Introduction
The National Certifying Commission for Anesthesiologist Assistants’ (NCCAA) purpose includes ensuring that Certified Anesthesiologist Assistants (CAAs) have appropriate exposure and clinical experience to have obtained the necessary knowledge and skills to practice safely and effectively. For entry level CAAs, NCCAA verifies academic qualifications with each academic program for certification eligibility and tests knowledge using a Certification exam. To maintain and protect the strength of the CAA credential, the NCCAA also collects a record of clinical experience from students training for certification as CAAs. Clinical hours and experiences are self-reported to the NCCAA via a digital application. The clinical experience record is reviewed to determine certification eligibility. Student Anesthesiologists Assistants (SAAs) are required to complete education and clinical training minimums prior to becoming eligible for board certification by examination.
General guidelines
SAAs must have the appropriate clinical experience to become competent and safe anesthesiologist assistants. Knowledge and skills that pertain to all phases of perioperative anesthesia delivery are both tested by examination and inclusion in clinical experience minimums to ensure the requisite knowledge and experience. Credit may only be claimed for a case if the learner personally implements and manages the anesthetic. Credit may NOT be claimed when learners observe anesthesia providers perform the anesthesia care. Two learners may only claim credit for the same case when both anesthesia learners have valuable learning opportunities, such as in high acuity patients.
The general guidelines below will help learners determine when a clinical experience should be claimed for credit to NCCAA:
When claiming credits, the learner should consider the following:
Does this clinical encounter provide educational value?
Examples of experiences that DO NOT qualify for credit based on educational value include:
- temporary relief for a short period of time when the learner has neither started nor finished the case;
- observation of anesthesia delivery where no decision making has been required or physical skills performed;
- anesthesia record keeping or charting only; or
- two learners in a routine case that does not provide valuable learning opportunities for more than one learner.
Examples of experiences that DO qualify for credit based on educational value include:
- Temporary relief when a significant event occurs requiring the learner to change the anesthetic management and implement changes such as induction, emergence, hemorrhage, aortic clamping/unclamping, cardiac ischemia, bronchospasm, accidental extubation, air embolism, intentional conversion of sedation or regional to general anesthesia, intraoperative fire or extubation for case termination; or
- Two learners in a case that has multiple learning opportunities such as liver transplants, rare presenting disease or surgical procedure, massive trauma, or complicated anesthetics with learning opportunities ample enough for two simultaneous learners.
Simulation is acceptable for claimed credit only where noted. No skill nor experiential learning can be completely mastered by simulation alone. Simulation offers valuable learning experience where scenarios are created that provide opportunity for learners to practice management and critical care decision making. Skills in simulation may be performed as often as necessary but may only be counted for fulfillment of any specific category as specified in these guidelines. When acceptable, simulation for credit must be personally performed by the learner without the guidance or assistance of other learners or proctors. Group simulation learning may not be counted for any category.
Procedures or skills are specific anesthetic interventions (eg. intubation, central line placement, regional block placement) that the learner is required to personally perform. The guidelines indicate when simulation of personal performance is permitted.
Procedures may only be counted when performed by the learner (observation alone of a procedure may not be counted).
One case may result in multiple procedures being counted but may only be claimed as (1) one anesthetic case. For example, an emergent cesarean section that results in the need for invasive blood pressure monitoring may only be counted as (1) one case. However, the student may count all procedures that were personally performed (arterial line, additional IV placement, spinal, intubation or other anesthetic interventions) throughout the case.
