New echo guidelines specify quality

The American Society of Echocardiography (ASE) has published a set of guidelines to promote quality echocardiography, recommending specific standards for training and accreditation, procedure guidelines and quality improvement.

"It is our hope that following such standards will lead to continued quality improvement, patient and provider satisfaction and improved patient outcomes," commented the report's lead author Michael H. Picard, MD, a former president of the Morrisville, N.C.-based ASE and the director of echocardiography at Massachusetts General Hospital in Boston. "The objective of the report is to provide a framework for echocardiographic quality assessment and improvement, and to offer standards that are realistic goals for every practitioner."

The guidelines, which are published in the January issue of the Journal of the American Society of Echocardiography, come in two principal parts: laboratory structure and imaging process.

Laboratory structure
Picard and colleagues proposed laboratory recommendations according to four groupings:

1. Physical laboratory: Existing echocardiography labs should be accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories and new labs should become accredited within two years. Beyond these requirements, labs need to ensure that adequately trained staff is on-hand in sufficient numbers.
2. Equipment: The equipment available for the performance of echocardiographic procedures must be capable of performing two-dimensional, M-mode, and color and spectral (both flow and tissue) Doppler imaging. Meanwhile, all displays must identify patient and institution information, maintain digital storage and be tested for accuracy.
3. Sonographer: All sonographers should become credentialed and participate in continuing education, while pursuing appropriate subspecialty training if performing specialized echocardiography in any area.
4. Physician: All physicians must have a minimum of level II training in transthoracic echocardiography (TTE) as defined by the American College of Cardiology and other organizations, or equivalent experience-based training. Laboratory supervisors must maintain specific credentials.

Imaging process
ASE recommended discrete imaging benchmarks for five areas affecting patient outcomes:

1. Patient selection: Only when the prior probability of patient benefit is sufficiently high and exceeds the risks of the test should echocardiography be performed. The goal of processes to improve patient selection for echocardiography is to minimize inappropriate studies. The authors stated that all echocardiography labs should make available American College of Cardiology Foundation and ASE appropriate use criteria, while encouraging the monitoring of imaging appropriateness.
2. Image acquisition: ASE recommended that sonographer performance be tracked and assessed to strengthen the completeness of each study, the criteria for which the authors explicated in the report.
3. Image interpretation: The authors suggested that readers follow a checklist to avoid errors and omissions in reports, while making sure to synthesize all findings at the end of a report.
4. Results communication: ASE offered an extensive list for completing echocardiography reports, including key elements, report timelines, standards for amendments and policies for reporting critical values.
5. Incorporation of results into care: The authors explained that "echocardiographers not only should be skilled in the interpretation of images but should aim to develop and implement strategies to educate their referring providers about what echocardiography can and cannot measure, when to use it, and what findings mean for both diagnostic and therapeutic decision making."

Quality assessment and improvement
ASE's report reflected the organization's contention that "[q]uality can be measured as adherence to established guidelines for the use of a technology to ensure patient satisfaction and outcomes...Thus, the standards recommended in this document are realistic goals for the average practitioner." The guidelines concluded with emphasis on tracking and assessing compliance and other quality indicators in order to deliver and continuously improve patient outcomes.