The CARE Bill: Regulating minimum education and credentialing standards for allied health professionals involved in radiology pr

Cath Lab Digest talks with:

Todd Chitwood, BS, RCIS, FSICP, President Elect of the SICP (Society of Invasive Cardiovascular Professionals) and Co-founder, Oregon Chapter of the SICP

Cindy Daniels, MS, RT(R), President, American Society of Radiologic Technologists

Jeff Davis, RRT, RCIS, FSICP, Society of Invasive Cardiovascular Professionals (SICP) representative to the JRC-CVT (Joint Review Committee on Education for Cardiovascular Technology)

Patti English, RT(R)(CV), MS, RCIS, JRC-CVT (Joint Review Committee on Education for Cardiovascular Technology) representative to the Alliance for Quality Medical Imaging and Radiation Therapy

Ginny Haselhuhn, BS, RT(R)(ARRT), Assistant Executive Director, American Registry of Radiologic Technologists (ARRT)

Christine Lung, CAE, American Society of Radiologic Technologists (ASRT), Director of Government Relations

Chris M. Nelson, RN, RCIS, FSICP, Treasurer, Cardiovascular Credentialing International (CCI); Past President, Society of Invasive Cardiovascular Professionals (SICP)

Why is the CARE Act necessary and important for allied health professionals and patients?

Jeff Davis (JRC-CVT): First, it is our belief that the CARE Bill will improve patient care. Secondarily, in our corner of the cath lab world, it will provide recognition of the credentials deemed appropriate for work in radiation and medical imaging, and this includes the Registered Cardiovascular Invasive Specialist (RCIS) credential.

Chris Nelson (CCI): We have to focus on the intent of the CARE Bill, which directs the Secretary for the Department of Health and Human Services, in consultation with recognized experts in medical imaging to establish standards to ensure the safety and accuracy of medical imaging studies, as well as putting into place standards that pertain to the people performing medical imaging and radiation therapy. That, I believe, is what brought the Alliance together. Everyone (on the Alliance) believes the intent of the bill is commendable. It’s all about providing safe care, accreditation of allied health schools and credentialing.

Cindy Daniels (ASRT): Speaking as someone living in a non-licensure state (one of the very few that remain in the United States), it is imperative for the CARE bill to be adopted. Currently, in Missouri, anyone can perform ionizing as well as non-ionizing procedures without appropriate education/training. For general diagnostics, nuclear medicine, and radiation therapy, you are not required in Missouri to have any type of credential to operate the machinery related any of those procedures. Unfortunately, there is the misperception by patients that the person performing the procedure, giving radiation doses for cancer treatment, is an educated, trained professional. This is not necessarily true in non-licensure, non-credentialing states. The quality of patient care may be compromised. It is not an issue in the hospitals where credentialed medical imaging and radiation therapy professionals are employed. However, there is a concern in the rural communities relating to misdiagnosis or even images that are sub-optimal. There have been instances when the radiologist or physician cannot even use the image to make a diagnosis.

Christine Lung (ASRT): At present, nine states do not license radiography. I believe there are 26 states that currently license nuclear medicine, and 30 states that license radiation therapy. One aspect of the CARE bill that often gets overlooked, except maybe by Congress, is the cost savings that can be attributed to reduction in repeat rates and the number of procedures which can be completed successfully. Each time an image has to be repeated, or if a procedure has to be discontinued and then rescheduled, there is a cost that gets added onto the health care ticket. We estimate that the CARE bill, in its reduction of repeat and diagnostic imaging rates, can save the federal government up to 92 million dollars just in Medicare costs alone.

Ginny Haselhuhn (ARRT): To state ARRT’s reasons for supporting the CARE Bill would be reiterating what has already been said. Some states don’t have any medical imaging regulations; the CARE bill would require their development and a higher standard of patient care. It is ARRT’s mission to promote high standards of patient care by recognizing qualified individuals in medical imaging, interventional procedures and radiation therapy.

Is there any data on the extent of excessive radiation during medical procedures in the U.S.?

Christine Lung (ASRT): When we first started working on the CARE bill in 1998, the FDA had just put out information on fluoroscopy burns suffered by patients going through cardiac catheterization and cardiovascular procedures. The report describes the types and the numbers of radiation burns through fluoroscopy procedures. That information is still resident on the FDA’s website, but there have not been any subsequent studies since those initial numbers were posted. I believe it was the FDA themselves who did that initial study (http://www.fda.gov/cdrh/radinj.html).

