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



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  1. Demonstrate team communication and leadership skills to work effectively with others as a member or leader of a health care team or other professional group.

  1. Demonstrate leadership skills by leading a group project to successful completion.

  2. Communicate with referring physician to assure appropriate examination selection, including actions to be taken if the requested procedure appears to be inappropriate.

  3. Collaborate with other health care team members to improve service delivery.

  1. Protect and preserve personal and confidential information of others to which access is provided.

  1. Adhere to privacy and regulatory standards and requirements regarding the accountability and protection of patient information.

  2. Identify potential abuses of confidential patient information.

  3. Describe the challenges associated with maintaining the confidentiality of patient information stored in computer systems and transmitted via networks.

  1. Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills.

  1. Listen to the “patient’s story,” extract important details from the history taking, and provide information to their patients in an understandable way.

  2. Demonstrate effective interviewing skills for patient assessment.

  3. Demonstrate effective communication skills with and provide psychosocial support to specific groups of people, such as the terminally ill, physically or emotionally impaired, culturally diverse patient, families, and colleagues.
  4. Demonstrate effective age-specific and gender-specific communications.

  5. Be receptive to the clinical significance of the patient’s personal beliefs and values for adaptation of an exam protocol or departmental policies.

  1. Demonstrate emotional resilience and stability, adaptability, flexibility and tolerance of ambiguity and anxiety.

  1. Maintain composure in all situations.

  2. Refrain from negative conversations

  3. Demonstrate self-awareness of personality traits.

  1. Follow appropriate protocol in resolution of conflict, exhibiting proper restraint when presented with potentially volatile situations.

  1. Maintain comprehensive, timely, and legible records for medical, legal, quality improvement and financial purposes.

  1. Maintain appropriate protocol, courtesy, tact, and confidentiality in business communication, both written and oral.

  1. Demonstrate an appropriate level of communication skills when orally presenting professional or scholarly work.

  1. Demonstrate technical writing ability in a variety of venue, including scholarly writing and business communications.

  1. Write an abstract according to published standards.

  2. Prepare a poster for presentation at a professional conference.

  3. Write scholarly articles.

  4. Develop patient procedure protocols.

  5. Develop department policies.

  6. Write business correspondence such as business letters, memos, or internal reports.

  7. Prepare reports, such as a needs assessment or progress report.

  8. Develop action plans for quality improvement projects.
  9. Develop patient education materials.

  1. Apply concepts of teaching and learning theories in design, implementation and evaluation in the education of patient, family, colleagues and the community.


  1. Track and analyze processes, procedures and outcomes using appropriate statistical and/or qualitative techniques.

  1. Use the evidence-based medicine (EBM) process of asking, acquiring, appraising, applying, and assessing to improve clinical practice.

  2. Analyze practice organization and management and perform practice based improvement activities.

  3. Develop a personal program of self-study and professional growth.

  1. Use benchmarking analysis and adjust processes, procedures and operations for comparison with published standards of care.

  1. Follow a systematic process for identifying and implementing best or better practices.

  2. Follow professional standards of practice and work within the NMAA scope of practice to improve patient care and safety and protect the public.

  1. Critically evaluate current literature and extant research to assess the effectiveness of diagnostic and therapeutic procedures.

  1. Identify credible sources of information.

  2. Determine applicability of information; clarifying patients’ questions and misunderstandings about procedures, conditions, or treatment options based on what they may have read.

  3. Use findings from literature and benchmarks to design and initiate appropriate research to investigate a given clinical situation in order to arrive at an optimal solution.
  4. Apply knowledge of research design and statistical methods to appraise the literature.

  1. Use feedback and observations to verify that changes were implemented to optimize patient care delivery and outcomes were effective

  1. Use information technology to effectively access, collect, analyze and disseminate data.

  1. Use current information technology and other sources to efficiently locate and retrieve relevant information from credible sources.

  2. Follow ethical principles in using information that may be sensitive.

  3. Be aware of appropriate regulations or legislation involving information sharing, storing, protecting, or deleting sensitive information.

  1. Provide discipline-specific education to patients, students, colleagues, and the public.

  1. Use opportunities to teach and learn as facets of professional practice.

  2. Develop learning relationships with clients, patients, students and colleagues.

  3. Assess what needs to be learned and demonstrate effective teaching techniques in settings that may be spontaneous or by design

  4. Select appropriate resources and activities to support teaching.

  5. Use evaluation and feedback to measure and enhance teaching effectiveness.

  6. Facilitate the transfer of learning.


  1. Demonstrate calm, compassionate, helpful demeanor toward those in need.

  1. Treat others with dignity and respect, demonstrating sensitivity and responsiveness to culture, age, gender, and disability.

  1. Discuss how diversity issues, health literacy or disparity issues might impact patient care and adherence to treatment.

  1. Consistently strive for excellence in professional activities.

  1. Be meticulous and careful in conducting professional tasks.

  2. Work systematically and complete assignments in a timely manner.

  3. Take responsibility for continuity of care.

  4. Recognize how NMAA patient care and professional practices might affect other health care professionals and the health care organization.

