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College of Respiratory
Therapists of Ontario

 

RESPIRATORY THERAPISTS AS ANESTHESIA ASSISTANTS

Professional Practice Guideline

 

 

March 1, 2024

PROFESSIONAL PRACTICE GUIDELINE

CRTO publications contain practice parameters and standards that should be considered by all Ontario Respiratory Therapists (RTs) in the care of their patients/clients and in the practice of the profession. CRTO publications are developed in consultation with professional practice leaders and describe current professional expectations. It is important to note that these CRTO publications may be used by the CRTO or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained.

It is important to note that employers may have policies related to Respiratory Therapists authority to perform certain procedures; including controlled acts and acts that fall within the public domain. If an employer’s policies are more restrictive than the CRTO’s expectations, the RT must abide by the employer’s policies. Where an employer’s policies are more permissive than the expectations of the CRTO, the RT must adhere to the expectations of the CRTO.

RETURN TO THE CRTO WEBSITE

QUESTIONS OR COMMENTS?

    This Professional Practice Guideline will be updated as new evidence emerges or as practice evolves. Comments on this guideline are welcome and should be addressed to:
    College of Respiratory Therapists of Ontario, 90 Adelaide Street West, Suite 300, Toronto, Ontario M5H 3V9
    Phone 416-591-7800 | Toll Free 1-800-261-0528 | Fax 416-591-7890 | E-mail questions@crto.on.ca

    INTRODUCTION

    For several decades, Registered Respiratory Therapists (RRTs) have worked alongside anesthetists in Ontario operating rooms, providing technical support on the proper use and maintenance of the anesthetic gas machine in addition to airway management. Since the implementation of the Anesthesia Care Team model in 2009, the role of Respiratory Therapists practicing under the supervision of an anesthesiologist has evolved to include several additional activities, such as the provision of conscious sedation, administration of anesthetic gas medications, insertion and management of arterial lines and the assessment of the depth of anesthesia. The locations where RRTs now provide these services have also expanded to include labor and delivery, emergency departments, and specialty suites such as endoscopy and private dental practices.

      Professional Titles, Roles & Responsibilities

      Professional Titles

      The title for this role RRTs plays in varies between institutions. Although the title of “Anesthesia Assistant” (AA) is not legislatively protected, it has been associated with this role in some facilities in Ontario. In the Canadian Anesthesia Society’s (CAS) 2022 Position Paper on Anesthesia Assistants the CAS has supported the development of the “Anesthesia Care Team” (ACT) concept of care in which the specialist physician anesthetist practices with the assistance of dedicated, trained, and certified Anesthesia Assistant individuals.

      Those working as AAs “should be experienced healthcare professionals who have pursued a defined period of didactic and clinical training specific to the competencies required to be an AA”.

      In addition, the position of the CRTO and the CAS is that an RRT must not use the title of Anesthesia Assistant unless they have completed a recognized Anesthesia Assistant educational program.

      CSRT’s Certified Clinical Anesthesia Assistant (CCAA)

      The Canadian Society for Respiratory Therapy (CSRT) offers a credential for Anesthesia Assistants – the Certified Clinical Anesthesia Assistant (CCAA). This credential is awarded to regulated health care professionals who (1) have completed an accredited anesthesia assistant program, and (2) have successfully passed the credentialing exam offered by the Canadian Board for Respiratory Care (CBRC). Those holding the CCAA credential must remain registered with the CSRT and participate in the continuing education program for the CCAA.

      Details of the program can be found on the CSRT website: www.csrt.com.

      The CCAA is not a substitute for registration with a regulatory body – in fact, maintenance of the CCAA requires ongoing registration with a regulator. ALL RTs wishing to practice in Ontario must be registered with the CRTO. The CRTO does not require its Members who work as AAs to obtain the CCAA designation.

