Supervision of Exercise Testing by Nonphysicians
2014; Lippincott Williams & Wilkins; Volume: 130; Issue: 12 Linguagem: Inglês
10.1161/cir.0000000000000101
ISSN1524-4539
AutoresJonathan Myers, Daniel E. Forman, Gary Balady, Barry A. Franklin, Jane Nelson‐Worel, Billie‐Jean Martin, William G. Herbert, Marco Guazzi, Ross Arena,
Tópico(s)Cardiovascular Effects of Exercise
ResumoHomeCirculationVol. 130, No. 12Supervision of Exercise Testing by Nonphysicians Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBSupervision of Exercise Testing by NonphysiciansA Scientific Statement From the American Heart Association Jonathan Myers, PhD, FAHA, Daniel E. Forman, MD, FAHA, Gary J. Balady, MD, FAHA, Barry A. Franklin, PhD, FAHA, Jane Nelson-Worel, MS, APNP, Billie-Jean Martin, MD, William G. Herbert, PhD, Marco Guazzi, MD, PhD and Ross Arena, PhD, PT, FAHAon behalf of the American Heart Association Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention of the Council on Clinical Cardiology, Council on Lifestyle and Cardiometabolic Health, Council on Epidemiology and Prevention, and Council on Cardiovascular and Stroke Nursing Jonathan MyersJonathan Myers , Daniel E. FormanDaniel E. Forman , Gary J. BaladyGary J. Balady , Barry A. FranklinBarry A. Franklin , Jane Nelson-WorelJane Nelson-Worel , Billie-Jean MartinBillie-Jean Martin , William G. HerbertWilliam G. Herbert , Marco GuazziMarco Guazzi and Ross ArenaRoss Arena and on behalf of the American Heart Association Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention of the Council on Clinical Cardiology, Council on Lifestyle and Cardiometabolic Health, Council on Epidemiology and Prevention, and Council on Cardiovascular and Stroke Nursing Originally published18 Aug 2014https://doi.org/10.1161/CIR.0000000000000101Circulation. 2014;130:1014–1027Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2014: Previous Version 1 IntroductionThe standard exercise test is a well-established procedure that has been widely used in cardiovascular medicine for many decades, with staffing issues that have changed over time. The test is frequently considered the "gatekeeper" to more expensive and/or invasive procedures since it is often the first diagnostic evaluation when coronary artery disease (CAD) is suspected. Thus, it is used to help guide decisions regarding diagnosis and/or medical and interventional management. Moreover, the prognostic value of aerobic capacity and other variables obtained during exercise is firmly established in those who are apparently healthy and in virtually all patient populations.1,2 Generally, peak or symptom-limited exercise testing is used to detect signs or symptoms of myocardial ischemia and to discern fundamental information on exercise capacity, exercise hemodynamics, dysrhythmias, oxygenation, neuroautonomic health, symptoms, and other physiological responses. In most instances, peak effort entails at least brief periods of high-intensity exercise, and evidence suggests that such vigorous physical exertion may cause a transient increase in the risk of cardiovascular events in high-risk individuals.3,4 Because the exercise test is typically performed in patients with known or suspected cardiovascular disease, guidelines and scientific statements on exercise testing have historically recommended physician presence for supervision as a means both to optimize functional and diagnostic testing decisions and safety and to administer emergency treatment should complications occur. However, systematic surveys of multiple centers and reports from individual clinical exercise laboratories have shown that contemporary exercise tests are often conducted and supervised by nonphysicians (eg, exercise physiologists, nurses, physical therapists [PTs], physician assistants [PAs]). These reports and empirical evidence suggest that testing efficacy and safety are similar in laboratories where tests are directly supervised by physicians and those where nonphysicians administer testing under the egis of a physician supervisor.5–11 This issue has been the topic of significant debate in the past, and there are currently no consistent or widely accepted standards on exercise test supervision.To some extent, staffing shifts in exercise testing laboratories have been motivated by growing priorities for cost containment and greater efficiencies of medical care. Nonphysician care providers often now conduct the mechanics of exercise testing under a physician's supervision at less cost than testing performed directly by physicians. Although the details of supervision and physician proximity vary between individuals and institutions, the key point is that direct physician contact with the patient has diminished5–12 while involvement by allied healthcare providers has expanded. A premise of this scientific statement is to characterize testing strategies that center attention on quality compared with cost. Nonphysicians may even provide some advantages in regard to patient care but not as surrogates for physicians' clinical skills and medical knowledge.Previous statements are related to physician qualifications for the supervision of exercise testing from the American Heart Association (AHA)/American College of Cardiology (ACC) and the American College of Physicians.13,14 Performance criteria and personnel certification programs have been available from the American College of Sports Medicine (ACSM) for >30 years, but