Disclaimer The templates in this document are for use by facilities participating in the Cardiac Care Network of Ontario’s (CCN) Echocardiography Quality Improvement Program (EQI). The templates are samples only and are to be modified by facilities according to individual laboratory requirements. This includes the addition of the organization’s logo. NOTE: Required documents must be submitted 2 weeks prior to the site visit for assessment by the site reviewer. Additional templates are not required to be submitted, however, they will help to complete a policy and procedure manual and may be reviewed during the site visit.

Table of Contents

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Section 1: Standards Regarding the Echocardiographic Examination 1 Required Documents

Requirements for Performing Complete Transthoracic Echocardiograms (TTE) 2 Protocol for Echocardiographic Imaging and Measurements 6

Process for Adult Transthoracic Echocardiogram 17 TTE Additional Imaging Views for Pathology (Adult) 19 Protocol for Echocardiographic Measurements and Doppler 22

Protocol for the Addition of Contrast to Echocardiography Studies 26 Agitated Saline Echocardiography Protocol 28

Additional Templates Normal Values for Echocardiographic Measurements and Hemodynamic Readings 30 Echocardiography Modalities 38

Echocardiography Consent Form 40 Emergency Practices 41

Transthoracic Echo (TTE) Patient Information Sheet 42

Section 2: Standards Regarding Echocardiographic Facilities, Equipment and 43

Standard Operating Procedures Required Documents

Echocardiography Equipment List 44 Additional Templates

Echocardiography Laboratory Requirements 45 Workplace Safety 50

12 x 10 Transthoracic Procedure room 52

Section 2.4: Additional Considerations for Laboratories Providing Stress 53 Echocardiography Examinations Required Documents

Requirements for Performing Stress Echocardiography Examinations 54 Treadmill Exercise Stress Echocardiography Procedure 56 Bicycle Stress Echocardiography Protocol 59

Comprehensive Dobutamine Stress Echo 62 Additional Templates 15 x 10 Stress Echo (treadmill) Procedure room 65

Patient Information Guide for Exercise Stress Echo 66

Section 2.5: Additional Considerations for Laboratories Providing Transesophageal 68

Echocardiographic Examinations Required Documents

Requirements for Performing Transesophageal Echocardiography (TEE) Examinations 69 Additional Templates

Transesophageal Echocardiography (TEE) Procedural Process 76

Transesophageal Echocardiography (TEE) (Adult) Physician Pre-printed Orders 78

Transesophageal Echocardiography (TEE) Patient Information Guide 79 Transesophageal Echocardiography (TEE) Procedural Sedation 81

15 x 10 Transesophogeal Echo Procedure room 83 Transesophageal Echo (TEE) Probe Maintenance, Sterilization and Storage 84

Section 3: Standards for Reporting of Echocardiographic Examinations 85 Required Documents

Standardized Report for Adult Transthoracic Echo 86

Section 4: Standards Regarding Laboratory Type and Personnel Involved in 88

Echocardiographic Examinations Required Documents

Reporting Responsibilities 89 Additional Templates

Echo Lab Staff Responsibilities 90 Echo Nurse Responsibilities 92 Training and Education Protocols 93

Section 6: Continuing Quality Assurance in the Echocardiographic Laboratory 95 Additional Templates

Quality Assurance 96

Section 1: Standards Regarding the Echocardiographic Examination

Required Documents

1. Requirements for Performing Complete Transthoracic Echocardiograms (TTE) 2. Protocol for Echocardiographic Imaging and Measurements 3. Process for Adult Transthoracic Echocardiogram 4. TTE Additional Imaging Views for Pathology (Adult) 5. Protocol for Echocardiographic Measurements and Doppler 6. Protocol for the Addition of Contrast to Echocardiography Studies 7. Agitated Saline Echocardiography Protocol

Additional Templates

1. Normal Values for Echocardiographic Measurements and Hemodynamic Readings 2. Echocardiography Modalities 3. Echocardiography Consent Form 4. Emergency Practices 5. Transthoracic Echo (TTE) Patient Information Sheet

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Requirements for Performing Complete Transthoracic Echocardiograms (TTE)

Proper performance of the study must include adequate explanation of the procedure and respectful interaction with the patient. Although the sequence of views may vary according to the patient, the full complement of views including Doppler tracings and measurements should be obtained and recorded in every patient. Specific comments on the quality of study with comments on technical deficiencies such as foreshortening and inadequate alignment in relation to Doppler assessment should be included.

The Echocardiographic Report Basic information required:

• Confirm written physician order and type of exam requested. • Verify name of patient, identification, demographics, date of birth +/- age, and gender. • Document patient's clinical history and presentation. • Document any contraindications to the procedure, such as medications, insufficient

patient preparation or the patient’s inability or unwillingness to tolerate the procedure. Professional expectations:

• Verification of patient identification. • Appropriate introduction of staff to patient. • Appropriate explanation of procedure ordered. • Professional patient staff interaction. • Respect of patient confidentiality and privacy. • Explanation of ECG leads placement prior to application.

Cardiac measurements required:

• Left ventricular internal systolic and diastolic dimensions. • Left ventricular (basal) septal and posterior wall thickness. • Left atrial size (anteroposterior dimension). • Aortic root and ascending aorta dimensions.

Evaluation of the structure and function of the anatomic components of the examination include the following: Left ventricle:

• Assessment of left ventricular dimensions, wall thickness, global left ventricular systolic function and ejection fraction (and method used), and presence or absence of regional wall motion abnormalities.

• Evaluation of left ventricular diastolic function (if relevant to the clinical indication).

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Right ventricle: • Assessment of right ventricular size and systolic function, presence of right ventricular

hypertrophy. Left atrium:

• Assessment of size. Right atrium:

• Assessment of size. Aortic valve:

• Aortic valve cusp morphology, presence and severity of stenosis or regurgitation. • Evaluation of gradients (peak and mean) and valve area, if stenotic.

Mitral valve:

• Mitral valve leaflet morphology, presence and severity of stenosis or regurgitation. • Evaluation of gradients (peak and mean) and valve area, if stenotic.

Tricuspid valve:

• Tricuspid valve leaflet morphology, presence and severity of stenosis or regurgitation. • Evaluation of gradients (peak and mean), if stenotic. • Estimation of right ventricular systolic pressure, if sufficient tricuspid regurgitation is

present. Pulmonic valve:

• Pulmonic valve morphology, presence and severity of stenosis or regurgitation. • Evaluation of gradients (peak and mean), if stenotic.

Aorta (including aortic root and ascending aorta):

• Dimensions. Interatrial septum:

• Intact presence or absence of ASD/shunt. Pericardium:

• Presence and size of pericardial effusion, assessment of hemodynamic effects of pericardial effusion (if present).

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Routine Echocardiograms The comprehensive echocardiographic examination will contain the following imaging components:

• Parasternal long-axis of the left ventricle, left atrium and aorta. • Parasternal short axis consisting of three short-axis cuts of the left ventricle (base, mid,

apex), pulmonary artery view and aortic valve view. • Right ventricular inflow view. • Right ventricular outflow view. • Apical four-chamber view. • Apical two-chamber view. • Apical three-chamber view (long-axis view). • Apical five-chamber view. • Apical imaging with particular attention to the left ventricular (LV) apex. • Subcostal long-axis view. • Subcostal short-axis view. • Subcostal inferior vena cava view. • Suprasternal views of the aorta.

The comprehensive examination will contain the following Doppler components:

• Parasternal long-axis two-dimensional (2D) with colour screening for aortic insufficiency and mitral regurgitation.

• Parasternal short-axis 2D with pulmonary artery colour and pulsed wave Doppler. • Right ventricle inflow view 2D with colour for tricuspid regurgitation. • Apical-four chamber view 2D with colour for mitral regurgitation and tricuspid

regurgitation; pulsed and continuous wave. • Apical five-chamber view with colour for aortic and mitral regurgitation and

pulsed/continuous wave Doppler of the aortic flow velocity. • Apical three-chamber (long-axis) view 2D with colour and aortic flow velocity. • Apical two-chamber with colour flow Doppler of the mitral valve. • Subcostal view with colour Doppler of the interatrial septum. • Suprasternal view with colour and pulsed wave/continuous wave Doppler of the

descending aorta.

The comprehensive examination will contain the following standard measurements: The following standard measurements must be obtained and recorded for all studies. Either M-mode or 2D can be used to obtain the measurements at end expiration, based on their respective strengths and limitations in specific situations.

• LV systolic and diastolic dimensions. • LV diastolic wall thickness (septum and posterior wall). • Ejection fraction (this should be quantified whenever technically possible by one of the

validated methods (preferably by Simpson’s biplane Method of Discs) and the method used should always be identified. Visual estimation should be reserved for cases in which quantitative assessment is not technically feasible.

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• Transvalvular aortic flow velocity. • Pulmonary valve velocity. • Diastolic parameters should be determined according to the current guidelines, and

diastolic function classified into categories of normal, mild dysfunction (impaired relaxation), moderate dysfunction (pseudonormalization) and severe dysfunction (restriction). This assessment is based on consideration of the relevant parameters available from the Echocardiographic examination which can include mitral inflow velocities, mitral deceleration time, isovolumic relaxation time, pulmonary venous systolic and diastolic velocities, and tissue Doppler assessment of mitral annular motion.

• Tricuspid regurgitation velocity to calculate right ventricular (RV) systolic pressure. • Measurements of the aortic root and ascending aorta (sinuses of Valsalva and proximal

ascending aorta) and to include the annulus if indicated. • Left atrial dimensions.

Where clinical indications or findings warrant include:

• Blood pressure and heart rate should be included in the setting of valvular heart disease to allow proper assessment of intracardiac hemodynamics.

• Transvalvular mean and maximal gradients with continuous wave Doppler for stenotic valves and valvular prostheses, including views from multiple windows, such as the suprasternal and right sternal border.

• Spectral display of complete envelope of continuous wave Doppler signal of valvular regurgitation.

• Proximal isovelocity surface area calculation or other quantitative methods for assessment of valvular regurgitation.

• Respiratory variation of mitral and tricuspid inflow Doppler (e.g., pericardial disease). • Hepatic venous flow pattern and inferior vena cava collapse. • Shunt calculation. • Descending aortic velocity and presence of flow reversal, for assessment of aortic

coarctation and regurgitation.

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Protocol for Echocardiographic Imaging and Measurements Standard E1 Standard E3 Standard E4 Preamble 1. Quantification of chamber and vessel size should be done on all studies. 2. Images of the four valves and colour flow Doppler assessment of each valve is required. 3. Left ventricular diastolic and systolic function assessed on all studies. 4. Right ventricular assessment separate from the left ventricular study. Abbreviation List AI Aortic Insufficiency AO Aorta ASD Atrial Septal Defect AV Aortic Valve CW Continuous Wave EDP End Diastolic Pulmonary EF Ejection Fraction ERO Effective Regurgitant Orifice IAS Intra Atrial Septum IVS Intra Ventricular Septum LA Left Atrium LAD Left Anterior Descending LM Left Main LV Left Ventricular LVES Left Ventricular End Systolic LVOT Left Ventricular Outflow Tract MPA Main Pulmonary Artery MR Mitral Regurgitation MV Mitral Valve NCC Non-Coronary Cusp PA Pulmonary Artery PDA Patent Ductus Arteriosus PFO Patent Foramen Ovalis PHT Pressure Half Time PISA Proximal Isovelocity Surface Area PR Pulmonary Regurgitation PV Pulmonary Valve PW Pulsed Wave

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RA Right Atrial RAP Right Atrial Pressure RCA Right Coronary Artery RCC Right Coronary Cusp RV Right Ventricular RVSP Right Ventricular Systolic Pressure RVOT Right Ventricular Outflow Tract SAM Systolic Anterior Motion S of V Sinus of Valsalva STJ Sinotubular Junction TR Tricuspid Regurgitation TV Tricuspid Valve TVI Tissue Velocity Index VSD Ventricular Septal Defect VTI Velocity Time Interval 2D Two Dimensional 3D Three Dimensional Parasternal Long Axis 1. 2D of RV, AO, LA, and LV

• Assessment of the RV wall and RV size. • Measurement of the LVOT, AV, S of V, STJ and ascending aorta diameter. • Measure the LA diameter from the AO (not the MV leaflets) to the LA posterior wall. • Assessment of LV function: anteroseptal and inferolateral walls from base to distal

segments. 2. 2D still at end-diastole to show LV wall and cavity measurements

• Measure IVS wall thickness below the level of the sigmoid septum. • Measure the LVED diameter at the level of the MV chords. • Measure the posterior wall thickness.

3. 2D still at end-systole to show LV wall and cavity measurements

• Scroll through to end-systole and measure the LVES diameter at the same level as the LVED.

