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  • 1. CERTIFICATION EXAMINATION IN NEUROPHYSIOLOGIC INTRAOPERATIVE MONITORING (Path 1: CNIM, Path 2: CNIM+EP) Handbook for Candidates WINTER 2010 TESTING PERIOD Application Deadline: January 15, 2010 Testing Begins: Saturday, February 27, 2010 Testing Ends: Saturday, March 13, 2010 SUMMER 2010 TESTING PERIOD Application Deadline: June 15, 2010 Testing Begins: Saturday, July 31, 2010 Testing Ends: Saturday, August 14, 2010 PROFESSIONAL TESTING CORPORATION 1350 BROADWAY 17th FLOOR NEW YORK, NY 10018 (212) 356-0660 WWW.PTCNY.COM
  • 2. Table of Contents Introduction ......................................................................2 Objectives.........................................................................2 Non Discrimination Policy .................................................2 Procedures Eligibility Requirements .....................................................3 Petition of Path 2 Eligibility................................................4 Administration ..................................................................4 Recertification...................................................................5 Application Procedures Completion of Documentation Form ..................................5 Completion of Application .................................................6 Fees..................................................................................7 Refunds ............................................................................7 Examination Procedures Examination Administration...............................................7 Online Tutorial and Sample Test ........................................7 Scheduling Your Examination Appointment .......................8 Changing Your Examination Appointment ..........................8 Special Requests ..............................................................8 Rules ................................................................................9 Exam Preparation Content of Examination ...................................................10 Neurophysiologic Intraoperative Monitoring Practice Analysis11 Evoked Potential Technology Practice Analysis .................... 17 Sample Questions ...........................................................21 References......................................................................22 Notification of Status Scoring ...........................................................................24 Report of Results ............................................................24 Attainment of Registration ..............................................24 Confidentiality.................................................................24 Code of Ethics/Standards of Practice...............................25 Violations and Sanctions .................................................26 Reporting Requirements..................................................26 Name/Address Changes..................................................28 1
  • 3. INTRODUCTION The American Board of Registration of Electroencephalographic and Evoked Potential Technologists (ABRET®) supports the concept of voluntary certification by examination for health care professionals in Neuophysiologic Intraoperative Monitoring. Certification focuses specifically on the individual and is an indication of current knowledge in Neurophysiologic Intraoperative Monitoring technology. ABRET® does not guarantee the job performance of any individual. The CNIM Examination Program is accredited by the National Commission for Cerifying Agencies (NCCA). OBJECTIVES OF THE AMERICAN BOARD OF REGISTRATION OF ELECTROENCEPHALOGRAPHIC AND EVOKED POTENTIAL TECHNOLOGISTS TO ESTABLISH COMPETENCY IN NEUROPHYSIOLOGIC INTRAOPERATIVE MONITORING BY: 1. Providing a standard of knowledge in neurophysiologic intraoperative monitoring required for certification. 2. Establishing and measuring the level of knowledge required for certification in neurophysiologic intraoperative monitoring by means of an objective written examination. 3. Formally recognizing those individuals who meet the eligibility requirements of the American Board of Registration of Electroencephalographic and Evoked Potential Technologists and pass the Certification Examination in Neurophysiologic Intraoperative Monitoring. 4. Encouraging continued professional growth in neurophysiologic intraoperative monitoring through mandatory continuing education and recertification. NON DISCRIMINATION STATEMENT The American Board of Registration of Electroencephalographic and Evoked Potential Technologists, Inc., does not discriminate on the basis of age, sex, race, religion, national origin, marital status, or handicapped condition. 2
  • 4. PROCEDURES ELIGIBILITY REQUIREMENTS The Certification Examination in Neurophysiologic Intraoperative Monitoring is designed and written for the advanced level electroneurodiagnostic professional who is currently practicing in an intraoperative environment. All candidates for initial and renewal of a lapsed credential must meet the following requirements by the application deadline. There are no alternative routes. 1. A minimum of 150 surgical cases monitored. At least 10% (10) of the documented cases must have been performed within twelve months of the application deadline. The Candidate must be present and an active participant in the set-up and monitoring of each case listed. ABRET® will accept documentation of up to two cases per day. Observation of a NIOM case, or studies performed while a student/trainee may not be included in the 150 cases. 2. Candidates must have a current neurodiagnostic credential, i.e. R. EEG T., R. EP T., or Canadian equivalent of the above, OR Bachelor’s degree. A copy of current registration, certification, OR verification of bachelor's degree must accompany the Application. 3. Candidate must provide proof of hands-on CPR/BCLS training. A copy of the CPR card or official documentation must accompany the Application. 4. Complete and submit an Application for the Certification Examination in Neurophysiologic Intraoperative Monitoring along with the required fee only after the above has been met and appropriately documented. Applications postmarked after the stated deadline may not be processed. NOTE: The candidate's supervisor or supervising physician must verify this eligibility by signing the Application. Eligibility options for Candidates previously certified: 1. Candidate is taking the examination for recertification no more than one year prior to expiration of his/her current CNIM credential. 2. Candidate is taking the examination to reinstate a lapsed CNIM credential. This candidate is considered a new potential certificant and must meet the current eligibility requirements and submit all required documentation. 3. Candidate must provide proof of hands-on CPR/BCLS training. A copy of the CPR card or official documentation must accompany the Application. 3
