Table 1.

Summary of Guideline Recommendations for Nonphysician Supervision of Exercise Tests

Organization	Guideline /Year	Recommendation
AHA/ACC	“Clinical Competence Statement on Stress Testing”13/2000 (PMID 11015355)	In most patients, exercise testing can be safely supervised by properly trained nurses, physician assistants, exercise physiologists, physical therapists, or medical technicians working under the direct supervision of the physician, who should be in the immediate vicinity or on the premises or the floor and available in case of emergency situations. It is recommended that nonphysicians who supervise the actual exercise test have certain cognitive skills (as outlined in this document) and that they be certified in exercise testing by organizations such as the ACSM. In general, the physician should be present to observe the patient continuously (ie, personally supervise) when the test is performed on a patient with a recent (within 7–10 d) history of documented acute coronary syndrome, severe left ventricular dysfunction, severe valvular stenosis (eg, aortic stenosis), or complex arrhythmia. In all instances, the healthcare provider should screen the patient for indications and contraindications immediately before the test.*
AHA	“Recommendations for Clinical Exercise Laboratories”12/2009 (PMID 19487589)	These guidelines call for risk stratification of people to be tested to determine the appropriate level of medical supervision needed during testing. The use of specially trained nonphysician healthcare professionals is appropriate to supervise clinical exercise testing if the individual supervising the test meets competency requirements for exercise test supervision, is fully trained in cardiopulmonary resuscitation, and is supervised by a physician skilled in exercise testing, who is immediately available and later reads over the test results. These nonphysician health professionals typically include exercise physiologists, nurses, nurse practitioners, and physician assistants but may include other health professionals. This practice should be compatible with state licensure regulations and statutory definitions for the practice of medicine before it is implemented.
AHA	“Exercise Standards for Testing and Training”19/2013	Exercise testing should be conducted only by well-trained personnel with sufficient knowledge of exercise physiology and ability to recognize important changes in rhythm and repolarization on the ECG. The degree of subject supervision needed during a test can be determined by the clinical status of the subject being tested. This determination is made by the physician or physician’s designated staff member, who asks pertinent questions about the subject’s medical history, performs a brief physical examination, and reviews the standard 12-lead ECG performed immediately before testing. Supervision can be assigned to a properly trained nonphysician (ie, a nurse, physician assistant, or exercise physiologist or specialist) for testing apparently healthy younger people (<40 y of age) and those with stable chest pain syndromes with additional flexibility. Possibly with the exception of young, apparently healthy individuals (eg, exercise testing of athletes), a physician should be immediately available during all exercise tests. The ACC/AHA/ACP document on clinical competence in stress testing provides additional details on the supervision and interpretation of exercise tests.13
ACSM	“Guidelines for Exercise Testing and Prescription”24/2010	Individuals who supervise exercise tests must have the cognitive and technical skills necessary to be competent to do so as are outlined in the ACC/AHA/ACP document on clinical competence in stress testing.13 In most cases, clinical exercise tests can be supervised by properly trained exercise physiologists, physical therapists, nurses, physician assistants, or medical technicians who are working under the direct supervision of a physician.* In situations in which the patient is deemed to be at increased risk for an adverse event during exercise testing, the physician should be physically present in the exercise testing room to personally supervise the test.
AACVPR	“Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs”25/2013	The level of supervision depends primarily on the type of patients being tested. For patients who are at higher risk (eg, those with recent myocardial infarction, heart failure, or arrhythmia), the supervising physician should determine the necessity for direct physician monitoring of the test.* In other cases, properly trained nonphysician healthcare professionals may conduct the test and directly monitor patient status throughout testing and recovery, provided that they have been deemed competent by the physician supervisor as per established guidelines.13 In all cases, the supervising physician must be immediately available to respond.

AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; ACC, American College of Cardiology; ACP, American College of Physicians; ACSM, American College of Sports Medicine; AHA, American Heart Association; and PMID, PubMed Identifier.

^*Three levels of supervision for diagnostic tests as follows: (1) personal supervision requires a physician’s presence in the room; (2) direct supervision requires a physician to be in the immediate vicinity or on the premises or the floor and available for emergencies; and (3) general supervision requires the physician to be available by phone or by page.¹³