Journal of Visceral Surgery (2019) 156, S15—S20

Available online at

ScienceDirect
www.sciencedirect.com

REVIEW

Presence of anesthesiologists and nurses in

the operating room: Liability of surgeons
and health care facilities
M. Fischler a,∗, J.L. Cardin b, T. Faucon c, R. Adam d

a
Anesthesiology department, hôpital Foch, 40, rue Worth, 92150 Suresnes, France
b
Gastro-intestinal surgery unit, polyclinique du Maine, 4, avenue Français-Libres, 53010
Laval cedex, France
c
Hôpital Privé Océane, 11, rue du Docteur Joseph Audic, 56001 Vannes cedex, France
d
Hôpital Privé Sévigné, 3, rue du Chêne-Germain, 35510 Cesson-Sévigné, France

Available online 10 June 2019

KEYWORDS Summary The presence of an anesthesiologist and certified registered nurse anesthesiologist
Anesthesiology; in the operating room remains a topic of discussion in many facilities. This article provides an
Surgery; overview on the legislation and recommendations on this topic and recounts some of the related
Organization; jurisprudence. The opinions of various actors, surgeons, anesthesiologists, anesthesiology-
Rules; intensive care physicians, certified registered nurse anesthesiologists, care-facility directors
Recommendations and insurance companies are included. Based on these elements, we attempt to answer the
question of presence of competence in anesthesiology in the operating room.
© 2019 Elsevier Masson SAS. All rights reserved.

Introduction private, as well as the insurance providers also have input

Surgeons can find themselves in an embarrassing situation
when they operate with only a certified registered nurse
anesthesiologist (CRNA) present in the operating room, or
worse, when no anesthesiology professional is present, and
the surveillance of the patient is left to the responsibility
of a registered nurse. Effectively, the distribution of tasks
and responsibilities between anesthesiologists, CRNA, and
surgeons in the operating room is an ever-recurring source
of difficulties or even adverse events. Yet very precise rules
and regulations exist that will conclusively be referred to in
case of litigation. The healthcare facility, whether public or
∗ does what?’’.
Corresponding author.
E-mail address: m.fischler@hopital-foch.org (M. Fischler).
about the organization of anesthesiology.
The practice of anesthesiology is particular in France in
that there are two distinct professional corps: anesthesi-
ologist/intensive care physicians (hereafter referred to as
anesthesiologists) and CRNA. Indeed, CRNA have laid claim
to autonomy for many years. This request relies heavily on
the recently created University Master standing of CRNA
training and certification (decree No 2014-1511 of December
15 2014) and was meant to solve the demographic prob-
lem that encumbered anesthesiologists in France [1]. While
some turn a blind eye, others support this capacity in the
name of validation of competencies. One of the conse-
quences of this debate is that actual practice varies widely,
a disparity that raises at least two essential questions:
‘‘Who should be present in the operating room?’’ and ‘‘Who

