Elizabeth F. McIlwain, MHS, RDCS, RCS, FASE

I am privileged to teach in the cardiovascular ultrasound program at LSU Health Sciences Center in New Orleans, LA. Each fall I meet a new group of students and have the opportunity to introduce them to the world of echocardiography. My first encounter with them is typically on a Monday afternoon shortly after they have had their initial lectures on ultrasound physics and introduction to echocardiography. They arrive in the scanning lab and begin the hands-on portion of their cardiac ultrasound training. Over the course of the semester they learn the basic controls of an ultrasound system and how to obtain the images and measurements that make up a complete echocardiogram. It never takes long for a student to ask “how do you know?” How do you know that is the right angle, tilt, or rotation? How do you know that is the best image? How do you know that is where you put the point for measuring? How do you know that is where you put the sample volume? These are questions they pose all semester. Answering those questions always brings me to the concept of precision, the role it plays in echocardiography, and the American Society of Echocardiography’s (ASE) guidelines and standards.

According to the Merriam-Webster Dictionary, “precise” is an adjective meaning “exactly or sharply defined or stated; minutely exact; strictly conforming to a pattern, standard, or convention; distinguished from every other.” One does not have to perform echocardiograms very long to understand the importance of being precise in obtaining images and making measurements. Without careful image acquisition and measurement analysis, it is easy to provide data that is inaccurate and/or inconclusive. Such data may lead to inappropriate diagnosis and treatment and is absolutely contrary to the standards an echo lab should uphold. The ASE is committed to excellence in cardiovascular ultrasound. Part of our brand promise is that ultrasound is used to provide an exceptional view of the cardiovascular system to enhance patient care. This commitment to quality and excellence requires precision when performing and analyzing an echocardiogram.

Precision requires that something is done in an exact manner and strictly conforms to a standard. The ASE advocates such quality through precision in every aspect of its mission. One of the most practical ways precision in echocardiography is supported is through the guidelines and standards. The ASE began developing guidelines in 1999, and to date has over 60 documents in publication. These guidelines are made available as reference sources. The documents are developed by experts in the field and provide recommendations for standards that can be followed when performing and analyzing cardiovascular ultrasound studies. There are standards on three-dimensional echocardiography, appropriate use criteria, cardio-oncology, cardiovascular sonography, chamber quantification, contrast echocardiography, diastolic function, disease-based assessment, Doppler echocardiography, echo-guided interventions, focused cardiac ultrasound, multimodality imaging, pediatric/congenital/fetal echocardiography, perioperative transesophageal echocardiography, reporting/quality, research, resynchronization/mechanics, stress echocardiography, training, valves, and vascular ultrasound.

When my students ask “how do you know…” I commonly cite the ASE guidelines and standards. The documents relating to chamber quantification (left and right), diastolic function, and assessment of valvular stenosis and regurgitation are frequent references that first semester. I utilize the printed article, posters, pocket guidelines, smart phone/tablet apps, and other presentation formats I have available. I direct them to the ASE Website and introduce them to the fact that there guidelines pertaining to many areas of their chosen profession. I want them to be aware that there are guidelines on basic and advanced topics (three-dimensional echocardiography, cardiac mechanics, interventions, research, etc). There are often updates to published documents and new guidelines are developed as a need is identified. It is vital that they understood the importance of precision in echocardiography and the role the guidelines and standards can play in ensuring that echocardiograms are done in a precise manner every time.

What role do the ASE guidelines and standards play in your lab? Hopefully there is a protocol that is followed, ensuring that complete echocardiograms are performed. But how are things assessed? Where, when, and how are measurements made? Is it important in your lab to take care not to introduce error by adjusting sweep speeds, scales, depth, etc? What measurements and calculations are utilized for assessment of a disease process? When someone asks “how do you know,” how do you respond? Do you have a set of standards in your lab that are referenced and available for review by your sonographers?

In our current healthcare climate it is more important than ever to ensure that echocardiography procedures produce reliable and reproducible information that is relevant to the care of the patient. As cardiovascular sonographers, we must take care to be precise in our labs. The ASE guidelines and standards provide a tool to facilitate the required precision. The articles are available on the ASE website ( http://www.asecho.org/guidelines ) and are open to the public and free of charge. They can be read on line or printed out as a hard copy for reference. The information can also be obtained in a wide variety of other formats—posters, binders, flipcharts, smart phone/tablet apps, and pocket guides. Regardless of your preference, there is a format for you and your lab. If you are utilizing the guidelines, kudos to you! If you are not, what is preventing you from taking advantage of this resource?