Changing Skill Sets: Evolution of the Cardiac Cath Lab Clinical Staff

 Amy Newell is a Vice President with Corazon, Inc., providing a full continuum of services for the heart, vascular, neuro and orthopedic specialties, and offering consulting, recruitment, and interim management services to hospitals nationwide. For more information, visit www.corazoninc.com.  To reach Amy, email anewell@corazoninc.com. 

Each month, Cath Lab Digest features many unique labs from across the country. In most, if not all, of these profiles, specific questions focusing on the cath lab staff are often asked, such as: 

• Does the organization offer continuing education opportunities?
• How is staff competency evaluated, and how often? (And, in our experience, perhaps the most discussed as we work with our client base):
• What licensed personnel work in the cardiac cath lab? 
• Is RCIS (registered cardiovascular invasive specialist) certification required? And if so, are staff incentives in place to assist with test preparation?

Certification, especially within the cardiac cath lab, has become a hot topic in the industry. Certification requirements can range from basic life support (BLS) to advanced cardiovascular life support (ACLS). Specific state nursing board and radiologic technology licensing is quite different, and may vary state-to-state, thus Corazon recommends that cath lab and cardiovascular program leadership work to understand the state-specific licensure requirements. Beyond what we would categorize as “standard” expectations for a cath lab professional is the pursuit to achieve a higher level of excellence, which can be accomplished specifically through the RCIS credential.¹ 

Facilities offering percutaneous coronary intervention (PCI) without on-site open-heart surgery come under greater scrutiny from multiple sources — their competition, the tertiary partner, and their state regulatory body as well. In the case of a community provider with lower case volumes, perhaps quality is under a microscope, though the debate about whether volume impacts quality has been around for many years for all types of organizations, and continues today!  

Further, states that regulate PCI services at facilities without open-heart surgery often have specific criteria that address clinical staff competency and/or training requirements. In Florida, for example, any licensed clinical personnel (e.g., registered nurse [RN], radiologic technologist [RT], etc.) regardless of RCIS certification, must have proof of 500 hours of training at a full service open-heart facility should they choose to work at a site without open-heart services.  

However, why should a program offering full service open-heart surgery be scrutinized any less related to licensed clinical staff or certification? Corazon believes they should not; in fact, all cath lab clinical staff offering PCI services, regardless of on-site open-heart surgery status, should be held to the same standards or expectations — including required or recommended certifications.

In our consulting work across the country, a familiar theme has emerged. Many states possess specific regulatory language for cath lab personnel in facilities offering PCI without on-site open-heart capabilities. As stated above, the state of Florida has a fairly strict requirement in place. But, as recently as 2010, the state of Washington became the first (and at the time of this writing, the only) state with a regulation that formally recognizes and acknowledges the RCIS certification. We believe it is only a matter of time before other states follow suit…and rightfully so.  

Globally speaking, most if not all hospitals with open-heart surgery off-site have incorporated specific expectations of the clinical staff, ranging from clinical competency, licensing requirements, clinical expertise, training, and 24/7/365 availability. Consider “licensure” requirements known to exist in most states for nursing and radiologic technologist personnel. A hospital should likewise encourage cath lab staff to pursue certification that will add value to the skill set and level of care delivery offered. Furthermore, these additional credentials no doubt differentiate the clinician and raise the bar to create increased professional opportunities.   

The RCIS credential is becoming the expectation, mostly due to a natural progression for cath labs to achieve excellence and obtain recognition by national societies such as the American College of Cardiology (ACC) and the Society for Cardiovascular Angiography and Interventions (SCAI). This is a trend that continues to grow — no doubt a major shift from more traditional on-the-job training for cath lab staff. Emergency medical technicians (EMTs), cardiovascular technologists, electrocardiogram (ECG) techs, or even transfers from the operating room used to have the opportunity to learn the responsibilities, skills, and dynamics of the cath lab. But, as healthcare industry and government scrutiny on quality and transparency increases, expectations are changing, which has greatly impacted cardiac cath lab staffing, and as a result, overall operations.   

Recruitment difficulties persist for expert talent in the cath lab; meanwhile, the dynamic within the cath lab has changed: many labs have relied on flexibility for their staff, specifically the ability to “cross-pollinate” team members from one role to another. This approach has been used to even help minimize the on-call burden as well. However, more recently, in our national recruitment experience for the placement of cath lab personnel, we have found that hospitals now usually require a minimum of 3-5 years of previous interventional experience, along with RCIS certification or the guarantee of achievement within 2 years of hiring. Seemingly, on-the-job training is fast becoming an outdated scenario in today’s healthcare environment.  

