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---



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            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 




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            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, 




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            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 




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               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.

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