Is the Radiologist In-house Today? Optimizing Ultrasound in the Age of Teleradiology

My dilemma: I am a radiologist at a pediatric hospital with multiple satellite ultrasound sites. Though most ultrasounds can be performed at the satellites, a small subset of advanced ultrasounds are only scheduled at our main hospital where a radiologist is available to scan. Recently, a family expected to schedule a complex scan at our satellite location near their home, so they understandably had questions when they were told to drive 2 hours to the main hospital instead. Is the quality of ultrasound services different? Would the radiologist scan if they traveled to our main hospital? Could they get the same study at a local non-pediatric, small community imaging center? They wanted answers! It was challenging to explain why it was worth their time to make such a long drive to get a “better” study. This led me to ask, what is the right answer at a time when teleradiology is commonplace?

Challenges and Potential Solutions of Teleradiology in Ultrasound

1. Retaining Clinical Context

Problem: Typically, radiologists interpret exams solely based on the images. However, additional patient history that was not in the original order and physical exam findings can be of tremendous value. For example, a sonographer might image a cutaneous vascular lesion compatible with a hemangioma. If a pediatric radiologist were present to ask additional questions, they would learn that the hemangioma only just appeared in the 2-month-old patient a couple of weeks ago, is rapidly growing, and is one of multiple cutaneous lesions concerning for infantile hemangiomas. Additionally, they could look at the color of the lesion and see if it blanches upon compression. Such additional historical and physical information warrants a recommendation in the ultrasound report for an abdominal ultrasound to assess for hepatic hemangioma involvement. If this clinical context is lost, then the full value and specificity of the superficial ultrasound could be lost as well.

Solution: If a radiologist is not present in-person for scanning or image review, the sonographer must know what questions to ask and what additional information might be helpful to the radiologist. Sonographers can add extra history and physical exam findings directly into the PACS technician notes, via institutional communication tools like Microsoft Teams, or on scanned worksheets. A radiologist might even talk directly with the family over the phone or ask the sonographer to include a picture of the patient in the medical record of the patient.

2. Optimizing Image Quality

Problem: The ability of the radiologist to provide image quality control is diminished when working remotely. There is more responsibility on the sonographer to optimize imaging and to recognize pitfalls independently. To this point, for example, consider a sonographer imaging a joint with concern for effusion and septic arthritis. However, she may not realize that the gain was set too low. Cartilage would look anechoic like joint fluid instead of the normal speckled hypoechoic appearance in cases such as this. Therefore, the images would look like there was a joint effusion when in fact there was no joint effusion at all.

Solution: Radiologists must provide feedback, ideally in real time, to sonographers. Standardized protocols, as well as in-person on-the-job training with experienced sonographers and radiologists, are also needed for sonographers to function independently at remote sites. In this case, the sonographer should ask a radiologist to review the images in real time so they can identify such mistakes, affording the sonographer opportunity to rescan the patient before they left.

3. Understanding Variability in Practices Between Institutions

Problem: Teleradiologists read for multiple sites, all with unique workflows and varying levels of sonography expertise. As a pediatric radiologist, I read pediatric studies from both pediatric and adult hospitals. There is a wide variety in the experience of the sonographers, as I learned recently when I opened a pyloric ultrasound exam only to realize that the sonographer had incorrectly imaged the gastroesophageal junction instead of the pylorus. I subsequently learned that this site did not have pediatric sonographers or pediatric sonography training.

An image of the gastroesophageal (GE) junction instead of the pylorus. The arrow points to the GE junction with gastroesophageal reflux during the exam, which can be mistaken for transit through a normal pylorus. Proximity to the spine (S) and the aorta (A) confirms the gastroesophageal junction is being imaged.

Solution: As a radiology team, we must provide additional resources to support sonographers if they are to assume more responsibility. At my institution, radiologists are available for questions 24 hours a day, 7 days a week to sonographers before, during, and after image acquisition. Additionally, we provide a free, CME-accredited, internet-based didactic series for optimizing pediatric imaging technique. We also solicit topic ideas from our affiliate institutions so that we can elevate the quality of imaging at all sites. When one person or one site has a particular ultrasound question, there are often many others with the same struggle.

After feedback and instruction between the radiologist and the sonographer, a sonographer can correctly identify a normal pylorus (arrow), which is confirmed by the adjacent duodenal bulb (D) and gallbladder (G).

