October 4, 2024 Washington Medical Commission P.O. Box 47866 Olympia, WA 98504-7866 ATTN: Amelia Boyd, Program Manager RE: INITIAL COMMENTS FOR WSR 24-18-157 – RULES IMPLEMENTING SB 5184 (ANESTHESIOLOGIST ASSISTANTS) Dear Members of the Washington Medical Commission, I am writing on behalf of the Certified Anesthesiologist Assistant (CAA) community to express our strong and urgent support for the implementation of Senate Bill 5184, which was passed by the Washington State Legislature in March of 2024. We believe this legislation represents an important step forward in improving patient care in Washington State by formally recognizing CAAs as licensed medical professionals within the anesthesia care team. As you develop the rules and regulations to implement this bill, I would like to offer the following recommendations to ensure an effective and timely rollout: 1. Licensing Timeline With Washington facing an anesthesia workforce shortage, we urge the Commission to establish a clear timeline for the initial licensing of CAAs in the state with the goal of CAA licensing beginning by the end of 2024 or in the first quarter of 2025. With an estimated initial cohort between 20 and 30, the agency will have sufficient time to efficiently manage the volume, ensuring a smooth and effective rollout for the new licensing process. The faster timeline is important to have CAAs providing clinical care as early in 2025 as possible. Many trained CAAs are already in Washington or are prepared to move here, growing as the profession gains recognition in the state. Additionally, with numerous students expected to graduate from CAA programs across the country in the next two years, Washington has a unique opportunity to attract these highly trained professionals. Starting the licensing process soon will encourage newly graduated CAAs to consider relocating to Washington, helping to address the state’s growing anesthesia workforce needs. 2. Flexibility for Hospitals and Anesthesia Groups Senate Bill 5184 provides a detailed and prescriptive framework for CAA practice in Washington, more so than in most other states. Given this, we believe there is little need to add further prescriptive elements in the rulemaking process. It is critical that anesthesia groups and hospitals retain flexibility in how CAAs are integrated into their specific care team models. Each hospital and anesthesia group may have its own unique structure, and we encourage the Commission to maintain a broad approach that supports effective integration without unnecessary restrictions. The language in Section 4 (1) very clearly ensures the supervising anesthesiologist has delegatory authority and the ability to assess competence based on education, training and experience – which is appropriate for a position like the CAA who operates as a physician extender. In conclusion, we believe the framework established by SB 5184 strikes the right balance between safety, supervision, and flexibility. We encourage the Washington Medical Commission to implement the legislation in a way that supports timely licensing, allows flexibility for hospitals and anesthesia groups, and ensures that CAAs can contribute fully to the anesthesia care team. We are confident that CAAs will be a valuable addition to the healthcare workforce in Washington, and we look forward to working with the Commission as this new profession is integrated into our state’s healthcare system. Thank you for considering these recommendations. We are happy to provide further information or clarification to support the process, ensuring CAAs can begin serving patients in Washington as soon as possible. Sincerely, Sarah Brown, President WA Academy of Anesthesiologist Assistants Spokane, WA

Ms. Boyd, Thank you for the opportunity to comment on proposed regulations for the licensure of Certified Anesthesiologist Assistants (CAAs) in our state. On behalf of the members of the Washington State Society of Anesthesiologists, we urge the Commission to take swift action on rules for licensure, so we can increase our health care workforce and expand access to trained, skilled and professional anesthesia care for patients. The scope of practice outlined in RCW 18.71D provides a comprehensive and detailed framework for CAA licensure that is consistent with their education and training, and reflects the work they perform in the 20 other states where they currently practice. The proposed rules adhere closely to the legislation adopted by lawmakers earlier this year and we support their adoption. This is a challenging time in health care. Hospital bed shortages have resulted in unprecedented wait times for patients who often need critical care. And operating rooms aren’t functioning at full capacity because we don’t have enough people to staff them. We hope the Commission will act expeditiously to implement rules for CAA licensure, and that our members will be working alongside their CAA colleagues in 2025. Thank you for your consideration.