  • 5. 4. Complete and submit an Application for the Certification Examination in Neurophysiologic Intraoperative Monitoring along with the required fee only after the above has been met and appropriately documented. Applications received after the stated deadline may not be processed. Candidates with an EEG or EP credential will take the Path 1 Examination. Candidates with a bachelor’s degree and no EEG or EP credential will take the Path 2 Examination. PETITION OF PATH 2 ELIGIBILITY Candidates who have earned an equivalent of 120 hours of college credit may petition the requirement of a bachelor's degree for examination eligibility. The following documentation must be submitted to the ABRET® Executive Office. 1. A completed current examination application with the required fees. 2. Official college transcripts 3. A letter of support for the candidate's state of eligibility from a supervisor 4. A letter from the candidate outlining how he/she satisfies the current eligibility requirements by an alternative path. If the candidate is deemed eligible for examination, the application will be forwarded to PTC for processing. If the candidate is not deemed eligible, the application and exam fee will be returned to the candidate, minus the processing fee. Published deadlines will apply to petitioned applications. ADMINISTRATION The Certification Program is sponsored by the American Board of Registration of Electroencephalographic and Evoked Potential Technologists, Inc. (ABRET®). The Certification Examination in Neurophysiologic Intraoperative Monitoring is administered for ABRET® by the Professional Testing Corporation (PTC), 1350 Broadway - 17th Floor, New York, New York 10018, www.ptcny.com. Questions concerning the administration of the examination should be referred to PTC. All other questions should be referred to the Executive Director at the ABRET® Executive Office, 2509 West Iles, Suite 102, Springfield, IL 62704, (217) 726-7980, e-mail: abreteo@att.net. 4
  • 6. RECERTIFICATION Technologists Certified in Neurophysiologic Intraoperative Monitoring must renew their credential every five years. To recertify, candidates must submit documentation of continuing education (CE), totaling a minimum of 50 hours directly related to the credential over the five year period. A CE documentation form can be obtained from the ABRET® Executive Office, 2509 West Iles, Suite 102, Springfield, IL 62704; telephone (217) 726-7980; e-mail: abreteo@att.net; or on the ABRET® website. www.abret.org. A random audit of CE documentation will be conducted. Technologists must keep records with proof of attendance. When a technologist fails to renew his/her credential, the credential expires and the technologist is unable to legally claim certification. APPLICATION PROCEDURE Obtain a Handbook for Candidates and an Application for the Certification Examination in Neurophysiologic Intraoperative Monitoring from the Professional Testing Corporation, 1350 Broadway – 17th Floor, New York, New York 10018, (212) 356-0660, or download from the PTC website, www.ptcny.com. Read and follow the directions on the Application and Handbook for Candidates. The candidate must accurately complete and submit the documentation form provided and be prepared for random auditing and verification by ABRET®. Errors on the Application or Documentation Form may postpone your eligibility for the examination. COMPLETION OF DOCUMENTATION FORM Complete the documentation form according to directions with all information requested. Do not submit more than 150 cases. Only the first 150 cases will be considered. Observation of a NIOM case, or studies performed while a student/trainee may not be included in the 150 cases. Monitoring performed in the operating room during a surgical procedure should be included. Pre-op testing and procedures do not satisfy this requirement. 5
  • 7. COMPLETION OF APPLICATION Complete or fill in as appropriate ALL information requested on the Application. Mark one response only unless otherwise indicated. Starting at the top of the Application, print your name, address, e-mail address, Social Security Number, and daytime phone number in the appropriate row of empty boxes. Eligibility and Background Information: All questions must be answered. Mark only one response unless otherwise indicated. Optional Information: These questions are optional. The information requested is to assist in complying with equal opportunity guidelines and will be used only in statistical summaries. Such information will in no way affect your test results. Supervisor’s Verification of Experience: Your completed Application must be signed by your supervisor or supervising physician. NO candidate will be accepted for the examination without this verification. Be sure the supervisor’s or physician’s signature, title, address, and telephone number are included. Applications without a supervisor’s or physician’s signature will not be accepted. Knowingly providing false information related to the examination requirements is a violation of ABRET®’s standards of practice and code of ethics and is subject to disciplinary actions including loss of credentials. SIGNATURE: When you have completed all required information, sign and date the Application in the space provided. Fold the completed Application, CNIM documentation form, proof of bachelor’s degree or credential, copy of current CPR card in applicant’s name and mail together with the appropriate fees (see page 7) in time to be postmarked by the deadline shown on the cover of this handbook to: CNIM EXAMINATION Professional Testing Corporation 1350 Broadway – 17th Floor New York, New York 10018 NOTE: Applications received after the deadline cannot be guaranteed acceptance. 6
  • 8. FEES 1. Application Fee for the Certification Examination in Neurophysiologic Intraoperative Monitoring Path 1.................................................................. $400.00 Path 2.................................................................. $690.00 2. Non-refundable Processing and Review Fee........... $20.00 3. Special Testing Center Fee outside U.S............... $100.00 MAKE CHECK OR MONEY ORDER PAYABLE TO: CNIM EXAMINATION DO NOT SEND CASH. Visa, MasterCard, and American Express are also accepted. Please complete and sign the Credit Card Payment Form on the application. REFUNDS There will be no refund of fees. Fees will not be transferred from one testing period to another. EXAMINATION PROCEDURES EXAMINATION ADMINISTRATION The Certification Examination in Neurophysiologic Intraoperative Monitoring is administered during an established two-week testing period on a daily basis, Monday through Saturday, excluding holidays, at computer- based testing facilities managed by PSI/LaserGrade Computer Testing, Inc. PSI/LaserGrade has several hundred testing sites in the United States, as well as Canada. Scheduling is done on a first-come, first-serve basis. To find a testing center near you visit: www.lasergrade.com or call PSI/LaserGrade at (800) 211-2754. Please note: Hours and days of availability vary at different centers. You will not be able to schedule your examination appointment until you have received an Eligibility Notice from PTC. ONLINE TUTORIAL AND SAMPLE TEST A Tutorial and a Sample Demonstration Test can be viewed online. • Browse to www.lasergrade.com • Select Test Taker/Candidates menu • Select Testing Software Demo • Select the "General Education Demo Test" • Click on the "Start LaserGrade Online Demo Test" button. This online Tutorial and Sample Test can give you an idea about the features of the testing software. 7