4. M-mode of the LV, AO, and LA

• M-mode is still a very useful tool and as part of a complete exam; m-mode spectrals of the LV, AO and LA are required. Measurements do not need to be made.

5. 2D of AV and MV

• Zoom on the AV cusps and assess the movement of the right coronary and non-coronary cusps; assess for thickening, prolapse and masses.

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• Zoom on the MV and assess both leaflets for movement, coaptation and thickness. • Enlarge the zoom so the MV chords are visualized and assess for SAM, thickening and

masses on the chords. 6. Colour flow images of AV and MV

• Assess colour flow in the LVOT, through the valve and in the ascending aorta. • Look for regurgitation and turbulence. • If there is AI do a vena contracta measurement – measure the narrowest neck of the AI

jet coming through the AV and then measure the diameter of the AV root. 7. 2D still image of AV at end-systole to measure AV diameter

• Zoom on the AV and freeze frame the aortic valve at end systole to view the insertion of both cusps into the annulus. Measure at the point of insertion of the RCC, at the annulus, to the insertion of the NCC for a diameter—using markers will ensure continuity with serial exams and multiple scanners.

8. 2D RV inflow showing RVF and TV function

• Assess right ventricular wall function and size. • Assess TV movement, coaptation and thickness.

9. Colour flow image of TV

• Sector down the colour over the TV and the RA and assess for TR. Scan through the valve to pick up any eccentric jets.

10. CW Doppler of TR for RVSP

• Using the colour as a guide, place the CW cursor into the most turbulent section of the TR jet and measure the spectral wave that shows best with a complete round segment.

Parasternal Short Axis 1. 2D of RVOT, AV, LA, RA and IAS

• Acquire a 2D image of the SAX view of the AV. • Swing slightly to the left and concentrate on TV, RA and RV looking for masses and valve

pathology. • Zoom on the AV – look at all 3 cusps for thickening, motion, masses and raphe (partial or

full). • By making small movements with the transducer, look for the RCA and then swing again

looking for the LM and LAD and circumflex. • Look at the RVOT and look for muscle bundles or other possible obstruction. • 2D image of the IAS looking for movement, aneurysm, thickening or defects.

2. Colour flow image of AV and IAS for ASD

• Zoom in on the AV and turn colour on for AI – comment on the location of the jet(s).

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• Move down and concentrate on the IAS and look for colour going from one side to the other through the wall; take the colour off and measure the diameter of the defect.

• Describe the flow – left to right, right to left or bidirectional. • PW on the colour jet to demonstrate the difference between PFO and ASD flow.

3. 2D of PV and PA

• Zoom in on the PV and look for motion of the cusps – if possible do a sax view to show all 3 cusps in one view. If the PW movement looks restricted, put the m-mode through to look for the “flying W.”

• Demonstrate the PA from RVOT to the pulmonary branches. • Freeze and measure the diameter of the MPA.

4. Colour flow image to assess RVOT, PV, PA and to look for PDA flow

• Turn on colour feature and concentrate on each section of the pulmonary starting with the RVOT looking for turbulent flow then moving to the PV looking for PR and any unusual jets--you may pick up a fistula or aortopulmonary window. Look carefully with the colour on in the MPA at the junction of the branches for a continuous PDA jet; if jet seen demonstrate flow velocities with Doppler.

• If PR seen, place the CW over the PR jet and obtain an EDP measurement.

5. Pulsed wave (PW) Doppler of RVOT velocity • PW just below the PV in the RVOT to get a PV VTI.

6. CW of PV flow

• Turn on the colour and place the CW cursor through the most turbulent section of the jet to obtain a PPG and MPG.

7. 2D and colour flow of TV

• Zoom in on the TV and look at coaptation of the leaflets, then turn on the colour and look for TR; complete an RVSP by CW placing the cursor through the most turbulent section of the jet to get a complete spectral (very important).

• Zoom out and look at the TR jet showing the full RA chamber. 8. 2D of RV and LV at base level

• PSAX of the LV at the base level – just below the MV annulus – the annulus should not be seen – both MV leaflets should be seen.

• RV wall function can be assessed here also. 9. 2D of RV and LV at mid ventricular level

• PSAX of the LV at mid ventricular level which commonly includes the papillary muscles • RV wall function can also be assessed here.

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10. 2D of RV and LV at apical level • PSAX of the LV at the apex – this may require movement of an interspace to get a true

apical sax image. • RV apex may be seen at this level.

Apical 4 and 5 Chamber (ch) 1. 2D showing all of each of the 4 chambers

• First apical view should incorporate all of the chambers – the edges of all the walls should be seen: appropriate depth setting required.

• From this view can assess the size of the atria compared to the ventricles. • The size of the RV compared to the LV. • Presence of pericardial fluid. • Presence of masses. • Compression of any of the chambers.

2. 2D of end-diastolic LV volume trace

• Change the depth setting – you do not need the atrial chambers in this view. • Obtain a true 4 chamber view of the LV – true apex with LVOT not showing. • Freeze frame at end-diastole and trace from the anterior MV annulus around the entire

chamber to the posterior MV annulus (using markers to start and finish ensures continuity between studies and between techs).

• Save the image. 3. 2D of end-systolic LV volume trace (estimates EF)

• Scroll the same image to end-systole and retrace the LV from anterior MV annulus around to the posterior MV annulus; ultrasound machine will calculate a 4 chamber EF.

• Save the image. 4. 2D still of LA and RA end-systolic volume traces

• Change the depth setting to ensure the RA and LA are completely visible in the 4 chamber view.

• Begin with the RA and measure from the anterior TV annulus, trace around the RA to the septal TV annulus during end-systole to obtain a volume – stop at the annulus—do not trace into the TV valve.

• Repeat for the LA and obtain a 4ch LA volume. • Store images.

5. 2D focusing on RV function

• RV study does not require a clear LV image. • Adjust your imaging plane slightly anterior to obtain a nice view of the RV from base to

apex.

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6. 2D still image with RV diameter just above the TV annulus - widest point • Once you have obtained a nice RV image, freeze frame and scroll until you have the

widest point of the RV and measure the diameter just above the TV annulus from internal ventricular septum to internal lateral RV free wall.

7. M-mode TAPSE measurement of RV motion

• Place the m-mode cursor through the anterior wall so it goes through the lateral TV annulus, hit m-mode—when you have a clear tracing, measure the lowest point of the spectral to the highest point. This is not a slope measurement but a motion measurement.

8. PW Doppler TDI to assess lateral tricuspid annulus motion

• Using the same image as before, turn the TDI on and place the PW cursor over the lateral TV annulus, adjusting the gain for better placement. Turn the PW on; adjust the scale and gain to get a clear spectral wave showing the systolic and diastolic wave forms. Freeze and place the caliper at the systolic peak, the diastolic E and diastolic A points. Store the measurements.

9. 2D of LVOT in 5 chamber view with and without colour flow

• Switching to a 5 chamber view, image the LVOT. • Turn the colour on and look at the LVOT colour flow for turbulence. • Assess for AI.

10. PW Doppler of LVOT velocity in 5ch view

• Open the LVOT so both AV cusps are visible; place the PW cursor just off the AV (not on the valve) and adjust the scale and gain to receive a nice tracing; freeze the frame and trace the spectral to get peak velocity, VTI, SV and CO.

11. CW Doppler of AV flow in 5ch view

• Using the same view, turn the colour on and place the CW cursor through the most turbulent part of the AV flow to obtain the highest gradient across the valve; adjust the scale and gain to receive a nice spectral image and trace the spectral to obtain a PPG, MPG, VTI and AVA.

• If AI viewed, place the CW cursor over the jet and obtain a PHT. 12. 2D with colour flow on entire IVS wall looking for VSD

• Using the 5ch view and concentrating on the IVS from the AV to the apex. • Visualize the IVS before putting the colour on to look for defects, aneurysms or

diverticulum. • Place colour sector over the IVS looking at the perimembranous right out to the

muscular apex. • If defect viewed, turn the colour off and measure the diameter of the defect if possible.

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• Doppler the shunt flow from the best possible angle to receive a peak velocity and gradient.

• A shunt ratio calculation should be obtained. 13. 2D imaging of MV and TV simultaneously

• 2D image of the MV and TV with the focus at the level of the valves, looking at movement, thickness and coaptation.

14. Colour flow and CW images of MV

• Focus on the MV and image separately before turning the colour on; scan through the valve, anterior to posterior and look for the best jet(s).

• If the MR jet is moderate or more perform a PISA –zoom in on the valve where the colour jet is coming through; change the colour scale to approximately 38, freeze frame the best cap and using the PISA preset measure the radius of the cap.

• Next unfreeze, place the CW cursor over the jet and obtain a MR spectral that can be outlined with the PISA package.

• The MR CW spectral is also important for looking at timing of the jet and density of the flow—this helps to decide the severity of the MR jet.

15. PW Doppler at the tips of the MV leaflets for diastolic function measurement

• Place the PW cursor at the tips of the MV leaflets in the 4ch view; obtain a nice PW spectral of the MV flow wave. Pick the E/A wave marker from the diastology preset list. Place the marker at the top of the E wave and move the marker down the slope of the E wave to the bottom to obtain the deceleration slope measurement—move the marker to the top of the A wave.

16. TDI of medial and lateral MV annulus for diastolic function measurement

• Acquire a 2D 4ch image showing the MV septal annulus and lateral annulus. Turn the TDI feature on, adjust the gain, place the PW marker on the septal annulus and obtain a clean spectral waveform showing the systolic and diastolic waves. Measure each wave using the TDI preset.

• Repeat the process for the lateral wall. 17. PW Doppler through the MV leaflets at the level of the annulus

• Obtain a 4ch LV image focusing on the MV and place the PW cursor through the MV at the level of the annulus. Turn on the spectral; there should be an image of a blunted E wave and an A wave. Using the diastology preset for MV A wave duration, measure the onset of the A wave to the end.

18. PW Doppler at the level of the LVOT while catching the MV inflow

• To measure the IVRT for diastolic function, place the PW cursor in the LVOT along the anterior MV leaflet so that the spectral wave will show the V1 AV spectral and the onset

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of the MV inflow waveform. Using the IVRT preset for diastolic function, measure from the end of the AV wave to the start of the MV wave—this will give you the IVRT.

19. Colour M-mode for colour flow propagation

• Acquire a 2D LV 4ch view showing the MV and the entire LV. Turn the colour on showing the MV inflow from valve to apex. Adjust the scale (opposite way from PISA) to 38. Put the m-mode cursor through the colour flow; the colour m-mode should show a line for the MV leaflet closed in systole and a flow jet in diastole. Freeze frame on a nice image and using the slope calipers, measure from the base of the colour jet to the top. Ensure that the jet is not cut off.

20. PW Doppler for pulmonary vein flow

• Using the 4ch view (centering the image on the LA, not the ventricles) and with 2D imaging, locate the orifice of the superior pulmonary veins.

• Turn the colour on and adjust the scale to enhance the flow jet, and then place the PW cursor in the vein. Hit the PW and look at the spectral—may need to adjust the scale to get a nice waveform. Always place the PW marker in the vein to get a cleaner spectral; if place the marker at the orifice, but in the LA, will receive artifact.

• Measure the systolic, diastolic and A wave points, then measure the A wave duration in diastolic function presets.

21. Colour flow image of TV

• Focus on the right heart and the TV, turn the colour on and scan through the TV looking for the largest TR jet.

• If the jet is more than mild, a PISA measurement can be performed for an ERO.

22. CW TV to get RVSP estimation • Place the CW cursor over the best TR jet and look for the cleanest spectral showing a

complete TR waveform to measure. If the full jet is not demonstrated, it may be due to a measurement of the valve opening or closing.

Apical 2ch 1. 2D showing LA and LV optimized for segmental function

• Demonstrate a 2D image of the LV showing the inferior and anterior walls; in this view may also see the coronary sinus. The MV anterior leaflet must be attached to the anterior wall, rather than inferior. Also use a depth setting that gives a full 2D view of the LA.

2. 2D of end-diastolic LV volume traced

• Assess LV wall motion, then freeze and scroll to an image at end-diastole and using the annulus as markers, trace the LV from the inferior annulus around the apex and down to the anterior annulus. Do not trace the pap muscles as part of the myocardium.

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3. 2D of end-systolic LV volume traced

• After completing the end-diastolic measurement, scroll through image to end-systole and repeat the process. This will provide an estimated biplane EF measurement.

4. 2D of end-systolic LA volume traced

• Trace the LA at end-systole for an LA volume; with the completed 4ch volume the computer should give an LA indexed measurement.

5. Colour flow of MV

• Image the MV leaflets and turn the colour on scanning through the leaflets to get the maximum jet.

