Infection Control — Adhere to infection control and universal precautions - Certified Ekg Technician Cet

SECTION 1

Historical Context & Motivation

For centuries, infectious diseases ravaged hospitals at alarming rates, and the connection between provider practices and patient infections remained poorly understood. The concept of infection control — the systematic application of procedures designed to prevent the transmission of pathogens in healthcare settings — evolved through hard-won clinical observations and scientific breakthroughs. Before the germ theory of disease gained acceptance, physicians and nurses frequently moved between patients, cadavers, and surgical fields without washing their hands or changing garments. Postoperative mortality rates often exceeded 50%, and puerperal fever killed new mothers in maternity wards at devastating rates. The recognition that invisible agents could spread from person to person through direct contact, contaminated equipment, and environmental surfaces fundamentally transformed healthcare delivery and laid the groundwork for the precautions that every EKG technician follows today.

1847 • Semmelweis and Hand Hygiene

Ignaz Semmelweis demonstrated that hand washing with chlorinated lime solution dramatically reduced puerperal fever mortality in Viennese maternity clinics, establishing the first evidence-based infection control intervention.

1867 • Lister's Antiseptic Technique

Joseph Lister introduced carbolic acid antisepsis during surgery, applying Louis Pasteur's germ theory to clinical practice and reducing surgical site infections from approximately 45% to 15%.

1928 • Discovery of Penicillin

Alexander Fleming's discovery of penicillin introduced the antibiotic era, initially reducing infection mortality but eventually giving rise to antimicrobial resistance, which reinforced the critical importance of prevention over treatment.

1987 • Universal Precautions Established

The CDC issued Universal Precautions guidelines in response to the HIV/AIDS epidemic, mandating that all blood and certain body fluids be treated as potentially infectious regardless of a patient's known diagnosis.

1996 • Standard Precautions Codified

The CDC combined Universal Precautions with Body Substance Isolation into a unified framework called Standard Precautions, expanding protections to include all body fluids, non-intact skin, and mucous membranes.

The evolution from Semmelweis's simple hand-washing intervention to today's comprehensive Standard Precautions framework reflects a deepening understanding of pathogen transmission. For the EKG technician, who routinely applies electrodes to patients' skin, manipulates reusable cables, and works across multiple patient encounters in a single shift, the central question is: how do we systematically prevent the transfer of microorganisms between patients, from patients to healthcare workers, and from healthcare workers to patients during electrocardiographic procedures?

SECTION 2

Core Principles & Definitions

Infection control in the EKG lab rests on several foundational principles that guide every patient encounter. Understanding these principles transforms rote procedural compliance into purposeful, evidence-based practice. The modern framework revolves around the assumption that every patient may harbor transmissible pathogens, whether or not they exhibit symptoms or carry a documented diagnosis. This assumption eliminates the dangerous practice of selectively applying precautions based on perceived risk and ensures consistent, protective behavior across all patient interactions.

Standard Precautions

The baseline level of infection prevention applied to all patients in all healthcare settings. These include hand hygiene, use of personal protective equipment (PPE), respiratory hygiene and cough etiquette, safe injection practices, and proper handling of contaminated surfaces and equipment.

Chain of Infection

Infection requires six linked elements: an infectious agent, a reservoir, a portal of exit, a mode of transmission, a portal of entry, and a susceptible host. Breaking any single link in this chain prevents infection. Infection control strategies target multiple links simultaneously for maximum effectiveness.

Hand Hygiene

The single most effective measure to prevent healthcare-associated infections (HAIs). The WHO's Five Moments for Hand Hygiene define the critical points: before patient contact, before aseptic tasks, after body fluid exposure, after patient contact, and after touching patient surroundings.

Personal Protective Equipment (PPE)

Barriers worn to protect the healthcare worker and the patient from pathogen transfer. For EKG technicians, this primarily includes gloves for every patient, with gowns, masks, and eye protection added based on the clinical situation and transmission-based precautions.

Transmission-Based Precautions

Additional safeguards layered on top of Standard Precautions for patients with known or suspected infections spread by contact, droplet, or airborne routes. These dictate specific PPE requirements and patient placement strategies beyond the baseline.