  • 9. SCHEDULING YOUR EXAMINATION APPOINTMENT Once your application has been received and processed, and your eligibility verified, you will be sent a postcard from PTC confirming receipt. Within 6 weeks prior to the first day of the testing window, you will be sent an Eligibility Notice. The Eligibility Notice plus current government issued photo identification must be presented in order to gain admission to the testing center. A candidate not receiving an Eligibility Notice or other correspondence at least three weeks before the beginning of the two-week testing period should contact the Professional Testing Corporation by telephone at (212) 356-0660. The Eligibility Notice will indicate where to call to schedule your examination appointment as well as the dates in which testing is available. Appointment times are first-come, first- serve, so schedule your appointment as soon as you receive your Eligibility Notice in order to maximize your chance of testing at your preferred location and on your preferred date. It is highly recommended that each candidate becomes familiar with the location of the testing site. CHANGING YOUR EXAMINATION APPOINTMENT If you need to cancel your examination appointment or reschedule to a different date within the two-week testing period you must contact PSI/LaserGrade at (800) 211-2754 no later than noon, Eastern Standard Time, of the second business day PRIOR to your scheduled appointment. Fees will not be transferred to another testing period. SPECIAL REQUESTS 1. Outside the United States and Canada: It may be possible to establish a special testing center to take a paper and pencil examination in your own country, for an additional fee of $100.00. A written request must accompany the candidate’s Application specifying the preferred test location and must be received EIGHT weeks before the testing date. Please contact PTC for details. 2. Special Needs Individuals: Special testing arrangements will be made for individuals with special needs. Submit the Application, Examination Fee, and a completed and signed Request for Special Accommodations Form, available from www.ptcny.com or by calling PTC at (212) 356-0660. Requests for special testing for individuals with special needs must be received at least EIGHT weeks before the testing period begins. 8
  • 10. RULES 1. Hand-held, battery or solar operated, nonprinting and nonprogrammable calculators are permitted. However, calculators are built into the testing software. 2. A centimeter ruler with "mm" markings may be brought to the examination for reference. 3. No books or other reference materials may be taken into the examination room. 4. No signaling devices, including cellular phones, pagers and alarms, may be operative during the examination. 5. Test documents and notes must remain in the examination room. Removing any test material by any means is prohibited. 6. No questions concerning content of the examination may be asked during the testing period. The candidate should listen to the instructions given by the Examiner and read the instructions provided on the computer and should carefully follow directions. 7. Anyone giving or receiving assistance of any kind will have the computer based testing terminated and be asked to leave the room. 8. Visitors are not permitted in the examination room. 9. ABRET® prohibits certain behaviors, including (but not limited to) the activities listed below. A. Copying test questions. B. Copying answers C. Permitting another to copy answers. D. Falsifying information required for admission to an examination. E. Impersonating another examinee. F. Taking the examination for any reason other than for the purpose of seeking accreditation. 10. Complaints and challenges must be submitted in writing within fourteen days after taking the examination. ABRET® will not consider late submissions. The procedure for submitting complaints and challenges is contained in the ABRET® policy on exam challenges located on the ABRET® website. 9
  • 11. EXAM PREPARATION CONTENT OF THE EXAM 1. The Certification Examination in Neurophysiologic Intraoperative Monitoring is composed of multiple-choice, objective questions with a total testing time of four (4) hours. Path 1 will consist of a maximum of 200 items based on the CNIM Practice Analysis. Path 2 will consist of a maximum of 200 items based on the CNIM Practice Analysis and 50 items based on the relevant portions of the Evoked Potential Practice Analysis. 2. The content for the examination is described in the Practice Analysis starting on page 11. 3. The questions for the examination are obtained from individuals with expertise in neurophysiologic intraoperative monitoring and evoked potentials and are reviewed for construction, accuracy, and appropriateness by ABRET®. 4. ABRET®, with the advice and assistance of the Professional Testing Corporation, prepares the examination. 5. The Certification Examination in Neurophysiologic Intraoperative Monitoring will be weighted in approximately the following manner: CNIM Practice Analysis Domain I Preparation and Application of Fundamental Concepts...............................................25% Domain II Intraoperative Phase..............................66% Domain III Post-Operative Phase ..............................6% Domain IV Ethics and Professional Issues ................3% EP Practice Analysis (Additional content for Path 2) Domain I Pre-Study Procedures..............................5% Domain II Performing the EP Study........................15% 10
  • 12. CNIM PRACTICE ANALYSIS FOR PATHS 1 AND 2 NEUROPHYSIOLOGIC INTRAOPERATIVE MONITORING PRACTICE ANALYSIS This Document represents a delineation of the tasks (T) performed and knowledge (K) applied by neurophysiologic intraoperative monitoring technologists in the practice of their profession. This practice takes place in the context of their unwavering commitment to patient care and safety and their adherence to the highest principles of ethical behavior. Domain I – Preparation and Application of Fundamental Concepts T-1 Perform a risk assessment by reviewing planned intraoperative procedures and preoperative diagnostic test results to determine the structures at risk and the modalities that should be monitored. The safe and effective performance of this task requires knowledge of: K-1 Medical terminology K-2 Evoked potentials, motor evoked potentials, EEG and EMG correlates of clinical entities K-3 General anatomy K-4 Risks associated with specific disorders/surgical procedures K-6 Medical conditions that may affect monitoring protocols K-38 Preoperative diagnostic tests (e.g., WADA, FMRI, MEG) T-2 Review patient history and medical conditions to identify pre-existing conditions that may affect the monitoring or outcomes. The safe and effective performance of this task requires knowledge of: K-1 Medical terminology K-3 General anatomy K-5 Elements of a patient history K-6 Medical conditions that may affect monitoring protocols K-38 Preoperative diagnostic tests (e.g., WADA, FMRI, MEG) 11