| Clinical Experiences | Guidelines | Examples |
|---|---|---|
| Anesthesia Cases (650) | ||
| Clinical Hours (2,000) | Time spent in directly performing clinical skills outlined in the NCCAA clinical experience requirements, time spent performing anesthesia associated tasks, and specific clinical time directly involved in patient care. Students may also log 25% of overnight on-call time where direct patient care was not involved. | Examples of anesthesia associated tasks involved with an anesthetic case include anesthesia room set-up, preoperative assessments, administration of the anesthetic and obstetric management. Examples of clinical experience not directly associated with an anesthetic case which may be logged for full clinical skill time include IV/Vascular Access, ICU, Pain Management, Preoperative Assessment. |
| Patient ASA Physical Status | ASA Physical Status Classification System definitions should be utilized. | |
| ASA Class 3 – 6 (150) | ||
| ASA Class 4 – 6 (10) | ||
| Emergent ASA Class E (35) | ||
| Geriatric (100) | Patient age is 65 or older at the time of the procedure. | |
| Pediatric | Patient age is from birth through age 18. | |
| 2 – 12 years old (30) | ||
| Less than 2 years old (10) | ||
| Intra-abdominal (75) | Any surgical case that enters the abdominal cavity via an open, laparoscopic or robotic approach. | Examples of this category are laparoscopic Cholecystectomy, Hysterectomy to include vaginal approach, Radical Prostatectomy, Nephrectomy, Kidney/Liver transplant, Bowel Resection, Laparoscopic Hernia repair, Diagnostic Laparoscopy, Appendectomy, and Bariatric surgery. Additional examples of intra-abdominal cases may include, Laparoscopic Peritoneal Dialysis catheter placement, Anterior Spinal Fusion, Adrenalectomy, Open Abdominal Aortic Aneurysm repair. Upper and Lower GI Endoscopy/ ERCP/ Percutaneous Nephrolithotomy procedures would not be considered open abdominal cases. |
| Intracranial (5) | Any surgical case with direct surgical contact on the brain. Three (3) of the cases must be open. Definitions for open intracranial surgical cases and corresponding examples can be found below. The remainder of the requirement may be met through additional open procedures or through closed procedures, examples of which can be found to the right. | Examples of closed intracranial procedures may include percutaneous procedures that access the brain (Gamma knife, aneurysm coiling). |
| Open (3) | Any surgical case that accesses the brain via a craniotomy, either through cranial flap, burr holes or transsphenoidal approach) | Examples of this category are tumor resection, craniotomy for A-V malformation/aneurysm surgery, V-P Shunts, deep brain stimulator placement. |
| ENT (20) | Any surgical case involving the head, neck and oropharyngeal area, excluding intracranial procedures. A variety of cases are expected to be performed in this category, ideally with the majority of the cases requiring general anesthesia with intubation. For example, 10 MAC cataracts and 10 ear tubes with mask anesthesia would provide only minimal diversity of experience and would not satisfy the intent of this category. | Examples of this category are scleral buckle, enucleation, vitrectomy, cataracts, strabismus repair, sinus surgery/rhinoplasty, maxillofacial reconstruction, orthognathic surgery, dental extractions, oral tumor resection, tonsillectomy, myringotomy, tympanoplasty/mastoidectomy, cochlear implant parotid gland/thyroid tumor resection, radical neck surgery, or tracheostomy. |
| Neuroskeletal (25) | Any surgical case that involves both the central nervous system and the axial skeleton. | Examples of this category are laminectomy and decompression, Anterior/Posterior spinal fusions, discectomy, Anterior/Posterior cervical fusion, Chiari malformation corrective surgery, scoliosis corrective surgery. Not included in this category are spinal cord stimulator insertion or spinal tap. |
| Cardiothoracic/Vascular | ||
| Heart (10) | Procedures on the heart. The requirement does not require cardiopulmonary bypass to be administered as part of the procedure, however, the intent of the category is for the learner to obtain diversity in the types of procedures performed on the heart and cases with cardiopulmonary bypass and cases without is recommended. | Examples of this category are open coronary artery revascularization (with or without CPB), valve replacement (open or via an intravascular approach), surgery involving the thoracic aorta, ablation surgery, atrial appendage surgery and heart transplant. Not included in this category are TEE, elective cardioversions, cardiac catheterizations, pacemaker insertions. |
