Published in this month’s issue of JASE are updated contrast guidelines and recommendations for radiation safety for sonographers. Both topics are timely and provide much needed information. I have devoted this month’s communication to highlighting these topics. I hope you will read both articles and take steps to implement the recommendations into your lab . — Elizabeth McIlwain, Council ChairEchocardiography is the most commonly used cardiac imaging modality because it provides real-time information regarding cardiac anatomy, function, and physiology in a manner that is portable, non-toxic, and does not emit radiation. When done appropriately, echocardiography can easily answer the clinical question in an efficient and cost effective manner. However, there are limitations with echocardiography that stem mostly from poor image quality. Studies have estimated that up to 20% of all echocardiograms performed are suboptimal.
Seems inconceivable—right? But in reality, non-diagnostic studies occur every day in good labs, small labs, and even academic labs. Perhaps you are thinking that this is simply the cost of limited image quality of cardiac ultrasound, but you would be forgetting about the true “value add” of echocardiography. An echocardiogram is cost effective, portable, does not emit radiation and, when enhanced, can provide valuable diagnostic information even on the most difficult to image patients. The “enhanced echocardiogram” refers to utilizing a pharmaceutical contrast agent to improve delineation of endocardial borders—thereby enhancing the image for better diagnostic accuracy. There have been many studies illustrating the beneficial use of contrast with echo. The benefits include accuracy, efficiency, and improved cost effectiveness. Yet, utilization of contrast echocardiography is at approximately 3% compared with the 20% of suboptimal studies—a dismal rate to say the least.
So, why is contrast usage so low even though it adds value to the echocardiogram? The barriers for contrast within our siloed echocardiography profession can be separated into 2 types of excuses.
Excuse 1: We need contrast BUT …it costs too much, takes too much time and/or we have limited resources .
Excuse 2: No need for contrast BECAUSE …our physicians do not believe it works, our sonographers are too good, machines are too good and/or we have perfect patients .
With excuse #1, both cost and time would be negated by the downstream effects associated with redundant testing. An enhanced echo would reduce need for repeat studies and additional imaging procedures, which are often more costly and may involve radiation exposure. Managing a lab with limited resources is a more difficult hurdle to overcome and requires a tailored approach that works for that particular facility. Implementing a workflow process is not easy, but is essential for any lab to successfully add enhanced echo (contrast) to its daily routine.
Excuse #2 illustrates the need for increased education and accountability. Sonographers do not purposely try to do a poor job, but if the echocardiogram is non-diagnostic it can potentially impact patient treatment, cost, radiation exposure (additional testing), and outcomes. The education piece is considerably easier to implement than the accountability aspect. However, a good way to address accountability is to include contrast utilization or percent of non-diagnostic studies to the lab’s quality assurance program and/or to sonographers’ annual evaluation.
Another issue recently brought to light involves the undesirable connotation associated with the term “contrast”. Contrast agents such as Ominpaque and Visipaque, used in angiography for catheterization and computed tomography, can have significant harmful consequences to certain patient populations. Consequently, the word contrast has a perceived negativity that is a barrier for echocardiography contrast studies. Referring physicians AND patients have concerns when “contrast” is mentioned due to renal insufficiency and radiation exposure associated with angiographic contrast. To negate the negative association of angiography contrast there has be a recent push to rebrand contrast echo as “enhanced echocardiography” or “echocardiography with enhancing agent.”
The value add of enhanced echocardiography is evident. It is ultimately the sonographer’s responsibility to use all of the tools and resources available to do what is in the best interest of the patient. An enhanced echocardiogram that immediately answers the clinical question is faster and safer for the patient than a non-diagnostic study with a follow up computed tomography angiography, nuclear study or magnetic resonance imaging. Published in this issue of JASE is the Guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography: A Focused Update from the American Society of Echocardiography. This paper discusses:
How to implement contrast administration policy/establishing intravenous access
Current contrast injection and infusion safety
Relevant recommended initiatives including rebranding contrast echo to enhanced echo
As the value of echo continues to advance, so does the role of the sonographer. Transesophageal echocardiography in angiography and surgical suites is continuing to increase and as a result sonographers are spending more time in areas that emit a lot of radiation. Additionally, in many facilities scanning patients recently injected with a radioisotope is part of the daily routine. These activities increase sonographer exposure to radiation. Concerns about radiation exposure and the lack of education/training for sonographers regarding radiation safety prompted the writing of Radiation Safety for the Cardiac Sonographer: Recommendations of the Radiation Safety Writing Group for the Council on Cardiovascular Sonography of the American Society of Echocardiography. This article, also published in this issue of JASE , highlights:
Basic radiation principles
Sources of radiation for the sonographer
Personal protection techniques
Regulatory and administrative issues
Both documents are timely and support the overall value-add of echocardiography. Hopefully, you will find these manuscripts helpful and useful in your day to day operations. Remember—radiation safety is important and it is now “ enhanced echocardiography ” instead of contrast echo!