Clinical Standards FAQs

Frequently Asked Questions (FAQs) from doctors and other healthcare workers

Does the College have any guidance on the use of sedation by non-anaesthetists?
An intercollegiate working party chaired by this College produced guidance on this topic in November 2001. Please see the report of the working party, entitled Implementing and Ensuring Safe Sedation Practice for Healthcare Procedures in Adults.

The College is aware of the increasing use of sedation by non-anaesthetists for a wide variety of procedures.  We are also aware of instances where guidance appears not to have been followed. Following a review, the Academy of Medical Royal Colleges has recently agreed to re-establish a working group, under the leadership of the RCoA, to revise the 2001 guidelines.   

How would an anaesthetist make the choice between using total intravenous anaesthesia (TIVA) and inhalational anaesthesia? How is the propensity to use each method changing over time?
TIVA is becoming more acceptable for a wider range of procedures than before, and some anaesthetists feel that it offers the benefit of a more pleasant and rapid recovery to street fitness.

However, as with conventional inhaled anaesthesia, TIVA must be administered by a suitably trained and experienced anaesthetist with full facilities for monitoring including direct vision of the cannula at all times. The requirement for recovery and postoperative pain control would be the same as for conventional inhaled anaesthesia.

In addition, the decision on whether to use TIVA or not rests with the individual anaesthetist at the time of the patient’s assessment for the procedure. Factors that influence this decision include: the wishes of the patient; the patient's current health; the patient's sensitivity or reaction to anaesthetic agents and the procedure which is to be undertaken. The increase in day-case patients and the move to a 'treatment centre' approach, particularly for ophthalmic and orthopaedic cases has increased the selection of TIVA.
Issued: January 2007

What is the risk to health from exposure to anaesthetics? What advice would the College give when pregnant nursing or theatre staff decline to work because they are worried about the risk of exposure to anaesthetics?
At various times, waste anaesthetic gases have been held responsible for spontaneous abortions in staff and their spouses, infertility, birth defects, impairment of skilled performance, cancer, liver and renal disease, blood dyscrasias and neurological symptoms. None of these has been confirmed, although there is no doubt that Nitrous Oxide (N2O) affects red cell maturation, and some dental surgeons exposed chronically to high levels of N2O have developed polyneuropathies.
(P Hutton 2002)

The COSHH legally binding workplace exposure limit for prolonged exposure to Isoflurane is 50 parts per million. Limits are not applied for short term exposure. The table of limits can be found on the COSHH website.

In most hospitals there is usually a large enough pool of staff for pregnant members of the operating theatre team who are seriously worried about the theoretical risk of exposure to concentrations lower than the limit to be moved to other duties during their pregnancy. However, in smaller departments this may not be possible. The options open to employers are clearly limited, and this should be a matter for local resolution.
Issued: January 2007

Is there a lower age limit for administering a general anaesthetic to children in district hospitals?
The College first published a set of Guidelines for the Provision of Anaesthetic Services in July 1999. These state that neonates will require treatment in specialist centres, ‘as may children under the age of five years, where no specialised local facilities exist.’ They have been revised twice since. The current version says that Distric General Hospitals (DGHs) should have facilities to resuscitate and stabilise children of all ages, and should be able to undertake straightforward surgical emergencies. The very young, and children with complex conditions will require transfer. In an acute or life-threatening emergency, the most appropriately qualified anaesthetist available must treat the patient.

We have moved increasingly away from age as a limiting factor towards competency, both of personnel and facilities.

A joint statement has been issued on general paediatric surgery provision in DGHs, and can be found on the British Association for Paediatric Surgeons website.
Updated: October 2011

What grades of staff should assist the anaesthetist and what specific qualifications do they require?
On this issue the RCoA endorses the AAGBI document The Anaesthesia Team (3rd edition 2010), and specifically the statement:

Anaesthetists must have dedicated qualified assistance wherever anaesthesia is administered, whether in the operating department, the obstetric unit or any other area.

Trained assistance should come from an Operating Department Practitioner (ODP), Anaesthetic Nurse or (College recognised) Physicians’ Assistant Anaesthesia (PA(A)). ODPs are all now qualified to the same national standard and registered with the Health Professions Council. A nurse's 'qualification' is not so clear as, since the loss of English National Board (ENB) courses, there is no UK standard; however, locally recognised, appropriate and specific training should have been completed. In Scotland a national standard has been developed, but elsewhere in the UK the individual hospital's clinical governance committee will assess and endorse the training of anaesthetic nurses and indemnify their enhanced practice accordingly.

The PA(A) is a new role and provides a qualified assistant when working alongside the anaesthetist. However, when the qualified (non-training) PA(A) is maintaining the anaesthetised patient in accordance with his/her scope of practice and without the anaesthetist in theatre, they too should have assistance by an ODP or anaesthetic nurse as indicated above.

For the safety of patients and the protection of those in the assistant role, neither an anaesthetist nor PA(A) should work without appropriate qualified assistance in the team. 
Updated: October 2011

Does the RCoA consider that the CCT in anaesthesia and specialist register status indicate that a consultant anaesthetist has undertaken appropriate Advanced Life Support (ALS) training, or does this have to be supplemented by a commercial (UK Resuscitation Council) ALS course?
The College requirements are deliberately flexible in this area, as anaesthetists may be able to demonstrate their continuing skills in their daily practice, and many are involved in teaching resuscitation skills to others. In our Guidelines for the Provision of Anaesthetic Services document you will see that we recommend that all clinicians dealing with patients should be 'appropriately trained' in resuscitation skills. Anaesthetists should be 'appropriately trained and assessed' in advanced life support. The reference level is that of the ALS courses or equivalent. The 'equivalence' aspect is one for local agreement; there are simply too many organisations providing these courses to be prescriptive.

That said, some Trusts simply accept the CCT qualification, ongoing clinical experience and the maintenance of CPD with in-house assessment in this area – others may demand specific certification confirming the doctor attended their requisite course recently. 
Updated: October 2011

What is the minimum number of sessions required to maintain anaesthetic skills?
There is no definitive answer to this question, although an average of two sessions per week is generally regarded as the minimum required to maintain currency. This is also what Regional Advisers would expect to see as a minimum allocation on job descriptions.

The relevant consideration is competence, not numbers. Anaesthetists must work within the limits of their competence, and to this end they must have had relevant training, ongoing experience, appropriate direct or transferable skills and continuing CPD.

It is the responsibility of individuals to ensure that they remain competent in those areas of work, both elective and emergency, which are agreed in the job plan and that discussions at annual appraisal ensure that appropriate sessions are allocated to ensure this.  Further details can be found in The Good Anaesthetist and The Good Practice Guide. 
Updated: October 2011

How much retraining is needed before it is safe to return to work after an absence?
The nature and duration of retraining required will vary from individual to individual. Factors to be taken into account include the original reason for the absence, the duration of absence, the individual’s current situation, the extent to which he or she was able to maintain contact with developments in anaesthesia while away, and the requirements of the post to which he or she will return.

A good re-entry programme will facilitate a phased return with close mentoring and regular checks which allow a two-way exchange of views on progress.  Detailed advice can be found in Recommendations for supporting a successful return to work after a period of absence.
Updated: October 2011

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