https://doi.org/10.1016/j.jviscsurg.2019.05.008
1878-7886/© 2019 Elsevier Masson SAS. All rights reserved.
S16
Legislation and recommendations
The decree No 94-1050 of December 5, 1994
relative to technical conditions of health care
facility functioning with regard to the
exercise of anesthesiology and modifying the
code of public health care
This decree imposes ‘‘organization that is capable of
handling any complication related to an operation or
anesthesiology at all times’’ and ‘‘continuous clinical
surveillance’’ [2]. Moreover, the operative activity must be
organized: ‘‘The planning of interventions is established
conjointly between the physicians performing the inter-
ventions and physician anesthesiologists, and the person
in charge of the organization of the operating rooms, tak-
ing into consideration the exigencies of hygiene and safety
in the functioning of the operative sector as well as the
possibility of providing post-interventional surveillance’’.
With regard to the pre-operative period, the French Soci-
ety of Anesthesiology and Intensive care (Société française
d’anesthésie-réanimation or SFAR) states: ‘‘The anesthesiol-
ogist, co-responsible for the safety of the patient, should not
accept, except in emergency settings, an operative program
that compromises patient safety in any way. Consequently,
the program is established conjointly by the surgeon and the
anesthesiologist’’ [3].
Decree of competency No◦ 2017-316 of March
10, 2017 relative to nursing acts under the
competence of a CRNA
According to two references in this decree (concerning both
the activity and necessary competences), the CRNA teaching
program has been profoundly modified with regard to mas-
ters and doctorate degrees, and European licensing. Seven
domains of competency are defined, the first five of which
define the role, the missions and prerogatives of the CRNA
in the peri-operative period [4].
The decree of March 10, 2017 [5] recapitulates the out-
lines of the preceding decree [6] with, however, some
important changes and precisions. The CRNA exercises his or
her anesthesiology activity under the exclusive control of an
anesthesiologist/intensive care physician as long as the that
physician: ‘‘had previously examined the patient and estab-
lished in writing the anesthesiology strategy including the
objectives, the choice and the conditions of implementation
of the techniques of anesthesia, and the anesthesiologist is
present on the site where the anesthesia is being performed
and can intervene at any time.’’ This precision defines that
the anesthesiologist physician must be physically present
and excludes any remoteness in clinic or in another room
outside the operating room or the post-operation recovery
room.
The term anesthetic protocol has been replaced by
anesthetic strategy, and must be established by the anes-
thesiologist who provides details with regard to the type
of anesthesia, the techniques of implementation and the
goals to obtain, including, for example, the physiological
limitations. Effectively, the term protocol in nursing ter-
minology means a prescription with pre-defined medication
dosages and chronological order of events without any pos-
sibility of modification or interpretation on the part of the
executor. This term did not conform to the good practice of
M. Fischler et al.
anesthesia, which must be modulable depending on the
surgical procedure, the physiological status of the patient
during the operation and eventually the instructions and
goals set forth by the anesthesiologist.
This legislation confirms the autonomy of the CRNA in
the practice of anesthesia but under the exclusive con-
trol of the anesthesiologist. It also implies that the CRNA
must acquire increasingly demanding competences during
the training period. No longer under the responsibility of
the anesthesiologist/intensive care physician, the CRNA now
practices under his or her own control for any anesthetic
procedure that comes under his or her care.
Thus the CRNA can intervene within the framework of
an anesthesiology procedure established by an anesthesiol-
ogist, and is responsible for:
• the organization and control of the site of anesthesia;
• the analysis of patient status, the evaluation of the risks
related to patient-related factors, surgery and the anes-
thesia;
• the implementation of the anesthesia procedure decided
by the anesthesiologist as appropriate to the setting;
• the maintenance of the patient’s physiological status dur-
ing the operation.
At all stages of an act of anesthesia, the CRNA should
be capable of detecting any anomaly, complication or
deterioration of physiological equilibrium and inform the
anesthesiologist without delay.
The code of medical deontology
Article 32 of the code of medical deontology (article R.4127-
32 of the Code of Public Health) details: ‘‘From the moment
that a physician accepts to personally care for a patient,
this physician is committed to provide conscientious and
devoted care based on sound science, and, if necessary, to
ask for assistance from a competent third party’’. A ‘‘care
contract’’ is established de facto that expresses the tacit
agreement between the patient who confides care to the
physician and the physician who assumes this care. This
applies to all physicians, whether they exercise in public
or private practice [7].
The article 47 alinea 1 of the same Code (article R.4127-
47 of the Code of Public Health) foresees that ‘‘Irrespective
of the circumstances, continuity of care must be assured’’
[8].
The recommendations of the Medical