In conclusion, teleradiology in ultrasound is here to stay. Our responsibility going forward is to optimize it, support our sonographers as they become more independent, and understand that while we as radiologists may not physically be there, there are many technological advances that we can leverage to optimize imaging.

Dr Lauren May, MD, is a pediatric radiologist at Nemours Children’s Health in Wilmington, DE. Her primary interests are in ultrasound and medical education. She can be contacted by email, Lauren.May@nemours.org.

Interested in reading more about ultrasound in pediatrics? Check out these posts from the Scan:

The Excitement of New Ultrasound Technologies and Their Effects on Imaging-Guided Interventions

Recent advancements in ultrasound technologies have generated excitement in the field of ultrasound-guided intervention. For me, an interventional radiologist, these developments create new potential to perform needed procedures and a complementary approach to addressing our patients’ complex medical conditions. Further, benefits from these technologies include enabling us to achieve better patient outcomes, improve patient satisfaction, gain operational efficiencies, and improve stake holder’s satisfaction.azar_nami

The new technologies to which I’m referring are ultrasound contrast and ultrasound fusion. Ultrasound fusion is an element of artificial intelligence that combines the anatomic details of cross-sectional imaging like CT scan, PET scan, and MRI with the power of real-time ultrasound and is gaining more acceptance and popularity in medicine. Similar to a car’s GPS, ultrasound fusion helps a user find something. The powerful tool enables the operator to find lesions, which normally are difficult or even impossible to find on standard ultrasound. Needle navigation in the form of virtual tracking is a bonus that identifies needle location even when it is obscured by air or bone. It’s also a great teaching tool for inexperienced physicians who are interested in interventional radiology.

Ultrasound contrast is also emerging as a powerful tool in the field of interventional radiology. It enables the operator to better visualize a lesion and characterize the lesion and surrounding tissue. Now, we also can perform an ultrasound contrast sinogram to assess any cavity or catheter location, which opens new horizons in the field of ultrasound intervention, mainly in pediatric intervention.

An additional benefit for ultrasound contrast that it can be given without worrying about renal injury. This is very valuable when it comes to avoiding the toxic effect of iodinated contrast, especially in renal transplant intervention. Also, its very sensitivity to assess bleeding when compared with that of Doppler ultrasound. This technology allows us to discharge our patients home earlier after procedures when the contrast study is negative.

This is a very exciting time in the field of interventional radiology (IR). So many procedures that we could not perform using real-time ultrasound in the past now can be safely done with only ultrasound. Our patients appreciate how convenient it is. The procedures are done quickly, without the need to move the patient from their bed onto a stiff CT scan table. The lack of ionizing radiation in IR is also an attractive concept to the patient (mainly pediatric and/or pregnant), the clinician, and our IR staff.

Our institution is very supportive of utilizing advanced ultrasound technologies, as ultrasound allows us to gain operational efficiencies and is a more cost-effective alternative to CT-guided procedures. Operational efficiencies are gained by doing interventional cases portably with ultrasound, thus allowing the interventional CT suite to be utilized for diagnostic exams, which bring additional revenue to the institution. The ordering clinicians are also cognizant of radiation dose reduction, so providing an alternative to CT-guided procedures appeals to them.

Even though the implementation of contrast-enhanced ultrasound and fusion has been slower in the United States when compared with our colleagues abroad, it has brought a lot of excitement to my colleagues and me in interventional radiology. Like any new technology, the more we use, the more we appreciate its value. I predict they will become the new norm in daily practice. These advancements will continue to evolve and be an essential part of medicine.

 

Interested in reading more about contrast ultrasound? Check out the following posts from the Scan:

 

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Nami Azar, MD, MBA, is an Associate Professor of Radiology in the Department of Radiology at University Hospitals of Cleveland Medical Center in Ohio.

The Expanding Scope and Diagnostic Capabilities of Vascular Ultrasound

Peripheral Vascular Disease (PVD) in the United States affects approximately 8 million to 12 million patients a year; some experts in the field believe this number may be underestimated. The disease is associated with significant cardiovascular morbidity and mortality, with a high rate of fatal and non-fatal cardiovascular events, such as myocardial infarction, stroke, renal failure, limb amputations, abdominal aortic aneurysms, pulmonary embolus, and progressive ischemic end-organ dysfunction. The reduction in quality of life from global vasculopathy in many patients can thus be significant.

