Ultrasound has emerged as a central component of perioperative patient care. As the use of ultrasound in perioperative medicine ranges from preoperative imaging and planning, to TEE in complex mitral valve repair, to focused ultrasound to resuscitate the post-operative patient, the creation of a “critical mass” of perioperative echocardiographers is crucial. As the critical mass grows to include cardiologists, cardiac anesthesiologists, critical care physicians, and general anesthesiologists, so does the need for cohesive leadership and a common thread. To ensure organization, standardization, quality assurance, research, and excellence in ultrasound education, we believe in the formation of a perioperative echocardiography leadership dyad. In our institution, our dyad consists of a Perioperative Echocardiography Medical Director and Perioperative Sonographer to lead the multidisciplinary team. There is significant value in having consistent champions whose singular focus is to unite, drive, and maintain perioperative echo clinical initiatives.
The Perioperative Echocardiography Leadership Dyad
At the University of Nebraska Medical Center, the Department of Anesthesiology in conjunction with the Division of Cardiology and the Echocardiography Laboratory has developed a robust Perioperative Echocardiography Consult Service (PECS). PECS consists of 21 physicians trained in various levels of echocardiography, and includes advanced trained echocardiologists, basic trained echocardiologists, and those who routinely utilize point of care ultrasound. The common thread and critical component of all of these providers is the access and communication with the PECS dyad. The echo education of these providers has been driven by the leadership dyad through the development of several echo courses. The PECS team provides transthoracic and transesophageal echocardiography and point of care ultrasound in a wide range of acute care settings. Since its inception in 2013, this clinical service PECS has performed 3,563 echocardiograms, 85.3% TEE and 14.7% TTE.
The Perioperative Sonographer: The Common Thread
As the number of ultrasound users increases, so does the need for cohesiveness, collaboration, and quality support. In our experience, the perioperative sonographer is the linear connection to the entire team. The ability of the perioperative sonographer to optimize provider workflow is crucial to efficiency, quality, and patient care. By acting as the PECS constant, the perioperative sonographer has an extensive role in Electronic Medical Record (EMR) software, Picture Archive Communication System (PACS), ultrasound software/hardware, and protocol-driven metrics. From order entry to a finalized report, the sonographer sees a daily list of all physician-ordered PECS ultrasounds, and assures all studies performed reach the EMR, but also reach PECS standards. Since the addition of a perioperative sonographer, we have been able to see a measureable increase in quality exams, EMR adherence, revenue, equipment longevity, and collaboration between subspecialties. The sonographer can be the ‘eyes and ears’ of the Medical Director, and provide vital service to all of the working providers, who often are using ultrasound in the midst of ongoing critical patient care.
Besides improving daily workflow, a significant role of the perioperative sonographer is to teach users how to implement a formal protocol during the execution of the exam. We have found our PECS faculty use echo differently, according to the clinical need. The perioperative sonographer assures ultrasound, at whatever level, is being conducted per protocol. This consistency improves ultrasound interpretation across subspecialty lines. In collaboration with the Echo Laboratory and the Division of Cardiology, joint Quality Assurance meetings are held quarterly and internal meetings monthly. These multidisciplinary meetings have brought significant teaching, quality improvement, and research to the PECS. None of this could be possible without the close working relationship between the sonographer and the Medical Director, and the active participation of the 20+ physicians who make up the PECS.
Beyond clinical and quality measures, sonographers can add a significant amount to the teaching of faculty and trainees. The development of echo courses, didactics, hands-on instruction, and simulated teaching modules can all be integrated to provide a multi-faceted approach to ultrasound instruction. Most physicians who teach ultrasound to a wide array of providers have found significant benefits to instructing in conjunction with a sonographer who may have more flexibility with clinical demands.
We realize that our program is unique. However, as the use of ultrasound within medicine expands, and the number of ultrasound users grows, so does the need for well-balanced and competent teams. While the previous norm has been for sonographers to primarily support work in echocardiography laboratories and operate in the perioperative realm on a need-only basis, we believe the addition of sonographers to the perioperative echo team is critical, beneficial, and productive. As the expansion of ultrasound in perioperative and critical care medicine continues to evolve, we have found a multidisciplinary team approach has made echo education, quality, and patient care both feasible and rewarding.
Sasha K. Shillcutt, MD, MS, FASE is an Associate Professor and the Vice Chair of Strategy and Clinical Transformation in the Department of Anesthesiology at the University of Nebraska Medical Center (UNMC). Dr. Shillcutt also serves as the Director of both the Clinical Research and Perioperative Echocardiography Program. She is the Course Director of the UNMC Department of Anesthesiology Perioperative and Critical Care Echocardiography Training Programs, and has NIH funded research through the National Institute of Aging on the use of echocardiography in perioperative patients. She is a member of the ASE Council on Perioperative Echocardiography Steering Committee.
Walker R. Thomas RDCS, FASE is an Instructor in the Department of Anesthesiology at the University of Nebraska Medical Center. He is the sonographer for all perioperative areas such as Preanesthesia Screening Clinic, Immediate Post-Anesthesia Care Unit, Operating Room, and Critical Care Units. He is instrumental in teaching several echocardiography courses, from focused ultrasound to 3D echocardiography and advanced imaging modalities, and is an active member of COPE.