The evolution and formalization of anesthesia assistant roles across Canada

Abstract

Purpose

The purpose of this Special Article is to document the evolution of the anesthesia assistant (AA) profession in Canada and summarize AA practice at Canadian institutions as it exists today, five decades after Quebec and 15 years after most other provinces formalized AA practice.

Source

Through the Management Committee of the Association of Canadian University Departments of Anesthesia (ACUDA), we conducted a purposeful sampling of all ACUDA chairs or their delegates. We requested the following data: history of AAs becoming a reality in their particular province or region; potential recruitment pools; training programs and curricula; pathway to credentialing; funding, pay, retention, recruitment, and status of union representation; and metrics.

Principal findings

Data were provided by 19 institutions in 8 provinces: Newfoundland and Labrador, Nova Scotia, Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia. Given the different health care governance structures across the provinces, AA roles vary in terms of its associated technical, clinical, and educational responsibilities. The role of AAs in supporting anesthesia care through equipment maintenance and assistance with airway management, resuscitation, and administration of regional anesthesia seems to be well established, as is their role in providing brief intraoperative relief for anesthesiologists during a stable period of anesthesia. Anesthesia assistant duties continue to evolve, becoming more aligned with the specific institution and less dependent on the supervising anesthesiologist. Apart from the initial metrics collected during the Ontario ACT implementation pilot projects, we are not aware of any formal metrics, current or ongoing, being collected across Canada, related to either patient safety events or perioperative efficiency.

Conclusions

This compilation of pan-Canadian AA data shows diverse models of practice and highlights the value to patients and the health care system as a whole of incorporating these allied professionals into the anesthesia care team (ACT). The present findings allow us to offer suggestions for consideration during discussions of retention, recruitment, program expansion, and cross-country collection of metrics and other data. We conclude by making six recommendations: 1. recognize that implementation of ACTs is a key element in solving the challenge of an increasing surgical backlog; 2. develop, or facilitate the development of, metrics and increase data-sharing nationally to enable health care authorities to better understand the importance of AAs in patient safety and perioperative efficiency; 3. develop and implement funding strategies to lower the barriers to AA training such as hospital-sponsored positions, ongoing salary support, and return-of-service arrangements; 4. ensure that salaries appropriately reflect the increased level of training and added levels of responsibility of certified AAs; 5. develop long-term strategies to ensure stable funding, recruitment and retention, and a better match between the number of AA training positions and the need for newly certified AAs; and 6. engage all stakeholders to acknowledge that AAs, as knowledgeable and specifically trained assistants, not only fulfill their defined clinical role but also contribute significantly to patient safety and clinical efficiency by assuming nondirect patient care tasks.

Alternate abstract:

Résumé

Objectif

Le but de cet article spécial est de documenter l’évolution de la profession d’assistant·e en anesthésie (AA) au Canada et de résumer la pratique des AA dans les établissements canadiens telle qu’elle existe aujourd’hui, cinquante ans après que le Québec et quinze ans après que la plupart des autres provinces ont officialisé la pratique des AA.

Sources

Par l’entremise du Comité de gestion de l’Association canadienne universitaire des départements d’anesthésie (ACUDA), nous avons réalisé un échantillonnage ciblé de tou·tes les président·es de l’ACUDA ou de leurs délégué·es. Nous avons demandé les données suivantes : historique de la concrétisation de la profession d’AA dans leur province ou région; bassins de recrutement potentiels; programmes de formation et programmes d’études; voie d’accès à l’accréditation; financement, rémunération, rétention, recrutement et état de la représentation syndicale; et données métriques.

Constatations principales

Des données ont été fournies par 19 institutions dans 8 provinces : Terre-Neuve-et-Labrador, Nouvelle-Écosse, Québec, Ontario, Manitoba, Saskatchewan, Alberta et Colombie-Britannique. Compte tenu des différentes structures de gouvernance des soins de santé dans les provinces, les rôles des AA varient en termes de responsabilités techniques, cliniques et éducatives connexes. Le rôle des AA dans le soutien des soins d’anesthésie par l’entretien du matériel et l’aide à la prise en charge des voies aériennes, à la réanimation et à l’administration de l’anesthésie régionale semble bien établi, tout comme leur rôle dans la fourniture d’un bref soulagement peropératoire aux anesthésiologistes pendant une période stable d’anesthésie. Les tâches des assistant·es en anesthésie continuent d’évoluer, devenant plus alignées sur l’établissement spécifique et moins dépendantes de l’anesthésiologiste superviseur·e. À l’exception des mesures initiales recueillies dans le cadre des projets pilotes de mise en œuvre des ESA (équipes de soins en anesthésie) en Ontario, nous ne sommes au courant d’aucune mesure officielle, actuelle ou en cours, recueillie dans l’ensemble du Canada, concernant les événements liés à la sécurité des patient·es ou à l’efficacité périopératoire.

Conclusion

Cette compilation de données pancanadiennes sur les AA présente divers modèles de pratique et souligne l’importance pour les patient·es et le système de soins de santé dans son ensemble d’intégrer ces professionnel·les connexes à l’équipe de soins d’anesthésie (ESA). Les résultats actuels nous permettent d’avancer des suggestions à prendre en compte lors des discussions sur le maintien en poste, le recrutement, l’expansion des programmes et la collecte de mesures et d’autres données à l’échelle du pays. Nous concluons en formulant six recommandations : 1. reconnaître que la mise en œuvre des ESA constitue un élément clé pour résoudre le problème de l’augmentation de l’arriéré chirurgical; 2. élaborer ou faciliter l’élaboration de mesures et accroître le partage des données à l’échelle nationale pour permettre aux autorités sanitaires de mieux comprendre l’importance des AA pour la sécurité des patient·es et l’efficacité périopératoire; 3. élaborer et mettre en œuvre des stratégies de financement pour réduire les obstacles à la formation des AA, comme les postes parrainés par les hôpitaux, le soutien salarial continu et les ententes de retour de service; 4. veiller à ce que les salaires reflètent de manière appropriée le niveau accru de formation et les niveaux de responsabilité accrus des AA certifié·es; 5. élaborer des stratégies à long terme pour assurer un financement, un recrutement et une rétention stables, ainsi qu’une meilleure adéquation entre le nombre de postes de formation des AA et le besoin de nouveaux et nouvelles AA certifié·es; et 6. inciter toutes les personnes impliquées à reconnaître que les AA, en tant qu’assistant·es compétent·es et spécialement formé·es, non seulement remplissent leur rôle clinique défini, mais contribuent également de manière significative à la sécurité des patient·es et à l’efficacité clinique en assumant des tâches de soins non directs aux patient·es.

Background

As noted by Martin et al., as a country, “Canada is among the world’s most devolved federations.”¹ Health care delivery is disconnected from direct federal oversight and is operationally regulated by provincial and territorial governments. Each Canadian province or territory has its own medical regulatory authority governing physician practice, and nursing practice is similarly regulated. In contrast, colleges regulating the practice of registered respiratory therapists (RRTs) exist in most but not all jurisdictions, making the oversight of RRTs less consistent across the country. This decentralization has resulted in a diverse evolution of the anesthesia assistant (AA) profession across provinces and territories, with RRTs, registered nurses (RNs), physician assistants (PAs), and international medical graduates (IMGs), participating to various degrees. Decentralization has also led to a myriad of credentials for AAs. The term “anesthesia assistant” or AA is not a legal term in Canada. An AA may be an RRT or an RN who has undertaken postgraduate training and obtained the Certified Clinical Anesthesia Assistant (CCAA) certification under the Canadian Society of Respiratory Therapy (CSRT); an RRT, RN, or IMG who has undergone postgraduate training and obtained the Clinical Assistant-Anesthesia (CA-Anesthesia) credential through the College of Physicians and Surgeons of Manitoba (CPSM); an RRT working in the operating room (OR) in Quebec, and credentialed by the Ordre professionnel des inhalothérapeutes du Québec (OPIQ; Montreal, QC, Canada); or an RRT or RN working in the OR outside of Quebec without having undertaken a formal AA curriculum. Among these different categories, there is not full equivalency or reciprocity.

