Effective Date of Rule: Thirty-one days after filing.

     Purpose: The purpose of these rules is to implement the new radiologist assistant (RA) profession created by SSB 6439 (chapter 246, Laws of 2008), now codified in chapter 18.84 RCW. These rules establish enforceable standards of practice, education and examination requirements, and licensing fees.

     Citation of Existing Rules Affected by this Order: Amending WAC 246-926-020, 246-926-140, 246-926-150, 246-926-180, 246-926-190, and 246-926-990.

     Statutory Authority for Adoption: RCW 18.84.040.

      Adopted under notice filed as WSR 09-24-101 on December 1, 2009.

     Changes Other than Editing from Proposed to Adopted Version: The proposed rule published in WSR 09-24-101 referred to the January 2005 American Registry of Radiologic Technologists Role Delineation document as the scope of practice for radiologist assistants. The only change was to incorporate the tasks directly into the rule language.

     A final cost-benefit analysis is available by contacting Susan Gragg, Department of Health, P.O. Box 47852, Olympia, WA 98504-7852, phone (360) 236-4941, fax (360) 236-2406, e-mail susan.gragg@doh.wa.gov.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 3, Amended 6, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 3, Amended 6, Repealed 0.

     Date Adopted: April 23, 2010.

Mary C. Selecky

Secretary

OTS-2741.3

AMENDATORY SECTION(Amending WSR 06-01-104, filed 12/21/05, effective 1/21/06)

WAC 246-926-020   Definitions.   The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.

     (1) (("Unprofessional conduct" as used in this chapter means the conduct described in RCW 18.130.180.

     (2) "Hospital" means any health care institution licensed pursuant to chapter 70.41 RCW.

     (3) "Nursing home" means any health care institution which comes under chapter 18.51 RCW.

     (4) "Department" means the department of health.

     (5) "Radiological technologist" means a person certified under chapter 18.84 RCW.

     (6) "Registered X-ray technician" means a person who is registered with the department, and who applies ionizing radiation at the direction of a licensed practitioner.

     (7) "Direct supervision" means the appropriate licensed practitioner is on the premises and is quickly and easily available.

     (8) "Mentally or physically disabled" means a radiological technologist or X-ray technician who is currently mentally incompetent or mentally ill as determined by a court, or who is unable to practice with reasonable skill and safety to patients by reason of any mental or physical condition and who continues to practice while so impaired.)) "ARRT" means the American Registry of Radiologic Technologists.

     (2) "Department" means the department of health.

     (3) "Direct supervision" means the appropriate licensed practitioner is on the premises and is quickly and easily available.

     (a) For a diagnostic, therapeutic, or nuclear medicine radiologic technologist, the appropriate licensed practitioner is a physician licensed under chapter 18.71 or 18.57 RCW.

     (b) For a radiologist assistant, the appropriate licensed practitioner is a radiologist.

     (4) "General supervision" for a radiologist assistant means the procedure is furnished under the supervising radiologist's overall direction and control. The supervising radiologist must be on-call or be available for consultation.

     (5) "Hospital" means any health care institution licensed pursuant to chapter 70.41 RCW.

     (6) "Nursing home" means any health care institution which comes under chapter 18.51 RCW.

     (7) "Personal supervision" for a radiologist assistant means the supervising radiologist must be in the room during the performance of the procedure.

     (8) "Radiological technologist" means a person certified under chapter 18.84 RCW.

     (9) "Radiologist" means a licensed physician licensed under chapter 18.71 or 18.57 RCW and certified by the American Board of Radiology or the American Osteopathic Board of Radiology.

     (10) "Radiologist assistant" means an advanced-level diagnostic radiologic technologist certified under chapter 18.84 RCW.

     (11) "Registered X-ray technician" means a person who is registered with the department, and who applies ionizing radiation at the direction of a licensed practitioner.

     (12) "Unprofessional conduct" as used in this chapter means the conduct described in RCW 18.130.180.

[Statutory Authority: RCW 18.84.040. 06-01-104, § 246-926-020, filed 12/21/05, effective 1/21/06. Statutory Authority: RCW 18.84.040 and 18.130.070. 92-05-010 (Order 237), § 246-926-020, filed 2/7/92, effective 2/19/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-926-020, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 18.130.070. 89-14-092 (Order PM 842), § 308-183-010, filed 6/30/89.]

