Ultrasound-Enhancing Agent and IV Administration in Cardiac Sonography: How Sonographers Play a Key Role in Positively Affecting Key Performance Indicators

Abstract

As the health system in the United States continuously searches for ways to reduce costs and improve the health care experience, cardiac sonographers are uniquely positioned to add to this initiative. Tasked with providing high-quality imaging studies in outpatient and inpatient areas, the scope of practice for sonographers continues to evolve. To ensure quality imaging, ultrasound-enhancing agents (UEAs) are needed in patients with suboptimal images to improve delineation of left ventricular endocardial borders. This process involves intravenous (IV) access and occurs in both patients in ambulatory clinics and hospitals. Historically, health care professionals delegated to perform these duties have been nursing, radiology, and nuclear medicine staff. Because these professionals have their own job responsibilities, the potential to complete a transthoracic echocardiogram (TTE) with UEA, in a timely fashion, may be compromised. Expanding the practice of cardiac sonographers to include these duties should be supported to facilitate uninterrupted patient care, efficiency, and stakeholder satisfaction.

A highly efficient and high-quality echocardiography laboratory in ambulatory clinics and hospitals serves as the catalyst for exceeding expectations across many stakeholders. Often, there are obstacles that prevent timely patient care due to operational challenges, such as the administration of intravenous (IV) lines and ultrasound-enhancing agents (UEAs). Administrators and department leaders should consider seeking opportunities to overcome these difficulties. Drawing from the diverse literature, it is important to explore the elements of a cardiac sonographer’s administration of IVs and UEA. Likewise, there are potential key performance indicators (KPIs) that are affected when health systems educate and delegate these responsibilities to sonographers. This symposium will also be supplemented with the viewpoints of echocardiography leaders who hold the advanced cardiac sonographer credential to illustrate the impact of sonographer administration of IVs and UEA.

Increased Role of Cardiac Sonographers and the Downstream Effects

The field of echocardiography has evolved greatly since its origin in the 1950s ¹ and the experimentation of contrast in 1969 by Gramiak et al. ² Because of its numerous advantages compared with other diagnostic imaging techniques and its advancement in technology, echocardiography plays a key role in both inpatient and outpatient care. Frequently, IV and UEA administration is needed during technically difficult studies to better delineate endocardial borders, Doppler enhancement, hypertrophic cardiomyopathy, cardiac masses, noncompaction, myocardial perfusion, stress echocardiography, and right heart assessment.^3,4 This skill set is often performed by nursing and nuclear medicine staff, but due to their training and competencies, this can result in patient care delays.

Because of the dependence on echocardiography throughout health systems across the country, the onus of responsibility relies on advanced cardiac sonographers and department leaders to create opportunities for success and satisfaction for many stakeholders, in particular sonographers, physicians, and patients. One opportunity to facilitate the administration of UEA and IVs in a more timely fashion is to fully engage/empower sonographers to perform these responsibilities, as it is within their scope of responsibility^5,6 and is fully supported by the American Society of Echocardiography (ASE) when the required training is available. ⁷ As international societal and accrediting bodies hold the profession accountable to engage in quality patient care, local echocardiography leaders are at the forefront to promote these best practice principles.^8,9

As hospital administrators glean data from numerous reports provided to them regularly, the need to understand the constraints of patient flow and throughput are magnified. In a recent literature review, Åhlin et al. ¹⁰ report on 12 barriers to inefficient patient throughput, specifically long lead times. Although not exclusively tied to an echocardiography laboratory, the connection of lead times and throughput are directly correlated with the operations of completing transthoracic echocardiography (TTE) in a timely fashion for many patients. In different scenarios, hospital discharge is dependent on the echocardiography studies we perform. As hospital capacity is limited due to less discharges, this effect is felt within emergency departments. Overcrowding in the emergency department has consequential effects on all patients, from both financial and quality of care perspectives. ¹¹ From a pandemic perspective, early administration of UEA has been proven beneficial to reduce exposure and optimize diagnostic quality. ¹² When sonographers are not trained to administer UEA, this process involves multiple professionals, thus increasing unnecessary exposure. Being better prepared with best practice methods and techniques, such as sonography IV and UEA administration, will aid in mitigating decreased throughput while not having to sacrifice quality.

