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The IAC Standards
and Guidelines |
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Echocardiography Standards |
2.1B Cardiac
Ultrasound Systems
2.1.1B Ultrasound
instruments utilized for transesophageal echocardiographic studies (
2.2B Transesophageal
Ultrasound Transducer
2.2.1B Transesophageal
ultrasound transducers must be those manufactured for the ultrasound system of
the facility.
2.2.2B Transesophageal
ultrasound transducers must
incorporate multiplane imaging capabilities.
2.2.3B A written policy must be established for cleaning/decontaminating the TEE transducer, ultrasound system, cables, etc., between patient use in accordance with local infection control policies/procedures.
2.2.4B The
manufacturer’s guidelines must be followed for the appropriate care and
cleansing of the TEE transducer and adhere to the appropriate
infectious disease standards to prevent the transmission of disease.
The structural and electrical integrity of the transducer must be
checked between each use, using an ultrasound transducer leakage
tester. “Passed” or “Failed” must be documented in the routine TEE
probe cleaning / maintenance log along with action taken if “Failed.”
2.3B The
annual procedure volume must be sufficient to maintain proficiency in exam
performance and interpretation.
2.4B Transesophageal
echocardiographic testing is performed for appropriate indications.1
2.4.1B Verification
of the Indication – A process must be in place in the facility for
obtaining and recording the indication. Before a study is performed, the
indication must be verified and any additional
2.5B Transesophageal
echocardiographic studies are appropriately ordered and scheduled.
2.5.1B Ordering
Process – The TEE order and/or requisition must clearly indicate the
type of study to be performed, reason(s) for the study and the clinical
question(s) to be answered. The order/requisition must be present in the
medical record of the patient.
2.5.2B Definition
of Procedure Types and Protocols –
2.5.2.1B A
TEE examination is one that examines all of the cardiac chambers, valves and
great vessels from multiple imaging planes and then uses the
(See Guidelines below for further
recommendations.)
2.5.2.2B The
TEE is a semi-invasive examination and usually is performed using conscious
sedation. The facility must demonstrate that all medical and technical staff
routinely adhere to the global conscious sedation policies in place for the
medical facility as required by the Joint Commission or other appropriate
accrediting organizations.
2.5.3B Scheduling– Sufficient time must be allotted for each study according to the procedure type. The performance time allotted for an uncomplicated, complete study (outside of the OR or interventional lab) is estimated to be 60 minutes, with an additional 15 to 30 minutes for complicated studies from patient encounter to departure. Sufficient time must be included in the scheduling process for adequate post-sedation monitoring.
2.5.3.1B An urgent or stat TEE study must be performed as soon as possible and may preempt other clinical facility activities.
2.5.3.2B Availability for emergencies: Qualified personnel and equipment must be available for urgent or stat studies outside normal working hours in inpatient facilities or where appropriate.
2.6B Transesophageal
Echocardiography is a semi-invasive examination, which, if performed incorrectly,
can lead to serious harm to patients and therefore, must be performed by
appropriately trained personnel.
2.6.1B All
performing physicians must be adequately trained and experienced to perform and
interpret the study.2
2.6.2B All
assisting sonographers and nurses must be adequately trained and validated as
competent in procedures and policies for assisting in invasive procedures using
conscious sedation.
2.7B Examination
performance must include proper technique.
2.7.1B Elements
of study performance include, but are not limited to:
2.7.1.1B transducer
insertion;
2.7.1.2B optimization
of equipment gain and display settings;
2.7.1.3B utilization
of appropriate Doppler technique and measurements;
2.7.1.4B optimization
of image orientation to enhance Doppler display; and
2.7.1.5B performance
of a 2-D/3-D/Doppler
transesophageal examination according to the facility
specific and appropriate protocol that incorporates all views and imaging
planes mandated by the Standards 2.8.6B (in any sequence).
2.7.2B Elements
of study quality include, but are not limited to:
2.7.2.1B demonstration of cardiac structure and function;
2.7.2.2B evaluation
of atrial and ventricular septal integrity;
2.7.2.3B evaluation
of left atria and left atrial appendage;
2.7.2.4B evaluation
of ascending aorta, descending aorta and aortic arch;
2.7.2.5B delineation
of the details of valvular anatomy;
2.7.2.6B optimal
recording and evaluation of spectral and color flow Doppler;
2.7.2.7B adherence
to the facility specific and appropriate protocol (except for sequence); and
2.7.2.8B imaging
of at least one right and one left pulmonary vein, with Doppler when appropriate.
2.8B Transesophageal
echocardiograms must be comprehensive and include standard components.
2.8.1B Technical
Personnel – Due to the complexity of the TEE study, appropriate
technical personnel must be available to assist the performing physician. These
personnel may include a sonographer and a nurse. The duties of these
individuals include, but are not limited to:
2.8.1.1B preparing
the patient for the test;
2.8.1.2B assisting
the physician with the ultrasound equipment;
2.8.1.3B monitoring
the patient during and after the examination; and
2.8.1.4B administration
of anesthetic medication and airway management.