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KEY TAKEAWAY

Think of Standard Precautions as your immune system's architecture — always active, always present, regardless of whether a specific threat has been identified. Just as your body doesn't wait for a confirmed pathogen before maintaining its epithelial barriers and mucosal defenses, Standard Precautions are your always-on professional defense system. Transmission-Based Precautions are the adaptive immune response: targeted, specific, and activated only when a particular threat is recognized. An EKG technician who applies only selective precautions is analogous to an immunocompromised host — vulnerable at every unprotected encounter.

SECTION 3

The Chain of Infection — Visual Explanation

The Chain of Infection illustrates the six sequential links required for disease transmission. The infectious agent (1) resides in a reservoir (2), exits through a portal of exit (3), travels via a mode of transmission (4), enters a new host through a portal of entry (5), and infects a susceptible host (6). Standard Precautions target multiple links: hand hygiene and surface disinfection address the reservoir and mode of transmission, while gloves protect portals of entry.

When an EKG technician performs a 12-lead electrocardiogram, each step in the procedure intersects with one or more links in the chain of infection. The patient's skin may serve as a reservoir harboring resident and transient flora, including potentially drug-resistant organisms such as MRSA or VRE. The act of applying and removing electrodes creates opportunities for organisms to access portals of entry — particularly if the patient has non-intact skin, intravenous access sites, or surgical wounds. Lead wires and the EKG machine itself can become fomites — inanimate objects that serve as vehicles for indirect contact transmission — if not properly disinfected between patients. Understanding where each precaution interrupts the chain empowers the technician to apply controls purposefully rather than mechanically.

SECTION 4

Mechanisms of Transmission & Precaution Categories

Pathogens relevant to the EKG setting are transmitted through three primary routes, each of which dictates a specific tier of Transmission-Based Precautions that supplement Standard Precautions. Understanding the mechanism behind each route clarifies why particular PPE items are selected and how environmental controls function. The three categories — contact, droplet, and airborne — are not mutually exclusive; some organisms, such as SARS-CoV-2, require precautions spanning multiple categories depending on the procedure being performed.

Contact Transmission

Contact transmission is the most common mode of pathogen spread in healthcare settings and the most relevant to EKG practice. Direct contact occurs when microorganisms transfer between an infected or colonized individual and a susceptible host through physical touch — for example, when a technician's ungloved hand touches a patient's skin colonized with MRSA and then touches the next patient. Indirect contact involves an intermediate contaminated object (fomite). EKG lead wires, electrode snap connectors, cable clips, and even the machine's touchscreen can serve as fomites. Studies have demonstrated that lead wires can harbor viable pathogens for hours to days if not properly disinfected between uses.

Droplet Transmission

Droplet transmission involves large respiratory particles (≥ 5 μm in diameter) generated when an infected person coughs, sneezes, or talks. These particles travel short distances — typically less than 1 meter — before settling on surfaces or mucous membranes. In the EKG setting, the technician works within the droplet zone while positioning leads on the patient's chest. Organisms spread via droplets include influenza, pertussis, and certain meningococcal species. A surgical mask provides adequate protection against droplet transmission for routine EKG procedures.

Airborne Transmission

Airborne transmission involves tiny droplet nuclei (< 5 μm) that remain suspended in the air for extended periods and can travel beyond standard room distances. Organisms such as Mycobacterium tuberculosis, varicella-zoster virus, and rubeola virus are transmitted via this route. Patients on airborne precautions are placed in negative-pressure airborne infection isolation rooms (AIIRs). When an EKG technician must enter such a room, an N95 or higher-level respirator is required, and the technician must have completed annual fit testing to ensure a proper facial seal.

Precaution Category	Particle Size / Mechanism	PPE Required for EKG Tech	Example Organisms
Standard	All body fluids, non-intact skin, mucous membranes	Gloves; hand hygiene before/after contact	Applied to all patients regardless of diagnosis
Contact	Direct or indirect contact with skin or fomites	Gloves + gown; dedicated or disposable equipment	MRSA, VRE, C. difficile, scabies
Droplet	Large particles ≥ 5 μm; travel < 1 m	Surgical mask + gloves; gown if close contact	Influenza, pertussis, mumps, N. meningitidis
Airborne	Droplet nuclei < 5 μm; remain airborne, travel far	N95 respirator + gloves; AIIR required	Tuberculosis, varicella, measles (rubeola)

Precaution categories relevant to EKG technician practice

SECTION 5

Infection Control Protocols Specific to EKG Procedures

While Standard Precautions provide a universal framework, the EKG technician must apply these principles to the specific workflow of electrocardiographic testing. A standard 12-lead EKG involves skin preparation, electrode placement on ten anatomical sites, cable attachment, tracing acquisition, and equipment removal and cleaning. Each of these steps presents distinct infection control considerations. The following diagram illustrates the EKG procedure workflow with infection control checkpoints mapped to each phase.

