Certified Anesthesiologist Assistants (CAAs) are highly skilled health professionals who work under the direction of licensed anesthesiologists to implement anesthesia care plans. CAAs work exclusively within the anesthesia care team environment as described by the American Society of Anesthesiologists (ASA). All CAAs possess a premedical background, a baccalaureate degree, and also complete a comprehensive didactic and clinical program at the graduate school level. CAAs are trained extensively in the delivery and maintenance of quality anesthesia care as well as advanced patient monitoring techniques. The goal of CAA education is to guide the transformation of qualified student applicants into competent health care practitioners who aspire to practice in the anesthesia care team. Certified Anesthesiologist Assistants and certified registered nurse anesthetists are both defined as "non-physician anesthetists" within the Centers for Medicare & Medicaid Services section of the Code of Federal Regulations.

Although both are considered to be equivalent clinical non-physician anesthesia providers and may serve as physician extenders in the delivery of anesthesia, CAAs and CRNAs are very different with regard to their educational background, training pathway and certification process.

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. A CAA 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 AA, 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.

According to CAAHEP standards for AA programs, the depth and duration of the total program, and particularly the clinical experience, shall be sufficient to assure the potential employer that the newly graduated CAA will be able to perform entry-level functions. The number, content and length of courses shall be appropriate to the training of an assistant to the anesthesiologist. The AA curriculum is based on an advanced graduate degree model, and at least two full academic years are required. The current programs are 24 to 28 months long. Graduates from all AA educational programs earn a masters-level degree.

The National Commission for Certification of Anesthesiologist Assistants (NCCAA) was founded in July 1989, to develop and administer the certification process for CAAs in the United States. The NCCAA consists of Commissioners representing ASA, AAAA, and at-large physician and CAA members. Graduates or senior students in their last semester in an AA educational program that has been accredited by CAAHEP may apply for initial certification. Initial certification is awarded to an AA who has successfully completed the Certifying Examination for Anesthesiologist Assistants administered by NCCAA in collaboration with the National Board of Medical Examiners (NBME). Certified AAs are permitted to use the designation CAA to indicate that they are currently certified. The content for the Certifying Examination for Anesthesiologist Assistants is based on knowledge and skills required for anesthetist practice. NCCAA has contracted with NBME to serve as a consultant for the development and ongoing administration of the Certifying Examination. A Test Committee of anesthesiologists and CAAs is responsible for writing and evaluating test questions for the examinations. The first Certifying Examination was administered in 1992. NCCAA maintains a database of Anesthesiologist Assistants-Certified from which certification of individual practitioners can be verified. Hospitals, practice groups, state boards, and others can verify an AAs certification, including a printed verification statement, by going to the Verify Certification page of NCCAA's web site, www.aa-nccaa.org The web site also contains additional information about the National Commission and about the certification process.

Emory University- Atlanta, Georgia Case Western Reserve University - Cleveland, Ohio Case Western Reserve University - Houston, Texas Case Western Reserve University - Washington, D.C. South University - Savannah, Georgia Nova Southeastern University - Fort Lauderdale, Florida Nova Southeastern University - Tampa, Florida University of Missouri-Kansas City - Kansas City, Missouri Quinnipiac University - Hamden, Connecticut University of Colorado - Aurora, Colorado Medical College of Wisconsin - Milwaukee, Wisconsin Indiana University - Indianapolis, Indiana NEOMED College of Graduate Studies - Rootstown, Ohio

According to the ASA statement on the Anesthesia Care Team, anesthesia care personally performed or medically directed by an anesthesiologist constitutes the practice of medicine. Certain aspects of anesthesia care may be delegated to other properly trained and credentialed professionals. These professionals, medically directed by the anesthesiologist, comprise the Anesthesia Care Team. The Care Team statement (last amended on October 21,2009) says, "Such delegation should be specifically defined by the anesthesiologist and should also be consistent with state law or regulations and medical staff policy. Although selected tasks of overall anesthesia care may be delegated to qualified members of the Anesthesia Care Team, overall responsibility for the Anesthesia Care Team and the patients safety, rests with the anesthesiologist. Anesthesiologists should determine which perioperative tasks, if any, may be delegated. The anesthesiologist may delegate specific tasks to qualified non-anesthesiologist members of the ACT providing that quality of care and patient safety are not compromised, but should participate in critical parts of the anesthetic and remain immediately physically available for management of emergencies regardless of the type of anesthetic." Members of the medically directed anesthesia care team may include anesthesiology residents as well as non-physicians such as anesthesiologist assistants and nurse anesthetists.

The scope of CAA clinical practice is generally the same as that of nurse anesthetists on the Anesthesia Care Team. Specifically, the local scope of practice of CAAs is usually defined by: The medically directing anesthesiologist, The hospital credentialing body, The state's board of medicine Any applicable state statute or regulation. States may also require a practice agreement between the sponsoring anesthesiologist and the CAAs who are medically directed.

Certified Anesthesiologist Assistants may be either licensed as CAAs or practice under the license of an anesthesiologist under the principle of delegation. Anesthesiologists may delegate those tasks or duties involved in the practice of anesthesiology to qualified individuals such as CAAs as long as the anesthesiologist is immediately available and the anesthesiologist retains ultimate responsibility for the care of the patient. The exact details regarding delegation and licensing of CAAs are different from state to state. In Indiana CAAs are licensed by the state Board of Medicine. Licensure was established for CAAs by Senate Bill 233. To be licensed in the state of Indiana a CAA must have: 1) completed a bacbelors degree 2) completed an accredited medical-based anesthesiologist assistant program certified by CAAHEP 3) passed the NCCAA certification exam 4) be certified by NCCAA or successor organization.

CMS recognizes both CRNAs and CAAs as non-physician anesthesia providers. Similarly, commercial insurance payors make no distinction between the two anesthetist types with regard to payments for services provided under medical direction by an anesthesiologist. According to the United States Code of Federal Regulations (42 C.F.R. § 482.52 Condition of participation: Anesthesia services) "If the hospital furnishes anesthesia services, they must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital. Standard: Organization and staffing. The organization of anesthesia services must be appropriate to the scope of the services offered. Anesthesia must be administered by only A qualified anesthesiologist; A doctor of medicine or osteopathy (other than an anesthesiologist); A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under State law; A certified registered nurse anesthetist (CRNA), as defined in 410.69(b) of the Federal Register, who is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or An anesthesiologist's assistant, as defined in 410.69(b) of the Federal Register, who is under the supervision of an anesthesiologist who is immediately available if needed."

In order to meet CMS requirements for medical direction, no more than 4 anesthetists (CAAs or CRNAs) may be concurrently directed by an anesthesiologist. The supervision ratio defined in state law or Board of Medicine guidelines and is 4:1 in the state of Indiana.

American Academy of Anesthesiologist Assitants (AAAA) American Society of Anesthesiologists