Should nurse practitioners in Iowa be allowed to supervise radiology technicians who perform a real-time medical imaging procedure known as fluoroscopy?

The Iowa Medical Society (IMS) says definitely not, and it’s asking the Polk County District Court to overturn a rule, which became effective May 15, that allows advanced registered nurse practitioners (ARNPs) to supervise those procedures.

The IMS last week filed suit against the Iowa Department of Public Health (IDPH) and the Iowa Board of Nursing over the rule, claiming that allowing ARNPs to supervise fluoroscopic procedures constitutes a “serious patient safety issue.” The medical society has more than 5,200 physician members.

The Iowa Society of Anesthesiologists has filed a separate petition with the court seeking to overturn the rule.

Used in conjunction with several types of medical procedures, fluoroscopies provide a continuous, live X-ray image on a monitor. The images can be used to guide the installation of a heart catheter or to display the function of the gastrointestinal tract, among other uses. According to the IMS petition, the procedure can deliver up to 3,500 times the radiation of a chest X-ray.

“Radiology is the practice of medicine,” said Dr. Timothy Kresowik, president of the IMS, in a press release. “Iowans deserve to know that the individuals performing and supervising procedures with potentially harmful levels of radiation have been educated and are qualified to do so.”

Kresowik, a vascular surgeon with University of Iowa Hospitals and Clinics in Iowa City, said national standards do not recognize supervision of fluoroscopy to be within the legitimate scope of nursing.

“It makes no sense for Iowa to require less education and training for nurses than the national education and training standards for radiologic technologists and radiology assistants,” he said.

Cheryll Jones, chairperson of the Iowa State Board of Health, said the board took its deliberations on the decision “very seriously,” and considered input from numerous groups before its vote.

“For us, one of the big (considerations) was that we had asked for documentation whether this practice had resulted in any injuries or incidents, because we knew that some nurse practitioners were doing this in rural areas,” she said.

In a recent letter to the Iowa Society of Anesthesiologists (ISA), Jones noted that ARNPs already supervise fluoroscopic procedures in several areas of practice in Iowa, and that the board was “not provided with any documented evidence that the supervision of fluoroscopy by ARNPs has resulted in any misadministration or reportable injuries in this state.”

Jones, who works as a pediatric nurse practitioner, also wrote that a rule adopted in August 2009 outlines specific educational requirements for nurses that “are sufficient to ensure competency to supervise these procedures.”

The nine-member board, which received 206 comments in favor of the amendment and 77 in opposition, voted 6-3 on March 10 to adopt the change.

Dr. Frank Cassady, president of the ISA, said that in addition to the increased risks of cancer and other complications due to radiation overexposure, anesthesiologists are also concerned the rule will lead to an improper expansion of nurses’ scope of practice.

“Nurses have publicly expressed their intention to expand the scope of their practice into the practice of interventional pain medicine,” Cassady said in a press release. “This highly specialized area of medicine uses fluoroscopy to place needles and inject medications in close proximity to a patient’s spine and other vital organs. … Iowans with chronic pain deserve a comprehensive medical evaluation, diagnosis and treatment by a licensed physician, regardless of whether they live in a small town or a big city.”

It’s rare for the Iowa Medical Society to seek judicial intervention in a State Board of Health rule, said Jeanine Freeman, the organization’s senior vice president for legal affairs.

“Over the last 10 to 12 years, we have not participated in legal action,” Freeman said. “This is an issue of very high concern to the medical community.”

The rule is “very general in nature and doesn’t address the level of training needed,” nor does it provide for oversight to determine whether the training the nurse has received is adequate, she said. “So it’s not good regulatory oversight.”

Nick Mauro, an attorney with the Crawford Quilty & Mauro Law Firm, which is representing the ISA, said it’s unclear how many nurses are supervising the procedure or what their credentials are.

“That’s part of the problem of it,” he said. “As far as we know, nurses were not authorized prior to this rule to do this, which raises a whole other level of concern. And indeed, why change the rules if they were already allowed to do this?”

According to the Iowa Board of Nursing website, an ARNP must be currently licensed as a registered nurse, have graduated from a board-approved advanced practice master’s program or complete a formal advanced practice education program and be certified by a national professional nursing certifying body recognized by the board.

In addition to asking the court to reverse the board’s decision, both the IMS and the ISA are seeking a stay to prevent ARNPs from supervising the procedures until the matter is ruled on.

Polly Carver-Kimm, a spokeswoman for the IDPH, said the department has received both petitions and is reviewing them.

IDPH Director Tom Newton said his department began looking at the issue in 2006, when differing definitions in the rules made it unclear who was author-ized to supervise the procedures. He said the department was also notified by an ARNP from a rural area that it was necessary for that nurse practitioner to supervise fluoroscopic procedures because a physician was unavailable.

“I think as we have health-care reform, we are going to have more of these (scope of practice) issues emerge,” Newton said. “How we do provide that quality of care locally without putting the patient at risk?”

The amended rule specifies that ARNPs are included in the list of licensed health-care professionals who may supervise the performance of fluoroscopic procedures. Under the previous version of the rule, physicians, chiropractors, podiatrists, dentists and physician’s assistants are other licensed practitioners who can supervise the procedures.

“Our doctors work extremely well with ARNPs,” the Iowa Medical Society’s Freeman said. “Our issue is that at some point, an ARNP cannot move into the practice of medicine. It’s just the vigilance in medicine that you have to have to ensure you have the appropriately trained person supervising procedures.”