As discussed, long lead times is a major focus of hospitals to ensure swift patient care. Regarding echocardiography, long lead times from order to completion results in decreased productivity, which is inherently a central theme in many laboratories. ¹³ These lead times are exacerbated by several barriers to UEA administration, including insufficient knowledge of utility and benefits of UEA, an absence of dedicated training for continued skill development, and a decreased availability for off-hours UEA use. ¹⁴ Despite the value and cost-effectiveness that UEA administration brings to the quality and management of patient care, many recent UEA studies have confirmed that administration remains lower than anticipated. ¹⁵

Workflow deficiencies continue to be a major concern related to the availability of UEA. Advanced cardiac sonographers and echocardiography department leaders understand this relationship, which should be transparently communicated to senior health care leadership so that problems can be solved together through fully empowering our field through education and continued competencies on UEA and IV administration. Of course, before seeking full implementation, echocardiography leaders should consult with their health system compliance and patient safety teams. It is paramount to ensure that this new initiative is compliant with current hospital/clinic policy and procedures.

Perspectives of Noninvasive Leaders on the Impact of Sonographer IV and UEA Administration

To further illustrate the impact that empowering sonographers with UEA and IV administration skill sets has on health care systems, empirically observed perspectives of advanced cardiac sonographer leaders are provided. Eight echocardiography leaders/educators were purposively surveyed on whether their health care system allowed their staff sonographers to administer UEA and start IVs. Advanced cardiac sonographers were chosen due to their ability to function at a high level to improve the efficiency of an echocardiography laboratory.^16,17 These leaders were all affiliated with Intersocietal Accreditation Commission (IAC)-accredited adult echocardiography laboratories across the United States. The survey respondents were then asked how these skill sets (or lack thereof) negatively or positively affected their laboratory. Out of the eight surveyed respondents, six were members of an echocardiography laboratory that permitted sonographer administration of UEA and five were members of a laboratory that permitted IV administration. Inpatient throughput/efficiency, sonographer satisfaction, physician satisfaction, patient satisfaction, and quality were the major themes derived from the survey respondents.

Inpatient Throughput and Efficiency

To better appreciate the impact that sonographer administration of IVs and UEA have on inpatient throughput and efficiency, it is important to consider the perspectives of three sonographer leaders. Chris, a laboratory director, stated,

The skillset of sonographers starting IVs in our system allows throughput to occur at a much smoother and salient pace. Often times, nursing personnel or radiology technologists are needed elsewhere and are unavailable which causes delays on scanning and reading of exams.

This perspective highlights the dependence of echocardiography laboratories on other departments to ensure an exhaustive TTE with UEA is completed.

The perspective of Matthew, a laboratory manager, was unique in that he was vital in the implementation of sonographer administration of UEA:

We performed time studies prospectively, which led to the decision to pilot sonographer administration of Definity. Sonographer productivity and efficiency was improved and the decision to use UEA’s for patient care was made on the spot, leading to an increase of more accurate diagnoses and left ventricular function. Outpatient patient IV starts by sonographers also decreased patient wait times due to the earlier detection for the use of UEAs and also improved accuracy of diagnoses and LV function.

Samuel, another laboratory manager, expounded upon several advantages in sonographer administration of UEA by stating,

Providing sonographers training to start IV & training to administer UEA saves study time, review time, improve their self-confidence, efficiency, productivity, reduces number of repeat echo-studies, reduces cost for the hospital, office and for the patient. Being trained and skilled in starting IVs and being able to administer UEA help cut down the waiting time for someone else come to start an IV and push UEA.

Sonographer Satisfaction

Sonographer satisfaction due to administration of UEA is evident in the perspectives of two leaders in their respective echocardiography laboratories. Thomas, a laboratory manager, stated,

Having the sonographers push UEA has positively affected our workflow in a significant way. We have seen a reduction in TAT (turnaround time) and an improvement in the overall quality of our exams. Sonographers are also more productive and happier working with fewer barriers. We have a standing order for ultrasound-enhancing agents sonographers are also happy and confident in the decision-making regarding contrast agents.

In addition to Thomas, Samuel opined that sonographer administration of UEA

Also directly helps improve the self-confidence of the sonographers, increase their efficiency and productivity, their job satisfaction, which makes any echo-lab an efficient lab providing high quality of care. Being able to start IVs and push UEA help build self-confidence as a sonographer being able to work independently.