2.8.2B Preparation
of the Patient – To perform TEE studies safely, appropriate safety
guidelines must be in place. Patients must have a functioning intravenous
access in place. Cardiac monitoring with standard telemetry leads must be
utilized. Instrumentation to monitor the blood pressure and oxygen saturation
of the patient before, during and after the examination must be available, as
well as oxygen with appropriate delivery devices if needed.
2.8.3B Procedural
Sedation – The facility must recognize the potential need for patient sedation in order to obtain an adequate examination. This may be provided by the anesthesia service or by a licensed provider. If moderate sedation is utilized, there must
be methods in place to assess the patient’s level of consciousness
pre-procedure and throughout the procedure. All procedures must be
explained to the patient and/or the parents or guardians of those
unable to give informed consent. Consent must be obtained in a manner
consistent with the rules and regulations required by the hospital or
facility. Written policies must exist for the use of moderate sedation including, but not limited to:
2.8.3.1B training requirements for personnel providing moderate sedation;
2.8.3.2B monitoring of vital signs and level of consciousness during and after the examination;
2.8.3.3B type of sedatives and appropriate dosing; and
2.8.3.4B monitoring during and after the examination.
2.8.4B Monitoring
the Patient – During the procedure, the vital signs and physiologic status of the patient must be continuously evaluated and recorded per the institutional policy.
The development of instability in either the vital signs or comfort of
the patient must be addressed by the performing physician. Facility
guidelines for the monitoring of patients who receive intravenous
anesthetic agents are required. These written guidelines must be in
place and available for all facilities where TEEs are performed. A list
of peri-procedural complications must be maintained.
2.8.5B Recovery
of the Patient
– Prior to discharge from the TEE facility, the patient must be
monitored for a sufficient amount of time to assure that no
complications have arisen either from the procedure or the medication
administered. The patient and/or the family must be instructed on any
post-procedure care that the physician feels is necessary. Information
must be given to outpatients that will allow them to recognize potential complications or side effects and contact the performing physician or physician on call after discharge. A method to track procedural complications must be maintained.
2.8.6B Components
of the Examination – A protocol must be in place that defines the
standard views and components of a comprehensive TEE examination. Indications
for performance of a TEE examination must be included. A complete TEE and
TEE-Doppler examination includes standard views from multiple planes including
views of all cardiac structures and selected extracardiac structures.
(See Guidelines below for further
recommendations.)
2.8.7B The
complete examination must include the following standard views while allowing
for patient tolerance and safety:
2.8.7.1B gastric
short axis and long axis views;
2.8.7.2B standard two- and four-chamber views;
2.8.7.3B short
and long axis views of the aortic valve with appropriate Doppler;
2.8.7.4B multiple
imaging planes of the mitral valve with appropriate Doppler;
2.8.7.5B multiple
imaging planes of the tricuspid valve with appropriate Doppler;
2.8.7.6B longitudinal
view of the pulmonic valve with appropriate Doppler;
2.8.7.7B multiple
imaging planes of the right atrium, left atrium and left atrial appendage with
appropriate Doppler;
2.8.7.8B Multiple imaging planes of the atrial septum and foramen ovale with appropriate Doppler. In cases of suspected cardiac source of emboli, when
no obvious intracardiac shunt is identified with color Doppler,
injection of agitated saline is required unless contraindicated
2.8.7.9B
imaging of the pulmonary veins with appropriate Doppler, when mitral
regurgitation is present;
2.8.7.10B multiple imaging planes of the ascending, descending and transverse arch of the aorta;
2.8.7.11B
long axis views of the main pulmonary artery and proximal portions of
the right and left pulmonary arteries;
2.8.7.12B images of the proximal inferior and superior vena cava; and;
2.8.7.13B imaging of the pericardial space and pericardium.
.
2.5B The facility should have a policy defining STAT echocardiogram indications.
2.5.2.1B Definition
of Procedure Types and Protocols
In
general, a TEE should be performed to answer clinical questions that cannot be
answered by transthoracic imaging. However, the routine practice of a facility
should be the performance of a comprehensive evaluation.
2.8.5B Recovery of the Patient
Provider
performing the procedure or designee should consider follow up phone
call or secure communication with the patient to ensure that there
weren’t any late developing complications or have any further questions
related to the procedure.
2.8.6B Components
of TEE Examination
The examination should be performed in a methodical fashion although the order
of imaging plane acquisitions and Doppler may vary so as to
answer the question at hand in an expeditious fashion. Although limited TEE
examinations may have a role in specific clinical situations, a facility should
generally perform comprehensive examinations routinely, due to the high yield
of unexpected findings.