[Statutory Authority: RCW 18.84.040. 06-01-104, § 246-926-140, filed 12/21/05, effective 1/21/06. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-926-140, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 18.84.040. 89-01-015 (Order PM 802), § 308-183-130, filed 12/9/88.]

     (1) The educational program completed; diagnostic radiologic technologist - radiography program; therapeutic radiologic technologist - radiation therapy technology program; and nuclear medicine technologist - nuclear medicine technology program; or

     (2) By meeting the alternative training requirements established in WAC 246-926-100((,)) and 246-926-110, 246-926-120, or 246-926-130.

[Statutory Authority: RCW 18.84.040 and 18.84.080. 92-05-010 (Order 237), § 246-926-150, filed 2/7/92, effective 2/19/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-926-150, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 18.84.040. 89-01-015 (Order PM 802), § 308-183-140, filed 12/9/88.]

     (a) The radiologic technologist has had the prerequisite training and thorough knowledge of the particular procedure to be performed;

     (b) Appropriate facilities are available for coping with any complication of the procedure as well as for emergency treatment of severe reactions to the diagnostic or therapeutic agent itself, including readily available appropriate resuscitative drugs, equipment, and personnel; and

     (c) After parenteral administration of a diagnostic or therapeutic agent, competent personnel and emergency facilities must be available to the patient for at least thirty minutes in case of a delayed reaction.

     (2) A certified radiologic technologist may perform venipuncture under the direct supervision of a physician licensed under chapter 18.71 or 18.57 RCW.

[Statutory Authority: RCW 18.84.040. 06-01-104, § 246-926-180, filed 12/21/05, effective 1/21/06. Statutory Authority: RCW 43.70.040. 92-19-060 (Order 302), § 246-926-180, filed 9/11/92, effective 10/12/92; 91-02-049 (Order 121), recodified as § 246-926-180, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 18.84.040. 89-01-015 (Order PM 802), § 308-183-170, filed 12/9/88.]

     (2) The examination shall be conducted in accordance with the ((American Registry of Radiologic Technologists)) ARRT security measures and contract.

     (3) Applicants taking the state examination must submit the application, supporting documents, and fees to the department of health for approval prior to being scheduled to take the examination.

     (4) Examination candidates shall be advised of the results of their examination in writing by the department of health.

     (5) The examination candidate must have a minimum scaled score of seventy-five to pass the examination.

[Statutory Authority: RCW 18.84.040. 06-01-104, § 246-926-190, filed 12/21/05, effective 1/21/06. Statutory Authority: RCW 18.84.040 and 18.84.080. 92-05-010 (Order 237), § 246-926-190, filed 2/7/92, effective 2/19/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-926-190, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 18.84.040. 89-01-015 (Order PM 802), § 308-183-190, filed 12/9/88.]

     (a) Enteral and parenteral procedures;

     (b) Injecting diagnostic agents to sites other than intravenous;

     (c) Diagnostic aspirations and localizations; and

     (d) Assisting radiologists with other invasive procedures.

     (2) The tasks a radiologist assistant may perform include the following:

     (a) Preimaging procedures.

     (i) Procedures that may be performed under general supervision:

     (A) Review of medical records to verify patient and procedure; obtain medical history and vital signs; perform physical examination, evaluate medical record, history, and physical examination for contraindications for the procedure (e.g., compliance with preparation instructions for the procedure, pregnancy, medications). Discrepancies and/or contraindications must be reviewed with the supervising radiologist;

     (B) Discuss examination/procedure details (including risks, benefits, and follow-up instructions) with patient or patient representative;

     (C) Obtain informed consent (patients must be able to communicate with the radiologist for questions or further information as needed);

     (D) Apply electrocardiography (ECG) leads and recognize life threatening abnormalities;

     (E) Routine urinary catheterization;

     (F) Venipuncture;

     (G) Administer oxygen as prescribed; and

     (H) Position patients to perform required procedure, using immobilization devices and modifying technique as necessary.

     (ii) Procedures that may be performed under direct supervision: Nonroutine catheterization (known anatomic anomalies, recent surgeries).

