Top Mistakes in Vascular Testing & 10 Simple Things to Improve Quality - SD

Introduction

Hello, my name is Marge Hutchinson.
I'm the director of Vascular Testing Accreditation
for the Intersocietal Accreditation Commission.
Today I'm going to talk about top mistakes in vascular
testing, simple ways
to improve quality in the vascular laboratory.

Top 10 Simple Ways to Improve Quality in the Vascular Laboratory

Hello, welcome to this discussion.
Today we're going to talk about simple things
to improve quality in the laboratory.
I've broken it down to 10,
and these are things that you can do in your laboratory
without any big, any great software additions,
anything that will not require huge amounts of money
or huge amounts of effort.
When you go into a, to do a study every day,
every patient, you need to think about quality.
You need to treat that patient
as though it is your only patient today,
because you will not ever have a second chance
to repeat the study.
You'll hardly ever have a physician say to their patient
that, well, the first study wasn't that great,
so I want you to go in and have a second one.
You only get one chance
to do a good quality study on everybody.

1. Clean Up Your Space

And the first thing you can do to help the quality
of your work is to clean up your space.
You want to be sure that everything is,
in its place.
You don't want all kinds of tangled things.
You want everything clean.
You want the patient to have a good experience,
and they will have more confidence in you if your,
place presents properly.
You wanna be sure that,
all of these,
miscellaneous items are,
out of the patient's view.
And, be sure that,
in between the patients,
you clean up all the remnants from the previous patient.

2. Get Comfortable

The second thing you need to do is get comfortable.
You don't want to be reaching across,
the entire machine
and the patient to find certain
buttons that you need to know.
Take time, position yourself
and your patient comfortably so
that you can reach the tools you need to document the study.

3. Follow Your Protocol

The third thing you wanna do is follow your protocol.
Your technical director, your medical director,
and many experts in the field have have worked long
and hard to give you good protocols.
And if you follow the protocol every single time,
every single patient, you will have all the images you need.
You will have all the measurements you need,
and you won't have to go back or,
or, call the patient back for missing,
images.
So following the protocol gets,
gets you a good study at the end of the day.

4. Know Your Machine

The fourth thing is,
know your machine comes
with many knobs and many buttons and many slider bars
and all kinds of things, but if you don't use them
and you don't tweak them, your image will not be
as good as it could be.
So don't be afraid to,
flip things, turn things,
adjust things.
You can always turn them back if you realize
that the image is not of good quality.
But don't be afraid to use the,
use the tools given to you.
And if you're really uncertain about what,
one thing does, you certainly have the right
and the expectation to call your applications people,
your equipment manufacturer,
and learn what all of those tools are there for
and how you can adjust them to improve your image quality.

5. Take Your Time

The fifth,
simple thing is to take your time.
Anytime you take your time, you improve your accuracy.
Don't rush, don't hurry.
At the end of the day, it's not
how fast you did your studies,
but how good you did your studies.
And so quality is the key,
but in order for that,
to be,
accurate, you have
to slow down and take your time.

6. Check Your Work

When you're done, you always wanna check your work,
make sure that,
the images equal,
the impressions or the findings.
You always wanna be sure that you have image
that documents,
that documents
what you think you have found.
Don't cut corners. Don't,
don't skip images.
Be sure you have all the required documentation.

7. Proof Your Final Reports

Now, this is a poor patient who's gotten,
this far,
into the, into the system.
And,
the problem is, is nobody proved the final report.
And so,
something may be wrong.
So you always want to take time
to look at your final reports.
You may wanna pull 10 a month,
and just, just sit down
and read them because,
inevitably,
someone will,
interchange the right for the left.
They will interchange,
the numbers and the velocities,
and it will look as though they have more,
pathology than they do.
So always, always, always incorporate some type
of a proofing system into your final reports.

8. Teamwork

Number eight is the key to any success is teamwork.
And many times we find ourselves in a room,
with the machine and the patient,
and we're struggling to find everything we need.
But don't forget that you have other colleagues who may,
who, who may be able to help you
with the images that you find.
They may be able to help you run the machine.
And don't forget that the patient is a wealth
of information about their own healthcare.
And so include the patient in your fact finding missions.
Always talk to them, figure out what their history is,
figure out if they've had the test done
before, what the findings were.
They can have a lot of information,
that will help you as you proceed through your study.

9. Review Before Patient Leaves

And then, of course, before you,
finish for the day,
you always wanna look at what you have,
look at your case study, look at your images,
make sure it's a complete study
before you let your patient go.
And be sure you have everything you need
to give the physician the required documentation
to make an accurate interpretation.