  • 13. T-3 Communicate the monitoring plan to the patient/caregivers in a manner consistent with their ability to understand in order to reassure the patient, establish rapport, and elicit cooperation. The safe and effective performance of this task requires knowledge of: K-3 General anatomy K-7 Age-specific criteria K-8 Techniques for establishing rapport K-9 Cognitive limitations K-10 Surgery specific monitoring protocols T-4 Determine the equipment and supplies required for the monitoring. The safe and effective performance of this task requires knowledge of: K-1 Medical terminology K-3 General anatomy K-5 Elements of a patient history K-10 Surgery specific monitoring protocols K-11 Uses of stimulating electrodes, recording electrodes and modality devices K-32 Characteristics of the differential amplifier (e.g. polarity, CMRR) K-38 Preoperative diagnostic tests (e.g., WADA, FMRI, MEG) T-5 Prepare the equipment and supplies for use. The safe and effective performance of this task requires knowledge of: K-10 Surgery specific monitoring protocols K-12 Infection control K-13 ACNS Guidelines K-14 Effects of instrument settings (e.g. filters, display gain, epoch) K-15 Montage modifications K-24 Electrical safety techniques K-32 Characteristics of the differential amplifier (e.g. polarity, CMRR) T-6 Confirm the surgical plan and monitoring requirements with the surgical team in order to determine if adjustments must be made. The safe and effective performance of this task requires knowledge of: K-1 Medical terminology K-3 General anatomy 12
  • 14. K-4 Risks associated with specific disorders/surgical procedures K-5 Elements of a patient history K-6 Medical conditions that may affect monitoring protocols K-10 Surgery specific monitoring protocols K-11 Uses of stimulating electrodes, recording electrodes and modality devices K-16 Effects of drugs/anesthetic agents on recordings K-17 Neuroanatomy: central and peripheral K-28 Modality specific potential waveforms K-31 Documentation and communication techniques K-38 Preoperative diagnostic tests (e.g., WADA, FMRI, MEG) Domain II – Intraoperative Phase T-1 Measure and mark the patient to determine the electrode sites. The safe and effective performance of this task requires knowledge of: K-3 General anatomy K-7 Age-specific criteria K-8 Techniques for establishing rapport K-9 Cognitive limitations K-12 Infection control K-13 ACNS Guidelines K-17 Neuroanatomy: central and peripheral K-18 Metric system K-19 Electrode placement systems (e.g. 10-20) T-2 Prepare the sites, securely apply recording and stimulating electrodes and check impedance. The safe and effective performance of this task requires knowledge of: K-7 Age-specific criteria K-8 Techniques for establishing rapport K-9 Cognitive limitations K-12 Infection control K-20 Conditions affecting impedance K-21 Electrode application techniques (e.g. paste, collodion, needle electrodes) K-22 Significant patient factors (e.g. patient cooperation, pain tolerance, adequate twitch) K-23 Range of standard impedance values K-24 Electrical safety techniques 13
  • 15. T-3 Obtain and report pre-incision baseline values based on the risk assessment. Perform assessment/measurement of peripheral systems relevant to the test modalities (visual, auditory, somatosensory, motor evoked potentials, EMG, EEG). The safe and effective performance of this task requires knowledge of: K-2 Evoked potentials, motor evoked potentials, EEG and EMG correlates of clinical entities K-4 Risks associated with specific disorders/surgical procedures K-6 Medical conditions that may affect monitoring protocols K-7 Age-specific criteria K-10 Surgery specific monitoring protocols K-11 Uses of stimulating electrodes, recording electrodes and modality devices K-13 ACNS Guidelines K-14 Effects of instrument settings (e.g. filters, display gain, epoch) K-15 Montage modifications K-16 Effects of drugs/anesthetic agents on recordings K-17 Neuroanatomy: central and peripheral K-24 Electrical safety techniques K-26 Troubleshooting techniques K-27 Artifact identification, and elimination K-28 Modality specific waveforms K-29 Digital instrumentation concepts (e.g. S/N ratio, sampling rate, analog to digital conversion) K-30 Significant surgical events (e.g. clamping, rotation, distraction) K-31 Documentation and communication techniques T-4 Monitor neurophysiologic functioning during intraoperative procedures: • Motor evoked potentials • Cortical mapping and EEG • Evoked potentials (somatosensory, brainstem auditory, visual) • EMG (peripheral and cranial) The safe and effective performance of this task requires knowledge of: K-2 Evoked potentials, motor evoked potentials, EEG and EMG correlates of clinical entities K-4 Risks associated with specific disorders/surgical procedures K-6 Medical conditions that may affect monitoring protocols K-7 Age-specific criteria 14
  • 16. K-10 Surgery specific monitoring protocols K-11 Uses of stimulating electrodes, recording electrodes and modality devices K-13 ACNS Guidelines K-14 Effects of instrument settings (e.g. filters, display gain, epoch) K-15 Montage modifications K-16 Effects of drugs/anesthetic agents on recordings K-26 Troubleshooting techniques K-27 Artifact identification, and elimination K-28 Modality specific waveforms K-29 Digital instrumentation concepts (e.g. S/N ratio, sampling rate, analog to digital conversion) K-30 Significant surgical events (e.g. clamping, rotation, distraction) K-31 Documentation and communication techniques T-5 Modify or adjust the recording strategy and/or instrument parameters based on the technologist’s evaluation of recorded data and the progress of the case. The safe and effective performance of this task requires knowledge of: K-2 Evoked potentials, motor evoked potentials, EEG and EMG correlates of clinical entities K-3 General anatomy K-4 Risks associated with specific disorders/surgical procedures K-6 Medical conditions that may affect monitoring protocols K-7 Age-specific criteria K-10 Surgery specific monitoring protocols K-11 Uses of stimulating electrodes, recording electrodes and modality devices K-13 ACNS Guidelines K-14 Effects of instrument settings (e.g. filters, display gain, epoch) K-15 Montage modifications K-16 Effects of drugs/anesthetic agents on recordings K-17 Neuroanatomy: central and peripheral K-26 Troubleshooting techniques K-27 Artifact identification, and elimination K-28 Modality specific waveforms K-29 Digital instrumentation concepts (e.g. S/N ratio, sampling rate, analog to digital conversion) K-30 Significant surgical events (e.g. clamping, rotation, distraction) K-31 Documentation and communication techniques 15
