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Contrast Echocardiography—A Standard of Practice
There are several approaches to IV certification including online laboratory who may be reluctant to give contrast to unstable patients.
courses, local community college classes, or a DVD with workbook (a The education should provide an understanding of the need for contrast,
nurse teaches this course). To date, there are no national standards for its established safety, and that subsequent patient monitoring is routine
IV certification; rather, each state board of nursing may have standards and does not present an additional burden. Consent for contrast
that apply to nurses and/or each employer may have additional administration depends on state mandates and/or facility standards.
requirements. Fortunately, many ultrasound schools are incorporating IV Always follow the guidelines of the manufacturers when utilizing any
insertion and contrast administration into their core curriculum, which medication and assess all patients for any condition that may preclude
serves to further contrast echocardiography as a standard of practice.
the use of contrast. Facilities that frequently use contrast may benefit
In addition to IV certification, the literature also supports the cross- from putting a system in place where the sonographer identifies contrast
training of sonographers to administer contrast provided there are need and initiates its utilization. Castello et al. have shown the efficacy of
appropriate policies and procedures in place with documented training a sonographer-driven contrast protocol to reduce patient wait time and
Implementation of sonographer contrast the improve diagnostic confidence of the physician. Accordingly, Castello
administration will vary depending on state and local regulation, facility
standards, and the general level of acceptance. However, there are
favorable consensus statements, guidelines, and other supportive
Myriad studies have proved that contrast
literature that may be drawn on to convince any detractors that the
sonographer administration model is sound and viable.
enhancement reduces exam redundancy,
have the concept in place typically have strict criteria for administration
improves diagnostic confidence, and can
that focus on patient safety. For example, the criteria may dictate that
only registered sonographers with appropriate documented training
alter patient management and/or the
may administer contrast under the direction of the medical director with
need for additional diagnostic imaging.
a patent IV port not actively used for other medications. Another
example could be the documentation of an IV certification course and
competency checklist for any technical staff performing IV insertion. The et al. believe the sonographer should be authorized to initiate the
medical director of the echocardiography laboratory needs to be the utilization of contrast with a standing order. This eliminates the need to
major driver in the process implementation and must have a trusting obtain a physician order for contrast, greatly reduces the number of
relationship with the staff.
uninterpretable studies, and improves wall-motion analysis.
absence of a medical director, individual cardiologists may be contacted
Concise Policy and Procedures to ascertain willingness to create a standing contrast order for patients
Policies refer to the rules or guidelines for implementation, whereas they refer for testing or for exams they interpret.
procedures correspond to the implementation of a policy. Policy
and procedures are meant to be updated on a regular basis in order to Outline of Required Elements for
accommodate the changing external environment. Depending on Contrast Adoption
the laboratory and facility, policy and procedures may need to be A number of elements have to be considered when considering contrast
vetted through the medical director and/or a policy and procedure adoption, including:
committee. Generally, administrative managers and/or directors update
echocardiography laboratory policy and procedures with the input and discussion and review of logistical and legal hurdles to process
feedback of the medical director and medical staff. To implement a new implementation with consensus among involved parties (e.g.
policy guideline such as IV certification or sonographer contrast administrator, medical director, technical staff, etc.);
administration, there must be concise language in the procedure creation of policy and procedures in terms of contrast use
section that clearly outlines the process. Sonographers, nurses, and and administration;
physicians should all be aware of the indications for contrast, injecting development and adoption of administration protocols for contrast
and imaging protocols, monitoring, and personnel responsibilities.
with provisions for contraindications, patient safety and additional
Protocols, Checklists, and Standing Orders cross-train and educate staff in IV certification, contrast
Protocols ensure process compliance and are an adjunct to the policy administration, etc.; and
and procedures. A contrast protocol allows for standardization of standing orders for contrast administration as deemed by
contrast utilization by following the defined criteria. For example, the sonographer (optional but recommended).
American Society of Echocardiography recommends use of contrast
when unable to visualize two or more wall segments.
In addition, For additional resources, tools, and examples, please visit the Contrast
the facility may want to consider implementing a safety checklist to Zone at www.asecho.org
identify patients with contraindications (known or suspected shunts,
hypersensitivity to perflutren, or pregnancy) or who may require Conclusion
additional monitoring (unstable cardiopulmonary conditions or Although contrast media in echocardiography has been available for over
pulmonary hypertension). Additional education will benefit inpatient and a decade, the widespread adoption of its use has not occurred. Myriad
intensive care unit (ICU) nursing staff outside of the echocardiography studies have proved that contrast enhancement reduces exam
US CARDIOLOGY 35