Birth of a Cath Lab Law

For the sake of establishing definitions for this article, the Washington State Department of Health recognizes fields of health care under the category of a license, a certificate or a registry. Registered nurses are licensed while radiation technologists are certified. The American Registry of Radiologic Technologists (ARRT) and the Cardiovascular Credentialing International (CCI) exam for the registered cardiovascular invasive specialist (RCIS) are both national registries and not considered a license. In the state of Washington, passing of the ARRT exam is required to obtain a state certificate for a radiologic technologist. The RCIS exam issued by CCI had no legal significance in the eyes of the state of Washington — until now.

In the fall of 2009, an event occurred that would change the lives of every cath lab registered cardiovascualr invasive specialist (RCIS) in the state of Washington. The Washington State Department of Health (WSDOH) received a complaint filed by a state hospital worker. The complaint raised questions about the legality and liability of cath lab personnel, specifically those holding the RCIS certification and what role they played assisting in cardiac cath lab procedures. 

Taking this complaint seriously, the WSDOH began to look harder at the cath lab scope of practice; specifically, at what duties cath lab staffs are certified to perform. The WSDOH had always been aware of the RCIS played an important role in Washington State cardiac centers but the issue of requiring a formal state certificate had never been addressed until now. Because of the complaint filed in 2009, the employment fate of every RCIS working in Washington State was placed at risk.

The effects of this complaint were so significant, that it reached the Washington State Capitol Building and landed on the desk of State Representative Dawn Morrell (Puyallup, Washington).  It was at that moment Representative Dawn Morrell would become one of the most important figures in the history of the RCIS.

In a 2011 interview, Representative Morrell stated, “I’m not sure people in cath labs (the RCIS) knew how close they were to losing their jobs.”

History of the RCIS in Washington State

Until now the RCIS was not recognized by the State to assist in cardiac procedures. Many Washington State hospitals required some form of license or certification for technologists, technicians or specialists, but when it came to the cath lab, that scope of practice had not been clarified by the WSDOH. 

When assisting the cardiologist, even basic tasks performed by the modern RCIS, such as injecting contrast or inflating a balloon were not covered by any state law. Technology and medical advancements had outpaced the outdated legislation and now it was time to deal with the issue of legal certification.

Previously, cath lab scope of practice had been handled at the level of the individual hospital policy. The WSDOH and hospitals in Washington State understood that individual institutions governed their own scope of practice in cath labs. These duties, however, were never officially blessed by the WSDOH.

One example of how this issue would impact cath lab staff occurred at a state medical center, following the 2009 complaint. WSDOH inspectors directed a RCIS not to return to work until they could obtain a surgical technologist certification. In the eyes of the WSDOH, the acquisition of a surgical technologist certification was a temporary stay and the medical center was informed that practice would not be allowed going forward.

As then Virginia Mason Medical Center cath lab manager, William Sims, RCIS, MBA, noted, “You could apply for a surgical tech certification, but that (scope of practice) is not what takes place in a cath lab.”

The alternatives the WSDOH had for addressing the issue were not clear and the need for a solution placed pressure on state hospitals.

Back in the state capital of Olympia, Representative Morrell immediately grasped the seriousness of the matter. She knew first-hand the value of competent, well-trained cath lab staff and how vital they are to both patient safety and to a hospital’s financial bottom line.

“My take is that if the doctors don’t trust the techs, they won’t come to your hospital. That happened to us for a while.”

Representative Morrell speaks from personal experience, because in her other job (being a Washington State Representative is considered a part-time job) she is an active cardiac cath lab RN for MultiCare Health System’s Good Samaritan Hospital in Puyallup, Washington. With the news of WSDOH placing stricter focus on cath lab liability, executives at MultiCare Health came to Representative Morrell for help. A few calls to the Department of Health revealed to the lawmaker what was at stake.

It is important to understand that this was not a simple fix. In Washington State, the Department of Health does not possess the power to create a certification or license for any field that it deems necessary. Creation of any new certification specifically for the RCIS would require passing a new state law, to be signed by the governor. Compounding the issue were government financial considerations.

