Iowa nurses not trained to oversee fluoroscopy, judge rules

An Iowa judge has overturned a state rule that allowed nurse practitioners to supervise fluoroscopy, ruling in favor of doctors who opposed the regulation.

The decision protects patients from risks associated with undertrained medical professionals overseeing the procedure, opponents of the rule said.

"This is really a patient safety issue," said family physician Lawrence Hutchison, MD, president of the Iowa Medical Society. "Radiologists have to have special training in order to supervise fluoroscopy. How can a nurse practitioner with no formal training supervise this procedure?"

Conflict over the rule started in 2009, when the Iowa Board of Nursing adopted a regulation allowing advanced registered nurse practitioners to provide direct supervision of fluoroscopy. The board contended that it had the authority to enact the rule under Iowa law, according to court documents. In March 2010, the Iowa Dept. of Public Health adopted similar regulations, allowing ARNPs to provide direct supervision of radiologic technologists and radiologic students during fluoroscopy.

In June 2010, the Iowa Medical Society and the Iowa Society of Anesthesiologists sued the state. The medical societies argued that the regulations violated state law, which prohibits the expansion of nursing into medicine without official recognition by doctors and others. In addition, the new rules were not in compliance with state standards for radiation health and safety, the societies said. The Litigation Center for the American Medical Association and the State Medical Societies made a monetary contribution to the case on behalf of the medical societies.

In November 2010, a judge granted an injunction against the rule while the lawsuit was ongoing.

In his Oct. 31 opinion, Artis I. Reis, Judge for the Fifth Judicial District of Iowa, said the fluoroscopy rule did not meet proper state guidelines. He ruled that the regulations were invalid and illegal (link).

"In order for ARNPs to provide 'direct supervision' of fluoroscopy as the term is defined within the Iowa Administrative Code, they must satisfy minimum education and safety standards, including continuing education requirements and an examination established by the Iowa Department of Public Health," he said in his ruling. "Even if the expansion of practice by [the nursing board] had been valid, which is not the case, neither the [board nor the department of public health] rules establish a curriculum or minimum criteria and safety standards."

Radiation risks raised concerns

At this article's deadline, the Iowa Dept. of Public Health was considering whether to appeal, said spokeswoman Polly Carver-Kimm.

In a letter submitted as part of the legal proceedings, the Iowa State Board of Health defended its decision to adopt the rules, stressing that the board and the public health department considered all feedback before approval. ARNPs are "currently supervising fluoroscopic procedures in several areas of practice, including needle localization and insertion of [peripherally inserted central catheter] lines," wrote Cheryll Jones, chair of the Iowa State Board of Health.

State health officials have seen no documented evidence that supervision of fluoroscopy by ARNPs has resulted in any problems or reported injuries in the state, Jones said. Training requirements already in place ensure nurses' competency to supervise fluoroscopy, she added.

The Iowa Nursing Assn. and the American Nursing Assn. did not return calls for comment by this article's deadline.

The Iowa Medical Society was pleased with the court's decision, Dr. Hutchison said.

Fluoroscopy includes higher doses of radiation than CT scans, he said. If administered improperly, patients and technicians would be exposed to even higher and more dangerous levels of radiation, he added.

Iowa doctors are not opposed to nurse practitioners supervising fluoroscopy in the future if they receive appropriate training, Dr. Hutchison said.

"We are very willing to reopen the lines of discussion and continue to work on getting them to a level where they can [oversee] fluoroscopy," he said. "If there are expert recommendations on what you have to do and they meet those, we absolutely will not stand in their way."