BILL ANALYSIS Ķ SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: SB 1199 AUTHOR: Dutton INTRODUCED: February 22, 2012 HEARING DATE: April 11, 2012 CONSULTANT: Moreno SUBJECT : Radiologic technologists. SUMMARY : Permits a radiologic technologist (RT), in administering contrast materials, to use any chemical solutions or equipment in accordance with the hospital or imaging center protocol and that is found to be an acceptable practice by the American College of Radiology (ACR) or other nationally recognized accreditation society. Permits supervised venipunctures on humans or phantom extremity to be counted towards the 10 venipunctures required to deem a RT sufficiently trained. Existing law: 1.Defines "radiologic technologist" as any person, other than a licentiate of the healing arts, making application of X-rays to human beings for diagnostic or therapeutic purposes, as specified. 2.Permits certified RTs with sufficient education and training to perform venipuncture in an upper extremity and to administer contrast materials under the general supervision of a licensed physician. 3.Deems training and education to sufficient if the RT has, among other things, performed 10 venipunctures under supervision. This bill: 1.Permits RTs, in administering contrast materials in order to ensure the security and integrity of the intravenous cannula, to use any chemical solutions or equipment in accordance with the hospital or imaging center protocol and that is found to be an acceptable practice by the ACR or other nationally recognized accreditation society. 2.Permits supervised venipunctures on humans or phantom extremity to be counted toward the 10 venipunctures required Continued--- SB 1199 | Page 2 to deem a RT sufficiently trained. FISCAL EFFECT : This bill has not been analyzed by a fiscal committee. COMMENTS : 1.Author's statement. According to the author, the Radiologic Health Branch (RHB) within the Department of Public Health (DPH) has recently stated that although the law does not specify how practice venipuncture should be performed, the practice should occur on a human being. However, doing so has become increasingly difficult due to concerns over liability and availability of volunteers. By allowing the RT to conduct practice venipunctures on a phantom simulator, it would decrease the need for human volunteers while still ensuring that RTs obtain sufficient practice. 2.Background. According to the website of Caņada College in Redwood City (which has a DPH-approved RT school), a RT is a health care professional who performs diagnostic imaging examinations with the use of X-rays, working directly with patients and physicians. RTs are educated in patient care, radiation safety, radiation protection, image and film processing, anatomy, physiology, patient positioning and examination techniques. RTs often specialize in a particular diagnostic imaging area, such as computed tomography magnetic resonance, mammography, bone densitometry, cardiovascular-interventional and general radiography. As of October 4, 2010-the date of the most recent list of schools that provide RT training that DPH has, there are 35 diagnostic RT schools, 6 therapeutic RT schools, 34 RT fluoroscopy permit schools, and 13 limited permit schools in California. 3.Injecting contrast materials. The ACR Practice Guideline for the Use of Intravascular Contrast Media states that the health care professional performing the injection may be a certified and/or licensed RT, nurse, physician assistant, physician, or other appropriately credentialed health care professional under the direct supervision of a radiologist or his or her physician designee, if the practice is in compliance with institutional and state regulations. Training and proficiency in cardiopulmonary resuscitation are recommended for those who attend to patients undergoing contrast-enhanced examinations. 4.DPH notices. In December 2010, DPH sent a notice to all California-approved radiologic technology and therapy schools stating that, based on legislative intent and enacted law, the SB 1199 | Page 3 RHB determined that the 10 venipunctures required to be considered sufficiently trained must be performed on a human being. The notice further stated that the required venipunctures are to be made under supervision, which infers harm to a human being. DPH stated that puncture techniques may be practiced on a mannequin but the required 10 venipunctures must be performed on a human being. In March 2011, DPH again issued a notice to provide clarification regarding existing statute related to the training required to legally perform venipuncture. DPH required RT schools to provide their venipuncture curriculum to document that the statutory training and education requirements in existing law were being met. Any school that does not meet the education and training requirements for venipuncture is required to incorporate the instruction into their curriculum by January 1, 2013. 