Forum: The Status of the RCIS

Participants (in alphabetical order): Kenneth A. Gorski, RN, RCIS, FSICP, Secretary, SICP Assistant Manager, Sones Cardiac Catheterization Laboratories, The Cleveland Clinic Foundation, Cleveland, Ohio Marsha Holton, BS, CCRN, RCIS, FSICP Cardiovascular Orientation Programs, Indian Head, Maryland Chris Nelson RN, RCIS, FSICP Treasurer, Cardiovascular Credentialing International Director, Cardiac Education & Technology, Sentara Healthcare, Norfolk, Virginia Doug Passey, RCIS, Secretary, CCI, Chair, Invasive Registry Exam Committee Director, Invasive Cardiology, Ogden Regional Medical Center, Ogden, Utah Elaine Shea, RCS, RCIS, FASE, President, CCI Technical Director, Noninvasive Cardiology Alta Bates Summit Medical Center, Berkeley, California Tracy Simpson, RCIS, FSICP, President, SICP HealthPark Medical Center, Fort Myers, Florida Aaron White, Executive Director Cardiovascular Credentialing International, Raleigh, North Carolina The Society of Invasive Cardiovascular Professionals (SICP) is a not-for-profit organization that has been established to support the highest quality of patient care given by all invasive cardiac cath lab professionals. The SICP has assumed a leadership role in professional practice, and defining a core curriculum for cardiovascular professionals. The SICP is committed to providing educational opportunities, monitoring pertinent legislative issues, and are actively involved in inter-societal relationships including the American College of Cardiology, the Society of Cardiac Angiography and Interventions, the American Society of Radiological Technologists, the American Board of Nursing, and many others. Cardiovascular Credentialing International (CCI) is a not-for-profit corporation established in September 1988, for the sole purpose of administering credentialing examinations as an independent credentialing agency. CCI is the resultant corporation of the merger of the testing components of the National Alliance of Cardiovascular Technologists (NACT), the American Cardiology Technologists Association (ACTA) and the National Board of Cardiovascular Testing (NBCVT). CCI represents the summation of testing processes for the cardiovascular professional that began in the 1960’s. Credentials offered are the RCIS (Registered Cardiovascular Invasive Specialist), RCS (Registered Cardiac Sonographer), RVS (Registered Vascular Specialist), and CCT (Certified Cardiographic Technician). What is the RCIS credential and its current status? Chris Nelson: The RCIS is a unified credential representing the multiple disciplines that contributed to the evolution of our profession. The credential can be acquired by individuals who graduate from an accredited CVT School or by licensed or allied health professionals who meet minimum qualifications to sit for the registry exam. The Registered Cardiovascular Invasive Specialist (RCIS) credential is the only credential which represents attainment of all the fundamental knowledge required to work in a cardiac catheterization laboratory. Cardiovascular Credentialing International (CCI), since 1968, has credentialed over 10,000 cardiovascular technologists and the numbers are growing. I am not sure that the RCIS credential has actually changed from its initial introduction. What I believe we have seen is greater support for people to acquire the credential, which I think is being driven by the National Patient Safety goals, by reimbursement, and by the expectations of patients to have qualified individuals caring for them. Marsha Holton: The RCIS credential is recognized by the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, the American Association of Critical Care Nurses, the American College of Cardiovascular Nurses, the Alliance of Cardiovascular Professionals, and the Society of Invasive Cardiovascular Professionals. Do you feel that the perceptions of the RCIS credential by hospitals, administrators and physicians have also changed? Tracy Simpson: That’s kind of a two-fold question, because your area or region of the country sometimes affects whether or not the RCIS is well-received. A lot of that is physician-driven. It is different in Florida than it was in Ohio, and it’s different in someplace like Texas than it is in states where there are not strong populations of RCISs. Doug Passey: Certain states give more freedom to those with the RCIS credential, whereas other states are more limited as to what they can do. So it’s probably not as well-promoted in some states. To give you an example of the spectrum of acceptance, in the state of Utah, RCISs are allowed to distribute medications with a physician present, and in other states, they are much more limited in what they’re allowed to do. Sometimes that limiting factor doesn’t always give the RCIS a whole lot of benefit. Chris Nelson: It’s important to recognize that the SICP (Society of Invasive Cardiovascular Professionals) was founded at the behest of the SCA&I (Society of Cardiac Angiography & Interventions) and they believe that it is important to have a professional society driving what invasive cardiovascular specialists do. Between that time (the SICP started in 1993), and present, we are beginning to see greater recognition. One of the important things is that the SCA&I has added members of the SICP’s board of directors to some of their key committees, specifically the Cardiovascular Laboratory Technologists Standards Committee and Catheterization Laboratory Standards Committee. Secondly, we