George Berdejo

George Berdejo, BA, RVT, FSVU

Prompt and accurate diagnosis of these disease processes is of utmost importance and high-quality vascular ultrasound plays an essential role. In fact, vascular ultrasound and the role of the vascular ultrasound professional has evolved and expanded rapidly and is at the core of modern vascular disease care in the United States and is emerging around the world.

Vascular ultrasound can be seen at the intersection of imaging, physiology, physiopathology, interventional medicine, and surgery and is utilized widely by healthcare providers from many specialties, including but not limited to vascular technologists and other subspecialty sonographers, vascular surgeons, vascular interventional radiologists, vascular medicine physicians, cardiologists, radiologists, and other vascular specialists with an interest in vascular disease.

At the core of any thriving vascular surgery practice is high-quality vascular ultrasound imaging. Duplex vascular ultrasound (DU) is used to evaluate all of the major vascular beds outside of the heart. The use of duplex ultrasonography for the study of vascular disease is firmly established but is also rapidly expanding. Thanks to continued improvements in the performance of ultrasound devices, vascular ultrasound can be used to perform a greater range of assessments in a noninvasive manner in some cases excluding the need for more invasive, expensive, contrast-based imaging modalities.

The recent proliferation of “less and minimally invasive” endovascular options currently available and offered to patients with various vascular disease processes has mandated better, less invasive, preferably noninvasive methods, to diagnose the disease that is being treated. Advances in technology have increased the diagnostic capabilities of vascular ultrasound and its role not only in diagnosis but also in planning and performing interventions and in patient follow-up and surveillance after intervention. Indeed, vascular ultrasound has become the standard “go-to” diagnostic imaging technique prior to most vascular interventions and has certainly emerged as the imaging technique of choice for following patients after most vascular interventions.

Endograft Evaluation. Duplex vascular ultrasound has emerged as the standard of care for surveillance after endovascular repair of abdominal aortic aneurysms. A major complication of this procedure is endoleak (persistent or recurrent flow within and pressurization of the residual aneurysm sac). This results in persistent risk of aneurysm rupture and potential death. Ultrasound assessment allows imaging and Doppler interrogation of deep structures and low-flow detection capabilities needed in patients with low-volume/low-velocity endoleak. Duplex vascular ultrasound, in good hands, has supplanted computed tomographic angiography as the primary surveillance technique in these patients. In addition, DU allows for the ability to resolve the deep structures of the abdomen to measure aneurysm sac size.

Hemodialysis Access Mapping and Surveillance. Higher frequency, better resolution, smaller footprint transducers that are currently available provide the high-resolution images that are needed to assess the veins and arteries of the upper extremity in order to plan the optimal access sites and also to provide the surveillance often needed postoperatively in order to maximize the life of the access and the quality of life for the dialysis patient.

Lower Extremity Vein Reflux Testing. Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. An estimated 40 percent of people in the United States have CVI. The seriousness of CVI, along with the complexities of treatment, increase as the disease progresses. Duplex ultrasound is integral in the evaluation, treatment and follow-up of these patients. Absent the appropriate equipment, the initial duplex reflux scan is among the most physically challenging, labor-intensive scans performed in vascular ultrasound. These exams account for 20%–25% of all the ultrasound scans performed in our practice.

Lower Extremity Arterial Mapping. Our philosophy regarding the practical evaluation of patients with known peripheral arterial disease who require intervention includes the use of duplex ultrasound as the primary first-line imaging modality precluding the use of more expensive, invasive, and nephrotoxic diagnostic arteriography in most patients.

Vascular ultrasound is now being used by increasing numbers of specialists who are employing both traditional and newer cutting-edge methods and techniques to improve patient care and management and who are dedicated to the delivery of quality care to their patients.

The future is bright for both vascular ultrasound and the vascular sonography professional!

 

Do you have any tips for performing vascular ultrasound? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

 

 

George Berdejo, BA, RVT, FSVU, is Director of Vascular Ultrasound Outpatient Services at White Plains Hospital in White Plains, New York. He is the Chair of the AVIDsymposium (www.AVIDsymposium.org) and is the current Chair of the Cardiovascular Community of the AIUM.

Who Owns POCUS?