• PISA and CW of the MR jet can be completed. ALAX 1. 2D of LV, RV, AO, LA, AV and MV

• From the 2ch view, turn slightly until the LVOT comes into view on the right side of the screen.

• Assess LV anteroseptal, inferolateral, and RV for regional wall motion abnormalities. • Review LVOT, MV and LA for pathology.

2. Colour flow imaging of MV and AV

• Turn on the colour and assess for abnormal flow or regurgitant jets not seen in other views.

Subcostal 1. 2D of 4 chamber view

• 2D image of the heart from just below the rib cage looking up; make small adjustments to show all 4 chambers, the TV and MV

• Look for pericardial effusion, extracardiac mass compressing the heart, pleural effusion and ascites

2. Colour flow on IAS to look for PFO or ASD

• Zoom in on the IAS showing it in its entirety, turn the colour on, decrease the colour scale if needed and look for flow crossing the IAS.

• Scan through to show SVC flow and the segment of the IAS where a sinus of venosus shunt would be located.

• If shunt flow is seen, turn off the colour and measure the defect diameter. A shunt ratio calculation is required.

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3. 2D of 5 chamber view • With slight movement demonstrate the LVOT and ascending aorta. This view is a good

alternative if unable to get an AS gradient from the apical views. 4. 2D of IVC

• While the IAS is in view, turn the transducer and demonstrate the IVC. Attempt to show a fairly long segment of the IVC so the ostium is visible, where the hepatic vein attaches and the distal segment of the IVC. Measure the diameter at the proximal segment about 5mm from the ostium.

• The size and movement of the IVC will help determine the RAP. 5. Colour on the IVC and Hepatic vein

• Turn on the colour and watch for flow reversal in the hepatic vein. PW Doppler in the vein and show the spectral.

6. M-mode to measure change in IVC diameter with sniff

• Place the m-mode cursor through the IVC where measurement of the diameter occurs. When a clean signal is achieved, ask the patient to sniff. Freeze the waveform and measure the maximum IVC diameter and the sniff diameter. The ultrasound machine should have presets for this.

7. SAX 2D view of AV, PA, pulmonary branches, TV, RA

• This SAX view is useful when the 3 AV cusps are not visible from any other view/or the PA, PV and branches are not visible; this is a good view to do an RVOT PW Doppler.

8. 2D abdominal view of the abdominal aorta

• From the subcostal view move slightly to the left and angle into the abdomen following the descending aorta as far as possible; observe for dilatation of the aorta (if seen), freeze and measure widest diameter and document the presence of thrombus.

Suprasternal 1. 2D of aortic arch

• Have the patient lie on their back and tilt their head back as if they are trying to see behind them. Set the transducer in the suprasternal notch and image all segments of the aortic arch. With fine movements the ascending, transverse, branches and descending aorta will be visible.

2. Colour on aortic arch

• Place the colour over the ascending aorta; move through the arch and into the branches – then along the descending aorta.

• Observe for turbulence, narrowing, shunting and flow reversal.

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3. CW of descending aorta to assess for coarctation • Place the CW cursor into the flow of the descending aorta and Doppler looking for

narrowing, increased turbulence and Doppler spectral run off. 4. Colour image of SVC flow

• From the suprasternal notch, move slightly left and with the colour on look for a continuous blue flow.

Note: If pathology is found during the course of the study, additional images and off angle views may be required for a complete study.

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Process for Adult Transthoracic Echocardiogram Standard E2 Standard F1 Example Purpose: To provide a standard process and outline expectations for best practice while performing an adult TTE. Pre-Test:

• Patient introductions and explanations with time for questions. • Patient identification. • Verbal & written consent obtained from patient to proceed with test. • Obtain height, weight, medication list, allergy list and cardiac history. • Review requisition to ensure indication appropriateness and determine focus of the

study. • Request that patient undress from the waist up and put on a gown. • Attach ECG electrodes, ensuring a good signal needed for looping and acquisition of

digital images. • Record resting blood pressure. • Ensure patient safety, comfort, confidentiality and modesty (drape with towel). • Request that patient lie in a left lateral position. • Use echo bed with cut out if available.

Test:

• Follow written protocol for the performance of an adult transthoracic study images and measurements.

• Perform a complete and thorough study, unless focused study preapproved due to circumstances.

• Focus on quality in a timely and efficient manner, with minimal patient discomfort. • Adult TTEs have an allotted time slot of 45 minutes with a 15 minute window for

complicated cases. • If a study is technically difficult or inadequate, the sonographer is expected to seek

assistance from a colleague to complete the study. • The sonographer is responsible for deciding if contrast use is beneficial. • Portable studies are to be completed when clinically indicated or requested. • Sterile probe covers are to be used during sterile procedures. • No test information can be provided to the patient by the sonographer: results are to be

communicated by physician. • Infection control guidelines are to be followed with patients suffering from an infectious

condition.

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Post-Test:

• Remove electrodes and clean gel from patient. • Stay with patient while they transition from the bed, assess stability. • Ensure patient modesty and assist getting dressed as needed. • Complete documentation of the preliminary report, and export to reading.

Cardiologist: Ensure all fields are completed and information is accurate.

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TTE Additional Imaging Views for Pathology (Adult) Standard E5 Preamble Besides the standard imaging views completed for a normal TTE study, additional views are required to help determine a diagnosis when pathology is present. Describe the laboratory protocols for abnormal pathology. Aortic Stenosis PLAX:

• Standard AV view with m mode to display timing of valve opening, and closing and thickness of cusps.

• Use of the zoom feature on the valve for careful AV root visualization and measure. • 2D diameter measurements of the Sinus of Valsalva, sinotubular junction and ascending

aorta. PSAX:

• AV 2D imaging using the zoom feature. • Adjustment of controls to enhance endocardial definition. • Adjust angle of view to ensure all 3 cusps are clearly viewed. • Planimetry of the valve.

APICAL 5ch:

• Zoom-in feature on 2D image of AV and LVOT. • Assess color by Doppler, any eccentricity of flow. • PW of the LVOT at the level of the cusps. • CW Doppler through the most turbulent flow of the AV color jet, for PPG and MPG. • Vena contract to assess AR severity. • ERO. • Pedoff (non-imaging transducer) flow velocity.

ALAX (Apical 3ch):

• 2D of AV function. • Color flow Doppler. • CW through AV.

Subcostal

• Alternate view: AV SAX showing the aorta, turn color on and place CW cursor in the most turbulent flow, for PPG/MPG.

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Suprasternal:

• Arch view concentrating on the ascending aorta: turn on the color and complete a CW Doppler and pedoff measurement for PPG and MPG.

Right Sternal Border:

• Turn patient on their right side and image the ascending aorta from the RPLAX view, turn the color on and find the turbulent area of the color flow using CW and/or pedoff probe—measure for the maxim PPG and MPG.

Pericardial Effusion PLAX:

• Set the depth setting to identify pericardial or pleural effusions. • Measure the diameter of the fluid during diastole from different points. • Assess for pericardial fat or thrombus.

PSAX - LV/RV:

• Set depth setting to view around the LV and the RV. • Measure the diameter of the fluid from different points, during diastole.

PSAX - AV/PV:

• Doppler the pulmonary outflow with pulsed wave and a slow sweep speed to view variation with respiration in the Doppler spectral waves.

• Turn respirometer on—leave on for duration. • Assess for fluid and measure.

Apical 4 Chamber View:

• Set depth setting to ensure all 4 chambers are completely viewed. • Measure fluid from different points around the heart during diastole. • Look for effects on the RV and RA. • Place m mode cursor through the RA and time collapse of the RA free wall between R-R. • Doppler MV inflow with pulsed wave and a slow sweep speed to watch for respiratory

variation. • Doppler TV concentrating on the E wave size, slow sweep speed and respiratory variation.

Apical 5 Chamber View:

• Doppler the AV LVOT with PW on a slow sweep speed and assess for respiratory variation. Subcostal view:

• Depth setting to see all around the heart. • Complete measurements at various points around the heart during diastole. • If RV collapses, place m mode through the RV free wall, through the IVS and through the

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LV to display the RV free wall movement to time the severity of the collapse. SAX:

• Measure IVC plethora and complete sniff test to assess collapsibility. • Pulse on the hepatic flow.

Document:

• Location of fluid: located, circular. • Diameter range from the views: circular pericardial effusion measuring 1.5 to 2 cm with

the highest measurement by RA. • Signs of tamponade: RV collapse throughout the R-R cycle.

Note: Most pathologies will require additional views and measurements hence the lab should have criteria in place to demonstrate the expected information to be obtained.

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Protocol for Echocardiographic Measurements and Doppler Purpose: To ensure consistent acquisition of echocardiographic measurements in a multi-staffed institution.

Abbreviation AS Aortic Stenosis AVA Aortic Valve Area CO Cardiac Output ECG Electrocardiogram LVED Left Ventricular End Diastolic LVEDd Left Ventricular End Diastolic diameter LVEDvol Left Ventricular End Diastolic volume MPG Mean Pressure Gradient NSR Normal Sinus Rhythm IVC Inferior Vena Cava RVID Right Ventricular Internal Diameter RVIDd Right Ventricular Internal Diameter in diastole SV Stroke Volume TAPSE Tricuspid Annular Plane Systolic Excursion TDI Tissue Doppler Imaging Most measurement techniques are completed in accordance with the recommendations of the ASE (American Society of Echo). 1. Most chamber and vessel dimensions are taken from 2D images using inner edge to inner

edge methodology. 2. Wall thickness measurements are from outer edge to outer edge. 3. Arrhythmias to be recognized and adjustments made to technique depending on the

dysrhythmia as per below. A good ECG signal is essential. • Patients in sinus rhythm, one cardiac cycle is required with measurements obtained

during held expiration. • Patients in atrial fibrillation require a 5 cycle loop that will be averaged. • Patients with frequent premature beats will require careful selection to ensure the

measurement is NOT made on a premature beat or after a premature beat. Wait for a sampling of NSR.

4. If measurement varies significantly with respiratory variation, 3 to 5 cycles are required with measurement made on held expiration. Taking measurements on held respiration avoids issues of respiratory variation.

5. The depth or calibration scale should be adjusted to enlarge the structure enough to make an accurate assessment.

6. Sweep speed should be adjusted when acquiring multiple cycle measurements.

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7. Contrast should be used to improve accuracy of LV volume measurements when study technically difficult.

Chamber (ch) Measurements 1. LVEDd – Plax 2D image – millimeters (mm) - measure inner edge to inner edge at peak of

the ECG “R” wave. Choose a perpendicular transverse diameter at the MV chord level. Avoid the basal septum where it tends to be sigmoid and avoid the MV annulus.

2. LVESd – Plax 2D image – (mm) - measure inner edge to inner edge at smallest chamber size and at the level of the MV chords.

3. Septal wall thickness – Plax – (mm) – outer edge to outer edge at peak of the ECG “R” wave. Avoid including the RV septum.

4. Inferolateral (posterior) wall thickness – Plax – (mm) – leading posterior endocardial edge to outer edge of epicardium at peak of ECG “R” wave.

5. LVEDvol – Apical 4ch – milliliters (ml) – trace endocardial edge at peak of ECG “R” wave excluding papillary muscle and trebeculations. Avoid foreshortening of the apex.

6. LVESvol – Ap4ch – (ml) – trace endocardial inner edge at smallest cavity size. 7. LVEDvol – Ap2ch – (ml) – repeat 4ch method using the 2ch view 8. LVESvol – Ap2ch – (ml) – repeat 4ch method using the 2ch view 9. RVIDd – Ap4ch – (mm) – inner edge to inner edge at peak of ECG “R” wave. Measure at the

base of the RV close to the TV annulus at its maximum diameter. Use an imaging window that maximizes the RV and RA without reducing the LV and LA.

10. TAPSE – Ap4ch – (mm) – m-mode cursor on lateral TV annulus to measure peak systolic velocity

11. RV TDI – Ap4ch – (cm/sec) – pulsed Doppler TDI gate on lateral TV annulus to measure peak systolic velocity

12. LA anterior/posterior diameter – Plax 2D – (mm) – trailing edge of aortic root wall to leading edge of posterior LA wall at maximum diameter in a plane passing through aortic valve cusps. Measurement should NOT be done from the MV leaflets or the MV annulus.

13. LA vol – Ap4ch – (ml) – trace inner edge of LA wall at maximum volume in end-systole. Do not include pulmonary veins or left atrial appendage as part of the LA volume. Do not measure atrial volumes from views that foreshorten the LV apex.

14. LA vol – Ap2ch – (ml) – same as 4ch view 15. RA vol – Ap4ch – (ml) - trace inner edge of RA wall at maximum volume in end-systole Vessel Measurements 1. Aortic diameters – Plax – (mm) – inner edge to inner edge measurements from 2D images.