can see physician support at all three levels of the triad: we have physician society representatives at the JRC (Joint Review Committee on Education in Cardiovascular Technology), the SICP and the CCI. The most recent addition to CCI’s sponsoring bodies is the American College of Cardiology (ACC). What an amazing opportunity to be able to network directly with the ACC. Marsha Holton: As the recognition of the RCIS continues, the perceptions of the hospital administrators and physician will also develop. The inclusion of another qualified and specifically educated individual to the invasive laboratories will enhance patient care. The needs of the patients in the cardiovascular laboratories are multi-faceted, and the best patient care is delivered by healthcare professionals from many disciplines, whether nurses, radiology technologists, registered cardiovascular invasive specialists, nurse practitioners, physician assistants, or respiratory therapists. All have a specific educational background, and all bring to the lab a specific ability to attend to patient needs. The American College of Cardiology recognizes nursing but not cardiovascular technology (non-paralegal). Are there any plans to change this through the use of physician voices and/or an RCIS task force? Aaron White: The ACC doesn’t have such a membership category in their cardiac care team yet, because they are inaugurating the concept with RNs and PAs. We’ve been told it may be just a beginning; the ACC may want to expand their membership category down the line, but it’s not something they’re going to jump into full force until they know the implications. Tracy Simpson: ACC does recognize the RCIS credential though. Ken Gorski: In 1955, the Inter-Session on Cardiology (which later became the American College of Cardiology) determined the need for specialized assistants for cardiology, because the needs were not being fully met by RNs and RTs. They sent a document to the American Medical Association recommending the creation of the Cardiovascular Technologist. The Invasive CVT is the only health care professional specifically trained in hemodynamics, pharmacology, sterile technique, scrub assisting, EKG interpretation, diagnostic and therapeutic invasive cardiac procedures, film processing, and the function and operation of fluoroscopic (X-ray) equipment. The credential RCIS, offered by Cardiovascular Credentialing International, is recognized as the cath lab credential of choice by the ACC and by the SCA&I, an organization founded by the pioneers of cardiac catheterization, Mason Sones and Melvin Judkins, to assure continued quality and training in the CCL. Aaron White: Yes, the ACC does recognize the credential and has for many years. However, the ACC does have to think about what might happen if they open up their membership to all these other groups. What is that going to do to the other professional societies, like the SICP, or like the ASE, whose membership dollars are focused on those same people? Ken Gorski: The ACC opened up this new category only in 2004, when they first started accepting Registered Nurses, Clinical Nurse Specialists, Nurse Practitioners, and Physician Assistants into a cardiac care associate (CCA) membership category. Like Aaron said, what happens now is that the American College of Cardiology will recognize nursing and physician assistant memberships, but how will that affect the other groups? It’s a very valid point. Aaron White: Dr. Joseph Messer, who is the American College of Cardiology’s representative on CCI’s board (he’s also been on the board previously as the American College of Chest Physicians’ representative) was a Trustee of the ACC when the new membership was adopted and it is his comment that the cardiac care team membership may be opened up one day to other non-physician categories. Again, like the ACC does on many other issues, any decision is going to be very calculated; they’re not going to just jump into it. They know there are other implications, and the ACC doesn’t want to step on anybody’s toes. Can you talk about the U.S. states that do recognize the RCIS credential? Aaron White: Certainly. The issue with recognition is that there is a full spectrum of just how the recognition is implemented in these states. For example, South Carolina has a bill which has just passed, that recognizes the RCIS, but it touches on administering meds, not imaging services. Then you can go all the way to Ohio, where the credential is recognized in a very open way by the administrative codes of the Department of Health. Texas also has a limited licensure with the Department of Health. Florida is an interesting state, because the documentation is pretty sketchy there, but it’s still an open question. There is also Arkansas, which recognizes the RCIS through the Department of Radiological Health Services, and this department provides limited licensure for imagining services. What are some of the goals for the RCIS, and what is being done at present to achieve those goals? Chris Nelson: One of the most important things is the Federal Minimum Standard campaign, or the current AHHS standards, because there are two federal pieces of legislation currently before the House and the Senate, looking at licensing the RCIS. There are two bills before the federal government. HR 1214 (Care Bill) and S 1197 (RadCare Bill). Both the House and Senate Bills direct the U.S. Secretary of Health and Human Services to establish minimum educational and