  5. Demonstrate ability to reflect on methods of improving professional behavior.

  1. Act with integrity and understand personal limitations.

  1. Refrain from performing tasks beyond personal capabilities or outside of professional scope of practice.

  2. Accept responsibility for mistakes and report mistakes as appropriate.

  3. Accept criticism and make an effort to improve.

  4. Reflect on difficult encounters and analyze how values, skills, and knowledge are affecting care of patients with challenging and/or terminal illnesses.

  5. Recognize and appropriately respond to impairment of self or colleagues.

  1. Demonstrate the professional attitudes that must be considered by the NMAA.

  1. Uphold the goals of the profession by supporting professional organizations, keeping professional confidences, maintaining competency, and exhibiting a professional image.

  2. Exhibit exemplary professional appearance and personal hygiene.

  3. Adhere to the scope of practice and standards of practice, including the role of state and federal regulations.

  4. Demonstrate conscientiousness and organization in addressing all professional obligations.

  1. Foster professional relationships with members of the health care team.

  1. Mentor students, technologists, and other members of the health care team.

  2. Enhance the professional relationship by keeping the patient as the main focus.

  3. Manage conflict among health professionals in a constructive manner.

  1. Demonstrate accountability to the health care organization and society by adhering to ethical business principles.

  1. Outline the nature of the special fiduciary relationship between the practitioner and the patient.

  1. Demonstrate a commitment to medico-legal and ethical principles.

  1. Apply the ethical principles of autonomy, non-malfeasance, beneficence, justice, paternalism, fidelity, veracity, altruism, integrity, respect, and compassion.

  2. Practice patient-centered care that encompasses confidentiality, respect, and autonomy via appropriate informed consent and shared decision making.


  1. Describe the structure, governance, financing and operation of the health care system and its facilities and how this influences patient care, research and educational activities at a local, state, regional and national level.

  1. Understand the structure and function of health care delivery systems and medical practices.

  2. Describe the various third-party payer systems, covered health benefits, formularies, preauthorization, appeals, disease management and quality improvement.

  3. Define and describe a patient population.

  1. Practice cost effective healthcare and resource allocation that do not compromise quality of care.

  1. Review and adjust coding practices and procedures to assure optimal and legal reimbursement.

  2. Analyze departmental budget, cost/revenue for optimal efficiency.

  3. Provide documented analysis and data for resource acquisition.

  4. Follow filing and documentation practices for practitioner reimbursement as directed by CMS policies and procedures, state, and federal law.

  1. Ensure compliance for all local, state, regional, and federal requirements for laboratory operations and personnel training and credentialing.

  1. Comply with current federal, regional and local regulations governing the laboratory.

  2. Conduct procedures and provide documentation for laboratory accreditation.

  3. Implement Joint Commission standards.

  1. Partner with health care managers and health care providers to assess, coordinate, and improve health care.

  1. Structure department staffing for quality care delivery and employee satisfaction.

  2. Conduct process for departmental strategic planning per institutional mission.

  3. Advocate for quality patient care and assist patients in dealing with system complexities.

  1. Understand the reciprocal impact of personal professional practice, health care teams, and the health care organization on the community and society.

  1. Identify ways in which an NMAA may interact with health-care professionals, health administrators, and community groups to positively impact the health and well being of one’s community.

  2. Gather information (e.g. demographics and socio-cultural beliefs) about the community in which one works and practices that affect health and disease.
  3. Participate in interdisciplinary team discussions, demonstrating the ability to accept, consider and respect the opinions of the other team members, while contributing an appropriate level of expertise to patient care.

  1. Describe the major legal mechanisms for oversight and regulation of medical practice, including those related to licensure and discipline, negligence, malpractice, risk management, doctor-patient relationships, confidentiality, and patient’s rights.

  1. Compare civil and criminal law.

  2. Explain civil procedures.

  3. Follow the prescribed standard of care for NMAA

  4. Distinguish between the different types of consent.

  5. Understand and comply with the patient’s directives in regard to medical care.

  6. Comply with employer and employee legal obligations.

Reference Section

  1. Owen MA, Pickett MW, Christian PE, Dillehay GL, Fulk LA, Gordon LL, Henkin RE, Smith M, Hubble WL, Thompson K, Keech FK, Nielsen, Stachowiak A. Nuclear medicine practitioner competencies. J Nucl Med Technol. 2007; 35(1):39-41.

  1. Pickett MW, Keech FK, Owen MA, Stachowiak A, Fulk LA, Murphy KH, Christian PE, Hunter K, Hubble WL, Gordon LL, Dillehay GL, Henkin RE. Position paper on the development of a middle level provider in nuclear medicine: The nuclear medicine practitioner. J Nucl Med Technol. 2006; 34(4):236-243.