Profession Council (MPC)
The 2001 MPC recommendations state: ‘‘Anesthesiology is a
medical act that can be provided only by a qualified anes-
thesiologist physician. The CRNA assists the anesthesiologist
in this task but cannot undertake any procedure of anesthe-
sia alone in the absence of a physician who is qualified in
anesthesiology and intensive-care. The CRNA is under the
exclusive responsibility of the anesthesiologist and/or the
chief of the anesthesiology service. No other specialist can
substitute for them and authorize or mandate a CRNA to
exercise alone. The anesthesiologist can entrust the CRNA,
temporarily, under his or her own responsibility, to look
after a patient under anesthesia, as long as the patient
does not present any particular risk, and that the anesthe-
siologist is readily available nearby and at all moments’’
[9].
Anesthesiologists and nurses in the OR
Recommendations with regard to surveillance
of patients during anesthesia (SFAR 1994)
The SFAR recommendations mention ‘‘Any general or local
anesthesia or sedation that may result in modification of
vital functions must be performed and followed by or in
the presence of a qualified anesthesiologist. The anesthe-
siologist can be assisted, if deemed necessary, by another
physician and/or nurse anesthesiologist, in particular at the
beginning or end of anesthesia.’’ [10] Additionally, ‘‘If the
anesthesiologist must leave the operating room, he or she
must entrust the continuation of the anesthesia to another
qualified anesthesiologist. If the patient is entrusted to an
anesthesiologist in training or a CRNA, the anesthesiologist
remains responsible for the act underway and must be able
to intervene without delay. Neither physicians in anesthe-
siology specialty training who are not yet certified nor a
CRNA are allowed to perform any anesthesia procedure in
the absence of qualified anesthesiologist. Their function is
one of assistance or surveillance only’’.
With regard to the role of the CRNA, the SFAR recom-
mends [11]: ‘‘Certified registered nurse anesthesiologists
(CRNA) are only authorized to perform procedures that
fall within their level of competence; their activity should
be commensurate with their qualification. They cannot
substitute for or replace the anesthesiologist whom they
assist’’ . . . ‘‘The composition and number of members of
the anesthesiology team, the distribution of roles, and the
autonomy of the CRNA during the procedure are determined
by the complexity of the projected procedure, the degree
of severity of the disease and the anterior condition of the
patient. This information must be evaluated by the anes-
thesiologist during pre-operative consultation and entered
in the patient’s anesthesia record’’ . . . ‘‘The CRNA exer-
cises in teamwork with the anesthesiologist. The nature
of the CRNA’s task ranges from execution of medical pre-
scriptions to the performance of clearly-indicated precise
tasks, entrusted according to individual competences. The
intervention of one or another party is variable according
to the anesthetic or surgical procedure. The CRNA can, in
the presence of the anesthesiologist, proceed to induction
of general anesthesia in accordance with the order of a
physician or established protocol. The anesthesiologist can
entrust the CRNA to supervise the patient during the anes-
thesia as long as the anesthesiologist remains close nearby
and can intervene without delay. The anesthesiologist must
be immediately and routinely informed of any anomaly.’’ . . .
‘‘In a private institution, irrespective of the employer, the
CRNA exercises his or her activity under the exclusive medi-
cal authority and responsibility of the anesthesiologist’’.
Of note, these SFAR recommendations have not been
revised in spite of the new Decree of Competence for CRNA
(Decree of Competence no 2017-316 of March 10, 2017).
This Decree cancelled the obligation of the presence of an
anesthesiologist during general anesthesia induction. The
anesthesiologist decides in advance whether his or her pres-
ence should be part of the procedure or not.
Jurisprudence
Cases that have gone to court are rare: two of them are
summarized later. They are examples of court cases that
incriminated the surgeon and/or the facility when the anes-
thesiologist was implicated because of his or her absence
from the operating room.
S17
Extended liability of the surgeon
The Court of Cassation reversed the judgement of the Court
of Appeals in one case where cardiac arrest occurred during
a face-lifting procedure when the anesthesiologist was not
in the operating room [12]. The court of Cassation indicated
that, even if perioperative surveillance is the duty of the
anesthesiologist with respect to his or her specialty, the sur-
geon can also be held responsible for overall prudence and
diligence of the procedure. It is up to the surgeon to imme-
diately stop an operation, should the absence of continued
surveillance fail to guarantee patient safety and expose the
patient to risks. The surgeon cannot ignore these risks and,
in fact, such adverse events have actually happened [13].
Extended liability of the health care facility
Intra-operative hypotension complicated by a cerebral vas-
cular accident (CVA), occurred while the anesthesiologist
was absent, having left the CRNA in charge of the patient.
The Court laid down the following elements against the
anesthesiologist and the health care facility: ‘‘It was not
possible to treat the hypotension that occurred at anes-
thetic induction because of the absence of Doctor X from