credentialing standards for personnel who plan and deliver radiation therapy and perform all types of diagnostic imaging procedures except medical ultrasound. The SICP is one of 17 sponsoring organizations of the Alliance for Quality Medical Imaging and Radiation Therapy a coalition that represents more than 250,000 healthcare professionals supporting the adoption of these standards. The SICP, JRC-CVT and CCI have worked together to draft the current language for the proposed Department of Health and Human Services regulations speaking to the Standards for Accreditation of Educational Programs for and the Credentialing of Medical Imaging and Radiation Therapy Personnel as they relate to the Invasive Cardiovascular Specialist. Tracy Simpson: From the SICP’s standpoint, our main goal, as well as CCI’s, is obviously to provide credential recognition at some point in the future. I think with all the different credential recognition fires that have been going on over the last several years in various states, we’re slowly moving in that direction. Ken Gorski: I think the first goal, however, would have to be national recognition along the same lines as other allied health professional groups, like the respiratory therapists, the EMTs and radiology technologists. Doug Passey: National recognition of the credential is a very good, productive way of looking at how best to take that next step forward with the RCIS. Chris Nelson: I think we could go so far as to say national and international recognition, because we are working with other societies outside the U.S. (you may have seen some of the Thailand article updates in Cath Lab Digest from the SICP, for example). As far as CCI’s standpoint regarding goals for the RCIS, last year we made the move to computer-based testing. We did that to increase the availability of credentialing exams, and for the benefit of the registrants. We strive to make sure that our exam matches the current job task analysis, so that the exam is aligned with didactic and clinical expectations from a professional practice standpoint. Marsha Holton: I have been part of a team that has presented at the Maryland General Assembly and Advisory Board Meetings with the Physicians Board of Licensure in Baltimore and in Annapolis. I was asked to represent the Society of Invasive Cardiovascular Professionals at these meetings, and to bring to the table the CCI and Society of Invasive Cardiovascular Professionals all information as to the Scope, Standards, and qualifications of those with the RCIS credential. We testified in support of House Bill 1025, which would identify the RCIS as another allied health professional that is then able to work in the cardiac catheterization laboratory under the physician’s supervision. The legislative process is in place. A summer study will be done in Maryland and in the fall of 2005, hearings will be held again, with the affected parties again giving testimony. Why be concerned about achieving international and national recognition for the RCIS prior to licensure? Chris Nelson: Licensure puts the regulation of the credential to the state. That’s not a bad thing, but it may not always be a good thing. If a state chooses to license a credential, whether it be RT, RN or RCIS, they own the credential, they own the process, and they may choose to test the individual differently or regulate profession outside of the current accepted Scope of Professional Practice. Ken Gorski: Each individual state licenses RNs, advance practice nurses, and so on, but each state has their own definitions of what those individuals are allowed to legally do within the confines of that geographical area. Aaron White: We have two, fairly well-established fields of nursing and radiological technologists at work in the cardiac cath lab. When we start throwing around the term licensure, it’s going to defeat a lot of our other purposes. Our main purpose will always be advancement of the field, with the end benefit being increases in the quality of patient care. For example, if RTs out there who don’t want to be RCISs start to feel that that we’re encroaching, we could start turf wars. That is definitely something we want to avoid. The RCIS is an all-encompassing credential of fundamental knowledge in a certain area. Chris Nelson: The reason we’re cautious is that recognition has to come before regulation. We (meaning CCI and the SICP) don’t believe that we have reached everybody in our field so that they fully understand exactly who we are, what we’re capable of doing and what we should be doing. We need to do this collaboratively. As previously mentioned, CCI and the SICP are members of the Alliance for Quality Medical Imaging and Radiation Therapy (AQMIRT). The AQMIRT is working on federal legislation for invasive professionals. CCI is also a member of the Coalition of Quality Ultrasound, which is a group that’s handling the non-invasive end. It’s more important that people really do appreciate who we are and what we can do before we go to the next level. As a professional specialty, it’s important to remember just how young we are when you compare the invasive cardiovascular specialist to the other established professions. We have only been recognized by the Department of Labor since 1983. Marsha Holton: Recognition before licensure allows all participants to have the same vocabulary. For example, in scientific articles, there are key words listed at the beginning that are important for the reader to understand if they are to