Carol Mitchell, PhD, RDMS, RDCS, RVT, RT(R), ACS, FASE

Margaret M. Park, BS, ACS, RVT, RDCS, FASE

Matt Umland, ACS, RDCS, FASE

Sue Phillip, RCS, FASE

In February of 2017, several discussions took place on the American Society of Echocardiography (ASE) Connect forum surrounding the role of sonographers in performing transesophageal echocardiography (TEE). Concerns were raised regarding, should a sonographer ever manipulate a TEE probe, is this advanced practice skill part of an advanced cardiac sonographer’s role, what training would be required for a sonographer to manipulate a TEE probe, and what if a sonographer is asked to manipulate the TEE probe and feels he/she is not qualified to do so. Sonographers with the Advanced Cardiovascular Sonographer (ACS) credential responded to these posts by describing selected institutions where ACS sonographers participated in rigorous training programs in order to gain the necessary skills to manipulate the TEE probe. However, while selected institutions may have developed institutional standards and training programs, there are no global educational standards for this skill set published by the Commission for Accreditation of Allied Health Education Programs (CAAHEP) for the Cardiovascular Technologist (CVT), Diagnostic Medical Sonography (DMS) nor Advanced Cardiovascular Sonographer (ACS) professions. In response to these discussion posts, the ASE Board of Directors extensively discussed this topic and subsequently developed a position statement at their 2017 February Board of Director’s meeting.

The ASE position statement on TEE reads as follows:

“ASE recognizes that sonographers are an integral part of the cardiac imaging team and support their active role during the performance of a TEE. However, that role should be limited to their scope of practice. Specifically, ASE supports sonographers using their expertise and skills to optimize images (i.e. adjust gain, contrast, and other machine settings) during the TEE exam. ASE does not advocate for sonographers to perform TEE intubation or manipulation of the probe. The decision was approved unanimously by the Board due to the infrequency of the practice at healthcare institutions, the diversity of laws and regulations per state, and lack of established processes that ensure competency for treating acute complications in performing TEE. The Board believes the field will continue to evolve and that sonographers will continue to need TEE education pertinent to their practice to stay current in this field.”

The Council on Cardiovascular Sonography recognizes that this statement is released at this time due to absent existing current standards regarding sonographer education and training in the manipulation of the transesophageal echo probe. The role of the sonographer in performing transesophageal echocardiography was initially defined largely in two guideline papers published by the American Society of Echocardiography (ASE) and the Society of cardiovascular Anesthesiologists (SCA). The first paper, entitled “ASE/SCA Recommendations and Guidelines for Continuous Quality Improvement in Perioperative Echocardiography,” specifically states that the “…role of the sonographer in the performance of TEE is limited to maximizing image quality by the manipulation of the controls on the ultrasonography system” (Matthew et al. 2006, p. 1418). The second paper, entitled “Guidelines for Cardiac Sonographer Education: Recommendations of the American Society of Echocardiography Sonographer Training and Education Committee,” states that “Additional techniques such as transesophageal, intravascular, intracardiac and intraoperative echocardiography are primarily performed by a trained physician” (Ehler et al. 2001, p. 78).

Furthermore, the American College of Cardiology (ACC) and American Heart Association (AHA) state in the Clinical competence Statement on Echcoardiography, that “training for the performance and interpretation of TEE is best obtained during a formal fellowship in cardiovascular medicine or its equivalent, and through active participation in a training program in general TTE” (Quinones et al. 2002, p. 1075). Thus, at this time there are no existing standards nor published educational guidelines recognized or accepted by national organizations endorsing the manipulation of the TEE probe by sonographers. However, it is important to recognize that many of these position statements were published prior to the existence of the Advanced Cardiovascular Sonographer position paper and professional definition.