There are only 420 individuals in Washington State who hold the RCIS credential. Because of cost, passing a law that would directly benefit such a small number of people would create a financial burden on the WSDOH’s budget due to the cost of enforcement and regulation.

As noted by Representative Morrell, “It would have cost an arm and a leg for your (RCIS) own insurance, and your own discipline pool. It was prohibitive.” In that statement rested the core of the conundrum. Trained cath lab staff may be vital to the safety of State’s cardiac patient population, but the State would lose money by creating a specific certification for the RCIS.

Representative Morrell pondered the issue. Her office was directly across the hall from the Washington State House Chambers, and by opening her door, she could hear the sounds of passionate lawmakers debating where to cut the budget with the least amount of pain.

In winter of 2010, the Washington State legislature was locked in a fiscal battle over a state budget with a record deficit. The State Representative from Puyallup knew her fellow legislators were in no mood to pass a law costing the state more money, no matter how vital the service might seem.

The Solution

Representative Morrell and her staff came up with a solution with the introduction of House Bill 2430 (HB 2430). The genius of the bill lay in its structure. Instead of creating a whole new certification specific to the RCIS, House Bill 2430 proposed to modify the existing radiation technologist law (RW 18.84.) In effect, this bill would add a new category called “Cardiovascular Invasive Specialist” (CIS) into the existing law.

The Washington State Radiologic Technologist Certification law contains specific categories that outline the scope of practice for every category applicable to the radiologic technologist field (MRI, CT, radiation therapy, and so on). Adding the category of Cardiovascular Invasive Specialist (CIS) would allow the Washington State Secretary of Health the legal means to certify anyone working in cardiac cath labs, and remove the question of liability.

The distinction here is important to note. This change would not mean that a CIS was considered a certified radiologic technologist in the eyes of the state. It also did not mean that a cath lab RCIS would be allowed to cross-train into MRI the way a radiologic technologist can. The law simply added the category of CIS to existing law.

If passed, HB 2430 would grant the State Secretary of Health the legal authority to set the scope of practice for the RCIS in Washington hospitals. It would also allow all state hospital cath labs to function under a universal set of standards. No longer would each hospital administration have to worry about which certification/license the WSDOH accepted for staff.

Satisfied with the bill’s language, Representative Morrell introduced it in to legislature for what became the difficult part. This legislative session was short on time, and just because a state representative introduces a bill does not guarantee it will become law, or for that matter, guarantee its getting out of committee. To pass such an obscure piece of legislation in a short congressional session, Representative Morrell needed help.

“I asked the Hospital Association to lobby for the bill, but they told me they had bigger fish to fry. However, they did say they would sign in to the committee as a sign of support.“

There was precious little time to rally support for the bill from other sources.  Email chains among cath lab managers were changing hands by the day. Virginia Mason Medical Center’s administration, for instance, allowed cath lab manager William Sims to utilize staff between cases to contact other cath labs for support of HB 2430. Everyone affected by the bill needed to email their state senator and representative to encourage them to support HB 2430.

Even then, things were happening fast. Word came that in 4 days, on January 11, 2010, the House Committee on Health and Wellness would hear testimony about HB 2430. Representative Morrell needed to muster what support she had quickly in preparation for the hearing.

On the day the bill was introduced for the Committee’s consideration, those few who were able to attend gathered in the House hearing room and introduced themselves. Scott Corson, RCIS instructor from Spokane Community College appeared to testify, along with staff and management from St. Peter’s Hospital in Olympia, MultiCare Health System in Tacoma and Virginia Mason Medical Center in Seattle. There was another surprise appearance that day, brought in by Representative Morrell to support the legislation — The Washington Chapter of the American College of Cardiology (ACC).

During the committee hearings, Daniel P. Fishbein, MD, FACC, President of the ACC (Washington Chapter) testified that the RCIS training and expertise is a vital part of the success and safety of the thousands of clinical procedures done each year in Washington State. Scott Corson testified on the amount of training and hours required by the students to pass the RCIS program. William Sims of Virginia Mason spoke on behalf of the state’s hospitals, testifying for the need of this vital staffing resource and how the loss of the RCIS would impact hospital staffing in the state.