understand the document. Recognition of the RCIS is the same thing. In order to know what the RCIS stands for, you must have a common bank of knowledge behind the credential, a common scope of practice that individual must possess, and a knowledge that others in the field believe that this credential is the gold standard that identifies the holder as an experienced person. Ken Gorski: One other thing to emphasize as well is that the Registered Cardiovascular Invasive Specialist, or RCIS, itself is a relatively new term, which I believe came into existence about 10 years ago. Prior to that, we had the credential known as the Registered Cardiovascular Technologist, or RCVT; prior to that, it was the Registered Cardiopulmonary Technologist, or RCPT. The RCVT credential was around beginning in the 1980’s, as a result of the registry exam given by CCI’s predecessors (the groups that eventually came together to form CCI). It’s been around for roughly 30 years as a credential. As Chris Nelson mentioned, CCI and SICP are members of the Alliance for Quality Medical Imaging and Radiation Therapy. This multi-disciplinary group has been working closely with the other professional groups on the Federal Consumer Assurance of Radiologic Excellence (CARE) Act, which was reintroduced to Congress this year. The CARE Act will require the Secretary of Health and Human Services to establish minimum standards for training, education, and employment in various imaging areas, such as the cath and EPS laboratories. Why does the grandfathering clause exist (i.e., after a some time in the cardiac cath lab, non-CVT-trained professionals can sit for boards)? Aaron White: Let me say that if an allied health professional has a bachelor’s degree in nursing, then it’s 6 months before they can sit for the exam. If they have an associate’s degree, it’s one year. Chris Nelson: We do not have a grandfathering clause CCI has established minimum qualifications to sit for the registry level exams. We currently support pathways for graduates of accredited schools, graduates of non-accredited schools, licensed and allied health professionals. The qualifications were originally designed to support the many licensed and allied health professionals who were working in the field and who mastered the trade through on-the-job training and continuing education that window of opportunity is closing as the professional societies, hospitals, and law makers are establishing minimum education standards for the professions they represent. CCI is currently reviewing their exam qualifications and we anticipate publishing recommendations to the professional societies this year. Cath Lab Digest received the following comment from a reader: RT(R), nursing, and RRTs have a 2+ year degree and license in the medical field.Why should we have to take another exam? It should be optional if the hospital recognizes the RCIS as important. We have had problems keeping nursing in the CCL field due to the fact they were requested to sit for the RCIS. Can you comment? Ken Gorski: The RCIS exam is a credential that recognizes abilities specific to the cardiac cath lab. It’s no different than a hospital requiring a ICU nurse to be CCRN-certified. It’s no different than an RT working in a CT area to be credentialed with RT(R)(CT). It’s an advanced registry that recognizes your knowledge base in invasive cardiovascular technology. One very important point is that the cardiologist in the catheterization laboratory works with a multi-disciplinary team of assistants to diagnose and treat cardiovascular disease. This team may be comprised of RNs, licensed practical nurses (LPNs), radiologic technologists [RT(R)s], cardiovascular technologists (CVTs), respiratory therapists, and other allied health professionals. The RCIS is an inclusionary exam, open to every member of the cath lab team. Aaron White: That is what the CCI always tries to relay to the individuals who call and ask us why an RT should take this exam or why an RN should take this exam It’s a credential of fundamental knowledge. Chris Nelson: If you go out to SICP’s website (www.sicp.com), and go to the library section, the prelude to the Scope of Practice and the Standards of Care again speaks to recognizing that our profession is founded on a multi-disciplinary approach to patient care. As far as the nurses are concerned, the RCIS credential should carry the same value as any other nursing specialty certification. It’s important, even when considering the previous question about the grandfathering clause, to emphasize that we are a multi-disciplinary group, comprised of RNs, RTs, etc., and over time, we have designed our credentialing in order to be able to accept those individuals. In addition, we are in the process of moving to close that window, and requiring people to attend more accredited programs of education. Ken Gorski: True. If you’ve got an invasive program, you might have a 12-to-18 month program that is basically just invasive cardiology with nothing else. Aaron White: Right. Bill Fischer’s program is 12 months, and an excellent program. Lancaster General College of Nursing and Health Sciences Program Director: William Fisher (800) 622-2544 wlfisher@lancastergeneral.org Cardiovascular Technologist Program Invasive Track, Lancaster, PA Degree: AST Status: Continuing Accreditation Concentration/Track: Invasive The point has been made that people coming into the cath lab have not received the same amount of instruction in hemodynamic