Table 2 Free-text responses exploring attitudes of anesthetist towards a proposed anesthesia-led advanced nurse practitioner model for low-risk elective colonoscopy patients

“The major concern is the ability of non-anesthetists to manage the airway in the event of laryngospasm or apnea.”

“Endoscopy is sometimes associated with significant sedation-related complications e.g. hypoxia, hypotension, bradycardia. A medically trained expert should be responsible for their management.”

“If the patients are high-risk, a non-anesthetist model for sedation will not be as safe as an anesthetist-led model”

“Complications during sedation for endoscopy can happen quickly. The patient population for endoscopy often involves sicker, older and more obese patient with significant comorbidities. These cases are challenging for highly skilled anesthetists.”

“As a community, if we wish to prioritize endoscopy within the constraint of limited resources, compromising safety is not acceptable.”

“The model could only work if all patients are low risk.”

“I think we should appreciate that colonoscopy by anesthetists is usually a "general anesthesia with propofol”.

“Sedation may appear easy, but this is only because anesthetists are highly skilled and trained. It’s important to recognize sedation related complications are common especially if propofol is being used.”

“Propofol should not be used by anybody who is not proficient in airway management”

“The reason why anesthesia is safe in Australia is because anesthesia provision for all patients is based on a one-doctor to one-patient relationship”.

“Who will take ultimate responsibility for any sedation related complications on these lists?”

“The patient must come first not the dollar.”

“A cost analysis of this model must be undertaken evaluating the proposed program - nurse training time, development of a structured program, costs of nurse specialists, costs of the anesthetists who teach on the course, content and the training. The model then needs to be tested clinically as part of an ethically approved quality improvement programme.”

“There are many factors that impact on endoscopy waiting times and efficiency of endoscopy lists. These include, but are not limited, to waiting for equipment turnover, proceduralist skill, whether the lists are training or teaching lists, patient complexity, and patient pathology. The anesthetist is often not the rate limiting step in efficiency.”

“We should not consider lowering the current standard of excellent care if we are not certain this proposed model will be safe. I do not think that the model is economically more efficient.”

“I can see why a non-anesthetist sedation model is appealing to management. It appears to be cheaper, but have any economic analyses taken into account sedation-related complications and potential litigation as a result of sedation without an anesthetist? What will patients think?”

“This program would not comply with current ANZCA guidelines for procedural sedation.”

“Any new model of sedation must comply with ANZCA guidelines on procedural sedation.”

“Any proposed changed to an anesthetist-led service for colonoscopy needs to be discussed with the patients and endoscopists. We need to explore their views as well.”

“Any new model should not compromise the training of our anesthesia residents and registrars.”

“The use of anesthesia registrars with 2:1 supervision would be an alternative and acceptable model.”

“I would be prepared to act as a supervisor for two anesthetic registrars administering procedural sedation, including propofol.”

“There is a flood of new medical graduates. Resources could be better allocated to training junior doctors in the provision of safe sedation in intensive care, radiology and emergency medicine.”

“Before this model is adopted, research needs to show that an anesthesia-led nurse sedation model is equivalent or superior to our current model of care.”

“Strong hospital support in funding this training programme will be needed. This model will need to be led and championed by the department of anesthesia.”

“I do not possess the necessary skill set to train nurses in this role.”

“There remains the issue of who is responsible for the ‘prescription’ of the medication’ This creates further logistically and training considerations.”

“It will completely depend upon the suitability of the nurses chosen for the role.”

“For this model to be safe, nurses need to train to the same level as Certified Registered Nurse Anesthetists (CRNAs) the USA. Anyone can give an anesthetic when things go well.”

“This model should be applied only with clear and strict guidelines.”