So, given this industry shift, hospital and cath lab leaders across the country are beginning to mandate RCIS certification. Essentially, this certification not only elevates the individual professionally, but as stated earlier, may afford greater career opportunities. Achieving RCIS certification is not easy; a significant investment of preparation (study) time and costs approximately $350.¹ There are five testing options for clinicians to consider¹: 

• RCIS1 – For individuals with at least two years of experience in invasive cardiovascular technology when applying for the test. A letter from the employer must be given as proof of experience for applicants to move forward with the testing procedure.
• RCIS2 – Requires an associate’s degree in an approved field, as well as one year of work experience in invasive cardiovascular technology. Candidates must provide transcripts as well as a letter of eligibility from their employer.
• RCIS3 – Requires a bachelor’s degree in an approved field as well as six months of work experience in invasive cardiovascular technology. Candidates must provide transcripts and a letter of eligibility from their employer.
• RCIS4 – Requires that the candidate has graduated from an accredited program in invasive cardiovascular technology. Candidates must provide transcripts and a student verification letter.
• RCIS5 – Requires that the candidate has graduated from a different program, has completed a minimum of one year of specialty training, and a minimum of 800 clinical hours. Candidates must provide transcripts, student verification letter, and clinical verification letter.

The Society of Invasive Cardiovascular Professionals (SICP) has always advocated for a higher standard of practice and excellence within the cardiac catheterization laboratory. The RCIS credential is offered through Cardiovascular Credentialing International (CCI), and has been recognized by the national societal bodies such as the ACC and the SCAI as a standard of practice. For years, these organizations have been raising the bar for labs across the country and endorsing the RCIS credential is no exception.

Moreover, flexibility has become an expectation, for programs both with and without on-site open-heart surgery. Indeed, clinical personnel must have the autonomy to move from one role to another within the cath lab team. Having the flexibility for staff to move from a scrub, monitor, and even circulator role (when appropriate) allows for higher morale and greater satisfaction among the staff. This scenario also depends upon local governing bodies and their specific language as to staff limitations within the cardiac cath lab setting. Additionally, a clear understanding of nursing policies and the cath lab “scope of service” is necessary. Our experience proves that these considerations have a direct impact as to “who can do what” within the cath lab setting, not only successfully, with quality outcomes, but legally and ethically as well.   

So, in considering flexibility, clinicians who possess RCIS certification have a greater opportunity to switch roles. The RCIS exam includes an in-depth pharmacologic component, so if state language allows non-nursing personnel to administer medications, possessing the RCIS can facilitate greater skill, as long as internal advanced education and competencies have been met.

In North Carolina, many cath labs are staffed solely with radiologic technologists and no nurses within the procedural suite. Internal advanced education and training provided by the nursing department, along with required competency fulfillment, assures that these clinicians are deemed competent to administer medications and narcotics within the cath lab. In Pennsylvania, with an exception from the Department of Health, along with the advanced education, training, and competency fulfillment, an RT with the RCIS credential can administer medications within the cath lab.  

So clearly, there is no ‘standard’ of practice across the country. In fact, despite state regulations, it remains at the discretion of organizational leadership whether or not to mandate RCIS certification. In some cases, cath lab professionals choose not to sit for the RCIS exam, which could pose challenges if the credential eventually becomes a requirement of the job. Corazon recommends that programs begin to consider this as a requirement for clinicians within the cath lab, and should assist with the financial cost, which can be significant.  

Further, if a clinical career ladder is in place, achieving the credential can serve as a “rung” in moving to a higher position in the organization. Being fully prepared to sit for the RCIS exam can take up to two years; thus, Corazon recommends including a clause in the cardiac cath lab employment agreement that clearly outlines this expectation, along with the appropriate timeline for completion of the RCIS exam.  

For those who possess the RCIS certification, we commend the effort, and hope the vast majority of cath lab professionals will eventually obtain the distinction as well. Corazon believes that cardiac cath labs across the United States offering PCI, whether with or without on-site open-heart surgery, should not only encourage but require clinical cath lab staff to obtain RCIS certification. Such a move can be one step towards the goal of achieving and maintaining the highest level of quality for patients.

Reference

1. Cardiovascular Credentialing International. Registered Cardiovascular Invasive Specialist. Available online at https://www.cci-online.org/content/registered-cardiovascular-invasive-specialist-rcis. Accessed August 21, 2014.