       

      Working under the Direction and Supervision of an Anesthesiologist

      The CAS 2022 Position Paper on Anesthesia Assistants stipulates that AAs work under the direction and supervision of an anesthetist. “The AA must not be used as a replacement for a physician anesthetist”. The same principle applies to all RTs, regardless of whether they have received AA training or not, which is that the RT is not to be the primary provider of anesthesia services.

      Scope of Practice, Competencies & Authorized Acts

      Scope of Practice

      The CRTO has determined that the concept of Respiratory Therapists (RTs) as Anesthesia Assistants is consistent with the scope of practice outlined in the Respiratory Therapy Act (RTA), which is as follows:

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      The providing of oxygen therapy, cardio-respiratory equipment monitoring and the assessment and treatment of cardio-respiratory and associated disorders to maintain or restore ventilation.

      For a comprehensive list of examples of technical, professional and administrative duties an AA may assist with, see the CAS 2019 Position Paper and the National Competency Framework 2016 document.

      Competencies

      Many of the procedures that Respiratory Therapists perform in the area of anesthesia are entry-to-practice competencies taught in respiratory therapy programs, however the degree of competency and skill can be expanded with the completion of the additional training. For those skills beyond entry-to-practice competency, many of the RRTs performing these activities have undergone on-site training.

      Others have completed Anesthesia Assistant educational programs. Although the CRTO does not specifically require its Members to undergo additional certification or “proof” of formalized training from its Members to carry out or to enhance their practice, the CRTO supports and encourages a consistent and measurable process to enhance the skills of its members through the completion of the AA educational program.

      Authorized Acts Performed by RRTs in an Operating Room Setting

      Many of the tasks performed by RRTs under the supervision of an anesthetists are done under the controlled acts that are authorized to Respiratory Therapists via the RTA, which are as follows:

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      1. Performing a prescribed procedure below the dermis, such as:

      • Arterial line insertion
      • Intravenous and/or intra-arterial catheter insertion
      • Pulmonary artery catheters and central venous catheter insertion
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      2. Intubation beyond the point in the nasal passages where they
      normally narrow or beyond the larynx.

      • Routine and difficult airway management
      • Oro/nasogastric tube insertion
      • Performing Bronchoscopy
      • Assisting in emergence from anesthesia (e.g., tracheal extubation, removal of laryngeal mask airway)
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      3. Suctioning beyond the point in the nasal passages where they normally narrow or beyond the larynx.

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      4. Administering a substance by injection or inhalation.

      • Assisting with induction and maintenance of anesthesia
      • Providing procedural sedation (e.g., administration of narcotics)
      • Administering blood products
      • Ventilation management
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      5. Administering a prescribed substance by inhalation.

      More information on controlled acts authorized to Respiratory Therapists can be found in the CRTO’s Interpretation of Authorized Act Professional Practice Guideline.

      Procedural Sedation

      The CAS position paper on Procedural sedation states that sedation may be provided by a team that includes a sedation supervisor (typically the anesthesiologist/ physician) and an approved and credentialed sedation assistant(s) (e.g., Respiratory Therapist, Anesthesia Assistant.)  Sedation administration may be delegated to the AA/RRT by the sedation supervision. The sedation supervisor retains responsibility for the patient and must remain immediately available to support the sedation assistant as necessary.

      Public Domain Activities Performed by RRTs in an Operating Room Setting

      Other tasks performed by RRTs under the direction and supervision of an anesthetist are not controlled acts, and therefore rest within the public domain. This means that these activities can be performed by any healthcare professional who possesses the requisite competencies. The following are examples of public domain activities routinely performed by RRTs providing anesthesia services:

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      Pre-operative assessments
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      Set up, calibration and troubleshooting of anesthesia equipment and patient monitors

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      Intraoperative and post-operative patient monitoring (e.g., EtCO2, SpO2)
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      Patient transfer to/from various care areas (e.g., Post Anesthetic Care Unit, ED, ICU, Surgical Floor)

      Authorizing Mechanisms

      Authorizing Mechanisms

      AAs execute medical orders and directives as prescribed by anesthesiologists. The RTA
      requires an order for all controlled acts authorized to Respiratory Therapists (regardless of practice setting) except* for:

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      Suctioning beyond the point in the nasal passages where they normally narrow or beyond the larynx; and

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      Administering a prescribed substance by inhalation

      * Please note: depending on the practice setting, other legislation may require an order even for these acts (e.g., the Public Hospitals Act). Almost all controlled acts authorized to Respiratory Therapists require a valid order.

