During my career I have had the privilege of seeing many new technologies introduced to the echocardiography lab. Several of these are now a part of a standard echocardiography procedure. Some of you do not remember a time when color Doppler and tissue Doppler were not available and considered routine. In the 1990s, transpulmonary contrast agents (echo contrast) were introduced to our labs. Echo contrast provides improved detection of cardiac borders and Doppler signals. This allows better assessment of wall motion abnormalities and flow lesions, especially in the difficult to image patient. Yet, over 20 years later, utilization of contrast remains inappropriately low.
In this day of transforming healthcare to provide better care for our patients, why is a tool that could provide information to answer the clinical question not being utilized more? This question is asked often. Typical responses revolve around intravenous (IV) access, reimbursement, and time.
The role of the sonographer in IV access is seen as a hurdle in many labs. Starting IVs is considered a part of our scope of practice ( asecho.org/practicefordiagnosticultrasoundprofessional/ ), is an element of our clinical practice standards ( www.sdms.org/positions/clinicalpractice.asp ), and is supported by the ASE. Typically the issues that arise with IV insertion are at the local and/or institutional level, and with perseverance a solution that addresses the concerns and best meets the needs of the patient and the lab can be found.
A second obstacle identified is reimbursement. There are now reimbursement codes for a contrast enhanced echocardiogram and mechanisms in place to bill for the cost of the contrast media. The billing department at your lab should be able to identify and set up the appropriate codes so that reimbursement is not a hurdle to contrast utilization. The coding and reimbursement section on the ASE website ( asecho.org/advocacy/coding-and-reimbursement/ ) also has information on this topic and a link to “ask a coding expert” should there be other questions.
The third commonly provided reason for not utilizing echo contrast is time. It takes too long to get the IV started, to obtain an order, to get the contrast media. It adds time to the study and there are already more than can/should be done in a day. There are any number of reasons that fall into this category. However, does it really add a significant amount of time to the procedure? When you consider the time a sonographer will take to obtain diagnostic quality images on a technically difficult patient and compare it to the time “added” to utilize contrast, is there that much of a difference? I am not suggesting that a study be rushed through because contrast is going to be used. However, a sonographer usually realizes relatively quickly when an image is going to fall into that “technically difficult” category. If contrast is an option, then moving on rather than spending time might be the better decision.
Another question that must be asked when dealing with the time obstacle is the risk-benefit consideration. If the goal is to provide better care, then the benefits of contrast versus the risk of additional time must be considered. In the December 2012 issue of JASE, the topic of this communication was how long an echocardiogram should take. That article suggested that the proper answer to the question was “as long as it takes to find the answer to the clinical question.” If using contrast provides information to help find that answer, the added time should not be a deterrent.
Intravenous access issues, reimbursement questions, and time are all valid considerations when contrast echocardiography is introduced into an echo lab. Who will start the IV, who will give the contrast, how will it be paid for, and how will it impact the patient volume of the lab are all questions that need to be addressed for contrast echocardiography to be successfully implemented into a lab’s procedures. These questions are not always easily answered. Often seeking answers and solutions to these questions identifies more problems. It must be remembered that these are simply issues that need to be addressed, and should not be reasons why contrast is not used on the echo lab. Two documents offer valuable insight into dealing with these issues when instituting contrast in the echo lab: the American Society of Echocardiography Consensus Statement on the Clinical Applications of Ultrasonic Contrast Agents in Echocardiography and Guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography: A Focused Update from the American Society of Echocardiography.
So if IV access, reimbursement, and time are taken off the table as reasons, then is the underutilization of contrast echocardiography more an issue of being aware of and accepting the value of contrast, recognizing its role in providing better care, and embracing the technology? I believe this is a question cardiac sonographers (and physicians) must thoughtfully and honestly answer if echo contrast is going to be used to its fullest potential.
We need not only to be aware of the availability of echo contrast agents but we must also recognize and accept the value of contrast. Using contrast in an echocardiogram is not an indictment on the skills of the sonographer, but a testament to the sonographer’s understanding of the physics of ultrasound, recognition of imaging limitations that cannot be overcome without additional enhancement, and desire to produce the highest quality study possible for patient.
Ultrasound image quality has improved drastically over the last 20 years; however, there are still times when adequate visualization of cardiac walls, structures, and blood flow information is just not obtainable. There are situations such as stress echocardiography when optimal (not simply adequate) wall definition is necessary to provide the most accurate information. Echo contrast meets these needs by clearly providing improved endocardial definition and Doppler signal detection.
Contrast echo is routinely utilized in some labs today. These are typically (but not always) in academic settings or in large tertiary type facilities that have a strong academic component. Unfortunately, contrast use in echo labs in general is still very low. Sonographers are aware of contrast echocardiography and its benefits and value but have not necessarily fully embraced it. In this era of transforming healthcare, it is time for us to embrace this technology, turn the excuses into opportunities, and step out and be leaders in our labs (large or small, busy or quiet) and make contrast an everyday tool in the echo lab.