  1. Competencies for the physician assistant profession. Journal of the American Academy of Physician Assistants. VOL 18. NO. 7. July 2005. pp. 16-18. Accessed Online 8/24/05 [http://www.nccpa.net/pdfs/Definition%20of%20PA%20Competencies%203.5%20for%20Publication.pdf]

  1. National Commission on Certification of Physician Assistants. Physician Assistant Knowledge and Skill Areas. Accessed Online 8/24/05. [http://www.nccpa.net/EX_knowledge.aspx?r=pance]

  1. American Association of Colleges of Nursing. Curriculum Standards. Acute Care Nursing Practitioner. Accessed Online 8/21/05. [http://www.aacn.nche.edu/Education/curriculum.htm]

  1. Accreditation Council of Graduate Medical Education. Outcome Project. Accessed Online 8/8/07 [URL: http://www.acgme.org/outcome/comp/compFull.asp ]

  1. American Board of Internal Medicine. Project Professionalism. Accessed Online 8/5/07 [URL: http://www.abim.org/pdf/profess.pdf]

  1. Nuclear Medicine Certification Board. Cardiology Examination: Detailed Content Outline. Accessed Online 8/24/05 [http://www.nmtcb.org/Content1.shtml]

  1. Washington Manual of Therapeutics, 29th Edition, Editors: Charles F Carey, Hans H Lee and Keith F Woeltje, 1998. Pages: 91-98.

  1. Oncology Nursing Exam Prep Guide. Accessed Online 8/30/05. [http://www.cna-nurses.ca/cna/documents/pdf/publications/CERT_Oncology_e.pdf]

  1. Oncology Nursing Society. Position on Oncology Services in the Ambulatory Setting. Accessed Online 8/30/05. [http://www.ons.org/publications/positions/AmbulatoryPractice.shtml]

  1. Nuclear Medicine Certification Board. Positron Imaging Examination: Exam Content Specifications. Accessed Online 9/01/05 [http://www.nmtcb.org/PET%20Content%20Outline.htm

  1. American Society of Radiological Technologists, Society of Nuclear Medicine. 2004. PET/CT Curriculum. Accessed Online 9/13/05 [http://www.crcpd.org/PET-CT_Fusion_Imaging/PETCT%20Curriculum%20Accepted%20021704.pd.pdf]

  1. Merriam SB, Simpson E L. (1995). A Guide to research for educators and trainers of adults. Malabar, FL: Krieger Publishing Company

  1. Meltzoff J. (1999). Critical thinking about research: Psychology and related fields. Washington, DC: American Psychological Association.

  1. AACE/AAES medical/surgical guidelines for clinical practice: management of thyroid carcinoma. U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Accessed Online 5/25/06. [URL: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=2848&nbr=2074&string= ]

  1. Competencies and Goals for Radiology Residents. University of Rochester, Department of Imaging Science. Accessed 05/25/06. [URL: http://www.urmc.rochester.edu/smd/Rad/ResidentGoals.pdf ]

`Overview for the Patient Care Curriculum
The role of the NMAA is to provide a quality patient care experience at the advanced level in diagnostic and therapeutic environments. The NMAA works under the direction of the supervising physician, making an initial assessment, performing routine and advanced procedures, and ensuring appropriate follow-up as needed. The NMAA synthesizes theoretical, scientific, and contemporary clinical knowledge for the personalized assessment and management of patients to provide efficient and effective patient care. The outcome is improved service delivery for the supervising physician, the referring physician, and the patient in terms of reduced costs or time, improved efficiency, and an enhanced patient experience.

NMAAs are committed to creating a patient centered experience and should be familiar with the clinical pathway the patient can expect to follow. Although working under the direction of the supervising physician, they demonstrate a high level of clinical decision making and autonomy. As part of their comprehensive responsibilities in patient care, NMAAs conduct physical examinations, collect relevant clinical information, address patient’s concerns and answer questions, and facilitate appropriate follow-up care.

The NMAA will build on existing knowledge and skills of a nuclear medicine technologist and is expected to maintain ACLS certification and demonstrate a comprehensive knowledge of anatomy, physiology, pathology and pathophysiology that would have been included in their undergraduate nuclear medicine technology program. In addition to instruction in advanced patient care skills, NMAA students could also be expected to take graduate level instruction in pathophysiology and clinical pharmacology.

Patient Care Curriculum Content

  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.

      1. Ethical and legal underpinnings of informed consent.

        1. Autonomy, veracity and confidentiality

        2. Who may give consent

          1. Competency issues

          2. Minors and mentally impaired adults

        3. Types of consent

          1. Express

          2. Implied by law

          3. Informed consent

        4. Components of valid informed consent

          1. Procedure that will be done

            1. Diagnosis

            2. Nature or purpose of the treatment or procedure.

          2. The name and qualifications of the person doing the procedure.
          3. The consequences or expected outcome.

          4. The risks involved, except for the very remote.

            1. Exceptions: risk of death or sterility, if applicable

          5. The alternatives to this procedure must be discussed

            1. Includes alternative of doing nothing

            2. Must then disclose the patient's prognosis

        5. Responsibilities of physician and health care providers

        6. When consent becomes invalid

          1. The procedure exceeds the consent given

          2. Inadequate information is given to the patient

          3. The nurse or technologist answers medically related questions

          4. The patient is given the consent form and told that it is just “routine papers”

          5. Force of circumstances

          6. Change of circumstances

      2. Capability of patient to give informed consent.

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

        1. Risks

        2. Benefits

        3. Alternatives

        4. Precautions used to reduce risks

      4. Assess patient’s understanding of the risks, benefits and alternatives and follow-up

      5. Responding to questions or directing questions to the appropriate health care professional

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

      1. Dietary requirements

      2. Modification of medication

        1. Restrictions

        2. Resumptions

      3. Follow-up appointments

      4. Next step in patient treatment algorithms

      5. Physical activity limitations

  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.

