|
|
| EXTENDING THE PROVISION OF ULTRASOUND
SERVICES IN THE UK |
|
September 2003
Jane Bates, Colin Deane, David Lindsell
|
| Ultrasound Service Provision in the UK -
Summary: |
In the UK, increasing demand for ultrasound services and inadequate resources
have led to long waiting lists with subsequent frustration of hospital
clinicians, general practitioners and their patients.
Dangers of inadequate service provision
Several options have been examined to improve patient access to ultrasound
services. Amongst these is the provision of ultrasound services outside
conventional ultrasound departments. The increasing availability of low cost
scanners and the perception that ultrasound is easy to perform encourages this
approach, which may appear superficially attractive.
There are, however, several potential problems which may lead to a poor quality
diagnostic service with consequent detrimental effects on patient care.
Examinations performed by staff not specifically nor adequately trained
in ultrasound scanning and interpretation may be misleading and dangerous to
patients. |
|
| A high quality ultrasound
service is dependent on: |
|
 Staffing: |
 |
The use of unqualified staff has adverse
implications for diagnostic accuracy and potentially significant medico-legal
consequences. Ultrasound scans must be performed by qualified, properly trained
personnel, to reduce the risk of misdiagnosis. |
| |
Staff must have access to regular continuing
professional development. |
| |
There is currently a national shortage of qualified
staff,1, 2. Providing ultrasound
services outside conventional ultrasound departments such as in out-patient
clinics, primary care trusts (PCTs) and diagnostic & treatment centres
(DTCs) requires careful consideration. Organisation of a service should make
the most effective use of qualified staff. |
| |
Training of additional staff is essential but places
additional burdens on clinical departments undertaking it. |
| Equipment: |
| |
Equipment purchased must be suitable for the work
required. Equipment must be regularly maintained, serviced and safety
checked. |
| |
Facilities for timely replacement of obsolete or
inadequate scanners should be in place. |
| |
Equipment usage should be maximised where possible,
for cost effectiveness. |
| Environment: |
| |
The scanning room/suite must be suitable for the
purpose |
| Diagnostic Accuracy and Quality Control: |
| |
A system should be in place for regularly assessing
the quality of the service and ensuring an acceptable level of diagnostic
accuracy. |
| |
Protocols should be in place to ensure standards of
scanning practice are maintained and should be reviewed regularly to maintain
best practice. |
| Mechanisms: |
| |
Must be in place to act appropriately on the results
of ultrasound scans and clear lines of onward referral to secondary and
tertiary care should be identified and agreed. |
|
|
| Extending Ultrasound Services - Introduction |
Background:
Over the last 20 years, ultrasound imaging has become a vital diagnostic tool
for an increasing number and range of clinical conditions, leading to an ever
increasing number of requests from both the primary care sector and from within
the hospital setting. Ultrasound services are provided by a variety of hospital
departments including Radiology, Obstetrics, Vascular and Cardiology.
The strength of ultrasound imaging lies in its safety, non-invasive nature and
comparatively low cost, which supports its use as a vital first line diagnostic
test in many different clinical scenarios.
In addition, ultrasound is increasingly contributing to minimally invasive
therapy and to more complex diagnostic procedures, increasing diagnostic
accuracy and enabling a greater range of treatment options to be offered to
patients.
This increase in scan requests has not been matched by resources. Radiology
departments in particular are facing a national staffing crisis, and there is a
well-documented shortage of both radiologists and sonographer practitioners,
with a requirement for almost 25% more posts in order to adequately address
current shortages.
1
Vacancy levels as high as 30% have been reported in some departments.
3
Many centres still do not have adequate equipment replacement programmes and
large numbers of out-of-date ultrasound scanners are still in service,
significantly reducing diagnostic capability .2 |
|
Demand
management:
It is possible to contain increasing demand by more aggressive prioritisation.
The removal from lists of scans whose contribution to patient management is
arguably minimal (such as screening procedures, or the follow-up of benign
disease) has been explored in some institutions.
Such a strategy may potentially free up resources to concentrate on symptomatic
and urgent referrals. However, insufficient evidence of the epidemiological
effects and consequences for patient management is available at present, and
such a course of action, in which established services are withdrawn, is
controversial, and unlikely to be readily acceptable to patients or clinicians.
