesthesiologist. The
policy should also define areas such as

- general expectations for the supervising licensed anesthesiologist and AA

- how the supervising licensed anesthesiologist and AA work together, which would include
decisions about delegation that are determined jointly
- requirements that the supervising licensed anesthesiologist has for the AA (e.g., specific
patient problems that are always referred to the supervising licensed anesthesiologist)
- how supervision will be documented
- specific lists of approved tasks

Note: State practice acts and licensure regulations must be used to define the licensed anesthesi-
ologist to supervised AA maximum ratio.

§ Reappointment: Reappointment should be based on unbiased, objective results of care

according to the organization’s existing quality assurance mechanisms.

Applicants must be able to demonstrate that they have maintained competence by documenting
that they have successfully provided anesthesia services for at least 350 patients annually dur
ing the reappointment cycle.

In addition, continuing education related to anesthesiology should be required.

10 A supplement to Briefings on Credentialing 781/639-1872 05/06

Anesthesiologist assistant Practice area 412

I understand that by making this request I am bound by the applicable bylaws or policies
of the hospital and hereby stipulate that I meet the minimum threshold criteria for this
request.

Applicant’s signature: ____________________________________________

Typed or printed name: __________________________________________

Date: __________________________________________________________

A supplement to Briefings on Credentialing 781/639-1872 05/06 11

Anesthesiologist assistant Practice area 412

Group Publisher: Kathryn Levesque Managing Editor: Maureen Coler,

Clinical Privilege White Papers klevesque@hcpro.com mcoler@hcpro.com
Advisory Board Senior Managing Editor: Edwin B. Niemeyer,
eniemeyer@comcast.net

James F. Callahan, DPA John E. Krettek Jr., MD, PhD Beverly Pybus
Executive vice president and CEO Neurological surgeon Senior consultant
American Society of Addiction Medicine Vice president for medical affairs The Greeley Company
Chevy Chase, MD Missouri Baptist Medical Center Marblehead, MA
St. Louis, MO
Sharon Fujikawa, PhD Richard Sheff, MD
Clinical professor, Dept. of Neurology Michael R. Milner, MMS, PA-C Chair and Executive Director
University of California, Irvine Medical Center Senior physician assistant consultant The Greeley Company,
Orange, CA Phoenix Indian Medical Center a division of HCPro, Inc.
Phoenix, AZ Marblehead, MA
John N. Kabalin, MD, FACS
Urologist/Laser surgeon
Scottsbluff Urology Associates
Scottsbluff, NE

The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials
committees in developing their own local approaches and policies for various credentialing issues. This information, including the
materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, addi-
tional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not
provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained.

Reproduction in any form outside the recipient’s institution is forbidden without prior written permission. Copyright 2006 HCPro, Inc.,
Marblehead, MA 01945.

12 A supplement to Briefings on Credentialing 781/639-1872 05/06