the operating room. The vascular risk factors that patient
Y presented required a specific surveillance. This was a fla-
grant case of imprudence because of the non-defendable
absence of the anesthesiologist from the operating room
who should have directly managed the patient because of
the risks related to the medical history. This constitutes
a fault against which the anesthesiologist could raise no
argument. The health care facility contended that the fault
against the anesthesiologist could not be imputed to the
institution. However, the court ruled that the facility did
not provide all the necessary means to prevent the patient’s
CVA. The liability of the health care facility was further
undisputedly implicated when the expert testimony under-
scored the absence of any record of any injection made
by the CRNA when hypotension occurred, the absence of
any therapy to measure hypercapnia, or the one-hour delay
between the CVA and the evacuation of the patient from the
operating room’’ [14].
Extended liability of the surgeon and health
care facility
A surgeon scheduled a cardiac surgery without enquiring
whether any anesthesiologist was available. During the oper-
ation, the anesthesiologist left the operating room to take
care of an emergency case; the surgeon, the perfusion spe-
cialist and the CRNA were present when the extra-corporeal
circulation was discontinued, but the CRNA did not resume
ventilation which led to major neurologic damage.
The High Court considered that the health care facil-
ity, the surgeon, the anesthesiologist and the perfusionist
all bore partial responsibility for the onset of the damage.
The medico-legal claim against the health care facility is
particularly interesting. Aside from the consideration that
the surgeon should have checked that the patient was ven-
tilated before stopping the extra-corporeal circulation, he
was condemned for having programmed the operation with-
out making sure that an anesthesiologist would be available
throughout the entire duration of the operation. The health
care facility was condemned for not having guaranteed
that another physician would be available to take care of
S18
emergency cases, as well as for allowing the surgeon to
operate under these conditions [15].
Viewpoints
The viewpoint of the anesthesiologist
Several organizational scenarios can be described.
One anesthesiologist and one CRNA assure the anesthetic
procedure: as indicated in the SFAR recommendations (1st
edition, January 1995) ‘‘The composition and number of
members of the anesthesiology team, the distribution of
roles and the autonomy of the CRNA during the procedure
are determined by the complexity of the projected proce-
dure, the degree of severity of the disease and the anterior
condition of the patient.’’ This implies that for high-risk
anesthesia procedures (risk related to the patient or the
surgical procedure), the team should be composed so that
the patient can be managed under optimal conditions. This
specifically concerns pediatric surgery, major heart surgery,
neurosurgery, thoracic, and vascular surgery, as well as oper-
ations with a high risk of bleeding. Except in emergencies,
a pre-anesthesia consultation, at least 48 hours before the
operation, should allow the anesthesiologist/intensive care
physician to foresee all the human and material elements
necessary for adequate accomplishment of the procedure.
The physician could therefore be blamed for not having
foreseen and provided the ‘‘means’’ with regard to the
‘‘needs’’.
One anesthesiologist and one CRNA assure anesthesia in
two adjacent operating rooms: this scenario occurs com-
monly in practice since many anesthesiologists argue that
it is possible to intervene when an intra-operative compli-
cation occurs by immediately switching positions. This
scenario is not in accordance with the several legislations
and with insurance company opinions cited above, this is
simply a creation of the mind. Two situations are possi-
ble: anesthetic induction and onset of an intra-operative
complication. Anesthetic induction must be performed by
an anesthesiologist: this implies that if an anesthesiolo-
gist is conducting anesthesia surveillance in one room, the
CRNA can be called in to continue the surveillance while
the anesthesiologist goes to the other room to perform the
induction. The two persons can then either remain where
they are or return to their original operating rooms, without
ever depriving the patient of anesthetic surveillance. This
sequence can be repeated up to four to eight times. When
a complication arises during anesthesia where the CRNA is
in charge, the immediate presence of the anesthesiologist is
required and therefore, again, a change of positions. In addi-
tional to these caricatural situations, the anesthesiologist
must assure the transfer of patients to the recovery room,
as well as assess or authorize the discharge of each and
every patient (prerogative of the anesthesiologist). Lastly,
any post-operative orders relative to intra-operative events
must be formulated by the anesthesiologist alone, not the
CRNA.
It is therefore easy to understand that this type of orga-
nization is at best ‘‘acrobatic’’ and is anything but prudent
in the assurance of patient safety. Effectively the pres-
ence of the anesthesiologist is mandatory at the beginning
of anesthesia and/or when any complication arises dur-
ing anesthesia. The physician must be able to intervene
without delay but at the same time not leave another
patient without surveillance. Considering the number of
