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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.

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N. Martin Giesecke, M.D., Chair

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August 1, 2013 Volume 77, Number 8
State Beat: Iowa High Court Upholds Rules Authorizing ARNPs to Supervise Fluoroscopy Jason Hansen, M.S., J.D.


On May 31, 2013 the Supreme Court of Iowa issued a decision which upholds rules allowing advanced registered nurse practitioners (ARNPs) to supervise radiologic technologists in their use of fluoroscopy machines. The ruling ends litigation that began in June 2010 when the Iowa Society of Anesthesiologists and Iowa Medical Society sued to prevent the implementation of fluoroscopy rules adopted by the Iowa Board of Nursing and the Iowa Department of Public Health.


In the original lawsuit, two rules were called into question. Under the challenged Board of Nursing rules, an ARNP could supervise the use of fluoroscopic X-ray equipment, provided he or she satisfies specified educational criteria, collaborates as needed, and complies with facility policies and procedures (Iowa Admin. Code 655-7.2(152)). The disputed Department of Public Health’s rules required radiologic technologists to perform fluoroscopy under the direct supervision of a licensed practitioner or an ARNP (Iowa Admin. Code 641-41.1(136C)).


In 2011, a district court determined the Board of Nursing and Department of Public Health exceeded their authority in adopting the rules. Unfortunately, the Supreme Court of Iowa overruled the lower court’s decision by finding that the Board of Nursing and Department of Public Health did have the requisite authority to adopt the rules in question. Regarding the Board of Nursing, the Supreme Court of Iowa concluded that the central issue of the case was whether the lower court was correct in overturning the board’s finding that ARNP supervision of fluoroscopy procedures was “recognized by the medical and nursing professions” within the context of Iowa Code section 152.1(6)(d). 152.1(6), which defines the practice of registered nursing and subsection (d) includes performing “… additional acts or nursing specialties which require education and training under emergency or other conditions which are recognized by the medical and nursing professions and are approved by the board as being proper to be performed by a registered nurse.”


In 1976, the state attorney general issued an opinion (1976 Op. Iowa Att’y Gen. 727) on the Board of Nursing’s authority under 152.1(6)(d). In the opinion, the attorney general stated in part:


There is nothing in that section or in any other provision of the Act which makes [reference] to any specific medical or nursing groups. Your board has the ultimate authority to further define nursing, and the Legislature apparently wants you to receive input from the medical and nursing professions. However, there is nothing mandatory that you specifically name those organizations from which you will allow input.


Agreeing with the attorney general’s opinion, the Supreme Court of Iowa stated: “The plain language of section 152.1(6)(d) allows the nursing board to decide whether the medical and nursing professions have recognized a particular practice of nurses. If the legislature had intended to give another agency or organization the power to determine recognition by the medical profession, it would have said so in this provision.” On this basis, and regardless of opposition from physician groups and the state medical board, the court found the Board of Nursing was authorized through 156.1(6)(d) to determine whether the medical and nursing professions recognized a specified practice of nurses.


Citing the following reasons, the court upheld the Board of Nursing’s determination that ARNP supervision of fluoroscopy is recognized by the nursing and medical boards:


  • Approximately 16 Iowa hospital credentialing committees granted ARNPs privileges to supervise fluoroscopy;
  • 40 Iowa medical doctors submitted comments in support of the proposed rule;
  • The Medical Board did not seek to stop ARNPs supervising fluoroscopy.



The Supreme Court of Iowa then examined whether the district court erred in invalidating the Department of Public Health rules. There, the issue centered on the difference between “operation” and “supervision.” In Iowa, ARNPs are not authorized to operate fluoroscopy machines. Since there was no language in the administrative code’s definition of supervision requiring ARNPs who supervise fluoroscopy to have the authority to operate the machines, the court rejected arguments that one supervising such equipment must be legally authorized to operate such a machine.


This recent decision is important to every anesthesiologist. The Supreme Court of Iowa was charged with applying the law. The governing statutes the court reviewed were – at one point – introduced, enacted and signed into law by lawmakers elected by the residents of Iowa. As witnessed in this most recent court decision, the laws elected officials write, amend or fail to amend have a direct impact on the patients treated in operating rooms and perioperative settings across the United States.


This week, and in the months to come, lobbyists and individuals will visit lawmakers, seeking support for legislation that will impact anesthesia and sedation delivery as well as perioperative care of patients in all anesthesiologists’ communities. While these lobbyists and individuals did not attend or graduate from medical or osteopathic school, or successfully complete an anesthesiology residency, they will claim to know what is best for your patients. You are the best advocate for your patients and your profession and your lawmakers need to hear your voices as they go through the legislative process.


The next legislative session is around the corner. Now is the time to get prepared. To learn more about how you can help protect your patients and promote your profession through state-level advocacy, contact ASA’s Director of State Affairs, Jason Hansen, at j.hansen@asahq.org.


Review the full opinion:

http://www.iowacourts.gov/Supreme_Court/Recent_Opinions/20130531/11-1977.pdf


See also, the Iowa Society of Anesthesiologists statement at: http://www.iasahq.org/index.php/component/content/article/41-uncategorised/69-supreme-court-reverses-district-court-ruling-on-supervision-of-fluoroscopy-by-arnps



Jason Hansen, M.S., J.D. is ASA Director of State Affairs.


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