Measure at maximum diameter in systole. a) LVOT annulus – freeze frame with AV cusps open and insertion of the non coronary

and right coronary cusps to the annulus are seen. Measure from the anterior annulus to the posterior annulus at the junction of the insertion of the cusps.

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b) Sinus of Valsalva – widest inner diameter between anterior and posterior sinus perpendicular to the aorta.

c) Sinotubular junction – smallest diameter at junction of the sinuses and ascending aorta.

d) Ascending aorta – widest perpendicular diameter above the level of the STJ. e) Transverse arch – widest perpendicular diameter avoiding the origins of the neck

vessels. f) Descending aorta – perpendicular diameter below the left subclavian artery origin.

2. Pulmonary diameters – Psax – (mm) – inner edge to inner edge perpendicular diameter

measurement. Do not measure if walls are not seen. Measure at maximum diameter during systole.

a) RVOT annulus – freeze frame and measure inner edge of anterior RVOT wall to leading edge of anterior aortic wall.

b) Pulmonary valve annulus – Diameter measured where PV cusps insert. c) Main pulmonary artery – measure widest diameter of the PA trunk. d) Pulmonary branches – if able to get nice image where edges are seen well –

measure the diameter of each branch at its’ widest point. 3. IVC diameter – subcostal view – (mm) – start with 2D image of IVC and then pass m-mode

cursor through perpendicularly 0.5 to 3 cm from entry of the hepatic vein. Obtain a nice m-mode tracing of the IVC and have patient sniff – freeze frame – and measure the IVC at maximum width and sniff width. If sniff cannot be performed measure the minimum IVC inspiratory diameter with respiratory marker turned on for timing.

Doppler

• Sampling should be as parallel to the jet as possible for pulsed wave (PW), continuous wave (CW) and TDI. Angle correction should be used only if absolutely necessary. Use color to assist with acquiring the correct angle.

• Filters, gains, scale, baseline, gate width, PFR and aliasing will need adjustments to

improve the quality. These variables may be set automatically according to presets however they should be reviewed and modified as needed.

• When measuring velocity, the vertical scale is to be expanded to produce a full size

image for better accuracy. • When measuring time intervals or slopes, maximum sweep speed should be

adjusted. • Measurements should be made on held expiration to eliminate respiratory variation.

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• Premature and post premature beats should not be measured. When there is atrial fibrillation or variable flutter, 3 to 5 cycles should be used and averaged for pressure gradients. Diastolic function cannot be assessed accurately with atrial arrhythmias or heart blocks.

• For measurements that require demonstration of respiratory variation such as

Tamponade or Constriction, use a slow sweep speed with respiratory marker turned on.

Hemodynamics in Valve Disease

Aortic Stenosis

Measurements required:

1. LVOT diameter (needed for AVA) 2. PW V1 peak velocity (AVA) 3. TVI of LVOT V1 (AVA,CO,SV) 4. CW V2 PPG and MPG and VTI 5. AVA will automatically be calculated from these measurements

1. LVOT diameter – Plax – (mm) – measure during systole – place calipers at the same level

used for the LVOT V1 velocity. Measure from septal endocardium to base of anterior MV leaflet.

2. PW V1 peak velocity – Ap5ch view – (m/sec) – place sample volume as close to AV annulus as possible to obtain maximum nonturbulent velocity.

3. TVI of LVOT V1 – Ap5ch – using the V1 spectral sample obtained in number 2 – trace the AV spectral from onset all the way around to closure – then drag to the onset of the next AV spectral waveform – if preset in place this will give you CO and SV also.

4. CW V2 – Ap5ch – (m/sec, mmhg) – using the continuous wave feature place the cursor in the most turbulent section of the AV flow and look for the best spectral wave to measure the AS velocity and gradient. The gradient should be double checked using the non-imaging Pedoff probe in multiple imaging windows (apical, right sternal border, suprasternal and subcostal)

Only the highest values with a complete spectral wave should be saved and averaged for calculating the AS PPG and AVA.

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Protocol for the Addition of Contrast to Echocardiography Studies Description: Contrast is an encapsulated micron-sized gas bubble used in medical ultrasound. The encapsulation is made of protein, lipid or surfactant. Definity brand contrast is composed of lipid-coated microspheres filled with octafluoropropane gas used for cardiac and vascular imaging. Indications Contraindications • Patients with technically difficult imaging

windows. • Allergy to contrast

• To delineate intracavity mass borders. • Shunt with right to left bidirectional flow. • To differentiate vascular masses and non-

vascular masses. • Within 24 hours of a lithotripsy procedure

(shock waves for kidney stones). • To enhance inadequate Doppler flow signals. • Refer to company information for updated

contraindications. • To differentiate between apical hypertrophy

and noncompaction. • Physician should make the decision whether

to give to pregnant patients. Determining Need:

• The need for contrast is decided early in the study by the sonographer. • Recommendation to complete the 4 chamber check at the beginning of the study to identify

the need early and arrange for the injection by the appropriate staff. • The administration of contrast is completed by the physician, a Registered Nurse or a

sonographer that has completed a program and a Delegated Act review. Supplies Needed:

• Large bore angiocaths • Skin prep • Tegaderm • Gauze • Tourniquet • Normal saline vials

• Contrast vials • Contrast vial agitator • 10 ml syringe • Needle • Gloves • Tape

Procedure:

• Explain to the patient the need to use contrast to provide a complete study. • Explain the risks and possible adverse reactions to patient and provide time to answer any

questions. • Obtain a verbal/written consent to continue. • A large bore angiocath in the antecubital vein is required (the larger the angiocath, the bigger

the bubble, the brighter the contrast results). • Apply tourniquet, prep skin as per organization policy, insert angiocath into vein – a closed

angiocath system works best – otherwise an IV line is required. • Ensure the ultrasound machine is on the contrast preset application package – manipulation of

the settings is important to receive maximum benefit from the injection.

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• Agitate contrast vial as directed to go from a clear solution to a milky colour. • Vent vial to release air; do not inject air into the vial. • In a 10 ml syringe, draw up 1 ml of contrast and 9 ml of saline. Roll in palms of hands to mix. • Draw up a saline flush syringe. • There are several ways to administer contrast: directly, or mixed in a mini bag and infused by

pump. • Occasionally there is a blackout in the far field – this will resolve after approximately 10 beats. • Swirling in the left ventricle may require lowering of mechanical index. • Acquire images and/or Doppler. • Zoom into the apex and assess for mural thrombus. • A good time to do an RVSP is when the contrast weakens. • Contrast bubbles can be broken down by changing the preset back to full strength and imaging. • Remove angiocath, apply pressure and apply bandage.

Considerations:

• Echo Lab should have an antihistamine kit in case of an adverse reaction. • Crash cart should be close by. • Patient should be kept for a minimum of 20 minutes from the time of injection to ensure they

have been properly assessed for a reaction. • Oxygen saturation monitor available in case of breathing difficulties – COPD or asthmatic

patients may require monitoring. • If a patient has an RVSP of greater than 70 mmhg: a physician should make the decision

whether to give contrast or not. • Pre-printed order forms in place for administration. • Any adverse reaction (most common are rashes and back pain) should be documented and

reported to the supervising Cardiologist so the patient can be assessed. • Contrast can be used for TTE, TEEs to help define LAA thrombus, and with stress tests to better

define all the LV walls. Reasons to Use Contrast:

• Patient obesity. • Horizontal or vertical cardiac placement. • Pneumothorax. • Patient immobile and cannot be positioned properly. • Pectus excavatum. • Narrow rib spaces. • Patient uncooperative or agitated.

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Agitated Saline Echocardiography Protocol • Defined as the intravenous injection of saline after agitation between two syringes. • Enhances the backscatter of the ultrasound beam. • The micro bubbles generated are too large to cross the pulmonary capillary bed;

visualization of saline in the left heart indicates either intracardiac or transpulmonary shunting.

Provocative maneuvers are used to increase RA pressure above LA pressure; right to left shunting more evident. 1. Valsalva Maneuver 2. Cough 3. Sniff Technique • Explain procedure and obtain written consent. • Use the term “agitated saline” and avoid description of "bubbles" if possible. • Insert large bore angiocath into the right antecubital vein (preferred site - shortest distance

to the heart for maximal agitation). • Using two 10 cc syringes, draw up 8.5 ml of normal saline, 1 ml of blood from the IV site and

0.5 ml of air. • Prior to injection, select a view with clear imaging of the intra-atrial septum and left heart:

apical 4 chamber or subcostal are preferred views. • Begin a loop so the first image does not show any saline and the agitated saline enters the

RA and into the RV. • Obtain a minimum of 10 beats in the loop so to enable counting the number of beats before

saline is seen in the left heart. • Agitate solution forcefully between two syringes that are attached to a 3way stopcock, until

solution appears cloudy. • First injection is performed at rest. • Second injection is performed with a provocative maneuver. • Valsalva should begin immediately before injection and released when there is dense

opacification. • Bowing of atrial septum towards LA indicates a satisfactory valsalva. • Up to 5 injections may be required to obtain a satisfactory study. • Abdominal compression with sudden release can be used during a TEE procedure - where a

patient cannot comply with instructions. • When leftward bulging of the IAS and dense contrast filling of the RA are present, the

sensitivity for PFO detection after a single injection is 95%; color flow Doppler alone is less than 50% sensitive.

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Results Results are coded as positive for PFO detection if there any micro bubbles seen in either of the left heart chambers within 5 beats of the entrance of the saline into the RA. Late appearance of contrast, > 5 beats, is most likely due to intrapulmonary shunting. Valsalva Maneuver Instructions: It is extremely important to give the patient clear instructions on the valsalva maneuver as proper valsalva is the key to clear results. “Mrs. T, could you please help me with this next part of the test? What I need you to do is stop breathing when I ask you to: please do not take a big breath in or let it out. Stop wherever you are in your breathing, and then push out with your stomach.” (Place your hand on their abdomen and have them push out against it). “When I say stop breathing and bear down, please do so until I instruct you to relax.” Perform a practice run with the patient to ensure your image stays in the frame. Perform the maneuver with the saline injection, storing at least 10 loops to review at a later time.

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Normal Values for Echocardiographic Measurements and Hemodynamic Readings Examples in Alphabetical order: Note - values may differ slightly at different institutions.

AAA Rupture Risk < 4 cm 0% /yr 4 to 5 cm 0.5 – 5% /yr 5 to 6 cm 3 – 15% /yr 6 to 7 cm 10 – 20% /yr 7 to 8 cm 20 – 40% /yr > 8cm 30 – 50% /YR Aortic Regurgitation (AR) Normal velocity 3 – 5 m/sec PHT by CW Mild > 400 msec Mod 250 – 400 msec Severe < 250 msec Vena Contracta Mild < 0.3 Severe > 0.6 cm Jet width Mild < 25% Severe > 65% Regurgitant volume Mild < 30 Moderate 30 -59 Severe >60 Regurgitant fraction Mild < 30 Moderate 30 - 49 Severe > 50 EROA Mild < 0.1 Moderate 0.1 – 0.29 Severe >0.3 Aortic Stenosis (AS) AVA Normal > 2cm2 Mild 1.5 - 2 Moderate 1.1 – 1.5 Mod severe 0.7 - 1 Severe < 0.7 PGs Normal < 20 mmhg Mild 20 - 40 Moderate 40 - 80 Severe > 80 mmhg Mean PGs Mild < 30 mmhg Moderate 30 – 50 Severe > 50 mmhg

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Velocity Mild < 3 cm/sec Moderate 3 – 4 Severe > 4 cm/sec BSA (body surface area) males 134 gm/m2 females 110 gm/m2 Cardiac Index (CI) CO/BSA Cardiac Output (CO) SV x HR Normal 4 – 6 L/min Congestive Heart Failure (CHF)

Readmission rate 22.6% /yr

5 yr mortality rate 50% Sleep apnea rate 45 – 55 % Atrial fibrillation 20% Coronary Artery Right dominant circulation 80% Left dominant 20% CRT Requirements Criteria Symptomatic Wide QRS > 130msec EF < 35% Diameters Aortic annulus 1.4 – 2.6 cm Sinus of Valsalva 2.1 – 3.9 cm Sinotubular junction 1.7 – 3.4 cm Ascending aorta 2.2 – 4 cm Transverse arch 2.2 – 3 cm Descending aorta 1.8 – 2.4 cm LA 2.3 – 3.8 cm Giant LA > 8 cm MV annulus Plax 1.8 – 3.4 cm MV annulus 4ch 1.9 – 3.1 cm MV annulus 2ch 2 – 2.7 cm LVEDd 3.5 – 6 cm LVESd 2.1 – 4 cm Fractional shortening 25 – 46 % IVS 6 – 11 mm PW 6 – 11 mm LVID 37 – 53 mm LVIS 23 – 36 mm RVID 25 – 38 mm