     (b) Pharmaceuticals.

     (i) Imaging agent procedures that may be performed under general supervision:

     (A) Monitor intravenous (IV) flow rate; and

     (B) Monitor patients for side effects or complications and report findings to the supervising radiologist as appropriate.

     (ii) Imaging contrast agent under direct supervision:

     (A) Administer contrast agents and/or radiopharmaceuticals as prescribed by the radiologist; and

     (B) Provide information to patients on the effects and potential side effects of the pharmaceutical required for the examination.

     (iii) Oral medications, excluding imaging agents, always require direct supervision.

     (iv) Parenteral medication administration procedures, excluding imaging agents, requiring direct supervision:

     (A) Monitor IV flow rate; and

     (B) Monitor patients for side effects or complications and report findings to the supervising radiologist as appropriate.

     (v) Parenteral medication administration procedures, excluding imaging agents, requiring personal supervision:

     (A) Administer general medications as prescribed by the radiologist;

     (B) Administer conscious sedation medications as prescribed by the radiologist; and

     (C) Provide information to patients on the effects and potential side effects of the pharmaceutical required for the examination.

     (c) Imaging procedures.

     (i) Procedures that may be performed under general supervision:

     (A) Operate a fixed/mobile fluoroscopic unit;

     (B) Document fluoroscopy time; and

     (C) Assess patient's vital signs and level of anxiety and/or pain, and inform the radiologist when appropriate.

     (ii) Fluoroscopic examinations and procedures that require direct supervision:

     (A) Upper GI;

     (B) Esophagus;

     (C) Small bowel studies;

     (D) Barium enema;

     (E) Cystogram;

     (F) T-tube cholangiogram;

     (G) Hysterosalpingogram (imaging only) if OB/GYN is present in the room;

     (H) Retrograde urethrogram;

     (I) Nasoenteric and oroenteric feeding tube placement;

     (J) Port injection;

     (K) Fistulogram/sonogram;

     (L) Loopogram; and

     (M) Swallowing study.

     (iii) Fluoroscopic examinations and procedures that require personal supervision: Hysterosalpingogram (imaging only) if OB/GYN is not present in the room.

     (iv) Contrast media administration and needle or catheter placement.

     (A) Procedures that may be performed under general supervision: Basic peripherally inserted central catheter (PICC) placement.

     (B) Procedures that may be performed under direct supervision:

     (I) Joint injection and aspiration;

     (II) Arthrogram (conventional, computed tomography (CT), and magnetic resonance (MR));

     (III) Complex peripherally inserted central catheter (PICC) placement;

     (IV) Thoracentesis and paracentesis with appropriate image guidance; and

     (V) Lower extremity venography.

     (C) Procedures that may be performed under personal supervision:

     (I) Lumbar puncture under fluoroscopic guidance;

     (II) Lumbar, thoracic, and cervical myelogram;

     (III) Nontunneled venous central line placement;

     (IV) Venous catheter placement for dialysis;

     (V) Breast needle localization; and

     (VI) Ductogram (galactogram).

     (d) Image review, requires general supervision:

     (i) Evaluate images for completeness and diagnostic quality;

     (ii) Recommend additional images in the same modality as required (general radiography, CT, MR);

     (iii) Evaluate images for diagnostic utility and report clinical observations to the radiologist;

     (iv) Review imaging procedures, make initial observations, and communicate observations only to the radiologist; and

     (v) Perform post-processing procedures:

     (A) Routine CT (e.g., 3D reconstruction, modifications to field of vision (FOV), slice spacing, algorithm);

     (B) Specialized CT (e.g., cardiac scoring, shunt graft measurements); and

     (C) MR data analysis (e.g., 3D reconstructions, maximum intensity projection (MIP), 3D surface rendering, volume rendering).

     (e) Postprocedures, requires general supervision:

     (i) Record previously communicated initial observations of imaging procedures according to approved protocols;

     (ii) Communicate radiologist's report to referring physician;

     (iii) Provide radiologist-prescribed post care instructions to patients;

     (iv) Perform follow-up patient evaluation and communicate findings to the radiologist;

     (v) Document procedure in appropriate record and document exceptions from established protocol or procedure; and

     (vi) Write patient discharge summary for review and cosignature by radiologist.