In addition, the resources subsequently made available may not necessarily be
transferable to other areas of ultrasound diagnosis. (For example, a reduction
in obstetric screening for low-risk women is unlikely to translate into an
increase in resources for symptomatic hepatobiliary patients, as the equipment
and staff skills required are different.) Justification of ultrasound scan
requests in terms of patient management is essential, and scans should be
performed in order to deliver value to the diagnostic and treatment process.
Patient benefits should be evident when planning new services. |
|
NHS
Capacity:
If adequately resourced, NHS hospital departments could increase their capacity
for scanning, improving access for hospital and primary care patients. Without
adequate resourcing increasing the number of examinations performed is only
possible by limiting the scope of scanning protocols. This option would clearly
have a negative effect on patient care and may be medico-legally indefensible.
4 |
|
Current
Trends:
In many areas, patients requiring ultrasound scans have been subjected to
delays, which potentially compromise their treatment. The reaction of some
clinicians, including those in the primary care sector, has therefore been to
consider ultrasound service provision outside conventional ultrasound
departments and there is a general perception that patient access can be
significantly improved by providing ultrasound scans in the setting of the GP
surgery or hospital outpatient clinics. Calls have been made to formulate a
national strategy for the future of ultrasound services. There are a number of
issues which must be seriously considered before embarking upon service
provision outside conventional departments.
4 |
|
| Issues for Consideration in Delivering/Extending
Ultrasound services |
|
| Staff Training & Education: |
| |
The Need for
Training: |
|
The greatest hazard of ultrasound
is the misinterpretation of the appearances by poorly trained or untrained
operators.
Ultrasound diagnosis is highly operator-dependent, and it is essential that
operators are properly trained. This applies to both medically and
non-medically qualified individuals. There is considerable evidence to support
the fact that diagnostic accuracy in ultrasound, and, thus, successful patient
management, is directly related to the skill, training and experience of the
operator. This has been recognised by the Chief Medical Officer who in his
assessment of the safety of diagnostic ultrasound concluded that the greatest
risk to patients was from inaccurate interpretation of the image rather than
any physical hazard of the ultrasonic field.
4 |
| |
Current training
systems: |
|
In the UK, post-graduate modular courses
are available through 20 universities, accredited and approved by the
Consortium for the Accreditation of Sonographic Education (CASE.) These provide
suitable training for various areas of ultrasound practice, and include
clinical placement for practical training in an approved ultrasound department,
with practical assessment to ensure basic competency. |
| |
Possible Future training
options: |
|
~ |
The crisis in recruitment and retention of qualified
post-graduate practitioners leads to the consideration of training options
which may address future developments: Limited or abbreviated training of
health care professionals, to perform a basic level of scanning within a narrow
range of applications, would be possible (see below). However, there are no
such recognised training programmes at present, and practical training would
still be required in the setting of the hospital department. There are also a
number of issues around employing this type of practitioner which must first be
addressed, including firm guidelines for particular areas of practice, and the
standards to be met. |
|
~ |
A further option would include undergraduate entry to
ultrasound education, dependent upon adequate educational programmes being in
place. Any scheme of this nature should aim to produce practitioners of at
least equal skill and level of practice to the current system. This may offer
school leavers an attractive career option, improving recruitment and
attracting further interest, long term funding and planning for the profession.
However, the problem of clinical placement still exists – and current
hospital departments do not have the facilities to significantly increase their
teaching commitments. |
|
|
Staffing
options for ultrasound units outside main ultrasound departments: |
|
|
- Using inadequately trained staff is
potentially dangerous, will have a detrimental effect on diagnosis, and is not
medico-legally defensible.
It is not an option for qualified healthcare professionals of any kind to
undertake ultrasound without proper training, due to the clear risk of
diagnostic misinterpretation and its subsequent effect on patient management.
The European Federation of Societies for Ultrasound in Medicine and Biology
(EFSUMB) has produced Minimum Training Standards for ultrasound practitioners,
which endorse the requirement for proper training.
6
- Staffing units by using qualified staff already working within the
NHS.
| This will: |
| |
|
remove them from hospital departments, causing further pressures on these
services and increasing waiting lists. |
| |
|
reduce the flexibility and capacity of hospital departments to deal with
major fluctuations in workloads – eg trauma, inpatient scanning and
variable demand from primary care. |
| |
|
compromise the long-term development of the quality of the ultrasound
service as a whole, removing staff from the multidisciplinary team setting.
|
| |
|
achieve fewer scans overall than can be performed in the setting of a
dedicated ultrasound department. (By scanning in remote and small sites
ultrasound practitioner time can be wasted in travelling and appointments that
are not filled or vacated when patients do not attend cannot be utilised at
short notice as they can in a hospital setting.) |
- Employing staff from abroad.
