To CT or not to CT – December 2016

When is it appropriate for a nuclear medicine technologist to perform CT and in what capacity?

The landscape of nuclear medicine has changed considerably over the last decade as has the entire field of medical radiation technology. As you are all aware, one of the major catalysts to this change is the introduction of hybrid scanners: SPECT/CT, PET/CT, PET/MR…where does it end?

What I would like to explore here is a facet of professional regulation that is often misunderstood; that is authorized practice. We are going to delve into the concepts of restricted activities, authorization and enhanced practice.  I hope that this gives you insight into the regulatory environment and the rationale behind some of the requirements of being a regulated professional in Alberta.

The current practice of nuclear medicine technologists in Alberta is governed by the Medical Diagnostic and Therapeutic Technologists Profession Regulation. The document was last amended by government in 2009 – a time when we were starting to hear about SPECT/CT and thinking “we’ll never get one, so why do I have to worry about it?”  Well, fast-forward seven years and you are hard-pressed to buy a gamma camera without a CT, of some sort, attached.  Working with a CT of some sort within a nuclear medicine department has become the norm in 2016 but we must step back, reflect on our practice and ask if we are authorized by the College to do this. Can I perform this restricted activity?

In response to these changes in practice the College addressed the question of authorization within the framework of practice by releasing a position statement CT in the Nuclear Medicine Environment.  What it says is that if a nuclear medicine technologist is performing CT with the intention of no more than attenuation correction and/or anatomical mapping, it is considered within the scope of any nuclear medicine technologist’s practice. It is important to focus on the intent of the actions and not the camera which you are operating.  Should the CT images that you are producing be used/interpreted separately from the nuclear medicine images, or if you are preparing and/or administering diagnostic imaging contrast media, it is required that you have the CT and Contrast Media enhanced practice authorization on your practice permit.

For some systems, the intent is obvious as the camera does not have the physical capability to produce diagnostic CT images; but, with some hybrid systems, this question is quite muddy. It is important for you to be aware of what the images that you are producing are being used for. Only attenuation correction (AC) or is the radiologist or resident “reading” the scan and commenting on what they see rather than  the former where the radiological images are purely augmenting the bone scan, MIBI or whatever nuclear medicine procedure you are performing?  The answer to this question will tell you whether you require the CT and Contrast Media enhanced practice authorization to perform these scans or not.

So moving back to the concept of restricted activities, some of you may not have heard the term. In Alberta’s Government Organization Act, government has published a finite list of health acts that may cause possible harm to the public.  This doesn’t suggest that these activities will cause harm, but there is the possibility for it.  Examples include application of ionizing radiation; application of non-ionizing radiation; preparation and administration of contrast media; and venipuncture.  Other examples include such health services as the prescription of contact lenses and surgical procedures.  It is a comprehensive list applicable to all regulated health professionals in Alberta.  When a College’s regulations are created, a subset of these restricted activities is incorporated by the College and government to give different groups of members’ different restricted activities and therefore different authorizations.

This is why CT and contrast media is such a big deal currently for nuclear medicine technologists. Having registration with the College does not authorize you, because the restricted activity isn’t in the nuclear medicine register list, to apply ionizing radiation in medical radiography (read CT) nor to prepare or administer contrast media.  The College wants to evolve practice and keep up with the times and we are very fortunate that some foresight was put into the regulation to allow for enhanced practice authorizations by “borrowing” restricted activities from other registers or other specialties of the College.  As a result, if it is a requirement that a nuclear medicine technologist perform CT over and above what is required for attenuation correction and anatomical mapping AND/OR is preparing and/or administering contrast media, they can complete a program of study and apply for the authorization as they must have the CT and Contrast Media enhanced practice authorization to be legally permitted to perform these additional restricted activities.

The College cannot police, nor does it want to, all registered practitioners to ensure that they are performing only those activities for which they are authorized. It therefore falls back to the regulated professional to ensure that they are performing within their authorizations in a safe and effective manner. As a regulated professional, this is your responsibility. In a worst case scenario, in any situation, something may go awry and a complaint may be brought upon a member of the College by the public.  If you are performing duties that you are authorized to perform, your professional liability insurance (PLI) policy will be valid for the occurrence as it is within your scope.  If you are performing something that you are not authorized for, something goes awry and a complaint results, your PLI will not be valid and you will be left with the personal consequences; both financial and professional.

Hopefully this explains the rationale and process for enhanced practice. Should you have any questions or concerns, please feel free to contact the College.  It’s imperative that we move practice forward together and communication is the best starting point.  We look forward to hearing from you.