  • 17. T-6 Remove the electrodes from the patient and the equipment from the surgical field and clean the electrode sites. The safe and effective performance of this task requires knowledge of: K-7 Age-specific criteria K-8 Techniques for establishing rapport K-12 Infection control K-22 Significant patient factors (e.g. patient cooperation, pain tolerance, adequate twitch) K-31 Documentation and communication techniques K-33 MSDS/OSHA standards Domain III - Post-Operative Phase T-1 Ensure that the on-going physiologic and non-physiologic documentation of factors pertaining to the intraoperative monitoring and surgical procedure is complete and comprehensive. The safe and effective performance of this task requires knowledge of: K-2 Evoked potentials, motor evoked potentials, EEG and EMG correlates of clinical entities K-6 Medical conditions that may affect monitoring protocols K-11 Uses of stimulating electrodes, recording electrodes and modality devices K-13 ACNS Guidelines K-16 Effects of drugs/anesthetic agents on recordings K-22 Significant patient factors (e.g. patient cooperation, pain tolerance, adequate twitch) K-26 Troubleshooting techniques K-27 Artifact identification, and elimination K-30 Significant surgical events (e.g. clamping, rotation, distraction) K-31 Documentation and communication techniques K-32 Significant patient factors (e.g. patient cooperation, pain tolerance, adequate twitch) T-2 Clean and disinfect reusable electrodes and equipment ad dispose of non-reusable supplies. The safe and effective performance of this task requires knowledge of: K-12 Infection control K-33 MSDS/OSHA standards 16
  • 18. T-3 Ensure that scheduled maintenance of equipment is performed. The safe and effective performance of this task requires knowledge of: K-13 ACNS Guidelines K-39 Data management and storage Domain IV – Ethics and Professional Issues T-1 Ensure patient safety. The safe and effective performance of this task requires knowledge of: K-6 Contraindications for specific modalities K-12 Infection control K-24 Electrical safety techniques K-33 MSDS/OSHA standards K-35 Allergies/sensitivities (e.g. latex, tape) T-2 Conduct practice in a manner consistent with the ABRET® Code of Ethics. The safe and effective performance of this task requires knowledge of: K-36 The ABRET® Code of Ethics T-3 Maintain patient confidentiality. The safe and effective performance of this task requires knowledge of: K-36 The ABRET® Code of Ethics K-37 HIPAA standards C Additional Evoked Potential Content for Path 2 EVOKED POTENTIAL TECHNOLOGY PRACTICE ANALYSIS Domain I - Pre-study Procedures T-1 Obtain patient health information and additional information from medical records and patient/caregivers in order to plan recording strategies and avoid adverse effects The safe and effective performance of this task requires knowledge of: K-1 Elements of a patient history K-2 Medical terminology K-3 Effects of medications on patients and recordings K-4 Neurological Disorders (e.g. tumors, vascular disease) K-5 Psychiatric Disorders 17
  • 19. K-6 Toxic/metabolic disorders K-7 Head trauma K-8 Neuroanatomy: central and peripheral K-9 Evoked potential correlates of clinical entities K-10 Sedation practices K-11 HIPAA T-2 Explain the testing procedure to patient/caregivers in a manner consistent with their ability to understand in order to establish rapport and elicit cooperation. The safe and effective performance of this task requires knowledge of: K-12 Components of each evoked potential modality (e.g. stimulating and recording parameters, instruments, ancillary devices) K-13 Age-specific criteria K-14 Techniques for establishing rapport K-15 Cognitive limitations T-3 Perform assessment/measurement of peripheral systems relevant to the test modalities (visual, auditory, somatosensory) The safe and effective performance of this task requires knowledge of: K-1 Elements of a patient history K-2 Medical terminology K-8 Neuroanatomy: central and peripheral K-12 Components of each evoked potential modality (e.g. stimulating and recording parameters, instruments, ancillary devices) K-13 Age-specific criteria K-14 Techniques for establishing rapport K-15 Cognitive limitations K-16 Assessment/measurement devices (e.g. eye charts, otoscope) K-17 Metric system Domain II – Performing the Evoked Potential Study T-1 Prepare the patient A. Measure and mark the patient to determine the electrode sites B. Prepare the sites for recording and stimulating electrodes in order to reduce impedance C. Securely apply the recording and stimulating electrodes D. Check impedance to ensure electrode integrity The safe and effective performance of this task requires knowledge of: K-8 Neuroanatomy: central and peripheral 18
  • 20. K-13 Age-specific criteria K-14 Techniques for establishing rapport K-15 Cognitive limitations K-17 Metric system K-18 Electrode placement (recording and stimulation) K-19 Infection control K-20 General anatomy K-21 Conditions affecting impedance K-22 Electrode application techniques (e.g. paste, collodion) K-23 MSDS/OSHA standards K-24 Characteristics of the differential amplifier (e.g. polarity, CMRR) K-25 Range of standard impedance values T-2 Perform the evoked potential study according to ACNS Guidelines while ensuring the integrity of the data and equipment The safe and effective performance of this task requires knowledge of: K-1 Elements of a patient history K-2 Medical terminology K-3 Effects of medications on patients and recordings K-4 Neurological Disorders (e.g. tumors, vascular disease) K-5 Psychiatric Disorders K-6 Toxic/metabolic disorders K-7 Head trauma K-8 Neuroanatomy: central and peripheral K-9 Evoked potential correlates to clinical entities K-12 Components of each evoked potential modality (e.g. stimulating and recording parameters, instruments, ancillary devices) K-13 Age-specific criteria K-15 Cognitive limitations K-18 Electrode placement (recording and stimulation) K-21 Conditions affecting impedance K-24 Characteristics of the differential amplifier (e.g. polarity, CMRR) K-26 ACNS Guidelines K-27 Troubleshooting techniques K-28 Artifact monitoring, identification, and elimination K-29 Evoked potential waveforms (e.g. obligate waveforms, generator sites) K-32 Digital instrumentation concepts (e.g. S/N ratio, sampling rate, analog to digital conversion) K-39 Waveform analysis (latency and amplitude) T-3 Modify or adjust the recording strategy and/or instrument parameters based on the technologist’s evaluation of recorded data to ensure a complete and comprehensive study 19