M. Fischler et al.
interventions, their sequence, the ever-present risk of
anomalies or complications requiring an opinion or inter-
vention of an anesthesiologist, an organizational set-up
consisting of a single anesthesiologist in one room and a
single CRNA in another is completely illusory. The argu-
ment that management can be assured by immediately
switching positions is nothing but trying to defend the unde-
fendable, an imprudent organization and functioning that
is harmful to the continuity of health care and patient
safety.
One anesthesiologist and two CRNAs assuring two simul-
taneous anesthesias in two operating rooms near each other:
this scenario assures the safety of patients in all cases.
An operating room registered nurse assuring the surveil-
lance of an anesthesia: this is often the case of patients
undergoing an operation under peripheral loco-regional
anesthesia. This is absolutely unacceptable.
The surgeon’s viewpoint
In line with the legislation cited above, the HAS has defined
15 key points for better teamwork [16]. Beyond these highly
debated 15 points, it is the overall consideration of patient
care that should be upheld. Specifically, for the surgeon,
there are several notions that must be recalled.
The health care facility can no longer abdicate its orga-
nizational responsibilities to the detriment of physicians.
When the rules of safety are notoriously not respected, the
health care facility cannot pretend to ignore the distortion
of the rules of the art and plead that it is up to the physician
to judge whether he or she can exercise under good condi-
tions. How else can one interpret the routine intervention
of the Judge in medico-legal missions when he or she asks
for clarification as to any violations or negligences . . . in the
functioning or organization of services?
The behavior of all team members and, in particular,
of physicians, is not neutral in terms of reference for the
paramedical personnel who observe and base their atti-
tudes on the physicians, especially when they are requested
to do so. The lack of professionalism of one or several
physicians can distort the exercise of the entire team. A
well-known example is that of ‘‘delegation’’ of anesthetic
surveillance to a circulating nurse when the anesthesiologist
is not present, irrespective of the presence or absence of a
CRNA. Not only is this shifting of responsibilities contrary to
the above-cited legislation, but it enhances the risk of neg-
ligence and errors, for example, in the sponge count at the
end of the operation. Dysfunction of the sort has led to a
criminal litigation of one surgeon [13].
In elective surgery, the legislation imposes the following
obligations:
• the name of the surgical procedure must be clear, without
any semantic blurring or ‘‘forgotten’’ terms that might
induce an erroneous interpretation, particularly as to the
foreseeable duration of the operation;
• verification, of the side or the level of the operation,
whenever appropriate;
• the good installation of the patient, which is performed
under the conjoined responsibility of both surgeon and
anesthesiologist;
• the effective physical presence of the anesthesiologist in
the operating room during the steps that are particularly
at risk: creation of the pneumoperitoneum, especially in
patients with difficult body habitus, or during a delicate
dissection;
Anesthesiologists and nurses in the OR
• useful intra-operative communication should be the rule.
Certainly the permanent presence of an anesthesiologist
or CRNA implies that they be kept informed of any oper-
ative difficulty or delicate operative step. Also it is up
to the surgeon to inform the anesthesiology team of any
unexpected finding, dangerous dissection, bleeding, or
other significant event that should also be noted in the
operative report;
• postoperative management should be decided conjointly,
and theoretically, by pre-determined protocol. However,
a verbal reminder can stimulate personal reflexes and par-
ticipates actively in the training of the younger physicians
or paramedical personnel. This is all the more pertinent in
that the coding of the procedure implicates de facto any
post-interventional act during the first 15 days whether
the patient is still in the hospital or not, irrespectively of
the procedure.
The viewpoint of the CRNA
The well-constructed and precise regulations should allow
the defense of an optimal organization of anesthesia with
rigorous attention to safety.
Aside from specifically complex high-risk procedures,
such as neurosurgery, heart surgery, transplantation surgery,
or pediatric surgery, for which ‘‘two pair of hands’’ are
strongly recommended, the so-called ‘‘N+1 rule’’ can be
retained as a model (three anesthetic professionals for two
operating rooms):
• one anesthesia professional, and, in particular, a CRNA
should be present in every room where anesthesia is being
performed;
• an anesthesiologist, present in the site and supervising
two operating rooms with a CRNA in each room respects
not only the rules of safety and the rules of the art, but
also the regulations.
The viewpoint of the chief executive officer
All health care facilities are under the obligation of provid-
ing means to accomplish their care activities, particularly
in the operating room for surgical activities. From then on,
the direction must ensure that nothing is missing, neither
human nor material resources. In legal terms, the this obli-
gation implies that the person in charge is obliged to make