10. Peer Review

Number nine outta 10 is peer review.
You can,
help each other
by reviewing each other's cases.
Now, of course, you wanna do this in a constructive manner,
not in a punitive manner,
but this will all help educate everyone on different areas
where someone may have done
something a little bit different.
You can always help people improve their scanning technique,
improve their interpretation technique
by looking what's happened in the past, evaluating it
and giving your expert opinion.

Accreditation

And lastly, although this is not,
the simple way to,
improve your quality, it certainly,
it certainly is,
well worth the effort
and it is,
going through accreditation.
What accreditation does is it,
it forces you to review all
of your,
laboratory functions,
your medical staff,
your technical staff, all of your policies, your procedures,
your cases, and it helps you to,
raise the bar for your lab.
So once you become accredited, you have a certain level
of quality, and then you can work for the rest of the time
striving to raise the bar and improve your quality.
And,
we also,
give you,
these little door clings
so that you can advertise to your patients
that you are a quality lab.
And,
that is what accreditation stands for, is,
improving your quality.
Thank you very much for,
participating in this,
lecture Top Mistakes in vascular testing.

Orientation to Changes at the IAC in 2012

First of all, let me do a little bit,
of,
orientation to the changes
that have happened at the IAC over the past few months here
in 2012.
You are very familiar with the acronym IAC L,
the little colored Logos.
However, in 2012,
we have gone through a rebranding,
situation and all of that has changed.
And now you will notice that,
the new logo is,
that
that is appearing here We are now the vascular
testing division.
IAC L is,
taking a back seat to that.
And at some point in the future,
the acronym will actually go away, the new colors for IAC
that you will appreciate.
As you look through our website
and all of our current documentation, again, you see
that IAC L has,
taken the caboose to the picture there.
And,
as you move forward
with your accreditation process, you will receive new logos
that will appear like this.
And we will ask you as time,
progresses
to change your old logos over
to the new vascular testing logo.
You will see that,
all of the,
divisions in the IAC,
also have gone through this,
same process.
So all of us have lost our acronyms,
and,
we are now all,
different divisions under
the one,
IAC name.

Physiologic Testing

Now as we,
move forward into the,
lecture,
the first thing we're gonna talk about is
physiologic testing.
And I will tell you that all of the cases
that I talk about today have come directly from
applicant laboratories.
We see here that,
on the first case study
that the ABIs are relatively normal,
1.03 on the right, 1.22 on the right,
and on the left, 1.24 and 1.20.
So,
based on this initial,
exam we file,
we do believe that the,
arterial flow is normal.
However, when we look at the waveforms, we do appreciate
that the waveforms do not support,
normal ABI.
And the interesting thing is, is that approximately,
in the common femoral vein, in the common femoral artery,
they do appear normal.
And,
although not of great quality,
the lower
DP image,
does appear to be phasic as well.
So the point of it is, is that when you see normal segment,
normal segmental pressures
and normal ABI, you should strive
to have normal waveforms.
And it is exactly this information that gets sent
to the physician, and he
or she has a difficult time,
with interpretation of,
because the waveforms appear to be suboptimal.

Now, in the next example, this is the exact same laboratory,
but different patients.
And in one patient on the right,
the ABI was 0.71,
and,
the left was 0.75.
The next patient also had a 0.71 ABI.
However, you see a pretty significant change in the way the
wave forms appear.
And the same is true for the left.
The first patient was 0.75. The second one is 0.7.
One would expect that regardless of the patient, that
waveforms would reflect,
pretty similar
because the ABIs are pretty similar.
So, so this is the responsibility of the sonographer
and the technologist to be sure
that when you're giving your,
interpreting physician the data
that the data is correct and accurate.
So when you see a discrepancy like this,
it is your responsibility to go back to the patient
and repeat the waveforms.
Whether they should be normal or abnormal.
0.71 should equal the same thing pretty
much across the board.

Now, the next physiologic study, we look at,
the DP
and the pt,
on the right,
ABI is 0.69
and 0.97.
And on the left,
there's only one and it is 0.86,
and it is interpreted as normal ABI in the right
with mild decrease on the left.
However, you look at those wave forms,
and they do not reflect relatively,
mild stenosis.
Certainly the proximal wave forms appear worse
than the distal ones.
However, the,
the top,
two on both sides bilaterally appear,
incredibly
non-diagnostic and do not reflect,
the findings of the pressures.
So again,
when you're submitting a study
to the physician for interpretation, this clearly does not
represent,
the waveforms clearly do not represent
what we, what the ABIs do.
So again, this is,
a technical issue
that must be corrected before the patient leaves and
before the study goes to the physician,