  • 21. The safe and effective performance of this task requires knowledge of: K-1 Elements of a patient history K-2 Medical terminology K-3 Effects of medications on patients and recordings K-4 Neurological Disorders (e.g. tumors, vascular disease) K-5 Psychiatric Disorders K-6 Toxic/metabolic disorders K-7 Head trauma K-8 Neuroanatomy: central and peripheral K-9 Evoked potential correlates to clinical entities K-12 Components of each evoked potential modality (e.g. stimulating and recording parameters, instruments, ancillary devices) K-13 Age-specific criteria K-15 Cognitive limitations K-18 Electrode placement (recording and stimulation) K-21 Conditions affecting impedance K-24 Characteristics of the differential amplifier (e.g. polarity, CMRR) K-26 ACNS Guidelines K-27 Troubleshooting techniques K-28 Artifact monitoring, identification, and elimination K-29 Evoked potential patterns (e.g. obligate waveforms, generator sites) K-30 Effects of instrument settings (e.g. filters, display gain, epoch) K-31 Montage modifications K-32 Digital instrumentation concepts (e.g. S/N ratio, sampling rate, analog to digital conversion) K-39 Waveform analysis (latency and amplitude) T-4 Remove the electrodes and clean the electrode sites The safe and effective performance of this task requires knowledge of: K-19 Infection control K-23 MSDS/OSHA standards 20
  • 22. SAMPLE QUESTIONS 1. Cortical potentials will be most affected by which of the following agents? 1. Narcotics 2. Barbiturates 3. Inhalational anesthetics 4. Neuromuscular blockers 2. Which of the following is a far-field potential? 1. N20 2. P14 3. Wave I 4. Erb's point 3. Which of the following is an effect of using alternating click polarity? 1. Reduces stimulus intensity 2. Minimizes stimulus artifact 3. Increases amplitude of wave I 4. Improved signal to noise ratio 4. ANKYLOSIS 1. Foot drop 2. Wrist drop 3. Fused joint 4. Arterial occlusion 5. Grounding the stimulated limb during a SSEP procedure decreases 1. stimulus artifact. 2. stimulus intensity. 3. stimulating electrode impedances. 4. spread of stimulating current. Answers to sample questions: 1.3, 2.2, 3.2, 4.3, 5.1 21
  • 23. REFERENCES The following references, or most recent editions of the following, may be of useful in preparing for the examination. The list does not attempt to include all acceptable materials, nor is it suggested that the Certification Examination in Neurophysiologic Intraoperative Monitoring questions are necessarily based on these references. American Clinical Neurophysiology Society Guidelines in Electroencephalography, Evoked Potentials, and Polysomnography, 2006 (www.acns.org) AORN “Standards, Recommended Practices, and Guidelines” (updated annually). (www.aornbookstore.org) (ISBN #MAN- 007) ASET Intraoperative Monitoring: Basics and Performance Issues; Intraoperative Monitoring: Sensory, Nerve and Muscle; Intraoperative Monitoring: EEG (www.aset.org). Barrow, D.L. Surgery of the Cranial Nerves of the Posterior Fossa. Thieme, 1993. (ISBN #1588901343) Chiappa K. Evoked Potentials in Clinical Medicine. 3rd edition. Raven Press, New York, 1997. (ISBN #0397516592) Ebersole, J.S. and Pedley, T.A. (eds.) Current Practice of Clinical Electroencephalography, 3rd edition. Lippincott Williams & Wilkins: Philadelphia, 2003. (ISBN #0781716942) Erwin, C.W. and Erwin, A.C. “Up and Down the Spinal Cord: Intraoperative Monitoring of Sensory and Motor Spinal Cord Pathways.” J. Clin Neurophysiol, 10(4), p 425-436, 1993. Husain, A. (ed). A Practical Approach to Neurophysiologic Intraoperative Monitoring. Demos: New York, 2008. (ISBN #9781933864099) Isley, M.R. and Balzer, J.R., et al. “Intraoperative Motor Evoked Potentials”, American Journal of Electroneurodiagnostic Technology, 41:4, 2001. Joint Commission on Accreditation for Healthcare Organizations. “National Patient Safety Goals” www.jointcommission.org Jones, S.J. Handbook of Spinal Cord Monitoring: Proceedings of the Fifth International Symposium on Spinal Cord Monitoring, London, June 2-5, 1992. Springer, 1994. (ISBN #079238833X) 22
  • 24. Kartush, J.M. and Bouchard, K.R., Neuromonitoring in Otology and Head and Neck Surgery. Raven Press: New York, 1992. (ISBN #0881678465) Leis, A.A. Atlas of Electromyography. Oxford University Press, 2000. (ISBN #0195112504) Misulis, K.E. Spehlmann’s Evoked Potential Primer. 3rd Edition. Butterworth-Heinemann: Boston, 2001. (ISBN #075067338) Moller, A.R. Intraoperative Neurophysiologic Monitoring. 2nd Edition. Humana Press., 2006. (ISBN #1588297039) Nuwer, M.R. (ed.) Intraoperative Monitoring of Neural Function: Handbook of Clinical Neurophysiology. Elsiver, 2008. (ISBN #044451824X) Phillips, N. Berry & Kohn’s Operating Room Technique. 11th Edition. Mosby, 2007. (ISBN #0323004832) Rothrock, J.C. and McEwen, D.R. Alexander’s Care of the Patient in Surgery. 13th Edition. Elsevier Health Sciences, 2006. (ISBN-13 #9780323039277) Russell, G.B. and Rodichok, L.D. (eds.) Primer of Intraoperative Neurophysiologic Monitoring. Butterworth- Heinemann, 1995. (ISBN #0750695536) Sullivan, L. and Altman, C. “Infection Control: 2008 Review and Update for Electroneurodiagnostic Technologists.” American Journal of Electroneurodiagnostic Technology. 48(3) p 140-165, 2008. Tatum, W.O. Handbook of EEG Interpretation. Demos: New York, 2007. (ISBN #01933864117) Tyner, F.S., Knott, J.R., and Mayer, W.B. Fundamentals of EEG Technology, Vol. 1: Basic Concepts and Methods. Raven Press: New York, 1983. (ISBN #089004385x) Wilson-Pauwels, L. Cranial Nerves in Health & Disease. 2nd Edition. BC Decker, 2002. (ISBN #1550091646) Zouridakis, G. and Papanicolaou, A. A Concise Guide to Intraoperative Monitoring. Lewis Publisher, 2000. (ISBN #0849308860) 23
  • 25. NOTIFICATION OF STATUS SCORING The Board sets the passing standard as the number of test questions it determines to be necessary for candidates to answer correctly in order to be considered at least minimally competent. This method focuses on the particular test that is being administered. Different forms of an examination are equated for difficulty and content coverage. This comprehensive approach makes use of information about the performance of similar groups in the past. ABRET® is concerned with reporting only valid scores. On rare occasions, misconduct or circumstances beyond the individual’s control may render a score invalid. If doubts are raised about a score because of these or other circumstances, ABRET® reserves the right to cancel any examination score, if, in the sole opinion of ABRET®, there is adequate reason to question its validity. REPORT OF RESULTS Candidates will be notified within six weeks whether they have passed or failed the written examination. Scores on the major areas of the examination and on the total examination will be reported. Candidates may request rescoring of the examination by contacting the Professional Testing Corporation in writing and providing their complete name, address, and social security number, and stating the reason for the request, name of the examination, and testing date. ATTAINMENT OF REGISTRATION Eligible candidates who pass the Certification Examination in Neurophysiologic Intraoperative Monitoring will be certified in neurophysiologic intraoperative monitoring for a period of five years, will be permitted to use the designation CNIM® after their names, and will receive a time limited Certificate from ABRET®. They will be eligible for recertification after 5 years and if not recertified, will no longer be permitted to use the CNIM designation. ABRET® provides state, regional, and national societies with the names and addresses of passing candidates upon request. CONFIDENTIALITY 1. ABRET® will release the individual test scores ONLY to the individual candidate. 2. Any questions concerning test results should be referred to ABRET® or the Professional Testing Corporation. 3. ABRET® provides the national END society with the names and addresses of passing candidates. 24