AHA/American College of Physicians statements in this area have been directed at the physician. However, in contemporary exercise laboratories, physicians often provide supervision or oversight but are less frequently physically present for testing. "Supervision" has been interpreted in different ways, and for the purposes of this document, 3 categories of physician supervision are used, depending on the type of patient being tested13: (1) personal supervision, requiring a physician's presence in the room; (2) direct supervision, requiring a physician to be in the immediate vicinity or on the premises or the floor and available for emergencies (explicitly defined as the ability to be in the testing room within 30 seconds of notification); and (3) general supervision, requiring the physician to be available by phone or by page (generally appropriate for healthy, asymptomatic individuals).The present statement responds to the need to specify the appropriate education, training, experience, and cognitive and procedural skills necessary for nonphysicians to conduct exercise testing and to delineate standards that maintain patient safety. This statement also responds to the need to provide physicians with guidance in terms of cognitive and procedural skills that strengthen their ability to supervise nonphysician health professionals who perform exercise testing.Key principles endorsed by this statement include recognition that proficiency and quality of exercise testing can be achieved by nonphysician health professionals but that physician participation also remains indispensable. Ideally, exercise testing entails a team approach. Nonphysician health professionals may administer and even supervise exercise testing independently, but physician involvement is essential with respect to delineation of testing policies/standards, medical safety standards and monitoring, physical proximity in emergent situations, and direct participation for patients at high risk.The necessity for this statement also evolves from changes in clinical practice patterns in regard to exercise testing in which many exercise tests—in some centers, most exercise tests—are administered by nonphysicians,5–12 including those in low- to high-risk patients. As these changes have evolved, ambiguity about the physician's role relative to the nonphysician has been increasingly common. Other AHA scientific statements address cardiopulmonary exercise testing and exercise and pharmacological imaging procedures specifically, each of which has its own unique set of cognitive and procedural skills.15–17 This document is intended to complement a previous ACC/AHA statement on clinical competence on exercise testing for physicians13 and to extend previous AHA scientific statements related to exercise testing.12,13,16–19 The writing group has considered current practice patterns; studies on risks associated with exercise testing; efforts by the ACSM and other organizations to formulate knowledge, skills, and abilities for conducting clinical exercise testing; legal implications; and the recognized scope of responsibilities for nonphysician health professionals who might perform exercise testing. Competence is a complex issue, and by its nature, an evidence basis for recommendations is not always available; when this is the case, the writing group has used consensus opinion to formulate recommendations.Continued Relevance of the Exercise TestPublication of this document on exercise test supervision is in the context of a broader debate on the utility and application of functional and diagnostic testing. Whereas exercise testing was originally based on the assumption that cardiac risk was determined primarily by obstructive CAD, which could be reliably detected by provocative testing,16 coronary risk is now attributed more to inflammatory processes, plaque stability, or the nature of coronary lesions.20 Therefore, many now regard biomarkers as superior gauges of risk and imaging as a preferred methodology to quantify or characterize plaque, calcium, or other pertinent anatomic lesions.Nonetheless, this statement presumes an enduring and unambiguous value of exercise testing. For ischemic heart disease, exercise testing yields a physiological perspective on plaque burden and is a pertinent gauge of hemodynamics, arrhythmias, symptoms, and other indexes that provide independent and additive information to inflammatory and other biopeptide markers, adding critical perspectives on prognostic evaluation and management choices.2 Moreover, exercise testing has substantive value as a means to delineate ischemic ECG, angina thresholds, and other abnormal physiological responses during activity, as well as facilitating pertinent assessments in heart failure, valvular heart disease, arrhythmias (supraventricular and ventricular), conduction disease, peripheral arterial disease, pulmonary hypertension, chronic obstructive pulmonary disease, and other subclinical disease processes that are increasingly prevalent in an aging population prone to chronic diseases and multimorbidity.2 Functional quantification is a key end point for all these conditions, and this measurement is enriched when integrated with hemodynamics, heart rate changes, conduction changes, and symptoms, as well as in combination with myocardial perfusion imaging,21 gas exchange,17 and associated metabolic parameters.22 Decisions about patient selection, type of test, and