      1. Pertinent patient laboratory biochemical markers relevant to pathology

        1. Chemistry

        2. Hematology

        3. Microbiology

        4. Histology/cytology

      2. Pertinent previous diagnostic imaging studies

        1. x-ray

        2. Ultrasound

        3. CT

        4. Nuclear procedures

        5. MRI

        6. Angiography

        7. Mammography

    1. Perform history and physical examinations. (See Appendix for History and Physicals for RA curriculum)

      1. Review of systems (See Appendix Review of Systems for RA curriculum)

      2. History of present illness

        1. Onset

        2. Provocation

        3. Quality

        4. Radiation

        5. Severity

        6. Time

        7. Previous Diagnosis

        8. Previous treatment

      3. Past medical history

        1. Medications

        2. Allergies

        3. Surgeries

        4. Medical conditions

      4. Family history

      1. Perform a focused physical exam

        1. Neurological

        2. General

        3. Psychosocial

        4. Cardiovascular

        5. Pulmonary

        6. Gastrointestinal

        7. Musculoskeletal

        8. Reproductive

        9. Genitourinary

        10. Pain

        11. Vital signs

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

    1. Consult with physician as needed.

    1. 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.

    1. Consult with the supervising physician or appropriate health care provider to determine a modified action plan when necessary.

    1. 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. Indications

      2. Contraindications

      3. Co-morbidities

      4. Legal issues

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

    1. Perform patient bladder catheterizations.

    1. Establish additional routes of radiopharmaceutical administration other than IV injection or oral
      1. Feeding tube

        1. Insertion

          1. NG

          2. OG

        1. Administration

          1. NG

          2. OG

          3. PEG

          4. Gastrostomy

      1. Rectal

        1. Insertion

        2. Administration

          1. Radiopharmaceuticals

          2. Pharmaceuticals

          3. Contrast media

      2. Administration into existing catheters or surgical routes

        1. Peritoneal catheters

        2. VP shunts

        3. Central lines

        4. Intra-arterial lines

    1. Monitor vital signs and physiological parameters.

      1. Blood pressure

      2. Pulse

      3. Pulse oxygen level

      4. Temperature

      5. O2 sats

      6. Endo-tidal CO2

      7. Capnography

      8. EKC

      9. Cardiac output

      10. Drainage catheters

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

      1. Indications/contraindications

      2. Manage adverse events

  1. Provide indicated intervention per patient emergency event.

    1. Provide supportive medical management.

    1. Adverse response

    2. Allergic response

    1. Provide basic life support.

    1. Provide advanced life support.

    1. Facilitate transfer to definitive care environment.

Overview for the Clinical Nuclear Medicine Curriculum

Clinical leadership exemplifies one of the most important roles of the NMAA and is integrated throughout the advanced practice curriculum. Those that practice clinical leadership learn to optimize everyone’s role and value in the service, not just their own. An enhanced clinical skill set is an important component of the NMAA practice model. However, advanced practice involves more than performing highly technical procedures; it also requires a high level of clinical decision-making. The successful NMAA internalizes individual and professional qualities that motivate him or her to initiate improvements in service delivery. Improving service delivery implies that each NMAA’s discreet role will be different, depending on the needs of the local practice. Some may choose to practice in a general nuclear medicine department while others may work in specialty areas such as cardiology, pediatrics, or oncology/therapy.

NMAA’s work under the direction of a supervising physician and follow protocols for most of their clinical work. They must clearly understand the types of decisions they can make and those they should not make. As the profession matures, it will become necessary to establish clinical benchmarks and make evidence-based practice decisions. Consequently, NMAA’s will find they will need to distribute and share information to ensure that the patient is cared for in an expeditious, efficient, and ethical manner.

It is important to recognize that adding clinical knowledge is not simply a matter of adding more technical skills and or adding advanced technical skills. The NMAA will be expected to provide clinical nuclear medicine technology services and will build on those skill sets to improve service delivery and provide an exceptional patient experience. The NMAA will review requests for imaging or radiotherapy procedures to ensure the appropriate study has been requested for the clinical presentation. This will entail an evaluation of collaborative laboratory results for indications and contraindications and may require the NMAA to order or facilitate adjunctive pharmaceuticals for the imaging procedure under the direction of the supervising physician. The NMAA may prescribe and administer pharmacologic and nonpharmacologic interventions or order complimentary diagnostic procedures as allowable by state and federal statutes. The NMAA may also prepare a comprehensive report for the supervising physician. NMAA students should expect to spend extensive time in the clinical setting and the classroom in order to master these skills.

