Dear Sirs,

I would like to comment on the proposed changes to 18VCA150-20-172 Delegation of Duties for the Board of Veterinary Medicine.  Specifically:  The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.

Unfortunately, if this regulation is implemented, this would place the burden of monitoring an intubated, anesthetized patient on either a veterinarian or a licensed veterinary technician (LVT).  We find ourselves unable to hire enough LVTs to perform the tasks now required by regulation.

I fear that the limitation of the staff authorized to assist and monitor during even minor procedures, or common procedures such as dentals and extractions, would tremendously increase the cost to the owners, without increasing patient safety.  Thereby decreasing the availability of these procedures to the majority of the pet owning public.

As an alternative I would suggest each hospital submit their veterinary assistant training program for Board review and approval, to ensure that staff involved in any anesthetic procedure are trained to competently ensure patient safety.

Thank you for your consideration,

Karen E. Bates, Hospital Manager

I feel this change will drastically impact our ability to practice veterinary medicine. I have practiced in our hospital for 21 years. We have an excellent training program for veterinary assistants, which allows them to monitor patients who are intubated. A technician or DVM is in the room at all times.  Although we strive to hire veterinary technicians, they are in short supply and high demand.  This new rule would greatly decrease the number of needed procedures we can provide, decrease the amount of pets who can be cared for, and decrease the amount of jobs we provide for our assistants.  If I thought that our assistants were not able to monitor our patients,  I would certainly change what we do. Our patient's lives are the most important aspect of veterinary medicine. If statistically you proved that an assistant is unable to monitor, I am willing to listen. Our hospital has had a very low mortality since the implementation of an assistant monitoring all of our equipment while the doctor and technician are performing their role. The reality is that veterinary medicine does not have enough licensed technicians for all of the jobs you would like them to perform. I ask you to carefully consider what I believe is a well intentioned change that will have a huge negative impact on our medicine.

To whom it may concern--?

If you no longer allow unlicensed veterinary assistants to monitor sedate or intubated patients, it would inhibit the potential of younger veterinary generations to come.

When I first started with VCA Alexandria Animal Hospital, I was not equipped with the vetertinary expirience that I have today. Never did I expect to be in this field surrounded by dogs, cats, and other wild life.

Growing up in the busy city of Alexandria my childhood and teenage years were spent on various sport teams and hanging out with friends. Sports are a very important building block in young teenage lives because it teaches self-control, sportsmanship, and most of all team work. All the values that we hold here at VCA Alexandria. Every day is a blessing because of the impact we make on eachothers lives and the animals.

Because of the dedication and hard work of our administrative and supervisory team here at VCA, I have had the honor of monitoring for many types of surguries and procedures. If not for anesthesia I would have never have found this passion.

It is hard to believe that myself, a young man who only enjoyed playing basketball and chasing around "the ladies" also graduationg high school with only a 2.0 GPA along with low self esteem would be welcomed with open arms into a family who not only care about themselves but the well-being of the animals that walk through the door.

I look in the mirror with pride now that I can say my life has evolved to being a team player, a B+ student with a 3.5 GPA in college, along with being a mentor to younger generations mentoring telling them the sky is the limit! All because of the love at first sight with anesthesia monitoring. 

New hires and a few less expirienced staff whether it was an LVT, assisistant and on occassions doctors began to ask me questions about trouble shooting machines or how to fix a problem when something starts to malfunction. Just simple things like that makes a person feel of value to a team, get more knowlege on basic to critical anesthesia monitoring, knowing there is much more to learn has ignighted a spark in me to become not only to reach for the stars for myself, but to also help others  surpass what I have and will do; past and present.

The Veterinary Technician demand is at an all-time high. Without letting assistants learn to monitor anesthesia, it may potentially suppress the desire of other men and women, young and old to pursue an education to become an LVT not knowing their hidden potential to become successful and not feel disposable in the work place.

Although I was awarded an LVT scholarship it still will not stop me from standing up for the next assistant whos eyes light up when a scaple blade is pulled out and the surgery start time begins.  

Thank you for your consideration,

Khalfani Carr, Emergency Veterinary Assistant

I am concerned with the current proposed wording of the amendment, as it is a potentially good use of staff and resources to allow certain established/experienced vet assistants to help with monitoring anesthesia.

We are a progressive and busy 24-hr clinic.  We have several highly trained LVTs but within the past year we altered our policies to have a vet assistant (VA) to be on board with every dental prophy procedure because the task of monitoring, along with performing the procedure a patient is anesthetized for, we felt opened up too much liability for a single person.  Anesthesia is probably the most liable time that any patient is subjected to, and for a vast majority of that time during the most important moments (induction & recovery) the veterinarian may not be directly present; rather instructions have been given to an LVT after a pre-sedation exam (at this point the vet is often in the office, on the phone, etc.).

We only delegate this task of helping the LVT to particular assistants who we feel are capable and trustworthy, and at most they are an additional set of hands for the LVT to direct about bagging patient, adjusting the flowmeter or gas, etc., while they record the stats on the surgery flowsheet, allowing ultimately a faster/more efficient procedure. 

This is also an excellent opportunity for learning for some of these assistants, many of whom have aspirations for LVT education themselves.  I propose that certain assistants, at the judgement of the veterinarian, be allowed to assist with anesthesia monitoring for at least the dental procedures due to the LVT's direct responsibility to perform the prophy.  Thank you.

Dear Sirs,

 I am a licensed veterinary technician working at a 24 hours general practice in the wonderful state of Virginia. I started out working as a veterinary assistant at my current hospital. I graduated from Northern Virginia Community College’s AVMA approved program and sat for boards in 2003. I am also regional technician supervisor for 13 other area hospitals. I assist them with training and mentoring of technicians and assistants. I am a VALVT member and NAVTA member.

I am sending this letter in regards to the prosed changes to 18VCA150-20-172 Delegation of Duties for the Board of Veterinary Medicine.  Specifically:  The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.

I understand the intention of the Board with the proposed law. In a perfect world,  licensed technicians would perform all technical skills in a veterinary practice. Unfortunately, we do not live in a perfect world. As I am sure you are aware, there is a great shortage of licensed technicians due to burnout, compassion fatigue and lack of pay. For every veterinarian there is 0.48 licensed techicians vs. human medicine for every doctor there are 2 .8 registered nurses. The Virginia DHP Count of Current Licenses for the FY ending June 30th, 2016 which lists 2032 licensed Veterinary Technicians, 4217 licensed Veterinarians and 772 Full Service Veterinary Facilities which translates to approximately 0.48 LVT per licensed veterinarian and 2.6 LVT’s per full service facility.  This falls well below most veterinary industry recommendations for a minimum of 1-2 FTE LVTs/ FTE veterinarian in a full-service GP veterinary practice. Workforce data from the same time period in the human medical profession show that 37115 Physicians and 104,873 Registered Nurses were licensed in the state of Virginia which represents 2.8 registered nurses for each licensed physician.

 With the proposed law, what I fear most is the limitation it would place on patient care. Taking care of patients is the reason why I became a licensed technician and why I have continued to remain in the field. I fear there will be veterinarian "monitoring" alone while doing surgery in order to follow the law.  Patients will not be intubated that really should be so a trained assistant can monitor them.  I do strongly believe in the current Virginia laws. Only licensed personal can induce anesthesia. Only licensed personal can place an endotracheal tube. I believe these laws help to protect our patients and protect the veterinary technician profession without crippling licensed technicians and veterinarians.

A side from patient care, I also fear  the proposed law  would increase the cost to owners because there would be a limited the number of procedures that could be offered to the public due to lack of licensed technicians. It would put more of a strain on the already limited licensed staff.

As an alternative I would suggest each hospital submit their veterinary assistant training program for the Board to review and approve.  This would help ensure that all staff involved with any anesthetic procedure is trained properly to increase patient safety. Currently our trained anesthesia veterinary assistants undergo an intense training program. Afterwards  a licensed technician or veterinarian helps to overseas the care of these patients.

Thank you for your consideration.

