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262
Fig. 15.23 UV disinfection equipment
J.T. Nomura and A.D. Nagdev
Newer ultraviolet light based HLD cleaning systems (Fig.15.23) may become
more commonplace soon [33]. They employ short wave UVC light in the 100–280nm
range, have short (2–10min) cleaning cycle, and provide HLD.These and other technological advances will allow clinicians a less cumbersome option for HLD, while
maintaining patient safety. Emerging data will allow clinicians greater options for
high-level disinfection, but current standards still recommend conventional practices.
Critical Devices
Critical devices are those that enter a sterile tissue or vasculature, and require sterilization. These items include surgical instruments and implantable cardiac devices.
Clinicians performing POC US will most commonly not be working with medical
devices that require critical sterilization.
Other Ultrasound Machine Elements
Careful attention should be paid to manufacturer instructions on cleaning of keyboards, machine, surface, probe holders, and monitors. While some germicidal
sprays may be used on the plastic surfaces, other areas may be permanently damaged by strong chemicals in the spray or wipe. However, probe holders in particular
should be cleaned as they accumulate dried gel and possibly bodily uids.
15 Ultrasound Safety andInfection Control
263
Ultrasound Gel asaSafety Issue
While US gel is discussed extensively in Chap. 14 (link), a brief discussion of ultrasound gel safety practices is synergistic with the safety issues with probe cleaning.
Ultrasound gel is water-based, and has been episodically associated with nosocomial infections [35, 36]. Recently the issue of when sterile US gel should be used
versus non-sterile gel has been explored by regulatory bodies [37–39].
POC US directors should consider creating policies for safe use of non-sterile
ultrasound gel (disposable bottles (Fig.15.24) or lling from large US reservoirs
with careful attention to lack of contact of the respective container openings), and
policies for use of sterile gel. Sterile gel (Fig.15.25) should be considered for all
Fig. 15.24 Prelled
bottles of US gel
Fig. 15.25 Sterile
lubricating gel packet
264
invasive procedures (external to the probe cover), US examinations on neonates, US
examinations on non-intact skin or fresh surgical sites, endocavitary or endoscopic
US procedures on internal mucous membranes, and other examinations of concern.
Non-sterile gel can be used for other ultrasound examinations so long the gel is
maintained per infection control guidelines. Gel warmers should only use dry heat
and be serviced per infection control policies of the institution.
J.T. Nomura and A.D. Nagdev
Summary
Bioeffects are possible with the use of diagnostic ultrasound and are related to a complex interplay of the tissues insonated, frequency, intensity, scanning mode, and dwell
time. Some of these parameters are under operator control. To adhere to the ALARA
principle, operators should be aware of and monitor ultrasound exposure as indicated
by the Thermal and Mechanical Indices. The concept of ultrasound bioeffects is only
one part of the risk-benet analysis in the emergent setting where the lack of information presents a clear danger to the patient and impacts clinical management.
Transducer maintenance should be a priority for all clinicians to ensure patient
safety. System upkeep involves fastidious cleaning for both the transducer and
ultrasound system. A clear departmental infection control protocol will ensure
patient safety, as well as detect early breaks in transducer surface integrity. When
performing examinations on intact non-mucosal surfaces, low-level disinfection
and use of non-sterile gel is adequate. When performing an ultrasound examination on non- intact skin we recommend using a transparent dressing cover over
the transducer. For endocavitary examinations, transesophageal echocardiography, or internal examinations, use of sterile gel on the exterior of the probe and
high-level disinfection is mandatory (via either the aide of hospital based sterile
processing or an internal highly organized departmental system). Guidelines
from transducer manufacturers in conjunction with the CDC can help dene current standards for HLD. Clinical sonographers should be knowledgeable in
regard to current disinfection and sterilization procedures to ensure infection
control and patient safety.
Pitfalls
1. Nonadherence to the ALARA principle.
2. Increasing the power output of an ultrasound system from manufacturer presets
without understanding the ODS and potential bioeffects.
3. Not utilizing the correct application preset with appropriate power, TI, and MI
for an examination.
4. Not having a standard protocol for both noninvasive and invasive probes.
15 Ultrasound Safety andInfection Control
265
5. Not having cleaning supplies on the machine or near the machine for POC use.
6. Not having provider and POC friendly logistics for invasive probe care.
7. Not setting responsibilities and accountability for machine and probe care.
8. Not having policies for use of non-sterile and sterile gel.
Key Recommendations
1. Identify, understand, and educate users about the ODS on your ultrasound
system.