Clinical Nuclear Medicine Curriculum Content

Core Imaging

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

    1. Review request for imaging procedures per protocol.

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

    1. Evaluate collaborative laboratory for indications/contraindications.

      1. Cardiac

        1. CK

        2. CKMB

        3. Troponin

        4. Lipid panel

        5. Prior EKG

        6. Prior cardiac procedures (cath, bypass, etc.)

      2. Hepatic

        1. LFTs

        2. Chemistry panel

      3. Pulmonary

        1. D-dimer

        2. BNP

        3. PT

        4. PTT

        5. INR

      4. Oncology

        1. Tumor markers (e.g., Ca-125, AFP, serum CEA, serum Thyroglobulin)

        2. Blood glucose

      5. Renal study

        1. Chemistry panel

        2. Urinalysis

      6. Thyroid

        1. Free T3

        2. Free T4

        3. TSH

        4. Thyroglobulin

        5. Thyroglobulin antibodies

      7. Parathyroid

        1. PTH

        2. Calcium

    1. Order or facilitate adjunctive pharmaceuticals for the imaging procedure under the direction of the supervising physician.

        1. Morphine

        2. SSKI

        3. Tagament

        4. Cardiac stress agents

        5. GI agents

          1. Cimetidine

          2. Ranitidine

          3. Pentagastrin

          4. Glucagon

          5. CCK or analog

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

    1. Perform routine nuclear medicine procedures.

    1. Perform sentinel node imaging and lymphatic mapping.

      1. Anatomy and physiology of lymphatic system

        1. Breast

          1. Contains greater concentration than any other part of the body

          2. Lymph node or gland

            1. Subclavian

            2. Interpectoral

            3. Axillary

            4. Parasternal (internal mammary)

        2. Melanoma

          1. Head and neck levels

            1. Submandibular triangle (I)

            2. Upper jugular (II)

            3. Middle jugular (III)

            4. Lower jugular (IV)

            5. Spinal accessory nerve lymph chain (V)

            6. Paratracheal (VI)

          2. Head and neck lymph drainage patterns

            1. Lower lip: Submental

            2. Scalp: parotid, suboccipital

            3. Parotid : levels I, II

            4. Oral cavity: levels I, II, III

            5. Oral pharynx: levels II, III, retro & parapharyngeal

            6. Nasopharynx: levels II, III, V

            7. Hypopharynx: levels Ii, III, IV, retro & parapharyngeal

            8. Supraglottis: levels II, III

            9. Glottis: levels III, IV, VI

            10. Thyorid: levels III, IV, V, VI

            11. Esophagus:levels III, IV, V, VI

          3. Torso/trunk (2) above umbilicus

            1. Axilla

            2. Groin

            3. Supraclavicular

            4. Costal margin

            5. Internal mammary

            6. Interval note

          1. Pelvis (below umbilicus)

            1. Inguinal

            2. Mesenteric

            3. Intestinal

            4. Mesocolic

            5. Iliac

            6. Retrosacral

          2. Extremities

            1. Arm (3)

              1. Axillary

                1. Apical

                2. Central

                3. Lateral

                4. Subscapular

                5. Para-trochlear (interval node sometimes present)

              2. Intercostal

              3. Subital

              4. Infraclavicular

              5. Pectoral

              6. Subscapular

              7. Supraclavicular

              8. Ttranverse cervical

            2. Leg (4)

              1. Inguinal

              2. Iliac

                1. External

                2. Common

                3. Internal

                4. Deep

                5. Superficial

              3. Para-aortic

              4. Lumbar

              5. Popliteal

              6. Superficial inguinal nodes

        1. Solid organ (e.g, biopsy-proven colorectal cancer)

      1. Injection technique

        1. Intradermal

          1. Local systemic route
          2. Melanoma

        2. Peritumoral

          1. Melanoma

          2. Breast

        3. Subcutaneous

        4. Periareolar

          1. Breast

        5. Perirectal

          1. Solid organ

      1. Radiopharmaceutical

        1. Agent: Tc99m sulfur colloid (filtered)

        2. Dose

        3. Route of administration (see injection technique)

        4. Volume limitation

        5. Particle size

        6. Needle size

      2. Pharmaceutical intervention: anesthetic

      3. Patient positioning and immobilization devices

        1. Positioning

          1. Therapy planning table

          2. Positioning devices (e.g. wedges)

        2. Immobilization

          1. Casts/masks

          2. Vacuum bags

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

      1. Equipment

        1. Masks

        2. Therapy planning table

        3. Positioning appliances

        4. Other ancillary equipment

      2. Laser positioning and reference marking

  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.

