Re: Submission College of Nurses of Ontario (CNO)-Scope of Practice Nurses in the Extended Class

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Clyde Lawson
5 years ago
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1 November 26, 2007 Barbara Sullivan Chair Health Professions Regulatory Advisory Council 55 St Clair Avenue West Suite 806 Box 18 Toronto, Ontario, Canada M4V 2Y7 Fax: Re: Submission College of Nurses of Ontario (CNO)-Scope of Practice Nurses in the Extended Class Dear Ms. Sullivan, For the past 28 years I have practiced in the field of diagnostic imaging and the past 24 years as a sonographer. I have practiced in both the acute care hospital setting as well as the private sector (IHFs). I have had the opportunity to teach ultrasound as a clinical instructor for Mohawk College for 15 years. Currently I coordinate the mobile services for STL Diagnostic Imaging for the Niagara, Hamilton, Burlington, Milton, Oakville, Brantford, Paris and Simcoe regions. STL Diagnostic Imaging provides mobile ultrasound and radiology services to the Long Term Care facilities, correctional facilities as well as CCAC clients. After reviewing the submission and attending the consultation session held in Toronto on November 20, 2007, as a registered sonographer in clinical practice I cannot support the submission request to include the application ultrasound energy for diagnostic purposes as part of the Scope of Practice for the Registered Nursed in the Extended Class. The Practice of Sonography Sonographers are employed in hospitals, independent health facilities (IHF s), fixed sites and mobile, research labs educational institutions and the commercial industry. In Ontario there are approximately 3000 sonographers that provide health services to individuals of all ages and developmental stages from infants to geriatric patients. The provision of health care is in conjunction with other healthcare professionals. The competent practice of sonography requires a significant body of knowledge. There are currently two accredited programs in Ontario, The Mitchener Institute for applied Sciences (18 month post graduate program) and the Mohawk-McMaster four year program. Both programs include theory and comprehensive clinical practice components. The programs are competence based and prepare the sonographer for the registry examinations and ultimately a career as a sonographer. 1

2 Sonography is heavily operator dependent. The skill of the sonographer determines the quality of the study and ensures that there is accurate representation of the patient s condition. Sonogrphers work independently. The reporting physician generally has contact with only the hard copy or digital images. The reporting physician even when consulting with the sonographer only scans the region of concern rather than repeating the full examination. If the individual performing the examination does not have the knowledge skill and judgment required to perform the ultrasound examination the public is placed at risk of harm. OBSERVATIONS Education It is noted in the submission that the proposed change in scope of practice, to perform ultrasound examinations, will have only minimal impact on education and training. Competence in sonography requires at minimum 18 months in a post graduate program. As a clinical instructor I have had the opportunity to teach nurses as well as other health professionals sonography a second discipline. Sonography requires at minimum the 18 month post graduate program and continued mentoring in post graduate clinical practice to maintain accurate high quality ultrasound services for the public Technology, as noted in the submission, is rapidly changing therefore only individuals that are competent and maintain continued competence should be performing ultrasounds examinations. Inaccurate information recorded in the images and lack of correlation with relevant clinical data (lab tests, previous imaging, and patient condition) can result in missed conditions, disease or pathology, miss-interpreted or invented lesions may result in unnecessary additional investigations or even unnecessary surgery. There are issues of infection control, intimate patient contact, performing controlled as in trans-vaginal and trans-rectal scans as well as administering substances by injection which can place the patient at risk of harm if the individual performing the procedure lacks the comprehensive training that will protect the public from harm. We have had the recent example of infection control issues related to trans-rectal biopsies. Clinical Practice If the nurse in the extended class performs the ultrasound examination, who will be reporting and rendering a diagnosis? One of the examples provides at the consultation session was performing venous doppler examinations at the Long Term Care facilities, to rule out deep vein thrombosis (DVT) which would be considered an urgent examination requiring treatment if the examination is positive. The patients in the Long Term Care facilities and Correctional facilities are 2

