Efficacy and time-efficiency of a “sonographer-driven” contrast echocardiography protocol in a high-volume echocardiography laboratory

doi:10.1067/mhj.2003.164

American Heart Journal

Volume 145, Issue 3, March 2003, Pages 535-541

https://doi.org/10.1067/mhj.2003.164 Get rights and content

Abstract

Background Contrast echocardiography (CE) has not gained widespread use despite numerous studies demonstrating its efficacy in the assessment of left ventricular (LV) function. Methods We sought to determine whether CE could be used in a high-volume echocardiography laboratory in a clinically effective and time efficient manner. We implemented a protocol with a feasibility phase and an established phase. Cost-benefit analyses were done on the basis of time use. Results During the feasibility and established phases, data on 119 and 672 patients, respectively, were obtained. After a “sonographer-driven” protocol, contrast studies represented 7% to 8% of the total number of routine transthoracic and stress studies. Stress studies accounted for only 15% of the total number of contrast studies. Obesity was the most common indication for contrast use. LV visualization indices and wall thickening assessment, as evaluated by 2 blinded readers, were significantly improved with CE compared with second harmonic imaging alone. The time to make the decision to use CE and the time taken to administer contrast decreased significantly from the feasibility phase to the established phase (8.3 ± 5 vs 7.6 ± 5 min, P < .01, and 13.4 ± 10 vs 10.2 ± 5 min, P < .001, respectively). On the basis of time use only, a cost analysis indicated that savings were obtained at a 10-minute reduction in study time. Conclusions A “sonographer-driven” CE protocol for LV assessment is feasible in high-volume echocardiography laboratories. It is clinically effective because it significantly improves LV global and regional wall motion visualization. A “sonographer-driven” CE protocol can reduce decision and administration times substantially, thus making CE time-efficient. (Am Heart J 2003;145:535-41.)

References (0)

Cited by (31)