      1. Dietary status
        1. NPO per department protocol

          1. Hepatobiliary

          2. Gastric empty

          3. Thyroid uptake/scan

          4. Gastric reflux

          5. C-14 urea breath test

        2. Pre-arranged meals

          1. Fatty

          2. Low iodine

          3. Low carbohydrate

          4. High protein

      2. Hydration per department protocol

        1. Renal imaging

        2. PET

      1. Medication discontinued per department protocol

        1. Thyroid uptake/scan

          1. T-3

          2. T-4

          3. Propylthyouracil/Tapazol

          4. iodinated contrast

        2. Adrenal medullary imaging

          1. Opioids

          2. Tricyclic antidepressants

          3. Sympoathicomimetics

          4. Antihypertensive/cardiovascular agents

          5. ACE inhibitors

          6. Antipsychotics

        3. C-14 Urea breath test

          1. Antibiotics

          2. Bismuth

          3. Sulfates

        4. Captopril renal scan

      • Diuretic

      • ACE inhibitor

      • Calcium antagonists

      • Angoitensin II receptor blockers

      1. Activity limitation as clinically indicated

  • PET- reduce physical activity,

  • PET: eliminate speech

      1. Laboratory evaluations as per department protocol (see competency #1)

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

      1. Medications as per department protocol

        1. Morphine intervention for hepatobiliary imaging

          1. Dose

          2. Dose limits

          3. Administration technique

        2. CCK intervention for hepatobiliary imaging

          1. Dose

          2. Administration technique

        3. Lasix (furosemide) for renal imaging

          1. Dose

          2. Administration technique

      2. Activity limitations as clinically indicated (See A above)

      3. Dietary status as per department protocol (See A above)

      4. Laboratory evaluation as per department protocol

      5. Vital signs: see Patient care Competency domain

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

      1. Activity limitations as clinically indicated

      2. Medications as directed by referring physician or supervising physician

        1. Administration of additional medications as directed by referring physician or supervising physician

        2. Ensure that patients do not take metformin containing medications 48 hours after administration of iodinated contrast material

        3. Insure children are rehydrated post diuretic study

      3. Dietary limitations

        1. NPO 1 hour post dose – thyroid uptake

        2. Hydration – facilitate urination

      4. Laboratory evaluation – as clinically indicated

  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.

      1. Adequacy

      2. Artifact

      3. Incidental findings

    1. Make a preliminary interpretation.

      1. Incidental findings

      2. Review correlative data

      3. Summarize findings with a concise statement addressing the referring physician’s question for ordering the study

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

      1. Patient identification

      2. Informed consent, as necessary

      3. Referral prescription

      4. Patient preparation

      5. Relevant clinical history

      6. Radiopharmaceutical, dose and route of administration

      7. Patient status prior to, during and following procedure/therapy

      8. Statement outlining patient radiation safety instructions, as necessary

      9. Recommendations for follow-up diagnostic or therapeutic procedures, as indicated

      10. Recommendations for follow-up, as needed

    1. Communicate initial observations as per supervising physician discretion.

    1. Report findings to referring physicians and patients per protocol.
      1. Recommend appropriate diagnostic or therapeutic procedures as indicated.

      2. Recommend appropriate follow-up, as needed.

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.

      1. Malignant versus benign tumors

      2. Proto-oncogenes

      3. Statistical interpretation

      4. Life style/environmental risks

      5. Clinical treatments

        1. curative/palliative

          1. Surgical

          2. Medical

          3. Medication

      6. Clinical studies

      7. Life expectancy

    1. Identify risk factors for cancer.

      1. Previous cancer/treatment

      2. Genetic risk

      3. Environmental risk

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

      1. Coordinate imaging protocols per protocol, reference patient care

      2. Tumor markers

      3. Evaluation for metastatic disease, reference patient care and core imaging

      4. Order or facilitate necessary laboratory and imaging studies per protocol and physician directive

    1. Evaluate clinical criteria for radionuclide therapy, including expected biodistribution of radiotherapeutic pharmaceutical.
      1. Bone marrow suppression and secondary to added chemotherapy within 6 week window