The role of allied health professionals working as assistants in anesthesia can be traced back to the end of World War II, when returning military medics were assigned to technical tasks in hospitals, such as setting up oxygen cylinders and maintaining anesthetic equipment. In the early 1950s, in response to the poliomyelitis epidemic in Canada, hospitals needed to rapidly adopt the use of positive-pressure mechanical ventilators, along with new technologies to alleviate hypoxemia. The emergence of these modalities created a need for dedicated physician helpers to assist with the integration and application of technologies to patient care.² This clinical role, variably known as “oxygen orderly,” “OR tech,” etc., emerged as a precursor to the respiratory therapy profession.^3,4 In 1973, Quebec moved to enact provincial legislation to protect the RRT designation, which included their practice in the OR.^{5, 6–7} Concomitantly, there is anecdotal information indicating that, since at least the mid-1960s, RNs across Canada have been assisting anesthesiologists in various capacities and to various degrees. Then, in 1999, an amendment to the Medical Act in Manitoba allowed for the licencing of PAs and clinical assistants (CAs) by the CPSM—formal AA training was initiated in 2006, with enrolment open to IMG, RRT, and RN applicants. In 2010, the CSRT and the Canadian Anesthesiologists’ Society (CAS) published the National Education Framework (NEF),⁸ and in 2016, they formalized the CCAA credentialing process based on the National Competency Framework (NCF).⁹

By the early 2000s, in addition to facing increasing patient complexity and advancing innovations in equipment, technology, and therapeutics, anesthesiologists were confronted with growing surgical wait lists and shortages of qualified staff. It was recognized that anesthesiologist-led anesthesia care teams (ACTs) with AAs and other professional team members were essential to deliver timely, patient-centred, and cost-efficient care.¹⁰ While RRTs have been working as AAs in Quebec for five decades, other provinces began to formally establish AAs as part of the ACT around 2008, albeit under different standards. Consequently, AA practice may be mostly compliant with the CAS Position Paper on Anesthesia Assistants (Appendix 5 of the CAS Guidelines to the Practice of Anesthesia),¹¹ but there are differences in implementation when comparisons are made with the NCF.⁹ Variation in AA training, credentialing, and practice remains between provinces.

The purpose of this article is to document the evolution of the AA profession and summarize AA practice at Canadian institutions as it exists today, five decades after Quebec and 15 years after most other provinces formalized AA practice.

Methods

Through the Management Committee of the Association of Canadian University Departments of Anesthesia (ACUDA), we identified and conducted a purposeful sampling¹² of all ACUDA chairs or their delegates. The sampling was supplemented with snowball sampling¹³ to identify suitable individuals from geographical areas that declined our initial invitation. All academic departments of anesthesia in Canada are represented in ACUDA; however, there are no members from Prince Edward Island, New Brunswick, or the three territories, as anesthesia trainees in those locations are affiliated with medical schools in other provinces. Each ACUDA chair was contacted up to four times seeking their participation in our study, and such participation was voluntary.

The following data were requested from each participant, if available: history of AAs becoming a reality in their particular province or region; potential recruitment pools (RRTs, RNs, IMGs, others); training programs and curricula (CSRT NCF, others); pathway to credentialing (college of respiratory therapy, college of nursing, medical regulatory authority); funding, pay, retention, recruitment, and status of union representation; and metrics (case turn-over time, reduction of overtime, concurrent supervision, and critical events if applicable).

Findings

Data, including any required qualifications or existing provincial governance of AAs, were provided by 19 institutions in the following 8 provinces: Newfoundland and Labrador, Nova Scotia, Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia (Table 1). There are CCAAs who are not RRTs, and the institutions range from teaching centres to small community centres. The participants who provided the data were ACUDA chairs and/or delegates, anesthesiologists, RRTs, and AAs involved in development of the AA profession or in setting up or currently overseeing an AA program in their respective institution.

Table 1. Anesthesia assistant qualifications and governance throughout Canada

	Province	Teaching/tertiary care	Large hospital	Small hospital	AA qualifications & governance of RRTs working as AAs
					CCAA required as AA	ACA required as AA	RRT required as AA (OPIQ)	RRT as AA under provincial RT college	RRT as AA (no provincial RT college)	Other
Janeway Children’s Health and Rehabilitation Centre, NLHS	NL	✓			CCAA, occasional RT to cover absences			✓
St. Clare’s Mercy Hospital, NLHS		✓			CCAA, occasional RT to cover absences			✓
Health Sciences Centre, NLHS		✓			CCAA, occasional RT to cover absences			✓
Outside of St. John's				✓	CCAA not required			✓		RTs act as AAs
QEII Health Sciences Centre	NS	✓			✓			✓		CCAAs expected for new AAs
IWK Health Centre		✓			✓a			✓		CCAAs required for new ped AAs
McGill University Health Centre	QC	✓					✓	✓
CHU de Québec		✓					✓	✓
Sunnybrook Health Sciences Centre	ON	✓			✓			✓
McKenzie Health			✓		✓			✓
The Ottawa Hospital		✓			✓			✓
London Health Sciences Centre		✓			✓			✓
St. Joseph’s Health Care London		✓			✓			✓
WRHA	MB	✓	✓			✓
Shared Health		✓		✓		✓
Royal University Hospital	SK	✓			✓			✓
Saskatoon City Hospital		✓						✓
St. Paul’s Hospital		✓						✓
Regina General Hospital		✓						✓
Pasqua Hospital		✓						✓
University of Alberta Hospital	AB	✓						✓		Mostly RTs; CCAA not required
Vancouver Acute Department of Anesthesia (VGH, UBCH)	BC	✓			✓				✓
Other BC centres (SPH/MSJ [PHC]; BCCH [PHSA]; and hospitals in the Fraser Health, Interior Health, Island Health, and Northern Health authorities)		✓	✓	✓	✓b				✓

^aOne registered nurse who is at the Women's Building/obstetrics who HAS CCAA designation

^bRegistered nurses are eligible for entry into the Thompson Rivers University AA program (Kamloops, BC, Canada)

AA = anesthesia assistant; AB = Alberta; ACA = Anesthesia Clinical Assistants, Physician Assistants; BC = British Columbia; BCCH = BC Children’s Hospital; CCAA = Certified Clinical Anesthesia Assistants; CHU = Centre hospitalier universitaire; MB = Manitoba; MSJ = Mount Saint Joseph Hospital; NL = Newfoundland and Labrador; NLHS = Newfoundland and Labrador Health Services; NS = Nova Scotia; ON = Ontario; ped = pediatric; PHC = Providence Health Care; PHSA = Provincial Health Services Agency; QC = Quebec; RT = respiratory therapist; RRT (OPIQ) = Registered Respiratory Therapist in Quebec under L’Ordre professionnel des inhalothérapeutes du Québec; SK = Saskatchewan; SPH = St. Paul’s Hospital; UBCH = UBC Hospital; VGH = Vancouver General Hospital; WHRA = Winnipeg Regional Health Authority

To facilitate reporting, the data are presented by province from the east to west coast. By no means are data from an individual province meant to represent the entire province, especially given health authority or institutional variations within individual provinces.

