Cardiology Technology Regulation Support Petition
Ontario Leads the Charge Towards Recognized Regulation
The Presentation as presented before the Social Policy Committee on Bill 60: Your Health Act
Good afternoon, Chair and committee members,
My name is Blair Arnold, president of the Ontario society of cardiology technologists (OSCT) and a registered cardiology technologist (RCT) with over 20 years experience in the field. Thank you for the opportunity to present today on behalf of the over 1100 registered cardiology technologists on Bill 60 to discuss proposed amendments to Ontario’s “Your Health Act”.
I would like to ask the committee to consider the addition of an amendment to regulate vital organ health professions such as cardiology technologists to better protect patient health and safety deficiencies caused by the duplication of testing and assessment due to improper administration by non cardiology technologists as well as erroneous referrals for physician specialist consultation. This would create greater efficiency and cost savings and strengthen recruitment and retention of vital organ allied health professionals.
Our members have received education and training in cardiac diagnostic testing including, ECG administration and interpretation, stress testing, ambulatory monitoring, implantable cardiac devices, cardiac catheterization and electrophysiology testing. They practice in teaching hospitals, community hospitals, outpatient labs and private physician practices. There are currently 4 accredited programs in Ontario who offer Cardiology technology as a 2-year diploma. Registered cardiology technologists (or RCTs) are uniquely trained to detect cardiac anomalies and activate appropriate responses and referrals to other health care professionals and services.
COVID-19 highlighted the value that RCTs bring to patients and the health system, but also unveiled glaring issues with regards to patient safety, access, and health spending. As RCTs are currently not a regulated profession but instead are delegated by physicians, this has left room for other professionals, namely nurses, respiratory therapists, and lab technicians to be tasked with performing the duties of an RCT. In the private clinical setting, even clerical staff has been trained on the job to perform some of this testing. The safety issue arises when the test is performed incorrectly, which is all too common, and results are either misinterpreted or go unnoticed by the operator. Our members have submitted many reports of patients suffering injury, or in extreme cases, death due to improperly performed tests and misinterpreted results. Though RCTs perform under the delegation of a physician, the presence of a physician during and immediately after testing is not assured and is in fact a rarity, as they attend to other practice demands. RCTs are entrusted to accurately perform and review the test results and notify the appropriate medical professional in the event immediate treatment or intervention is required, as they have received specialized and specific training in the interpretation of these tests.
I recently received a report from one of our members detailing the outcome of poor testing performed by a non-RCT on a 10-year-old child. This patient was sent to a private outpatient clinic for an ECG, a simple and inexpensive preliminary test, which triggered an urgent consult, one week later, to a pediatric cardiologist due to “suspected Brugada syndrome”, a serious condition affecting the electrical signals that pass through the heart which can result in severe injury and death. At the consult, a repeat ECG was performed by an RCT and showed a completely normal result. The RCT then, upon reviewing the previous ECG completed at the lab, moved.
2 of the chest electrodes one rib spacing, which is approximately 1 CM on a child and was able to replicate the same “Brugada” pattern. The cost of a simple test being performed incorrectly by a non-RCT was 3-fold: lost time from work, school, and incredible stress for the patient and their family, the expense of a pediatric cardiologist consult, repeat ECG and an echocardiogram, and the loss of a consult appointment slot that could have served another patient with a legitimate cardiac complaint.
We recognize and appreciate our healthcare colleague’s role in providing care to Ontarians, however they have not received adequate education and training in this space to deliver the right care at the right time to Ontarians, nor can Ontarians be sure they are receiving testing by a qualified professional.
Post COVID patient volumes have swollen over the last 12 months, with many patients presenting to emergency departments and urgent care clinics with exacerbated illness due to a lack of access to appropriate diagnostic testing during the height of the pandemic. Budgetary concerns have driven many health systems to elect to place the responsibility of cardiac diagnostic testing on to other professionals including nurses, respiratory therapists, and lab technicians to avoid extra spending on human resources in the form of RCTs. The reverse outcome is an increase in spending namely: overtime due to increased workload, the need for repeat testing by an RCT due to improperly conducted tests, erroneous referrals to cardiologists and emergency departments, patient injury requiring hospitalization, and in extreme cases, death.