Submitted on behalf of the Washington Association of Nurse Anesthesiology (WANA). In 2024, SB 5184 passed the legislature allowing a new anesthesia provider into the state of WA. WA state is the first state on the west coast to license anesthesiologist assistants (AAs). WANA recommends that rules for this profession include education of the public, proper signage in facilities and on consent paperwork, and notice to prospective patients of who is providing their anesthesia care. Because an AA is a new profession in WA, WANA strongly recommends the Commission mandate all practicing AAs use only their official title “Certified Anesthesiologist Assistant” or “Anesthesiologist Assistant” on all facility identification and upon introduction to prospective patients. Proper use of titles is crucial for patient safety because it clearly informs patients about their provider's qualifications and prevents confusion with other healthcare professionals, promoting transparency and informed decision-making. During the 2024 session, WANA raised concerns about the proposed scope of practice for AAs. In other states where AAs are licensed, there has been failure to meet regulatory medical direction criteria, raising concerns about patient safety and the quality of care when the criteria are not followed. Given the critical nature of anesthesia, it is essential to ensure stringent oversight and accountability when introducing AAs in Washington to avoid potential risks to patient outcomes. Therefore, amendments were offered and accepted to alter the scope of practice for AAs in WA to more closely align with the depth of their training as an assistant. Included in these amendments was the removal of any temporary licensure for an AA who has not yet passed their certification exam. The language that remains in RCW Chapter 18.71D could be misconstrued to allow licensure for an AA who is only certification-eligible rather than fully certified. WANA raised this concern with the committee chair and staff to define the intent of the language that remained after amendments in RCW 18.71D.020 2(a) “That the applicant has completed an accredited anesthesiologist assistant program approved by the commission and is eligible to take the examination approved by the commission.” WANA received communication from Representative Riccelli via email on February 18, 2024, stating his striker amendment (that was accepted) “eliminates the issuance of a … license for persons who have completed an anesthesiologist assistance program, but not passed a certification examination.” Bill language was further clarified with House committee staff on February 19, 2024, in communication to WANA stating “the anesthesiologist assistant will have to wait for a license and to practice until they have passed the exam” (communication available upon request). WANA recommends that the Commission explicitly align rules with the intent of the legislature and ensure verification of certification exam passage is provided to the Commission prior to granting licensure. Consistent with most other professions, health care providers must demonstrate a novice level of professional competency by passing a certification exam prior to receiving a license to care for patients. Further amendments during the 2024 session removed the following activities from AA scope of practice that were written in the original bill: “1) Removes an anesthesiologist assistant's authority to order oxygen therapy and respiratory therapy, 2) Removes an anesthesiologist assistant's authority to obtain informed consent for anesthesia and related procedures, 3) Removes an anesthesiologist assistant's authority to establish central lines.” WANA recommends that the Commission establish rulemaking that would include these details as beyond the scope of practice for an AA (may not be delegated), to align with the intent of the legislature. According to Centers for Medicare and Medicaid (CMS), Health and Human Services (HHS) 42 CFR Ch. IV §415.110, for each patient, the physician must: (i) perform a pre-anesthetic examination and evaluation; (ii) prescribes the anesthesia plan; (iii) personally participates in the most demanding aspects of the anesthesia plan including, if applicable, induction and emergence; (iv) ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual as defined in operating instructions; (v) monitors the course of anesthesia administration at frequent intervals; (vi) remains physically present and available for immediate diagnosis and treatment of emergencies; (vii) provides indicated post-anesthesia care. https://www.govinfo.gov/content/pkg/CFR-2011-title42-vol3/pdf/CFR-2011-title42-vol3-sec415-110.pdf In RCW Chapter 18.71D, section 010 (3) states “’Assists’ means the anesthesiology assistant personally performs…” which clearly is not interpreted as “assist” by a usual definition which is “to give support or aid” or “to be present as a spectator” according to Merriam-Webster. RCW Chapter 18.71D.040 1(a) and 1(b) allows an AA to personally perform (stated as assist) the preoperative and postoperative consultation or evaluation. This is in direct violation of CMS § 415.110 (a)1(i) physician anesthesiologist MUST “perform the pre-anesthetic examination and evaluation” and CMS § 415.110 (a)1(vii) requiring the physician anesthesiologist “provides indicated post-anesthesia care”. Additionally, the language of RCW Chapter 18.71D.040 1(c) is in direct conflict with CMS § 415.110 (a)1(ii) stating physician anesthesiologist “prescribes the anesthesia plan”. RCW Chapter 18.71D.040 1(j) allows an AA to personally perform (stated as assists with) “general anesthesia, including induction, maintenance, and emergence.” This is not aligned with RCW 18.71D.010 (7) requiring the physician anesthesiologist be “… personally participating in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence” which is also a requirement of CMS § 415.110 (a)1(iii) REQUIRING that physician anesthesiologist “personally participate in the most demanding aspects of the anesthesia plan.” The AA may not perform these demanding aspects without a physician anesthesiologist physically present in the room. RCW Chapter 18.71D.040 (r) allows: “Assisting with, ordering, and interpreting appropriate preoperative, point of care, intraoperative, or postoperative diagnostic tests or procedures…” CMS § 415.110 (a)1(vi) requires the physician anesthesiologist to remain “physically present and available for immediate diagnosis and treatment.” These outlined standards of care provide for the PHYSICIAN, and not the AA, to diagnose and order treatments. CMS and HHS play a significant role in protecting the public by overseeing the health and safety of millions of Americans by: 1. Setting and Enforcing Standards: CMS establishes guidelines for healthcare providers that ensure high standards of care. These standards help guarantee that care is delivered safely and effectively, protecting patients from harm and ensuring they receive quality care. 2. Regulating Access to Care: CMS ensures access to essential healthcare services (including for vulnerable populations) by setting rules for reimbursement and care delivery under … the Affordable Care Act. 3. Monitoring Quality and Safety: Both HHS and CMS are involved in monitoring healthcare facilities, ensuring compliance with federal regulations and enforcing standards related to patient safety. 4. Promoting Evidence-Based Practices: CMS and HHS develop and promote evidence-based guidelines and policies aimed at improving patient outcomes and reducing risks. WANA urges the Commission to ensure the scope of AA practice in WA state aligns with federal regulations established by CMS and HHS and not stray from these outlined standards. These federal regulatory bodies enforce healthcare standards, ensure access to quality care, and protect patients by promoting safe, evidence-based medical practices. RCW Chapter 18.71D has components in direct violation of the established federal rules, as referenced above in CMS/HHS 42 CFR Ch. IV §415.110. When making rules for this new profession, it is critical that the Commission ensure consistency with federal standards and regulations to protect the health and well-being of the public. Numerous studies evaluating the ability of physician anesthesiologists to meet the seven requirements of medical direction detailed in CMS/HHS 42 CFR Ch. IV §415.110 have shown that a ratio of more than 1:1 (i.e. 1:2, 1:3 or 1:4) results in failure of the physician anesthesiologist to meet these medical direction requirements. WANA strongly urges the Commission to limit the supervision ratio to 1:2 for AAs in Washington State to prevent gaps in patient care. A higher supervision ratio increases the risk of physician anesthesiologists being unable to meet critical medical direction requirements, potentially leaving patients vulnerable and without the proper care during high-risk procedures. Without strict limits, patient care could be severely compromised, leading to devastating consequences in anesthesia care.