The Adult Echocardiography Advanced Cardiovascular Sonographer (ACS) “is a highly skilled professional qualified by education experience and certification to provide services” (p. 2) that involve overseeing staff sonographer image quality, obtaining additional imaging views to ensure that the all data is acquired to answer the clinical question, develops educational in-services, and develops and monitors ongoing quality initiatives in the echocardiography laboratory. As this young profession continues to grow and there are more sonographers earning this credential and graduating from formal ACS education programs, the scope of practice for this individual has the potential to further develop as the healthcare environment continues to change.

In 2009, Mark Adams wrote an article for the ASE Intraoperative Council Communication entitled “The Cardiac Sonographer in the Operating Room: Who’s Left Holding the Probe?” This article discusses how the sonographer’s role evolved in the administration of contrast and how this may parallel future opportunities for sonographers to be part of an imaging team in the operating room. This may include providing education regarding TEE to cardiac anesthesiologists, fellows, and residents, maintaining equipment, and assisting with development of TEE educational guidelines.

As reported previously, roles of allied health professionals, such as the sonographer or ACS often evolve and require the development of new skills. The role of the sonographer in the operating room and in the cardiac catheterization lab has recently come to attention as the role of echo in in these arenas continues to grow. Many of the procedures performed in these environments are very dependent on echo imaging and can be time consuming. With the changing healthcare environment and the need not only for sonographers, but also the ACS to continue to evolve, the ASE Council on Cardiovascular Sonography has asked the Committee on Accreditation for the Advanced Cardiovascular Sonographer (CoA-ACS) to examine the didactic and clinical skills that would be needed to expand the ACS role not only in the adult echocardiography laboratory but also the role this professional could potentially play in TEEs in the perioperative environment. To date, guidelines, standards, and training for sonographer’s hands-on assistance with TEE do not exist. The ASE Council on Cardiovascular Sonography will continue to follow–up with CoA-ACS and will assist in any way possible to continue to provide input into additional educational domains that could be added to the current ACS curriculum.

ASE’s Board of Directors believes the practice of sonography will continue to evolve and supports the sonographers that are adapting to changing practice dynamics. ASE’s board statement reflects current practice parameters and cardiac sonographer educational standards as stated by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) for the professions of cardiovascular technologist (CVT), diagnostic medical sonographer (DMS), and advanced cardiovascular sonographer (ACS). ASE acknowledges that some institutions have well-trained sonographers with expanded roles in the operating room and cardiac catheterization laboratory environments and does not dispute their institution’s right to support these expanded roles. However, at this time, there are no published sonographer practice standards that provide guidance for sonographer education and training in the skill of performing and manipulating the TEE probe. Therefore, ASE and its policies must reflect current education and practice standards on behalf of patients before advocating for a new practice standard for advanced cardiac sonographers that has not yet been fully developed. Having stated this, ASE does recognize that the future of healthcare is an ever changing landscape, and position statements will need to be adapted over time as education and practice standards evolve.

Carol Mitchell, PhD, RDMS, RDCS, RVT, RT(R), ACS, FASE, is an Assistant Professor of Cardiovascular Medicine at the University of Wisconsin, School of Medicine and Public Health. Dr. Mitchell currently serves as Chair of the ASE Council on Cardiovascular Sonography Steering Committee.

Margaret M. Park, BS, ACS, RVT, RDCS, FASE, is a Lead Imaging Specialist at the Cleveland Clinic Coordinating Center for Clinical Research (C5), Imaging Core Lab, and a Clinical Research Coordinator, for the Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio. She serves as Chair-elect of the ASE Council of Cardiovascular Sonography Steering Committee.

Matt Umland, ACS, RDCS, FASE, is Echocardiography Director/Advanced Cardiac Sonographer at Aurora Healthcare, Milwaukee, Wisconsin and Chair of Committee on Accreditation for Advanced Cardiovascular Sonography(CoACS).

Sue Phillip, RCS, FASE, is Administrative Director of Echo Programs for Johns Hopkins Medicine, including the Adult Echo Lab, Echo Research lab, Johns Hopkins School of Cardiac Sonography, and the Global Echo Education Programs. She is the Council Representative to the ASE Executive Committee.