Eric J. Walker, MHA, RVT, RDCS

Yvonne B. Prince, AS, RDMS, RVT, RDCS

Mary E. Wingold, BS, RDMS, RVT, RDCS

Ronald W. Gimbel, PhD

Note from Patrick D. Coon, RCCS, RDCS, FASE, Immediate Past Chair of the Council on Cardiovascular Sonography Steering Committee: In today’s healthcare environment, “hybrid” noninvasive laboratories are becoming more and more commonplace as institutions search for efficiency and quicker patient throughput. As such, the challenges to operate hybrid labs are many. This month, we have invited guest authors to describe the model they have developed at Clemson and the challenges faced as well as some creative solutions to those problems. The opinions and experiences of the authors, however, are not necessarily those of the American Society of Echocardiography nor is the invitation to write about their experience an endorsement of that approach. That being said, the experience at Clemson is just one model to develop such a hybrid lab and is presented to start a discussion on how best to go about it.

According to the Bureau of Labor Statistics, the projected employment of diagnostic medical sonographers will increase by 24% from 2014 to 2024. At the same time, employment demands are increasing, cardiologists and cardiology fellows nationwide are beginning to expand their clinical practice by performing minimally invasive procedures to treat peripheral, visceral, and cerebrovascular arteries. This is the impetus behind the rise in hybrid labs (i.e. labs performing both adult echocardiography and vascular sonography) aimed at increasing clinical efficiency and patient satisfaction. Finding qualified, dually-credentialed sonographers may prove difficult for employers. Recognizing these various factors, faculty at Clemson University’s Cardiovascular Imaging Leadership Concentration have developed a layered, hands-on approach focused on teaching critical thinking, customer service, and psychomotor skills needed to prepare the next generation of competent cardiovascular sonographers.

As stated by Deborah Szigeti, sonographers performing in jobs requiring more than one ARDMS credential must exhibit the “desire to actively develop knowledge and skills.” Personal drive alone, however, does not guarantee individuals are adequately trained to provide high quality patient care. In her paper, Perese mentioned the challenges in cross-training personnel to perform both adult echocardiography and noninvasive vascular testing and mentioned the difficulty in finding those individuals who are truly proficient in both modalities. Additionally, Perese and Naqvi detailed the increased efficiency and improved patient satisfaction that results from offering “multiple exams on a single patient in one room with one machine.” Because CAHPS Clinician & Group Survey (CG-CAHPS) have become the new paradigm in driving reimbursement under the Affordable Care Act, hybrid labs employing multidisciplinary sonographers offer an increased opportunity to maximize reimbursement and provide exceptional customer experiences without compromising clinical quality.

Healthcare educators face a steep challenge in training tomorrow’s workforce. Didactic accomplishments alone cannot predict student success in the clinical environment. Often performance factors such as personal initiative, adaptability, critical thinking skills, teamwork, workflow comprehension, perseverance, and the ability to accept performance feedback humble the most accomplished academic performer. Burns et al. have described the challenges in helping “the student become a safe, competent, compassionate, independent, and collaborative clinician” by developing “conceptual frameworks.” Recognizing these issues, our faculty deploy a focused approach to develop clinically curious cardiovascular sonographers able to meet the demands of dedicated and hybrid labs nationwide.

Building curriculum happened in two distinct yet interrelated stages. In the first stage, didactic course work was developed from the American Registry of Diagnostic Medical Sonographers (ARDMS) test content outlines for Sonography Principles and Instrumentation (SPI), Adult Echocardiography (AE), and Vascular Technology (VT). This approachensures not only adequate test preparation for students but also compliance with programmatic accreditation standards and guidelines set forth by the Joint Review Committee for Cardiovascular Technology (JRC-CVT).

The second stage centered on developing objective, reproducible scan lab exercises focused on building skill in aggregate steps. Our blueprint of deliberately focusing scan lab exercises on the Intersocietal Accreditation Commission (IAC) standards and guidelines for noninvasive cardiovascular imaging drives home the ultimate goal of all clinical locations: high quality patient care. Using an inquisitive, incremental, and open-minded methodology, faculty supports each student’s efforts in learning best practices for performing a wide variety of noninvasive vascular tests and adult echocardiography on classmates and volunteer patients during their junior year. From obtaining patient history and physical assessments to building an electronic preliminary report, students are able to positively contribute to patient care on their first day of clinicals. This approach has shown encouraging results such as positive job placement and registry pass rates as well as improved clinical efficiency.

One common misperception that merits discussion is a sonographer’s inability to perform a wide variety of testing in an expert manner. While this train of thought may be pervasive, it is extremely shortsighted. Understanding the entire cardiovascular system allows sonographers to link cardiac issues (congestive heart failure, severe aortic stenosis, etc.) with their residual effects on peripheral vascular waveforms (pulsatile lower extremity venous flow, bilateral tardus parvus common carotid flow, etc.). Having a more global hemodynamic understanding is critical in assessing patients suffering from the systemic nature of cardiovascular disease. As stated previously, more and more cardiology practices have expanded their services to include intervention of peripheral, extracranial cerebrovascular, and visceral blood vessels. Arming sonographers working in the cardiology setting with the requisite skills to identify and assess vascular pathology and interventional efficacy provides optimal logistics for the patient. Simply stated, this approach supports accurate determination of the extent of disease, thereby reducing the need for additional, more costly, and potentially more invasive diagnostic testing. As collaborative clinicians, sonographers must be able to answer the clinical question for each patient by obtaining accurate information at the time of evaluation.

With the advancing roles in the cardiovascular imaging industry, the need for progressive training of dually-credentialed sonographers has propelled the development of the method currently being used by the faculty at Clemson University’s Cardiovascular Imaging Leadership Concentration. This mechanism fulfills a broad spectrum of needs within the pedagogy of modern instruction and practical application within the medical community. This contemporary approach produces adroit, adaptable clinicians, who offer high quality patient care with cost-effective efficiency.

Eric J. Walker, MHA, RVT, RDCS, is the Program Director of the Clemson University Cardiovascular Imaging Leadership Concentration and Greenville Health System.

Yvonne B. Prince, AS, RDMS, RVT, RDCS and Mary E. Wingold, BS, RDMS, RVT, RDCS are CVT Educators at the Greenville Health System.

Ronald W. Gimbel, PhD, is the Department Chair of Public Health Science at Clemson University.