| Lung (5) | Any surgical case on the lungs via an open thoracotomy approach or laparoscopic approach. | Examples of this category are lobectomy via thoracotomy or video assisted thoracoscopy (VATS), pulmonary bleb/bullae surgery, pleurectomy and decortication or lung transplant. Not included in this category are bronchoscopy procedures and chest tube placement by itself without a corresponding lung procedure. |
| Vascular (15) | Any surgical case on the vascular system. | Examples of this category are carotid endarterectomy, aorta-bifemoral surgery either open or via endovascular stent, A-V fistula creation/revision, access port placement. Not included in this category would be vein stripping, central line placement. |
| Obstetrical Cases (including Deliveries, C-Section & Procedures) (35) | An anesthetic for a surgical case involving a pregnant patient. Of the 35 total required cases, (20) cases must be direct obstetric management related to the delivery of the fetus, with a minimum of (10) anesthetics for labor and delivery, and a minimum of (10) anesthetics for cesarean delivery. The remaining (15) surgical cases for the category may be anesthetics for patients that are pregnant, but not for the purpose of the delivery of the fetus. Of course, additional surgical cases for delivery (eg. cesarean delivery) may be counted to fulfill this category as well. If the learner is only involved for the initiation/placement of the regional technique and not the periodic management and/or the surgical management then the learner should only count the regional technique and not the obstetrical case. Note: If a vaginal delivery anesthetic converts to a C-Section, the learner should only count one obstetrical case, but may count multiple anesthetic techniques (epidural placement and general anesthesia if applicable). | Examples of the category are cerclage and anesthesia for the non-laboring pregnant patient including but not limited to: appendectomy, cystoscopy, cholecystectomy and other anesthetic cases. |
| Cesarean Delivery (10) | Anesthetic delivered for the purpose of cesarean delivery. The learner may count the case for this category when a labor epidural is continued for cesarean delivery, including when the learner has counted the placement of the epidural and management of analgesia for labor. | |
| Analgesia for Labor (10) | The learner provides care for the patient with an epidural. Care includes periodic assessment, redosing and adjusting dosage, additional anesthetic interventions throughout the course of labor. The learner need not be the exclusive provider of care noted above to count the case for analgesia for labor. The learner may count the case for this category whether the student placed the epidural catheter, or another provider placed the epidural catheter. | |
| General Anesthesia (400) | Student learners should only count cases in which they are directly involved in the induction, maintenance and/or emergence of the general anesthetic. Emergence is counted under a separate category and must occur in at least 250 of the 400 general anesthesia cases reported. | |
| Induction, Maintenance & Emergence | ||
| Mask Induction (25) | A case with anesthesia induction technique using a mask and potent inhalation anesthetic agents exclusive of IV induction agents. | Examples of the category are myringotomy and tube placement, joint manipulation, exam under anesthesia cases, cardioversions and GU cases. |
| Mask Management (30) | Mask ventilation and mask management is the skill of proper patient positioning, provider hand positioning, and use of oral and nasal airway adjuncts to successfully ventilate a patient using a bag-mask technique. To qualify for this category, mask ventilation must serve as the primary airway management technique for the anesthetic or a substantial portion thereof. Cases in which mask ventilation consists only of a few positive pressure breaths prior to placement of a supraglottic airway device or endotracheal tube do not qualify. | Examples include mask induction cases, electroconvulsive therapy (ECT), BMT, and other procedures in which mask ventilation is the intended and sustained method of airway management. |
| Supraglottic Airway Device Placement (35) | An airway management technique with a device that does not enter the glottic opening. Placement must be successful to be counted. | Examples of the category are laryngeal mask airway (LMA), iGel© and laryngeal tubes. |
| Tracheal Intubation (250) | Successful placement of an endotracheal tube through the glottic opening into the trachea. | |
| Nasal Intubation (5) | Successful placement of an endotracheal tube through the glottic opening into the trachea utilizing an intubation technique via the nasopharyngeal route. | |