As the Ontario population ages, with cardiac disease incidence rates estimated to be between 4.2-25.3%, early and accurate detection and treatment of these disease would save the province approximately $20-80000 per patient per day in saved hospitalization costs alone.
If we truly care about Ontarians, Registered Cardiology Technologists NEED to be regulated to bring reinforcements to the frontline of our health care system, make “right time, right care” more accessible, protect our health care budget and to align with the plan to “stay open for health system stability and recovery,
Thank you for this opportunity.
*This was presented verbally before the Social Policy Committee on Bill 60: Your Health Act
Request to Participate in Social Policy Committee
Introduction
Despite being the second leading cause of death in Canada, many effective treatments exist for heart diseases. However, physicians’ ability to prevent, diagnose, and treat cardiac issues relies on having patient data that is accurate, relevant, and timely. Given that this field involves such a vital organ and is essential in the treatment of cardiac conditions, it is absolutely crucial that tests are performed by those with the skills and training required to do so properly. Yet, in Ontario, formal education, and registration as a Cardiology Technologist (CT) is not required to carry out cardiac testing. In an effort to reduce staffing costs, medical professionals such as registered nurses and lab technicians, and even clerical staff are being given the responsibilities of CTs despite lacking appropriate training. Ultimately, this is to the detriment of the healthcare system. Failure to carry out tests properly, performing a test inappropriate to the situation, or an inability to recognize an emergency while testing can—and has—resulted in additional legal and labour costs to hospitals and needless harm to patients.
We recommend that the Ministry of Health regulate the profession of Cardiology Technologists in order to reduce inefficiencies in cardiac testing and raise the standard of care for patients across the province.
Personal Bio:
I, Blair Arnold, graduated from the Mohawk College one year Cardiology Technology program in 2001, and wrote the certifying exam from the now defunct group Cardiology Technologists Association of Ontario (CTAO). I graduated from the accelerated post-graduate Diploma program Diagnostic Cardiac Sonography from Mohawk College in 2002.
I pursued a career in Implantable Cardiac Devices taking up a full-time post at St. Michaels Hospital (now Unity Health) in Toronto in 2003. In 2006, I joined St. Joseph’s Health Centre (now Unity Health) to head up their Pacemaker program and became program coordinator in 2007 for the Diagnostic Cardiology Department. I wrote and obtained credentials with The Canadian Advanced Implantable Cardiac Devices Exam in 2006 and The International Heart Rhythm Examiners (IBHRE) exam in 2007.
In 2008 I was elected as Assistant Education Director for the Ontario Society of Cardiology Technologists (OSCT) and served in that capacity until 2014. I was then elected as Education Director for the OSCT in 2014 and held that position until 2022, concurrently performing as Vice-president between 2020 and 2022. May 2022 I was elected President of the OSCT and Ontario representative for the Canadian Society of Cardiology Technologists (CSCT).
From 2012-2013 I taught Implantable Cardiac Devices at a private college on a part-time basis.
I have worked continuously in cardiology technology for 20 years as a Cardiac Device Specialist and maintain good standing status within my provincial certifying body, the OSCT.
Ontario Society of Cardiology Technologists (OSCT) Background:
The OSCT was formed from two provincial groups, the Cardiology Technologists Association of Ontario (CTAO) and Ontario Society of Cardiology Association Professionals (OSCAP) in 2004. The current function of the OSCT is to:
- ensure members maintain in good standing through annual dues payment to the association and submission of continuing education units (CEU’s) in compliance with the CEU Standards focusing on Cardiology and patient safety.
- provide ongoing education to members and the public regarding cardiology technology.
- liaise with associate provincial societies in cardiology technology.
- maintain an accurate and complete database of members.
- discipline members in the event of a complaint of misconduct.
- ensure safe practices in the health system through education and disciplinary procedures.
- ensure mindfulness of health budgets across the health system through education and annual general meetings.
Issue Summary:
The old adage “an ounce of prevention is worth a pound of cure” is exceptionally apt in the cardiac diagnostics space. Highly trained and qualified Registered Cardiology Technologists (“RCT” s) are the first line of defense against patient harm from delayed or missed treatment, increased cost from repeat testing due to poor quality data, and timely and appropriate referral to associate medical professionals to address detected anomalies.