Chris Nelson (CCI): Here is a quotation from the amendment to the Public Health Service Act of 2005:

7 of out every 10 Americans undergo a medical imaging exam or radiation therapy...

The administration of medical imaging exams and radiation therapy treatments and the effect on individuals of such procedures have substantial, direct effect upon public health. It is in the interest of public health and safety to minimize unnecessary or inappropriate exposure to radiation due to the performance of medical imaging and radiation therapy procedures by personnel lacking appropriate education and credentials. It is in the interest of public health and safety to have a continuing supply of adequately educated persons and appropriate accreditation and certification programs administered by state governments … Persons who perform or plan medical imaging or radiation therapy, including those employed at federal facilities, or reimbursed by federal health programs should be required to demonstrate competence by reason of education, training and experience.

(Note: The most comprehensive information on the CARE/RadCARE bills can be found in the Government Relations section at www.asrt.org. The quote above is from ASRT’s CARE bill materials.)

I remember one sentinel event in the publication of a particular article in a variety of journals. Cath Lab Digest also reprinted this article. It showed a picture of a patient’s back with a burn. If memory serves me correctly, it was a patient that had a 12-hour EP procedure. While the intent may have been of value, there was definitely some overkill, the results of which certainly got people’s attention. I vividly remember that this article was one of the calls to action for the field during that time.

Is it correct to say that the primary importance of the CARE bill for those working in the cardiac cath lab is in the bill’s acknowledgement of the RCIS credential?

Chris Nelson (CCI): That is the approach we are taking and why we got involved in the Alliance. Some of the benefits just discussed by Christine are not typically things seen in the cardiovascular world. In the cath lab, it’s the physician who is actually administering and managing fluoroscopy, and we rarely bring patients back for repeat exams.

Cost reduction is a salty topic at the moment. Congress stands to gain 2.8 billion in savings over five years from the imaging provision of the Deficit Reduction Act (DRA) of 2005. Reports on over-utilization of imaging services makes imaging vulnerable.

In the overall scheme of the Deficit Reduction Act, that’s small potatoes and an easy target, but for all of us in medical imaging, the cuts that have been proposed are dramatic.

Todd Chitwood (SICP): I would not say that the primary importance is the acknowledgment of the RCIS - however, it is very important that this group of professionals, who have demonstrated that they meet an educational standard through testing and credentialing, are included. After all, the RCIS has a solid education in radiation safety and principles surrounding the use of fluoroscopy in the invasive cardiovascular area. This education and training should not be dismissed; rather it should be properly exploited.

What was the role of the ASRT and then the Alliance in putting together the bill?

Christine Lung (ASRT): ASRT actually started working on this initiative back in the late 1960s. As an organization, ASRT recognized that technologists, back when they were still called x-ray technicians, needed some sort of standardized educational background as well as certification to show that they had the competency to successfully perform medical imaging procedures. This movement that started back in the 1960s came to partial fruition in 1981, when the Consumer-Patient Health and Safety Radiation Act was passed by Congress. The 1981 Act set education and credentialing standards for radiographers, radiation therapists, nuclear medicine technologists, and dental radiographers. However, the standards that were set were only a federal guideline. There was no enforcement and nothing in the legislation requiring states to adopt those standards, or even for the federal government to hold its own programs to those standards.

Fast-forward to 1998, when there were some states who had adopted part of those standards, or a variation of those recommended federal standards. Yet there was still no consistency throughout the country, and still no uniformity in what had been adopted by the participating states. As a result, the ASRT House of Delegates charged the organization with developing a legislative approach to strengthen the provisions in the act and also make it enforceable, meaning we were to come up with some way of holding the federal government responsible for enforcing the standards within their own programs, and hopefully the states as well. The first version of the CARE bill was introduced in the 106th Congress, back in late 2000. This bill dealt with education and credentialing standards but would have relied on the states to take the federal standard and write it into some sort of licensure that would apply in all state jurisdictions. It was during this period that the Alliance also started as well. ASRT at first took the approach that this legislation would affect mostly radiologic technologists; however, as we started investigating further, we realized that medical imaging had really stopped being the domain of traditional radiology. Medical imaging was being used in cath labs, it was being used more in physicians’ offices and different specialties had developed to incorporate that usage in other practice settings. So ASRT started working with cardiovascular technologists, with medical physicists, etc., all groups that eventually joined the Alliance. We were able to take a small, narrowly-focused piece of legislation and turn it into something to benefit everyone involved in the performance of medical imaging.