History, formalization, and funding

Data on funding, union vs nonunion representation, and financial support for AAs in different institutions across Canada are summarized in Table 2.

Table 2. Funding, union vs nonunion, financial support

Province	Hospital	Funding	Union	Tuition Support	Practicum Support	Recent one-time or salary adjustments
NL	Janeway Children’s Health and Rehabilitation Centre, NLHS	NLHS	Association of Allied Health Professionals		Sometimes	Annual nonpensionable market adjustment of CAD 12–24 K for AAs
	St. Clare’s Mercy Hospital, NHLS
	Health Sciences Centre, NLHS
	Outside of St. John’s		Newfoundland Association of Public Employees
NS	QEII Health Sciences Centre	NS Health	NSGEU		✓	One-time retention bonus
	IWK Health Centre			Yes (previously)	✓
QC	McGill University Health Centre	Provincial	FIQ
	CHU de Québec
ON	Sunnybrook Health Sciences Center	Hospital	Nonunion	✓	✓	Market adjustments followed by competitive pay scale
	MacKenzie Health		Nonunion
	The Ottawa Hospital		Local RT union, OPSEU
	London Health Sciences Centre
	St Joseph’s Healthcare London
MB	WHRA	Manitoba Health	PCAM	✓	✓
	Shared Health
SK	Royal University Hospital	Saskatchewan Health Authority	HSAS	✓	✓	Market adjustments followed by competitive pay scale
	Saskatoon City Hospital
	St. Paul's Hospital
	Regina General Hospital
	Pasqua Hospital
AB	University of Alberta Hospital	Alberta Health	HSAA
BC	Vancouver Acute Department of Anesthesia (VGH, UBCH)	Vancouver Coastal Health	HSA BC (RT Union Grid Level 11)			Market adjustment April 2024
	Other BC centres (SPH/MSJ [PHC]; BCCH [PHSA]; and hospitals in the Fraser Health, Interior Health, Island Health, and Northern Health authorities)	Health authorities	HSA BC (RT Union Grid Level 11)	✓	✓	Market adjustment April 2024

AB = Alberta; BC = British Columbia; BCCH = BC Children’s Hospital; CHU = Centre hospitalier universitaire; FIQ = Fédération Interprofessionnelle de la santé du Québec; HSAA = Health Sciences Association of Alberta; HSA BC = Health Sciences Association of British Columbia; HSAS = Health Sciences Association of Saskatchewan; MB = Manitoba; MSJ = Mount Saint Joseph Hospital; NL = Newfoundland and Labrador; NLHS = Newfoundland and Labrador Health Services; NS = Nova Scotia; NSGEU = Nova Scotia Government Employee Union; ON = Ontario; OPSEU = Ontario Public Service Employees Union; PCAM = Physician and Clinical Assistants of Manitoba; PHC = Providence Health Care; PHSA = Provincial Health Services Agency; QC = Quebec; SK = Saskatchewan; SPH = St. Paul’s Hospital; UBCH = UBC Hospital; VGH = Vancouver General Hospital; WHRA = Winnipeg Regional Health Authority

Newfoundland and Labrador

The development of the CAS “Position Paper on Anesthesia Assistants”¹¹ and the NCF established by the CSRT⁹ contributed to formal recognition of the AA role in 2008. Before this milestone, since at least the early 1990s, RRTs had worked informally in the OR environment. Currently, a total of nine CCAAs are positioned across three tertiary care hospitals in St. John’s, with another position to be added in January 2024 and a further CCAA appointment expected with the planned expansion of the cardiac surgery program. Elsewhere in Newfoundland and Labrador, there are no CCAAs or full-time RRT positions in hospital ORs, although there are some less well-defined roles for RRTs. Currently, there is no AA training program in the province, but for trainees who undertake the didactic component elsewhere, the clinical component can be completed in St John’s; trainees in these positions are funded.

Practitioners in AA positions have recently received an “annual non-pensionable market adjustment” (specifically, CAD 24,000 for AA I, CAD 18,000 for AA II, and CAD 12,000 for anesthesia respiratory therapists), as their remuneration was well below comparable positions elsewhere in Canada. These adjustments compare to adjustments of CAD 10,000–16,000 for RRTs in this province.

Nova Scotia

The training of anesthesia technicians started in the 1960s, when it typically consisted of a 4–6-week period of “on-the-job” instruction with little formal curriculum.¹⁴ Six anesthesia technicians were hired originally to provide technical support. Starting in the early 2000s, “AAs were trained to provide anesthesia physician relief, a distinct role from that of anesthesia technicians” (ESM eAppendix 1). Significant development and expansion of the role has occurred over the ensuing years. The scope of practice has transitioned from a predominantly technical focus to a clinical focus. Currently, there are 37 AAs in the province.

The AAs originate primarily from the locally trained RRT pool; there is one RN (ESM eAppendix 1). Training for AAs is geared toward post-RRT certification. The first AAs (early 2000s) were trained through Cariboo College (Kamloops, BC, Canada)1 with practicums completed in Halifax. Since then, the didactic component is undertaken virtually through Thompson Rivers University (TRU). Three or four students enrol in the program each year. Recently, Cape Breton Regional Hospital posted an expression of interest for one RRT to undergo AA training, which will support expansion of the profession geographically.

Since 2018, all newly graduating AAs must pass the CSRT’s CCAA examination. Those who completed training before this date were “grandfathered” into the designation. According to the CSRT, as of May 2023, 31 of the 37 AAs in the province hold the CCAA designation. This categorization requires annual membership in good standing with the CSRT and the Nova Scotia College of Respiratory Therapists (ESM eAppendix 1), which is the provincial licencing body for RRTs. There is currently no separate licence for AAs. The single RN employed as an AA is credentialed by the Nova Scotia College of Nursing.

Anesthesia assistant trainees in the Central Zone of Nova Scotia Health are paid during their practicums. Their salary is commensurate with that of perfusionists. Select cohorts receive funding to cover training costs in exchange for a two-year return-of-service agreement (ESM eAppendix 1). Recently, the government of Nova Scotia offered an additional retention bonus for ongoing work.¹⁵

Quebec

In 1965, Dr. Léon Longtin, an anesthesiologist at the Université de Montréal, founded the first respiratory therapist in-hospital training program in Canada, known as the École de technologie en thérapie inhalatoire (Institut Lavoisier/Hôpital Rosemont).^5,16 The first graduates were allowed to work in the OR after two years of training. The program operated for three years before being transferred to the Collège d'enseignement general et professionnel (CEGEP) system.¹⁷ By 1969, all respiratory therapy training programs in Quebec had been integrated into the college system. Graduates were required to obtain a three-year vocational training diploma.^5,18 That same year, the Association des anesthésiologistes du Québec, wanting to train professionals dedicated exclusively to assisting anesthesiologists in the OR, proposed adding an “anesthesia assistance” component to the initial training of RRTs, which already included respiratory and cardiovascular physiology and techniques of respiratory resuscitation. The program was then renamed “respiratory therapy-anesthesia course.”

All personnel functioning as AA equivalents in Quebec are RRTs and do not require additional postgraduate training. Admission to the respiratory therapy training program in colleges is based on specific requirements as determined by the Ministère de l'Enseignement supérieur du Quebec.¹⁹ The title of “respiratory therapist” was established, and has been protected since 1973. It is regulated under the professional code of the Office des professions du Québec.²⁰ The code specifically states that an individual may use the title, “Registered Respiratory Therapist” or “Technician in Inhalation Therapy and Anesthesia” only if they hold a valid permit for that purpose and are entered on the rolls of OPIQ, the regulatory body for respiratory therapists in Quebec. In particular, RNs, IMGs, and PAs are not permitted to work in the OR in the capacity of an AA in Quebec unless they have earned the protected RRT title.

