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Title 22 is a subsection of the California Code of Regulations (CCR) which is over 700 pages long. Section 70435 (b)(2) of Title 22 pertains to the makeup of the surgical team during cardiac surgery. This section of regulation defines a surgical team for cardiac cases requiring extracorporeal bypass as three surgeons with the primary surgeon being board-certified or eligible for certification by the American Board of Thoracic Surgery or the American Board of Surgery. The first and second assistants are required to be physicians. A hospital may apply for a waiver from the California Department of Health and Safety to allow PAs to second assistant (typically to harvest conduit).
Because of the wording of the regulation, physician assistants in California are only allowed to first assist in off-pump cardiac surgery cases.
Although PAs routinely first assist in cardiothoracic surgery in ORs across the country, little published data exists to demonstrate the safety and efficacy of PAs as first assistants for cardiac surgery. In previous efforts by California PAs to advocate for change to the ban on PAs as first assistants for patients on bypass, the lack of such studies has been cited by regulators as a reason not to change the rule. Only Kaiser San Francisco has had a waiver in a pilot program with the Department of Health Services to allow PAs to first assist when patients are on bypass.
In an effort to find an effective solution to this issue, The Association of PAs in Cardiovascular Surgery, the California Academy of Physician Assistants, and the American Academy of Physician Assistants have convened a workgroup to develop a solution.
The workgroup, convened in 2009, began by studying the issue to determine the most reasonable and effective approach. After evaluation and discussion, the Workgroup determined that, rather than pursuing a rule change, they would approach the state with a request that DHS develop a mechanism to assure that waivers to authorize PAs to first assist when patients are on bypass are readily available.
A key member of the Workgroup pursued a study on Safety and Efficacy of Physician Assistants as First Assistant Surgeons in Cardiac Surgery which was presented at the meeting of APACVS, as a poster at the AAPA Annual Conference, and has been recently published by the Journal of the American Academy of Physician Assistants. Working with the CAPA policy staff, the Workgroup has identified the DHS staff members in charge of the regulation and are preparing, in a step wise fashion coordinated with other California surgical priorities, to meet with DHS leaders to propose this solution.
Additional Information
Safety and Efficacy of Physician Assistants as First Assistant Surgeons in Cardiac Surgery
Edward A. Ranzenbach, PA-C, MPAS, FAPACVS, DFAAPA, Li Poa, MD, FACS; Miguel Puig-Palomar, MD; Madeline Holtzman, MD; Shari Miller, PA-C; Michael Mohr, PA-C. Journal of the American Academy of Physician Assistants August 10, 2012
http://www.jaapa.com/the-safety-and-efficacy-of-physician-assistants-as-first-assistant-surgeons-in-cardiac-surgery/article/251421/
The cardiovascular physician assistant: The angel in the room.
Anthony P. Furnary, MD Journal of the American Academy of Physician Assistants August 9, 2012
http://www.jaapa.com/the-cardiovascular-physician-assistant-the-angel-in-the-room/article/251422/
August, 2012