Time to consider nonphysician anaesthesia providers in Europe?

If we were ever to require an emergency anaesthetic for a surgical or diagnostic procedure in a foreign European country, who would provide the anaesthesia– an anaesthesiologist, a nurse anaesthetist or an anaesthesia technician? In the face of a shortage of anaesthesiologists, how would we modify the composition of our anaesthesia team? Meeusen et al.,1 in the present issue of the Journal, surveyed nonphysician anaesthesia providers in 31 European countries, collecting information on their qualifications, their role, their tasks and their responsibilities. This subject, which is a major issue for our discipline, has for many years been largely overlooked. With economic and workforce pressures, who provides the anaesthesia is a question that is once more pertinent and topical. An important point from the survey is that, unlike the United States, in Europe anaesthesia can only be delivered under the responsibility of an anaesthesiologist. But this survey also identified important differences with regard to the training, the tasks they are allowed to perform and the responsibilities of nursing staff within the anaesthesia team. Among the various models of the latter, there are two main variations that seem to prevail. The ‘nurse anaesthetist’ model, in which the anaesthesia team includes a nurse, with 1–4 years of specific training in anaesthesia, who is allowed to manage the maintenance of anaesthesia, without direct supervision by the anaesthesiologist. In some countries, for some low-risk patients and for certain types of surgical procedures, they are allowed to give anaesthesia independently, from induction to recovery. The ‘circulation nurse’ model, consisting of nurses who work specifically in the operating room and who assist the anaesthesiologist, in addition to other disciplines of the operating room, for tasks such as inserting an intravenous line, preparing or administering drugs. They always work under the direct supervision of the anaesthesiologist and cannot be left alone for the maintenance of anaesthesia. In addition to these models, a third model has recently been proposed for the administration of sedation, essentially for gastrointestinal endoscopy. In some centres, nurses or technicians from disciplines other than anaesthesia receive specific training and deliver minimal or moderate sedation in low-risk patients.2 No study has yet determined whether any one of these models is better, in terms of quality and safety of care, and cost-effectiveness, than another. Recent anaesthesia mortality surveys from Australia, which has no nurse anaesthetists, and from France and the Netherlands, which do, showed similar results for direct anaesthesia-related mortality rates, reporting 0.55, 0.7 and 0.8 deaths per 100 000, respectively.3–5 However, the nurse anaesthetist model offers greater flexibility for the anaesthesia team and requires, for a given activity, a lower number of physicians. One physician can cover several operating rooms, each of them staffed with a nurse anaesthetist; the predominant team arrangement being a 1: 2 ratio.6,7 This survey confirms other studies that found great variability in the anaesthesia workforce and workload in Europe.8 On a broad analysis, the greatest density of anaesthesiologists is found where the workload is greatest. The number of anaesthetics given varies between 3.4 anaesthetics per 100 people per year in eastern Europe and 9.6 in western Europe, though the density of anaesthesiologists in these two groups of countries is 6.1 and 14.5 anaesthesiologists per 100 000 people, respectively.9 However, a closer look at the western European data fails to demonstrate a relationship between the density of anaesthesia providers and the workload. Sweden, for example, has a similar density of anaesthesiologists and four times the density of nurse anaesthetists than France; the rate of anaesthetics is 2.1 times greater in France than in Sweden.8 Similarly, the density of anaesthesiologists is 35% greater in Germany than in Switzerland, but the rate of anaesthetics is 13% greater in Switzerland. These findings might be explained by differences between registered and practising physicians and nurses, the proportions of part-time workers, vacation allowances and working conditions in general. In addition, the activities covered by anaesthesiologists and nurse anaesthetists, such as anaesthetics delivered outside the operating room, activities in ICU, intermediate care units, pain therapy units and emergency wards, may differ greatly in each country. The main explanation for this diversity is that each country has built a different organization in which the skill mix of anaesthesia team members varies significantly. This variability in European practice could be regarded as helpful as it shows that in countries with similar safety requirements, in terms of the responsibilities of anaesthesiologists in the anaesthesia team, the ratio between anaesthesiologists and nonphysician anaesthesia providers, and the tasks covered by anaesthesia team, there is a range of adaptations that appear to work. This message is important and it may be helpful to us if, in the near future, pressures of economy and supply force us to review our practice and the composition of the anaesthesia team. Economic pressure may result from the demand to provide more anaesthetics but reduce anaesthesia costs, while simultaneously, at least in some countries, there will be a shortage of anaesthesiologists. Different surveys from France, Italy and Spain have shown that anaesthetic activity has been increasing continuously since the 1980s. The rate of anaesthetics, which was 6.6 per 100 people in 1980, had risen by the end of the 1990s to 9, 8.5 and 13.5 per 100 people, in Catalonia, Italy and France, respectively.10–12 The expected growth in the elderly population, for which the rate of anaesthetics has been shown to reach 20–30 per 100 people above 70 years, and the continuously growing demand for anaesthetics outside the operating room suggest that the pressure for providing more anaesthetics will continue into the next decade.11,13 So long as economic pressure on hospital costs continues, management attention on operating room costs, the most expensive site in the hospital, will escalate. To any manager seeking to squeeze more out of anaesthesia, a cost comparison of different European centres will be represented chiefly by the salaries of both physician and nonphysician anaesthesia providers. This analysis may be too superficial to pick up the marked differences that exist in the composition of the anaesthesia team and the tasks that it covers. At the same time, there is no guarantee that the number of new anaesthesiologists arriving on the market will be sufficient to permit an expansion of activity and the replacement of the baby-boomers who will retire by mid-2010. The recent data of Egger Halbeis and Schubert9 and Pontone et al.14 on the demography of anaesthesiologists in Europe are alarming in that they predict a shortage of anaesthesiologists that may reach 30–35% by 2020 in eight out of 14 European countries. This is a worrying position that might endanger progress in anaesthesia during the course of the next decade. A succession of advances has brought improved safety, which, in turn, has permitted more complexity with increasingly higher risk challenges. Anaesthesia is now identified as an essential component of acute care in hospitals, servicing 50–60% of patients during their hospital stay. Anaesthesia has become so essential for a range of interventional and diagnostic procedures that there is no alternative but to meet the demand. To do this requires adequate recruitment to the specialty to train enough providers. Where anaesthesiologists are in short supply, the gap may be filled by training a greater number of nurse anaesthetists. If not, it is possible that alternative solutions would be sought outside anaesthesia, as is presently the case for sedation in gastrointestinal endoscopy.15 For all these reasons, the survey by Meeusen et al. touches an important aspect of our discipline. The authors rightly suggest that anaesthesia should pay greater attention to the role of nonphysician anaesthesia providers. It would be of advantage to all if the basic requirements for their training, their responsibilities and the limits of their practice could be standardized within Europe, as they already represent a migrating workforce. The sooner this is done, the better placed we will be to deal with the consequences of the expected shortage of European anaesthesiologists. Acknowledgements The authors have no conflicts of interest.