Expanded competencies for the nuclear medicine advanced associate (nmaa) introduction

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15 May 2008


EXPANDED COMPETENCIES FOR THE

NUCLEAR MEDICINE ADVANCED ASSOCIATE (NMAA)

INTRODUCTION

The SNMTS (formerly the Society of Nuclear Medicine Technologist Section) published the first draft of expected competencies for the Nuclear Medicine Advanced Practitioner (NMAA) in March 2007 (1). These competencies were based on existing scopes of practice, knowledge base, and the clinical skills expected of other lateral middle-level providers, primarily Physician Assistants (PA), Radiologist Assistants (RA), and Nurse Practitioners (NP). Results from the 2005 SNMTS physician survey (2) were also used to guide the development of practice areas for the NMAA (3-5).

The first document focused on the desired clinical and administrative skill sets. It was assumed that because these programs would be offered at the graduate level, course work in research methods, ethical and professional issues, and health care systems issues would be included in an institution’s curriculum and so were purposefully omitted from the document. Upon further consideration, the Advanced Practice Task Force decided to expand the original competency list and explicitly outline all the knowledge, skills, and attitudes that should be demonstrated by an advanced practice professional. This decision was prompted by an extensive literature search on curriculum development for graduate level education in the health professions with the intention to more fully align the NMAA competencies with complementary actions and perspectives of other participants in the medical field.

The general concepts included in the competency domains outlined in this document have been embraced by a broad spectrum of health and medical education programs throughout the US and Europe. They are similar to education models promoted by the Accreditation Council of Graduate Medical Education (ACGME)’s “Outcomes Project” (6). This project resulted in the establishment of baseline standards and competencies for medical residents to meet the needs of the modern healthcare system, far surpassing the more traditional roles of dispensing patient care and medical knowledge. Additionally, Project Professionalism, published by the American Board of Internal Medicine, serves as a guide for altruistic and communication characteristics that are also important for instruction and assessment in medical education (7). Accordingly, the Advanced Practice Task Force has added competencies in Interpersonal and Communication, Practice-Based Decision Making, and Professionalism. The section on Administrative Competencies has been renamed Systems-Based Practice. Competencies pertaining to patient care as found in the original General Core Competencies have been outlined and expanded upon in a new competency domain, Patient Care. The remaining competencies in the General Core plus those in the Cardiology, Oncology and Therapy, and Elective Competencies have been combined into a new domain, Clinical Nuclear Medicine.

It is anticipated that NMAAs will be required to demonstrate a high level of autonomy, technical sophistication, advanced clinical knowledge and strong critical thinking and decision-making skills. They will be highly capable and motivated professionals, comfortable with the sciences, seeking increased clinical responsibilities and education at an advanced degree level. The new competencies will more clearly delineate for the profession and the public what can be expected of the practicing NMAA.

NMAAs are projected to work in general nuclear medicine settings as well as in specialty settings, such as oncology and cardiology. The scope of practice for the NMAA is anticipated to subsume many of the patient care and managerial functions currently provided by a wide array of ancillary personnel and will also include advanced knowledge and skills of the practicing nuclear medicine technologist. Additionally, the NMAA could assume certain physician tasks under the discretion of the overseeing radiologist or attending physician. Candidates for NMAA programs would be credentialed by Nuclear Medicine Technology Certification Board (NMTCB) or the American Registry of Radiologic Technologists (ARRT-N) and have clinical practice experience deemed appropriate by institutional admissions committees. The NMTCB and the ARRT have agreed to collaborate for the development of a certification examination for the credentialing of advanced imaging practitioners.



COMPETENCY DOMAINS

The core competencies outlined in this document are intended to serve as a guide in the development of the curriculum for NMAA programs, which will be offered at the master’s degree level. These competencies primarily reflect the clinical tasks of an NMAA but NMAAs may take on additional responsibilities at the discretion of the supervising physician. They were compiled in consideration of tasks required to work with general as well as specific patient populations in diagnostic and therapeutic settings.

These core competencies drive the professional curriculum in terms of content and most importantly, in terms of assessment. The professional curriculum is expected to utilize a competency-based model where responsibilities and functions are defined by clinical competencies integrated with physician interaction and supervision. Education programs will be outcomes based and must provide learning opportunities in each competency domain. Assessment of student achievement in each of the domains should be undertaken at multiple intervals using multiple assessment methods.

