Performance of Adult Cardiac Catheterization:Nonphysicians Should Not Function as Independent

Operators—A Position Statement

Debra Marshall, 1 MD, Charles E. Chambers, 2* MD, Fred Heupler, Jr., 3 MD, and the LaboratoryPerformance Standards Committee of the Society for Cardiac Angiography and Interventions

Key words: cardiac catheterization; cardiologist

INTRODUCTION

The Society for Cardiac Angiography and Interven-tions (SCA&I), which was founded in 1978 by pioneersin coronary angiography, is in a unique position to definestandards of competence for performing cardiac catheter-ization procedures [1]. The Laboratory PerformanceStandards Committee of the SCA&I, chaired initially byDr. Melvin Judkins, has maintained a leadership role indeveloping guidelines for training and credentialing,administration, and assessment of outcomes in the car-diac catheterization laboratory [2–4].

The Laboratory Performance Standards Committee hasdeveloped this position statement to address the role ofnonphysicians as independent operators in the cardiaccatheterization laboratory, with emphasis on training,patient safety, and ethics. In this statement, the termnonphysicianincludes physician assistants, nurse practi-tioners, and technical staff.

PHYSICIANS PERFORMING DIAGNOSTICCARDIAC CATHETERIZATION

An independent operator in the cardiac catheterizationlaboratory must be proficient not only in the technicalaspects of invasive procedures, but also in the cognitiveaspects, including preprocedure evaluation, indications,cardiac physiology and pathophysiology, emergency car-diac care, radiation safety, and interpretation and clinicalapplication of the cardiac catheterization data. The SCA&I,the American College of Cardiology, and the AmericanHeart Association have recommended guidelines forproper training in diagnostic cardiac catheterizations,specific technical and nontechnical knowledge base, andthe maintenance of skills, including continuing educationand annual case volumes [5–7]. In recognition of the

increasing complexity of interventional cardiology, for-mal specialty board certification in this discipline will beinitiated in 1999 [8].

NONPHYSICIANS PARTICIPATION INDIAGNOSTIC CARDIAC CATHETERIZATION

The spectrum of participation in cardiac catheterizationprocedures is broad, and it includes physician-supervisedassistance in catheterizations by nonphysicians, indepen-dent nonphysician performance of the procedure underthe auspices of a physician, and independent nonphysi-cian performance and billing for the diagnostic proce-dure. Nonphysicians who perform cardiac catheteriza-tions as an assistant to a physician are not independentoperators. Their role will not be considered in thisposition statement.

The literature is scant regarding nonphysicians indepen-dently performing cardiac catheterization. DeMots et al.[9] compared the performance of 150 cardiac catheteriza-tions by a physician assistant to similar cases performedby a cardiology fellow. Both groups were supervised byan experienced physician; no significant differences were

1Department of Cardiology, University of California at Los Ange-les, Los Angeles, California2Department of Cardiology, Pennsylvania State University, Her-shey, Pennsylvania3Department of Cardiology, Cleveland Clinic Foundation, Cleve-land, Ohio

*Correspondence to: Charles E. Chambers, MD, Hershey MedicalCenter, Section of Cardiology-H047, 500 University Drive, Hershey,PA 17033

Received 3 May 1999; Revision accepted 6 May 1999

Catheterization and Cardiovascular Interventions 48:167–169 (1999)

r 1999 Wiley-Liss, Inc.

seen between the two groups. Physician assistants nolonger perform cardiac catheterization procedures in theinstitution where this practice was described. With 1million diagnostic catheterizations performed annuallyby physicians, it is difficult to apply these data on 150procedures to standard practice.

TRAINING, PATIENT SAFETY, AND ETHICS

Training

Physician training for cardiac catheterization requires a3-year internal medicine residency and a 3-year cardiol-ogy fellowship that includes 12-month training in thecardiac catheterization laboratory with didactic instruc-tion. In contrast, there are no formal guidelines regardingtraining for nonphysicians as independent operators forcardiac catheterization.

Patient Safety

Specialty training, clinical judgment, and experienceare required for excellent results in the cardiac catheteriza-tion laboratory. Before a diagnostic catheterization, assess-ment of indications and patient risk require a physician’sevaluation of the history, physical findings, and noninva-sive studies [5]. During a procedure, the ability torecognize and respond appropriately to emergenciesrequires a well-trained physician. Proper interpretationand correlation of angiographic and hemodynamic datamust be applied during the case.