an upper extremity study,
and you see on the left, the waveforms are,
phasic.
They look pretty nice. The pressures are pretty
much,
the same.
There's not much disease going on on the right,
however, you see that the proximal
waveforms are not too bad.
But as you move distally, axillary, brachial radial, those,
wave forms begin to deteriorate a little bit.
We do not,
truly appreciate a great change in the
pressures bilaterally.
And this interpretation read abnormal left.
And I'm just going to,
backtrack a little bit
and again, reiterate
that the left wave forms are not the issue.
They are the right. And so this, this,
is an interpretation error,
in that,
the physician has inadvertently reported the wrong arm
as being the abnormal one.
And, and we see this regularly,
where,
wrong sides are reported.
The documentation does not support the
interpretation, that sort of thing.
So there needs to be some type of a watchdog situation
where these are pulled,
on an on occasion,
you say once a month or so, you pull 10 or so studies
and you review them for final report accuracy.

Gray Scale Ultrasound

Now, we'll talk a little bit about gray scale ultrasound.
The biggest thing you can do
to help your interpreting physician is to put the vessels,
in the center of the image.
And especially on venous studies,
when you're actually compressing that vessel, when you,
push on these vessels, they're going to slide off
to the side of the image
and the physician is not going to see them.
So you wanna center your vessels,
you wanna do your compressions directly down,
and you do not want to push the vessels,
off to the side.
Another important aspect here is to use your focus zones,
move those things around.
Don't be afraid to adjust them
and help improve the image so that,
the physician can see without a doubt
that the vessel is patent.
A lot of people,
think that,
by optimizing their image,
we mean to put color on it.
And, and all color does is give you a
little bit of variation.
In, in the image,
you really still don't know what you're looking at.
But it does, it does draw your eye to,
to a certain section.
However, as you can see, every one of these images is,
relatively non-diagnostic.
And what you need to do is tweak your image,
clean up your gains, use your focus zones, use whatever,
knobs or,
or anything that your equipment has to,
to improve your image, to, to improve your quality.
You wanna be able to see the walls of the vessels,
and then you won't be mistaking,
plaque,
for noise and that sort of thing.
We get some images at the IAC
and the case studies that look like this.
Oftentimes they're labeled,
but even the labeling does not help us
identify what the vessel is.
So again, you need to tweak your image
to the best of your ability.
You always want to give,
the physician,
the most accurate information you can,
because at the end of the day, all he
or she has to,
use to interpret the study is exactly
what you have given them.
So if you give them,
bad non-diagnostic images,
chances are the interpretation is going to be vague
or,
may even be inaccurate.

Compression Technique

When you're doing compression technique, it is,
absolutely critical to get complete compression
of a vein in order to determine whether it
is thrombo or not.
And,
this can be a technical issue.
You want to do complete compression
wall to wall compression.
You wanna be sure that the vessel stays
in the center of the screen.
You wanna do a compression directly down on top
of the vessel, not from the side and that sort of thing.
So when you're trying to document compression, you need
to be absolutely complete compression.

Spectral Doppler

A little bit about,
spectral doppler
with your ultrasound, you'll see that,
this is a pretty good image at the top part of the screen.
However, when you zero in on the actual,
sample volume,
you see it appears to be outside of the vessel.
And so you wanna be very specific about where you place
that sample volume.
And of course, when you,
use your calipers
to measure the peak velocity, you do see that,
the,
cursor is at the peak,
but it's the peak of the image, not the peak
of the waveform.
And so that becomes an inaccurate,
in an inaccurate measurement.
And on the, on the second,
waveform there,
you can't even, you can't even see as much of a peak
as you do in the first one.
And so,
that is critical to accurate interpretation,
of course, is,
obviously demonstrating the peak
of the waveform.
Now, here's a very nice clear image which,
you see the exact,
envelope of the waveform.
However, for whatever reason,
the caliper falls about halfway down the peak systolic,
velocity there.
And so even when you have good images,
you have to slow down.
You have to take your time and pay attention
and appreciate that,
the,
cursor
or the caliper may not be where you think it is.
So you have to look at what you're doing,
and you have to take your time to be sure
that the calipers are placed in the proper area
for accurate measurements.