Sincerely,

Amanda Blankenship LVT

Dear Board Members,

I am a veterinarian who has practiced small animal medicine for over 25 years, most of those in the state of Virginia.  Please consider the following comments regarding proposed changes to Article 18VAC150-20-172, Delegation of Duties, of the Virginia Register of Regulations, Volume 33, Issue 9, pages 952-953:

 B. Injections involving anesthetic or chemotherapy drugs, subgingival scaling, or the placement of intravenous catheters shall not be delegated to an assistant.  An assistant shall also not be delegated the induction of sedation or anesthesia by any means.  The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.

The new provision in the above regulation that specifically prohibits a veterinarian from delegating anesthetic monitoring of an intubated patient to an unlicensed, trained assistant concerns me. In my experience, the demand for Licensed Veterinary Technicians (LVTs) far outstrips the supply.  VCA-Alexandria Animal Hospital currently employs 11 LVTs and needs more.  Consistently months and sometimes even years go by with few or no applicants for open LVT positions.  This phenomenon is not isolated to our hospital as evidenced by examination of  the Virginia DHP Count of Current Licenses.  During the preceding Fiscal Year ending June 30th, 2016, there were 2,032 Licensed Veterinary Technicians, 4,217 licensed Veterinarians and 772 Full Service Veterinary Facilities.  This equates to approximately 0.48 LVTs per Licensed Veterinarian and a mere 2.6 LVTs per full service facility.  Bearing in mind that those numbers assume equal distribution of LVTs by facility, which is almost certainly not the case, the number of LVTs at some practices is likely even fewer.  In any event, those numbers fall woefully short of most veterinary industry recommendations for a minimum of 1-2 full time employed LVTs per full time employed veterinarian in a full-service General Practice Veterinary Facility.  Workforce data from the same time period in the human medical profession show that there were 37,115 Physicians and 104,873 Registered Nurses licensed in the state of Virginia.  This reflects a dramatically different ratio of 2.8 Registered Nurses for each Licensed Physician.  A comparison of workforce data from human medicine to veterinary medicine is not perfect, but there are many similarities in the amount and type of labor needed to provide patient care in both fields.  Perhaps one of the most striking similarities is that both professions are currently experiencing a shortage of licensed support care staff, with that of veterinary medicine obviously being the more severe. 

This well intentioned proposed regulatory change, undoubtedly meant to improve patient safety and promote the LVT profession, will instead have profoundly negative consequences for both the quality and availability of veterinary care in Virginia precisely because it comes during a severe shortage of LVTs in the state.  In light of this reality, there are only a handful of options open to practitioners seeking to comply.  Consider the following scenarios:

          1.  A typically understaffed facility necessarily and dramatically reduces the amount and types of services requiring intubation to accommodate the increased demand for man-hours associated with anesthetic monitoring and recovery.  There is no option available to the owner to simply go to another facility because the LVT shortage is a state-wide problem.  The net result is that the availability of veterinary care suffers in general.  Wait times for elective procedures become protracted and, in the emergency environment, diminished capacity can lead to patients being turned away with disastrous consequences.

          2.  LVTs and/or veterinarians monitoring stable but intubated patients during routine anesthesia and through extubated recovery are unavoidably diverted from providing monitoring and care to patients which may require more or specialized attention but simply do not have an endotracheal tube in place.  Both the quality and availability of care to the non-intubated patient is thereby potentially decreased.

          3.  A veterinary practitioner, doctors and LVTs alike, at any given practice may find themselves tempted to avoid intubating patients that should be.  This places them in the position of being forced to choose, between what is best for their patients and clients or abiding by the regulation. A regulation should never interfere with best practices, but this almost certainly will occur with the inevitable resulting reduction in the quality of patient care.

          4.  A veterinarian or LVT may find themselves trying to simultaneously perform a procedure on an intubated patient while monitoring anesthesia themselves.  Alternatively, one LVT may be tasked with monitoring multiple patients at the same time. That kind of divided attention is untenable and, again, the quality of patient care will suffer.

          5.  Some practices will simply be unable to comply in all circumstances and will instead choose to disregard the regulation on a case by case basis.  That is a sad reality, but a reality non-the-less.

All of the aforementioned scenarios are definitely less desirable than the current situation that exists in most practices.  Historically, well-trained and yet unlicensed technician assistants have safely provided anesthetic monitoring for intubated patients.  From the time of LVT or DVM induction and intubation all the way through extubation and recovery, these routine procedures have always been overseen by either a Licensed Veterinarian or LVT providing immediate, direct supervision and support to the assistant. 

There is no escaping the fact that there is a dearth of LVTs in Virginia at the present time.  Mandating specific duties to LVTs via this proposed regulation only exacerbates the problem.  Until the current crisis is mitigated, I believe that a more efficacious solution exists.  Our patients, our clients and the veterinary profession in Virginia as a whole would be better served by a standardized, detailed anesthetic assistant training syllabus.  Such best practices standardization could easily be developed by a recognized body such as the American Veterinary Medical Association (AVMA), the American Animal Hospital Association (AAHA), or equivalent as deemed appropriate by the Board, and implemented by individual hospitals and clinics.  Following Board approval, such a program would allow unlicensed technician assistants who have successfully completed the training program to monitor intubated anesthetized patients under appropriate supervision of Licensed Veterinarians or LVTs. 

Thank you for taking the time to review and consider the above comments.

Very Respectfully,

Rena Allen, DVM

VA License # 0301005796

Medical Director, VCA-Alexandria Animal Hospital

2660 Duke Street

Alexandria, VA 22306

phone: 703-751-2022

e-mail: rena.allen@vca.com

I am making this comment as a licensed veterinarian in this state, and not as a representative of the VVMA.

I know the intent of this change was to protect the public and their pets..Unfortunately, I suspect the result of this change will be the opposite.

I have been in practice in Southwest Virginia for over 40 years, and we employ three licensed veterinary technicans. However, I know most practices in this region do not employ any licensed technicians...simply because of the lack of availability of licensed technicians., and the reluctance of licensed technician's wanting to live and work in this region.

Thus, as they try to follow the letter of this revised law, veterinarians will use injectable anesthetic agents and be reluctant to intubate, even in cases where intubation would be safer for the pet. I know that forcing veterinarians to make this medical decision based on the law rather than the needs of the patient is not the intent of the change, but will, ultimately, be the result.

This letter is in reference to the Board's proposed changes to 18VCA150-20-172 Delegation of Duties for the Board of Veterinary Medicine stopping the ability to use assistants to monitor intubated patients and require LVT's to be the primary responsible personnel to monitor these patients.   There are always reasons for the board to consider making these types of changes.  Perhaps there have been too many cases reported of compromised care of patients or perhaps the licensed veterinary technicians would like to have their profession recognized for the efforts in attaining their degrees. Changing the regulations might at first appear to be a quick way of fixing these types of situations however, making these types of changes would create a tremendous burden to the practice of veterinary medicine not to mention potentially reduce the quality of care to our patients.  

Many veterinary practices are in rural areas where they have trouble attracting licensed veterinary technicians.  Even those practices in more urban locations often have less than a 1:3 ratio of technicians to veterinarians. Unlike in human medicine where there are greater than five nurses licensed to number of doctors.  Changing the regulations in an attempt to give greater recognition to the technician field is not going to solve this shortage.  It will only cause the current technicians to work harder and perhaps lead to burn out in their profession.  

As far as safety issues regarding the use of assistants to monitor intubated patients many hospitals use in house training programs to teach these requirements to their staff. Perhaps the regulations could state that assistants performing these tasks can do so under the direct supervision of a licensed technician and/or veterinarian.  I would like to hope this is already the case.  

Ultimately, the doctor is fully responsible for a patients care.  If limitations to how we can use our staff continues we will be severely limited in our daily duties.  Many practices will suffer economically while others may even prosper from the referrals of these patients.  Many patients may get compromised care by using injectable anesthestics in place of gas anesthestics if they have no licensed technicians or worse yet doctors might compromise their care by trying to monitor and perform surgery at the same time.  

I ask that these regulations not be accepted for these reasons and that the reasons for considering these changes be pursued under a different agenda.  