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TV annulus 1.7 – 2.8 cm PV annulus 1.1 – 2.2 cm Right pulmonary artery 1.4 – 2.7 cm Coronary artery SAX 2- 4 mm Coronary sinus 3 – 8 mm IVC proximal 12 – 23 mm IVC distal 11 – 25 mm Hepatic vein 6 – 11 mm Diastolic Function E/A ratio 1.1 – 1.5 Impaired < 1.0 Pseudonormal 1.1 – 1.5 Restricted > 2.0 MV E Normal 0.7 – 1.2 Abn relaxation < 0.5 m/sec Restricted > 1.2 MV A Normal 0.4 – 0.8 Abn relaxation > 0.8 Restricted < 0.3 m/sec DT slope Normal 167 - 240 c Valsalva Preserved E/A ratio Abnormal relaxation > 240 c Valsalva No change in E/A Pseudonormal 160 - 240 c Valsalva E/A ratio reversal Restricted < 150 c Valsalva Reduced or reversed E/A Fixed restricted

c Valsalva No response to preload reduction

IVRT over 40 yrs 76 +/- 13 msec Under 40 69 +/- 12 msec Impaired >90 Restricted < 60 Pul veins Normal S wave 0.3 – 0.66 D wave 0.3 – 0.7 A reversal < 35 cm/sec Pseudonormal A reversal > 35 > 30 of MV A duration Restricted As pseudo Ebsteins Criteria > 8 mm/m2 (BSA)

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ECG Anterior MI V1, V2, V3, V4 Lateral MI I, AVL, V5, V6 Inferior MI II, III, AVF RV MI V4R Posterior MI V1, V2, V8, V9 Ejection Fraction (EF) Normal 55 – 65 % Mildly reduced 45 – 55 % Moderately reduced 35 – 45 % Grade 4 < 35% Eisenmengers RVSP > 120 mmhg EPSS Normal 5 – 7 mm Abnormal > 10 mm ERO Grade 1 < 10 mm2 Grade 2 10 – 25 Grade 3 25 – 35 Grade 4 > 35 mm2 Hypoglycemia Glucose reading < 4 INR Normal 1.2 With therapy 2 - 3 IVC CRI (cavity respiratory index)

< 20 mm & collapses > 50% with sniff

RAP 3 - 5

< 20 mm & collapses < 50% with sniff

RAP 8 -10

> 20 mm & collapses < 50% with sniff

RAP 15

> 20 mm diameter & no collapse RAP 20 Ventilated patients Use CVP < 12 mm diameter RAP < 10 Unable to sniff IVC diameter with m-mode

& respirometer on 20% decrease = 50% with sniff

JVP 2 – 4 cm

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LA pressure Normal 4 – 12 mmhg Increased pressure > 12 mmhg LA EF < 30% Increased pressure > 20 mmhg MV E wave > 1.5 m/sec

without MS or MR Increased PAP LVSF abnormal With PFO or ASD 4 x (peak shunt vel)2 + RAP LVEDP Normal 3 – 12 mmhg Abnormal > 20 mmhg MV DT < 140 msec Shortened IVRT <60 Pul vein A reversal peak vel

> 35 cm/s Pul vein A reversal flow

duration > 30 msec LV SP Normal 100 – 140 mmhg LV Mass Index Normal males 50 – 102 g/m2 females 44 – 88 g/m2 LVOT Obstruction > 50 mmhg Mitral Valve Avge velocity 0.9 ( 0.6 – 1.3 ) VTI 10 – 13 cm Mitral Regurgitation Normal 4 – 6 m/sec Moderate to severe MV E wave > 2.5 Rule of 4-7 for severe MR ERO 4 Regurgitant fraction >50 Regurg volume > 60 Vena contracta > 7 Central jet Mild < 20% of LA Severe > 40% of LA Regurgitant volume Mild < 30 Moderate 30 - 59 Severe > 60

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Regurgitant fraction Mild < 30% Moderate 30 – 50 % Severe > 50% EROA Mild 0.2 Moderate 0.2 – 0.39 Severe > 0.40 MV E wave > 1.2 cm2 Mitral Stenosis MVA Normal > 3.4 cm2 Mild > 2 cm2 Moderate 1.5 – 2 cm2 Moderate to severe 1 – 1.5

cm2 Severe < 1cm2 PHT Normal < 100 msec Mild 100 - 150 Moderate 150 - 200 Severe > 220 msec MPG Mild 5 mmhg Moderate 6 – 12 Severe > 12 mmhg MPI Grade 1 < 0.4% Grade 2 0.4 – 0.6 Grade 3 0.6 – 1 Grade 4 > 1 % MV Scallops Anterior leaflet A1, A2, A3 Posterior leaflet P1, P2, P3 5ch view A1, P1 4ch view A2, P2 4ch angled posteriorly A3, P3 TEE 2ch view P3, A2, P1 TEE LAA view P3, A2, A1 Noncompaction Ratio of noncompacted to

compacted wall thickness at end > 2:1

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systole Pericardial Effusion Mild < 1 cm separation = 300 ml

fluid Moderate 1 to 2 cm = 500 ml Severe > 2 cm = > 700 ml Pericarditis - Constriction Septal motion Respiratory shift MV E/A ratio > 1.5 MV DT < 160 MV inflow resp variation present Hepatic Doppler Inspiratory diastolic flow

reversal Mitral septal annulus e’ > 7 cm/sec Mitral lateral annulus e’ Lower than septal e’ PISA Grade 1 radius diameter < 4 mm Grade 2 5 – 7 mm Grade 3 8 – 10 mm Grade 4 > 10 mm Radius > 10 = ERO > 35 mm2 Pulmonary Artery Pressure (PAP)

systolic 15 – 30 mmhg

mean 9 – 18 mmhg PAEDP 4 – 12 mmhg Pulmonary Stenosis PPG Normal < 5 Mild 5 - 30 Moderate 30 - 64 Severe > 64 mmhg Pulse Pressure Syst B/P - Diast B/P Pulse Alternans ECG alternating signal size Tamponade, end stage CHF,

LV dysf QP:QS Ratio For significant shunts 1.5:1 Restrictive CM Septal motion Normal Mitral E/A ratio > 1.5 Mitral DT < 160 Mitral inflow respiratory

variation absent

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Hepatic vein Doppler Expiratory diastolic flow RA Pressure Normal 2 – 8 mmhg Increased Dilated IVC and hepatic

veins Dilated Coronary sinus Bowing of IAS to the left RA size increased CW of TR velocity dagger

shaped E/A TV ratio > 1:1 Decreased RV IVRT < 54 RVEDP Normal 2 – 8 mmhg RV SP Normal 15 – 30 mmhg RVSP for HTN Normal 15 – 30 mmhg Mild 30 - 40 Moderate 40 - 70 Severe > 70 mmhg Stroke volume (SV) Normal 70 ml Tricuspid Regurgitation Normal velocity 2.5 m/sec Jet area Mild < 5 Moderate 5 - 10 Severe > 10 Vena Contracta Severe > 0.7 PISA radius Mild < 0.5 Moderate 0.6 – 0.9 Severe > 0.9 Tricuspid Stenosis TVA Normal 7 – 9 cm2 Stenosis < 2cm2 MPG Mild < 2 mmhg Moderate 2-6 Severe > 6 mmhg VTI AV 18 - 22 MV 10 - 13

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Echocardiography Modalities Short descriptions of specific modalities and guidelines regarding the length of the exam. Adult Transthoracic (TTE) study Multiple images and measurements of the heart are obtained from a variety of imaging windows and stored digitally for reading. All images, Doppler, and measurements are obtained through the chest wall. This is a noninvasive test. A complete comprehensive study can take 45 minutes to complete depending on the pathology seen. Transesophageal Echo (TEE) study A specialized transesophageal probe is passed into the client’s esophagus by a physician (cardiologist or anaesthetist) and the imaging is completed through the esophageal wall. Many images and measurements are completed with 2D and 3D capabilities. This is an invasive test that requires sedation, monitoring, and additional staff to monitor the patient during recovery phase. Used for a more detailed examination of the heart than obtained by TTE. TEEs take 60 minutes to complete – 30 minutes of prep work, 20 – 30 minutes of imaging. There is an additional 45 – 60 minutes of recovery required depending on the sedation used. Stress Echo – Treadmill A test using a combination of cardiac imaging, treadmill walking, vitals monitoring and 12-lead ECG acquisition. Resting images are taken, followed by the client walking on the treadmill until one of the listed end points for the test occurs. The patient is quickly returned to the procedure bed for continuous capture of peak images and recovery images. This test takes 45 minutes to complete. Stress Echo – Bicycle Specialized stress bed is required that has a bicycle attached. The client is secured onto the bed and instructions are given. Resting images are taken with the bed turned so the

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client is lying on their left side. The bed is returned to a supine position and the client bicycles until an end point for the test has been reached. The bed is returned to a left sided position while the client continues to bicycle and peak images are taken. This test takes approximately 45 minutes to complete. Stress Echo – Dobutamine A specialized test that involves cardiac imaging, medication administration, vitals monitoring, 12-lead ECG acquisition, and requires additional staffing. An IV is started and medication is administered that has inotropic and chronotropic effects on the heart. The test determines how well blood and oxygen move through the coronary arteries to the muscle of the heart. This test takes 60 minutes to complete – 20 minutes of prep time and resting image acquisition – 15 to 20 minutes of medication administration and peak imaging – and 20 minutes for the heart to return to normal and post imaging. Contrast and agitated saline In addition to completing the above services 10 to 20 minutes can be added to the time for additional imaging with a contrast agent or agitated saline study. Contrast may be used for a variety of reasons however the most common is to visualize the muscle of the heart. Difficult-to-image patients are common and require an intravenous and contrast injection to improve the quality of the assessment. Agitated saline studies are added to a transthoracic or transesophageal study to rule out shunt flow.

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Echocardiography Consent Form (TTE / TEE / ESE) (Circle appropriate modality(s) I, ________________________________________, hereby consent to the following (Print name of Patient or Substitute Decision Maker) investigative procedure: _______________________________________________ (Print and include the modality. Do not abbreviate) ________________________________________________________________________to be performed upon______________________________________________________ (Print name of Patient) by _________________________________________________or their delegate and by (Print Name and Designation of Health Practitioner) other physicians and health practitioners whose assistance he/she requires.

1. I have been given a full explanation of the procedure, who will be providing the procedure, the reasons why I need the procedure, any alternatives to the procedure, the risks and any side effects of the procedure.

2. I confirm that I understand this information.

3. I have had the opportunity to ask questions that have been answered to my satisfaction.

Date (Witness signature) (Signature of patient/ substitute decision-maker) (Print name of witness) (Print name of patient/ substitute decision-maker) STATEMENT BY HEALTH PRACTITIONER I declare that I have explained the nature of the above treatment or procedure, its expected benefits, material risks and side effects, alternative courses of action, the likely consequences of not having the procedure and answered all related questions. _____________________ _________________________________ ___________________________ (Date) (Signature of Health Practitioner) (Printed Name of Health Practitioner)

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Emergency Practices Written policies and procedures are required to be in place for emergency situations that may occur.

Cardiac Arrest: • Assess ECG and for a pulse. • Activate code blue and call for help. • Start chest compressions while crash cart retrieved. • Do compressions at 100/min – no mouth to mouth. • Insert airway: ear to mouth for appropriate size. • Connect ambu bag to oxygen and administer as directed. • Keep ECG on to assess for a pulse. • Document all aspects of event.

Fire: • Remove patient from fire area. • Activate the alarm. • Call fire code (i.e. code red). • Close doors to affected area. • Evacuate staff and patients to safe area. • Know your fire route and location of fire hoses.

Hypoglycemic Event: • Call for help. • Monitor patient symptoms. • Test blood sugar level with glucometer. • Treat as per institution policy (i.e. orange juice, sugar tablets). • Repeat glucometer reading in 15 minutes. • Continue monitoring vitals and symptoms.

Extravasation of Dobutamine: • Discontinue IV immediately and remove cannula. • Elevate affected area. • Do not restart the medication. • Do not apply hot or cold compresses. • Notify physician to assess site.

First Aid: • Splashed TEE sterilization fluid in eye: using the eye wash station, rinse eye for 15 minutes

immediately and then report to occupational health. • Ingestion of small amount of solution: do not induce vomiting, instead rinse mouth followed by

drinking a large quantity of water. • Inhalation of fumes (with breathing difficulties): move to fresh air immediately, if difficulty

continues, seek medical help. • Skin contact: wash contaminated area thoroughly with soap and water. Seek medical help if

irritation develops or persists.