This workflow diagram maps the standard 12-lead EKG procedure from patient approach to completion, with infection control checkpoints (marked ✦) embedded at critical transition points. Note that hand hygiene occurs at minimum twice per encounter — before patient contact and after glove removal — and that equipment disinfection is mandatory before the system is considered ready for the next patient.

Electrode and Lead Wire Management

Electrodes used in EKG testing must be single-use disposable items. Reusing electrodes between patients is a direct violation of infection control standards, as the adhesive pads contact the patient's skin and may harbor transient microorganisms. After removal, used electrodes are discarded in regular medical waste (not biohazard sharps containers, as they are not sharps). Lead wires, however, are reusable and represent a frequently underappreciated vector for cross-contamination. Studies published in the American Journal of Infection Control have isolated viable MRSA, VRE, and Acinetobacter baumannii from insufficiently cleaned EKG lead wires. Wires must be wiped with a hospital-approved intermediate-level disinfectant (such as quaternary ammonium compounds or accelerated hydrogen peroxide) after every patient encounter, with adequate wet contact time per the manufacturer's instructions for use (IFU).

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CLINICAL ALERT

If an EKG is performed on a patient under contact precautions for C. difficile, alcohol-based hand rub (ABHR) is insufficient for hand hygiene. C. difficile spores are resistant to alcohol; only soap and water with vigorous mechanical friction will remove them. Additionally, the EKG machine and all cables should ideally remain in the patient's room (dedicated equipment) or undergo thorough cleaning with a sporicidal agent such as a bleach-based disinfectant before leaving the room.

SECTION 6

Worked Example — EKG on a Patient in Isolation

The following scenario walks through the complete infection control decision-making process an EKG technician would follow when performing a 12-lead EKG on a patient under contact and droplet precautions.

Scenario: 12-Lead EKG on a Patient with Influenza and MRSA Colonization

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Step 1 — Review Isolation Signage and Orders

Before entering the room, the technician reads the isolation sign posted on the door. The patient is on both contact precautions (for MRSA wound colonization) and droplet precautions (for confirmed influenza A). The technician verifies the EKG order in the electronic health record and confirms the patient's identity using two identifiers.

Required PPE identified: gloves + gown (contact) + surgical mask (droplet)
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Step 2 — Perform Hand Hygiene and Don PPE in Correct Sequence

The technician performs hand hygiene with alcohol-based hand rub (ABHR) outside the room. PPE is donned in the correct CDC-recommended sequence: gown first → surgical mask → gloves last. Gloves are applied last and must extend over the gown cuffs to eliminate any gap in barrier protection. The technician ensures the mask covers both the nose and mouth snugly.

Donning sequence: Gown → Mask → Gloves (over cuffs)
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Step 3 — Prepare and Perform the EKG

The technician brings the EKG machine into the room (ideally a dedicated or disposable-cover-protected machine). Skin prep sites are cleaned and disposable electrodes are placed on the standard 10 anatomical landmarks. The 12-lead tracing is acquired and verified for quality. Because the patient has an MRSA-colonized wound on the left forearm, the technician avoids placing the left arm lead directly on or near the wound, repositioning it to intact skin proximally and documenting the modification.

Tracing acquired with documented lead repositioning to avoid contaminated wound site
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Step 4 — Remove Electrodes and Doff PPE in Correct Sequence

Electrodes are removed and discarded in the in-room waste receptacle. PPE is removed in the CDC-recommended doffing sequence, which is the reverse of donning: gloves first → hand hygiene → gown → mask → hand hygiene. Gloves are peeled off using the glove-in-glove technique, avoiding contact between bare skin and the contaminated outer surface. The gown is removed by breaking the ties and rolling it away from the body so the contaminated exterior folds inward.