which end points are to be prioritized require sophistication and expertise.The blend of physician and nonphysician personnel adds to the potential for excellence and efficiency. The range of clinical needs and testing modalities implies the need for a variety of testing expertise, with physicians often benefitting from complementary skill sets of allied providers. Therefore, instead of focusing on exercise testing personnel as a single prototype with redundant roles, it is important to identify where physicians and nonphysicians overlap and where they differ and thus how they can best complement one another to optimize test performance and safety.Evolution of Exercise Test SupervisionOver the past 30 years since the AHA released its first set of standards for adult exercise testing laboratories,23 the role of the physician in ensuring that the exercise laboratory is properly equipped and appropriately staffed with qualified personnel who adhere to a written set of policies and procedures specific to that laboratory has not changed. However, the issue of whether all exercise tests should be directly and personally supervised by a physician has evolved over time, as has the range of patients being tested. In 1979, the AHA stated that "a physician must be immediately available, but may delegate the actual conduct of the test where he has determined it can be safely performed by experienced paramedical personnel."23 Since that time, the AHA, ACC, ACSM, and American Association of Cardiovascular and Pulmonary Rehabilitation have consistently addressed this issue in subsequent iterations of their respective guidelines.12,16,24,25 In 2000, the ACC/AHA/American College of Physicians–American College of Internal Medicine Competency Task Force focused its efforts on outlining the specific cognitive and training requirements for those personnel involved with the supervision and interpretation of exercise ECG testing and with stress imaging tests administered to adults, children, and adolescents. That seminal document was the first to look beyond the specific professional type (eg, physician, nurse, exercise physiologist) and focus on specific competencies of the individual staff member.13 Detailed recommendations of the most recent version of professional guidelines are provided in Table 1.12,13,16,24,25 Common to each of the published guidelines are several key recommendations: Patients are screened before exercise testing to identify the most appropriate personnel to supervise the test; exercise testing may be supervised by nonphysician staff who are deemed competent according to the criteria as outlined in the ACC/AHA statement13; a physician is always immediately available to assist as needed (ie, to provide direct supervision as defined in Table 1); and in high-risk patients, the physician personally supervises the test (as defined in Table 1).Table 1. Summary of Guideline Recommendations for Nonphysician Supervision of Exercise TestsOrganizationGuideline /YearRecommendationAHA/ACC"Clinical Competence Statement on Stress Testing"13/2000(PMID 11015355)In most patients, exercise testing can be safely supervised by properly trained nurses, physician assistants, exercise physiologists, physical therapists, or medical technicians working under the direct supervision of the physician, who should be in the immediate vicinity or on the premises or the floor and available in case of emergency situations. It is recommended that nonphysicians who supervise the actual exercise test have certain cognitive skills (as outlined in this document) and that they be certified in exercise testing by organizations such as the ACSM. In general, the physician should be present to observe the patient continuously (ie, personally supervise) when the test is performed on a patient with a recent (within 7–10 d) history of documented acute coronary syndrome, severe left ventricular dysfunction, severe valvular stenosis (eg, aortic stenosis), or complex arrhythmia. In all instances, the healthcare provider should screen the patient for indications and contraindications immediately before the test.*AHA"Recommendations for Clinical Exercise Laboratories"12/2009(PMID 19487589)These guidelines call for risk stratification of people to be tested to determine the appropriate level of medical supervision needed during testing. The use of specially trained nonphysician healthcare professionals is appropriate to supervise clinical exercise testing if the individual supervising the test meets competency requirements for exercise test supervision, is fully trained in cardiopulmonary resuscitation, and is supervised by a physician skilled in exercise testing, who is immediately available and later reads over the test results. These nonphysician health professionals typically include exercise physiologists, nurses, nurse practitioners, and physician assistants but may include other health professionals. This practice should be compatible with state licensure regulations and statutory definitions for the practice of medicine before it is implemented.AHA"Exercise Standards forTesting and Training"19/2013Exercise testing should be conducted only by well-trained personnel with sufficient knowledge of exercise physiology and ability to recognize important changes in rhythm and repolarization on the ECG. The degree of subject supervision needed during a test can be determined by the clinical status of the subject being