| Total Intravenous Anesthesia (75) | A case where only IV anesthetic agents are used for induction and maintenance for the entire case. Sedation cases would be appropriate in this category. However, the learner must administer the medications for credit in this category. | Examples of the category are spinal fusion with TIVA (if the majority of the case was TIVA but inhalation agent is used towards the end of the case for transition to emergence, the student may count it as total IV anesthesia ), GU cases, and orthopedic procedures with sedation. |
| Emergence from anesthesia (250) | For this category, emergence is defined as the ending stage of anesthesia featuring the transition from unconsciousness to complete wakefulness and recovery of consciousness. Skills learned in this category involve managing complications occurring during emergence. While there is no set time or test for when emergence has occurred, patients whose care is transitioned with the patient remaining unresponsive should not be counted in this category. | |
| Regional Techniques | ||
| Actual Administration | ||
| Spinal (10/max. 5 simulated) | Note: In the situation where the student learner utilizes a combination spinal/epidural technique, the student may count both procedures for the same case. | |
| Epidural (10/max. 5 simulated) | Note: In the situation where the student learner utilizes a combination spinal/epidural technique, the student may count both procedures for the same case. | |
| Peripheral (10/max. 10 simulated) | ||
| Management (40) | For purposes of this category, regional management is defined as the maintenance of the patient and the block after having been administered a regional anesthetic via spinal, epidural or peripheral nerve block whether placed by the student or by another anesthesia provider. | An example: learner takes over the management of a labor epidural after another anesthesia provider administers (places) the epidural. |
| Ultrasound Guided Procedures (20) | If ultrasound is used for a successful procedure performed by the learner, then the learner may count ultrasound guided technique as well as the procedure. | If a learner utilizes ultrasound to place a central line, the learner may claim both ultrasound guided technique as well as central line placement provided the learner performed the procedure while utilizing ultrasound. Other examples include arterial line placement or peripheral nerve blocks. |
| Alternative Airway Management | ||
| All airway techniques other than direct laryngoscopy and supraglottic airway device (30) | The intent of the category is for the learner to gain experience in multiple alternative airway management and placement techniques. | Examples of the category are light wand, use of an intubating stylet (Bougie), intubating LMA, retrograde tracheal intubation and video laryngoscopy (eg. Glidescope©, McGrath©, Airtraq©). |
| Endoscopic techniques (5/max. 5 simulated) | This category requires a minimum of (5) endoscopic intubations. These may all be performed utilizing simulation, however, the learner should seek opportunities to perform this skill on an appropriate patient. | An example of the category is flexible bronchoscope |
| Arterial Pressure Catheter | ||
| Arterial Puncture/Catheter Insertion (25) | Placement of a peripheral intra-arterial catheter with the intention of monitoring arterial blood pressure or the arterial puncture for collection of an arterial blood gas sample. | Examples of the category are radial artery catheter, brachial artery catheter or femoral artery catheter. |
| Intra-arterial BP monitoring (30) | Monitoring of an intra-arterial catheter waveform during a surgical procedure for the purposes of managing the patient’s hemodynamic status. The arterial line may have been placed by the learner or another provider. | |
| Central Venous Catheter | ||
| Placement (5/max. 2 simulated) | This category may be counted when the learner places the central venous catheter. The insertion may be assisted but the learner should perform the needle direction and insertion of the cannula to be counted. Peripherally Inserted Central Catheters (PICC) lines are not included in this category. | Examples of the category are internal Jugular cannulation, Subclavian cannulation, and Femoral cannulation. |
| Monitoring (15) | Monitoring of central venous waveforms for a surgical case. The catheter insertion may have been placed by the learner or another provider. | |
| Intravenous Catheter Placement (125) | Successful insertion of an IV catheter in any peripheral location. The student may count multiple catheters in the same patient if more than one is required for a particular case. | |
| Gastric Tube Placement (5) | Successful insertion of an oro-gastric or naso-gastric tube. | |
| Placement of One Lung Isolation Device (5/max. 2 simulated) | Successful intubation including successful isolation of one lung. | Examples of the category are double-Lumen bronchial tube and single lumen bronchial blocker. |
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