2. Monitor and correct inappropriate use of MI and TI settings such as not utilizing
ocular presets on ocular ultrasound or spectral Doppler for fetal heart rate
measurements.
3. Create and provide cleaning protocols, logistics, and supplies for POC use.
4. When performing ultrasound examination on non-intact skin, cover the trans-
ducer with a clear adhesive dressing.
5. To ensure patient safety, a clearly dened process of HLD must be in place for
endocavitary and TEE transducer cleaning.
Acknowledgment Dr. J.Brian Fowlkes for his assistance with reviewing and editing the bioeffects data.
Dr. Andreas Dewitz for his donation of gures for the chapter.
References
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Institute of Ultrasound in Medicine; 2014, pp.1–61.
8. OBrien WD, Deng CX, Harris GR, etal. The risk of exposure to diagnostic ultrasound in post-
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9. Abramowicz JS, Barnett SB, Duck FA, Edmonds PD, Hynynen KH, Ziskin MC.Fetal thermal
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12. Stratmeyer ME, Greenleaf JF, Dalecki D, Salvesen KA.Fetal ultrasound mechanical effects.
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13. Sheiner E, Abramowicz JS.Clinical end users worldwide show poor knowledge regarding
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14. Bagley J, Thomas K, DiGiacinto D. Safety practices of sonographers and their knowl-
edge of the biologic effects of sonography. J Diagn Med Sonography. 2011;27:252–61.
doi:10.1177/8756479311424431.
15. Akhtar W, Arain MA, Ali A, etal. Ultrasound biosafety during pregnancy: what do operators
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2011;30(7):981–5.
16. Houston LE, Allsworth J, Macones GA.Ultrasound is safe… right?: resident and maternal-
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2011:1–1. http://www.aium.org/ofcialStatements/43.
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protocol. Minerva Anestesiol. 2009;75(5):313–7.
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15 Ultrasound Safety andInfection Control
31. Casalegno J-S, Le Bail CK, Eibach D, Valdeyron M-L, Lamblin G, Jacquemoud H, etal. High
risk HPV contamination of endocavity vaginal ultrasound probes: an underestimated route of
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Chapter 16
Ultrasound Quality Improvement
Patrick S. Hunt, Christopher David Wilbert, and Zachary T. Grambos
Objectives
• Dene the purpose of Ultrasound Quality Assurance and Improvement (QI)
• Provide an overview of Ultrasound Quality Assurance and Improvement
• Dene a practical and stepwise process for improvement of ultrasound quality
Introduction
Ultrasound quality assurance and improvement is the engine that drives a successful
clinical US program. Every department that uses clinical ultrasound should have an
integrated quality assurance and quality improvement plan (QI) [2, 27, 29]. While
the details of each QI system may differ from program to program, the primary
objectives of the program are to ensure a quality product, facilitate education,
improve both provider and departmental performance, and to help satisfy
credentialing pathways [2, 27].
P.S. Hunt, MD, MBA (*)
Department of Emergency Medicine, Palmetto Health Richland,
Columbia, SC, USA
e-mail: huntpat@sc.rr.com
C.D. Wilbert, MD • Z.T. Grambos, MD, FAAEM
Department of Emergency Medicine, St. Thomas Rutherford/Midtown Hospital,
Murfreesboro, TN, USA
e-mail: grambos1256@gmail.com
V. S. Tayal et al. (eds.), Ultrasound Program Management,
https://doi.org/10.1007/978-3-319-63143-1_16
269© Springer International Publishing AG 2018
270
P.S. Hunt et al.
It is the US director’s responsibility to develop, monitor, and revise the QI process [2]. QI programs include the processes as well as the hardware and software
that make these processes work. The process your program ultimately uses for QI
will depend greatly on the hardware and software system deployed.
The US director’s goals regarding QI are multifaceted. At a minimum they must
evaluate images that are submitted to ensure they satisfy the minimum imaging
requirements (gain/depth/focus) and conrm the images have been interpreted correctly. The director must also provide appropriate feedback to both develop good
practice and change detrimental practice. This can be done at the bedside in real
time or at a later time in person or electronically [27].