Doffing sequence: Gloves → Hand hygiene → Gown → Mask → Hand hygiene
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Step 5 — Disinfect Equipment

The EKG machine surfaces, lead wires, cable connectors, touchscreen, and cart handles are wiped down with an EPA-registered, hospital-approved intermediate-level disinfectant. Because MRSA is involved, the technician ensures adequate wet contact time (typically 1–3 minutes depending on the product's IFU). If a disposable cover was used on the machine, it is removed and discarded in the room before the machine exits. A final hand hygiene is performed after equipment cleaning.

Equipment disinfected per IFU contact time; machine cleared for next patient use

SECTION 7

Strengths & Limitations of Precaution Tiers

No single precaution tier is universally sufficient for every clinical scenario, and each carries trade-offs between protection, resource consumption, workflow efficiency, and patient experience. Understanding these trade-offs enables the EKG technician to advocate for appropriate precautions without over- or under-applying them — both of which carry risks. Over-application contributes to PPE waste, increased costs, patient isolation-related psychological harm, and potential delays in care. Under-application directly increases the risk of healthcare-associated infections, which represent a leading cause of morbidity and mortality in the United States.

Precaution Tier	Strengths	Limitations
Standard Precautions	Universally applied; eliminates the need for diagnostic certainty before protecting oneself; low cost per encounter; forms a reliable behavioral baseline	Insufficient alone for highly transmissible or airborne organisms; compliance fatigue is well-documented; effectiveness depends entirely on consistent execution
Contact Precautions	Highly effective against organisms spread by touch (MRSA, VRE, C. difficile); use of dedicated equipment minimizes fomite risk	Increased PPE consumption and cost; patients may experience social isolation and reduced nursing visits; donning/doffing adds time to each encounter
Droplet Precautions	Surgical masks are low-cost and widely available; effective for respiratory pathogens with large-particle transmission; patient can remain in a standard room	Mask discomfort and communication barriers; not protective against airborne nuclei; patients with cough may generate aerosols during some procedures
Airborne Precautions	Highest level of respiratory protection; N95 respirators filter ≥ 95% of airborne particles ≥ 0.3 μm; negative-pressure rooms prevent environmental spread	Limited supply of AIIRs; N95 requires annual fit testing; discomfort during prolonged wear; significant cost; restricts patient mobility and visitation

Comparative strengths and limitations of each precaution tier

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KEY TAKEAWAY

Precaution tiers function like layers in a defense-in-depth cybersecurity model. Standard Precautions are the firewall — always active, broadly protective, but not designed to stop every sophisticated threat. Contact, droplet, and airborne precautions are analogous to intrusion detection systems and endpoint protection: deployed in targeted layers based on the specific threat profile. Removing any layer creates a vulnerability, and each layer alone is insufficient. Effective infection control, like effective security, depends on consistent, layered application of complementary strategies.

SECTION 8

Connection to Regulatory Standards & Quality Metrics

Infection control practices for EKG technicians do not exist in isolation; they are embedded within a broader regulatory and quality improvement ecosystem. Multiple federal and accrediting agencies establish, enforce, and measure compliance with infection control standards. Understanding how your daily practice connects to these larger frameworks demonstrates clinical professionalism and prepares you for the compliance-related questions on the CET certification examination.

Agency / Standard	Role in Infection Control	Relevance to EKG Technicians
OSHA — Bloodborne Pathogens Standard (29 CFR 1910.1030)	Mandates Exposure Control Plans, requires employer provision of PPE, mandates hepatitis B vaccination for at-risk workers, establishes post-exposure protocols	EKG techs must have access to and training on their facility's Exposure Control Plan; must report needlestick or mucous membrane exposures immediately
CDC — Standard & Transmission-Based Precautions	Publishes evidence-based guidelines for hand hygiene, PPE use, environmental cleaning, and isolation categories; updated as new evidence emerges	CDC guidelines form the clinical knowledge base for CET exam questions on infection control and universal/standard precautions
The Joint Commission (TJC)	Accredits hospitals and evaluates compliance with National Patient Safety Goals (NPSGs), including HAI reduction; conducts unannounced surveys	NPSG.07.01.01 specifically requires hand hygiene compliance; EKG departments are subject to observation during TJC surveys
CMS — Conditions of Participation	Ties Medicare/Medicaid reimbursement to compliance with infection prevention standards; HAI rates influence hospital value-based purchasing scores	Infection control violations can result in financial penalties for the facility; all staff, including EKG techs, contribute to institutional compliance