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Transthoracic Echo (TTE) Patient Information Sheet What is an Echocardiogram? • An echocardiogram is a safe and painless diagnostic procedure that uses high frequency sound

waves to take moving pictures of the heart. The sound waves are directed at the heart from a small, hand held transducer (camera) which sends and receives signals that appear on the screen as a moving image of the heart.

• These images are in black and white; however colour can be added to show the blood moving in and out of the chambers. Many measurements are taken during the test to determine how well your heart is working.

What should I do to prepare for the test? No special preparations are required. Patients may eat and perform normal activities (unless otherwise instructed), and continue to take medications as prescribed by their physician. How long is this test? The test takes approximately 45 minutes to complete. A specially trained sonographer will perform the test. Does it hurt? Ultrasound cannot be felt and does not hurt. If patients experience discomfort, they should notify the sonographer performing the test. There are no known harmful effects from diagnostic cardiac ultrasound. What will happen during the test? • Patients will be given an explanation before the test starts and have time to ask questions. • Patients will be asked to disrobe from the waist up, and be given a gown to put on. • Three electrodes will be attached to the patient’s chest to obtain an ECG signal. • A blood pressure will be taken at the beginning of the test. • Patients will be asked to lie on the examining table on their left side during the test and a series of

images and measurements will be acquired over the course of the 45 minutes. How do I get the results? Although the sonographer performing the test can see what is occurring with the patient’s heart, he/she cannot provide any information. The test must be read and interpreted by the cardiologist who will then send a report to the physician who requested the test. That physician will provide you with the results of your test. Patients are to arrive 15 minutes before the appointment time. We are located _______________________ phone _______________________

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Section 2: Standards Regarding Echocardiographic Facilities, Equipment and Standard Operating Procedures

Required Documents

1. Echocardiography Equipment List

Additional Templates

1. Echocardiography Laboratory Requirements 2. Workplace Safety 3. 12 x 10 Transthoracic Procedure room

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Echocardiography Equipment List Machine Age Service 2 Vivid 7 6 yrs. Under contract Vivid I 4 yrs. Under contract Vivid 7 3 yrs. Under contract Philips IE33 3 yrs. No contract - research Vscan 1 yr. Under contract Vivid E9 2 yrs. No contract - research Probes 3 x 3.5 MHZ adult 6 yrs. /3 yrs. Under contract 1 x 5MHZ and 12 MHZ pediatric

6 yrs. Under contract

3 Pedoff probes 6 yrs./3 yrs. Under contract 2 GE TEE probes 6 yrs. Under contract 1 Philips TEE probe with 3D

3 yrs. No contract

1 carotid probe 2 yrs. No contract Stress Machines 1 treadmill unit with 12 lead monitor

10 yrs. Serviced by hospital biomed

1 recumbant exercise bike

5 yrs. Serviced by hospital biomed

Workstations 3 GE workstations 6 yrs. No longer under contract 7 Xcelera workstations 1 yr. Under contract Probes and cables serviced and replaced by biomed

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Echocardiography Laboratory Requirements This document provides recommendations for resources required by echocardiography laboratories to provide a laboratory environment that is safe for patients and staff. Adult Transthoracic Lab Setup Staff: • Echocardiologists (Medical Director) • Qualified sonographers (Technical Director) • Clerical staff • Lab/Office Manager • Biomedical services • Information Technology support staff/service • Housekeeping staff Rooms: • Room sizes must meet the requirement of the “Guidelines for the Provision of

Echocardiography in Canada.” The standard for the minimum size of a transthoracic echo room is 15m2 within the patient care area.

• A hand wash sink is required in the room. Equipment: • Ultrasound machines – current updates applied • Probes – 3.5Mhz, 5Mhz • Blood pressure cuff and stethoscope/ Vital Signs Monitor • Echo beds with cutouts • Ergonomic chair for sonographer • Contrast agitator machine • Refrigerator to store contrast • Work stations/desk • Photocopier/fax machine • Computers • Phones or emergency call bell system in all rooms • Emergency cart • Medical oxygen supply (portable tank or piped in) with flow meter • Lamps

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Supplies: • Ultrasound gel • Electrodes • Alcohol wipes • T spray or other transducer cleaner • Sanitizing wipes (for bed, B/P cuff, etc.) • IV angiocaths for contrast and agitated saline injections • 3 way stopcock • Medical tape • Tegaderm • Gauze 2x2 and 4x4 • Tourniquet • IV Solutions (Normal saline and D5W) • IV pole • IV tubing • 10 and 3 ml syringes • Needles (18/21 gauge) • Contrast • Sterile probe covers • Oxygen tubing • Oxygen face masks • Office supplies and stationery • Laundry basket(s) • Hand sanitizer • Medical exam gloves (latex free) • Sharps containers • Waste baskets • Isolations gowns • Face mask (N95) • Eye protection (safety glasses; goggles; face shields; visors attached to masks)

Medications: • Anaphylaxis kit Linen: • Bed sheets • Pillow cases • Paper cover for procedure bed • Patient gowns • Towels • Isolation gowns

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Paperwork: • Reports • Requisitions • Worksheet

Transesophageal Echo Lab Setup **Additional to the TTE lab Staff:

• Registered Nurse or Anesthesia Assistant • Anesthesiologist

Room: • The “Guidelines for the Provision of Echocardiography in Canada” recommends the

TEE room size is larger than the transthoracic echo room (15m2) in order to accommodate potential emergency situations. CCN recommends a minimum of 18.6m2.

• A sink that is large enough to rinse TEE probes and a cleaning station (with ventilation) separate from the scanning room.

• Locked and secure cabinet for anesthetic agents and narcotics. Equipment: • Ultrasound machine with 3D capabilities • TEE probes • TEE probe cleaning station • 12 lead monitor • Eye wash station • Suction unit and equipment • Storage unit for TEE probes • Vital signs monitor (BP, HR, O2 sat) Supplies: • Medication cups • K basins • Denture cups • Suction tubing • Suction catheter • Bite guards • Airway protective devices • Sterilization solution

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Medications: • Midazolam • Fentanyl • Propofol • Naloxone • Lidocaine viscous • Lidocaine spray • Resuscitation medications (kept in emergency cart) Linen: Same as above Paperwork: • TEE Consent forms • TEE worksheet • TEE pretest Anesthesia checklist • Requisition with indication • Medical history sheet • Pre-printed orders • Sterilization log Stress Lab Setup ** Additional to the TTE lab Staff: • ECG Technician • Registered Nurse or physician in the room Room: The stress lab requires the largest of the rooms due to the equipment required. A patient care area of 15m2 – 18.6m2 is recommended. In order to provide a safe environment for the patient, configuration of the space is important. A safe and easy transfer from the treadmill to the bed is vital. Equipment: • Treadmill and 12 lead monitor • Oxygen saturation monitor • Special echo bed with cutouts • IV infusion pump • Recumbent bike with special echocardiography bed • Ultrasound machine with stress program (DSE preset, TM and bike continuous

capture presets) • Patient weigh scale

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Supplies: • Abrasive tape • Razors • IV 50 ml mini bags D5W and normal saline • IV pump tubing with secondary lines • Disposable boot covers Linen: Same as TTE Medications: • Dobutamine vials 250 mg/20 ml • Atropine • Metoprolol • Nitroglycerine spray • Naloxone Paperwork: • Worksheets for each of the stress procedures • Dobutamine dosage guide • Consent forms • Pre-printed orders • Requisitions with indications and history

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Workplace Safety Written policies and procedures are required to be in place to monitor, prevent, diffuse and document unsafe workplace events. Violence and Harassment:

• Everyone has the right to work in a safe and healthy environment. • Violence is a common hazard in the health care sector with patient violence being the most

common including: o Threatening conduct that may result in physical or psychological injury. o Abusive behavior. o Bullying. o Intimidation.

Risk Management:

• Have a code of behavior/code of ethics policy in place. • Be aware of your surroundings and actions. • Be aware of signs of oncoming aggressive behavior. • Remove yourself from the threat. • Call security for assistance. • Call code white as per institution policy. • Never approach a questionable situation alone. • Document episodes and report to management.

Safe Footwear:

• Appropriate footwear regulations protect staff from injury. • No sandals, flip-flops, open-toe shoes, or high heels.

Infection Prevention:

• Essential to the well-being of patients and staff. • Eliminating the hazard is the preferred method. • Annual flu vaccination of staff is recommended. • Perform regular hand hygiene before and after each patient. • Follow infection control practices for isolation patients (i.e. gowns, masks, gloves).

Safe Storage: • Housekeeping practices and proper storage eliminates clutter that can lead to injury. • Safe handling of environmental hazards: • Cluttered and poorly arranged work areas. • Dangerous storage of equipment and materials. • Contaminated floor and work surfaces. • Overflowing waste bins and sharps containers. • Spills and leaks on the floor. • Improperly stored items that can fall from above onto a patient or staff member.

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Chemical Safety:

• WHIMS regulations and staff compliance in place. • Need to be aware of hazardous materials and chemicals in the area. • Need to be stored and labeled correctly. • Need to reduce exposure to hazards. • Need to know how to respond with the appropriate first aid measures. • Have written policies in place.

Rights and Responsibilities of Workers:

• Occupational Health and Safety Act. • Know your rights and responsibilities to protect the well-being of the worker and prevent injury

in the workplace. • Right to participate: be part of the process to identify and resolve concerns. • Right to know about any workplace hazards. • Right to refuse work if there is a danger to either their own health or the health of another

worker. • Responsible for wearing protective gear. • Responsible for reporting incidents to supervisor. • Responsible not to operate equipment in a manner that may endanger employees. • Responsible for patient safety.

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Section 2.4: Additional Considerations for Laboratories Providing Stress Echocardiography Examinations

Required Documents

1. Requirements for Performing Stress Echocardiography Examinations 2. Treadmill Exercise Stress Echocardiography Procedure 3. Bicycle Stress Echocardiography Protocol 4. Comprehensive Dobutamine Stress Echo

Additional Templates

1. 15 x 10 Stress Echo (treadmill) Procedure room 2. Patient Information Guide for Exercise Stress Echo

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Requirements for Performing Stress Echocardiography Examinations

Proper performance of the study must include adequate explanation of the procedure and respectful interaction with the patient. Although the sequence of views may vary according to the patient, the full complement of stress echocardiography views should be acquired and recorded. Doppler measurements should be obtained and recorded in patients as per indication. Specific comments on the quality of study with comments on technical deficiencies such as foreshortening and inadequate alignment in relation to Doppler assessment should be included.

The echocardiography laboratory must follow proper cleaning, disinfection, and maintenance procedures as stipulated by manufacturer and hospital or facility standards.

Facilities and procedures must be available for observation and recovery of patients by appropriately trained and qualified personnel, prior to discharge home or back to their referring location.

Appropriately trained and qualified personnel are required to monitor the patient, operate the treadmill or supine bicycle, record the electrocardiogram and, in the case of pharmacologic stress echo, administer medication. The individual(s) carrying out the examination must not be expected to provide these functions.

All stress procedures must be explained to the patient and/or the guardian of those unable to give informed consent. Consent must be obtained in a manner consistent with the rules and regulations outlined by the hospital or facility.

Larger rooms must be provided to perform stress echo, in order to accommodate extra equipment, personnel and potential resuscitation procedures. It is recommended that these rooms be at least 150 to 200 square feet.

Facilities and procedures must be available for observation and recovery of patients by appropriately trained and qualified personnel prior to discharge home or return to their referring location.

Standard FS5: In addition to the echocardiographic imaging system requirements, as outlined above, echocardiography equipment utilized for stress echo studies shall:

• Allow for accurate “triggered” acquisition of images and side-by-side image display; • Ensure adequate memory to allow performance of multi-stage stress echocardiogram

studies; and • Have the capability of side-by-side comparison of images from baseline and different stages

of stress. Side-by-side review may be accomplished within the ultrasound stress package or on a dedicated offline workstation.

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Standard FS6: In addition to the standard features noted above, laboratories providing stress echo require the following additional facilities: • Treadmill/bicycle • ECG monitoring • Blood pressure monitoring • Oxygen • Resuscitation medications and equipment • IV equipment • Drug cabinet • A means of rapidly calling for help with an unstable patient (e.g. phone, intercom, arrest

buzzer). Treadmill/ Bike Stress Echocardiography: The required images are acquired at rest and immediately post exercise;

• Parasternal long-axis • Parasternal short-axis • Apical four chamber • Apical two chamber/or apical three chamber

Acquisition of rest images and three other stages of the pharmacologic stress echo are obtained: Standard protocols include:

• Rest image • Low dose • Peak • Recovery

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Treadmill Exercise Stress Echocardiography Procedure Purpose To outline a standard process and provide information to ensure best practice is followed. Procedure Pre-test:

• Prior to study date, patient will be notified by phone or mail with the date and time of test, instructions to wear comfortable clothing and shoes, and a reminder to have someone available to drive them home.

