Ultrasound Machine Audit

It's my turn to hijack the blog now, mainly because I couldn't work out a better location to post my recent work. However don't be disarmed, this is still very much ultrasound based. Whilst bed-bound with a bout of tonsilitis I decided to audit the use of POCUS in WSHT, with a focus on how well we document our findings - it's dry, but try and enjoy... (if you make it to the end there's a treat)

 

Ultrasound Audit in Worthing Hospital Emergency Department

T. Muth, February 2018

 

Aim:

To assess if the use of the department ultrasound is in accordance with the Royal College of Radiologists’ Standards of Provision (1)

 

Methods:

Data from the months of December 2017 and February 2018 were used to analyse all saved images to ensure that their records are compliant with the guidance stated above. The raw files from the ultrasound hard drive were then associated with the patients’ respective clinical notes from the emergency department, using computerised medical records

 

Background:

The POCUS movement has exploded recently with the easy education and data sharing spread by online methods. However, fundamentally it is easy and fast to use with minimal risk to the patient. It has helped reduce time to diagnosis and aid in bedside procedures such as difficult vascular access. However for the pictures to be transferred to the hospital-wide image software from ED and be trusted in ongoing care the images need to be reliably documented and saved. Along with this the user needs to be aware of their limitations and keep their skills up to date.

The Examination-specific standards dictate that:

·         The department should have written guidelines for the range of ultrasound examinations undertaken

·         All ultrasounds should be justified

·         A range of images should be saved to PACS to provide a records of the examination for case review and audit purposes

They further state that each scan report should include:

·         Patient’s ID

·         Date of scan and report

·         Clinical information and indication for scan

·         Name of examination performed

·         Name of scanner

·         Description of findings

·         Limitations encountered

·         Comparison of previous relevant imaging

·         Conclusion – answer to the question asked when performing the scan

·         Documentation of communication with referrer when findings are important or unexpected

These guidelines form the basis of this quality improvement project, hopefully highlighting where documentation and file management can be improved within the emergency department

 

Results:

70 scans were saved to the ultrasound machine hard drive within the dates of 20th December 2017 and February 20th 2018. 15 of these files were excluded from the audit as they had no images/videos attached, allowing 55 files to be analysed. 11 files include videos only whilst 29 contained photos only. 29 files contained both videos and images

Patient’s ID

A total of 45 patients (82%) had some form of identification- 16 had at least their MRN number and 29 had name only. 10 had no identifiable information

Date and time of scan

All files automatically had date and time logged on the computer

Indication for scan

25 out of 55 scans did not have a documented indication on the report. The most common indication was ‘Flank Pain’ with 6 documented, closely followed by abdo pain, 5, and chest pain, 4. Accordingly 15 of these scans were abdominal scans, excluding 6 aorta scans, 1 fast scan, 2 IVC scans and 2 gall-bladder scans (on image interpretation). 15 scans were echocardiograms, and the remainder were either unclear, bladder scans or pre-natal scans

Name of professional

7 users in total logged scans during the period used. 17 scans did not have a documented user

Description of findings

The majority of cases, 24, did not have documentation of the scan in the clerking notes. 21 cases were documented with findings. Due to lack of patient identifiable information it was not possible to locate the notes of 10 scans.

Comparison with relevant imaging

Of the 21 scans that had documented findings, only 6 were not verified by further imaging and investigations. A total of 14 scans were verified to have the correct findings on POCUS by further imaging, including ultrasound and CT. There was 1 incorrect finding (documented as ‘hydronephrosis present’ which was excluded by CT)

 

Conclusion:

The majority of documentation was well done. However, of the 55 patient images analysed, only 21 were documented in the patient notes which is under half of all cases. Reassuringly nearly all of these documented cases were deemed correct by definitive investigation, supporting the use of POCUS as a helpful tool in the ED for speeding up diagnosis

 

Next Steps:

The aim for the future is to have images from the ultrasound machine uploaded to the trust PACS system. In order for this to occur, documentation needs to be accurate to ensure correct files are allocated to the correct patient. Accordingly, this audit will hopefully act as education for staff about current guidelines for POCUS in the emergency department. Such a tool to improve the documentation would be to have a print out of the guidelines in simplified form on the ultrasound machine itself to act as a prompt when inputting data. A further audit will be carried out to ensure the implemented changes improve documentation

 

References:

1.       The Royal College of Radiologists, the Society and College of Radiographers. Standards for the provision of an ultrasound service. London: The Royal College of Radiologists, 2014. Ref No. BFCR(14)17.

 

Here's a couple of cool images picked up on my searches - try and guess what they're showing, answers below.

Picture 1: Aorta scan, enlarged with clear aneurysm

Picture 2: Sniff test showing the collapsing IVC