Key regulatory agencies and their relevance to EKG technician infection control practice

As healthcare evolves toward value-based care models, infection prevention has become a measurable quality indicator with direct financial implications. The Hospital-Acquired Condition Reduction Program penalizes the bottom-quartile hospitals in HAI rates by reducing their Medicare reimbursement by 1%. Looking ahead, antimicrobial stewardship programs, rapid molecular diagnostics, and emerging disinfection technologies (such as UV-C light devices for equipment decontamination) will further shape how EKG technicians approach infection control. The fundamental principles — break the chain, apply Standard Precautions universally, and add transmission-based layers when indicated — will remain constant even as the specific tools and organisms change.

SECTION 9

Practice Problems

Question 1: CONCEPTUAL

Explain why Standard Precautions require the EKG technician to wear gloves for every patient encounter, even when the patient has no known infection and appears healthy. What fundamental principle of infection control underlies this requirement?

Show answer

Standard Precautions are founded on the principle that all blood and body fluids should be treated as potentially infectious regardless of the patient's known diagnosis. Many colonized or infected patients are asymptomatic carriers — they harbor transmissible organisms (such as MRSA, hepatitis B or C, or HIV) without exhibiting clinical signs. Furthermore, the patient's infectious status may not yet be documented in their medical record. Selective gloving based on perceived risk creates dangerous gaps in barrier protection and relies on fallible clinical judgment. By gloving for every encounter, the technician creates a consistent, evidence-based barrier that protects both the patient and the healthcare worker, regardless of what is known or unknown about the patient's microbial status.

Question 2: BASIC CALCULATION

An EKG technician performs an average of 18 EKGs per 8-hour shift. According to the WHO's Five Moments for Hand Hygiene, the technician should perform hand hygiene at minimum before patient contact and after patient contact (moments 1 and 4). How many minimum hand hygiene events should the technician perform per shift related to direct patient contact alone? If each ABHR application takes approximately 20 seconds and each soap-and-water wash takes approximately 40 seconds, what is the minimum total time spent on hand hygiene per shift if 90% of events use ABHR and 10% use soap and water?

Show answer

With 18 patients and a minimum of 2 hand hygiene events per patient (before and after contact), the technician performs 18 × 2 = 36 hand hygiene events per shift. Of these, 90% use ABHR: 36 × 0.90 = 32.4, rounded to approximately 32 ABHR events × 20 seconds = 640 seconds. The remaining 10% use soap and water: 36 × 0.10 = 3.6, rounded to approximately 4 events × 40 seconds = 160 seconds. Total minimum hand hygiene time = 640 + 160 = 800 seconds ≈ 13.3 minutes per shift. This calculation demonstrates that hand hygiene, while critically important, represents a modest time investment — approximately 2.8% of an 8-hour shift — yet delivers the single greatest return on infection prevention.

Question 3: INTERMEDIATE

You are called to perform an EKG on a patient in a negative-pressure room. The isolation sign indicates airborne and contact precautions for suspected pulmonary tuberculosis and a concurrent MRSA-positive wound. Describe the complete sequence of PPE donning and doffing, identify which hand hygiene agent to use and when, and explain whether the EKG machine should remain in the room or be removed after the procedure.

Show answer

Donning sequence (outside the room or in anteroom): (1) hand hygiene with ABHR, (2) gown, (3) N95 respirator — perform a user seal check, (4) eye protection if risk of splash, (5) gloves over gown cuffs. Inside the room, perform the EKG using disposable electrodes. Doffing sequence (inside the room except for respirator): (1) remove gloves, (2) hand hygiene with ABHR, (3) remove gown rolling contaminated side inward, (4) exit room, (5) remove N95 respirator by grasping the straps (not the front), (6) hand hygiene with ABHR. For MRSA, ABHR is effective because MRSA is a vegetative bacterium susceptible to alcohol. However, if C. difficile were involved, soap and water would be mandatory. Regarding the EKG machine: ideally, a dedicated machine should be kept in the room. If one must be removed, all surfaces and cables must be thoroughly disinfected with an EPA-registered intermediate-level disinfectant with appropriate contact time before removal. The machine should not pass through the anteroom until disinfection is complete and the surfaces are dry.