      Both direct orders and medical directives are valid authorizing mechanisms and either be used by an RRT providing anesthesia services. The only exception to this is when controlled substances are administer, in which case a direct order must be used. More information on this can be found in the section entitled Controlled Substances.

      More information on authorizing mechanisms can be found in the CRTO’s Orders for Medical Care Professional Practice Guideline.

      Delegation

      Delegation is the transfer of legal authority to perform a controlled act to a person not authorized to perform that controlled act. When the task to be performed is neither authorized to Respiratory Therapists nor part of the public domain, it must be delegated to the RRT from another competent, regulated health care professional who has the authority to perform the controlled act. The following are examples of tasks that RRTs might receive delegation for when providing anesthesia services:

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      Dispensing medication
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      Putting an instrument, hand or finger beyond the opening of the urethra, beyond the anal verge or into an artificial opening into the body

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      Application of a form of energy for nerve conduction studies, cardioversion, defibrillation or transcutaneous cardiac pacing

      More information on delegation can be found in the CRTO’s Delegation of Controlled Acts Professional Practice Guideline.

      Please Note:

      RRTs who wish to use ultrasound in their practice (e.g., for guided arterial line insertions) no longer require delegation.

      However, an order is still required.

      • As outlined in the CRTO Orders for Medical Care Professional Practice Guideline (PPG) there are two types of orders:
        1. A direct order (naming an individual patient)
        2. A medical directive (for a broad group/type of patient)

      The Federation of Health Regulatory Colleges of Ontario (FHRCO) has additional information on these processes, as well as templates that combine a medical directive with a delegation document.

      Controlled Substances

      RRTs are authorized to administer controlled substances and other medications to a particular patient or group of patients, provided they have a valid order. It is essential to first determine if a controlled substance is being administered or dispensed. If the obtained medication is prepared and administered at that time to a patient, then it’s considered to be administration and not dispensing (e.g., providing procedural sedation to a patient in the OR).

      The Controlled Drugs and Substances Act states that the physician who orders a controlled substance must name the individual patient in the prescription. Because of this restriction, medical directives for a broad range of patients cannot be used to gain possession of a controlled substance.

      More information on controlled substances can be found in the CRTO’s Handling, Administration and Dispensing of Controlled Substances Position Statement.

      Dispensing

      The RTA does not authorize RTs to dispense medication, however, this controlled act can be delegated to an RT from a regulated healthcare professional who has the authority to delegate dispensing. In addition, RTs can obtain possession of a controlled substance through a prescription issued by an authorized practitioner; usually a physician.

      More information on Dispensing can be found in the CRTO’s Administering & Dispensing Medications Professional Practice Guideline

      Documentation

      The purpose of documentation is to preserve a permanent and accurate record of the care a patient receives. This includes documentation in the patient’s Personal Health Records (PHR), as well as equipment maintenance records, transfer of accountability (TOA) reports, adverse event/critical incident reports, etc. RTs working as AAs may document in a paper record, in an electronic system, or a combination, as specified by the facility where the patient care is provided. In addition, each phase of the continuum of anesthesia care (pre-operative, intra-operative and post-operative) has its own unique documentation requirements. However, RTs working as Anesthesia Assistants are required to adhere to the same documentation standards as RTs in any other practice setting and are responsible for documenting their own actions.  Note: It is not acceptable to allow another healthcare provider to record or document for the AA/RRT.

      More information on the CRTO’s Documentation Standards can be found in the CRTO’s Documentation PPG and CRTO’s Standards of Practice – Standard 7.