Incidence of Severe Adverse Drug Reactions to Ultrasound Enhancement Agents in a Contemporary Echocardiography Practice
2024, Journal of the American Society of Echocardiography
Prior data indicate a very rare risk of serious adverse drug reaction (ADR) to ultrasound enhancement agents (UEAs). We sought to evaluate the frequency of ADR to UEA administration in contemporary practice.
We retrospectively reviewed 4 US health systems to characterize the frequency and severity of ADR to UEA. Adverse drug reactions were considered severe when cardiopulmonary involvement was present and critical when there was loss of consciousness, loss of pulse, or ST-segment elevation. Rates of isolated back pain and headache were derived from the Mayo Clinic Rochester stress echocardiography database where systematic prospective reporting of ADR was performed.
Among 26,539 Definity and 11,579 Lumason administrations in the Mayo Clinic Rochester stress echocardiography database, isolated back pain or headache was more frequent with Definity (0.49% vs 0.04%, P < .0001) but less common with Definity infusion versus bolus (0.08% vs 0.53%, P = .007). Among all sites there were 201,834 Definity and 84,943 Lumason administrations. Severe and critical ADR were more frequent with Lumason than with Definity (0.0848% vs 0.0114% and 0.0330% vs 0.0010%, respectively; P < .001 for each). Among the 3 health systems with >2,000 Lumason administrations, the frequency of severe ADR with Lumason ranged from 0.0755% to 0.1093% and the frequency of critical ADR ranged from 0.0293% to 0.0525%. Severe ADR rates with Definity were stable over time but increased in more recent years with Lumason (P = .02). Patients with an ADR to Lumason since the beginning of 2021 were more likely to have received a COVID-19 vaccination compared with matched controls (88% vs 75%; P = .05) and more likely to have received Moderna than Pfizer-Biotech (71% vs 26%, P < .001).
Severe and critical ADR, while rare, were more frequent with Lumason, and the frequency has increased in more recent years. Additional work is needed to better understand factors, including associations with recently developed mRNA vaccines, which may be contributing to the increased rates of ADR to UEA since 2021.
Advanced Echocardiography Techniques: The Future Stethoscope of Systemic Diseases
2022, Current Problems in Cardiology
Cardiovascular disease (CVD) has been showing patterns of extensive rise in prevalence in the contemporary era, affecting the quality of life of millions of people and leading the causes of death worldwide. It has been a provocative challenge for modern medicine to diagnose CVD in its crib, owing to its etiological factors being attributed to a large array of systemic diseases, as well as its non-binary hideous nature that gradually leads to functional disability. Novel echocardiography techniques have enabled the cardiac ultrasound to provide a comprehensive analysis of the heart in an objective, feasible, time- and cost-effective manner. Speckle tracking echocardiography, contrast echocardiography, and 3D echocardiography have shown the highest potential for widespread use. The uses of novel modalities have been elaborately demonstrated in this study as a proof of concept that echocardiography has a place in routine general practice with supportive evidence being as recent as its role in the concurrent COVID-19 pandemic. Despite such evidence, many uses remain off-label and unexploited in practice. Generalization of echocardiography at the point of care can become a much-needed turning point in the clinical approach to case management. To actualize such aspirations, we recommend further prospective and interventional studies to examine the effect of implementing advanced techniques at the point of care on the decision-making process and evaluate their effectiveness in prevention of cardiovascular morbidities and mortalities.
Identification of Need for Ultrasound Enhancing Agent Study (the IN-USE Study)
2020, Journal of the American Society of Echocardiography
Citation Excerpt :
Current barriers to their use include insufficient awareness of the utility and benefit of UEAs, lack of training in administration of UEAs, absence of a formal training pathway for development of skills in IV placement, and mechanisms to identify a priori which patients might require IV placement for UEA administration. Reasons for low UEA use at our institution may include historical requirements for verbal approval for use from the attending TTE reader or cardiology fellow (a policy no longer in place), storing of UEAs in the echocardiography laboratory (vs sites of most common use), lack of use of UEAs for off-hours emergent studies by fellows or on weekends, and insufficient training of nurses and other health professionals for administration of UEAs.6 An additional barrier to the use of UEAs is the insufficient number of trained personnel to place IV lines.
Ultrasound enhancing agents (UEAs) are routinely used to improve transthoracic echocardiographic (TTE) image quality, yet anticipation of UEA need is a barrier to their use.
Structured report data from 171,509 consecutive TTE studies in 97,515 patients who underwent TTE imaging from January 26, 2000, to September 20, 2018, were analyzed. Trends in UEA use and suboptimal image quality were examined. Among outpatients (92,291 TTE examinations, n = 56,479), the data set was randomly split into a 75% derivation sample and a 25% validation sample. Logistic regression was used to model the composite of either UEA receipt or suboptimal image quality (two or more nonvisualized segments) using only variables available at the start of the TTE examination. Model performance was tested in the validation sample.
A total of 4,444 TTE examinations (2.6%) in 3,827 patients (3.9%) involved UEAs, and 28,468 TTE examinations (16.6%) in 21,994 patients (22.5%) were suboptimal. UEA use increased over the observation period. Among TTE studies with suboptimal image quality, UEA use was lower in women (P < .0001). Among outpatients referred for TTE imaging, older age, greater weight, and higher heart rate best predicted UEA use or suboptimal image quality. Model performance in the validation sample was excellent (C statistic = 0.74 [95% CI, 0.73–0.75]; calibration slope = 1.11 [95% CI, 1.06–1.15]).