As of 2020, the OPIQ had a total of 4,404 members. Of these, 1,348 indicated “assistance anesthésique” as their primary specialty and another 60 identified analgesia-sedation as their primary specialty; thus, 32% of RRTs work in anesthesia.²¹

All respiratory therapy training programs must meet competencies related to both general respiratory therapy and anesthesia.²² These competencies are defined provincially. No Quebec respiratory therapy training programs are required to follow the NCF for respiratory therapy²³ or the NCF for AAs.⁹ Anecdotally, both NCFs are consulted to ensure a robust curriculum.

While the exact number of hours varies across CEGEPs, the current curriculum for the anesthesia component includes 120 hr of didactic learning and 280–365 hr of full-time clinical learning. These clinical hours are below the minimum requirements for CCAA training accredited by the CSRT²⁴ or CA-Anesthesia training by the CPSM. Notably, all RRTs in Quebec have the same base salary regardless of one’s location of work (e.g., in the OR, in the intensive care unit).2

Ontario

In the 1960s and 1970s, various hospitals throughout Ontario employed individual RRTs or RNs on an ad hoc basis in the OR to set up anesthesia equipment and support anesthesiologists in other ways. There were no specific rules, regulations, or formal standards required for these individuals to fulfill these roles or carry out the attendant responsibilities. In the late 1980s and 1990s, with the increasing complexity and volume of cardiac and vascular surgeries, RRTs in some Ontario ORs began to take on more clinical roles, including advanced airway management, insertion of arterial lines, assistance with pulmonary arterial line insertions, measurement of thermodilution cardiac output, point-of-care testing, and cell salvage. In the late 1990s and early 2000s, the role of RRTs in the OR expanded to other activities, including sedation for transesophageal echocardiography, peribulbar blocks, and other forms of regional anesthesia.

In 1992, as recommended in the Barer–Stoddart report,²⁵ the provincial and territorial governments jointly implemented a 10% reduction in postgraduate medical training positions and a minimum two-year prelicensure requirement for physicians.²⁶ An anesthesia-related shortage of health human resources developed as an unintended consequence of adopting these recommendations.^27,28 This shortage necessitated a change in the patient care delivery paradigm,^10,29 which in turn led to the development of ACTs, and the formalization of AAs into perioperative care. The April 2006 report of the Operative Anesthesia Committee, entitled “Transforming the Delivery of Operative Anesthesia Services in Ontario,” recommended adoption of the ACT model.³⁰ Subsequently, in 2009, the ACT Implementation Advisory Committee was created to oversee the initiative. In its evaluation, this committee reported, “The quality audit [of implementing an ACT] demonstrated positive feedback from AAs, anesthesiologists and surgeons. The economic evaluation identified an overall reduction in cost per case for selected procedures and an increase in number of surgeries completed during the study period. It was noted however that there were additional costs for hospitals in implementing the ACT model.”³¹ Metrics on “team environment,” “patient safety,” and “job satisfaction” were also positive.

As a result of the 2006 report, AA training was established at Algonquin College (Ottawa, ON, Canada), Fanshawe College (London, ON, Canada), and the Michener Institute of Technology (Toronto, ON, Canada) in 2007. In 2010, these institutions adopted the NEF established by the CSRT.⁸ There has been no coordinated effort within the province to rationalize the number of AAs needed or to maintain the capacity of these training programs. In 2016, the CSRT went on to establish a certification process for the designation of CCAA based on the NCF and the CCAA exam.^9,32 As of 2018, only individuals who have completed an accredited CCAA program, as postgraduate training, are permitted to take the CCAA national certification exam. Professionals already working in the field were “grandfathered.” This certification was available to many health care professionals, including RNs;³² however, in Ontario, most CCAAs have been recruited from the ranks of RRTs. In April 2022, there were 276 CCAAs, none of whom were PAs or IMGs.

The College of Respiratory Therapists in Ontario (CRTO) regulates RRTs in the province and supports the CCAA designation.³³ Nevertheless, “the CRTO does not require its Members who work as AAs to obtain the CCAA designation.”³⁴

Certified Clinical Anesthesia Assistants training is at the postgraduate level, and trainees incur additional costs.³⁵ The cost of training remains a barrier for many, particularly as a person’s remuneration may not increase substantially after a period of training. Despite the report of the ACT Implementation Advisory Committee, which showed improved safety, improved team climate, greater job satisfaction, increased efficiency, and beneficial economic impact,³¹ the number of AA positions in Ontario has not increased significantly since 2009. Combined with the additional costs for CCAA training, the minimal pay differential compared with “non-CCAA” RRTs, and salary discrepancies between unionized and nonunionized environments, recruitment is challenging.

Manitoba

The mid-2000s served as a watershed moment for Manitoba. Previously, departments of anesthesia in Winnipeg hospitals operated relatively independently in terms of staffing, organization, and delivery of clinical services—the roles and responsibilities of allied health workers were institution-specific and many of the positions reported directly to the anesthesiology department head. In 2006, the Winnipeg Regional Health Authority (WRHA) and The University of Manitoba, Faculty of Medicine collaborated to overhaul the medical administrative structure. The organizational imperative aligned with the advent of two new anesthesia allied health professionals, the ACA and the Ophthalmic Sedation Practitioner.

The Government of Manitoba had previously (in 1999) amended the Medical Act to allow for the licencing of PAs and CAs. The legislation, known at the time as the “Clinical Assistants (CA) and Physician Assistants (PA) Regulation,” permitted the CPSM to establish criteria for licensure, to maintain a register of members, and to regulate practice. Changing the Medical Act was only the first step in an arduous lobbying process that took the college registrar, the university’s dean of medicine, the WRHA, and other stakeholders more than six years to convince Manitoba Health, a department of the government operating under the Minister of Health, and the University of Manitoba of the virtue and value of PAs. Competition for funding of alternative health care providers had arisen owing to the lobbying efforts on behalf of nurse practitioners, clinical nurse specialists, and other advanced practice nursing roles, around the same time as the federal government funded the Canadian Nurse Practitioner Initiative.³⁶ In April 2006, funding from the WRHA was made available to start training ACAs in Manitoba. The legislation was updated and amended as the “Regulated Health Professions Act” (C.C.S.M. c. R117) in 2009. The wording is clear: PAs and CAs are physician extenders, not independent practitioners; they work with a degree of autonomy that is negotiated and agreed upon by the supervising physician(s) and the PA/CA.³⁷ The distinction between a PA and a CA is an important one. A PA is either a graduate of the University of Manitoba Master of Physician Assistant Program (established in 2008) or an Armed Forces medic. Their supervising physician does not need to be physically present in the same facility. In contrast, a CA-Anesthesia (known as an ACA before 2009) is a graduate of a one-year CPSM-approved training program developed and run by the University of Manitoba’s Department of Anesthesiology, Perioperative and Pain Medicine. The supervising anesthesiologist must be immediately available. The legislation is available online; the job description and contract of supervision are approved by the provincial medical regulatory body; and the classroom and clinical curriculum have been established, along with distinct admission and evaluation processes. The first class of four ACAs began their full-time positions in January 2008 following the one-year training program. Full details of the program including history, structure, competencies, and funding are available online as ESM eAppendix 2.

Clinical Assistant-Anesthesia report to the CPSM and their supervising anesthesiologist, not the regulatory colleges of their former discipline (e.g., RN or RRT). Any CA-Anesthesia who is an IMG would not have been practicing as a physician in Manitoba and as such would have no former regulating bodies. The training for CA-Anesthesia therefore follows successful completion of a person’s initial health care qualification.