I have been a small animal practioner for 21 years.  The hard facts are that if the regulation is approved as worded (unlicensed assistants would no longer be permitted to monitor an intubated patient during anesthesia and recovery) our ability to provide surgical and dental procedures will be dramatically diminished. There are nowhere near enough LVTs available in the state of Virginia to enable practices to adhere to such a regulation and continue to provide the current number of anesthetic procedures.  To have an LVT (or veterinarian) be required to monitor a patient until extubation prevents them from moving on to the next procedure. In a busy practice where each LVT /DVM pair is doing 6 procedures per day, this will add about 1.5-2 hours per day of unproductive time while the LVT waits for the patient to be extubated. This has a negative impact on the economic health of the practice, as well as the ability of the practice to provide the care our patients need. In addition, requiring the LVT that is performing a dental procedure to also be doing the anesthetic monitoring simultaneous would dramatically reduce the standard of care that we currently have and compromise patient safety. To change from our current structure, where the patients are continuously monitored throughout their anesthetic procedure (including temperature, blood pressure, oxygen saturation, ECG and capnograph) to a situation where the technician who is focused on the dental prophy or the veterinarian who is actively doing surgery has to also be monitoring, is a terrible idea that will lead to increased anesthetic risk for the patients.   The answer is not and can not be "Hire more LVTs" - since there very few LVTs out there to hire.  Until the situation of the LVT shortage is corrected, the best solution is to mandate that every antesthetized patient is monitored by a trained veterinary assistant, that has completed a a specified, regulated anesthetic training program.

I vigorously oppose this provision that would mandate only licensed personnel can monitor intubated patients. 

Dear Board Members,

I am a veterinarian who has practiced small animal medicine for 15 years, all in the state of Virginia.  Please consider the following comments regarding proposed changes to Article 18VAC150-20-172, Delegation of Duties, of the Virginia Register of Regulations, Volume 33, Issue 9, pages 952-953:

 B. Injections involving anesthetic or chemotherapy drugs, subgingival scaling, or the placement of intravenous catheters shall not be delegated to an assistant.  An assistant shall also not be delegated the induction of sedation or anesthesia by any means.  The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.

The new provision in the above regulation that specifically prohibits a veterinarian from delegating anesthetic monitoring of an intubated patient to an unlicensed, trained assistant concerns me.

The proposed regulatory change, intended to protect patients and promote the LVT profession, will instead have negative consequences on the quality, availability, and cost of veterinary care in Virginia, due to the severe shortage of LVTs in the state.

Other solutions can still protect veterinary patients.  Detailed training for anesthetic assistants could be developed, and demonstrated by practices, or a standardized curriculum developed by the Board or professional organization such as AAHA. Prior to veterinary school, while working as a technician assistant, I received extremely thorough training in anesthetic monitoring, always under the supervision of an LVT and veterinarian. During anesthetic rotations in veterinary school, I found that the training I received as an assistant was more complete than that of certain classmates who had worked as LVTs. A rigorous training program would allow unlicensed technician assistants to responsibly monitor intubated anesthetized patients under appropriate supervision of Licensed Veterinarians or LVTs. 

Thank you for taking the time to review and consider the above comments.

Respectfully,

Shannon Talbott, DVM

VA License # 0301200547

Associate Veterinarian, VCA-Alexandria Animal Hospital

2660 Duke Street

Alexandria, VA 22306

703-751-2022

The new provision in the above listed regulation that specifically prohibits a veterinarian from delegating anesthetic monitoring of an intubated patient to an unlicensed, trained assistant concerns me.  The proposed change will have a negative consequences on the quality, availability and cost of veterinary car in Virginia, due to gthe severe shortage of LVTs in the state.  The LVT program does not grandfather in some very experienced and well trained veterinary nurses working in many and our practice.

Respectifully

Rachel C Coligan, DVM

As a concerned member of the veterinary community I am writing in regards to the proposed changes to Article 18VAC150-20-172, Delegation of Duties, of the Virginia Register of Regulations, Volume 33, Issue 9, pages 952-953:

 B. Injections involving anesthetic or chemotherapy drugs, subgingival scaling, or the placement of intravenous catheters shall not be delegated to an assistant.  An assistant shall also not be delegated the induction of sedation or anesthesia by any means.  The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.

As an LVT working in a busy GP/ER facility my concerns are mainly with the impact on the level of care that I and my fellow technicians will be able to provide to our patients if the board decides to pass this proposal. While there will also undoubtedly be resulting economic effects, my current focus lies in the ability to continue providing the highest standards of care for the patients in our hospitals.

Delegating anesthetic monitoring of intubated patients solely to a veterinarian or licensed technician will place additional levels of burden on teams that are already stretched thin by the lack of available LVT’s. The most current statistics indicate that in Virginia there are 0.48 licensed technicians for every veterinarian, not taking into consideration the uneven distribution between urban and rural practices. Given the high rate of burnout resulting in a large number of graduates leaving the field less than 5 years after graduating, the veterinary community is going to be hard pressed to employ enough staff to abide by regulations.

Following the institution of this new regulation there are a few different possible options that practices will be forced to employ. Hospitals that perform more than one procedure at a time are likely to end up having a single technician monitoring all the patients, or technicians that are required to simultaneously monitor anesthesia while performing dentals. Veterinarians may also be forced to monitor their patient during surgeries which puts patients at risk as one person cannot properly concentrate on both tasks. These solutions all carry higher levels of risk than having a trained assistant monitor each patient individually.

Other hospitals may choose to avoid intubating patients at all and move towards injectable anesthesia in order to comply with the law and utilize their available staff. As an industry, we have spent years educating clients on why proper anesthetic management is a benefit to their pets, only to see the potential for this to slow as practices are being forced to choose whether they break the law to provide proper anesthesia or provide substandard care that could result in increased patient risk.

While I appreciate the effort to emphasize the importance of licensed staff in practices, with a state-wide shortage of technicians I do not see this proposal resulting in the outcome that the board expects. Instead I truly believe it will result in a decline in patient safety and care, and may further result in more LVTs abandoning their careers as more responsibility is placed on their shoulders.

In my experience, there are assistants currently monitoring anesthesia in private practices that are highly trained and I ask the board to consider allowing those who have proven their competency through testing or training programs to continue monitoring intubated patients.

Thank you for your consideration,

Sarah McKinney

I am against the proposed changes to put further limitations on veterinary assistants.    I have had 4 licensed vet tech employed in my 18 years at this clinic.  They are difficult to recruit to Southwest Virginia and they don't want to stay.  The last Vet Tech I employed started as an assistant. I paid for her to do online Vet tech training.  As soon as her contract to pay back her education expired, she moved on. (She is now an RN).  My current two assistants have a combined experience of 37 years in this hospital. Neither want to move forward with their education and go to an on-line or brick and mortar tech program. These two assistants have been trained and worked under 4 vet techs.  They have been trained to work the mechanical ventilator and  the Surgivet monitoring equipment by the respective manufacturers.  They are well versed with the workings of the anesthetic equipment. They have attended CE classes sporadically throughout their tenure here.  They are competent and always under supervision.

Our day consists of one doctor doing surgery and the other doctor doing appointments.  There is never an incident where our assistants are unsupervised monitoring anesthesia.  There is always a doctor present.  On days when there is only one doctor working,  we do not do surgery. 

We are located in Galax, VA.  The southwestern tip of the state.  We have a poor rural demographic.  The financial hardship of paying for vet care is a never ending challenge in this area.  Forcing my clinic to recruit a veterinary technician to my area will be impossible and expensive. There are not enough vet technician's in the state of Virginia to recruit one to SW VA.   

I am willing to invest in my assistants. I can send my assistants to a certification class on anesthesia, if the board of Vet medicine and VMRCVM wants to create one.  I encourage my assistants to attend continuing education classes yearly to further their knowledge. They periodically take advantage of the benefit.   I can change my policy and make it a requirement of their employment.  I would be happy to forward their continuing education opportunities to the board.  Logistically for us in South west Va finding and keeping a LVT will be difficult. To comply with the new ruling, we  will be unable to offer surgery or increase the cost substantially since two doctors will have to be involved in the surgery.  This ruling puts an unnecessary financial burden on my clients with no compensatory gain.

