Background
Incomplete echocardiographic assessment accounts for approximately 10% of preventable diagnostic errors and may place children at risk for adverse outcomes or increased testing. The aim of this study was to determine if physician review of images improves study completeness.
Methods
A prospective quality improvement (QI) study initiated physician review of first-time echocardiographic studies for completeness before patient discharge. Studies were incomplete if not all anatomic structures were diagnostically demonstrated. QI examinations were compared with controls obtained before study initiation. Demographic and clinical information and duration of scan were collected during the control and QI periods. An anonymous survey was administered to the sonographers to assess perceptions of the intervention.
Results
There were no differences between the QI ( n = 63) and control ( n = 63) groups in age, height, weight, and technical barriers. After study completion, 35% of control scans versus 5% of QI scans were incomplete ( P < .001). In the QI group, the sonographer, physician, or both returned to scan in 12 (19%), nine (14%), and two (3%) studies, respectively. QI studies were longer than control studies (44 vs 36 min, P = .003) before review. Physician review added a median of 6 min (range, 1–28 min). The majority of sonographers believed that immediate review improved communication, and 50% believed that it improved their job satisfaction.
Conclusions
Review of initial outpatient echocardiographic examinations before patient discharge significantly improves study completeness. Review adds a nominal amount of time to total study duration, improves sonographer-physician communication, and may prevent unnecessary testing, potentially reducing the cost of care.
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Methods
Institutional review board approval was obtained for a prospective QI study with retrospective controls. Echocardiographic examinations were eligible for inclusion if they were first-time outpatient studies performed at either the main hospital campus or a primary satellite location where studies were conducted according to the same protocol and by the same sonographers and interpreting attending cardiologists. Echocardiographic studies were excluded if patients had known diagnoses of congenital heart disease from prior institutions or were unable to tolerate a full echocardiographic examination, necessitating truncation of the planned complete examination.
The planned intervention required that sonographers review all images (including two-dimensional imaging, measured dimensions, color Doppler images, and spectral Doppler waveforms) with the attending cardiologist before patient discharge from the laboratory. The physician was to evaluate the study for diagnostic quality and completeness and direct further imaging as necessary. Studies were considered complete if all anatomic structures were diagnostically evaluated. For the purposes of this study, pulmonary vein assessment was considered complete if at least two pulmonary veins were seen by color Doppler interrogation. Assessment of coronary arteries was considered complete if the origins of the right and left coronary arteries could be demonstrated by two-dimensional imaging. The full protocol is described in Table 1 . After image review and before patient discharge from the laboratory, the attending cardiologist documented whether the study was complete as submitted or if further images were necessary. If the study was incomplete, the sonographer or the attending cardiologist would obtain further images. The time added to the study for review and additional image acquisition, if necessary, was documented, as was the study duration before review. Final study completeness as well as barriers to completion were collected. In most situations, the reviewing attending physician became the interpreting attending physician, but this was left to the discretion of the attending physicians involved and the daily work flow of the echocardiography laboratory. The need for revaluation as a result of incomplete echocardiographic studies was evaluated for each patient within the 12 months after the QI initiative.
| Position | Sweep | 2D, color clip | Spectral Doppler |
|---|---|---|---|
| Subxiphoid transverse plane | Sweep side to side, then from spine to cardiac apex | ||
| Subxiphoid sagittal | Sweep from aorta to IVC | IVC and hepatics Abdominal aorta | Abdominal aorta Hepatic vein |
| Subxiphoid coronal | Sweep posterior to anterior | Atrial septum Superior vena cava LVOT RVOT | ASD (if present) LVOT RVOT |
| Subxiphoid sagittal | SVC/IVC to apex | SVC/IVC atrial septum | |
| Subxiphoid right anterior oblique | Sweep from TV to anterior | RV inflow/outflow | |
| Parasternal long axis | Sweep from LV inflow/outflow to TV and then to RVOT Sweep septum in sections for VSD | LV inflow/outflow RV inflow RVOT Aortic measurements | Tricuspid regurgitation RVOT |
| Parasternal short axis | Sweep from base of heart to cardiac apex | Aortic valve Coronary origins RVOT and branch PAs TV Mitral valve Left ventricle at papillary level for function measurements M-mode | RVOT Tricuspid regurgitation VSDs if present |
| Apical | Posterior-to-anterior sweep from coronary sinus to RVOT | Four chamber Pulmonary vein and left atrium Mitral valve LVOT TV and right ventricle RVOT Three-chamber view Two-chamber view Biplane EF Tissue Doppler of mitral annulus TAPSE | Pulmonary vein Mitral valve LVOT TV RVOT |
| Suprasternal notch short axis | Sweep for arch sidedness | SVC, innominate vein Branch PAs Pulmonary veins | SVC |
| Suprasternal notch sagittal | Ductal sweep | Aortic arch | Ascending aorta Descending aorta |
| High right parasternal view | SVC/IVC Atrial septum |
Control patients were chosen from the 3 months before QI initiative implementation, using the same inclusion criteria. Study completeness was evaluated by one investigator (J.T.J.) using personal review of the images as well as review of the completed study report. Scan time and barriers to completion were collected. In addition, repeat testing as a result of incomplete echocardiographic studies for the subsequent 12 months was collected from the medical record. To account for interrater variability, a sample of 10 patients from the control group was chosen, and their studies were reviewed for completeness by a second author (J.A.C.).
