Summary
Background
In daily cardiology practice, porters are usually required to transfer inpatients who need an echocardiogram to the echocardiographic department (echo-lab).
Aims
To assess echo-lab personnel workflow and patient transfer delay by comparing the use of a new, ultraportable, echoscopic, pocket-sized device at the bedside with patient transfer to the echo-lab for conventional transthoracic echocardiography, in patients needing pericardial control after cardiac invasive procedures.
Methods
After validation of echoscopic capabilities for pericardial effusion, left ventricular function and mitral regurgitation grade compared with conventional echocardiography, we evaluated echo-lab personnel workflow and time to perform bedside echoscopy for pericardial control evaluation after invasive cardiac procedures. This strategy was compared with conventional evaluation at the echo-lab, in terms of personnel workflow, and patients’ transfer, waiting and examination times.
Results
Concordance between echoscopy and conventional echocardiography for evaluation of pericardial effusion was good (0.97; kappa value 0.86). For left ventricular systolic function and mitral regurgitation evaluations, concordances were 0.96 (kappa value 0.90) and 0.96 (kappa value 0.86), respectively. In the second part of the study, the mean total time required in the bedside echoscopy group was 20.3 ± 5.4 mins vs. 66.0 ± 16.4 mins in the conventional echo-lab group ( p < 0.001). The echo-lab strategy needed porters in 100% of cases; 69% of patients needed a wheelchair.
Conclusion
The use of miniaturized echoscopic tools for pericardial control after invasive cardiac procedures was feasible and accurate, allowing improvement in echo-lab workflow and avoiding patient waiting time and transfer.
Résumé
Prérequis
En pratique cardiologique, il est souvent indispensable de transférer les patients hospitalisés au laboratoire d’échocardiographie.
Objectifs
Évaluer le travail du personnel du service d’échocardiographie et le temps de transfert des patients au cours d’une stratégie utilisant un nouvel appareil échoscopique miniaturisé, au lit des patients nécessitant un contrôle du péricarde, après une procédure cardiaque invasive, en comparaison au transfert des patients pour une échocardiographie conventionnelle.
Méthodes
Après une première étape de validation des capacités de l’échoscopie dans l’épanchement péricardique, la fonction ventriculaire gauche (VG) et le grade d’insuffisance mitrale, nous avons évalué l’amélioration en terme de personnel mobilisé, de temps de transfert et de temps d’attente, obtenue grâce à l’échoscopie au lit du patient pour contrôle du péricarde après procédures cardiaques invasives en comparaison à l’évaluation conventionnelle.
Résultats
La concordance entre échoscopie et échocardiographie conventionnelle pour l’évaluation du péricarde était bonne (0,97 avec kappa = 0,86). Pour la fonction systolique VG et l’évaluation de l’insuffisance mitrale, les concordances étaient de 0,96 et 0,96 (kappa = 0,90 et 0,86), respectivement. Le temps total moyen requis pour réaliser l’échoscopie au lit du patient était de 20,3 ± 5,4 minutes alors qu’il était de 66,0 ± 16,4 minutes dans le groupe échocardiographie conventionnelle ( p < 0,001). La stratégie conventionnelle a nécessité des brancardiers dans 100 % des cas (fauteuil roulant 69 % des cas).
Conclusion
L’utilisation de machines miniaturisées d’échoscopie pour le contrôle du péricarde après procédures cardiaques invasives, est faisable, fiable, permet d’améliorer le fonctionnement du laboratoire d’échocardiographie et évite aux patients le temps d’attente et le transfert.
Introduction
Organization of echocardiographic departments (echo-labs) in cardiological institutions has become a real problem due to the dramatic reduction in human resources while demand continues to increase. Porters are usually required to transfer inpatients who need an echocardiogram to the echo-lab, particularly after invasive cardiac or surgical procedures. This is a major cause of patient discomfort and is time consuming in terms of human resources for what is a limited, targeted echocardiographic evaluation that is principally focused on the pericardium and left ventricular (LV) function in such patients.
Due to improvements in electronic technology, portable equipment has been developed for the past 10 years . However, these devices have a variety of limitations (insufficient image quality, size and width or battery autonomy) and are difficult to implement in the echo-lab workflow. An important effort has been made recently to miniaturize ultrasound systems, which has yielded a generation of genuinely pocket-sized ultrasound devices that have grayscale imaging and colour Doppler capabilities ( Figs. 1 and 2 ). As a result of this ultimate portability without degradation of image quality, the performance of echoscopic evaluation directly at the patient’s bedside appears to be feasible for limited diagnostic issues.
We hypothesized that integration of an echoscopic approach in an echo-lab with delocalized evaluation at the bedside would improve workflow and reduce inpatient discomfort without a loss of quality in terms of medical diagnosis. Therefore, we designed this study with two aims: first, to verify that echoscopic evaluation of targeted endpoints such as pericardial effusion, mitral regurgitation (MR) grade and LV function was similar to that obtained with conventional echocardiographic systems; and second, to compare a bedside delocalized strategy with a conventional one (within the echo-lab) based on variables such as use of human resources, transfer and waiting times, and patient comfort.