How many organizations are involved with the Alliance?


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Anonymoussays: March 15.2010 at 11:39 am

RCIS is credentialing that anyone can get once they have worked in an area for a certain number of years. They do not necessarially have to get properly trained in radiation safety. The only proper radiation training that any individual can get is to go through a radiology program. RCIS training program touches only the tip of the iceberg when it comes to understanding radiation and safety during procedures. The CARE bill should require that an individual educated in radiation be present during any radiographic procedure. No ifs, ands or buts.

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Heartteksays: November 15.2011 at 11:20 am

Your statement is a perfect example of the dogma and ignorance that beleaguers this discussion.

1. In order to sit for the RCIS exam one must AT THE VERY LEAST have worked, not just "in any area", but in INVASIVE cardiovascular technology, for a specified time frame (minimum 2 years for those without a medical science degree), AND have this documented by a letter of support and endorsement from either an MD or RCIS-credentialed supervisor.

2. This was designed in the early stages of CCI to offer a pathway for OJT CVT's who had decades of cath lab experience and felt competent to sit for the certification exam. In the last 10 years, the cath tech jobs that have NOT required RCVT or RCIS just to apply, have gone from rare to non-existent. The claim that "anyone" working a few years in a cath lab can become RCIS is like saying anyone with zero education in law can become a lawyer: sure, you just have to pass the bar. Guess what percentage of attorneys do that without a law degree? <.01%

3. I find it typically smug and hypocritical for those trained to Xray bones to claim superiority in the CARDIAC cath lab. For you to claim that RCIS techs, who ARE trained in radiation safety as it pertains to the cath lab (minimizing scatter through minimal distance between patient/source, effective collimation, field sizing, etc), are an unlicensed danger when it is the RT who enters the lab, often as a scrub tech, injecting dye and supporting interventional wires inside coronaries with little or NO idea or education as to the hemodynamic safety requirements and protocols for such INFINITELY more delicate work. If you'd like to swap stats on patient morbidity in cath lab radiation burns in RCIS-assisted caths versus injection/wire/catheter error in RT-assisted caths, I would LOVE to have that debate. ANY invasive cardiologist will agree that tech error in injection of air bubbles, perforation by wire, or even improper sheath pulls FAR outweigh the concerns of radiation exposure in all but the most extreme instances. And this is all without considering the fact that 90% of the flouro and cine done in cath labs is done BY THE GOD DAMN CARDIOLOGIST. What little IS done by RCIS (occasional panning, switching views) is done under direct supervision of the MD, who happens to supersede the RT's authority in patient safety, despite how high you sit on your horse.

You RT's can pretend this about patient safety all you want. We all know it's actually about protecting your turf, and securing your job future in the cath lab. Which is amazingly selfish, considering that RCIS cannot work in any other dept, but YOU have MANY choices. We both have 2 year degrees in our field and substantial credentialing exams. The difference is RCIS spend those 2 years studying the HEART, while your training is spread over CT, Nuc. Med, Mammo, and a dozen other categories that have ZERO to do with cath lab protocol. Thanks for being a part of the ever-expanding egotistical world of allied health arrogance.

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Cardiogirlsays: February 19.2013 at 08:18 am

This is absolutely correct. I couldn't have said it better myself. Gloria Ball, RCIS

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Anonymoussays: June 3.2010 at 17:31 pm

The RCIS is NOT a credential that "just anyone" can get once they have worked in an area for a certain number of years. It is a credential that is studied for just like any other registry ie: the nurse's board. And we were taught radiation safety quite extensively due to the above subject matter. So maybe this "just anyone" RCIS that has been in the cath lab for 16 years can get the RT credential add on since I have had training with several radiologist, not to mention my preceptor was the biggest, baddest rad tech in the country and I could probably pass the RT exam before I passed my RCIS registry, so proper radiation training? Let's compare. Plus, we are all under the physicians supervision anyway and I sometimes question their radiation safety too.