For both groups, age at study, height, weight, gender, and name of sonographer were collected. Barriers to completion were collected and included patient motion or agitation, poor acoustic windows, and inability to reposition the patient. Studies that were truncated and did not include all standard echocardiographic views because of such barriers were excluded before review.
Following the collection of all QI patients, an anonymous survey was administered to the sonographers assessing their perceptions of the intervention. Survey questions included assessment of sonographers’ perceptions of the effect of the intervention on efficiency, performance, communication with attending physicians, and job satisfaction using a Likert-type scale ( Appendix 1 ). In addition, areas for optional comments were provided. The comments were analyzed by one investigator (J.T.J.) for positive or negative themes.
Statistical Analysis
Before initiation of the study, for the purposes of a power analysis, we estimated a 30% incomplete rate in the control studies. We considered that a decrease in the rate of incomplete studies to 10% would represent a clinically meaningful change. Two-sided α was set at 0.05. An estimated sample size of 62 patients per group would provide 80% power. Demographic variables were compared between the two groups using two-tailed Student’s t tests. Initial scan time and total scan time were compared using rank sum tests because they were not normally distributed. Sonographer distribution, study completeness, anatomic location of incompletely examined structures, and barriers to study completion were compared between the QI group and the control group using the Fisher exact tests. The κ statistic was used to compare the ratings of completeness in the control patients between the two reviewers for interrater reliability. Summary statistics were used to describe review time, need for additional scanning, and survey items.
Methods
Institutional review board approval was obtained for a prospective QI study with retrospective controls. Echocardiographic examinations were eligible for inclusion if they were first-time outpatient studies performed at either the main hospital campus or a primary satellite location where studies were conducted according to the same protocol and by the same sonographers and interpreting attending cardiologists. Echocardiographic studies were excluded if patients had known diagnoses of congenital heart disease from prior institutions or were unable to tolerate a full echocardiographic examination, necessitating truncation of the planned complete examination.
The planned intervention required that sonographers review all images (including two-dimensional imaging, measured dimensions, color Doppler images, and spectral Doppler waveforms) with the attending cardiologist before patient discharge from the laboratory. The physician was to evaluate the study for diagnostic quality and completeness and direct further imaging as necessary. Studies were considered complete if all anatomic structures were diagnostically evaluated. For the purposes of this study, pulmonary vein assessment was considered complete if at least two pulmonary veins were seen by color Doppler interrogation. Assessment of coronary arteries was considered complete if the origins of the right and left coronary arteries could be demonstrated by two-dimensional imaging. The full protocol is described in Table 1 . After image review and before patient discharge from the laboratory, the attending cardiologist documented whether the study was complete as submitted or if further images were necessary. If the study was incomplete, the sonographer or the attending cardiologist would obtain further images. The time added to the study for review and additional image acquisition, if necessary, was documented, as was the study duration before review. Final study completeness as well as barriers to completion were collected. In most situations, the reviewing attending physician became the interpreting attending physician, but this was left to the discretion of the attending physicians involved and the daily work flow of the echocardiography laboratory. The need for revaluation as a result of incomplete echocardiographic studies was evaluated for each patient within the 12 months after the QI initiative.
| Position | Sweep | 2D, color clip | Spectral Doppler |
|---|---|---|---|
| Subxiphoid transverse plane | Sweep side to side, then from spine to cardiac apex | ||
| Subxiphoid sagittal | Sweep from aorta to IVC | IVC and hepatics Abdominal aorta | Abdominal aorta Hepatic vein |
| Subxiphoid coronal | Sweep posterior to anterior | Atrial septum Superior vena cava LVOT RVOT | ASD (if present) LVOT RVOT |
| Subxiphoid sagittal | SVC/IVC to apex | SVC/IVC atrial septum | |
| Subxiphoid right anterior oblique | Sweep from TV to anterior | RV inflow/outflow | |
| Parasternal long axis | Sweep from LV inflow/outflow to TV and then to RVOT Sweep septum in sections for VSD | LV inflow/outflow RV inflow RVOT Aortic measurements | Tricuspid regurgitation RVOT |
| Parasternal short axis | Sweep from base of heart to cardiac apex | Aortic valve Coronary origins RVOT and branch PAs TV Mitral valve Left ventricle at papillary level for function measurements M-mode | RVOT Tricuspid regurgitation VSDs if present |
| Apical | Posterior-to-anterior sweep from coronary sinus to RVOT | Four chamber Pulmonary vein and left atrium Mitral valve LVOT TV and right ventricle RVOT Three-chamber view Two-chamber view Biplane EF Tissue Doppler of mitral annulus TAPSE | Pulmonary vein Mitral valve LVOT TV RVOT |
| Suprasternal notch short axis | Sweep for arch sidedness | SVC, innominate vein Branch PAs Pulmonary veins | SVC |
| Suprasternal notch sagittal | Ductal sweep | Aortic arch | Ascending aorta Descending aorta |
| High right parasternal view | SVC/IVC Atrial septum |
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