Critical Issues In Vascular Ultrasound: Initiatives To Improve Patient Care
Douglas L. Wooster, MD, Varun Kapila, Elizabeth M. Wooster, MEd.
University of Toronto, Toronto, ON, Canada.
OBJECTIVES: To assay quality issues in vascular ultrasound and identify approaches to improve patient care.
METHODS: A literature and clinical practice review was conducted to identify critical issues in each domain of vascular ultrasound (VUS) (carotid, aortic, peripheral venous, peripheral arterial, and renal/mesenteric). Quality improvement (QI) theory was applied to identify and classify gaps and to assay QI strategies. Common themes were derived from the issues identified in terms of indications, technical and interpretation protocols and their applications. Credentialing and licensing of technologists, specialty training and registration of interpreting physicians and accreditation of facilities were reviewed to identify valid approaches to improved patient care.
RESULTS: There are recognized concerns in all domains. Critical issues cited in the literature include standardization of guidelines and protocols, training and credentialing of technologists and physicians and detail and accuracy of interpretation reports. The clinical review demonstrated the following: indication appropriateness (54 - 90%), carotid protocol variations (12 - 22%), errors in technical domains (30%), variable definitions of aortic measurement (17%), calculation of ABI (12 - 33%), and incomplete venous studies (45 - 62%). Interpretation deficiencies were noted: confusion of carotid velocities and ratios (12%), description of arterial stenosis and relationship of imaging to velocities, ratio and percent stenosis and ABI (18%), misleading venous nomenclature (22%) and incomplete reporting of limited venous studies (55%). Licensing and accreditation initiatives have been shown to improve job satisfaction for technologists (77%) and consistency of studies (60%) but may not improve patient care. Quality improvement theory provided a framework to assist with thematic analysis.
CONCLUSIONS: Despite clinical reliable findings from VUS, critical issues exist. These issues result in the delivery of inconsistent findings and may impact patient care. Use of the QI framework provided guidance for the thematic analysis and suggestions for future improvement. A systematic approach with standards and guidelines, consistent application and high-level expectations is recommended.
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