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Imaging
Contrast Echocardiography—A Standard of Practice
Marti L McCulloch, BS, MBA, RDCS, FASE
1
and Robert J Davis, RCS
2
1. Director; 2. Manager, Echocardiography, Electrocardiography, and Cardiac Magnetic Resonance Imaging,
Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston
Abstract
Purpose: Contrast echocardiography is a valuable tool that allows significant improvement in image quality. However, approximately 20% of
echocardiograms performed remain technically limited and non-utilization of contrast is most likely due to workflow concerns and/or processes-
related implementation. This article will focus on minimizing barriers, thereby allowing incorporation of contrast enhancement as a necessary and
vital standard of practice. Findings: Several studies have clearly illustrated the benefit and safety of contrast enhancement for improving both
endocardial border definition and diagnostic confidence of the physician. Studies have also shown contrast enhancement to be efficient, cost-
effective, and capable of positively altering patient management in terms of medical management and/or the need for additional imaging. Although
contrast enhancement is undoubtedly advantageous, it remains underutilized. Summary: There are several best practice examples noted in the
literature. These best practices outline the steps to overcome the difficulties related to contrast enhancement, such as additional support for starting
intravenous (IV) therapies, administration of the contrast, and standing orders with defined protocols and criteria for patient safety.
Keywords
Contrast, contrast enhancement, contrast protocol, intravenous (IV) certification
Disclosure: Marti L McCulloch, BS, MBA, RDCS, FASE, is on the advisory board of Siemens Ultrasound and the speakers’ bureau of Lantheus Medical Imaging. Robert J Davis, RCS,
has no conflicts of interest to declare.
Received: August 21, 2009 Accepted: October 6, 2009
Correspondence: Marti L McCulloch, BS, MBA, RDCS, FASE, Director, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, 6565 Fannin, F9-093, Houston, Texas.
E: mlmcculloch@tmhs.org
The cardiac imaging field has experienced significant improvements Maximizing Resources
over the last decade due to technological advances. Cardiac computed The major limitations of contrast implementation in an echocardiography
tomography (CT), cardiac magnetic resonance imaging (MRI), nuclear laboratory typically involve the division of labor and responsibilities and the
cardiology, and echocardiography have all become feasible imaging additional time and effort it takes to perform the contrast exam.
1–5
While
modalities for physicians to evaluate in order to answer specific efficiency and labor remain valid administrative concerns, providing a
diagnostic questions. Each of the aforementioned modalities has quality study for diagnostic accuracy must be the primary focus for superior
strengths and weaknesses, but only echocardiography is radiation-free, patient care. In an effort to drive quality while maintaining efficiency, cross-
will not induce claustrophobia, and is not bound to respiratory or rhythm training staff to perform these additional functions is a helpful option.
gating. However, it does have certain limitations in terms of image IV access is required for the administration of contrast and typically
quality due mainly to body habitus. In order to remain competitive with outpatients do not have such access. Therefore, echocardiography
the high-resolution image quality of other modalities, the field of laboratories that do not have or that are in short supply of nursing staff
echocardiography must embrace contrast enhancement. Although may opt to cross-train other medical staff to assist with IV insertion.
5–7
contrast echocardiography has been clinically available for over a Many associated health professionals are trained in venipuncture, including
decade, the acceptance rate by professionals in the field has been phlebotomists, emergency medical technicians, radiology, and nuclear
limited by barriers in terms of the process of incorporating contrast into medicine technicians.
2
IV insertion is a proficiency that can be obtained
daily practice. The literature supports innovative approaches, such as by most medical staff, including stress technicians and cardiac
maximizing resources (intravenous [IV] certification and contrast sonographers.
1–7
IV certification typically involves didactic training coupled
competency), concise policy and procedures, and protocol-driven with practical, hands-on experience. A certificate of completion is earned
standing orders. The purpose of this article is to highlight best practice after passing a test for comprehension. Once the education is complete, the
sharing in an effort to encourage contrast enhancement and laboratory or facility determines how many contiguous, successful IV
incorporate it throughout all echocardiography laboratories as a insertions are required in order to be signed off. Thereafter, an in-service
standard of practice. with a competency checklist needs to be performed annually.
34 © TOUCH BRIEFINGS 2009