The CA-Anesthesia trainee position is funded at a rate of approximately CAD 90,000 for 100 hr biweekly. The salary for a full-time position in the region, originally negotiated by the university’s Department of Anesthesiology, Perioperative and Pain Medicine with WRHA Human Relations, is now settled between government representatives and the Physician and Clinical Assistants of Manitoba, the union formed by clinical assistants and physical assistants in 2015 to secure representation by and for their profession. Creation of a union was deemed necessary to prevent annexation into an established provincial union that had declared its “right to bargain” exclusively for allied health professionals. Remuneration depends on a contractual obligation of 2,080 hr yearly (four ten-hour days per week plus call) or 2,600 hr yearly (five ten-hour days per week including shift work and call). The range for the latter option is CAD 156,000–191,000 over six step increments. Notably, CA-Anesthesia are employees of the WRHA. They are compensated from the provincial government’s medical remuneration budget, under the direction of the two regional health authorities: the WRHA and Shared Health. Physician extenders carry medical malpractice liability insurance.

Since 2007, there have been 21 trainees. Of these, 16 are currently practicing after three retirements and two relocations to other provinces. Three new trainees began their training in October 2023—Manitoba has committed to an additional nine trainee positions (two of which will fill the relocation vacancies) over the next three years, for a guaranteed funding allotment of 27 positions in anesthesia.

Anesthesia human resource planning accounts for service delivery in multiple locations (e.g., ORs, off-service sites, pain and preadmission clinics, maternity units, stepdown units, and intensive care units) and is a product of timely, ongoing dialogue with the government and the health authorities. This dialogue involves reviewing of regional service delivery expectations in tandem with consideration of personnel issues, such as maternity leaves and retirements. The discourse should also include negotiation of sustainable funding to maintain the integrity of the AA training program over time.

Saskatchewan

Data were received from the Royal University Hospital, Saskatoon City Hospital, and St Paul’s Hospital in Saskatoon, and the Regina General and Pasqua Hospitals in Regina. Before 1997, RNs with on-the-job training provided anesthesia assistance at these hospitals. At the Royal University Hospital, one RRT maintained anesthesia equipment, and two additional RRTs were recruited between 1998 and 2003 to provide dedicated anesthesia clinical assistance. The combined RN/RRT model slowly transitioned to an RRT-dominated model, with some hires having had “formal” training, and others trained on the job. Around 2016, as the CSRT CCAA certification process was formalized, CCAA certification became a requirement for AA recruitments. Recently, the Saskatchewan Health Authority approved the hiring of additional CCAAs, increasing their number from three to six in Regina, and to a total of 15 in Saskatoon. All RRTs in Saskatchewan are governed by the Saskatchewan College of Respiratory Therapists. The CCAA salary is generally 8% higher than the highest RRT pay grade.

Alberta

At the University of Alberta Hospital (Edmonton, AB, Canada), the first “tech” was hired from the orderly staff in 1965 to work in the cardiac room, setting up monitors and managing the blood gas machine. In 1973, the Department of Anesthesia created the technical position of “anesthesia equipment mechanic” and provided on-the-job training. Except for one individual (who had taken a two-year anesthesia technician course abroad), every person hired for the position was an RRT who completed one year of in-hospital training. The present-day department has 21.3 full-time equivalents covered by 24 people.

In total, more than 100 RRTs with various levels of skill and experience are working in the ORs of all major hospitals in Alberta. The current plan is to create a provincial standard for AAs in Alberta with initiatives to adapt the in-hospital training program from Vancouver General Hospital, and to establish accreditation by the CSRT. Work has begun on development of educational components for the program; however, a substantial portion of the curriculum remains to be completed. Recruitment will likely be from the current pool of RRTs. A physician lead for the ACT implementation plan has been hired, and a provincial educator/program director has been funded. The proposed job title is Respiratory Care Practitioner Anesthesia (RCP-A). Trainees would complete educational modules, receive clinical exposure, and be tested before receiving the designation. For now, education for AAs continues to follow an on-the-job model, with paid training in a hospital setting. Registered respiratory therapists in the OR who currently hold the CCAA designation will be fast-tracked through certain portions of the program.

All RRTs are governed by the College of Respiratory Therapists of Alberta. Those working in public facilities are part of a single large collective bargaining unit within the Health Sciences Association of Alberta union. There are three pay grids for RRTs. Currently, most RRTs working in the OR environment are in the second pay grid, whereas supervisors and most educators are in the third pay grid. The difference between grids is minimal and is currently not an important reason for pursuing a career as an RCP-A. Once the program is better established, and advanced practice roles become well defined, practitioners would be justified in applying for a classification change to a new grid level that reflects the level of training and responsibilities of the job.

British Columbia

Initially known as anesthesia technologists, RRTs working as AAs were introduced in the mid-1990s after a coroner’s inquest related to an intraoperative critical incident. These RRTs received limited advanced training before starting their work in the OR. Until 2000, AAs were available only during daytime hours. Their assistance during complex procedures such as lung or liver transplant and trauma surgery became recognized as essential, prompting the move toward 24-hr AA coverage at the major teaching hospitals. Nevertheless, poor remuneration and lack of acknowledgement of their advanced skill set resulted in multiple unfilled positions. An adjustment in compensation to reflect the responsibilities of the position was created in 2006 through a memorandum of agreement with the Vancouver General Hospital (VGH) administration, with reclassification of AAs from grid level eight to 11 and implemented provincewide as a result of arbitration in 2012.

All AAs at VGH and UBC Hospital (UBCH) in the Vancouver Coastal Health authority, collectively served by the Vancouver Acute Department of Anesthesia (VADA), come from RRT backgrounds. As a stipulation of funding, new recruits undertake a formal AA training program whereas existing members were required to complete only the didactic portion of the virtual AA postdiploma program offered by TRU. Over time, despite availability of the TRU program, it became clear that the unique role filled by AAs at VGH and UBCH would be best taught through a locally developed and administered course. In 2015, the hospital administration funded the development of the VADA ACA training program. This program was created using the CSRT’s NEF Document⁸ and benefited from the sanctioned use of “Fundamentals of Anesthesia Care,” a compilation of the learning modules used in the Manitoba CA-Anesthesia training program. Vancouver Acute Department of Anesthesia members edited the individual modules and created new modules as required (the VADA ACA training program is not the same as the Manitoba program and is not regulated by the BC College of Physicians and Surgeons). An AA educator was hired from the existing AA pool to help create both the modules and a schedule for students that included clinical and didactic sessions. In late 2016, the first four students were enrolled and upon completion of the training, they took the CSRT’s CCAA examination. In 2019, the VADA program received accreditation with provisions from the CSRT and it is now fully accredited. Several cohorts of trainees have completed the program and some have also been trained for other local hospitals. In total, the VADA program has trained 26 CCAAs whereas TRU has trained approximately two dozen CCAAs. Students are not responsible for tuition and are paid at their current salary level during the training.

Outside VGH/UBCH, other notable sites such as St. Paul’s Hospital and Mount Saint Joseph Hospital (Providence Health Care); BC Children’s Hospital (Provincial Health Services Authority); and hospitals in the Fraser Health, Island Health, Interior Health, and Northern Health authorities all require new AAs to take the TRU AA Diploma program. There are two streams: the accelerated TRU AA program is a one-year curriculum during which the AA student completes 36 weeks of didactic coursework followed by a 16-week clinical practicum at the hospitals with TRU educators. The nonaccelerated AA program can be completed over two years via open learning at TRU.