I am a C-AA in St. Louis Missouri and am avidly awaiting the opportunity to be back near my family and work in WA asap. I support the current rules draft, as it aligns with the statute. This addition of more anaesthetists to Washington state will greatly enhance the workforce, as C-AAs and CRNAs are seemlessly interchangeable within the anaesthesia care team model, which works in a 1 physician to 4 anaesthetist ratio. I personally, and we in the Washington Academy of Anaesthesiologist Assistants, are looking forward to a smooth rules making process with clear timelines. Thank you, Charlie Chase secretary and treasure of the Washington Academy of Anaesthesiologist Assistants.

I am a CAA from Miami, FL and am eager to work in WA as soon as possible. I want to be near my family and be able to deliver the same care in Washington, as I do in a Florida. My boys are 4 years old and 2 years old, and I'd like them to be near their grandpa and aunt and uncle. I look forward to moving closer to family and performing the same job I currently do as CAA in Florida. Thank you for your efforts to license CAAs in Washington. Christine Kohlsaat, Vice President of the Washington Academy of Anesthesiologist Assistants

The AA bill was agreed upon in the legislature to: Not allow AAs to do central lines. Not allow AAs to do epidurals. That AAs need to be supervised during induction and emergence. That there will not be a temporary license for AAs. This agreement allowed the legislation to get enough votes to be signed into law. Introducing these concepts in rulemaking will likely create more legislation in the future and could mean changes to newly established rules in the near future.