As Thomas illustrated the direct correlation between UEA/IV administration and sonographer satisfaction, the dependency on other health care professionals to complete these tasks maintains the potential to lower morale in these areas as they have their own job description responsibilities to perform.

Physician Satisfaction

As new processes and systems are needed to improve deficiencies, it is important to remain transparent with physicians and gain their insight into their thoughts on what they need to remain successful in the work they do. The input that Matthew, a laboratory manager, provided was valuable because of his involvement from the ground up of sonographer administration of UEA and IV. He stated, “Physician involvement and support drove a system initiative towards both aspects of sonographer training for the use of UEA’s.”

Patient Satisfaction

Of course, at the end of clinical day, it is an expectation that sonographers have taken care of each patient and tried to exceed their expectations. Ann, a hospital administrator, and Cynthia, an educator, expressed similar experiences in overall satisfaction from different stakeholders. Ann stated, “this improves patient throughput, patient & staff satisfaction, and physician satisfaction.” Cynthia underscored that “Sonographer administration of UEA and IVs improves efficiency and all-around satisfaction for many stakeholders in healthcare systems.”

Samuel, a laboratory manager, approached sonographer administration of IVs and UEA from an operational standpoint. He suggested,

These skillsets ensure less time for the patient during the study with fewer number of images for the patients with a better quality, diagnostic test, which leads to improved patient satisfaction as well as reading physician’s job satisfaction. Additionally, sometimes sonographers need to pause their study and to come back later to finish their echo with UEA because at the first time the patient didn’t have any IV access to use, this is very inconvenient for both the sonographer and for the patient.

Quality

The following narrative by Erica, a laboratory director, provided a unique perspective on how the quality of our TTE improves uniquely due to sonographer administration of UEA:

The biggest change we have noted with sonographer administration is better visualization. The sonographers understand the physics of the contrast bubble and know how the rate of administration will impact the image. This gives them better control of the image quality. They control how fast or slow, how much, if you need a little (or a lot) more etc. They do not feel the pressure of holding up someone else who may be needed elsewhere so if the sonographer needs to take a few minutes longer to get the image and answer needed with the contrast it is not an issue.

Catherine, another laboratory manager, presented her perspective on the potential effects of sonographers prohibited from administering UEA and having to wait on other health care professionals to assist:

Because nurses are often busy with other patients, there are often delays in getting a nurse to administer UEAs, despite creating many processes to try to improve the workflow (such as doing an apical look before starting the exam to notify the RN early). These delays trickle down to other patients who are waiting to get an echo. I feel like the biggest danger in organizations that have frequent long delays is that UEAs will not be used when needed, as sonographers are trying to perform an expected high volume of studies and don’t feel like they have time to wait on a nurse. This puts the patient at risk for having important pathologies missed, such as thrombus or wall motion abnormalities. Missing pathology may lead to increased unnecessary downstream testing and, most importantly, may have a negative impact on patient morbidity and mortality.

Samuel opined on the unfortunate realities in the profession when it comes to the inability to administer UEA due to the lack of sonographer privileges to inject and having to wait on other staff members:

Sometimes, to avoid the delay requesting others to come & administer the UEA the sonographer end up not using UEA to save time and finishes the study anyway leading to a poor-quality study, or even sometimes a non-diagnostic study. Poor quality study without UEA images makes the reading physician less confident making their final conclusion, clinical decisions, and management. The poor quality or non-diagnostic echo-studies leads to higher number of repeat echo as well as other alternative diagnostic expensive tests such as CT.

When the answer is to sacrifice quality care, this likely provides a disservice to patients.

Conclusion

Patient throughput is one of many important KPIs that are tracked by health care executives. Some departments, especially the echocardiography laboratory, play a key role in ensuring this metric is met. One barrier is long lead times due to a lack of resources to administer UEA and start IVs. Sonographer UEA and IV administration is not only supported by clinical best practice and laboratory-accrediting agencies but has been empirically demonstrated to improve the efficiency of echocardiography laboratories and downstream health system patient care operations. As patient throughput is always a top priority of hospitals, echocardiography leaders can leverage current best practices and lend their knowledge/experience to senior leaders to overcome barriers to productivity and quality patient care.