The debate over point-of-care ultrasound (POCUS) governance was rekindled recently when the Canadian Association of Radiologists published a POCUS position statement. The statement rankled some prominent POCUS leaders who hotly debated the statement’s merit via Twitter. This is a debate certainly worth having, but it is hardly a new one. Some likened it to the “turf battles” that emergency physicians successfully overcame well over a decade ago. To be clear, there is a governance problem, largely the result of technology/machine availability outpacing the development of POCUS training, credentialing, and employment guidelines and standards. Referring to the POCUS realm as the “wild, wild west” as Zwank and colleagues did, is somewhat apropos. But to develop the best solutions, we must first define the problem.empty conference room

The problem – “who”…or “how”? The statement seems to frame the problem around who is best qualified to govern POCUS. Most would agree that radiologists are imaging experts with the most training in interpreting ultrasound. But if using Bahner’s popular I-AIM framework, the image interpretation that most radiologists practice is only one aspect of POCUS. POCUS is a separate entity from consultative ultrasound. Clinician-performed at the point of care, POCUS has different goals, primary of which is to answer focused questions that guide and expedite proper definitive care. Its versatility allows it to be employed well outside of the domain of traditional diagnostic ultrasound, enhancing the safety of bedside procedures, improving the physical exam, and directing further testing & timely care. But when did you last see a radiologist at the bedside of a patient outside of the interventional radiology (IR) suite…one willing to personally “clinically correlate” the image findings rather than just include the phrase in their report?

Rhetorical questions aside, if we lived in a perfect and resource-rich world, we might all be able to dedicate a full year to the performance of ultrasound, or even better, radiologists would come to the bedside to perform the exam within minutes of the order. But we don’t. Fortunately, there’s already quite a bit of data suggesting that the requisite training for non-radiologists to safely employ POCUS isn’t as extensive as some might have us think. Additionally, the American Medical Association’s resolution (AMA HR. 802) long ago recommended that training and education standards for the employment of ultrasound be developed by each physician’s respective specialty society, effectively recognizing the importance of self-governance of this modality. I would argue that the problem, therefore, centers less around the “who” and more around the “how” of governance.

Practical solutions – Interprofessional collaboration is key: The desire to ensure patient safety is the common ground here. We all want to ensure POCUS is safely employed, but how do we best do so? Training and utilization standards can ensure this, but overly restrictive standards can create unnecessary barriers that limit POCUS employment and prevent patients from reaping the demonstrated benefits of POCUS. The radiology specialty undoubtedly has a wealth of valuable expertise to contribute to this debate. Their well-established and validated training and imaging standards could well-serve as a framework upon which POCUS standards could be built and certainly makes them deserving of a seat at the table. But given how and where POCUS is employed, surely the clinicians doing so deserve a seat also. To suggest that “non-imagers” are incapable of developing rigorous, evidence-based training and utilization standards that allow for the safe employment of POCUS simply isn’t fair, nor is it well-substantiated, if we’re using emergency physicians as an example.

Furthermore, unilaterally developed statements such as this are what drive us to remain in our respective silos and can hinder the progress still required in this realm. The solution is a collaborative one, considerate and respectful of the diagnostic ultrasound knowledge and experience of imaging experts, the setting in which POCUS is employed, and the variety of ways clinicians can capably employ it to enhance patient care at the bedside. This collaborative concept isn’t mine, nor is it new, thankfully (more thoughtful discourse on the topic can be found here and here). It’s time that we recognize and leverage the talent that each discipline can offer toward the safe, effective employment of POCUS. It’s time to embrace interdisciplinary and interprofessional collaboration.

The inherent value of POCUS lies in its ability to transcend clinical specialties, settings, and practice scopes. It is distinctly different from consultative ultrasound and therefore shouldn’t be bound by standards created long before POCUS existed. It is a valuable, patient-centered adjunct that demands new standards that are 1) considerate of both its versatility and the multitude of settings in which it can be employed, 2) considerate of the experience of those who have previously employed US, and 3) created by all those actively employing it to enhance the care they directly provide at the bedside. But rest assured, ultrasound no longer belongs only to radiologists, or any one specialty/profession for that matter, and that’s a good thing.

 

Have you integrated a collaboratively developed approach to POCUS training and/or utilization?  Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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Jonathan Monti, DSc, PA-C, RDMS, is an Associate Professor of the US Army / Baylor EMPA Residency Program at Madigan Army Medical Center and President of the Society of Point-of-Care Ultrasound (SPOCUS). He is actively engaged in research that assesses POCUS training and its unconventional employment by a myriad of users.