AHA Clarifies When Non-MDs May Supervise Cardiac Stress Tests
DALLAS, TX — Nonphysicians with appropriate training and sufficient experience may safely conduct and oversee cardiac stress tests without a physician being present in the room, but a physician must be there when a high-risk patient is being tested. This recommendation is spelled out in a new AHA scientific statement on the supervision of clinical exercise testing by nonphysicians—which includes clinical exercise physiologists, registered nurses, nurse practitioners, physician assistants, and physical therapists.
"The key take-away is that it's okay to do what we all do anyway," writing group chair Dr Jonathan Myers (VA Palo Alto Health Care System, CA) told heartwire. "The statement provides . . . a license or permission for a nonphysician to conduct . . . an exercise test [in most cases], provided they have the appropriate knowledge, background, skills, and abilities" to do so and are supported by a nearby physician who can evaluate the patient prior to the test or handle any rare medical emergency that may arise.
This society-issued statement supports earlier ones about exercise testing, but it also delves further and "provides guidance for the first time . . . about who should be conducting the exercise test, when the cardiologist should be present for the test, and when they may not need to be present," Myers said.
The statement was published online August 18, 2014 in Circulation.
Can Non-MDs Safely Supervise Stress Tests?
The need for the current statement arose from practice changes in which many exercise tests—and in some centers, most exercise tests—are being administered by nonphysicians, and the supervising physician is less frequently physically present for the testing, the group writes.
Performance criteria and personnel-certification programs for clinical exercise testing have been available from the American College of Sports Medicine (ACSM) for more than 30 years, but AHA/American College of Physicians statements have been directed at physicians, they add.
The current statement spells out essential knowledge, practical experience, and skills required by nonphysician exercise-laboratory personnel and how to acquire this competence.
Based on a patient's level of risk, the statement defines three categories of required physician supervision: the physician must be present in the room where test is conducted; or 30 seconds away (eg, down the hall); or reachable by phone or a page (eg, in another building).
Nonphysician staff should know how to assess a patient's pretest risk of complications and also recognize when they need to stop an exercise test. "Sometimes the resting electrocardiogram will contraindicate the test," Myers said.
The writing group identified high-risk patients as including those with increased risk for CAD instability, moderate to severe valvular stenosis, a history of malignant ventricular arrhythmias, significant pulmonary arterial hypertension/secondary pulmonary hypertension, and questionable conduction disease.
Their main recommendations are:
Myers and the other members of the writing group have no conflicts of interest.
DALLAS, TX — Nonphysicians with appropriate training and sufficient experience may safely conduct and oversee cardiac stress tests without a physician being present in the room, but a physician must be there when a high-risk patient is being tested. This recommendation is spelled out in a new AHA scientific statement on the supervision of clinical exercise testing by nonphysicians—which includes clinical exercise physiologists, registered nurses, nurse practitioners, physician assistants, and physical therapists.
"The key take-away is that it's okay to do what we all do anyway," writing group chair Dr Jonathan Myers (VA Palo Alto Health Care System, CA) told heartwire. "The statement provides . . . a license or permission for a nonphysician to conduct . . . an exercise test [in most cases], provided they have the appropriate knowledge, background, skills, and abilities" to do so and are supported by a nearby physician who can evaluate the patient prior to the test or handle any rare medical emergency that may arise.
This society-issued statement supports earlier ones about exercise testing, but it also delves further and "provides guidance for the first time . . . about who should be conducting the exercise test, when the cardiologist should be present for the test, and when they may not need to be present," Myers said.
The statement was published online August 18, 2014 in Circulation.
Can Non-MDs Safely Supervise Stress Tests?
The need for the current statement arose from practice changes in which many exercise tests—and in some centers, most exercise tests—are being administered by nonphysicians, and the supervising physician is less frequently physically present for the testing, the group writes.
Performance criteria and personnel-certification programs for clinical exercise testing have been available from the American College of Sports Medicine (ACSM) for more than 30 years, but AHA/American College of Physicians statements have been directed at physicians, they add.
The current statement spells out essential knowledge, practical experience, and skills required by nonphysician exercise-laboratory personnel and how to acquire this competence.
Based on a patient's level of risk, the statement defines three categories of required physician supervision: the physician must be present in the room where test is conducted; or 30 seconds away (eg, down the hall); or reachable by phone or a page (eg, in another building).
Nonphysician staff should know how to assess a patient's pretest risk of complications and also recognize when they need to stop an exercise test. "Sometimes the resting electrocardiogram will contraindicate the test," Myers said.
The writing group identified high-risk patients as including those with increased risk for CAD instability, moderate to severe valvular stenosis, a history of malignant ventricular arrhythmias, significant pulmonary arterial hypertension/secondary pulmonary hypertension, and questionable conduction disease.
Their main recommendations are:
In most cases, clinical exercise tests can be safely supervised by properly trained nonphysician healthcare professionals who are fully trained in cardiopulmonary resuscitation and supported by a nearby physician skilled in exercise testing or emergency medicine who can make pretest risk assessments and deal with any complications.
Nonphysician exercise-laboratory personnel who supervise exercise testing should have advanced training or certification such as that from the ACSM.
Physicians and nonphysicians who supervise cardiac stress tests should perform a minimum of 200 tests to establish proficiency and should do 50 tests a year to maintain proficiency.
For high-risk patients, a trained supervising physician must be in the room during exercise testing.
Nonphysician exercise-testing personnel must be capable of screening for and identifying high-risk patients and alerting the supervising physician.
Clinical exercise facilities should have an emergency medical response plan and personnel should take part in periodic emergency drills.
Nonphysician healthcare professionals bring different, valuable skills related to exercise science and patient care to the team, but the supervising physician is the final authority for the safety of the cardiac stress tests and the quality of the test interpretation.
Myers and the other members of the writing group have no conflicts of interest.
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