The six competency domains are Patient Care, Clinical Nuclear Medicine, Interpersonal and Communication Skills, Practice-based Decision Making, Professionalism, and Systems-Based Practice. Patient Care Competencies are described for general nuclear medicine procedures in all settings. Clinical Nuclear Medicine competencies incorporate general nuclear medicine procedures with specialty competences outlined for cardiology, therapy, and elective competencies for those skills in which some NMAAs may choose to become proficient depending on their practice setting and the evolution of the profession. Interpersonal Communication focuses on the ability to work effectively with others as a member or leader of a health care team or other professional group with an emphasis on demonstrating team communication skills and leadership skills. Practice-based decision making is the ability to analyze practice experience and perform practice-based improvement activities using a systematic methodology and may involve such activities as quality improvement programs, patient safety programs, or grand round conferences. Professionalism encompasses the adherence to ethical principles such as the provision of care, confidentiality, informed consent, autonomy as well as accountability to patients, society, and the profession. Systems-based Practice, formerly known as Administrative Competencies, encompasses many of the quality assurance, accreditation, and coding and billing duties required to those assuming administrative tasks.

PATIENT CARE


  1. Communicate effectively and demonstrate caring, respectful and ethical behaviors when interacting with patients, their families, physicians and other health care professionals. [see Interpersonal and Communication Skills competency domain)




  1. Counsel and educate patients and their families.

    1. Obtain patient informed consent for required procedures according to state law and institutional policy.

    2. Educate patients on pre-procedural preparation and post-procedural care.




  1. Make informed decisions about diagnostic and therapeutic procedures under the direction of the supervising physician and based on patient information and preferences, up-to-date scientific evidence, and clinical judgment.

    1. Gather and evaluate essential information including correlative studies about patients and arrange follow-up as necessary under the direction of the supervising physician.

    2. Perform history and physical examinations

    3. Evaluate findings for contraindications to testing and for indicators of additional patient pathology.

    4. Consult with physician as needed.

    5. Counsel patient and family as indicated.




  1. Determine and implement a plan of care

    1. Use professional judgment to recommend or adapt protocols for procedures to improve diagnostic quality and outcome.

    2. Consult with the supervising physician or appropriate health care provider to determine a modified action plan when necessary.
    3. Report findings to the supervising physicians and patients per protocol.





  1. Order and administer sedating pharmaceuticals under the direction of the supervising physician and monitor patients who are receiving sedating pharmaceuticals as indicated by patient profile and diagnostic or therapeutic procedure as allowable by institutional, state, and federal statutes.




  1. Implement additional requirements for patient care for diagnostic or therapeutic procedures.

    1. Perform patient bladder catheterizations.

    2. Implement additional routes of radiopharmaceutical administration other than IV injection or oral

    3. Monitor vital signs and physiological parameters.

    4. Evaluate the need for contrast media in consultation with the supervising physician.




  1. Provide indicated intervention per patient emergency event.

    1. Provide supportive medical management

    2. Basic life support

    3. Advanced life support

    4. Facilitate transfer to definitive care environment.


CLINICAL NUCLEAR MEDICINE
General Core Competencies


  1. Review requests and physician directives for nuclear medicine procedures.

    1. Review request for imaging procedures per protocol.

    2. Ensure the appropriate diagnostic study has been requested for the clinical presentation in consultation with the referring physician.

    3. Evaluate collaborative laboratory for indications/contraindications.
    4. Order or facilitate adjunctive pharmaceuticals for the imaging procedure under the direction of the supervising physician.





  1. Competently perform clinical nuclear medicine procedures considered essential in the area of practice.

  1. Perform routine nuclear medicine procedures

  2. Perform sentinel node imaging and lymphatic mapping

  3. Prepare patients and ancillary equipment for radiation therapy planning using positron and multimodality imaging systems




  1. Prescribe and administer pharmacologic and nonpharmacologic interventions under the direction of the supervising physician and as indicated by patient profile and diagnostic procedure as allowable by state and federal statutes.

    1. Perform pre-procedure requirements and interventions as may be required.

    2. Perform intra-procedure requirements as may be required.

    3. Perform post-procedure requirements as may be required.




  1. Order complimentary diagnostic procedures as indicated by patient testing results under the direction of the supervising physician.



  1. Analyze results of the procedure and prepare a comprehensive report for the supervising physician.

  1. Assess image quality and other associated data.

  2. Make a preliminary interpretation.

  3. Document initial observations of imaging procedures according to protocol.

  4. Communicate initial observations as per supervising physician discretion.

  5. Report findings to referring physicians and patients per protocol.


Therapy Core Competencies

  1. Review request for radionuclide therapy procedures under the direction of the supervising physician, analyzing the indications, contraindications, complications for therapeutic interventions.