Ethics

Honesty is the ethical obligation to disclose relevantinformation to the patient. The credentials of the primaryoperator for an invasive procedure are clearly relevant tothe patient [5]. All current guidelines for performance ofinvasive procedures designate physicians, not their surro-gates, as primary operators. Patients have the right toexpect that these guidelines are being followed for theirinvasive procedures.

Beneficence

Beneficence is the ethical obligation to act in thepatient’s best interest. Patients, the public, and thegovernment are seeking greater assurances that physi-cians hold the best interests of their patients above theirown [5]. Current Healthcare Financing Administration(HCFA) reimbursement guidelines mandate that cardiaccatheterization procedures be performed by physicians.Given the present adequate supply of physicians toperform cardiac catheterization procedures, it is difficultto justify using uncredentialed nonphysicians with lim-

ited training as primary operators for diagnostic cardiaccatheterization [10].

CONCLUSION

Members of the Laboratory Performance StandardsCommittee and the Board of Trustees of the Society forCardiac Angiography and Interventions strongly recom-mend that nonphysicians should not perform diagnosticcardiac catheterization as independent operators. Thesociety also strongly supports continued adherence topreviously published training and credentialing guide-lines for independent operators in the cardiac catheteriza-tion laboratory.

REFERENCES

1. Society of Cardiac Angiography Training Program StandardsCommittee: Standards of training in cardiac catheterization andangiography. Cathet Cardiovasc Diagn 1980;6:345–348.

2. Judkins MP. Guidelines for approval of professional staff forprivileges in the cardiac catheterization laboratory. Cathet Cardio-vasc Diagn 1984;10:199–201.

3. Society of Cardiac Angiography Laboratory Performance Stan-dards Committee. Guidelines for professional staff privileges inthe cardiac catheterization laboratory. Cathet Cardiovasc Diagn1990;21:203–204.

4. Heupler FA, Chambers CE, Dear WE, Angello DA, Heisler M.Guidelines for internal peer review in the cardiac catheterizationlaboratory. Cathet Cardiovasc Diagn 1997;40:21–32.

5. American College of Cardiology/American Heart Assn. TaskForce Cardiac Catheterization: ACC/AHA guidelines for cardiaccatheterization and cardiac catheterization laboratories. Circula-tion 1991;84:213–2247.

6. Society for Cardiac Angiography and Interventions Committee onTraining Standards. Core curriculum for adult and pediatricinvasive training programs. Cathet Cardiovasc Diagn 1996;37:392–408.

7. Pepine CJ, Babb JD, Brinker JA, Douglas JS, Jacobs AK, JohnsonWL, Vetrovec GW. Task Force 3: training in cardiac catheteriza-tion and interventional cardiology. J Am Coll Cardiol 1995;25:1–34.

8. Hirshfeld JF, Ellis SG, Faxon DP. ACC clinical competencestatement, recommendation for the assessment and maintenance ofproficiency in coronary interventional procedures. J Am CollCardiol 1998;31:722–743.

9. DeMots H, Coombs B, Murphy E, Palac R. Coronary angiographyperformed by a physician assistant. Am J Cardiol 1987;60:784–787.

10. 25th Bethesda Conference. Future personnel needs for cardiovas-cular health care. J Am Coll Cardiol 1994;24:275–328.

APPENDIX A

Members of the Laboratory Performance StandardsCommittee include Michael J. Cowley, MD, chair; CharlesE. Chamber, MD, co-chair; Frank V. Aguirre, MD;

168 Marshall et al.

William Armstrong, MD; Stephen Balter, PhD; JamesBlankenship, MD; Gordon Boak, MD; John Burns, MD;John D. Coulson, MD; Wayne E. Dear, MD; John Dervan,MD; James C. Dillon, MD; Lowell Gerber, MD; Jerry E.Goss, MD; Frederick A. Heupler, Jr., MD; Kenneth R.Jutzy, MD; Neal S. Kleinman, MD; Francis Y.K. Lau,MD; Pei-Jan Paul Lin, PhD; Manuel de la Llata-Romero,MD; Debra Marshall, MD; Masayoshi Matsuno, MD;Paul T. McEniery, MD; Gregory Mishkel, MD; Sami B.Nazzal, MD; Soraya Nouri, MD; William Phillips, MD;

Ahmed A.E. Ghamry Sabe, MD; Sheldon Sbar, MD;Marc J. Schweiger, MD; William C. Sheldon, MD;Robert Siegel, MD; and Sarah Vernon, MD

APPENDIX B

The ACC Cardiac Catheterization Committee hasreviewed this article and has given its endorsement(level II).

Performance of Adult Cardiac Catheterization 169