National Competency Skill Standards for Performing Autonomic Testing

Autonomic testing technologists practice in accordance with the facility policy and procedure manual which details every aspect and type of recording.

ASET – The Neurodiagnostic Society presents this document to provide the national criteria for evaluating competencies for technologists performing autonomic testing. The elements for quality patient care and interaction as well as basic knowledge and technical performance are covered. The technical components include those defined in Phillip A. Low, M.D., Laboratory Evaluation of Autonomic Function, published by the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) in 2003.

Section I: Autonomic Testing Core Knowledge Statements

The autonomic testing technologist has the knowledge base to interact with the patient and obtain quality, interpretable autonomic function tests that will yield information about the sympathetic, parasympathetic, and enteric nervous systems. The technologist possesses the appropriate knowledge level of diseases to correlate patient history and clinical symptoms to determine appropriate maneuvers to be performed during the autonomic test.

Technical Skills and Other Abilities:

1.1 The autonomic testing technologist provides a safe testing environment by:

• Verifying identity of patient (two patient identifiers).
• Inquiring about any allergies or skin sensitivities prior to procedure.
• Disinfecting pads/plates/straps/capsules and any device used for testing after each procedure according to facility policies and procedures or using disposable products^{1, 2}.
• Following standard precautions for infection prevention including sterile techniques according to facility policy and procedures^{1, 2}.
• Observes patient safety and comfort protocols as established by facility policy and procedures.
• Recognizing/responding to life-threatening situations.
• Complying with facility policy and procedures for emergency and disaster situations and with hazardous material handling procedures according to safety data sheets (SDS).
• Maintaining instrument/equipment in good working order, including annual biomedical safety checks.
• Taking appropriate precautions to ensure electrical safety making sure no wires are frayed, extension cords are not in use, 3-pronged grounded plugs are in use; and damaged cords and outlets are reported according to facility policy, removed from use until properly repaired according to facility policy and procedure.
• Maintaining certification in Basic Life Support (BLS) and following facility policy and procedures for respiratory or cardiopulmonary crisis.
• Following facility policy and procedures for safety procedures, patient isolation and sedation.
• Maintaining instrument/equipment in good working order, including annual biomedical safety checks.
• Taking appropriate precautions to ensure electrical safety making sure no wires are frayed, extension cords are not in use, 3-pronged grounded plugs are in use, and damaged cords and outlets are reported and removed from use until properly repaired according to facility policy and procedure.
• Following HIPAA policy and facility procedures for cybersecurity and safety of electronic records.

1.2 The autonomic testing technologist establishes rapport with the patient and the patient’s family/caretaker by:

• Using personal communication skills to achieve patient relaxation/cooperation.
• Explaining all test procedures.
• Review contraindications before beginning the study.
• Instructing the patient in properly performing breathing techniques for both Heart Rate Deep Breathing (HRDB) and Valsalva Maneuver Ratio (i.e., VR where VR = max HR/min HR).
• Explaining device application method (ECG leads, blood pressure cuff, belts/ pads/ plates/straps/capsules, etc.).
• Interacting on a level appropriate for patient’s age and cognitive ability.
• Maintaining respect and patient confidentiality.

1.3 The autonomic testing technologist evaluates the patient to:

• Assess cognitive abilities, mental state, and comprehension level, such as following commands, understanding the procedure.
• Note the patient’s overall physical condition.
• Ascertain the patient’s capacity to cooperate with the procedures.
• Determine if any procedure is contraindicated.
• Accommodate for disabilities or special needs.
• Determine the possible need for assistance or emergency intervention.

1.4 The autonomic testing technologist prepares patient demographics that include:

• Patient’s information (name, age, ID number, DOB, referring physician, etc.).
• Testing time, date and technologist’s name or initials.
• Pertinent patient history and familial medical history.
• Previous autonomic function test reports.
• Current medication(s) and time of last dosage, specifically analgesic, anticholinergic, and parasympathetic agents.
• May note the time of last meal according to lab protocols.
• Time, date, and circumstances of last symptoms.
• Patient’s mental, behavioral and consciousness states.
• Documentation of any pacemaker/defibrillator device placement.
• Documentation of any recent invasive eye procedures or chest/abdominal surgical procedures.

1.5 The autonomic testing technologist’s test procedures follow a method that includes:

Quantitative Sudomotor Axon Reflex Test (QSART) Distribution:

• Monitoring desiccant filter for moisture capacity and replace as needed based on manufacturer recommendation.
• Checking Q-sweat device channels are within proper parameters and troubleshoot as needed following manufacturer recommendation.
• Preparing recording sites by proper measurement:
  • medial forearm (75% of the distance from the ulnar epicondyle to the pisiform bone)
  • proximal leg (lateral aspect, 5 cm distal to the fibular head)
  • distal leg (medial aspect, 5 cm proximal to the medial malleolus)
  • proximal foot (on a flat surface over the extensor digitorum brevis muscle)
• Attaching multicompartmental sweat capsules (4 sites) or prepared capsules and ground pads/plates.
• Achieving proper baseline.
• Inserting 10% acetylcholine (Ach) into the proper compartment of the capsules (not applicable if using prepared capsules).
• Applying appropriate stimuli (2 mA) for 5 minutes.
• Recording during stimulus application and for 5 subsequent minutes.

Heart Rate Response to Deep Breathing (HRDB)

• Attaching photoplethysmographic device to patient’s finger and ECG electrodes.
• Performing two series of recordings with an intervening 3–5 minutes of supine rest:
  • A series consists of eight deep breaths with five seconds of inhalation and five seconds of exhalation.
• Encouraging and comforting patient to successfully record smooth breaths with maximal inspiration to the top of the bar and total expiration to the bottom of the bar.
• Identifying cardiac rhythms or ECG artifact.

Valsalva Maneuver

• Attaching photoplethysmographic device to patient’s finger and ECG electrodes appropriately.
• Achieving proper baseline.
• Performing two maneuverers with an intervening 3–5 minutes of supine rest:
  • A maneuver consists of a patient taking a deep breath and exhaling to maintain a specific pressure for 15 seconds.
• Understanding of waveforms and whether a 20-degree tilt is necessary.
• Replicating waveforms.

Tilt Table

• Attaching photoplethysmographic device to patient’s finger and ECG electrodes appropriately.
• Securing straps to patient.
• Correct positioning of patient’s arms.
• Provide hand warmth as needed.
• Alerting patient prior to tilt maneuver.