• On arrival, after introductions and patient identification confirmed, patient will receive a full explanation of the test procedure and potential risks, with the opportunity to ask questions.

• A verbal and/ written consent must be obtained to continue. Test:

• Ensure patient is wearing comfortable shoes to walk in. • Patient will be required to disrobe from the waist up and don a gown open in the

front. • Documentation of patient height, weight, age, resting B/P and current

medications. • A cardiac history is taken and recorded for the reading cardiologist. • 12-lead ECG is attached ensuring a good signal with appropriate prep to the skin. • The technologist will take standing and supine ECGs at rest for baseline. • Use tissue harmonics (reduces near field artifact, improves resolution, enhances

myocardium, and improves endocardial border definition). • Decide early in the process the need for a contrast agent, used with each

acquisition. • The sonographer acquires digital loops of the imaging views Apical 4ch, 2ch,

ALAX, PLAX and PSAX at rest. The machine preset should have a continuous capture or stacking function.

• Choose either the Bruce or the Modified protocol. • Reinforce instructions and explanation of treadmill format immediately prior to

starting the test. • Remind patient to speak up if having any symptoms or concerns while on the

treadmill. • Remind patient of increase in incline and speed about 10 seconds before it

occurs. • Encourage patient to stay on treadmill to reach or surpass the target heart rate.

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• Check patient B/P at each stage and document. • Continually watch 12-lead ECG for arrhythmias and ST changes. • Stop treadmill when test end point has been reached. • Assist patient back onto bed in a left lateral position so the sonographer can

acquire peak images while heart rate is at its maximum. • Continue to monitor B/P and any symptoms. • Complete the test with post imaging when heart rate is below 100 beats/minute

and document. Test End Points:

• Reached or surpassed target heart rate. • Drop in systolic blood pressure from baseline despite an increase in workload. • ST segment or QRS changes such as excessive ST depression (> 2 mm of

horizontal or down-sloping). • ST elevation > 1 mm in leads without diagnostic Q waves (other than V1 or AVR). • Arrhythmias: ventricular tachycardia, multifocal frequent PVCs, heart block. • Severe symptoms: moderate to severe angina, presyncope, ataxia, pallor. • Machine technical difficulties—patient safety is a priority. • Patient refuses to continue.

Policy

• Respect patient’s modesty and privacy by draping the patient throughout the test.

• Respect patient’s right to refuse test or stop upon request. • Ensure proper test supervision by physician, location and availability prior to

starting the test. • Patient’s ability to walk on treadmill should be assessed by staff as early as

possible. Need to change test type should be discussed and approved by the supervising physician.

• Ensure requisition filled out and appropriateness of test indication. • Confidentiality: test results are not to be given to patient by the sonographer in a

preliminary format. • Use contrast if unable to see any of the walls of the myocardium to ensure a

complete study. • Medications and equipment available to treat and monitor if patient has

symptoms. • Crash cart is in close proximity and staff aware of emergency response protocols. • Appropriate room size and current equipment, to ensure patient safety in an

emergency situation. • Preprinted order forms preferred for the use of contrast, oxygen, nitroglycerine

and written instructions for administration.

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Treatment of Symptoms:

• Moderate or severe angina: stop test, return patient to the bed, do an immediate blood pressure, apply oxygen—notify physician for assessment of 12 lead ECG and vitals, and give Nitroglycerine if ordered.

• ST depression of > 2 mm or elevation > 1 mm: stop test and return patient to bed, perform immediate images, and monitor vitals and symptoms.

• Presyncope, dizziness, unwell feeling: stop test, return to bed and monitor vitals.

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Bicycle Stress Echocardiography Protocol Equipment:

• Recumbent bicycle attached to an echo bed with cut outs for imaging • 12-lead ECG monitoring unit that connects to an echo machine • Prep materials for skin – alcohol, gauze, razor and abrasive tape • Electrodes • Automatic blood pressure unit • IV and contrast supplies • Pre-printed bike stress worksheets

Staff:

• Sonographer • ECG technologist • Supervising physician

Pre Test:

• Reminder notice sent to patient before the day of the procedure to wear comfortable clothing and shoes.

• No eating or drinking 2 hours before the test. • Personal medications are taken as prescribed unless otherwise instructed by physician. • On day of test: introductions, patient ID confirmed, test explanation and time for

questions to be answered. • Written consent to proceed with test. • If client is an inpatient, check ID band. • If the staff determines the patient will not be able to pedal the bike on their side the

supervising physician must assess and change the test accordingly. • If the supervising physician is not available, the test is postponed until the patient is

reassessed. • Have patient undress from the waist up and put on a gown. • Skin prep and application of 12-lead ECG electrodes ensuring a good ECG signal on both

machines. • Baseline ECG supine and standing. • Baseline blood pressure. • Height, weight and BSA. • Cardiac history, allergies and a list of current medications – if patient is taking beta

blocker, patient may not reach a high enough maximum heart rate. • Harness patient to the bed comfortably, put on shoe covers and place feet in footholds,

then tilt bed for preliminary images. • Ensure the patient’s legs are not over or under extended: important the patient is

comfortable while pedaling. • Choose the continuous capture stress package.

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• Store the resting images as required - example apical 4, apical 2, PLAX, PSAX - decide at this time whether contrast will be needed.

• Do measurements and EF at rest. • Return patient to a supine position - explain about the pedaling, the stages, lights and a

quick practice pedal before starting. Exercise Test:

• Have patient pedal until green light comes on. • Start ECG timer and bike timer at the same time. • Do a blood pressure every 2 minutes and multiply the systolic blood pressure number by

the heart rate at each stage for the RPP (Rate Pressure Product). • A minimum RPP of 20,000 is required to make it a readable test. • Monitor for symptoms and arrhythmias throughout test. • If the patient is having symptoms or arrhythmias or any other problem - the supervising

physician must be notified and assess patient to determine if test should continue. • Each stage is 2 minutes long as preset into the ECG monitor and ultrasound machine. • Have patient continue pedaling each stage until they reach an end point. • Tilt bed again for peak images - decrease workload by 2 stages; have patient continue

pedaling while peak images are being acquired. • When images have been acquired, patient can stop pedaling. • Start the recovery phase on the treadmill. • Document length of time biked, watts, RPP, symptoms, vitals, and any arrhythmias.

Post Test:

• When heart rate below 100 beats/ min post images can be taken. • Position patient back in a supine position, remove feet from pedal boots and remove

harness. • Clean gel from patient’s chest, assist with dressing if needed. • Sanitize the echo bed, harness, ECG leads, blood pressure cuff, transducer and pillow

after each patient. End Points:

• Moderate or severe angina. • ST elevation > than 1 mm or depression > 2 mm. • Nausea and other symptoms with an abrupt change in vital signs. • Frequent serious arrhythmias - VT, heart block, rapid sustained SVT. • Technical difficulties with equipment. • Patient refuses to continue test. • Regional wall motion seen.

Contraindications:

• Acute cardiac events or ECG changes - uncontrolled arrhythmias at rest. • Recent MI.

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• Unstable angina. • Severe pathology found in pre images - aortic stenosis, intracardiac mass, pericardial

effusion - all pathology must be reviewed by the supervising physician. • Severe hypertension - systolic > 225 and diastolic > 110 mm Hg. • Patient refuses the test after explanation and questions have been completed.

Bike Exercise Stress Worksheet: Should include the following columns: Sample

Bike Protocol Watts Heart Rate Blood Pressure Symptoms and comments

Rest xx 60 130/70 Stage 1 ( 0-2 min) 10 82 148/66 mild dyspnea Stage 2 ( 2-4 min ) 30 100 160/80 dyspnea

Stage 3 ( 4-6 min ) 60 121 186/90 legs sore, burning in chest, dyspnea

Stage 4 ( 6-8 min ) 90 155 194/92 stopped chest pains - oxygen and nitro given

Recovery Exercise time 7 min 12 sec

Mets 8.60

RPP 194 x 155 = 30,070

Interpretation of Bicycle Stress Echocardiography:

• Due to the limitations of the bike stress echo, this test is not indicated for everyone. Patients should be assessed prior to performing the test.

• Conditions such as fibromyalgia, rheumatoid arthritis, peripheral vascular disease may affect the test RPP making it inconclusive for CAD.

Criteria for Reporting:

• Negative test: All segments that were active and augmenting at baseline and remain active with exercise, plus a decrease in overall cavity size and improvement in overall contractility.

• Positive test: Two or more adjacent segments—which demonstrated normal thickening at baseline but decreased or absent thickening with stress—in at least 2 imaging planes.

• Indeterminate test: All other responses, with an explanatory note.

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Comprehensive Dobutamine Stress Echo Pre-test:

• Set up room and equipment for test. • Check oxygen unit. • Ensure supervising physician is available; patient should not eat or drink a large amount 2 hours

before the test. • If patient is diabetic, they should have something small to eat or drink. • Confirm patient identification. • Review indication for appropriateness and the need to do additional images. • Take cardiac history and a list of current medications: important to know if patient is taking

beta blockers. • Ask about medication allergies. • Obtain age, height, weight, resting blood pressure, heart rate and pre-test rhythm. • Explanation given to patient with time to answer questions. • Obtain verbal and written consent. • Remind patient the test can be stopped if intolerable. • Assist patient with undressing (if required) from the waist up and put on a gown, open in the

front. • Remind patient to notify staff if having any symptoms. • Connect 12-lead ECG so rhythm and S-T segment can be monitored throughout the test. • Ensure a clear ECG signal for proper looping of digital images: very important for assessing wall

motion. • Perform standing and supine resting ECGs for baseline. • Premix dobutamine in IV mini bag. • Calculate target heart rate according to patient age. • Chart appropriate dosing for each stage of the test according to weight.

Test:

• Start intravenous with a flush line of N/S or D5W. • Piggyback dobutamine mini bag into flush line; dobutamine line must be infused by pump, do

not start med until resting images taken. • Capture resting images and store loops. • Obtain Apical 4ch, Apical 2ch, ALAX optional, PLAX, and 3 SAX views. • Use tissue harmonics, reduces artifacts and enhances borders. • Perform resting Simpsons EF and LV dimensional measurements. • Start medication as DSE protocol instructs, increasing every 3 minutes. • Perform images at each stage, record rest, low dose, peak and post images into the protocol

preset in the ultrasound machine. • Check patient’s blood pressure at each stage. • Ask patient frequently whether they are having any symptoms. • If within 10 beats of target heart rate in stage 5, try isometric exercises like hand squeezing or

leg rises to reach target—if not successful, give atropine as per protocol or physician’s orders. • Turn medication off when target heart rate reached or other end point reached.

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Post Test:

• Perform recovery ECG, blood pressure and heart rate and rhythm. • Remove gel from chest, remove IV, apply pressure and bandage. • Assist patient to get dressed (if needed). • Assess patient for dizziness or lightheadedness; proceed to recovery area for observation. • Have patient escorted via wheelchair to door to meet escort. • Patient may eat and drink as soon as test completed.

Test End Points:

• Target heart rate reached or surpassed. • Develops new regional wall motion abnormality at least moderate in severity. • Maximum pharmacological dose and exercise completed. • Unstable arrhythmias. • Severe hypertension – systolic > 225 OR diastolic > 95 mmhg. • Hypotension – systolic < 80 and patient symptomatic. • Intolerable symptoms and patient requests test stopped.

Adverse Responses: Potential Adverse Responses to Test Actions Moderate or severe chest pain/ angina • Stop medication

• Notify physician • Assess vital signs • Apply oxygen and administer Nitroglycerine as per

physician’s orders • Obtain 12-Lead ECG • Image heart

Sustained Ventricular Arrhythmia (VT) • Stop medication • Notify physician • Assess patient responsiveness • If patient becomes unresponsive with sustained VT,

initiate CPR and call a code blue. Palpitations (SVT) • Document symptoms and duration

• Administer Betaloc as per physician’s orders Tremors/Shivering • Usually seen with faster heart rates and resolves on

its own • Hold for observation

Headache/Nausea • Headache is common if patient is prone to headaches, apply cool cloth to forehead

• Frequent symptom with wall motion, stop medication if wall motion seen

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Sensation of need to urinate • Common in men, feeling will stop when medication is stopped

Potential Adverse Responses to Test Actions Lightheadedness • Check B/P, if hypotensive, administer saline bolus as

per physician order Atrial Fibrillation • Supervising physician should assess patient and

determine if patient requires being sent to ER to be treated and monitored

Supervising cardiologist should be notified to assess patient before discharge.