Anesthesia assistant positions in British Columbia are funded by the various provincial health authorities. Overall, the involvement of AAs in the province has evolved significantly from the 1980s when AAs primarily worked as equipment persons to now where AAs at most hospitals have become an integral part of the ACT.

Models of care

The care responsibilities of AAs are set out in Table 3. Given the different health care governance structures across the provinces, AA roles vary in terms of its associated technical, clinical, and educational responsibilities. For example, obtaining difficult intravenous access with ultrasound outside the OR setting without an anesthesiologist present is requested in Winnipeg but is expected at the IWK-Pediatrics in Halifax. Global job descriptions are published for comparison—for instance, the CSRT outlines 12 discrete roles that can be performed by CCAAs under the direction of an anesthesia specialist physician.⁹ In Manitoba, the CA-Anesthesia job description is available through the CPSM website. It defines the scope of practice for all CA-Anesthesia, but the actual practice of an individual CA-Anesthesia includes those tasks, responsibilities, and anesthesia-related duties that the supervising anesthesiologist is capable of performing and comfortable delegating, and that the CA-Anesthesia is competent to perform.³⁸ In Quebec, RRT roles are defined by legislation C-26, “Professional Code” (section 37.1, subsection 7).²⁰

Table 3. Models of care and anesthesia assistant roles*

Hospital	Province	Arterial line insertion	Out-of-OR difficult IV starts	Maintain & assist with equipment	Airway management (intubation, supraglottic airway, BMV)	Assist with difficult airways	Assist with complex cases, regional anesthesia, and resuscitation
Janeway Children’s Health and Rehabilitation Centre, NLHS	NL	CCAA, RT	CCAA, RT	CCAA, RT	CCAA, RT	CCAA, RT	CCAA, RT
St. Clare’s Mercy, NLHS
Health Sciences Centre, NLHS
Outside St. John's, NLHS		RT	RT	RT	RT	RT	RT
QEII Health Sciences Centre	NS	CCAA	CCAA	CCAA, RT	CCAA	CCAA	CCAA
IWK Health Centre, Women's Building/OB
IWK Health Centre, Children’s Building/ped
McGill University Health Centre	QC			RT (OPIQ)	RT (OPIQ)	RT (OPIQ)	RT (OPIQ)
CHU de Québec
Sunnybrook Health Sciences Centre	ON	CCAA	CCAA	CCAA, Technician	CCAA	CCAA	CCAA
MacKenzie Health			CCAA	CCAA
The Ottawa Hospital				CCAA, RT
London Health Sciences Centre
St. Joseph’s Healthcare London
WRHA	MB	ACA	As requested	ACA	ACA	ACA	ACA
Shared Health
Royal University Hospital	SK	CCAA		CCAA	CCAA	CCAA	CCAA
Saskatoon City Hospital
St. Paul’s Hospital
Regina General Hospital
Pasqua Hospital
University of Alberta Hospital	AB	RT		RT	RT	RT	RT
Vancouver Acute Department of Anesthesia (VGH, UBCH)	BC	CCAA	CCAA	CCAA	CCAA	CCAA	CCAA
Other BC centres (SPH/MSJ [PHC]; BCCH [PHSA]; and hospitals in the Fraser Health, Interior Health, Island Health, and Northern Health authorities)		CCAA	CCAA	CCAA	CCAA	CCAA	CCAA

Hospital	Province	Ongoing intra-op monitoring, short periods of anesthesiologist relief	Provide OR/off-site IV sedation (anesthesiologist immediately available)	Provide IV sedation off-site or for particular OR slates (anesthesiologist not involved)	Other	24/7 availability	Overall ratio of AAs to anesthesia locations
Janeway Children’s Health and Rehabilitation Centre, NLHS	NL	CCAA, RT		RN		No call schedule but occ. called in	≤ 1:3
St. Clare’s Mercy, NLHS							Approx. 1:2
Health Sciences Centre, NLHS				RN, RT (specialized unit)			Between 1:2 and 1:3
Outside St. John's, NLHS		RT		RT, RN		N/S	N/A
QEII Health Sciences Centre	NS	CCAA	CCAA		Opthalmology 2-3:1; out-of-OR GA or sedation 1:1; on cardiac arrest team at VG hospital 24/7	Call schedule but gaps	Approx. 1:3
IWK Health Centre, Women's Building/OB						24/7 in-house overage with some gaps	1:2
IWK Health Centre, Children’s Building/ped					PICC Line Insertion: CCAA. Any out of OR Anesthesia GA 1:1	Call Schedule 24/7 (home call)	1:1 off-site & high acuity; approx. 1:2 for general OR
McGill University Health Centre	QC	RT (OPIQ)	RT (OPIQ)			In-house 07:00–24:00, 7 days a week	1:1
CHU de Québec
Sunnybrook Health Sciences Centre	ON	CCAA	CCAA		OB support, trauma team with anesthesia, burn unit with anesthesia	Call schedule	1:3
MacKenzie Health					Endoscopy 2:1; block room; out-of-OR emergency response team; enhanced block program for hip #	In-house 0700–2400, 7 days a week	1:3 to ≤ 1:3
The Ottawa Hospital				RN in ED, some by RT	Cataracts 5:1; ECT 1:1	No call schedule but occ. called in	≤ 1:3
London Health Sciences Centre				RN	Peds remote 1:1; ECT 1:1		≤ 1:3
St. Joseph’s Healthcare London					Cataracts 2:1; ECT 1:1	No	≤ 1:3
WRHA	MB	ACA	ACA	ACA, RN		Yes	N/A
Shared Health
Royal University Hospital	SK	CCAA	CCAA			Yes	≤ 1:3
Saskatoon City Hospital
St. Paul’s Hospital
Regina General Hospital
Pasqua Hospital
University of Alberta Hospital	AB	RT				Yes	≤ 1:3
Vancouver Acute Department of Anesthesia (VGH, UBCH)	BC	CCAA	CCAA			Yes	≤ 1:3
Other BC centres (SPH/MSJ [PHC]; BCCH [PHSA]; and hospitals in the Fraser Health, Interior Health, Island Health, and Northern Health authorities)		CCAA	CCAA			Yes	≤ 1:3

*The roles described here are but a sample of roles described by some institutions and in the literature and by no means are meant to be exhaustive

AA = anesthesia assistant; AB = Alberta; ACA = Anesthesia Clinical Assistants, Physician Assistants, College of Physicians and Surgeons of Manitoba; BC = British Columbia; BCCH = BC Children’s Hospital;BMV = bag-mask ventilation; CCAA = Certified Clinical Anesthesia Assistants, Canadian Society of Respiratory Therapists; CHU = Centre hospitalier universitaire; ECT = electroconvulsive therapy; ED = Emergency Department; IV = intravenous; MB = Manitoba; MSJ = Mount Saint Joseph Hospital; NL = Newfoundland and Labrador; NLHS = Newfoundland and Labrador Health Services; NS = Nova Scotia; OB = obstetrics; ON = Ontario; OPIQ = L’Ordre professionnel des inhalothérapeutes du Québec; OR = operating room; PHC = Providence Health Care; PHSA = Provincial Health Services Agency; QC = Quebec; ped = pediatric; RT = Respiratory Therapists; Shared Health = Health Sciences Centre, peripheral hospitals (Manitoba); SK = Saskatchewan; SPH = St. Paul’s Hospital; UBCH = UBC Hospital; VGH = Vancouver General Hospital; WRHA = Winnipeg Regional Health Authority

The role of AAs in supporting anesthesia care through equipment maintenance and assistance with airway management, resuscitation, and administration of regional anesthesia seems to be well established within the institutions that provided data for this Special Article, as is their role in providing brief intraoperative relief for anesthesiologists during a stable period of anesthesia. Nevertheless, there is greater variation in the approach to delivery of intravenous sedation. Some centres specify that the anesthesiologist must be immediately available whereas others permit independent off-site delivery of sedation without direct anesthesiologist oversight. Some but not all centres allow AAs to insert arterial catheters. Based on the information we received, AA duties are continuing to evolve, becoming more aligned with the specific institution and less dependent on the supervising anesthesiologist.