As Dr. Fishbein began his testimony, Committee members from both political parties showed concern as they heard the facts being presented. At one point during the hearing, an exasperated Committee Chairwoman, Representative Eileen Cody, asked William Sims the most poignant question of the day: “How has this (lack of certification and oversight) been allowed to go on so long?”

The HB 2430 ran into formal opposition from the Washington Society of Radiological Technologists (WSRT) and its President-Elect, Pamela Lee.

Ms. Lee’s main opposition was based on the amount of radiation safety training the RCIS students received. She testified that radiation burns are on the rise in cardiac cath labs due to the lack of training.

Following her testimony, there were no questions by the committee to Ms. Lee. 

On January 28, 2009, HB 2430 passed the vote of the full House of Representatives by a vote of 97-0. It was then sent to the Senate Committee on Health and Long Term Care.

Testimony for HB 2430 was heard by the Senate Committee, and the bill was passed by the full State Senate, in a 45-0 vote.

The nation’s first law recognizing the Cardiovascular Invasive Specialist as a certified profession was signed into law by Governor Chris Gregoire on March 17, 2010. 

The Aftermath

For Representative Morrell, the victory stood as one of her biggest accomplishments. The passage of HB 2430 had the rare distinction of passing as a bi-partisan, unanimous victory. “Not all bills come this easy,” she says. “Sometimes they can take up to 10 years to fight their way into law.”

Representative Morrell, a Democrat, was especially thankful to the ACC and was quick to point out that bi-partisan support was also key. “I had (State Representative) Bill Hinkle on the Republican side help me out. He is a paramedic and has dealt with cath labs for years.”

So where do RCISs around the country, facing the same issue, go from here?

House Bill 2430 can have a positive effect across the country in other states. Individual state DOH may recognize the value of the RCIS in cardiac cath labs, but have similar struggles with developing the scope of practice in cath labs. Washington State House Bill 2430 can provide a template for finding ways to solve potential liability issues.

Representative Morrell agrees. “This law can become a template. It happens all the time. For instance, we (Washington State) used the same law passed in Oklahoma to regulate sales of Sudafed. We said ‘Hey, we like that idea. Please send us your legislation.’”

But Ms. Morrell warns that passage of similar legislation in other states may not come as easy as it did in Washington. For such an important field, the RCIS is smaller and less organized nationally than other organizations.

Ms. Morrell suggests that technologists holding the RCIS are going to have to bind together and approach their state representatives in groups. She also suggests RCIS professionals seek out state politicians aware of what goes on in a cath lab and seek the backing of their national organizations.

It is apparent that many things need to come together for legislation like HB 2430 to be passed in other states. This may require coordinated efforts of state hospital associations, DOH in individual states and the power of national organizations such as the Society of Invasive Cardiovascular Professionals (SICP) and the ACC.

RCIS programs should also become involved, since their funding may be at stake. In order to maintain the highest professional standards in America’s cardiac centers, the CCI exam is still the standard for measuring knowledge and competency, and it is these programs that are the pillars of the RCIS.

It is also going to take the knowledge of people who have been there before. “I’d love to help organize this,” said Representative Morrell. No doubt others in the State of Washington feel the same.

In the fall of 2011, the DOH will roll out the announcement as to when the new certification will be required for all Washington State cath lab technologists. As of this writing, Representative Morrell, RN, is no longer in the House of Representatives. She continues her work as a cath lab nurse for Good Samaritan. William Sims, RCIS, MBA, is now the operations manager for the Cardiovascular Procedure Unit at the University of Washington Medical Center. Dr. Fishbein still holds office for the Washington State Chapter of the ACC and is an active practitioner at the University of Washington. Co-authors James McRae, RCIS, and Scott Corson, RCIS, testified at the Senate Hearing.

James McRae can be contacted at I_claudio2000@yahoo.com.