Please consider not implementing this new ruling.  Thank you for your consideration.

Heather Jenkins, DVM, CVA

I am writing to express my concern with the proposed changes regarding the delegation of duties to veterinary assistants.  I want to echo what other veterinarians have said.  By limiting the staff that are capable of administering and monitoring anesthesia, it will severely limit our ability to give quality care to patients in a timely manner.  

Delegating anesthetic monitoring of intubated patients solely to a veterinarian or licensed technician will place additional levels of burden on teams that are already stretched thin by the lack of available LVT’s. The most current statistics indicate that in Virginia there are 0.48 licensed technicians for every veterinarian, not taking into consideration the uneven distribution between urban and rural practices. Given the high rate of burnout resulting in a large number of graduates leaving the field less than 5 years after graduating, the veterinary community is going to be hard pressed to employ enough staff to abide by regulations.

Please reconsider the change to these regulations.

I am concerned that the proposed regulatory language unreasonably  limits the use of experienced assistants under the direct supervision of  a veterinarian.  It will also increase costs for clients especially for those who provide low cost spay and neuter services for shelters and rescue groups since often lvts are not available  to service these procedures or the cost of providing them would limit access to these services for lower income individuals.  The summary in the town hall language is also inaccurate and does not truly reflect the proposed language.  I would suggest language which supports the use of assistants to help monitor patients under the supervision of a licensed individual. This recognizes the role of lvts but maintains the ability of veterinarians to provide cost effective and timely services. It also discourages the use of less than ideal anesthetic techniques (injectable only) to meet regulatory guidelines by veterinarians who are unable to hire adequate numbers of lvts.

I am commenting on proposed regulation change 18VAC150-20-172, Delegation of duties.  My specific concern is with section B, second sentence.  "An assistant shall also not be delegated the induction of sedation or anesthesia by any means. The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered".  My concern is the burden on both the veterinarian and the pet owner requiring all intubated animals to be monitored only by licensed individuals.  Currently, there are not enough available licensed technicians in the state of Virginia, especially in rural areas, to accommodate this proposed change.  Also, the increased staff costs would increase the cost of care making veterinary medicine unaffordable for many Virginians.  Most Veterinarians in the Common Wealth want to provide the best care possible and would agree that unlicensed individuals should not be making medical decisions.  But unlicensed assistants monitoring patients under the supervision of licensed DVMs and LVTs is different and necessary for many practices to be able to provide surgical/dental care to their patients.  I think the regulation should read something like "An assistant shall also not be delegated the induction of sedation or anesthesia. A sedated or anesthetized patient may be monitored by an assistant under the direct supervision of a licensed veterinarian or licensed veterinary technician and a licensed individual must remain on premises until the patient is fully recovered". 

                                                                                                                                February 1, 2017

Dear Board of Veterinary Medicine Members,

                My name is Dr. Joseph A. May and as most of you know, I just finished serving eight years on the Board of Veterinary Medicine. I have concerns about the following changes to the regulations concerning the practice of Veterinary Medicine posted on the Town Hall Web Site.

5. Advertising in a manner which that is false, deceptive, or misleading or which that makes subjective claims of superiority

Suggest rewriting to make it flow better:

 5. Advertising in a manner that is false, deceptive, misleading, or makes subjective claims of superiority

B. Injections involving anesthetic or chemotherapy drugs, subgingival scaling, or the placement of intravenous catheters shall not be delegated to an assistant. An assistant shall also not be delegated the induction of sedation or anesthesia by any means. The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.

This proposal has caused a great deal of angst among Veterinarians especially in rural practices. It basically prohibits an assistant from monitoring or recovering an anesthetized patient. I have been told that the words “provided the patient is no longer intubated and” was accidently added from wording from a previous document that the Board approved and will be deleted. I do remember the wording above without the added words but do not ever remember ever seeing a document with the added words in it. It is possible that it came from a committee to study revisions but to my knowledge, it was never discussed by the full board or approved. I along with several other board members would never approve of such a proposal as it would create a severe hardship on many practitioners. There seems to be a push by some in the Veterinary community to restrict more things routinely done successfully for years by assistants trained within the hospital to licensed personnel only. To me, this is extremely short sighted and creates an extreme hardship on many practitioners. Currently there is only one licensed LVT for every four practitioners and many rural practices can simply not attract LVTs to come to their area and work in the practice. The Licensed DVM remains responsible for the safety of the patient regardless of who is helping with that patient and regulations should not restrict his ability to use his professional judgement. In addition, regulations such as this also hampers the ability of an LVT to train and delegate staff they are supervising so they can use the skills they were trained for to take over tasks typically done by the DVM to improve overall patient care. They are highly trained and should not be regulated into doing tasks that others can be easily trained to do. Instead of passing regulations to restrict assistants, we should take a cue from our human counterparts and allow LVTs to use their skills and play a greater part in patient care similar to the way Nurse Practitioners assist MDs.

B. Additional C. The following tasks that may be delegated by a licensed veterinarian to a properly trained assistant include but are not limited to the following:

1. Grooming;

2. Feeding;

3. Cleaning;

4. Restraining;

5. Assisting in radiology;

6. Setting up diagnostic tests;

7. Prepping for surgery Clipping and scrubbing in preparation for surgery;

8. Dental polishing and scaling of teeth above the gum line (supragingival);

9. Drawing blood samples; or

10. Filling of Schedule VI prescriptions under the direction of a veterinarian licensed in Virginia.

In the proposal above, I feel the words “include but are not limited to the following” needs to remain in the regulation and not be deleted. By removing it, it restricts assistants to doing ONLY those tasks listed. There are many more tasks not listed that a trained assistant can safely do and as mentioned previously, the Licensed DVM remains responsible whenever a task is delegated.  Again, rural practitioners often do not have the opportunity to have an abundance of LVTs in their practice and must rely on trained assistants to lend a helping hand. If you notice “assist with surgery” is not listed above so with a strict interpretation of the regulation, it would prohibit a trained assistant from donning a pair of sterile gloves and helping with a difficult abdominal surgery which could actually lead to the animal dying on the table. I see no reason to change this wording and I actually made a motion to leave it when it was discussed by the board but my motion failed for a lack of a second. I hope the board will reconsider.

I would also suggest replacing “Clipping and scrubbing in preparation for surgery” with “assisting in surgery” to be more comprehensive.

3. Whenever the establishment is closed, all general and working stock of Schedule II through V drugs and any dispensed prescriptions that were not delivered during normal business hours shall be securely stored as required for the general stock.

4. Prescriptions that have been dispensed and prepared for delivery shall be maintained under lock or in an area that is not readily accessible to the public and may be delivered to an owner by an unlicensed person, as designated by the veterinarian.

While the two proposals above are designed to help prevent diversion of drugs meant for our patients, I am concerned that it would also limit the opportunity of assistants or kennel personnel to administer prescribed controlled drugs such as phenobarbital to boarders when a DVM or LVT is not on the premises. It is a common practice for these folks to treat animals in the hospital when they come in to feed and clean on weekends or after hours and provisions need to be made to allow this.

A. Agricultural or equine ambulatory practice. An agricultural or equine ambulatory establishment is a mobile practice in which health care is performed at the location of the animal. Surgery on large animals may be performed as part of an agricultural or equine ambulatory practice provided the establishment has surgical supplies, instruments, and equipment commensurate with the kind of surgical procedures performed. All agricultural or equine ambulatory establishments shall meet the requirements of a stationary establishment for laboratory, radiology, and minimum equipment, with the exception of equipment for assisted ventilation.

B. House call or proceduralist establishment. A house call or proceduralist establishment is an ambulatory practice in which health care of small animals is performed at the residence of the owner of the small animal or another establishment registered by the board. A veterinarian who has established a veterinarian-owner-patient relationship with an animal at the owner's residence or at another registered veterinary establishment may also provide care for that animal at the location of the patient.