In Newfoundland and Labrador, Nova Scotia, Quebec, Ontario, and Saskatchewan, AA practice is governed by each province’s college of respiratory therapists. In Manitoba, AA practice is governed by the CPSM. In British Columbia, there is no self-governing college of respiratory therapists, which has led to debates about proposed amendments to Bill 36, the Health Professions and Occupations Act.

In Nova Scotia, Quebec, and Manitoba, departments of anesthesia have either direct oversight of or a close reporting structure with hospital or regional health authorities regarding both day-to-day decisions and the recruitment and retention of AAs. In Saskatchewan, there are no AAs practicing outside of Regina or Saskatoon, and AAs in those two cities report to nursing. In Ontario, oversight and overall planning for recruitment and retention of AAs varies from institution to institution. In some institutions, the department of anesthesia has little or no role in overall resource planning, or in the recruitment and retention of AAs. In British Columbia, where CCAA clinical practice is unregulated, AAs function under hospital policies of “delegated functions,” based to some extent on the CSRT’s NCF; as a result, the scope of practice is highly variable from one health authority to another.

In Quebec, the ratio of AAs to anesthesia locations is 1:1 for every OR, whereas outside of Quebec, our data indicate an AA ratio of ≤ 1:3. On-call coverage varies from 24/7 in certain provinces, cities, and individual institutions, including Halifax, Quebec, some Ontario hospitals, Manitoba, Regina, Saskatoon, and VADA, to no on-call coverage but call-in under certain circumstances, as is the case in some other Ontario hospitals.

Generally speaking, across provinces, nonclinical matters such as payroll, human resources, parking, and performance reviews are managed by the administration of either the hospital or the regional health authority.

Metrics

Apart from the initial metrics collected during the Ontario ACT implementation pilot projects,³⁹ we are not aware of any formal metrics, current or ongoing, being collected across Canada, related to either patient safety events or perioperative efficiency.

Nevertheless, anecdotal information is available from every province highlighting the advantages of incorporating AAs into an ACT model. The following are a few examples:

• Reduced turnover time through engagement in parallel processing of patients (e.g., the AA manages transport to, and handover in, the postanesthesia care unit, then returns to the OR to set up the room for the next procedure while the anesthesiologist is assessing the next patient in the preoperative holding area), which increases the number of cases completed during regular hours, reduces staff overtime hours, and facilitates handling of emergency cases

• Shortened time to anesthesia readiness owing to expert assistance preparing for and assisting with regional anesthesia procedures

• Insertion of arterial and central venous catheters for cardiac surgical cases in some jurisdictions

• Timely attention to consults or assessments in the preanesthesia clinic while the AA manages sedation and monitoring for a slate of off-site procedures⁴⁰

• Reduced case costs for certain types of surgery (cataract, hip replacement)

• Assistance with difficult airways and airway emergencies and unstable patients

• Timely checking of anesthesia machines and troubleshooting of equipment problems

• Enhanced safety climate in the OR⁴¹

Discussion

Canada is well-known for its decentralized health care system.¹ Likely as a result, the evolution pathway for AAs in Canada has been long and complex, starting in Quebec in 1969, followed by the notification of changes in 2003 to the CAS “Guidelines to the Practice of Anesthesia,”¹⁰ the publication of “Position Paper on Anesthesia Assistants” in the Appendix 5 of the CAS Guidelines in 2006⁴² implementation of pilot projects in Ontario in 2006,⁴³ regulation of CA-Anesthesia under the CPSM in Manitoba in 2006, development of an NEF in 2010 by the CSRT,⁸ and the creation of an NCF in 2016.⁹ While the CSRT is the credentialing body for CCAAs (similar to the Royal College of Physicians and Surgeons of Canada for specialist physicians), provinces and territories may regulate their own licencing of RRTs, RNs, or CA-Anesthesia. Institutional AA practices therefore reflect the respective provincial regulations, and as a result, there is no single national standard. The evolution and implementation of AA programs as reported by the institutions that contributed to this paper reveal jurisdictional diversity in terms of training requirements, salary and reporting structures, anesthesiologist to AA ratios, and models of care.

We chose to present the data province by province rather than in chronological sequence because of the diverse evolution of AAs in different provinces coupled with the interinstitutional and/or interhealth authority differences within individual provinces. Our data suggest that, decades after it began, the AA model of care in Canada continues to exhibit significant variation. This variation is likely to continue because of decentralization. This might be seen as a system that offers needed flexibility to adapt to local needs; conversely, this diversity might be seen as an opportunity for change. We wanted to highlight this diversity in the hopes of initiating further discussions and dialogues about AAs in Canada.

Given that 15 years have elapsed since the topic of AAs was first addressed at a CAS forum, it could be that the opportunity to build common expectations and job roles related to the credentialing and clinical work of AAs across the country has passed. Nonetheless, it may yet be possible to unite expectations around curriculum content, delivery methodologies, and training approaches through the sharing of educational program materials. As well, a pan-Canadian approach to certification and accreditation would afford AAs the possibility of interprovincial portability. There is consensus among the authors, all of whom have the experience of working with or as AAs, that members of this profession improve patient safety, efficiency, and working conditions for anesthesiologists and thereby support the provision of anesthesia care.

Unionization of AAs varies across provinces, with some provinces being fully unionized, others nonunionized, and some a mixture of both models. Bargaining units representing AAs, as is the case for RRTs in Quebec and CA-Anesthesia in Manitoba, reflect a different remuneration scale than units representing RRTs who are or are not CCAAs. Differences in funding models exist, including funding of trainees for the didactic and clinical program elements in Manitoba, funding of trainees during their practicums in Halifax, and self-funding of tuition and practicums in other jurisdictions. The pay scale during employment as an AA also varies. The key element is whether the pay scale is commensurate with the extra training and responsibilities, given the implications for retention, recruitment, and sustainability. Certainly, discussions about underwriting expenses incurred during both the didactic and the practical segments of training programs and the provision of enhanced remuneration models that reflect the added responsibilities and demands placed upon certified/trained AAs would be welcome.

The recruitment pools and credentialing of AAs differ from province to province, depending in part on regional evolution of the role and in part on differences in health care delivery systems. Generally, but with exceptions in Manitoba and Quebec, AAs have an entry-to-practice credential (e.g., RRT) and maintain their original credential or licence in addition to the AA credential.³²

In many countries around the world, trained individuals (e.g., RNs, technicians) assist anesthesiologists in a team-based perioperative care environment. Such team-based care has been shown to improve patient safety,⁴⁴ reduce intraoperative errors,⁴⁵ and resolve critical events.^46,47 In Canada, the Ontario ACT implementation pilot projects showed reductions in case costs and improvements in patient safety, the team environment, and job satisfaction.³⁹ Nevertheless, there is a need for an initial hospital investment of resources before many of these benefits can be accrued.⁴⁸ With preliminary results of improved patient safety and reduced case costs, AAs working within an ACT would seem to be an essential linchpin in this era of cost consciousness in health care. With the increasing surgical backlog and the current federal–provincial discussions on the Canada Health Transfer, the need for meaningful metrics on perioperative patient safety and efficiency, coupled with increased data sharing seems evermore relevant.⁴⁹

This Special Article has some limitations. For example, it summarizes data from only 19 institutions and therefore does not necessarily provide a complete picture of AA practice in Canada. In particular, there may well be other models of anesthesia assistance not described here. Anecdotally, we are aware of instances where one anesthesiologist supervises AAs in more than one OR, especially during different phases of anesthesia, a practice potentially contrary to the CAS Position Paper¹¹ but not formally reported for inclusion in our data set. Nevertheless, this paper represents a snapshot of the current state of AA practice in many major institutions, mostly teaching centres.

