Wyman W. Lai, MD, MPH, FASE

Most pediatric echocardiography laboratories have multiple missions. In addition to supporting busy outpatient practices, almost all of the larger pediatric laboratories are affiliated with active surgical and interventional catheterization programs. These inpatient services require remote transthoracic and transesophageal echocardiography support. Specially trained personnel are required for fetal echocardiography, which often includes a consultation. The larger pediatric echocardiography laboratories are also a part of academic training programs with teaching and research responsibilities. Because of these myriad responsibilities, even laboratories of similar size can vary greatly in organization, depending on the demands of the connected services.

Other factors contribute to the complexity of pediatric echocardiography services. One of the great joys of pediatric echocardiography is the variety of disease seen on a daily basis. This variety, however, presents a great challenge for laboratory organizers. The list of potential diseases is so long as to be beyond the space allotted for this column. Echocardiography systems must meet the needs of patients varying in size from fetuses to adults. In addition, subspecialty patients, such as those who have undergone heart transplantation or those with primary pulmonary hypertension, bring special demands. The specialized services provided by pediatric echocardiography laboratories are both labor intensive and time-consuming.

To investigate the organizational structure of pediatric echocardiography laboratories, ASE’s PCHD Council has formed a Committee on Laboratory Organization and Productivity. The goal of this committee is to look into the issues of organization that impact the daily function of our laboratories, especially personnel productivity. The committee will send out a basic survey to most of the major pediatric echocardiography laboratories in North America, and the results will be presented at the ASE 2011 Annual Scientific Sessions. Benchmark data will be collected on the average number of studies performed per sonographer and the number of studies read per physician. The number of ultrasound systems, use of sedation, and presence of dedicated research personnel will be noted. This initial survey will only begin to delve into the intricacies of pediatric echocardiography laboratory organization, and more will follow.

One of the major reasons for looking into laboratory organization is to find ways of improving personnel productivity. In academic programs around the country, administrators are using aggregate data to set productivity targets for pediatric cardiologists. The source of this data is sometimes nebulous, and its accuracy is difficult to verify. Some of the difficulties with comparing personnel from different institutions stem from the differences in acuity in laboratories; some laboratories are dominated by screening examinations for outpatient practices while others provide a full array of subspecialty outpatient and inpatient services. In addition to their echocardiography demands, attending physicians may spend time on the wards or intensive care units, in cardiac magnetic resonance imaging, or with administrative duties. The medical or technical director of the echocardiography laboratory is generally responsible for a staff of sonographers, and frequently also scheduling and billing personnel.

The services provided by sonographers also vary widely. Sonographers in some laboratories perform both pediatric and fetal echocardiograms. Some laboratories ask sonographers to assist with transesophageal echocardiograms. The acuity of disease greatly affects the time required to perform a study. A preoperative or postoperative study on patients with complex congenital heart disease requires more time for image acquisition and post-processing than a screening examination for a murmur. For myocardial function studies, post-processing may include the analysis of speckle tracking and 3D echocardiography datasets. Another significant difference in workflow stems from a requirement in some laboratories for the sonographer to enter a full preliminary report into the electronic reporting system.

As our institutions begin to focus more on increasing personnel productivity, our laboratories face the need to simultaneously improve efficiency while maintaining study quality. The ASE has appropriately supported laboratory accreditation as a means of demonstrating a commitment to quality and the acceptance of standards. Laboratory accreditation, however, brings with it a demand on personnel to document continuing educational activities and quality assurance measures. At some point, the pressures of increasing productivity will bump up against the demands of maintaining quality. Because of the abovementioned variety in services, each pediatric echocardiography laboratory will need to decide for itself where to define the happy medium between limited studies emphasizing rapid patient turnover and drawn-out studies that provide no additional useful information.

The organization of pediatric echocardiography laboratories will be a subject of great interest over the next decade, as the field of pediatric cardiology—and medicine, more broadly—moves towards evidence-based practice and an emphasis on following guidelines and standards. There are few subspecialties that depend as much as ours on imaging for the diagnosis and daily management of patients. We must ensure that the expectations for personnel productivity are reasonable and not blindly applied to all laboratories without consideration of service demands that vary widely in scope and complexity.

The Committee of Laboratory Organization and Productivity is just beginning to examine the issues discussed here. The ASE is providing a significant service by supporting the activities of the committee, and we will need the input of all of Council members to be successful. If you are a laboratory director, please respond to our survey requests. We will likely be sending out an annual survey in order to acquire better information as we refine our questions, and to follow trends. If you are not a laboratory director, be on the lookout for our committee report and offer ideas for improving the process. Thanks in advance for your assistance.