     (f) Other procedures.

     (i) Procedures that may be performed under general supervision:

     (A) Participate in quality improvement activities within radiology practice (e.g., quality of care, patient flow, reject-repeat analysis, patient satisfaction); and

     (B) Assist with data collection and review for clinical trials or other research.

     (ii) Procedures that may be performed under personal supervision: Additional procedures deemed appropriate by the radiologist.

     (g) When performing any task or procedure, the radiologist assistant must be able to recognize and respond to medical emergencies (e.g., drug reactions, cardiac arrest, hypoglycemia) and activate emergency response systems, including notification of the radiologist.

     (3) Initial findings and observations made by a radiologist assistant communicated solely to the supervising radiologist do not constitute diagnoses or interpretations.

     (4) At the direction of the supervising radiologist, a radiologist assistant may administer imaging agents and prescribed medications; however, nothing in this chapter allows a radiologist assistant to prescribe medications.

[]

     (a) Graduate from an educational program recognized by the ARRT;

     (b) Obtain a passing score on the national ARRT registered radiologist assistant examination; and

     (c) Submit the application, supporting documents, and fees to the department of health.

     (2) An individual certified as a radiologist practitioner assistant through the certification board of radiology practitioner assistants who takes and passes the national ARRT registered radiologist assistant examination by December 31, 2011, shall be considered to have met the education and examination requirements for certification as a radiologist assistant.

[]

     (a) The plan must be approved before the radiologist assistant can practice.

     (b) The plan must be signed by both the radiologist assistant and a radiologist licensed in this state.

     (c) A radiologist assistant may assist a radiologist other than his or her supervising radiologist so long as it is done with the knowledge and agreement of the supervising radiologist, and is reflected in an approved supervisory plan.

     (2) A radiologist assistant can have multiple supervisory plans provided each one is approved by the department.

     (3) A radiologist assistant does not have to be employed by his or her supervising radiologist.

     (4) Changes to supervisory plans.

     (a) The radiologist assistant must submit a new supervisory plan to change any part of the supervisory plan. The changes are not effective until the new plan is approved by the department.

     (b) If the supervisory relationship ends, the radiologist assistant must immediately cease practice under that plan and must notify the department in writing within seven calendar days.

[]

Title of Fee	Fee
(2) The following nonrefundable fees will be charged for certified diagnostic, therapeutic, and nuclear medicine radiologic technologists:
Application	$150.00
Renewal	70.00
Late renewal penalty	50.00
Expired certificate reissuance	80.00
Certification of registration or certificate	15.00
Duplicate registration or certificate	15.00
(3) The following nonrefundable fees will be charged for registered X-ray technicians:
Application	75.00
Renewal	75.00
Late renewal penalty	50.00
Expired reissuance	50.00
Certification of registration or certificate	15.00
Duplicate registration or certificate	15.00
(4) The following nonrefundable fees will be charged for certified radiologist assistants:
Application	150.00
Renewal	150.00
Late renewal penalty	75.00
Expired reissuance	75.00
Certification of registration or certificate	15.00
Duplicate registration or certificate	15.00

[Statutory Authority: RCW 43.70.110, 43.70.250 and 2008 c 329. 08-16-008, § 246-926-990, filed 7/24/08, effective 7/25/08. Statutory Authority: RCW 18.84.040. 06-01-104, § 246-926-990, filed 12/21/05, effective 1/21/06. Statutory Authority: RCW 43.70.250, [43.70.]280 and 43.70.110. 05-12-012, § 246-926-990, filed 5/20/05, effective 7/1/05. Statutory Authority: RCW 43.70.250. 99-08-101, § 246-926-990, filed 4/6/99, effective 7/1/99. Statutory Authority: RCW 43.70.280. 98-05-060, § 246-926-990, filed 2/13/98, effective 3/16/98. Statutory Authority: RCW 18.84.040 and 18.84.100. 92-05-010 (Order 237), § 246-926-990, filed 2/7/92, effective 2/19/92. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-926-990, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 18.84.040. 89-01-015 (Order PM 802), § 308-183-180, filed 12/9/88.]

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