The concept of DTCs assumes ‘additionality’ and that the staffing of
these units will come from staff bought in from other countries. Whilst this
does get around the current staffing crisis in this country the teaching and
training of ultrasound varies enormously elsewhere. If this model is pursued
then there must be robust mechanisms in place to assess the adequacy of the
skills of any such practitioners employed in the PCT/DTC setting.
- Training more staff
Usually, CASE accredited training is the required minimum standard for
employment of sonographer practitioners within UK NHS Ultrasound Departments.
These courses are open to, and accessed by, both medically and non-medically
qualified healthcare professionals.
NHS Ultrasound Departments provide practical training for these programmes, and
clinical placements in busy departments put an additional burden on the
service, limiting patient throughput. Departments must find a compromise
between maximising the number of trainees whilst maintaining the necessary
throughput of patients.
- Variation in Levels of Training and Practice:
In order to ensure basic minimum training standards and address increasing
demands, the European Federation accepts that three different levels of
scanning practice may be necessary.3
Limited practical training, in conjunction with appropriate theoretical
education, might enable a range of clinicians and practitioners to undertake
some basic scanning, leaving existing, fully qualified ultrasound practitioners
to provide the more complex scanning and specialist procedures.
Focussed ultrasound training may be applicable to some hospital specialists,
such as intensivists and emergency physicians, to utilise ultrasound for very
limited purposes such as to detect and drain pleural fluid collections, to
obtain vascular access and to detect free fluid within the abdomen. However
this will not be applicable in primary care where the range of diagnostic
problems is much broader.
These approaches depend on proper training, but to a more limited extent than
current post-graduate diploma courses. It is fair to say, however, that even
limited training would present a burden to NHS departments and cannot be
currently accommodated without further resources, or without severely
compromising the services.
|
|
|
Continuing
Professional Development (CPD) |
|
|
| |
Staff must have access to continuing
professional development, to keep abreast of current techniques and
developments, and to renew and extend their skills. This must be taken into
account when planning a service. |
| |
There must be regular appraisal and
quality assurance to ensure that those practising ultrasound see an adequate
number of patients and pathologies to maintain clinical standards. This can be
very difficult in small ultrasound clinics . |
|
|
Health
& Safety |
|
|
| |
The employer must be aware of the
regulations governing health & safety for staff. |
| |
Attention must be paid to providing an
ergonomically suitable environment in which to scan. Work related
musculo-skeletal disorder (WRMSD) has been found to affect up to 80% of
sonographer practitioners.
7 |
| |
Where staff work extended hours to
maximise the utilisation of equipment for evening and weekend sessions, care
should be taken that working patterns fall within the European Working Time
Directive. |
|
|
Equipment |
|
|
| |
Equipment purchased must be adequate
for the intended purpose, and should have the required image quality and
functionality. It should be born in mind that less expensive equipment has a
limited performance in comparison to the higher-end more expensive technology,
and patients may subsequently require referral for further diagnostic
investigations to hospital departments if poor quality equipment is used. |
| |
Equipment must be regularly
safety-tested for patient and staff protection. Adequate cleaning and
disinfection protocols should be put in place. |
| |
Equipment must be regularly
maintained, in line with the manufacturer’s recommendations. A programme
of regular equipment checks should be performed. |
| |
Old equipment and equipment with
inadequate image resolution or functionality for the examinations performed
should be promptly replaced. |
| |
Accessory equipment, such as
examination couches and scanning stools must be of appropriate safety standard
and ergonomic design to prevent injury.
8 |
| |
Utilising available equipment within
NHS hospital departments to its maximum potential, by scanning during evenings
and weekends, may often be more cost effective than purchasing new equipment
for location in other, peripheral units, where it may be under-utilised.
However, extended use of equipment requires more frequent maintenance and
replacement, and is also dependent upon additional qualified staff to utilise
it properly. |
|
|
Environment |
|
|
| |
A private room should be provided for
scanning procedures. |
| |
The room should be dark, with no
natural light entry, and dimmer switch lighting. |
| |
The room may need to be air
conditioned due to heat production from the scanning equipment. |
| |
A chaperone should always be
available, particularly bearing in mind that a significant proportion of scans
are performed for gynaecological and urological reasons and these often
necessitate the use of intimate examinations and intracavitary probes. |
| |
Planning should take account of
provision for disabled patients, the proximity of toilet facilities and
adequate waiting & recovery areas. |
|
|
Diagnostic
Accuracy and Quality Control |
|
|
| |
A mechanism of audit/quality control
to ensure patients continue to receive the expected level of diagnostic
accuracy should be in place, with regular checks on the service quality.