      2. Unintended thyroid ablation

      3. Pulmonary fibrosis secondary to pulmonary metastasis

      4. Exclude patients with pain from other causes which is mimicking bone pain

      5. Evaluate impending spinal cord compression or impending long bone fractures

      6. Evaluate renal function to lower dosage or delay therapy

      7. Exclude pregnant patients

      8. Exclude patients for 2-3 days receiving other phosphonate-based therapy

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

    1. Obtain translator/interpreter services as necessary.

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

      1. Educate the patient on the risks, benefits and alternatives to the procedure.

        1. Thyroid disease1

          1. Benign thyroid disease

            1. Risks

              1. More than one I-131 treatment may be necessary

              2. Risk of hypothyroidism is high resulting in lifelong daily ingestion of thyroid medication

              3. Long term follow-up necessary

              4. Ophthalmopathy may improve or worsen or develop after I-131 (Graves Disease)

              5. Radiation thyroiditis/thyroid storm (rare)

            2. Benefits

              1. Reduction/cell death of overactive thyroid tissue

              2. Reduce/ eliminate dependent medications
              3. Reduce/ eliminate associated symptoms

              4. Prevents cardiac damage

            3. Alternative to treatment:

              1. Surgery

              2. Pharmaceutical therapy

              3. No therapy

          2. Malignant thyroid disease

            1. Risks

              1. Normal as well as cancerous thyroid tissue will be destroyed. Other normal tissues may also be affected

              2. More than one I-131 treatment may be necessary

              3. Early side effects

                1. Mucositis

                2. Nausea/vomiting

                3. Pain/tenderness in salivary glands

                4. Loss of salivia or taste

                5. Metallic-like alterations in taste

                6. Neck pain/swelling (rare)

                7. Temporary decreased white blood cell count (increased susceptibility to infection) (very rare)

              4. Late side effects

                1. Temporary infertility

                2. Permanent damage to salivary glands

                  1. Loss of saliva or saliolethiasis

                  2. Excessive dental caries

                  3. Reduced taste

                3. Dry eyes

                4. Epiphora from scarring of lacrimal ducts

                5. Development of other malignancies (rare)

                  1. Stomach

                  2. Bladder

                  3. Colon

                  4. Salivary glands

                  5. Leukemia (dose related and most significant late sequelae)

              1. Lifelong daily ingestion of thyroid medication will be required

              2. Long term follow-up necessary

            1. Benefits

              1. Destruction of malignant and normal thyroid tissue

            2. Alternatives to treatment
              1. External beam therapy

              2. Surgery

        1. Palliative bone therapy (P-32, Sm-153, Sr-89)2

          1. Risks

            1. Potential for pain flare at 7 to 10 days post RX

            2. Reduction in leukocytes, platelet counts resulting in bleeding/infection and potentially, death

            3. Chance of total pain relief rare

            4. Not a curative treatment

          2. Benefits

            1. Bone pain reduction

            2. Improved mobility/quality of life

            3. Reduce dependence on narcotic and non-narcotic analgesics

            4. Improve performance status and possibly survival

            5. Reduce co-treatment costs

          3. Alternatives to treatment

            1. External beam therapy

            2. Chemotherapy

        2. Non-Hodgkin’s Lymphoma (I-131 Tositumomab, Y-90 Ibritumomab tiuxetan)3

          1. Risks

            1. Hematologic events

              1. Neutropenia

              2. Thrombocytopenia

              3. Anemia

              4. Ecchymosis

            2. Digestive symptoms

              1. Nausea

              2. Vomiting

              3. Diarrhea

              4. Anorexia

              5. Abdominal enlargement

              6. Constipation

            3. Musculoskeletal system

              1. Arthralgia

              2. Myalgia

            4. Nervous system

              1. Dizziness

              2. Insomnia

            5. Respiratory system

              1. Dyspnea

              2. Increased cough

              3. Rhinitis

              4. Bronchospasm

            1. Skin/appendages
              1. Pruritus

              2. Rash

            2. Whole body

              1. Fever

              2. Infection

              3. Chills

              4. Abdominal pain

              5. Pain

              6. Headache

              7. Throat irritation

              8. Back pain

              9. Flushing

            3. Cardiovascular

              1. Hypotension

            4. Anaphylatic shock (acute)

              1. Death

            5. Non response to treatment protocol

            6. HAMA

            7. Hypothyroidism (Bexxar)

              1. Lifelong daily ingestion of thyroid medication may be required

          1. Benefits

            1. Target treatment to CD-20 antigen expressed on normal and abnormal B-cells resulting in cell destruction/death (possible partial or complete remission)