tested. This determination is made by the physician or physician's designated staff member, who asks pertinent questions about the subject's medical history, performs a brief physical examination, and reviews the standard 12-lead ECG performed immediately before testing. Supervision can be assigned to a properly trained nonphysician (ie, a nurse, physician assistant, or exercise physiologist or specialist) for testing apparently healthy younger people ( 2.1 million exercise tests is given in Table 3, with specific reference to year of publication, morbidity and mortality rates, total complications, and direct supervision (ie, physician versus nonphysician).5–9,11,28–40 Subjects included apparently healthy individuals and adults with known or suspected cardiovascular disease, athletes, and patients with a history of high-risk cardiac conditions, including chronic heart failure (ie, New York Heart Association class II–IV heart failure caused by left ventricular systolic dysfunction), hypertrophic cardiomyopathy, pulmonary hypertension, aortic stenosis, malignant ventricular arrhythmias, or combinations thereof. Complications were defined primarily as the occurrence of acute myocardial infarction or exercise-induced threatening arrhythmias (ventricular tachycardia, ventricular fibrillation, or marked bradycardia) that mandated immediate medical treatment. However, other complications were broadly reported in some studies and included supraventricular tachycardias, atrial fibrillation, stroke, transient ischemic attack, nonsustained ventricular tachycardia, syncope, implantable cardioverter-defibrillator discharges requiring hospitalization, and vasovagal episodes, resulting in considerable variation in the associated test morbidity and total complications.Table 3. Complication Rates of Exercise Testing (1971–2012)ReferenceYearTests, nMorbidity Rate, n per 1000Mortality Rate, n per 1000Total Complications, n per 1000Physician Supervised?Rochmis and Blackburn281971≈170 0000.240.100.34Yes*Scherer and Kaltenbach301979353 638†000Yes*712 285‡0.140.020.16Yes*Atterhog et al31197950 0000.520.040.56Yes*Stuart and Ellestad291980518 4480.840.050.89Yes*Young et al3219841377§23.2023.2Yes*Lem et al33198540500.0300.03No‖Cahalin et al9198718 7070.380.090.47No‖DeBusk341988>12 000NR0.25NRNo‖Allen et al3519886478.0078.0YesGibbons et al36198971 9140.070.010.08Yes*Knight et al8199528 1330.3200.32No‖Franklin et al5199758 0470.210.030.24No‖Ilia and Gueron37199738 9701.1001.10YesSquires et al719992893.4603.46No‖Myers et al6200075 8280.1200.12Yes*Scardovi et al3820073952.5302.53NRKane et al39200885920.9300.93No‖Keteyian et al40200944110.4500.45Yes/No¶Skalski et al11201250601.5801.58No‖NR indicates not reported.*The majority of these tests (73% to >85%) were directly supervised by physicians.†Athletes.‡Coronary patients.§Patients with a history of malignant ventricular arrhythmias; complications (morbidity rate) were defined as the occurrence of serious arrhythmias during exercise testing (ie, ventricular fibrillation, ventricular tachycardia, or bradycardia) that mandated immediate medical treatment (cardioversion/defibrillation, use of intravenous drugs, or closed-chest compression).‖"No" signifies that these tests were directly supervised by a specially trained/certified allied health professional (eg, clinical exercise physiologist, nurse, physical therapist) with a physician available in the immediate area for pretest evaluation of selected patients and to assist in the event of an emergency.¶All exercise tests were directly supervised by a physician or an allied health professional (eg, clinical exercise physiologist or nurse) with medical supervision in close proximity.A review of these separate studies (Table 3) shows that 16 of the 19 reports included complication rates derived from >1000 exercise tests. The reported death rate for testing, which generally included a follow-up period to capture patients hospitalized as a result of a documented adverse event (ie, death within 48 hours of the exercise test), ranged between 0 and 0.25 per 1000 tests. In the same populations, the combined rates for morbidity and mortality (total complications) were between 0 and 78.0 events per 1000 tests. However, the latter complication rate (78.0 events per 1000 tests) was derived from 5 reported cases of sustained ventricular tachycardia in 64 exercise tests in patients with a history of life-threatening ventricular arrhythmias.35 Similarly, in a series of 263 patients with a history of malignant ventricular arrhythmias who underwent a total of 1377 peak or sign- or symptom-limited exercise tests, investigators reported 32 episodes of sustained ventricular tachycardia, ventricular fibrillation, or profound bradycardia mandating immediate medical treatment.32 Although no deaths or myocardial infarctions were noted in either report,32,35 combining these 2 studies of high-risk patients yields an alarming complication rate, 25.7 per 1000 tests. If these 2 reports involving small numbers of extremely high-risk patients are excluded from Table 3, the total complication rate ranges from 0 to 3.46 events per 1000 tests. Although it is not possible from these data to stratify risk by population or testing method, the rate of total complications appears higher in populations who are undergoing diagnostic exercise testing, including patients with chronic heart failu
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