9 It
is important to validate the diagnostic accuracy of ultrasound in the Primary
Care setting, and this is likely to require the involvement of hospital
departments. |
| |
An independent operator routinely
working in isolation, without the benefit of audit, feedback or the ability to
discuss cases and technological advances with colleagues, may not be able to
sustain an adequate standard of good practice. |
| |
Scanning protocols/ schemes of work
should be in place to ensure best practice.
10 |
|
|
| Conclusion |
Increasing the capacity of hospital ultrasound departments to
accommodate increasing demand requires appropriate additional resources. There
are significant advantages to utilising already established hospital
departments, in terms of equipment, staffing and quality issues.
Staffing ultrasound services outside conventional ultrasound departments
by:
- Using inadequately trained staff,
- Using existing qualified hospital staff or
- Putting pressure on hospital departments to train more staff (which will
impact negatively on already busy departments)
are unacceptable options which will have a highly negative effect on
patient care.
The quality of service provided must be closely monitored and adequate
standards maintained. The ideal model for the provision of ultrasound outside
main ultrasound departments is the ‘hub and spoke’ model, whereby
staff working in peripheral units are part of a central hospital team. This
allows experienced support to be available to them, allows appropriate onward
referral for other imaging, or to appropriate clinicians, and also provides a
mechanism for maintaining adequate standards.
An alternative way of ensuring high clinical standards is the use of
teleimaging, which allows a practitioner scanning in isolation direct access to
a second opinion from the base department. If ultrasound scanning is to be
undertaken outside conventional departments then it should ideally take place
in units with a sufficiently large critical mass to ensure adequate quality
control and to minimise under-utilisation of staff and equipment which may
occur in isolated or single-handed units.
‘Level One’ Scanning is an option which may contribute to a solution
to the crisis, providing a basic level of primary care service, and also
freeing up extra resources within hospital departments in the long term.
However, this level of basic scanning is unlikely to be of significant value in
general practice, which requires a broad-based approach to recognise a range of
pathologies and ultrasound appearances.
Providing a scanning service of this nature would be dependent upon:
- Adequate training – (which is not currently available in any
recognised or audited way)
- The ability of operators to recognise their limitations
- A clear mechanism in place for referral of patients for further imaging or
investigation
- A robust audit/ quality control system to monitor diagnostic accuracy
Even limited practical training of this nature has implications for the
existing service, and it is clear that further resources must be employed in
order to progress any strategy of this kind.
The current system in the UK of providing ultrasound services with properly
qualified post-graduate sonographer practitioners and medical practitioners is
highly successful in terms of diagnostic accuracy and acceptability, making the
crisis in sonographer and radiologist recruitment of particular concern. In the
long term, sonographer numbers can only be maintained and improved if
attractive working conditions and career structure are provided. Even so, the
capacity of hospital departments to train more practitioners is already
severely limited, and cannot be significantly expanded without proper resources
and long term planning. |
|
| REFERENCES: |
- Modernising the Clinical Ultrasound Service. South West London Workforce
Development Confederation. Southbank University, Faculty of Health. 2003
- Audit Commission Report – Radiology, August 2002
- Diagnostic Imaging Services – Barnet & Chase Farm Hospitals NHS
Trust. Commission for Health Improvement, November 2002.
- Bates JA. The Troubled future of ultrasound in Primary Care. National
Association of Primary Care Review, 75 – 77, 2003
- Safe Use of Diagnostic Ultrasound – CMO’s Update. November 1994
- Minimum Training Requirements for the Practice of Medical Ultrasound in
Europe. EFSUMB Educational & Professional Standards Committee, January 2003
- Society of Radiographers. The causes of muskuloskeletal injury amongst
sonographers in the UK. SoR, London: 2002
- Industry Standards for the Prevention of Work Related Musculoskeletal
Disorders in Sonography. Society of Diagnostic Medial Sonography, Texas, May
2003
- Dubbins PA. Ultrasound in Primary Care, Optimising Management. National
Association of Primary Care Review, 79 – 81, 2003
- UKAS. Guidelines for Professional Working Practice. UKAS, London. 1996.
|
|
|
|
 |
Back To BMUS
Clinical Protocols |
|
|
|