In this large, single-center, retrospective study, UEA use remained substantially below rates of suboptimal image quality, despite increases over time. Among outpatients, a simple prediction rule using three routinely collected variables available before TTE image acquisition predicted potential benefit from UEAs with high accuracy. If confirmed in other cohorts, this rule may be used to identify patients who may benefit from intravenous placement for UEA administration before TTE image acquisition, thus potentially improving work-flow efficiency.
Clinical Applications of Ultrasonic Enhancing Agents in Echocardiography: 2018 American Society of Echocardiography Guidelines Update
2018, Journal of the American Society of Echocardiography
Citation Excerpt :
Although serious side effects are exceedingly rare, there should always be a physician present on site when contrast is administered. Two single-center studies in Europe and Canada have demonstrated improved efficiency with sonographer-driven contrast echocardiographic protocols through reductions in time to decision for contrast use and time to administration of contrast, resulting in potential cost savings.127,128 This also underscores that training in the recognition of need for UEA must be a standard component of sonographer education, complemented by echocardiography laboratory implementation of standing orders for UEA administration.
Clinical application and laboratory protocols for performing contrast echocardiography
2013, Indian Heart Journal
Technically difficult echocardiographic studies with suboptimal images remain a significant challenge in clinical practice despite advances in imaging technologies over the past decades. Use of microbubble ultrasound contrast for left ventricular opacification and enhancement of endocardial border detection during rest or stress echocardiography has become an essential component of the operation of the modern echocardiography laboratory. Contrast echocardiography has been demonstrated to improve diagnostic accuracy and confidence across a range of indications including quantitative assessment of left ventricular systolic function, wall motion analysis, and left ventricular structural abnormalities. Enhancement of Doppler signals and myocardial contrast echocardiography for perfusion remain off-label uses. Implementation of a contrast protocol is feasible for most laboratories and both physicians and sonographers will require training in contrast specific imaging techniques for optimal use. Previous concerns regarding the safety of contrast agents have since been addressed by more recent data supporting its excellent safety profile and overall cost-effectiveness.
Feasibility of Sonographer-Administered Echocontrast in a Large-Volume Tertiary-Care Echocardiography Laboratory
2013, Canadian Journal of Cardiology
Citation Excerpt :
Although our patient characteristics in both SOC and SAP groups were not significantly different, our study demonstrated that application of the CE protocol in the SAP group was more feasible than in the SOC group. The time difference was attributed to a major challenge of the SOC protocol: There is no staff dedicated to performing IV access and contrast administration in a timely fashion.3,5,11 In clinical practice, physicians and nurses are responsible for handling a variety of issues related to patient care.
Contrast echocardiography has been shown to improve diagnostic quality, especially in technically difficult patients. However, the learning curve and increased time for preparation and image acquisition have led to low use.
We sought to determine whether the contrast echocardiography procedure performed independently by a specialized, trained sonographer could improve efficiency. In our centre, routine echocardiograms were scheduled for 1 hour, and any study exceeding 1 hour would result in patient booking cancellations. We compared the standard of care, in which a physician or nurse administers echocontrast, with a sonographer-administered program (SAP).
The time to complete contrast echocardiograms was significantly reduced by the SAP strategy (43 min 17 s ± 23 min 42 s vs 1 h 1 min 6 s ± 31 min 0 s, P < 0.001). Subgroup analysis of the inpatients and outpatients demonstrated similar results. Only 10% of studies (6 of 61) in the SAP exceeded 60 minutes, compared with 45% (34 of 76) in the standard-of-care group (P < 0.001). Based on study volumes in our centre, the net improvement in productivity with the SAP could be up to 5.3% annually.
Sonographer-administered echocontrast is feasible and potentially removes a barrier to implementation of contrast echocardiography.
L'échocardiographie de contraste a contribué à améliorer la qualité diagnostique, particulièrement chez les patients techniquement difficiles. Cependant, la courbe d'apprentissage et l'augmentation du temps nécessaire à la préparation et à l'acquisition de l'image ont mené à une plus faible utilisation.
Nous avons tenté de déterminer si la procédure de l'échocardiographie de contraste effectué indépendamment par un échographiste spécialisé et formé pourrait améliorer l'efficacité. Dans notre centre, les échocardiogrammes de pratique courante étaient prévus pour durer 1 heure, et aucune étude excédant 1 heure entraînerait des annulations de rendez-vous de patient. Nous avons comparé les normes de soins selon lesquelles un médecin ou une infirmière fait subir au patient l'échocontraste au moyen d'un programme exécuté par l'échographiste.
Le temps nécessaire pour mener à terme les échocardiogrammes de contraste a été significativement réduit par la stratégie du programme exécuté par l'échographiste (43 min 17 s ± 23 min 42 s vs 1 h 1 min 6 s ± 31 min 0 s, P < 0,001). L'analyse du sous-groupe de patients hospitalisés et de consultants externes démontrait des résultats similaires. Seulement 10 % des études (6 de 61) du programme exécuté par l’échographiste excédaient 60 minutes comparativement à 45 % (34 de 76) du groupe selon les normes de soins (P < 0,001). Selon les volumes d'étude à notre centre, l'amélioration nette de la productivité au moyen du programme exécuté par l’échographiste pourrait être au-dessus de 5,3 % annuellement.
L'échocontraste exécuté par un échographiste est réalisable et élimine possiblement les obstacles de l'exécution de l'échocardiographie de contraste.

View all citing articles on Scopus

View full text

Clinical Investigations: Imaging and Diagnostic TestingEfficacy and time-efficiency of a “sonographer-driven” contrast echocardiography protocol in a high-volume echocardiography laboratory

Abstract

Clinical Investigations: Imaging and Diagnostic Testing
Efficacy and time-efficiency of a “sonographer-driven” contrast echocardiography protocol in a high-volume echocardiography laboratory