1. Surgery may be performed only in a surgical suite at a registered establishment that has passed inspection.

In the proposed regulations above concerning House Call Practices, there is no provision to attend an animal at a place other than “the owner’s home or an establishment registered by the Board”.  Practitioners need to be able to see a patient at a boarding kennel or wherever it is located and the wording should be more like those concerning Ambulatory practice above. It should also not restrict them to only see patients they have seen before and already have a veterinary-owner-patient relationship.  I would suggest clarifying the first sentence to include all locations and delete the second sentence. I do not think the Board is intentionally restricting this but likely has just not thought of the consequences.

The proposal above concerning the restriction on Surgery really needs to be eliminated or modified as well. “Surgery” is a term that can encompass many procedures from lancing an abscess or suturing a small wound under a local to thoracic surgery requiring specialized equipment and numerous personnel. As written above, it prevents a house call practitioner from doing any minor surgical procedures that could easily and safely do in the field. These include lancing of abscesses, draining seromas, or removing small bumps and suturing small wounds under local anesthesia. Again, the practitioner is ultimately responsible for all decisions concerning patient care and he should be allowed to use his professional judgement on how best to treat his patients after discussing it with the owner. I would suggest either eliminating the wording above or modifying it so that it only pertained to surgeries that require general anesthesia.

While I am on the subject of surgery, there are other regulations that restrict surgical procedures to be performed in a room specifically set up for surgery and others that prohibit certain equipment from being in the room. I agree completely that any hospital performing surgery should have a room set up for it but there needs to be a common sense approach to the regulations. As I have said before, the practitioner is ultimately responsible for the results and he should be allowed to use his professional judgement on where and how to perform a specific surgery. There are many surgeries that should only be performed in a sterile room but there are others such as repairing contaminated or infected wounds or lancing abscesses that should not be. Advanced dental extractions are clearly surgical procedures but they should be performed in an area set up specifically for dental procedures where dental equipment and dental x-rays are readily available and not necessarily in an operating room set up for other procedures. Often, more than one type of surgery such as a neuter combined with a dental extraction and teeth cleaning are performed on a single patient.  It makes perfect sense to do both procedures at a single location rather than extending anesthesia to move the patient between two locations in the hospital.

I respectfully ask that the Board review regulations and modify them as needed with these points in mind. It is far better to allow the practitioner to use his best judgement than to create restrictive regulations that are not based on common sense.

Thank you for the opportunity to express my opinions and I hope the Board will find it helpful.

Joseph A. May, DVM

Collinsville, Virginia

I am opposed to the proposed changes to put further limitations on veterinary assistants. Currently, there are not enough available licensed technicians in the state of Virginia, especially in rural areas to accommodate this proposed change. I have worked at King's Mountain Animal Clinic for 28 years and we have had only a few of LVT's work for us in that period, they are hard to recruit to come and stay in our area.  Also, the increased staff costs would increase the cost of care making veterinary medicine unaffordable for many Virginians, especially in rural areas!

I feel it is unrealistic to only have LVT's monitor anesthesia.  How many LVT's are there in Virginia vs how many are needed? We have had a shortage of LVT's in Virginia as long as I can remember and in our neighboring state of Md, one does not have to be liscensed to even perform these duties. That being said, I believe standard of care would dictate that only a liscensed LVT or DVM should be inducing and should always be on hand during anesthetic episodes.  Veterinary Assistants commonly play a role in helping to monitor patients as well as receiving valuable training in this area.  Is it safer to have an LVT performing a dental and trying to monitor anesthesia by themselves or to have an assistant monitoring and recording and conveying information to either an LVT or a DVM? I feel closer attention is payed to the patient when multiple people are involved.  I would propose the Board does not limit the ability of practices to utilize this important part of staffing.

I feel this provision would severely restrict our ability to provide necessary surgical services as licensed techs are in short supply and hard to find.  Many assistants are well trained and have been at their jobs for years.  While we as the veterinarian are ultimately responsible for the patient, having an assistant to monitor allows us to concentrate more on the surgery while still being present should any anesthetic problems arise.  Whil monitoring equipment is helpful and important those machines malfunction more often than attending assistants.  I believe we provide better service to our clients and patients when we can have trained assistants helping us with anesthesia and patient care before during and after surgery/anesthesia.

I am writing to oppose the proposed wording of the veterinary regulation listed below in italics.  While I understand the reasoning behind this proposal, implementation is impractical and at times may actually be detrimental to a patient (in times during an emergency when anesthesia is needed and an LVT is not available).  I feel the regulation should read: "When possible, a licensed technician should intubate and monitor anesthesia (unless a veterinarian chooses to do so themselves).  If an LVT/RVT/CVT are unavailable, a veterinarian should directly oversee (or directly perform when needed) intubation and the monitoring of anesthesia.  In cases where a licensed technician is not available, it is very important for a veterinarian to be present during the entire anesthesia process." - Dr Lauren Kloer

B. Injections involving anesthetic or chemotherapy drugs, subgingival scaling, or the placement of intravenous catheters shall not be delegated to an assistant. An assistant shall also not be delegated the induction of sedation or anesthesia by any means. The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered."

 

As someone who spent the time and effort to go to tech school I am often comflicted when I see the line between tech and assistant blurred.  This is one of those occasions.  I read all of the comments and completely understand the problem, with the shortage of techs.  I do agree assistants can be trained to do basic anesthetic monitoring though I wish it did not have to be this way.  Would you prefer I liscnsed nurse monitor you if you had surgery or just a nurse assistant?  But again I understand the shortage resulting in an unfortunate situation.  So I agree we should allow only trusted assistants with this task however I would never allow an assistant to induce anesthesia or intubate an animal.  Here in Virginia beach we are in the process of developing a tech program locally, I know it won't help in the rural areas much.  Hopefully as the profession grows I hope we can find more ways to keep people in the profession longer through better pay, more education opportunities and overall better job satisfaction.

I am writing to oppose the changes in the following paragraph: Injections involving anesthetic or chemotherapy drugs, subgingival scaling, or the placement of intravenous catheters shall not be delegated to an assistant. An assistant shall also not be delegated the induction of sedation or anesthesia by any means. The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.

It is unrealistic to think all veterinary practices in VA have enough LVT's on staff to have one on the premises at all times. While routine surgeries might be scheduled when a LVT is scheduled to work, emergencies arise at all possible times. Assistants need to be allowed to monitor anesthesia with a veterinarian present in the room. Ultimately the veterinarian is responsible for the anesthesia, but assistants can be adequately trained to monitor anesthesia under direct supervision. Does the board really want to prevent a veterinarian from doing a necessary procedure requiring anesthesia because a LVT is not available? This is compleltey impractical.

I am writing to oppose the changes in the following paragraph: Injections involving anesthetic or chemotherapy drugs, subgingival scaling, or the placement of intravenous catheters shall not be delegated to an assistant. An assistant shall also not be delegated the induction of sedation or anesthesia by any means. The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.

This change would be impossible to implement in many practices due to the limited number of LVT's in Virginia. In practices with numerous LVT's the regulation would dramatically increase surgical costs to the owner.  More importantly the burden of safe anesthetic procedures  should remain under the control of the veterinarian. An appropriately trained assistant is capable of monitoring an anesthetized patient throughout a surgical procedure.

I was present at the Legislative and Regulatory Committee where the change regarding monitoring of sedated and anesthetized patients was discussed and approved.  As I remember it, the discussion was not about what happens during surgery, when licensed staff are present.  The change was proposed in response to complaints regarding deaths which occurred when patients that had not fully recovered from anesthesia were left in the care of an unlicensed individual when the licensed staff left for the day.  Perhaps the concerns of the previous commenters could be resolved by rephrasing the section in question to read “The postoperative monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.”

To Whom It May Concern,

The proposed changes would cause increased economic hardship to the veterinary community by mandating LVT to perform all duties when it comes to anesthesia. Properly trained nursing assistants under the direct supervision of a licensed veterinarian allows many clinics to employ more staff and frees more LVTs to perform more important duties and have more supervision over nursing staff. Veterinary practices throughout the state would have a difficult time replacing all their nursing staff with LVT.

