This document provides guiding principles and key considerations to support health facilities plan for the expanded role of specialist anaesthetists in response to the COVID-19 pandemic.
People infected with the Delta variant of COVID-19 have approximately double the risk of hospital admission, when compared with the Alpha variant. Approximately 20% of adult patients hospitalised with Delta will require admission to the intensive care unit (ICU).
Modelling from various sources has predicted a likely need for supplementation of staff in ICUs from other specialists.1, 2 This could include specialist anaesthetists.3
Anaesthetists have skills that are transferable to the acute care of patients with COVID-19. The role of anaesthetists has been successfully expanded in other countries which have had large numbers of COVID-19 patients in hospitals, leading to overwhelmed ICU resources.
When planning for the expanded role of specialist anaesthetists, health services should be guided by the these overarching principles:
With these principles in mind, the following key elements should be considered.
The NSW Ministry of Health has outlined the requirements for senior and junior medical officers working in roles that are different to their usual clinical roles in NSW public hospitals during the pandemic.4
Where a medical practitioner is working outside their usual clinical role, a local assessment should be undertaken that considers the suitability of the officer working in that role.
For junior medical officers, the local assessment must be undertaken by a senior medical officer (e.g. Director of Training, Head of Department) with an understanding of the individual's skills, experience and qualifications, as well as an understanding of the clinical duties the junior medical officer is being required to undertake.
Local assessments should be appropriately documented, and consider:
For senior medical officers (specialists), the local assessment should be undertaken by the Executive Director of Medical Services (or other senior medical officer delegate of the Chief Executive) with knowledge in the specialty area, which should be appropriately documented.
It should consider whether the practitioner's existing clinical privileges already allow them to work in that different clinical role, because those privileges are applicable to that different role. In such a case, the practitioner may be deployed to that role within the LHD/SN without a further re-credentialing process.
If the local assessment determines that there needs to be an amendment to the senior medical officer's existing clinical privileges in order for them to undertake a different role, then the existing mechanisms of the Medical and Dental Appointment Advisory Committee (MDAAC) should be used as far as practicable to amend those clinical privileges. The existing mechanisms can be streamlined, if required.
Anaesthetists may have varying experience and training to contribute to the care of patients in intensive care, emergency departments and resuscitation of patients with COVID-19. The additional roles should be suited to the individual's qualifications, training, experience and expertise (see
Medical Board of Australia's statement2020).5
Scope of practice for medical practitioners is not determined by the Australian Health Practitioner Regulation Agency (AHPRA). AHPRA states that it is the responsibility of the individual practitioners to determine their own competency for their scope of practice.6 Hospitals will often specify the scope of practice of clinicians in their employment contract (refer to the section on 'Mutual agreement'.
Generally, medical practitioners who have trained in Australia have both general and specialist training registration.5 The AHPRA statement applies equally to those with 'specialist only' and 'specialist and general' registration.
From a registration point of view, AHPRA's concerns are around anaesthetists using false titles. For example, although they may be doing the work of an intensivist, anaesthetists are not to claim they are intensivists.
The health service must have a process in place to arrange individuals according to their health risk factors when considering/requesting redeployment.
When anaesthetists are asked to perform duties outside their scope of practice, such as taking on an intensive care role, they will be indemnified by NSW Health 'where they act professionally and in accordance with the mandated guidelines, policy or lawful directions of their employer'.7
For individual anaesthetists to undertake roles outside of their normal practice of anaesthesia, a mutual agreement between the anaesthetist and the healthcare organisation must be agreed to first.
When an anaesthetist is undertaking expanded roles, clear lines of support are needed. This support could be from a nominated specialist intensive care physician.
Similarly, there will need to be the usual support from trainee medical staff, nursing and allied health. A formal clinical governance structure and escalation pathway is also important.
A suitable process for additional training should be implemented. Refer to
Adult intensive care workforce report in COVID-19 pandemic - Appendix 2 for suggested training.
For anaesthetic trainees, any secondments should not be to the detriment of their training accreditation. This will require ongoing communication between the trainee, employer and the accrediting college (e.g. Australian and New Zealand College of Anaesthetists).
Anaesthetists are at particular risk of acquiring COVID-19 due to their routine practice of aerosol- generating procedures (AGPs) in their normal clinical practice.8
The key components of protection are:
Further resources and educational materials are available via the
Clinical Excellence Commission (CEC) website.9 The
COVID-19 Infection Prevention and Control Manual also provides further detailed guidance on infection prevention and control requirements for the management of patients or clients with suspected, probable or confirmed COVID-19.10
The preferential use of regional anaesthesia, when appropriate, can minimise the use of general anaesthesia with the associated AGP risk.11
The NSW government has passed a
public health order that mandates all healthcare staff working in healthcare facilities (public and private) be vaccinated against COVID-19 (first dose by 30 September 2021).12
Health Care Worker COVID-19 Risk Assessment Matrix details how healthcare facilities should
assess staff who have been exposed to COVID-19.13 Please refer to the matrix for
More detail about expanded clinical roles can be found in the related
Adult intensive care workforce report in COVID-19 pandemic.3
As per the
NSW Health Role Delineation of Clinical Services, close observation units (Level 3) are a dedicated unit in adult health facilities with no intensive care service. These units provide higher levels of monitoring and observation than standard ward-based care, such as cardiac monitoring and additional staff.14
The literature and international experience supports that endotracheal intubation should be performed by the most experienced person available. This approach helps to minimise time to successful intubation in the hypoxic patient and potentially reduces staff exposure to airborne transmission during an AGP.15
This type of respiratory support helps to relieve the caseload on available ICU beds. It should be recognised that NIV poses a special risk of aerosolisation and spread of COVID-19 within the patient care environment. Appropriate infection control measures, including engineering (ventilation) measures, must be implemented. For further details, see
Care of adult patients with COVID-19 in acute inpatient wards.16
Intensive Care CoP
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health
To be used as a guide of overarching principles to aid the planning of the expanded role of specialist anaesthetists in the response to the COVID-19 pandemic.
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