3 a challenge to scan even for an experienced sonographer. This patient population has complex medical histories with associated pathologies. Working with this patient population on daily basis, I believe a nurse practitioner with minimal training performing a limited number of examinations; will not meet the required level of competence to service this patient population. It was suggested that the nurse practitioners could perform only limited studies for DVT to eliminate the need to transfer the patients to hospitals. I agree that patient in Long Term Care facilities patients are fragile and best served by providing the imaging services in house. At STL the requests for DVT examinations are a very small percentage of the overall examination requests for the Long Term Care Facilities as well as the Correctional facilities. To provide a comprehensive imaging service to the above noted facilities would require the 18 month ultrasound program and the additional clinical expertise to become a competent generalist in ultrasound. Imaging services cannot be fractured and compartmentalized. It is not realistic to suggest that training in only one examination will provide adequate imaging services to any patient population that was discussed at the consultation session in Toronto, whether the service required is in a Long term Care facility, correctional facility or remote regions of Ontario. There was a suggestion that perhaps in some instances all that is required is expertise in pelvic scans. A request for a pelvic exam for assessment of right lower quadrant (RLQ) pain is common. The uterus and ovaries may be normal but the individual performing the examination must have the knowledge, skill and judgment to expand the examination to respond to the clinical concern rather than the specific order. Sonographers expand the examination order to respond to the clinical exam indication routinely. The cause of the pain could be appendicitis, diverticulitis, ulcerative colitis or a bowel mass, which requires expertise in bowel imaging. The cause of pain could be an ectopic pregnancy (pregnancy in a fallopian tube) which is a medical emergency and requires expertise in obstetrical imaging. The cause could be a stone in the ureter which requires expertise in abdominal scanning to provided a diagnosis for the pain. There could be a hernia or a rupture in the abdominal wall which requires additional skill sets in musculoskeletal scanning. This apparent simple pelvic examination has the potential to draw on the full skill set of a general sonographer trained in the full scope of ultrasound examinations. Allowing individuals with any less than the full technical to perform ultrasound examinations has the potential to place the patient at risk of harm. The concepts of knowledge, skill and judgment were expressed though out The consultation session, but there is no evidence in the submission for a plan to ensure that the knowledge skill and judgment is attained and maintained. When the presenters were asked to provide a examples of a process that would ensure that the nurse practitioner of the extended class would not exceed their scope of practice, there were no convincing arguments provided. 3

4 Mobile Ultrasound With the improved quality in mobile ultrasound units there is the apparent concept that the units require less skill to operate. With the installation of ultrasound units in emergency departments the concept is provided as example. In fact, one nurse presenter at the consultation session suggested that all that is required is a four hour course. The emergency physicians have radiologists and sonographers available to them for urgent consultation. This use in the emergency department is extremely limited in scope, based on discussion with certain physicians practicing in emergency departments. Working with mobile units routinely I can assure you that there is the same skill set required for mobile units as for any fixed site. Four hours is not adequate training in the clinical setting the nurse presenters were suggesting such as Long Term Care facilities. The nurse presenter s comments appear to be based on a lack of evidence based research. RECOMMENDATIONS 1. In Ontario we have sonographers who are qualified imaging professionals that currently provide a high quality ultrasound service in a safe patient care environment. We would recommend working with the Ontario Society of Medical Diagnostic Sonographers (OSDMS) in enhancing current imaging services to close any potential gaps in the delivery of ultrasound services. 2. The expansion of mobile ultrasound services as well as radiography services would provide comprehensive imaging services that would address the issues discussed at the consultation session November 20. The funding level for mobile imaging services would require review to support more comprehensive services. The benefits of an expanded mobile service would result in ultimate cost saving to the medical system, related to patient transfer costs, as well as patient and public safety. In the Long Care facilities it would also provide a compassionate, high quality imaging service in safe supportive environment for a fragile patient population. There are other mobile imaging providers in Ontario beyond STL Diagnostic Imaging. In Manitoba, there is a Hospital based mobile service. I would recommend working with the representatives of the diagnostic imaging community to develop a more comprehensive imaging service. 3. Establish standardized educational requirements for the practice of sonography across Ontario. 4. Set minimum educational and clinical competence standards in legislation for the practice of sonography to protect the public from risk of harm. 5. The nurse presenters at the consultation session expressed that they were not attempting to replace physicians, therefore by extension, I would assume that they are not attempting to replace sonographers or other allied health care professionals. The nurse presenters recommended 4

5 that we work in a collaborative environment drawing on various levels of medical expertise. I agree, and to that end we should look at the most appropriate model of health care delivery to provide competent imaging services for the patient population in Ontario. SUMMARY STATEMENT The submission by the College of Nurses of Ontario (CNO) and the nurse presenters at the consultation session did not provide adequate evidence based data to ensure that the expanded scope of practice would protect the public from risk of harm. In the public interest, I do not support the expanded scope of practice and urge HPRAC to consider the potential risk of harm in their recommendations. Thank you for the opportunity to provide comments in the consultation process. Sincerely, Danica Prusic BA, RDMS, RTR, CRGS, ADipHSA Cc Ontario Society of Medical Diagnostic Sonographers Canadian Society of Diagnostic Medical Sonographers Canadian Association of Registered Diagnostic Medical Professionals Ontario Association of Medical Radiation Technologists 5

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