Thank you for your consideration,

Katy Wilson, DVM

As a concerned Virginia veterinarian, who has spent over a decade involved in private clinical practice both as an assistant and a veterinarian, I wish to add my name to the list of my colleagues requesting the Board reconsider the wording and implementation of the underlined passage in the proposed regulation:

18VAC150-20-172. Delegation of duties.

B. Injections involving anesthetic or chemotherapy drugs, subgingival scaling, or the placement of intravenous catheters shall not be delegated to an assistant. An assistant shall also not be delegated the induction of sedation or anesthesia by any means. The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.

As has been amply researched and argued by my colleagues, the supply of Licensed Veterinary Technicians (LVTs) in Virginia is currently woefully inadequate to implement the policy as worded, without having a severe deleterious effect on patient care and the economics of practice.  I can testify firsthand that assistants properly trained in the monitoring of patients under anesthesia (in this case, specifically referring to intubated patients) only enhance efficiency and quality of care.  This is of vital importance in large, busy practices in urban/suburban areas, and can be absolutely essential for practices in rural areas or underserved communities, where LVTs can be few and far between.  Again, as my colleagues have pointed out, to deny practitioners this option would be to unnecessarily divide the attention of veterinarians and licensed technicians away from the immediate care of individual patients, and take away their flexibility to intervene with other patients when required.

Furthermore, implementing this policy now would necessarily require practices to make economic decisions about cutting back on the number of patients served, while simultaneously causing them to cut back on the quality of care provided to avoid being in non-compliance with the proposed rule (the classic example would be using more general anesthesia without intubation).  It seems to me responsible governance would be about promoting both the economic growth of the industry and the value of high-quality care to the public it serves.

Nothing we are counter-proposing is intended to somehow absolve veterinarians and licensed technicians of ensuring the well-being of their patients under general anesthesia.  In fact, we know from experience that well-trained anesthetic assistants only make the quality of medicine and surgery provided better.  We are only stating that, while we appreciate the Board’s intent to recognize the value of LVTs, we find the proposed rule incredibly impractical at this time, given the shortage of licensed technicians and relatively high burn-out rate.

We would suggest amending the proposed rule to read:  “…The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered….”

While I am no longer in private practice, I feel I have plenty of expertise to offer in this argument, and it is a matter near and dear to my heart.  Thank you very much for your consideration.

Jeremy Dubin, DVM

Supervisory Public Health Veterinarian

USDA-Food Safety Inspection Service (Landover, MD Circuit)

As I read the comments made by my colleagues on the proposed changes to anesthetic monitoring, I would like to make comment on their thoughts by just saying 'DITTO'!  However, I think Dr. Dubin covers all the relevant information on this subject, and, Lee Henkel makes a brilliant statement on a slight change in the wording of the regulation.  

Everyone knows it is impossible, in rural Virginia, to have the recommended 'three LVTs for each Veterinarian'. And, even if it were possible to draw LVTs to rural areas, and, then, keep them, it would/could be cost prohibitive. This, in turn, would result in increased costs to the public and, ultimately, reduce the medical care many of our clients provide to their pets.  

The Regulatory Board needs to remember that the Veterinarian is ultimately responsible for the care of the patient.  And, if that Vet has properly trained an assistant in the care and monitoring of an anesthetized patient, the risks to the patient should be minimal, while a Vet is readily available. That is--'on the premises'. It seems that this would maintain and provide 'the standard of care', and would not blur the line of who is ultimately responsible.  

Thank you for your time.

Dr. Sheryl Carls 

February 7, 2017

Dear Virginia Board of Veterinary Medicine,

I am writing to urge that the Board reconsider implementing the proposed changes to 18 VAC 150-20-172 as currently written.   Specifically, I am concerned that limiting anesthesia monitoring of intubated animals to DVMs and LVTs will have the unintended effect of reducing the overall quality of veterinary care in Virginia.

As other commenters have pointed out, Virginia, like many other states, has a shortage of LVTs.  Despite our concerted efforts to recruit LVTs, including a tuition reimbursement program, Banfield’s ratio of LVTs to DVMs is approximately 1:12.  Banfield currently employs 118 DVMs in the state of Virginia and only 16 LVTs.  In contrast, Banfield Hospitals employ 291 veterinary assistants in Virginia.  In those hospitals which do not currently have an LVT, the proposed changes would drastically limit that hospital’s ability to perform surgery and pose an unacceptable compromise to patient care by forcing the DVM to simultaneously perform surgery and monitor anesthesia.

All veterinary assistants at Banfield undergo rigorous training, including training in anesthesia monitoring.  Further, all veterinary assistants who assist with anesthesia monitoring at Banfield do so under the direct supervision of an LVT or DVM.  Prohibiting veterinary assistants from performing a task which they have been performing safely for years under LVT and DVM supervision is unnecessary and will adversely impact the quality of veterinary care in Virginia.  On behalf of Banfield and the veterinary industry I implore the Board to reconsider the proposed changes to 18 VAC 150-20-172.

Sincerely,

Daniel Aja, DVM

Chief Medical Officer

Banfield Pet Hospital

18101 SE 6th Way

Vancouver, Washington 98683

www.banfield.com

There regulations are completely missing the point.

It does not matter who is monitoring the animal, what matters is that they have the critical thinking skills to understand if the animal is having a problem following anesthesia.

And that VA needs to establish a reasonable standard of care for vets that will protect our pets.

Take Molly Mittens case

Molly had a routine spay procedure with anesthesia and her surgery ended at approx. 1130 AM

At 1:30 PM, I was told the surgery went fine and Molly was waking up well

At 4:40 PM, a licenses that lacked any critical thinking ability notes Molly is unresponsive.  This vet does nothing.  She does not call the owner to report the change, she does not assess Molly or do any vital signs or notify a vet with some intelligence.  Instead, she turns off the lights and leaves a sweet innocent 6 month old kitten alone in the dark.  I was never notified or given the opportunity to transfer Molly to a 24 hour vet.  It gets worse.

At 9 PM, a tech checks on Molly and notes she is unresponsive.  Again the tech does nothing.  No call to me, no call to a vet.  The tech again leaves Molly alone in the dark.

In the morning, MOLLY IS FOUND DEAD.  Then i get all kinds of phone calls, work, home and cell.  Too little, too late to save Molly.

Now to add insult to injury.  I filed a complaint with this Board.  And the Board which has the mandate to ensure vets follow a reasonable standard of care, finds this lack of care to be completely appropriate. The vet and tech did nothing wrong.  It is Molly's fault that she is having a reaction to the anesthesia. Of course, that was why she was at the vets so that they could assess her for any problems post anesthesia and then TREAT HER.  How do you blame a kitten for her own death, when the vets failed to do anything for her and try to find out what was wrong or at least do a set of vital signs or check her oxygen levels.  Maybe consider reintubation until she is more awake.  Maybe give a reversal agent.  Those are the kinds of efforts that I as an RN would make if my human patient was not waking up well after surgery.  If I failed to take those actions, I would be negligent.

So the problem is not who monitors the animal, the problem is that this Board has set the care in Molly's case as ACCEPTABLE veterinary care in VA.  There was no wrongdoing.  It is fine to leave a kitten that you have documented twice is non responsive after anesthesia all alone to die and not even call the owner until the kitten is dead.

If the board does not hold vets to a higher standard than this, it is completely irrelevant as to who monitors the pet.  Bring the janitor in or the groundskeepers, they would have done better than Kristen P, licensed vet in VA. Practicing in Front Royal.

If anyone doubts the above facts, please email me at MollyMittens7@gmail.com.  I will be happy to share poor Molly's records and this board's lack of accountability, in my opinion.

