Marti L. McCullough, BS, MBA, RDCS, FASE

“The intent of the accreditation process is two-fold. It is designed to recognize laboratories that provide quality echocardiography services. It is also designed to be used as an educational tool to improve overall quality of the laboratory.” 2010 ICAEL STANDARDS FOR ACCREDITATION (pg. 4)

This statement summarizes the purpose of accreditation, which many of us in the profession may not fully appreciate until we are in the process of accreditation or re-accreditation. Typically, the individual who spearheads the accreditation process and paperwork is the only one who is involved in the process intimately enough to fully appreciate the standards put in place to further assure a higher quality echocardiography laboratory; therefore the following is a brief accreditation update.

As you may be aware, the new 2010 ICAEL Standards for Adult Echocardiography are available, with intended implementation in December 2010. To be honest, it has been a couple of years since I have reviewed the ICAEL Standards. However, the other day a peer asked my opinion regarding the addition of Standard 3.2.3 (page 22)-Part II, which refers to the utilization of contrast for suboptimal image quality. I immediately pulled the standards from the ICAEL Website ( http://www.icael.org/icael/index.htm ) and reviewed the text with all the 2010 additions, easily identified as the highlighted sections of the document.

It is true, the ICAEL has added contrast as a quality standard to be used for suboptimal image quality or when two or more contiguous myocardial segments are not visualized. The standard also mandates a written policy for use of contrast agents as well as a policy for alternative testing when contrast can’t be used. It is the latter point that poses an immediate question for facilities that currently do not utilize contrast. What happens to an accredited laboratory with suboptimal studies that does not utilize contrast? Perhaps nothing, provided there is a policy defining a process for alternative testing when echocardiography is inadequate. And even though it is painful to mention inadequate and echocardiography in the same sentence, I believe the more relevant question is “ What happens to the patient when a suboptimal echocardiogram in performed?” The addition of Standard 3.2.3 (page 22)-Part II effectively minimizes the burden of a suboptimal study for the patient as well as for the referring physician.

In support of contrast agents, harmonic capabilities have been added to the instrumentation piece in Part II, Section 1 (pg. 18). The line item specifically states that harmonics should be included on ultrasound systems to optimize ultrasound contrast agents. It truly amazes me that some laboratories would practice without harmonics, let alone contrast—again, what about the patient?

Additional measurements include left atrial volume index , which has consistently shown prognostic value in multiple outcome based manuscripts. The left atrial volume measurement is now an option, along with left atrial dimension at end-systole. And at last— diastolic function parameters have made the standards! Diastolic function is mentioned in both the Elements of an Examination (pg. 22) and in the Examination Interpretation (pg. 24).

Report timeliness has been added to the Quality Assurance section in Part I (5.1.7). Report turnaround times are critical to the overarching quality of the study because regardless of how perfectly an echo is performed or how well the study is interpreted, if the result doesn’t reach the referring physician in a timely manner, the rationale for the study becomes irrelevant. In fact, report timeliness is a Joint Commission measure that is audited in addition to measuring (through an audit) whether the study was performed as ordered and whether or not the interpretation contains relevant information.

Appropriate use criteria (AUC) have been added to the Quality Assurance Section in Part I (5.1.1 – 5.1.4). The AUC Standard mandates incorporation of published criteria and measurement of appropriate usage in a minimum of 30 consecutive studies annually. In addition, there needs to be a policy regarding monitoring of AUC with implementation of an education program to include trends, improvement goals and confidential reporting of ordering and interpreting practices. AUC for transthoracic and transesophageal echocardiography were published in 2007, and stress criteria published in 2008. The underlying intent of AUC is to mitigate government involvement in echocardiography, specifically with respect to precertification, which has tremendous implications for patient care and the practice of echocardiography. However, the true benefit of AUC reflects appropriate patient care and management— again, it is all about the patient.

The ICAEL represents improved quality with documented standards that can be used for accreditation, or alternatively, as an education tool regarding quality echocardiography standards. I am truly impressed with the 2010 additions. The ICAEL Governing Board, including ASE representatives Helga Lombardo, RDCS; Rick Rigling, BS, RDCS, secretary; Geoffrey Rose, MD, FACC, FASE, president; and Raymond Stainback, MD, president-elect , should be commended for their proliferation and adherence to quality in the field of echocardiography. Thank You!

Please visit the ASE Website ( www.asecho.org ) to read about Kathy Kendall, RDCS, Sonographer Volunteer of the Month!