Ms. Boyd: SB 5184 passed the legislature only after a strategic agreement was reached between interested parties and legislators, ensuring it garnered the necessary votes to become law. We believe that if the commission does not address the intent of the legislature in the rulemaking process, it may lead to ongoing challenges and necessitate further legislative efforts to find a resolution. We hope to work collaboratively to avoid such conflicts and ensure a smooth path forward. Washington Association of Nurse Anesthesiology wants to highlight three areas of concern for this next rulemaking meeting and appreciates the opportunity to do so. First, Anesthesiologist Assistants should not be given temporary (interim) licensure. This provision was intentionally removed from the bill as part of an agreement among interested parties and legislators, who acknowledged that the unique environment in which AAs function requires full board certification before granting any licensure. Second, in proposed Rule 246-921-200 2 c AAs are given the authority to order medications. Under the same rule, 2 w (4) AAs are specifically not allowed to order medications. The agreement during the 2024 session, among interested parties and legislators, was that AAs are not allowed to order or prescribe medications. Naturally, AAs may pick up and administer medications only after they have been ordered and prescribed by a physician anesthesiologist. Third, the section of rules WAC 246-921-300 is directly copied from WAC 246-919-601 which pertains to physicians and physician assistants. AAs are neither of these occupations and WANA urges great caution in applying the same rules across the board to very different professions. Indeed, the following direct quotation is found on the American Academy of Anesthesiologist Assistants (AAAA®) webpage (CAA being interchangeable with AA in this quote): “Although CAAs and physician assistants (PAs) both function as physician extenders, they do not perform the same functions. Each has its own separate educational curriculum, standards for accreditation, and its own agency for certification. PAs receive a generalist education and may practice in many different fields under the supervision of a physician who is qualified and credentialed in that field. An AA may not practice outside of the field of anesthesia or apart from the supervision of an anesthesiologist. A CAA may not practice as a physician's assistant unless the CAA has also completed a PA training program and passed the National Commission for the Certification of Physician Assistants (NCCPA) exam. Likewise, a PA may not identify him- or herself as a CAA unless he or she has completed an accredited AA program and passed the National Commission for the Certification of Anesthesiologist Assistants (NCCAA) exam. If also certified as a CAA, such a dual-credentialed PA would be required to practice as an anesthetist only as an extender for an anesthesiologist and could not provide anesthesia care at the direction of a physician of any other specialty.” https://aaaa.memberclicks.net/faqs#:~:text=An%20AA%20may%20not%20practice,Physician%20Assistants%20(NCCPA)%20exam

To the Honorable Members of the Washington Medical Commission, We understand that in the rule-making process for the rules on the Anesthesiologist Assistants bill (SB 5184), there have been some questions about legislative intent during the negotiations and the version of the bill that passed. As the sponsors of SB 5184, we believe the bill is very clear regarding intent when it comes to scope of practice for Anesthesiologists Assistants (AAs). The listed elements of scope for AAs in the law is intended to be where there is explicit authority for AAs to do this work. However, this is not an exhaustive list as the language in the statute stipulates per the following: • Sec 4 (1) very clearly states that “An anesthesiologist assistant may not exceed the scope of their supervising anesthesiologist’s practice and may assist with those duties and responsibilities delegated to them by the supervising anesthesiologist, and for which they are competent to assist with based on their education, training and experience.” This gives the supervising anesthesiologist the ability in the law to determine the duties for the Anesthesiologist Assistant based on the needs of their practice. • Sec 4 (1) also states, “Duties which an anesthesiologist may delegate to an anesthesiologist assistant include but are not limited to:” and then lists the explicit authorized duties. However, the “include but are not limited to” language in this bill, combined with the first sentence clearly states that the supervising anesthesiologist is the ultimate arbiter of the delegation of duties. The language of the law clearly indicates that the statute itself is not a limiting document. • In addition, in Sec 4 (1) (w) the law states within the explicit delegation of duties “Assisting with other tasks not prohibited by law under the supervision of a licensed anesthesiologist that an anesthesiologist assistant has been trained and is proficient to assist with.” Once again, this is clearly ensuring the only duties that are prohibited are those specifically prohibited within the statute. In the negotiations on the bill as it moved toward passage, none of this language regarding the authority of the supervising anesthesiologist was altered, changed, or removed. Although some language regarding explicit authority for certain procedures was removed, the language that allows the supervising anesthesiologist to continue to allow an AA to assist with these procedures based on their training, experience and competency remained. It is for this reason that we, as sponsors of the bill, agreed to these changes. The effect statement for the bill clearly outlined this as well, using the language “removes authority” rather than “prohibits.” We urge the Medical Commission to minimize changes to this statutory section in the rule and leave the language intact to retain the effect in policy that we intended as sponsors. Sincerely, Senator Annette Cleveland Senator Ann Rivers 49th Legislative District 18th Legislative District