The data presented here are primarily derived from historical accounts and current reports provided by AAs and anesthesiologists engaged in the AA profession within their respective institutions. In an effort to mitigate potential biases, the authors implemented strategies to ensure trustworthiness, following the framework outlined by Lincoln and Guba.⁵⁰ To strengthen the credibility of the findings, the lead author and coauthors engaged in frequent verification exercises on the reported data and connected with organizations such as provincial colleges of respiratory therapists, the CAS, the CSRT, and AA education facilities.

In summary, this compilation of pan-Canadian AA data highlights the value to patients and the health care system as a whole of incorporating these allied professionals into the ACT and allows us to offer suggestions for consideration during discussions of retention, recruitment, program expansion, and cross-country collection of metrics and other data. The data presented here confirm the reality of diverse AA practice. As authors of this Special Article, we are not in a position to endorse or reject any particular model of AA practice. For that purpose, a more comprehensive study and additional data collection are needed. There is also urgency to provide tangible support for AA recruitment and retention.

Recommendations to highlight and emphasize in ongoing dialogue

The following recommendations reflect a consensus among the authors:

1. Recognize that implementation of ACTs is a key element in solving the challenge of an increasing surgical backlog

2. Develop, or facilitate the development of, metrics and increase data-sharing nationally to enable health care authorities to better understand the importance of AAs in patient safety and perioperative efficiency

3. Develop and implement funding strategies to lower the barriers to AA training such as hospital-sponsored positions, ongoing salary support, and return-of-service arrangements

4. Ensure that salaries appropriately reflect the increased level of training and added levels of responsibility of certified AAs

5. Develop long-term strategies to ensure stable funding, recruitment and retention, and a better match between the number of AA training positions and the need for newly certified AAs

6. Engage all stakeholders (administrators, funders, health care authorities) to acknowledge that AAs, as knowledgeable and specifically trained assistants, not only fulfill their defined clinical role but also contribute significantly to patient safety and clinical efficiency by assuming nondirect patient care tasks such as “readying the cockpit” and ensuring that supplies and equipment are stocked, maintained, and in working order, among other tasks

Author contributions

Homer Yang, Judith Littleford, and Marco Zaccagnini contributed to all aspects of this manuscript, including conception and design; acquisition, analysis, and interpretation of data; and drafting the article. Beverley A. Orser, Rob Bryan, and Ken LeDez contributed to the conception and design of the study. Mateen Raazi and Chris Christodoulou contributed to the conception of the study. Hamed Umedaly, Mitch Giffin, Irfaan Ali, Derek Dillane, Jason Foerster, Mateen Raazi, Monica Olsen, Rob Bryan, Natalie Buu, Adam Law, Brandon D’Souza, and Ken LeDez contributed to the acquisition of data. Ken LeDez contributed to the analysis of data. All authors contributed to the interpretation of data and drafting the article.

Acknowledgements

We would like to express our sincere appreciation to Carolyn McCoy, Director of Accreditation Services and Professional Practice, Canadian Society of Respiratory Therapists (Ottawa, ON, Canada) for all her assistance. We also would like to thank Mark Carolan, Supervisor, Anesthesia Technology, Vancouver Acute Department of Anesthesia (Vancouver, BC, Canada). Historical information was also received from Alva Noel, OR RRT, Sunnybrook Health Sciences Centre (retired); Mike O’Donnel, OR RRT, Sunnybrook Health Sciences Centre (retired); Fred Cashin, RRT, previous roles: Site Leader, Toronto Western Hospital; Manager, Respiratory Therapy Services Mackenzie Health; and Patrick Nellis, MBA, RRT, CCAA, FCSRT, previous roles: Practice Leader at University Health Network (UHN); AA Program Faculty at The Michener Institute at UHN (Toronto, ON, Canada). We appreciate the additional information about RRT practice in Quebec provided by Marise Tétreault, L‘Ordre professionnel des inhalothérapeutes du Québec (Montreal, QC, Canada), and Dr. Valérie Milot-Roy, anesthesiologist, Centre hospitalier universitaire de Québec–Université Laval (Quebec City, QC, Canada). The help of these individuals greatly facilitated data collection for this paper. We would also like to thank William Pope, MD, LLB, FRCPC and the College of Physicians and Surgeons of Manitoba (Winnipeg, MB, Canada) for their assistance in preparing the Electronic Supplementary Material regarding Manitoba.

Disclosures

Dr. Mitch Giffin is a retired anesthesiologist and was a key person in setting up the AA program at the Vancouver Acute Department of Anesthesia. All other authors either work with or work as AAs. Drs Hamed Umedaly, Derek Dillane, Mateen Raazi, Beverley A. Orser, and Chris Christodoulou have either direct or indirect responsibilities for the hiring of AAs. Otherwise, all authors declare no conflicts of interest.

Funding statement

There was no funding for this study. All work undertaken was on a voluntary basis.

Editorial responsibility

This submission was handled by Dr. Adrian Gelb, Guest Editor, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

Glossary of terms and abbreviations

Anesthesia assistant (AA)

For the purposes of this article, AA is a general term that may refer to certified clinical anesthesia assistants, anesthesia clinical assistants (Manitoba), registered respiratory therapists (Quebec) who work in the operating room, or registered respiratory therapists outside of Quebec who work in the operating room assisting anesthesiologists without having undertaken a formalized curriculum. “Anesthesia assistant” is not a legal term in Canada.

ACA

Anesthesia clinical assistant—the historical term used in Manitoba

ACT

Anesthesia care team

ACUDA

Association of Canadian University Departments of Anesthesia

CA-Anesthesia

The present-day legal term in Manitoba; CA (clinical assistant)

CAS

Canadian Anesthesiologists’ Society

CCAA

Certified clinical anesthesia assistants, registered under the CSRT

CEGEP

French acronym for collège d'enseignement général et professionnel, (general and professional teaching college in English), the first level of postsecondary education in Quebec for technical programs or preceding university education

CPSM

College of Physicians and Surgeons of Manitoba

CRTO

College of Respiratory Therapists of Ontario

CSRT

Canadian Society of Respiratory Therapists

FTE

Full-time equivalents

HHR

Health human resources

IMG

International medical graduate

NCF

National competency framework, CSRT

NEF

National education framework, CSRT

OPIQ

L‘Ordre professionnel des inhalothérapeutes du Québec

OR

Operating room

PA

Physician assistant

RCP-A

Respiratory care practitioner anesthesia (University of Alberta Hospital)

RN

Registered nurse

RRT

Registered respiratory therapist

UBCH

UBC Hospital

VADA

Vancouver Acute Department of Anesthesia

VADA ACA

Anesthesia clinical assistant training program developed by VADA

VGH

Vancouver General Hospital

WRHA

Winnipeg Regional Health Authority

1

Thompson Rivers University (TRU) as of 1 April 2005

2

Canadian Society of Respiratory Therapists. Respiratory therapist and anesthesia assistant professional salary scale analysis; 2021.

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