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There should be a dedicated trained assistant (i.e. an ODP, anaesthetic nurse or equivalent) who holds a valid registration with the appropriate regulatory body, immediately available in every location in which anaesthesia care is being delivered, whether this is by an anaesthetist or an AA.^39,112

The safe management of unstable patients depends on close liaison between emergency physicians and anaesthetists,^33,34 to ensure that clear guidelines are in place, emergency department support staff are trained to assist with tracheal intubation, and audit and discussion of complications is undertaken regularly.

A local training module should be provided for anaesthetists in training according to their grade, supervised by a nominated educational lead. This programme should develop understanding of the widespread nature of cardiovascular disease, optimisation and risk stratification, as well as perioperative management. The RCoA revised training curriculum (2010) provides explicit detail of the requirements.⁴²

Anaesthetists returning to paediatric practice after a period of absence should have a structured plan of induction and supervision in place which supports their learning needs so that they are competent to provide safe perioperative care for common non-complex elective and emergency procedures in children aged one year and older.⁶³

Anaesthesia for ECT is frequently performed in remote locations. Ideally, a consultant or an autonomously practising anaesthetist (see Glossary) should provide general anaesthesia. Appropriately trained recovery and operating department staff should be provided, and the guidance provided for anaesthetic provision in remote sites should be followed.⁶⁹

IPS should be staffed by multidisciplinary teams (MDTs) led by appropriately trained autonomously practising anaesthetists (see Glossary). The minimum training requirement for new appointments to IPS lead roles is stage 3 Special Interest Area Pain Medicine training.^1.3

Anaesthesia associates should work under the supervision of a consultant anaesthetist at all times as outlined by the RCoA.^97,93 In some emergency situations, a ratio of one to one and direct supervision may be more appropriate in view of the high incidence of comorbidities, complications and mortality.

Patients with morbid obesity who require emergency surgery should have experienced anaesthetists and surgeons available (typically, but not exclusively, at consultant level) to minimise operative time.¹⁷³ A surgical team familiar with emergency surgery in patients with morbid obesity and the complications associated with laparoscopic surgery should be available.

All patients over the age of 65 undergoing emergency laparotomy should have a formal assessment of frailty. Surgeons, anaesthetists and intensivists should ensure frailty has been taken into account when assessing the mortality risk as the NELA risk score does not take frailty into account.¹²⁹ 

Additional programmed activities for consultant or autonomously practising anaesthetists should be allocated for elective caesarean birth lists and antenatal anaesthetic clinics (or to review referrals if no formal clinic is in place).²³ Time is required to identify and follow up potential anaesthetic morbidity and to arrange continuing investigation and referral.