Color Doppler

A little bit about color.
Now, don't be afraid to change your frequencies.
Move your color around,
your color.
Frequency can be decreased.
You'll see a lot better,
color flow with that.
A lot of people are afraid to,
change their,
their settings on their machines,
but they're there for your use to optimize your images.
Don't be afraid. If you tweak it too far to one side,
you can always tweak it back.
So,
use all of the tools
that your equipment,
has for you.
The color box is critical
to getting the image,
properly.
Obviously,
your color box is angled in the direction
of your flow, and in this situation,
it is angled against the direction of flow.
So that becomes a very non-diagnostic image.
You cannot see,
you cannot see,
a much color flow at all.
Then when you angle it at 90 degrees,
you do pick up a little bit better image.
However, when you angle it correctly to the opposite,
the opposite angle in the direction of flow,
you see the vessel fills very nicely
and becomes a very diagnostic image.
And you can put your spectral in there and,
and get a very nice,
envelope.
So,
I have,
put all three of them up there so
that you can appreciate a side by side image of
how important it is to,
angle your color box in the proper angle.
Now, even though color is a good thing, in some pillow,
in some places, when you have too much
color, it's a problem.
So you have to turn down your gain,
because here we have way too much color, way too much gain,
and you cannot even see the vessel.
You don't know what, you don't even know
what you're looking at in this image.
So,
too much of a good thing,
is not good.

Angle Correction

A 60 degree angle correction is absolutely,
critical
to getting,
proper,
peak systolic velocities.
And so we've taken the same patient, the exact same image,
and we have just,
simply moved the angle around.
So on the first image, we have a 19 degree angle,
and our peak systolic velocity is 82.
We,
increase it a little bit to 36,
and our velocity jumps up pretty good to 96.
When we go over the 60 degree,
angle at 69 degrees,
the peak s systolic velocity is now two 17.
And when you go way up above at 76 degrees,
your peak systolic velocity is 3 22.
So the angle correction is critical,
to getting accurate measurements.
The true technical way to do this,
the most accurate way would be a 56 degree angle
where you get a 1 39,
velocity.
And this is,
simply a image of, of the,
all the different velocity changes there.
And,
you can see how they go all the way from 82
to 3 22, the same patient, same area of the vessel,
same pathology, but based on a very simple,
technical maneuver.
The velocity can change pretty significantly.
And the accurate one, of course, 56 degrees,
139 centimeters per second.

Probe Selection

Probe selection.
We certainly do have designated probes
and presets on our machine.
And,
that is, is all determined
by the manufacturer of the machine.
However,
if you are doing a study with the,
appropriate probe
and you do not see what you are looking for,
or you do not see anything, it is certainly
absolutely perfectly okay to change probes.
Now you have to document that you've changed your probe.
You may not get all the information that you normally would
with your,
with the, with the correct probe.
However, you do get to see the pathology this way.
So if you have,
two or three probes on your machine
and you don't see it, go ahead and switch 'em out.
Use whatever tools you have at your
disposal to get the image.
And as long as you tell your doctor what you've done
and document that on your final report, nobody's gonna care
how you got the image as long as you got it accurately.

Doppler Sample Placement

Now, a little bit about,
doppler sample placement.
You wanna be absolutely certain that the sample volume is
inside the vessel, and whether you correct it to walls
or flow, that's totally up to you and your policy.
However, you do want to be sure
that the sample volume is in the flow.

Summary

So my summary image here is,
a very nice,
carotid study, and we have all
of the information here that we need.
We have a very good clean,
image on top.
We have a very good clean spectrum.
You'll always want to properly,
annotate your vessel.
And,
you want to be able to say what side you're on,
and you wanna be able to say where, what vessel you're in
and where you're at in that vessel.
And you wanna change this for every different segment
as you move forward in your study.
You cannot,
leave the proximal right ICA on there,
even when you're moving forward
and when you're changing sides.
So you wanna be absolutely accurate.
Take your time to take the old annotation off
and the new annotation,
put back on.
The second thing you wanna do
to get a good study is you wanna angle correct your boxes.
We've talked,
as we've talked
before, you wanna be sure your sample
volume is,
either,
parallel and,
to flow or walls.
And that is the angle correction.
And it will tell you on the side of the screen
or somewhere on your screen what your angle is.
You can keep it at 60,
but then you have to heel toe the probe in order
to get the vessel angled properly.
Or you can adjust that 60 all the way down
to 45 if you need to.
So you always wanna be sure
that your angle is appropriate according to
how your policy is written
and according to how your diagnostic criteria was validated.
You wanna be sure that when you're giving the,
interpreting physician samples, you wanna give them
as much information as possible.
So fill that whole,
axis up with, with spectrums,
make sure your doctor has as much information as possible.
You wanna be sure when you're measuring your peak,
velocities, that you have good clean envelopes
to your waveform so that your measurment can be
as accurate as possible.
You wanna place your calipers exactly where they need to be
to do accurate,
measurements of your spectrum.
And if you do all of those things,
on each
and every study, you will in fact have a very perfect,
image and you will have a very good diagnostic
and accurate exam.
Thank you very much for,
participating in this,
lecture.