Question 4: APPLIED

During a 12-lead EKG, you notice that the patient has a Stage III pressure ulcer with purulent drainage on their sacral area. While repositioning the patient to place posterior leads for a 15-lead EKG, your glove tears and your bare hand contacts the wound drainage. Describe the immediate steps you should take, including the relevant OSHA-mandated procedures, and identify which link(s) in the chain of infection this exposure event involves.

Show answer

Immediate steps: (1) Stop the procedure, remove the torn glove, and immediately wash the exposed skin thoroughly with soap and running water for at least 20 seconds. Do not use bleach or caustic agents on the skin. (2) Apply a clean bandage if any break in your own skin is present. (3) Don new gloves if continuing the procedure, or arrange for another technician to complete it. (4) Report the exposure to your supervisor immediately and complete an incident/exposure report per your facility's Exposure Control Plan, as mandated by OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030). (5) Proceed to Employee Health or the Emergency Department for post-exposure evaluation, which may include baseline bloodwork (HIV, hepatitis B and C panels) and assessment for prophylactic treatment. The chain of infection links involved are: the wound serves as the portal of exit (link 3), the drainage on the hand represents indirect contact as the mode of transmission (link 4), and any break in your skin integrity would constitute the portal of entry (link 5). This scenario reinforces the importance of glove integrity checks and the practice of double-gloving when handling patients with draining wounds.

Question 5: CRITICAL THINKING

A hospital's infection control committee reports that EKG lead wire contamination rates have increased from 12% to 34% over six months, coinciding with a staffing shortage that has led to technicians performing 25+ EKGs per shift. Propose a multi-faceted intervention plan that addresses root causes across all three domains: human factors, equipment design, and systems/policy. For each domain, describe at least two specific interventions and explain how each interrupts the chain of infection.

Show answer

Human factors interventions: (1) Implement real-time feedback systems, such as UV-fluorescence auditing of lead wires at random intervals, to give technicians immediate visual evidence of contamination — this addresses compliance fatigue by making the invisible visible and disrupts the reservoir link. (2) Redesign the shift schedule to cap patient volume per technician at a sustainable level (e.g., 20 EKGs per 8 hours) and provide designated 'cleaning breaks' between clusters of patients, directly reducing the time pressure that leads to skipped disinfection steps. Equipment design interventions: (1) Transition to disposable lead wire sets for patients under contact precautions, eliminating the fomite risk entirely by removing the reservoir. (2) Adopt antimicrobial-coated lead wires that incorporate silver or copper alloy surfaces, which provide a supplementary reduction in microbial burden between manual cleaning events. Systems/policy interventions: (1) Integrate a mandatory 'equipment cleaned' checkbox into the EKG machine software that must be completed before a new patient encounter can be initiated, creating a forcing function at the mode of transmission link. (2) Establish a standardized disinfection protocol with pre-packaged, single-use disinfectant wipe kits attached to each EKG cart, reducing the steps required to locate and apply the correct disinfectant. Each of these interventions targets specific links in the chain — primarily the reservoir (contaminated wires), mode of transmission (contact via fomites), and portal of entry (subsequent patient's skin) — and together they exemplify the Swiss cheese model of error prevention, where multiple overlapping barriers compensate for the inevitable holes in any single layer.

SUMMARY

Summary — Infection Control & Universal Precautions for EKG Technicians

Summary

Infection control in the EKG setting is built upon Standard Precautions — the always-on baseline applied to every patient regardless of known diagnosis. These include hand hygiene (the single most effective intervention), glove use for all patient contact, use of single-use disposable electrodes, and thorough disinfection of lead wires and equipment between patients. The chain of infection provides the conceptual framework: every precaution is designed to break one or more of its six links — infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

When patients carry organisms requiring additional protection, Transmission-Based Precautions (contact, droplet, and airborne) are layered on top of Standard Precautions. The EKG technician must know the correct donning and doffing sequences, understand when soap and water is required over ABHR (notably for C. difficile), and recognize the regulatory standards from OSHA, CDC, The Joint Commission, and CMS that govern infection prevention practices. Mastery of these principles protects patients, protects the technician, supports institutional compliance, and is essential knowledge for the CET certification examination.