Respectfully submitted,

Molly Mittens' Mom, RN, JD 

I feel that veterinary assistants are an essential part of the team that cares for anesthetized patients in veterinary medicine.  They act as another set of eyes while the LVT or DVM is performing the procedure, and allow the LVT or DVM to focus fully on the procedure, resulting in better outome and shorter anesthesia times to the obvious benefit of the patient.  These assistants will also gain experience at the side of the licensed personel, so that they gain ability and also inspiration to want to further their own education.  When supervised by licensed staff, I feel assitants should be able to monitor anesthesia,  and place IV catheters. 

I am writing in response to ‘18VAC150-20-172. Delegation of duties’ proposed changes on the Virginia Regulatory Town Hall website. 

B. Injections involving anesthetic or chemotherapy drugs, subgingival scaling, or the placement of intravenous catheters shall not be delegated to an assistant. An assistant shall also not be delegated the induction of sedation or anesthesia by any means. The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premises until the patient is fully recovered.

- I do not think that the word anesthetic should be taken out as I do think only LVTs or veterinarians should be giving anesthetic injections. However, assistants should be able to monitor patients that are sedated/anesthetized even if they are still intubated. Not every facility has enough LVTs on hand to monitor each sedated patient that is intubated. By limiting this job to only licensed personnel, then will have to find more LVTs which is hard to do in rural Virginia.  The delegation of monitoring sedated/anesthetized patients that are intubated should be given by the veterinarian to either an LVT or assistant that has adequate training to safely monitor an intubated patient. 

C. The following tasks that may be delegated by a licensed veterinarian to a properly trained assistant include but are not limited to the following:

1. Grooming;

2. Feeding;

3. Cleaning;

4. Restraining;

5. Assisting in radiology;

6. Setting up diagnostic tests;

7. Prepping for surgery Clipping and scrubbing in preparation for surgery;

8. Dental polishing and scaling of teeth above the gum line (supragingival);

9. Drawing blood samples; or

10. Filling of Schedule VI prescriptions under the direction of a veterinarian licensed in Virginia.

- The phrase ‘include but are not limited to the following’ should not be removed from the regulations as assistants are trained to do several other tasks and have both the talent and ability to do more than what is listed above. With removal of the phrase, it makes it seem like assistants will only be able to do 1-10 on the list and nothing more. 

Sincerely, 

Hillary Rader, DVM 

King's Mountain Animal Clinic - Collinsville, VA

  In the past couple of years, the Roanoke Valley has had three(one has since reopened) veterinary clinics close. In each of those cases, it has been difficult to impossible for clients and other veterinary clinics to obtain the patients' complete medical records After reading current regulations, it appears that a closing clinic is only required to notify clients if they sell or transfer all of the records to another facility. If they just close, they are not required to notify clients or transfer records.

In the past, this may not have been an issue as veterinary clinics rarely closed and patient records may have been limited to annual exams and vaccines. However, times have changed and economic situations have led to sudden closure of several clinics in our area alone. I am sure this situation is not limited to the Roanoke Valley. In addition, modern medicine and changing relationships with our pets have led medical records to be more complex. Most records include expensive lab tests and advanced diagnostics. Our patients and clients deserve to have access to these records.   

As we are modifying the current regulations, I would like us to develop a protocol for hospitals to follow that would better facilitate access to complete (not just vaccine) medical records for patients when a client closes but does not sell records to another entity.

In addition, I would like to concur with the numerous other comments regarding delegating monitoring anesthesia to a trained unlicensed assistant.  I believe that a trained unlicensed assistant should be able to monitor an ANESTHETIZED patient while under direct supervision of a veterinarian or LVT.  The use of the term anesthesia vs just sedation would be an important distinction in a court of law.  If needed, hospitals could submit a particular training protocol or possibly have assistants take a class or test to prove competence.  

Thank you.

Please feel free to contact me at my office 540-890-8500 if you would like more information.

I am writing to express opposition to the terminology used and implications of changing anesthetic monitoring procedures.  I do not feel that anesthetic monitoring of intubated patients should be limited to LVT's and DVM's only.  Our rural area, yet busy practice, would struggle to practice in line with this type of regulation, as LVT's are very few in number and we have multiple doctors performing surgical procedures at the same time in our practice.  I feel very confident in the ability of many of my assistants to adequately monitor and recover patients, and simply do not see a need for this type of regulation.

My name is Dr. Hiedi Orr.  I have practiced veterinary medicine in the state of Virginia for sixteen years.  I have concerns about the following changes in the regulations concerning the practice of veterinary medicine in Virginia.   Thank you for taking the time to address my concerns.  Please feel free to contact me via email at wvuproud1996@gmail.com or via phone 276-647-3714 if needed.  

1)   18VAC150-20-172

B:  Injections involving anesthetic or chemotherapy drugs, subgingival scaling, or the placement of intravenous catheters shall not be delegated to an assistant.  An assistant shall also not be delegated the induction of sedation or anesthesia by any means.  The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided the veterinarian of licensed veterinary technician remains on the premises until the patient is fully recovered. 

I am opposed to assistants not being able to place intravenous catheters.  If assistants were allowed to place intravenous catheters they would be trained by a LVT or veterinarian.  I feel assistants being able to place IV catheters will benefit the licensed veterinary technicians and veterinarians.  This will free up the licensed veterinary technicians to help in surgery if needed.   My biggest reason for wanting assistants to place intravenous catheters is in  case of an emergency (example :  if there is  only one veterinarian and that veterinarian  and the LVT were working on a patient and another patient presented as an emergency and need an intravenous catheter). 

I am opposed to the words “provided the patient is no longer intubated.”  I feel trained assistants should be able to extubate patients if directed to so by a veterinarian.   We have trained assistants to perform this task when needed.  As veterinarians we are the ones responsible for our patients, thus anything that occurs when they are in our care is our responsibility.  We do not delegate tasks to untrained assistants or LVTs.

C. The following tasks that may be delegated by a licensed veterinarian to a properly trained assistant include but are not limited to the following: 

I am opposed to removing the words “include but are not limited to the following.”  By removing these words you are putting very specific limitations on what procedures can actually be performed by a trained assistant.  Many veterinary clinics, including our own, do not have the luxury of employing several licensed veterinary technicians.   We do, however, train our veterinary assistants so they can be of the greatest benefit to us.  

This comment may only apply to our facility as a teaching hospital.  I request that the line 

Those amendments include (i) clarification that only the veterinarian or licensed veterinary technician has access to Schedule II through V drugs;  could be changed to  (i) clarification that only the veterinarian, licensed veterinary technician, or other licensed medical professionals has access to Schedule II through V drugs;  We employ licensed pharmacists and pharmacy technicians and would appreciate them having access to II through V drugs.   If this is already inferred in the proposed change, then the revision is not needed. 

In 18VAC150-20-130 B the requirement is Prior to allowing a preceptee or extern in veterinary medicine to perform surgery on a patient unassisted by a licensed veterinarian, a licensed veterinarian shall receive written approval from the owner.   In 18VAC150-20-173. the requirement is If a veterinary student, preceptee, or extern is to perform the surgery, the informed consent shall include that information.   These statements may appear to be in conflict as the first requires informed consent on unassisted surgeries, the second infers any  surgeries. A clarification of these two statements may be helpful

As a practice owner in rural Virginia, I am very concerned about the restrictions on duties that can be delegated to an assistant.  Our practice has been actively seeking a liscensed technician for several years but have yet to have one interested in moving to Halifax.  By my interpretation of the proposed rules, our practice would no longer be able to offer surgical services due to a lack of availability of someone to monitor anesthesia.  Furthermore, none of the 3 other practices in our county would be able to either.  Our practice has enjoyed great success utilizing talented, well trained assistants to work along side our doctors.  The assistants do not perform their duties without the doctor present and are trained to communicate with the doctor to provide high quality  care. I feel that the intent of the new regulations is to improve patient care.  However, the end result will be a lack of care provided in rural Virginia.  I strongly suggest removing the proposed restrictions on veterinary assistants duties as I truly believe that it will be in the best interest of the profession as well as the patients.

Below is the corrected  version of the proposed regulatory change and I am writing in support of this change.  I am horrified to read other comments stating that veterinarians and technicians have more important things to do in the course of their busy day than stay on premesis when a patient is recovering from anesthesia.  Seriously?  We are all taught that recovery is one of the most high risk times in an anesthetic episode and clearly there have been enough cases presented to the Board to prompt this clarification.  It seems like common sense, but clearly is not.