Methods
The two parts of this study took place at the University Cardiology Hospital of Bordeaux-Pessac, which has 350 rooms spread over six floors. The echo-lab, cardiology departments, coronary and intensive care units and cardiothoracic surgery department are located on different floors of the same hospital building. In the echo-lab, 15,000 transthoracic echocardiography (TTE) examinations are performed per year. All the examinations done by students or certified sonographers are reviewed by cardiologists with a high level of competence in TTE, using commercially available software for image reviewing and reporting (ComPACS; MediMatic S.R.L., Genoa, Italy). The standard report and images are stored on the hospital’s Picture Archiving and Communication System (PACS) network. This study was approved by our university’s ethics committee.
Validation of echoscopy capabilities compared with conventional echocardiography
One hundred unselected patients referred to the Bordeaux Cardiology Hospital’s echo-lab for conventional indications were enrolled in the first step of this prospective study, to validate the use of the compact echoscopic device vs. conventional TTE performed at the echo-lab. There were no particular exclusion criteria. All patients underwent two ultrasonic examinations: the first was a standard echocardiographic examination performed by an expert physician; this was followed by another cardiac evaluation using a pocket-sized ultrasound device (VSCAN, General Electric Inc., Milwaukee, WI, USA), performed and interpreted by a blinded expert physician. All patients were informed and completed a consent form prior to participation.
For the standard TTE examination, commercially available, top-of-the-line, full-feature echocardiographic systems were used, including Sequoia 512 (Siemens Medical Solutions, Mountainview, CA, USA), IE33 (Philips Medical Systems, Boston, MA, USA), and Vivid 7 (GE Medical Systems, Milwaukee, WI, USA). Next, an evaluation was done using the ultraportable instrument by a physician experienced with TTE and blinded to the results of the standard examination. Each physician completed a summary report that included the following evaluation criteria: semi-quantitative LV systolic function, MR severity and pericardial effusion. Judgment criteria were: ultrasound window quality, good/average/insufficient; LV function, normal/moderate dysfunction/severe dysfunction; mitral regurgitation, absent/mild/moderate/severe; pericardium, normal/slight effusion/moderate effusion/severe effusion.
Comparison of bedside echoscopic evaluation with conventional echo-lab echocardiography
We enrolled 91 consecutive patients who headed to the echo-lab after cardiac invasive procedures such as coronary artery bypass graft (CABG) or radiofrequency catheter ablation (RFCA), or pericardial drainage for pericardial control. Over 6 weeks, 59 patients were included in the bedside echoscopic evaluation group. Then, over the next 3 weeks, 32 patients were included in the conventional TTE group. We excluded patients with prosthetic valve surgery or plasty associated with CABG (needing Doppler analysis). Demographic and clinical characteristics of the study population and reasons for the cardiac echo evaluation were systematically collected.
The mean judgment criterion was time spent by the sonographer for echoscopic evaluation compared with transferring inpatients to the echo-lab for conventional TTE evaluation. In addition, the mode of transfer and the need for additional personnel (such as porters) or oxygen therapy were noted.
For the bedside echoscopy group, we collected the sonographer’s travel time between the echo-lab and the hospital ward (return trip) for each patient, the duration of the examination conducted by the sonographer and the time required for the referent physician to control and write the report. For the conventional echo-lab group, we registered the need for a porter to transfer the patients to the echo-lab (with or without a wheelchair), the duration of transfer (from admission department to the echo-lab plus travel time from the echo-lab to the patient’s ward; return trip), the time spent by the patient in the waiting room, the duration of the examination and the time required for the referent physician to control and write the report. The main objective was to compare the sonographer’s travel time in the bedside group with the transfer time plus waiting time for patients in the echo-lab group. Each sonographer systematically filled out the same summary report as described for the first part of the study.
The conventional TTE examination performed in the echo-lab was done using a high-end ultrasound scanner (Sequoia 512 [Siemens Medical Solutions, Mountainview, CA, USA] or Vivid S6 [General Electric Medical Systems, Horten, Norway]). All patients were informed verbally and filled out a consent form. All echocardiograms were performed by certified sonographers (L.D.M. and R.C.) .
The ultraportable ultrasound device
VSCAN (General Electric Medical Systems, Milwaukee, WI, USA) is a pocket-sized ultrasound device with a unit size of 135 × 73 × 28 mm and a transducer size of 120 × 33 × 26 mm. ( Figs. 1 and 2 ) The VSCAN weighs around 390 g and its display measures 3.5 inches, with a resolution of 240 × 320 pixels. The entire unit, including transducer, can fit into the pocket of a laboratory coat along with a small tube of gel. It provides a black-and-white mode for displaying anatomy in real time and a colour-coded overlay for real-time blood flow imaging. The broad-bandwidth phased array probe ranges from 1.7 to 3.8 MHz. The device includes electronic callipers capable of linear measurements. There is an auto-optimize function that automatically adjusts gain function for all depths. Recordings were obtained in standard parasternal, apical and subcostal views, in black-and-white and colour Doppler mode. All images were recorded on the system memory card for later review.
Statistical analysis
Statistical analysis was carried out with the StatEl ® version 2 software (AdScience, Paris, France). Concordances between non-parametric data were assessed by Cohen’s kappa test. Concordance was deemed good when the kappa coefficient was between 0.6 and 0.8, and excellent when it exceeded 0.8. Continuous values were expressed as means ± standard deviations. Comparisons between two groups for parametric data were made using the t test. Comparisons between two groups for qualitative data were made using the chi-square test or Fisher’s test for small samples. Differences were considered significant at p < 0.05.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