5.American Registry of Radiologic Technologists standards. The 2012 American Registry of Radiologic Technologists (AART) certification handbook outlines clinical competency requirements for radiography. With regard to "general patient care," the requirements lay out six patient care activities in which RTs must demonstrate clinical competency, including venipuncture. The handbook states that "the activities should be performed on patients; however, simulation is acceptable if the state or institutional regulations prohibit candidates from performing the procedure on patients." The handbook goes on to further state: The ARRT requirements specify that certain clinical procedures may be simulated. Simulations must meet the following criteria: (a) the student is required to competently demonstrate skills as similar as circumstances permit to the cognitive, psychomotor, and affective skills required in the clinical setting; (b) the program director is confident that the skills required to competently perform the simulated task will generalize or transfer to the clinical setting, and, if applicable, the student will evaluate related images, positioning a fellow student for a projection without actually activating the x-ray beam, and performing venipuncture by demonstrating aseptic technique on another person, but then inserting the needle into an artificial forearm or grapefruit. 6.Other professions. RHB performed a limited survey of training programs for phlebotomy, registered and vocational nursing, SB 1199 | Page 4 physicians, and physician assistants in March 2011. All contacts indicated that simulator phantoms or mannequins are used for familiarizing trainees with equipment use, aseptic techniques, inserting needles, and finding veins. However, all contacts stated that completion of training occurred only after competently performing a number of venipunctures on live persons. The number of required venipunctures ranged from 20 to over 200. 7.RT programs and venipuncture training. A number of directors of RT programs wrote to Committee staff to express concerns over their ability to comply with the training requirements related to venipuncture in current law. Specifically, school staff state that it is very difficult for students to perform venipuncture because many clinical sites where RTs receive training do not permit students to needle stick patients. These school staff indicate that the schools themselves do not have the capacity to have students perform venipuncture and it is a struggle to coordinate between sites to get students the required venipuncture experience. 8.Support. The sponsor of this bill, the California Radiological Society (CRS), states that the ability of students to perform venipunctures on human volunteers has been increasingly difficult due to concerns over liability and availability of volunteers. CRS states that unless the current law is modified to allow the use of simulator phantoms, many schools have indicated that their ability to train RTs will be impaired. In addition, CRS writes that it is necessary for RTs to be allowed to inject materials that are approved by the ACR, other than the actual contrast materials. An example of this would be the use of saline, which in some cases can support the patency of the cannula or port for injection. The Merced College Diagnostic Radiologic Technology Program writes that it is especially disconcerting that RT schools have until the end of this year to be in compliance with existing law as there is no way they can abide by how it reads. The Merced College Diagnostic Radiologic Technology Program further states that, while it is not the standard of practice in all radiology settings, the radiology community would like the statute to allow RTs to inject other substances related to a contrast injection. 9.Policy comments. a. This bill expands the types of materials that can be administered intravenously when RTs are administering SB 1199 | Page 5 contrast materials that are found to be acceptable by ACR or other nationally recognized accreditation society. However, it does not appear that ACR has set any standard. It is unclear, then, what will be the practical impact of this provision. b. AART guidelines on venipunctures state that simulation should only be used if state law prohibits performing venipunctures on humans, which California statute does not do. Additionally, other professions that perform venipuncture, such as phlebotomists, must perform the training venipunctures on human beings. By permitting training venipunctures to be performed on something other than humans, this bill appears to go against national guidelines and is not in line with training standards for other professionals that perform venipunctures. The Committee may wish to consider if it wishes to permit someone to be certified as a RT and perform venipuncture without ever having been required to perform it on a human subject. If so, this bill should define the term "phantom extremity" or use a term that is already defined in statute. c. RT training programs have provided comments to the Committee indicating that in many cases, RTs do not perform venipuncture in their places of practice once they are certified. If this is the case, and it is becoming increasingly difficult to meet the venipuncture training requirements in existing law, the Committee may wish to consider whether it continues to make sense to have venipuncture remain part of their certification requirement. An alternative could be to have a separate certification, whether as part of their initial certification training program or while supervised in a practice setting, for those RTs who will be performing venipuncture as part of their practice. SUPPORT AND OPPOSITION : Support: California Radiological Society (sponsor) California Medical Association Merced College Diagnostic Radiologic Technology Program Four individuals Oppose: None received. -- END -- SB 1199 | Page 6