Position statement from the British Society of Echocardiography: Post-pandemic workflow challenges

As the Covid-19 pandemic enters into a more controlled phase, this statement has been prepared to clarify the position of the BSE regarding the various proposals put forwards by different stakeholders to facilitate with the catching up of backlog clinical echocardiography activity in the UK.

Context:

Out-patient echocardiography

1. We know from feedback from our membership that waiting list times for out-patient echocardiography have risen since March 2020.
2. Waiting list times vary regionally but have doubled in some areas. Echocardiography remains an under-recruited profession.
3. An estimated increase of 20-25% in the size of the workforce is required to fully staff current NHS outpatient echocardiography facilities.
4. This requirement is very likely to increase further in England with the establishment of diagnostic hubs in accordance with the recently proposed NHS England long-term plan.
5. The BSE is undertaking a professional workforce survey to secure accurate workforce data.

In-patient echocardiography

1. The importance of delivering a time-relevant in-patient echocardiography service has been brought into focus by the pandemic, emphasising the importance of echocardiography as a rapid diagnostic tool to stream-line in-patient care.
2. According to the Richards report of 2020 on diagnostic tests, more than 50% of NHS Trusts are currently unable to deliver this service.
3. The additional requirement for personal protective equipment for echocardiographers undertaking inpatient studies has also affected work-streams.

As a Council we are guided by three over-riding priorities in writing this position statement:

1. Patient safety.
2. To maintain pre-pandemic quality standards in echocardiography.
3. To prevent the creation of healthcare inequities.

Work-flow options to address waiting lists and increased demand for echocardiography:

BSE Council supports the following processes to meet patient needs.

Emphasise and up-resource triaging

• Accurate triaging is the key process by which inappropriate demand on echocardiography services can be reduced.
• Senior team members should be deployed to triage using both the provided referral data and further information sought as necessary: creation of a triaging team may be required.
• We advocate a strong focus on triaging of both existing and new out-patient echo referrals to address work-flow issues.
• Triaging documents should be used both by the primary care referrer and the referral triaging team.
• Up-to-date national triaging guidance should be used to reduce health-care inequity: these can be accessed via the BSE website and in poster format on request.

Look at the time in motion process of echocardiography to maximise useful scanning time

• Use support workers to provide direct patient-care provision before and after the study is performed: for example, assisting with patient-positioning, height, weight and blood pressure measurement.
• Use technology and reporting protocols to reduce reporting times. For example, where the minimum dataset confirm normality a ‘normal echo’ report could be issued automatically to save sonographer time.
• Optimise staffing levels and echo machine utilisation by using echocardiographers to alternately scan and report at half-hourly intervals allowing the safe provision of half-hourly appointments: this is beneficial when machine and scanning room access is the limiting factor, not when staff shortages are the issue.
• Provide additional echocardiography lists to ‘catch-up’ with workload: sharing these amongst the echocardiography team will help prevent injuries to echocardiographers from repetitive strain. These lists should be adequately remunerated: this should be a Trust-level priority. This is a short-term solution only. The long-term solution centres on addressing workforce issues at every stage of sonographer career development.
• Use targeted studies for selected patient groups where there is established safe practice; for example, follow-up studies in cardio-oncology patients undergoing left ventricular function surveillance.
  • Sonographers leading and providing these services must be of appropriate seniority and competency to provide a safety net around unexpected findings.
  • Quality benchmarks in repeat scan patient groups will include adequate time for the performance of a fuller study where indicated, strong leadership, clear lines of shared accountability and appropriate quality assurance processes to ensure diagnostic accuracy is maintained.
  • Please see the cardio-oncology guideline on our website for guidance.
• We do not advocate the use of an abbreviated minimum dataset for first-time echocardiography in patients who have been triaged as requiring echocardiography using up to date triage guidelines: there is currently insufficient patient safety data available.
• Where ‘patient-focussed’ or ‘abbreviated echo’ protocols are being actively researched to evidence patient safety the following considerations should be made:
  1. How missed diagnoses are counted and managed on an individual patient basis.
  2. How patients are consented to receive an abbreviated protocol.
  3. How work-flow effect is assessed including time needed for rescanning.
  4. The operator must be of sufficient seniority to carry the additional clinical risk inherent in abbreviated scanning protocols. They will need to be adequately clinically trained to be able to judge when to deviate from the protocol to acquire a minimum dataset.

Create and make use of in-patient echo teams

• Channelling resource into the acute echocardiography team is a potentially powerful way of relieving capacity on outpatient work. An acute echo team can be drawn from appropriately qualified personnel for example cardiology registrars or consultants, or intensive care echo teams whose primary responsibility is not to provide an outpatient echo service.
• In-patient teams can relieve pressure on outpatient echo provision by addressing urgent requests for patients who cannot come to the department or who require urgent decision-making based on echocardiography.
• In the small group of patients where a pre-discharge echo is clinically required for example post electrophysiology procedures and TAVI, in-patient echo teams can be used to rule out pericardial collections or targeted questions.
• Accessing and activating the in-patient echo team needs to be straightforward for referring clinicians.
• The Level I protocol should be used accurately and reported against the clinical questions appropriate for a level I study. The level I protocol is designed to answer specific urgent clinical questions and trigger a level II study where indicated. It is not designed as a ‘screening’ protocol and should not be used in that way.
• Where a clinical setting/question is outside the capabilities of the Level I dataset a Level II transthoracic study, or another more appropriate imaging technique should be undertaken and reported in the clinical context to the requesting clinician.
• Inpatient echo teams should be run with clear leadership, direct lines of communication to the parent department and in-built quality assurance and learning processes for all members.

BSE Council June 2021