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