There are many options for QI systems currently on the market. When clinical
ultrasound programs began to develop, QI generally consisted of printed images and
logs. However, today there are complete digital solutions that help to integrate the QI
system to the workow of the ultrasound program. The system that works best for
each institution will vary depending on how robust the program is, the amount of
administrative and nancial support, as well as the type of machine and support from
IT.As cost for data storage and bandwidth have continued to decrease, options for
dynamic video review are now more available than ever. While dynamic video is
superior to static images, the increased cost, time and labor must be weighted when
determining which method of image review is ideal for each program [2, 15, 27].
Process ofQI
Often the QI process is developed in parallel with the credentialing process. During
this process a program should determine how they will handle scans completed by both
credentialed and non-credentialed sonographers with regard to QI.While most programs will review all scans by non-credentialed sonographers, programs must also
decide on the percentage of cases that will be selected for review from credentialed
sonographers. This can be a percentage of completed scans or a xed number of
scans per year depending on practice habits and prior training/credentialing for the
group [1, 2, 28].
It is to be expected that the QI process will look slightly different for every
department. Residency programs can expect a continual process given that new residents start every year and must be trained. In community programs the process may
require more work at the outset and then stabilize once all the members of the group
have been credentialed. However, there are ve key aspects of QI that should be
universal to all settings [2].
1. Images must be obtained and stored for review.
2. The sonographer must document their ndings for each study completed.
3. Images must be reviewed by the QI director and feedback given on both technical
and clinical grounds.
4. Feedback on images must be reviewed by the sonographer.
5. Data on the feedback given and the exams completed must be stored for later
review.
16 Ultrasound Quality Improvement
271
QA Data Flow
Feedback
Obtain Images
Ultrasonographer
QA Data Record
Fig. 16.1 An example QI owsheet showing the data ow in the QI process
Images and QA Data
are Reviewed
Images are Archived
These ve aspects of a QI program can be viewed as the ow diagram below
(Fig.16.1)
We will now look at each of these topics in more detail.
Images Must BeObtained andStored forReview
Given the variety of ultrasound systems and methods of capturing and storing ultrasound images it is not practical to list every option (Chaps. 17 and 18).
It is preferred that once the images are captured that they be transferred to an
external archive system for review and storage. While QI can by directly completed
on the ultrasound machine, ultimately the machines are not designed for long-term
storage and date retrieval. Depending on the systems in place a program may prefer
to use still images or video or both for review [1, 2].
The ideal image ow process allows for uploading of images and clips from the
ultrasound machine directly to the EMR, to a QI system, to the ultrasound director,
and back to the performing sonographer in a HIPAA compliant manner [1, 2].
272
Patient/ exam demographics:
Primary person obtaining/ interpreting images: _________________
Secondary person obtaining/ interpreting images: ________________
Additional person(s) obtaining/ interpreting images: _________________
The Sonologist Must Document Their Findings forEach Study
Completed
After completion of an ultrasound study a sonographer should complete a US
report form that corresponds with their documentation of the ndings that go into
the chart. This sheet should also allow the sonographer to self-reect and comment on the adequacy of their ndings. This sheet should allow the sonographer
to directly answer the yes/no questions regarding ndings from their examination. On the US report forms, the sonographer should identify the indication for
the exam as well as which views they were able to obtain. The sonographer
should also comment on their interpretation of the images [1, 2, 27]. These forms
can either be in paper format or computerized. Some workow solutions allow
these forms to be lled out on the machine and then submitted with the exam,
while others allow the user to complete the forms on the actual QI application.
The ACEP Ultrasound Standard Reporting Guidelines [31] suggest the following
data elements be included in all studies (Fig.16.2).
Below is a simple paper-based QI form (Fig.16.3).
Patient name: _______________________________
Patient gender: M F
DOB: ___ / ___ / ___
MR#: _____________________
Bar Code/Patient Identifier: ____________________
Hosptial Name: ____________________
Date and time of exam: ___ / ___ / ___
Exam type:
Clinical category:
Initial exam
Repeat exam
P.S. Hunt et al.
Diagnostic
Educational
Procedural
Resuscitative
Symptom based
Therapeutic
Unknown/other
Fig. 16.2 An example of a standard patient demographic form for a limited point-of-care ultrasound examination