  • 26. CODE OF ETHICS AND STANDARDS OF PRACTICE The American Board of Registration Of Electroencephalographic and Evoked Potential Technologists (“ABRET®) is a nonprofit credentialing board for Electroencephalographic (“EEG”)Technologists, Evoked Potential (“EP”) Technologists, and Neurophysiologic Intraoperative Monitoring (“CNIM”) Technologists and Long Term Monitoring (“CLTM”) Technologists, and seeks to encourage, establish and maintain the highest standards, traditions and principles of these technologies. ABRET® Registered and Certified Technologists should recognize their responsibilities, not only to their patients, but also to society, to other health care professionals and to themselves. The following principles have been adopted by the Board of Directors in order to encourage personnel to aspire to the highest possible professional practice. An ABRET® Registered technologist or Certified individual shall 1. Do everything in his or her power to insure that the current Guidelines of the American Clinical Neurophysiology Society are complied with in the department in which he or she works. 2. Preserve human dignity, respect patient's rights and support the well being of the patient under his or her care. The Registered or Certified person shall avoid discrimination against individuals on the basis of race, creed, religion, sex, age and national origin. 3. Appreciate the importance of thoroughness in the performance of duty, compassion with patients and the significance of the tasks he or she perform. 4. Preserve the confidentiality of medical and personal information of a patient. 5. Strive to remain abreast of current technology and to study and apply scientific advances in his or her specialty. Carry out their professional work in a competent and objective manner. 6. Abide by laws related to the profession and to general public health and safety and avoid dishonest, unethical or illegal practices. 25
  • 27. 7. Refuse primary responsibility for interpretation of testing or monitoring of Electroencephalograms, Evoked Potentials, or Neurophysiologic Intraoperative Monitoring for purposes of clinical diagnosis and treatment. Individuals who are licensed or otherwise authorized by practice standards to provide interpretation are excluded. 8. Be truthful, forthcoming, and cooperative in their dealings with ABRET®. 9. Be in continuous compliance with ABRET®’s rules (as amended from time to time by ABRET®). 10. Respect ABRET®’s intellectual property rights. VIOLATIONS TO ABRET CODE OF ETHICS AND STANDARDS OF PRACTICE PURPOSE OF STANDARDS: ABRET® has developed this Code of Ethics to articulate standards of conduct required for eligibility for certification and continued certification of EEG, EP, CNIM and CLTM technologists. Maintenance of board certification will require adherence to the ABRET® Code of Ethics. Individuals who fail to meet these requirements may have their certification suspended or revoked. ABRET® does not guarantee the job performance of any individual. REPORTING REQUIREMENTS An individual convicted of a felony related to electroencephalographic, evoked potential, long term monitoring or neurophysiologic intraoperative monitoring practice and/or public health and safety (including, but not limited to felonies involving rape, sexual abuse of a patient or child, actual or threatened use of a weapon, violence, and the prohibited sale, distribution or possession of a controlled substance) must notify ABRET® of such conviction and shall be ineligible to apply for registration, certification, or renewed registration for a period of three (3) years from the exhaustion of appeals or final release from confinement, whichever is later. 26
  • 28. 1. Grounds for Disciplinary Action. ABRET® may deny, suspend, revoke, or take other action regarding an application or certification if an individual is not in compliance with this Disciplinary Policy. Grounds for disciplinary action include (but are not limited to): A. Ineligibility for certification, regardless of when the ineligibility is discovered; B. An irregular event in connection with an ABRET® examination including (but not limited to) copying answers, copying examination materials, and causing a disruption in the testing area; C. Providing fraudulent or misleading information; D. Failure to pay fees when due; E. Unauthorized possession or misuse of ABRET® credentials, examinations, and other intellectual property; F. Misrepresentation of certification status; G. Failure to provide requested information in a timely manner; H. Failure to inform ABRET® of changes or adverse actions; I. Impairment of professional performance because of habitual use of alcohol, drugs, or other substance, or any physical or mental condition; J. Gross or repeated negligence or malpractice in professional work; K. Noncompliance with laws related to the profession and to general public health and safety; L. Accepting primary responsibility for interpretation of testing or monitoring for purposes of clinical diagnosis and treatment (Individuals who are licensed or otherwise authorized by practice standards to provide interpretation are excluded.); M. Failure to maintain a current professional credential as required by the jurisdiction in which the individual practices (this may include a license, certificate, or registration); N. The conviction of, plea of guilty to, or plea of nolo contendere to a felony or misdemeanor related to public health and safety or the profession; O. Disciplinary action by a licensing board or professional organization other than ABRET®; and P. Other failure to maintain continuous compliance with ABRET® standards, policies, and procedures. 27