For those practitioners who are convinced that their on the job assistants are as well trained as a LVT, perhaps they would be willing to have their cleints sign a consent giving permission for someone who is not licensed/educated specifically in anesthesia monitoring & emergencies to monitor their pet throughout their anesthesia event.  The board is requesting a change in current regs that would require a consent from clients when vet students and vet tech students are working on their pets, so why not include unlicensed, unregulated assistants in that as well?  I expect that the pet owners of Virginia expect better than that!

Is the problem truly that there are not enough LVTs. There are many options for education for LVTs now but people are leaving the profession faster than new LVTs are entering.  Perhaps it is time to stop sticking our heads in the sand and start taking the actions necessary to keep LVTs practicing for more than 4-5 years on average.

I stand with the lisenced technician that taught me, Kris Keane. All her hard work in teaching technicians to become the hard working individual and educated individual she is today should not go unrewarded. As a successful student of hers and a technician in practice for 9 years, if it wasn't for her knowledge that she and the other wonderful D.V.M. at BRCC, I would have not saved as many lives or educated so many people. (Specially my brachycephalic friends) I also have passed on some knowledge in help training two other lisenced technicians that graduated from BRCC and are doing incredible things. Do not allow uneducated people in anatomy to be able to place tracheal tube... as a doctor be more aware of time saving vs. patient priority. Patients should be the right choice.

Below is the corrected  version of the proposed regulatory change and I am writing in support of this change.  I am horrified to read other comments stating that veterinarians and technicians have more important things to do in the course of their busy day than stay on premesis when a patient is recovering from anesthesia.  Seriously?  We are all taught that recovery is one of the most high risk times in an anesthetic episode and clearly there have been enough cases presented to the Board to prompt this clarification.  It seems like common sense, but clearly is not.

For those practitioners who are convinced that their on the job assistants are as well trained as a LVT, perhaps they would be willing to have their cleints sign a consent giving permission for someone who is not licensed/educated specifically in anesthesia monitoring & emergencies to monitor their pet throughout their anesthesia event.  The board is requesting a change in current regs that would require a consent from clients when vet students and vet tech students are working on their pets, so why not include unlicensed, unregulated assistants in that as well?  I expect that the pet owners of Virginia expect better than that!

Is the problem truly that there are not enough LVTs. There are many options for education for LVTs now but people are leaving the profession faster than new LVTs are entering.  Perhaps it is time to stop sticking our heads in the sand and start taking the actions necessary to keep LVTs practicing for more than 4-5 years on average.

Our patients deserve skilled, licensed technicians caring for them during all aspects of their anesthetic experience. Recovery is known to be a very dangerous time- who better to monitor them through this period than a LVT? We are fortunate to have multiple Veterinary Technology programs in the state putting out excellent graduates every year. Online programs are easily available as well. I would suggest that veterinarians start paying a competetive wage and utilizing their LVT's to their fullest extent, in order to keep them in the field longer than 4-5 years. If you have assistants that you feel are so capable, maybe you should step up and help them get through an on line program in order to get their license? There are many ways to increase the number of veterinary techincians in your practice if you really want to. 

I support the board 100%. I can't prescribe medicine, diagnose a patient, or perform surgery as a licensed equine veterinary technician so why should an assistant NOT be limited to what they can do as well? Does my education and passed board exam mean nothing? The board is doing this for the safety of the patient and by doing so is preserving the need for LVTs. And that makes me happy. To those of you who have previously commented disagreeing with the board, SHAME ON YOU. 

I support the proposed delegation of duties regulation changes, for the safety of our patients and the peace of mind of our clients.  If I was being admitted to a hospital for an anesthetic procedure I most certainly would not want a nursing assistant to be monitoring my anesthesia, why should our clients expect less from their veterinarian.  Highly trained assistants who would like to advance their skills should consider entering a Technician program.  There are plenty of quality on-site and on-line programs available in Va.

Anne Norback, LVT

C. The following tasks that may be delegated by a licensed veterinarian to a properly trained assistant include but are not limited to the following.

The phrase ‘include but are not limited to the following’ should not be removed from the regulations as assistants are trained to do several other tasks and have both the talent and ability to do more than what is listed above. With removal of the phrase, it makes it seem like assistants will may only be able to do 1-10 on the list and nothing more. 

I am writing in support of the proposed changes to the regulations. Prior to obtaining my DVM, I worked as one of the "talented, highly-trained assistants" in a practice in Virginia. After completing my veterinary training, I understand that using an unlicensed individual to perform tasks that should be peformed by an LVT placed our patients at risk. I was a conscientious, reliable assitant, but I did not have the proper training and licensing to perform those tasks or troubleshoot any problems that arose. I would suggest that practices currently utilitizing talented assistants to perform these duties should consider supporting those assistants in obtaining their license through an accredited veterinary technology program. Our practice has one assistant enrolled in the part time program at NVCC, and we consider this to be an investment in the future of our practice.  

I do not support section B of 18VAC150-20-172 Delegation of Duties statement saying " The monitoring of a sedated or anesthetized patient may be delegated to an assistant, provided the patient is no longer intubated and provided a veterinarian or licensed veterinary technician remains on premisis until the patient is fully recovered".  During the recovery process following any anesthetic event is the very most risky part of anesthesia.  Research shows that we lose most of our patents in the recovery process of anesthesia usually within 3 hours following an anesthetic event. Veterinarians and Licensed Veterinary Technicians are trained individuals who know the most common and most uncommon things to look for in a patient post anesthesia. I a Licensed Veterinary Technician do not feel comfortable with an assistant recovering any of my anesthetized patients no matter how routine the surgery or anesthesia may be. Should an assistant be able to recover an anesthetized  or be apart of any anesthetic event, they become a trained professional. I honestly do feel that if of this is allowed it will take Veterinary Medicine in the wrong direction.  There does need to be a line drawn between when an assistant is appropriate for certain roles in the veterinary work place. As assistants are vital members of the veterinary community,but they are much more useful in other areas such as animal restraint, blood draws, assisting the Dr in appointments, and many other areas. Please keep trained and educated personnel only in anesthesia. 

Don't get me wrong, I truly value our assistants and many are such strong parts of our team and profession. I began my career as an assistant for nearly 7 years. That being said, these duties should NOT be delegated to an assistant.

Anesthesia is an art- isn't that what we are taught in school? It is more than practical skill. It is more than a set of eyes on a patient. I understand that some practices may think they have the best assistants or training program, but that is not the case for all practices in the state of Virginia- which this regulatory action would govern.

As a technician, we receive the knowledge, anatomy, physiology, pharmacology, and practical skills that allow us to do our jobs. Assistants are not trained as extensively in these subjects. If they are, then they should consider becoming an LVT.

If you were to walk into a hospital and a medical assistant told you they were going to monitor you during anesthesia, I would hope you would have a problem with that.

We just rallied for years to increase our CE requirements to ensure we are up to date with most recent advances and protocols in veterinary medicine, and many technicians complained about that too. How are you going to vouch for your assistants' education when you complain about TWO additional hours of CE for yourself?  If you are a practice owner, or technician in a busy practice, and think there is something more important you can attend to than making sure your patient fully recovers from anesthesia, maybe you are the one that should reconsider your profession.

For those complaining about the technician shortage- perhaps we as technicians should value ourselves, education, and abilities more to increase public awareness of the importance of our jobs... 

Practice owners- consider treating and paying your technicians so they want to stay in the field.

In a perfect world, there would only be DVMs and LVTs, and hopefully we can get there soon.  Unfortunately, with such a demand for LVTs in the state of Virginia, it is just not a reality at this time.  We struggle with this in general and specialty practice alike.  I propose the following:

"A licensed technician or DVM should intubate and monitor anesthesia.  If an LVT is unavailable, a veterinarian should directly oversee the monitoring of anesthesia performed by an unlicensed assistant and the DVM shall be present during the entire anesthesia."