sure that all possible means have been mobilized to accom-
plish the obliged task. Of note, if all these means have been
mobilized, a poor result can never be retained in a claim.
The HAS has set up certification procedures with regard
to the organization of operative suites. An incomplete anes-
thesiology team is a reason for the experts to sanction or
withhold certification of the health care facility. In this case,
the HAS can transmit the decision to the Regional Health
Agency which in turn can question the facility’s authoriza-
tion to practice surgery.
Anesthesia-related morbidity is still important (minor
complications in 20% of cases, major in 0.5% of cases,
sometimes with permanent damage [17]) given that half
of these complications are avoidable. The simple fact of
having one anesthesiology professional in each operating
room assures the immediate management of any anesthesia-
related adverse event.
Audits conducted by insurance companies of weak points
in health care facilities underscore the regulatory exigencies
requiring the presence of the anesthesiology team in the
operating room (one anesthesia actor per operating room
S19
and at least one anesthesiologist for two operating rooms
(with two CRNAs). This framework must be followed to the
letter, according to legislative fiat and the recommendations
of Learned Societies. It is essential that all operations be
approved by all physicians attending the weekly scheduling
meeting (operative suite head, directors of care, anesthesi-
ologist and surgeon).
Pragmatically, the optimal management of patients
depends on the presence of at least one member of the
anesthesiology team in the operating room from induction to
wake-up as a guarantee of safety and quality of anesthesia
and surgery. Starting from there, the obligation of providing
adequate means must be respected by the chief executive
officers.
The viewpoint of insurance companies
In response to the question ‘‘Are one anesthesiologist and
two CRNAs for two operating rooms sufficient for patient
surveillance during surgery?’’, the Mutuelle d’assurance des
professionnels de la santé (MACSF) insurance company pub-
lished on its website on May 23, 2016 the text that follows:
‘‘As long as the anesthesiologist is ready to intervene at
any moment, he or she can entrust the surveillance of the
patient to a CRNA and manage two operating rooms at the
same time, as long as they are not too far away from one
another’’ [18].
In response to the question ‘‘Can one anesthesiolo-
gist supervise several operating room simultaneously?’’, the
SHAM insurance company published on its website May 28,
2016: ‘‘The supervision of several anesthesia cases simulta-
neously, is not, in itself, contrary to the regulations, as long
as the safety of patients is maintained in case of an adverse
event (anesthesiologist within earshot). Consequently, it up
to the health care facility to determine an organization that
is compatible with the safety of the anesthetized patient.
This being said, and subject to the evaluation of judges, one
anesthesiologist for two operating rooms associated with the
permanent presence of a CRNA at the patient’s side seems
to be an adequate level of safety, with the understanding
that a reinforced medical presence should be available in
case of a particularly high-risk operation. Anything less than
this ratio could compromise patient safety. Effectively, the
greater the number of operating rooms supervised by the
same anesthesiologist, the more the capacity of the anes-
thesiologist to intervene with patients-in-need is reduced.’’
[19].
Malpractice lawyers are familiar with these positions and
know how to use them [20].
Conclusion
This overview regarding the presence of anesthesiologists
in the operating room and the number of rooms that can
be supervised simultaneously shows clearly that the liabil-
ity of all actors is engaged and will be pursued in case of
an adverse event; this is true not only for the anesthesiolo-
gist and the CRNA but also for the surgeon and health care
facility.
Other points should be evoked:
• the pressure to produce, whether medical or financial,
cannot justify non-respect of the rules of safety in anes-
thesiology;
• the patients should be informed of who is in charge of
their surveillance;
S20
• the French Public Insurance Company does not specify
the number of operations an anesthesiologist can simul-
taneously supervise. Taking into consideration the details
above, it is clear that planned oversight of more than
two operating rooms per anesthesiologist would be a very
pejorative element in case of a medio-legal claim;
• Mazzocco et al. showed that behavioral deviations in the
operating room are more strongly predictive of adverse
events than the ASA score [21]. This is an essential ele-
ment for medico-legal expert testimony, because, while
it is well admitted that there is no such thing as zero risk,
the fact that everything possible was effectively sought
and done correctly must be established;
• the answer to these questions may evolve in the future
because of the modifications of the range of activities
and responsibilities of health care providers [22]. For ins-
tance, obstetrical sonography has already been delegated
to midwives that have been trained in the discipline. In
Great Britain, nurses are trained to perform technical acts
and in particular, screening colonoscopy. Legislation must
be changed accordingly.
Disclosure of interest
The authors declare that they have no competing interest.
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