            2. Durable response to therapy - results comparable to chemotherapy and external beam therapy

            3. Short outpatient treatment protocol (14 days)

            4. Improved quality of life during/following treatment protocol

          2. Alternative to treatment

            1. Chemotherapy

            2. External beam therapy

            3. Watch/wait – no therapy

        1. Polycythemia4

          1. Risks

            1. Hematologic event (transient reduction in platelets and leucocytes) resulting in possible bleeding/infection

          2. Benefits

            1. Reduction in total RBC volume

            2. Repeat treatments possible

            3. Reduction in platelet counts to prevent clotting

          3. Alternative to Treatment:

            1. Chemotherapy

            2. Pharmacological therapy

        2. Malignant effusion5

          1. Risks

            1. Hematologic events (transient reduction in platelet and leukocyte counts; rare)

            1. Sub-optimal treatment outcome due to loculation in thoracic or peritoneal cavity

            2. Tissue necrosis

            3. Not a curative treatment

          1. Benefit

            1. Reduction of malignant cells in the thoracic or peritoneal cavity

            2. Delayed fluid build-up in thoracic or peritoneal cavity

            3. Repeat procedures possible

          2. Alternatives to treatment

            1. Chemotherapy (treatment of choice)

        1. Selective Internal Radiation Therapy (SIRT)6

          1. Risks

            1. Chronic pain

            2. Ulceration/bleeding

            3. Lung edema/fibrosis when lung shunting exceeds 20%

            4. Local radiotherapeutic treatment may include destruction of normal liver tissue

            5. Not a curative treatment

          2. Benefits

            1. Local radiotherapeutic treatment to embolized liver tumors produces cell death to malignant tumor

            2. Procedure may be repeated

            3. Short treatment protocol performed over 7-14 days (diagnostic + therapeutic)

          3. Alternatives to treatment

            1. Surgery

            2. Chemotherapy

            3. Hepatic arterial embolization with or without chemotherapy

            4. Liver transplantation (probably not an alternative)

        2. Radiosynoviorthesis (RSV)

          1. Risks

            1. Pain

            2. Joint inflammation

            3. Infection

            4. Not curative procedure

          2. Benefit
            1. Reduction in painful joint swelling including post-op prosthesis

            2. Procedure may be repeated

          3. Alternative to treatment

            1. Pharmacological therapy

            2. Surgery

      1. Assess patient’s understanding of risks, benefits and alternatives and follow-up

        1. Address and document patient’s questions and concerns

          1. Consider cultural diversity and ethical issues

          2. When approved by patient, include family members/friends to improve communication/understanding

          1. Identify the need for an interpreter, as necessary

            1. Language

            2. Hearing impaired

          2. Document as per institutional protocol

            1. Discussion topics

              1. Risks

              2. Benefits

              3. Alternatives to treatment

            2. Patient’s questions, issues or concerns

            3. Barriers to communication

              1. Emotional

              2. Psychological

              3. Physical (Motor deficit)

              4. Cultural/Spiritual

              5. Age Specific

                1. Neonate

                2. Pediatric

                3. Adolescent

                4. Geriatric

            4. Final discussion outcome

              1. Consent to treat

              2. Refusal of treatment

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

      1. Dietary requirements

        1. Low iodine diet 10-14 days pre-treatment – I-131 rx – thyroid cancer

        2. NPO

          1. I-131 treatment (benign and malignant treatment protocols)
          2. Selective Internal Radiation Therapy (SIRT)6

      2. Modification of medications

        1. Restrictions

          1. Thyroid

            1. Thyroid hormones (unless rhTSH is used)

            2. Iodinated contrast

            3. Medications that may limit/restrict the ability of thyroid tissue to absorb radioactive iodine

          2. Bone palliation

            1. Oral/systemic myelosuppressive chemo

            2. Bisphosphonates

        2. Resumptions – per procedural protocol and referring physician/radiologists directives

      3. Follow-up appointments – per procedural protocol and referring physician/radiologists directives to include:

        1. Diagnostic imaging

        2. Laboratory follow-up

        3. Referring physician follow-up

        4. Treating physician follow-up

      1. Next step in patient treatment algorithms – in consultation with treating physician, per referring physician’s directives

      2. Counsel patient for post-administration requirement to reduce exposure rates to the public and document compliance

        1. Oral and written instructions given to patient.

          1. 2 copies of written instructions

            1. Chart copy signed by patient

              1. receipt of document noted in final patient report

            2. Patient copy reviewed with patient and/or family member:

              1. I-131:

                1. Maintaining appropriate distance from others

                2. Separate sleeping arrangements

                3. Minimize time spent in public places

                4. Precautions to reduce the spread of contamination including urine and other body fluids

                5. Effective contraceptive methods

                6. Length of time for each precaution

              2. Beta emitting radiopharmaceuticals (Sr-89, Sm-153, P-32)

                1. Hand washing technique

                2. Precautions to reduce the spread of contamination including urine and other body fluids

                3. Use of condoms for sexual relations

                4. Effective contraceptive methods

  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.

      1. Recent radioiodine uptake or qualitative thyroid scan

      2. Thyroid hormone levels

      3. Delivered activity

      4. Fixed dose regimen based on disease

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

      1. Post-operative ablation

      2. Treatment of presumed thyroid cancer in the neck or mediastinal lymph nodes

      3. Treatment of distant metastases

      4. Dosimetrically determined thyroid calculations; customize dose levels from body clearance times

      5. External beam therapy plus I-131 for bone disease

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

      1. Based on whole body bone imaging study

      2. Sr-89

        1. Dose

        2. Route of administration

      1. P-32

        1. Dose

        2. Route of administration

      2. Sm-153

        1. Dose

        2. Route of administration

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

      1. Based on diagnostic whole body biodistribution scan

      2. I-131 – dose calculations based on:

        1. Platelet counts

        2. Total body residence time

        3. Activity time using body mass to calculate

      3. Y-90 – dose calculations based on:

        1. Patient’s weight

        2. Platelet count

    1. Calculate radionuclide therapy dose for polycythemia, basing dose selection on accepted standards.

      1. Extent of disease

      2. Weight

      3. Blood counts

      4. Typical doses

    1. Calculate radionuclide therapy dose for malignant effusion, basing dose selection on accepted standards.

      1. Based on depth in tissue, activity administered and uniformity of distribution:

      2. Intraperitoneal dose range

      3. Intrapleural dose range

      4. Radiosynoviorthesis – dose based on size of joint, depth of tissue, administered activity and uniformity of distribution:

      5. Proximal interphalangeal joints

      6. Knee joints – 5-6 mCi is typical

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

      1. Tumor volume from CT

      2. Liver size

      3. Lung shunting

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

    1. Rituxan

    2. SSKI

    3. Thyrogen

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

    1. CBC

    2. TSH

    3. Serum HCG

  1. Report procedure to supervising physician according to protocol.

    1. Overview of protocol compliance

    2. Patient identification

    3. Informed consent

    4. Referral prescription

    5. Patient preparation

    6. Relevant clinical history

    7. Radiopharmaceutical, dose and route of administration

    8. Patient status prior to, during and following therapy

    9. Brief statement outlining patient radiation safety instructions

    10. Recommendations for follow-up diagnostic or therapeutic procedures, as indicated

    11. Recommend appropriate follow-up, as needed

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

    1. Bone marrow suppression

    2. Supportive care for symptoms

      1. Pain management

      2. Nausea

      3. Fatigue

      4. GI disturbance

Elective Competencies
These procedures consist of those tasks that are infrequently performed in most practice settings but might be particularly useful to some NMAAs in some settings.

  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.

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