Until relatively recently, obtaining education and certification in cardiology technology was restricted mainly to the GTHA in Ontario causing a deficit in access to timely, quality diagnostic assessment for patients outside of this locus. Northern Ontario and rural areas continue to experience difficulties in recruiting and maintaining registered cardiology technologists due to a wage disparity in comparison to Southern Ontario resulting in patients being required to travel to Urban areas or completely forgo this valuable testing. In these locales it is common practice to replace RCT’s with RN’s, RPN’s, and Lab technicians causing further strain to their respective practices and duties. In lieu of the aforementioned, professionals, clerical staff within private practice clinics are known to perform cardiac diagnostic testing. Replacing RCTs in this manner produces the following outcomes:
- increased spending: reimbursing RN’s, RT’s and MLT’s performing additional tasks often results in overtime due to increased workload. RN and RT salaries are being used for duties outside of their main scope of practice and occupancy profile.
- RN’s, RPN’s and RT’s do not receive an equivalent and comprehensive course of study to recognize potentially exacerbating heart rhythms, which can cause a delay or loss of timely treatment resulting in increased patient risk, harm, health spending and decrease in successful patient outcomes.
- Physician presence during or immediately after testing is not guaranteed. Due to the nature of their practice, providing timely review and diagnosis of the captured data is rarely available. Physicians rely on RCTs to relay results that require immediate attention to provide enhanced patient safety and expeditious access to appropriate medical intervention.
We urge the Ministry of Health to regulate RCTs to ensure patients receive the same standard of care regardless of their locale.
Relevant Considerations:
Aging is associated with an increased prevalence of cardiac arrhythmias, which contribute to higher morbidity and mortality in the elderly1. The frequency of cardiac arrhythmias, particularly atrial fibrillation, and ventricular tachyarrhythmia, is projected to increase as the population ages, greatly impacting health care resource utilization1.
The number of seniors aged 65 and over is projected to increase significantly from 2.7 million, or 18.1 per cent of population, in 2021 to 4.4 million, or 21.8 per cent, by 20462. Rapid growth in the share and number of seniors will continue over the 2021–2031 period as the last cohorts of baby boomers turn age 65.
Currently 5.8% of Ontarians live in the Northern region of the province, with up to 22% of that population aged 65 and over. The number of seniors is projected grow by 86 per cent in the suburban GTA (ibid). Province wide 2,774,242 Ontarians are over the age of 653.
Accurate and early detection of arrhythmias leads to improved patient outcomes and reduced health spending4. RCT’s are uniquely qualified to detect cardiac electrical anomalies where other professions have neither the time nor expertise to observe such arrhythmias. Of our over 1100 members, nearly all can provide at minimum anecdotal data demonstrating the detection of previously unnoticed arrhythmias. For example, undetected and unreported atrial fibrillation (AF) can result in:
- stroke (CVA)
- exacerbated heart failure.
- hospitalization
- costly surgical intervention i.e., Catheter ablation, surgical ablation
Due to the expediency of this application submission, a complete accounting of sources was not immediately available. We can provide further data, testimonials and sources should our application be accepted for review.
The following is an overview of the ways in which our cause aligns with Bill 60:
(a) a detailed description of the service or services to be provided in the proposed integrated community health services center and how it will provide connected and convenient care…
Electrocardiogram (ECG) and Exercise Tolerance Testing (ETT/GXT/Nuclear stress testing):
a. accurate placement of electrodes to properly isolate specific cardiac chambers to indicate location of disease, areas for further investigation
b. preliminary detection arrhythmia(s) (abnormal heart rhythms) and efficiently refer to the appropriate medical professional.
c. preliminary interpretation of the waveforms (electrical heart signals) to triage urgency of care i.e Code STEMI activation, referral to ER/urgent care etc., to prevent repetition of improper or illegible testing and double billing of OHIP, delayed treatment requiring hospitalization and treatment of avoidable complications.
d. prevent harmful and expensive medical intervention because of inaccurate testing.