  • 29. 2. Sanctions. If an individual is not exonerated or acquitted of all allegations, ABRET® may impose one or more of the following sanctions for a violation of this Disciplinary Policy: A. Denial or suspension of eligibility; B. Denial of certification; C. Revocation of certification; D. Non-renewal of certification; E. Suspension of certification for a specific period of time; F. Reprimand; G. Probation; or H. Other corrective action. Candidates or certificants may appeal the decision of the Discipline Committee to the ABRET® Board of Directors by submitting a written appeals statement within 30 days. It is the candidate’s responsibility to initiate this appeal in accordance with ABRET®’s policies. Each candidate must affirm that the information provided in the Application is true and correct to the best of his or her knowledge. Each candidate further agrees to hold ABRET® and its sponsoring organizations blameless from any claim for damages as a result of any action it may take in connection with this Application, the registration examination, or the results thereof. NAME/ADDRESS CHANGES The candidate is responsible for promptly notifying the Professional Testing Corporation of address or name changes prior to the examination date. The credentialed technologist is responsible for notifying the ABRET® Executive Office of address or name changes after passing the examination. PTC09205 28
  • 30. Application for Certification Examination in Neurophysiologic Intraoperative Monitoring Please read the directions in the Handbook for Candidates carefully before completing this Application. MARKING INSTRUCTIONS: This form will be scanned by computer, so please make your marks heavy and dark, filling the circles completely. Please print uppercase letters and avoid contact with the edge of the box. See example provided. Candidate Information Last Name First Name Middle Initial Number and Street Apartment Number City State/Province Zip/Postal Code E-mail Address Social Security Number Daytime Phone - - - - Testing Period: Winter Summer Eligibility and Background Information Darken only one choice for each question unless otherwise directed. A. ELIGIBILITY: (See Handbook.) C. YEARS OF EXPERIENCE IN NEURODIAGNOSTICS: INITIAL CERTIFICATION Less than one Three to five More than ten PATH 1: Neurodiagnostic Credential One to two Six to ten (Provide EP, EEG, or RET (Canadian). ) D. YEARS OF EXPERIENCE IN EVOKED POTENTIALS: ABRET EP Number: ABRET EEG Number: Less than one Three to five More than ten One to two Six to ten C.B.R.E.T EEG Number: E. TRAINING IN NEUROPHYSIOLOGIC INTRAOPERATIVE MONITORING: (Darken all that apply.) Neurodiagnostic training program PATH 2: Bachelor's Degree or higher (Include documentation.) On-the-job ASET courses RECERTIFICATION or REINSTATEMENT Other courses Recertification prior to credential expiration (Provide name certified under, date and CNIM Number below.) F. HIGHEST ACADEMIC LEVEL ATTAINED: GED or equivalent Reinstatement of credential (Provide name certified under, date and CNIM Number below.) High School Graduate Name: _______________________________________ Vo-tech school graduate or Associate Degree Certification Date: (MM/YY) ABRET CNIM Number: Bachelor's Degree Master's Degree / Doctorate B. PERCENT OF WORKING TIME CURRENTLY SPENT IN (Complete Page 2) NEUROPHYSIOLOGIC MONITORING: Less than 25% 25 to 75% More than 75% 10801 ABRET-CNIM, PROFESSIONAL TESTING CORPORATION, 1350 BROADWAY, 17th FLOOR, NEW YORK, NY 10018 WWW.PTCNY.COM (212) 356-0660 ALL RIGHTS RESERVED PTC09209
  • 31. Application for Certification Examination in Neurophysiologic Intraoperative Monitoring Eligibility and Background Information G. PROCEDURES YOU PERSONALLY RECORD IN THE H. PRIMARY REASON FOR TAKING EXAMINATION: OPERATING ROOM: (Darken all that apply.) (Darken only one response.) Job requirement Professional advancement Intraoperative Scalp EEG Motor Pathway Salary increase Personal goal Cranial Nerve Supplied EMG Electrocorticography Job security School requirement VEPs Spinal Nerve EMG Competency demonstration Other (specify below) BAEPs Cortical Mapping I. HAVE YOU TAKEN THIS EXAMINATION BEFORE? No Yes If yes, indicate month, year, and name under which SSEPs/Spinal Monitoring Other (please specify below) the examination was taken. Date (month/year) Name Supervisor's Verification of Experience Optional Information Supervisor's Verification of Experience I certify that to the best of my knowledge the listed experience Note: Information related to race, age, and gender is optional and is requested only to is correct and complete. assist in complying with general guidelines pertaining to equal opportunity. Such data will be used only in statistical summaries and in no way will affect your test results. SIGNATURE: Race: Age Range: Gender: TITLE: African American Under 25 Male INSTITUTION: Asian 25 to 29 Female Hispanic 30 to 39 PHONE: 40 to 49 Native American ADDRESS: White 50 to 59 Other 60+ CITY/STATE: Candidate Signature COMPLETE ENTIRE APPLICATION BEFORE SIGNING BELOW. I have read the Handbook for Candidates and understand that I am responsible for knowing its contents. I certify that the information given in this Application is in accordance with Handbook instructions and is accurate, correct, and complete. NON-DISCLOSURE AGREEMENT AND GENERAL TERMS OF USE This examination is confidential and proprietary. It is made available to you, the examinee, solely for the purpose of assessing your competency in the area referenced in the title of this examination. You are expressly prohibited from disclosing, publishing, reproducing, or transmitting this examination, in whole or in part, in any form or by any means, verbal or written, electronic or mechanical, for any purpose, without the prior express written permission of the American Board of Registration of Electroencephalographic and Evoked Potential Technologist ("ABRET"). Yes, "I Agree." No, "I Do Not Agree." CANDIDATE SIGNATURE: DATE: CREDIT CARD PAYMENT FOR OFFICE USE ONLY If you want to charge your application fee on your credit card provide all of the following information. Date Name (as it appears on your card): Address (as it appears on your statement): Charge my credit card for the total fee of: $ Expiration date (month/year): Fee: / Card type: Visa MasterCard American Express CC Check Card Number: Signature: 10801 ABRET-CNIM, PROFESSIONAL TESTING CORPORATION, 1350 BROADWAY, 17th FLOOR, NEW YORK, NY 10018 WWW.PTCNY.COM (212) 356-0660 ALL RIGHTS RESERVED PTC09209
  • 32. CNIM DOCUMENTATION FORM Fill out the form completely. Indicate hospital name and phone number of OR scheduling office or hospital office for verification of cases. You only need to write information down once. If more than one hospital, indicate as hospital #1, #2, etc. Candidate must be present and an active participant in the set-up and monitoring of each case. ABRET will accept up to two cases per day. CANDIDATE NAME: NO DATE HOSPITAL NAME/ PRIMARY TYPE OF SURGERY TIME IN/ MODALITY (IES) Of PHONE NUMBER SURGEON OUT OF MONITORED PROCEDURE ROOM I certify that the information provided is true and accurate. Submit completed form with your application. Random auditing will be conducted by ABRET. _________________________________________________ Signature of Medical Director or Supervisor Date page ____ of ____ ___________________________________________________________________ 11/07 Print Name Phone #