    1. Interpret epidemiological data, research and trends related to incidence and prevalence of cancer.

    2. Identify risk factors for cancer.

    3. Conduct imaging protocols and evaluate images and laboratory values for presence of disease and metastasis.

    4. Evaluate clinical criteria for radionuclide therapy, including expected biodistribution of radiotherapeutic pharmaceutical.




  1. Counsel and educate the patients and their families regarding the proposed therapeutic intervention.

    1. Obtain translator/interpreter services as necessary.

    2. Obtain patient informed consent for required procedures according to state law and institutional policy.

    3. Educate patients on pre-procedural and post procedural care.




  1. Calculate and administer appropriate therapeutic dosage based upon imaging and laboratory results under the direction of the supervising physician.

    1. Calculate radionuclide therapy dose for benign thyroid disease, basing dose selection on accepted standards.

    2. Calculate radionuclide therapy dose for malignant thyroid disease, basing dose selection on accepted standards.

    3. Calculate radionuclide therapy dose for palliative bone therapy, basing dose selection on accepted standards.

    4. Calculate radionuclide therapy dose for non-Hodgkin’s lymphoma, basing dose selection on accepted standards.

    5. Calculate radionuclide therapy dose for polycythemia, basing dose selection on accepted standards.
    6. Calculate radionuclide therapy dose for malignant effusion, basing dose selection on accepted standards.


    7. Calculate radionuclide therapy dose for selective internal radiation therapy (SIRT), basing dose selection on accepted standards.




  1. Order or facilitate adjunctive pharmaceuticals for radiotherapy according to protocol.




  1. Ensure appropriate laboratory work has been completed prior to treatment.




  1. Report procedure to supervising physician according to protocol.




  1. In conjunction with referring and supervising physician, monitor patient and provide post therapy intervention as needed for adverse side effects.


Elective Competencies


  1. Administer radiopharmaceuticals for radionuclide cisternography, cerebrospinal fluid shunt evaluations, cerebrospinal fluid leaks or for intraperitoneal procedures using aseptic technique and radiation safety standards at the discretion of the supervising physician

    1. Explain complete procedure to patient/ family.

    2. Ensure scheduled imaging timeline compliance.

    3. Prepare injection site adhering to predetermined aseptic/ sterile technique.

    4. Conduct a Joint Commission recommended “time out” procedure.

    5. Monitor room, contents and personnel as per institutional Radiation Safety Guidelines.


  1. Participate in image guided biopsy at the discretion of the supervising physician.

    1. Prepare sterile field and biopsy area using aseptic/sterile technique.
    2. Obtain informed consent for biopsy.


    3. Evaluate for complications prohibiting safe biopsy.

    4. Identify appropriate instruments and use according to recommended standards of practice.

    5. Prepare biopsied tissue for pathological examination according to guidelines for specific tissue type, include appropriate transport media slide preparation and documentation.

    6. Close and dress wound according to recommended standards of practice.

    7. Order appropriate follow-up imaging studies appropriate to biopsy site and procedure.

    8. Conduct a Joint Commission recommended “time out” procedure.

    9. Appropriately intervene for complications.

    10. Advise patient of needed follow-up care.




  1. Manage pain and sedation for patients receiving diagnostic testing or therapeutic treatment.

    1. Prescribe pharmacologic and nonpharmacologic interventions as allowable by state and federal statues.

    2. Monitor patient response to sedation and provide intervention according to accepted standards of practice.



Cardiology Competencies

  1. Successfully complete Advanced Cardiac Life Support credentialing.

  1. Assess normal ECG to determine patient safety for stress testing.

  2. Assess abnormal ECG conduction in preparation for stress testing.




  1. Develop procedural policies and standards for pre-cardiac arrest emergencies that might occur within the department as directed by institutional policy and practice standards.
  1. Identify the signs and symptoms of symptomatic bradycardia and symptomatic tachycardia.


  2. Follow a step-by-step course of action for patients who develop asymptomatic bradycardia or tachycardia while in office (before, during or after stress test).

  3. Follow a step-by-step course of action for patients who develop signs and symptoms of bradycardia or tachycardia while in office (before, during or after stress test).