Holter monitoring:
a. appropriate application of electrodes for 24, 48 or 72 hr. continuous monitoring of the cardiac electrical signals to prevent repeat testing and OHIP billing.
b. review the information accurately and report to the appropriate entities (internal medicine, cardiology etc.) regarding any abnormal or urgent findings to allow patients to access timely and appropriate care.
c. early detection of possible substantial injury causing arrhythmias, and timely activation of emergency care (i.e. nocturnal asystole (“flatlining”) resulting in head trauma and hospitalization during waking hours)
Implantable Cardiac Device assessment and programming: accurate interpretation of recorded data to target device therapy programming to:
a. improve quality of life scores
b. improve ability to perform activities of daily living.
c. reduce repeated, long-term hospitalization from heart failure exacerbation, uncontrolled arrhythmias etc.
d. refer patients for targeted medical therapy in a timely and efficient manner.
e. early surgical site observation preventing costly repeat surgical intervention, hospitalization, and long-term medical support.
f. refer patients to adequate and timely medical intervention to reduce or eliminate the need for costly hospitalization and/or in home care.
(i) capacity to improve patient wait times.
• access to qualified staff to perform and interpret testing.
• rapid referral to urgent medical intervention from qualified technologists to referring or most responsible physician (MRP)
• Accurate testing from highly trained and qualified professionals eliminates need for repeat testing thus repeat billing of diagnostic tests upon transfer of care due to illegibility, erroneous administration and/or insufficient data which often delays appropriate medical intervention.
ii) Plans to improve patient experiences and access to care in the proposed integrated
community health services center, and
Registered Cardiology Technologists are highly trained, educated and skilled in:
a. Trauma informed care
b. Inclusion and diversity sensitivity and accommodation of care
c. Appropriate acquisition of consent
d. Appropriate communication of recommendations for continuing care
(iii) Plans to integrate with the health system.
Within the hospital setting integration is well established. Challenges arise with unqualified operators of diagnostic cardiac testing within private, “off-site” clinics transferring patients to emergency departments with inaccurate or incomplete diagnostic information. Timely and appropriate care is often delayed pending repeat testing within the hospital system resulting in delayed care, increased billing for patient occupation in the emergency department and, in certain instances, an increased need for medical intervention due to complications arising from delays in treatment.
(b) details of the applicant’s quality assurance and continuous quality improvement programming, including policies for infection prevention and control.
Adequately trained and certified technologists are required to undergo consistent, monitored education annually to maintain working, practical knowledge of emerging technologies and therapy and their role in providing care and infection prevention and control within the greater health system by:
a. Submitting a detailed record annually to the Ontario Society of Cardiology Technologists (OSCT) of cardiology focused activities that enhance their practice and knowledge of current and emerging technologies and therapies
b. Maintain current certification of CPR/BCLS and ACLS certification.
c. Demonstrate and provide proof of annual education in:
1. Infection control practices
2. Aseptic techniques
3. Maintenance and cleaning of diagnostic hardware i.e., ECG machines, ambulatory monitors, monitoring cables.
4. Hand hygiene.
5. Industry standard PPE donning and doffing practices.
Appendix
1. Mirza, M., Strunets, A., Shen W., Jahangir, A. Mechanisms of Arrhythmias and Conduction Disorders in Older Adults. (2012). Clinics in Geriatric Medicine, 28(4), 555-573. DOI: 10.1016/j.cger.2012.08.005
2. Government of Ontario. Ontario population projections. (2022). Government of Ontario. Available from: https://www.ontario.ca/page/ontario-population-projections
3. Statistics Canada. Older Adults and Population Aging: Statistisc. (2023). Statistics Canada. Available from: https://www.statcan.gc.ca/en/subjects-start/older_adults_and_ population_aging
4. Schnabel, R., Marinelli, E., Arbelo, E., Boriani, G., Boveda, S., Buckley, C., Camm, A.J J., Casadei, B., Chua, W., Dagres, N., de Melis, M., Desteghe, L., Diederichsen, S., Duncker, D., Eckardt, L., Eisert, C., Engler, D., Fabritz, L., Freedman, B. . . . Kirchhof, P. Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference. EP Europace, 25(1), 6-27. (2022). DOI: https://doi.org/10.1093/europace/euac062