monitoring, pharmacology, and radiation safety (the latter is of course not applicable to RTs), as those who are trained in an accredited CVT program. Ken Gorski: That all depends on your institution and location. In Ohio, they are very specific about the type of training required to work in a fluoroscopic area. This includes basic radiation safety and unit-specific equipment training. In the Cleveland Clinic Cath Lab, all our nurses and techs go through the same radiation orientation program, and they have to pass a test that I wrote. The test material is based on a manual put together in the state of Texas, where they have similar requirements. The manual is Minimizing Risks from Fluoroscopic X-Rays by Louis Wagner (University of Texas Houston) and Benjamin Archer (Baylor College of Medicine), both professors of radiologic science. Staff physicians and cardiovascular medicine fellows take the same exam as well, with a couple more detailed questions on the bioeffects of fluoroscopic radiation; some of my fellows have told me the study material has been a great reference for their interventional cardiology boards. All of my cath lab nurses and techs have to go through the same fluoroscopic orientation and pass the same exam. Right now, there is no mechanism to award CEUs to RCIS instructors for the time they spend teaching. Why is that? Chris Nelson: That’s not technically true, although the SICP, to my knowledge, has not established categories for CEs, when you apply for them, unlike the ASRT, which has CEs if you attend, CEs if you write an article meaning, for the person who does the work. It is really more of a development issue, and they have not yet had a chance to put that together. However, most of the programs that we’re involved in are also opened up to RTs, so those faculty members, through the ASRT, are able to get CEs for presenting, and those are widely accepted by CCI, AACN (American College of Cardiovascular Nursing), and so forth. Tracy Simpson: SICP is currently undergoing the rigorous process of CEU approval. We are in midst of putting together the CEU program for approval that we need. The SICP has also spoken with the ASRT and ACCN, and we’re going to closely model how the ASRT and ACCN handle CEUs, so those are things that are in the pipeline. Ken Gorski: The other thing that should be mentioned is that the CCI as a credentialing body and the SICP as a professional group are involved with other organizations and in trying to work cooperatively with them. We’re getting involved with the ACCN, we’re working with the ASRT and other groups on the Federal CARE Act… there is also the benefit of ACC now being part of CCI, and our constant work with the SCA&I. The SICP continues to seek out physician groups, nursing groups, and allied health organizations. Marsha Holton: The Cardiovas-cular Orientation Program, which I put together with Wes Todd, BS, RCIS, is one of the ways staff instructors and preceptors can accrue continuing educational credits (email MarshaSICP@aol.com for more information). The AACN has certified this program for 36 Category A Credits. The program is currently being evaluated by the ASRT for similar credentialing. As these and other programs develop and become credentialed, then the preceptors and instructors that meet the requirements of the associations can be awarded continuing educational credits. What are some ways that individuals could get involved if they’d like to help advance the credential? Ken Gorski: To advance the profession, you need to be involved with professional groups, like the SICP, a group promoting the invasive cardiovascular credential. Getting involved, sitting for the credential and showing people what you can do, are all paths to getting recognition. Go to the professional groups when you have issues and you’re looking for assistance. You can come either asking for help or offering your professional expertise, such as through joining an education committee, legislation committee, and so on. Tracy Simpson: I’m living proof of how the Society can help you. I had issues with recognition in Ohio, and I contacted CCI and the SICP, who were then able to help me. I’m also living proof of how you can get involved it’s through your professional society that you can have a voice and have a place to actually exercise it. Chris Nelson: You could very easily couple our discussion of the RCIS credential with a discussion on education. Most of the groups that I have been involved with who were start-ups or grass-roots organizations, got together because they wanted to meet and educate each other. They then started having monthly meetings where they talked on a variety of topics. Now, because the SICP has moved to state chapters, there is an opportunity for people to receive guidance in developing these local groups. We should be seeing chapters cropping up more and more each day. Tracy Simpson: That’s definitely true. The SICP has chapters in Texas, Indiana, Ohio, Florida, and Connecticut thus far. Marsha Holton: I have been asked to work with the educators at the EURO-PCR conference on this topic. Their interest is that this credential and the educational components be developed to achieve international recognition and standards. This is the first year we have been asked to speak at the European Nurse/Technologist Symposium, and we are very excited about the ability to share experiences and expertise with our European counterparts. SICP

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