The anesthesiologist shortage is now a ‘full-blown crisis.’ Should Canada use nurse anesthetists?

The effects of a shortage of anesthesiologists could be improved if specially trained nurses were allowed to provide anesthesia care — something they do in the United States, nursing advocates say. 

But physicians’ groups have pushed back against the idea in at least two provinces since it was raised more than 25 years ago, even as surgical wait times have grown since the pandemic.

In the U.S., there are 65,000 certified registered nurse anesthetists (CRNAs) working. In Canada, nurses haven’t been able to provide anesthesia since the Second World War ended, says Valerie Grdisa, the CEO of the Canadian Nurses Association. .

Now nurse associations, and some Canadian nurses working in the U.S. as nurse anesthetists, are calling attention to how effectively they could solve the dearth of anesthesia care providers in this country. 

While Grdisa notes that the U.S. health-care system has considerable problems with access and cost, one thing it does well is making efficient use of its employees.

“They’re optimizing their very talented workforce in ways we’re not [in order] to get better value for money at same or equal outcomes,” said Grdisa, who holds a PhD in nursing. She was part of an effort to establish a nurse practitioner program in anesthesia at the University of Toronto that ran for a few years in the early 2000s, but she said it was dismantled before graduates could enter the Ontario health-care workforce after “an active physician lobby” convinced the province to abandon the idea.

Nurse anesthetists in the U.S. administer more than 58 million anesthetics — drugs that cause a loss of feeling or awareness — to patients each year, according to the American Association of Nurse Anesthesiology. In rural areas, they provide more than 80 per cent of anesthesia care.

Canadian nurse Joe Toma lives in Windsor, Ont., and works as a nurse anesthetist just across the border in Detroit at a hospital called Henry Ford Health. He says three classmates who graduated with him from CRNA training also make the same half-hour commute each day.

On the day he spoke with CBC, Toma said he had done a shift in the endoscopy unit, where the interior of a patient’s organ is examined with a scope. Since one anesthesiologist can oversee up to four CRNAs at his hospital, Toma and two others were in rooms with patients, while the anesthesiologist worked in the pre-op area evaluating patients ahead of their procedures.

“So that’s like a great utilization right there where one person is out in the pre-op and recovery area evaluating patients and able to respond if any emergency occurred,” Toma said. 

“Obviously Canada has long wait times and I think everybody knows that one of the major contributing factors is the lack of anesthesia providers,” he said. “So, if you had CRNAs in Canada, you would definitely improve operating room access to Canadian citizens.”

Surgical waits

In the years leading into the pandemic, surgical wait times were long but improving, according to data from the Canadian Institute for Health Information (CIHI). But closures associated with COVID-19 meant close to 600,000 fewer surgeries than normal were performed in the two years between April 2020 and March 2022. 

While surgical volumes have returned to pre-pandemic levels, the CIHI data shows that today fewer people get their surgeries within the recommended timeframe — 48 hours for a hip fracture, for example — than they did in 2019.

An editorial published late last year in the Canadian Journal of Anesthesia said the shortage of anesthesiologists in Canada has evolved into a full-blown crisis and creates a major barrier to surgical access, “with the majority of Canadian anesthesiology departments now reporting significant challenges with recruitment and retention.”

While overall there is a global shortage of anesthesiologists in keeping with an overall health-care worker shortage, the editorial also said anesthesia human resources in Canada have been handled “in a patchwork manner” at the provincial and local levels and that calls for a national strategy on anesthesia for more than three decades have had limited effect. 

Canadian CRNA Josh Booth works in the Detroit area at William Beaumont University Hospital, though unlike Toma, he now lives on the U.S. side in Bloomfield Hills, Mich.

“I am friends with nurses who work in operating rooms in southern Ontario, and they have told me that they don’t understand how there are no nurse anesthetists practising in Canada,” Booth told Dr. Brian Goldman, host of White Coat, Black Art. 

While he acknowledges there are a range of reasons why surgeries can be postponed, Booth says lack of anesthesia care is one of the reasons a backlog of surgeries remains. 

He says he knows of approximately 200 fellow Canadians who work as nurse anesthetists in the U.S., and he believes some of them would want to provide care in Canada, yet “it seems as if nothing is changing.”

B.C. plan scuttled

In 2012, the B.C. government said it was examining options for nurse practitioner-anesthetists and was committed to moving ahead. The B.C. Nurses’ Union said it was fully behind the plan.

But it didn’t move forward either then or again in 2021, which is when the province said it was considering creating new nursing roles like nurse anesthetists once more.

“Utilizing nurse anesthetists in B.C. would be a positive step towards collaboration among various health disciplines and be beneficial to improving patient care,” the B.C. Nurses’ Union said in a written statement provided to CBC.

A spokesperson for B.C.’s Ministry of Health said that it added 152 anesthesiologists and 71 anesthesia assistants between 2020 and 2024. During that time it also established a working group to find anesthesiologists to work as locums in places with the highest need and increased anesthesia residency spots for new grads, the spokesperson said.

The Canadian Anesthesiologists’ Society defines anesthesia assistants as a specially trained health professional who participates in the care of stable surgical patients under the supervision of anesthesiologists.

CRNAs are qualified as autonomous anesthesia providers capable of making independent decisions about patient care and can work in settings both with and without a supervising anesthesiologist. They can intubate patients, provide anesthesia for people undergoing surgery and administer epidurals in labour and delivery wards, for example. 

The Canadian Anesthesiologists’ Society opposed the plan in 2021 to introduce CRNAs and came out with a position statement that said it “firmly rejects” nurse anesthetists in Canada. It says the job is meant for doctors.

Dr. Giuseppe Fuda, an anesthesiologist at Montreal’s Jewish General Hospital, is president of the Canadian Anesthesiologists’ Society.

“We prefer to work on an anesthetist assistant system that we have instead of importing American solutions,” said Fuda.

While some of the time the shortage of anesthesiologists may be behind a surgery cancellation, Fuda said “most often they’re not.”

“There are other reasons why, unfortunately, surgeries are cancelled. And that could be due to a nursing shortage or beds that are not available. Sick calls, sometimes even equipment that is missing,” he said. “It happened to me yesterday where we were missing equipment to be able to fix a broken hip, and we had to cancel a surgery because of that.”

Fuda said the society has been working to address the shortage by increasing residency spots for medical graduates interested in anesthesiology, reducing barriers for internationally trained anesthesiologists, and fixing bottlenecks in hospitals that limit access to beds.

Grdisa, with the Canadian Nurses Association, said “a physician-dominant system in Canada” has prevented nurse anesthetists from working here, “even though we know that it would be better workforce optimization and reduce costs.”

An article in the Canadian Journal of Anesthesia in December titled “The anesthesia human resources crisis in Canada” — written by anesthesiologists — said the current model “is not meeting population needs.”

WATCH | Anesthesia shortage affects access to epidurals: 

The accompanying editorial stressed the importance of learning from how anesthesia care is delivered in other countries. “Such appraisal will necessarily involve an examination of our own longstanding biases and an openness to new ideas.”

Grdisa said Canada’s health-care system is the second-most expensive among OECD nations, and a “siloed” model where the workforce isn’t used to its full capacity is to blame.

“It’s really unfortunate that we have these skilled, highly talented nurses across the nation that seek graduate-level education south of the border, and they cannot be optimized in the Canadian health-care system.”