  4. Identify the proper medications and dosages for stable cardiac rhythms.

  5. List contraindications and precautions of common cardiac medications:

  6. Follow a step-by-step approach to handling an ST elevated myocardial infarction (STEMI).

  7. Follow a step-by-step approach to handling a stroke situation.

  8. Follow a step-by-step approach to handling other patient incidents.

  9. Identify and delegate personnel to perform various tasks in preparation for cardiac emergencies.

  10. Incorporate the appropriate federal, state, and institutional guidelines into departmental policies and procedures.


  1. Develop procedural policies and standards for cardiac arrest emergencies that occur within the department as directed by institutional policy and practice standards and provide indicated intervention for a cardiac emergency event.

  1. Establish IV access.

  2. Identify and administer the appropriate medications for commonly occurring cardiac arrhythmias under the direction of the supervising physician.

  3. Perform cardiac compression or defibrillate patient if required.

  4. Facilitate the ordering of labs or other tests as needed for a cardiac arrest event under the direction of the supervising physician.

  5. Facilitate admission of patient to hospital if necessary.


  1. Provide indicated intervention for non-cardiac emergency events.





  1. Manage crash cart for compliance.

  1. Follow the appropriate guidelines in implementing regulation for managing the department’s crash cart.

  2. Inventory crash cart components according to institutional policy.

  3. Properly dispose of expired drugs.

  4. Replace expired drugs.

  5. Perform quality assurance testing on defibrillator and document results.




  1. Take comprehensive patient history and evaluate for patient pathology.

  1. Interview patient and document on department form a complete past and current cardiac history.

  2. Establish NPO compliance.

  3. Evaluate ambulatory ability.

  4. Review non-cardiac history for prevalence to study requested.

  5. Perform physical assessment.




  1. Evaluate patient laboratory biochemical markers relevant to cardiac pathology.

  1. Review most recent laboratory test results relevant to cardiovascular diseases.

  2. Order relevant blood tests if necessary (including pregnancy testing).




  1. Evaluate patient medications for contraindications to stress testing.

  1. Understand contraindications to each type of stress test and evaluate for each.

  2. Review patient medications for contraindications to exercise stress testing.

  3. Conduct preoperative evaluation for orthopedic or other surgery..




  1. Obtain patient informed consent as required for nuclear cardiology procedures according to state law and hospital policy.
  1. Understand the ethical and legal underpinnings of informed consent.


  2. Determine capability of patient to give informed consent.

  3. Explain procedure to the patient, including all components of a valid informed consent.

  4. Obtain the patient’s or guardian’s signature.




  1. Conduct treadmill testing per all protocol options under the direction of the supervising physician.

  1. Prepare patient for exercise protocol.

  2. Determine type of exercise stress test.




  1. Monitor ECG tracings and blood pressure for specific pathology and cardiac events during stress testing.

  2. Use the appropriate termination protocols.

  3. Calculate the Duke Treadmill Score.




  1. Prescribe and administer interventional drugs for pharmacological stress under the direction of the supervising physician.

  1. Explain the indications and contraindications for each pharmacologic stress agent.

  2. Identify the physiological action of each pharmacologic agent as it relates to stress-testing.

  3. Calculate total dose, volume, and dose rate for each of the most common pharmacological stress agents.

  4. Set up drug administration pump.

  5. Prepare pharmacologic agents for administration utilizing sterile technique.

  6. Administer pharmacologic agents.

  7. Monitor the patient’s response to pharmacologic agents and treat patients appropriately in the event of an adverse effect.




  1. Analyze results of the stress test and imaging portion of the examination and prepare a comprehensive report for the supervising physician.
  1. Create a comprehensive report detailing the results of the stress portion of the test.


  2. Examine rotating raw data from both stress and resting image acquisitions and evaluate image quality.

  3. Review data for incidental finding outside of the heart.

  4. Compare and contrast stress vs. resting processed images for perfusion defects.

  5. Determine if the heart-to-lung ratio and TID are abnormal.

  6. Evaluate the wall motion of stress and resting images for ejection fraction and kinetic abnormalities.

  7. Review and evaluate bull’s eye polar maps and summed stress scores.

  8. Create a comprehensive report detailing the results of the imaging portion of the test.




  1. Facilitate or recommend patient-specific cardiac related procedures based on nuclear cardiology examination results (outcomes management) according to the supervising physician.

  1. Order or facilitate scheduling of complimentary diagnostic procedures as indicated.

  2. Identify the clinical pathways as outlined by the AMA/ACC for cardiac disease.


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