Letter from the Editor

The Scope of Practice in the Cath Lab: Are there limits as to what cath lab staff should do?

Morton Kern, MD Clinical Editor Clinical Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California mortonkern005 @ hotmail. com
Morton Kern, MD Clinical Editor Clinical Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California mortonkern005 @ hotmail. com
At my hospital, [no relation to the university hospital], a scrub person assists in catheter/balloon/stent exchanges over the wire. A scrub person does pullbacks from the pulmonary artery, can and does perform LV grams, inserts sheaths in the femoral and brachial arteries and veins. The scrub person also sutures pacemaker pockets and positions wires into the great coronary vein during EP cases. The scrub person works in conjunction with the attending physician in determining coronary disease (reviewing the findings). Is there a ‘gold standard’ in cath lab for staff responsibilities or professional expectations? From what I understand, in some labs, the experienced techs are essentially doing the entire cath procedure, that is performing vascular access, seating the catheter, performing the angiograms, passing the angioplasty wire, placing the and deploying the stent, and installing the vascular closure device. All this with the physician present or at least nearby. This sounds to me exactly the same as the procedures I would teach a physician in training (e.g., a fellow training in cardiovascular disease program). Technically, almost anyone can learn the manual skills necessary to do a heart cath and related interventions. The issue is not just performance, but accepting responsibility for any and all complications and anticipating, avoiding and managing any adverse events that occur with the procedure, as well as using good judgment to proceed or abort a maneuver. This process is harder to teach, but certainly is expected of the operating physician. This is also why physicians are doing most of a cardiac cath procedure. What is the appropriate range of activities for the non-physician staff member in the cath? Perhaps in some labs, a tech doing the entire procedure, just as a senior cardiology fellow, is appropriate under the specific direct supervision of a physician. In other labs, a division of labor is needed, with nurses having one set of responsibilities, techs having another different set with some crossover and radiographic techs having still another set, with again, limited crossover training. There is no ‘gold standard’ across the nation. Local practice establishes cath lab standards. The reason that there is no gold standard for the scope of what can be done in the cath lab comes from several important interacting competencies and laws: 1) Nurse/tech individual competence; 2) Physician competence; 3) Hospital policies; 4) Health care regulatory laws the most important of which is that it is illegal to practice medicine without a license. It is also important to recall that patients have expectations of the physician who they believe is performing the procedure. It is not ethical to ghost out the job to subordinates. How will you explain your complication to the patient when the physician will not take responsibility for that part of the procedure? Nurse/tech duty requirements can be viewed as tasks within the three stages of the cath experience: 1) Pre-procedure setup and preparation; 2) Critical procedures (the angiogram, hemodynamic study and percutaneous intervention); 3) Post-procedure care (including access site management). 1) Pre-procedure duties consist of checking clinically important aspects related to the patient entering into the lab (consent, labs, indications, complicating conditions like drug or food allergies, pulses and records of prior procedures with their associated problems, or access or contrast reaction). The nurse/tech should be knowledgeable, able to communicate clearly and sympathetically, and compulsive enough to collect this information in order to protect the patient from medical misadventure. Once in the room and on the table, the nurse/tech duties include IV access, groin preparation, ECG monitoring and hemodynamic setups. Pre- and intra-procedural medication knowledge and administration are critical. All personnel in the lab should be familiar with the scope of these activities. Critical procedures begin with the arterial puncture. 2) Critical procedures. The cath is initiated with arterial puncture. As the most common cause of morbidity (injury or complication), this task should be taken on by a physician or by a person acting under the direct supervision of a physician nearby (direct supervision, to me, means within feet, to lay hands on the problem if needed and take all responsibility for the person the physician is supervising). The physician is responsible for everything that happens during the critical procedures, so his competence is always on the line. This is the practice of cardiovascular medicine. The physician’s trust in the lab personnel also is part of his competence. The transfer of critical procedures to competent techs requires time, effort, education and physician trust. The variations on these components form the standard of practice in the lab for that particular case. Non-critical tasks of critical procedures. (A non-critical task during a critical procedure to me means that task that is not required to be done by physician and generally not life-threatening. But recall that anything done wrong or poorly in the lab can potentially be life-threatening.) Performing angiography. Seating angiographic catheters is not very difficult most of the time, but must be done carefully. Most left Judkins catheters can almost seat themselves. However, the right Judkins catheter requires some training to seat. Anyone can be trained to seat most catheters, but recognition and anticipation of features which may lead to a dissection of the coronary ostia or aorta is the key to catheter safety. Under physician supervision, this critical procedure could be delegated but again, a complication with this task becomes life-threatening. Contrast injection during angiography is a non-critical task performed by an assistant or the operator. Hemodynamic studies. Passing catheters can induce arrthymias or rarely, perforate a structure. Pulling back catheters during hemodynamic recording is a non-critical task of a critical procedure. (The pressure wave recordings should be accurately obtained). Percutaneous interventions. Passing angioplasty guidewires is an acquired critical skill. Over time, most trainees can achieve the goal and deliver the wire to the target artery beyond the stenosis. Manipulating the wire and positioning a balloon/stent is also associated with potentially devastating consequences and falls into the task category of critical procedure (needing direct physician supervision). Angioplasty balloon inflation is a non-critical task performed by an assistant or the operator. Special devices. Intraaortic balloon pumps, rotoblators, AngioJets, thrombus aspiration systems, cutting balloons, filterwires, etc., are not straightforward methodologies and require concentrated expert experience to use these devices safely. These device tasks are critical procedures and fall to the physician. However, in some labs, physician experience (and selected device competence) with an infrequently used device may be less than that of the nurse/techs working with the numerous other physicians on a daily basis. What should be the scope of practice in this situation? The physician selecting the device is still responsible for all aspects of its use and complications. He is the one being paid and is the one putting the patient at risk. The nurse/tech and lab itself will be at risk should they take on the placement and use of a specialty device with which the physician is not entirely competent, comfortable and certified. These activities fall outside the scope of nurse/tech practice. Assistance with these critical procedures is needed, but solo or direct performance by a trained tech, even with direct supervision, is questionable, mainly for the reasons that this is part of the practice of cardiovascular medicine and the ethically difficult explanation of complications should they occur. A physician who is not comfortable with a special technique or procedure required in the course of a cath should not be performing a critical procedure which may require this technique. For example, if a physician is not comfortable with a filterwire and has not achieved competence in the device use, he/she should not have a filterwire placed by a tech which requires that individual to perform the critical placement and recovery. If a complication occurs, who takes the responsibility? 3) Post-procedure duties. For vascular closure, the physician is responsible for arterial closure either by compression or closure device. Manual/mechanical access site compression is usually delegated to the staff with indirect physician supervision (indirect supervision indicates the physician is in the area but not immediately in the room). However, in some labs, the nurse/techs are trained on vascular closure devices, certified (and trusted) by the physician and hospital policy, and permitted to close the artery alone, often with the physician in the control room (i.e., indirectly supervised). I believe the scope of practice in any lab can be divided into tasks performed by the nurse/tech without supervision, tasks performed with remote supervision (e.g. vascular closure devices), tasks with direct supervision (e.g. critical procedures such as seating an angiographic catheter) and tasks which should be performed only by physicians (e.g. complex devices). In the future, with policies, procedures and task structures in place, the nurse/tech roles can be expanded and possibly replace more physician tasks, but the balance between risk and benefit to these practices and to our patients must be carefully weighed.