Anonymous--Texas

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Anonymoussays: August 11.2010 at 13:16 pm

Anonymous on August 11, 2010 at 1:05 pm
Schools who offer any medical study should be under the same scrutiny as the students. Quality of teaching should be a priority. On the medical sites, students should NOT be overseers of other students. A qualified Rad tech, CVT tech or nurse should be the person who oversees all actions performed by any student. Remember that no second year student is going to volunteer having contributed to an error of another first year student. Not only does this violate the quality of health care that patients receive but is unfair to both students. Further more, any medical school in question should know their school dress code. I was dismissed from a CVT program for making an error when I was only being supervised by another student. I was also written up for being out of dress code when in fact I was in property dress. This altered my entire life and changed a course I had prepared for years.

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Anonymoussays: February 20.2011 at 19:58 pm

So, I understand you could fail the radiation safety portion and still pass the boards. You cannot do that with the RT exam.

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samuelandersonsays: April 25.2011 at 02:42 am

The Care Bill cannot reduce patient care and it may just assist in improving patient compliance and treatment methodology. This is a fantastic opportunity for the health services to use this Bill to their advantage.

Regards,
Samuel
Patient Compliance

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RCIS in CAsays: November 15.2011 at 11:26 am

1. In order to sit for the RCIS exam one must AT THE VERY LEAST have worked, not just "in any area", but in INVASIVE cardiovascular technology, for a specified time frame (minimum 2 years for those without a medical science degree), AND have this documented by a letter of support and endorsement from either an MD or RCIS-credentialed supervisor.

2. This was designed in the early stages of CCI to offer a pathway for OJT CVT's who had decades of cath lab experience and felt competent to sit for the certification exam. In the last 10 years, the cath tech jobs that have NOT required RCVT or RCIS just to apply, have gone from rare to non-existent. The claim that "anyone" working a few years in a cath lab can become RCIS is like saying anyone with zero education in law can become a lawyer: sure, you just have to pass the bar. Guess what percentage of attorneys do that without a law degree? <.01%

3. I find it typically smug and hypocritical for those trained to Xray bones to claim superiority in the CARDIAC cath lab. For you to claim that RCIS techs, who ARE trained in radiation safety as it pertains to the cath lab (minimizing scatter through minimal distance between patient/source, effective collimation, field sizing, etc), are an unlicensed danger when it is the RT who enters the lab, often as a scrub tech, injecting dye and supporting interventional wires inside coronaries with little or NO idea or education as to the hemodynamic safety requirements and protocols for such INFINITELY more delicate work. If you'd like to swap stats on patient morbidity in cath lab radiation burns in RCIS-assisted caths versus injection/wire/catheter error in RT-assisted caths, I would LOVE to have that debate. ANY invasive cardiologist will agree that tech error in injection of air bubbles, perforation by wire, or even improper sheath pulls FAR outweigh the concerns of radiation exposure in all but the most extreme instances. And this is all without considering the fact that 90% of the flouro and cine done in cath labs is done BY THE GOD DAMN CARDIOLOGIST. What little IS done by RCIS (occasional panning, switching views) is done under direct supervision of the MD, who happens to supersede the RT's authority in patient safety, despite how high you sit on your horse.

You RT's can pretend this about patient safety all you want. We all know it's actually about protecting your turf, and securing your job future in the cath lab. Which is amazingly selfish, considering that RCIS cannot work in any other dept, but YOU have MANY choices. We both have 2 year degrees in our field and substantial credentialing exams. The difference is RCIS spend those 2 years studying the HEART, while your training is spread over CT, Nuc. Med, Mammo, and a dozen other categories that have ZERO to do with cath lab protocol. Thanks for being a part of the ever-expanding egotistical world of allied health arrogance.

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Wadesays: February 28.2013 at 00:43 am

That is fantastically stated. I have said the same thing for years. I am a degreed CVT that has not sat for the RCIS as of yet, but I have spent years precepting new RT's on their role in the Cath Lab. It takes an RT months and months of daily on the job training to get everything that our role is during these procedures. Some get it and become strong assets in the lab, some are merely camera positioners. But.. No RT has ever had to train me how to pan and position X ray in procedures. No RT has ever had to explain how to make radiation safer for both the Patient and Lab staff. I got that in CVT school. Do I know the best position on how to shoot images of a foot fracture? .. NO.. Because I don't need to. This push for the RT's in the cath lab is a joke. In my new lab I am not allowed to pan the table as that has to be done by an RT. No RCIS, No CVT with 8 years of scrubbing and panning and training RT's. This is what the Care Bill hopes to accomplish? The only person benefitting from that Care is an RT.. Who I probably trained. Good job!!! Were obviously headed in the right direction.. Down.

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