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Patient Information Guide for Exercise Stress Echo Institute name, phone number and location (map if desired). What is an Exercise Stress Echocardiogram? An exercise stress echo is a test where pictures of the heart are taken before the highest heart rate, at the highest heart rate, and while recovering after reaching the highest heart rate after walking on a treadmill or riding a stationary bicycle. The test is used to assess heart function with exercise and determine how well blood and oxygen get through the arteries to the heart muscle. What should I do to prepare for the test?

• Many people find it uncomfortable to exercise on a full stomach so we ask that you do not have a large meal two hours before the test. You may have fluids and small snacks in this time period.

• Wear comfortable, loose clothing, as well as running shoes or good walking shoes. • Continue to take your usual medications as prescribed by your doctor. • Please bring a list of your current medications.

How long is the test? The test takes 45 to 60 minutes to complete. What will happen during the test?

• You will be given a complete explanation of the test with time for questions and a verbal consent to begin the test.

• There will be a sonographer and ECG technician in the room. The doctor may not be in the room; however will be available if needed at any time.

• The ECG technician will place electrodes on your chest—your heart rhythm and blood pressure will be monitored throughout.

• The sonographer will take images of your heart at various times. • The referring doctor will have made the choice of doing a treadmill or bicycle test. The

procedures differ slightly but measure the same thing. • If you are having a treadmill test, the ECG technician will familiarize you with the

treadmill and demonstrate how to walk on it. The speed and slope of the treadmill will change every three minutes until a target heart rate (determined by age) has been reached.

• If you are having a bicycle stress test, the ECG technician will familiarize you with the bike that is attached to the bed. The pedaling difficulty will increase every two minutes until a target has been reached. A target is based on your heart rate and your blood pressure; your blood pressure will be taken every two minutes.

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How do I get the results?

• The test will be read and reported by a cardiologist, and that report will go to your doctor.

• The results of the test will be given to you by the referring physician or your family doctor.

• The sonographer and ECG technician in the room are not able to provide you with test results.

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Section 2.5: Additional Considerations for Laboratories Providing Transesophageal Echocardiographic Examinations

Required Documents

1. Requirements for Performing Transesophageal Echocardiography (TEE) Examinations

Additional Templates

1. Transesophageal Echocardiography (TEE) Procedural Process 2. Transesophageal Echocardiography (TEE) (Adult) Physician Pre-printed Orders 3. Transesophageal Echocardiography (TEE) Patient Information Guide 4. Transesophageal Echocardiography (TEE) Procedural Sedation 5. 15 x 10 Transesophageal Echo Procedure room 6. Transesophageal Echo (TEE) Probe Maintenance, Sterilization and Storage

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Requirements for Performing Transesophageal Echocardiography (TEE) Examinations Proper performance of the study must include adequate explanation of the procedure and respectful interaction with the patient. Although the sequence of views may vary according to the patient, the full complement of TEE views including Doppler tracings with measurements should be obtained and recorded in every patient. Specific comments on the quality of study with comments on technical deficiencies such as foreshortening and inadequate alignment in relation to Doppler assessment should be included. Appropriately trained and qualified personnel are required to provide sedation and monitoring of the patient through the procedure and recovery. The individual(s) carrying out the examination must not be expected to provide this monitoring function during the procedure. All TEE procedures must be explained to the patient and/or the guardian of those unable to give informed consent. Consent must be obtained in a manner consistent with the rules and regulations outlined by the hospital or facility. Where sonographers are involved in the consent process, procedures must be in keeping with the provisions of their credentialing body as well as relevant scope of practice established by the hospital or facility. The echocardiography laboratory must follow proper cleaning, disinfection, and maintenance procedures as stipulated by manufacturer and hospital or facility standards.

Basic Information Required: • Confirm physician order and type of exam requested. • Verify name of patient, identification and demographics, date of birth+/- age, gender. • Document patient's clinical history and presentation. • Document any contraindications to the procedure, such as medications, insufficient patient

preparation or the patient's inability or unwillingness to tolerate the procedure. Professional Expectations:

• Verification of patient identification. • Appropriate introduction of staff to patient. • Appropriate explanation of procedure ordered. • Documentation of signed informed consent. • Respect of patient confidentiality and privacy. • Explanation of ECG lead placement prior to application.

Appropriate safety guidelines/policies must be in place in order to perform transesophageal echocardiography. Monitoring of ECG (heart rate, rhythm), blood pressure and oxygen saturation of the patient prior, during and after the exam must occur. Oxygen will be administered if required. Maintain patent intravenous for the duration of the procedure as well as post procedure.

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Transesophageal echocardiographic systems require transesophageal transducers manufactured for the specific ultrasound system in the laboratory and should incorporate multiplane imaging. All facilities performing TEE should ensure that examining rooms must be of appropriate size:

• Larger rooms must be provided to perform TEE echo, in order to accommodate extra equipment, personnel during potential resuscitation procedures.

• It is recommended that rooms be at least 150 to 200 square feet. Laboratories performing TEE require the following additional equipment:

• Blood pressure monitoring • Oxygen • Resuscitation medications and equipment • Intravenous equipment • Lockable drug cabinet • Oximetry • Suction • Emergency call system • A large sink

Evaluation of the structure and function of the anatomic components of the examination, include the following: Left ventricle:

• Assessment of left ventricular dimensions, wall thickness, global left ventricular systolic function and ejection fraction (and method used), and presence or absence of regional wall motion abnormalities.

• Evaluation of left ventricular diastolic function (if relevant to the clinical indication). Right ventricle:

• Assessment of right ventricular size and systolic function, presence of right ventricular hypertrophy.

Left atrium:

• Assessment of size • Left atrial appendage • Pulmonary veins

Right atrium:

• Assessment of size • Superior vena cava and inferior vena cava • Eustachian valve/ Chiari network • Right atrial appendage

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Interatrial septum: • Intact presence or absence of ASD/patent foramen ovale • Fossa ovalis coronary sinus

Aortic valve:

• Aortic valve cusp morphology, presence and severity of stenosis or regurgitation • Evaluation of gradients (peak and mean) and valve area, if stenotic • Prosthetic aortic valve (if present)

Mitral valve:

• Mitral valve leaflet morphology, presence and severity of stenosis or regurgitation • Mitral annulus • Evaluation of gradients (peak and mean) and valve area, if stenotic • Evaluation of the chordae tendinae and papillary muscles • Prosthetic mitral valve (if present)

Tricuspid valve:

• Tricuspid valve leaflet morphology, presence and severity of stenosis or regurgitation • Tricuspid annulus • Evaluation of gradients (peak and mean), if stenotic • Estimation of right ventricular systolic pressure • Evaluation of the chordae tendinae and papillary muscles

Pulmonic valve:

• Pulmonic valve morphology, presence and severity of stenosis or regurgitation • Evaluation of gradients (peak and mean), if stenotic • Evaluation of the main pulmonary artery

Aorta (including aortic annulus, sinuses of Valsalva, coronary ostia, sinotubular junction and proximal ascending aorta):

• Dimensions Thoracic aorta (ascending, descending and arch):

• Dimensions Left subclavian artery and left brachiocephalic vein Left ventricular outflow tract:

• Gradients • Dimension

Pericardium:

• Presence and size of pericardial effusion, assessment of hemodynamic effects of pericardial effusion (if present)

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Routine Transesophageal Echocardiograms The comprehensive TEE examination will contain the following imaging components:

• Mid esophageal four chamber view

• Mid esophageal two chamber view

• Mid esophageal long axis view

• Transgastric short axis view – mid level

• Transgastric two chamber view

• Transgastric basal short axis view

• Mid esophageal mitral commissural view

• Mid esophageal aortic short axis view

• Mid esophageal aortic long axis view

• Transgastric long axis view

• Deep transgastric long axis view

• Mid esophageal bicaval view

• Mid esophageal right ventricular inflow-outflow view

• Transgastric right ventricular inflow view

• Mid esophageal ascending aortic short axis view

• Mid esophageal ascending aortic long axis view

• Descending aortic short axis view

• Descending aortic long axis view

• Upper esophageal aortic arch long axis view

• Upper esophageal aortic arch short axis view The comprehensive TEE examination will contain the following Doppler components:

• Mid esophageal four chamber view colour and pulsed wave Doppler for mitral stenosis/regurgitation and tricuspid stenosis/regurgitation and pulmonary venous flows

• Mid esophageal two chamber view colour and pulsed wave Doppler for mitral stenosis/regurgitation

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• Mid esophageal long axis view-colour Doppler to assess for mitral and aortic regurgitation

• Transgastric two chamber view - colour Doppler to assess for mitral regurgitation

• Transgastric basal short axis view

• Mid esophageal mitral commissural view colour flow Doppler to assess origin of regurgitation

• Mid esophageal aortic short axis view-colour Doppler to assess for aortic regurgitation

• Mid esophageal aortic long axis view-colour Doppler to assess for aortic regurgitation, flow

velocities across the left ventricular outflow tract

• Transgastric long axis view-colour Doppler to assess aorta and regurgitation Continuous wave Doppler to assess aortic velocities and pulsed wave for LVOT velocities.

• Deep transgastric long axis view-colour Doppler to assess aorta and regurgitation

continuous Doppler to assess aortic velocities and pulsed wave for LVOT velocities

• Mid esophageal bicaval view-colour Doppler to assess inferior and superior cava flow interatrial shunt and pulsed wave Doppler - pulmonary venous velocities

• Mid esophageal right ventricular inflow-outflow view colour Doppler across the tricuspid

valve, pulmonic regurgitation

• Transgastric right ventricular inflow view-colour Doppler to assess tricuspid regurgitation

• Mid esophageal ascending aortic short axis view

• Mid esophageal ascending aortic long axis view

• Descending aortic short axis view

• Descending aortic long axis view

• Upper esophageal aortic arch long axis view colour Doppler to assess flow

• Upper esophageal aortic arch short axis view colour Doppler and continuous Doppler to assess pulmonary valve and main pulmonary artery velocities

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The comprehensive TEE examination will contain the following standard measurements: The following standard measurements must be obtained and recorded for all studies where technically feasible.

• Transgastric mid short axis LV diastolic wall thickness (septum and posterior wall)

• Transgastric mid short axis LV systolic and diastolic dimensions

• Ejection fraction (this should be quantitated whenever technically possible by one of the validated methods (preferably by Simpson’s biplane Method of Discs) and the method used should always be identified. Visual estimation should be reserved for cases in which quantitative assessment is not technically feasible.

• Pulmonary valve velocity

• Diastolic parameters should be determined according to the current guidelines, and

diastolic function classified into categories of normal, mild dysfunction (impaired relaxation), moderate dysfunction (pseudonormalization) and severe dysfunction (restriction). This assessment is based on consideration of the relevant parameters available from the echocardiographic examination which can include mitral inflow velocities, mitral deceleration time, isovolumic relaxation time, pulmonary venous systolic and diastolic velocities, and tissue Doppler assessment of mitral annular motion.

• Tricuspid regurgitation velocity to calculate right ventricular (RV) systolic pressure

• Mid esophageal AV long axis-measurements of the aortic root and ascending aorta (sinuses

of Valsalva sinotubular junction, and proximal ascending aorta and annulus

• Left atrial dimensions Where clinical indications or findings warrant include:

• Transvalvular mean and maximal gradients with continuous wave Doppler for stenotic valves and valvular prostheses

• Spectral display of complete envelope of continuous wave Doppler signal of valvular regurgitation

• Proximal isovelocity surface area calculation or other quantitative methods for assessment of valvular regurgitation

• Respiratory variation of mitral and tricuspid inflow Doppler (e.g., pericardial disease)

• Shunt calculation

• Sufficient time must be given to monitor the TEE patients post procedure, for any

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complications arising from either the procedure or the medication.

• Facilities and procedures must be available for observation and recovery of patients by appropriately trained and qualified personnel prior to discharge home or return to their referring location.

• Post procedure instructions must be given to the patient and /or family member(s).

Additional instructions will be provided to the patient if required. Information must be provided that allows the patient to contact or call the physician should complications occur post discharge.

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Transesophageal Echocardiography (TEE) Procedural Process Pre-Procedure Room preparation:

• TEE probe is connected to ultrasound machine, and the calibration completed • Check controls on TEE probe prior to intubation • Place bite guard on probe • Prepare supplies needed to perform the procedure (i.e. lubricant, gloves, lidocaine, sedation

medications, IV set up, oxygen and suction tubing) • Enter patient demographics/information • Ensure crash cart is located in the TEE room • Ensure availability of performing cardiologist

Patient preparation: • Reminder phone calls/notices sent out prior to procedure date—patient instructed to be NPO

for 6 hours prior to time of appointment • Patient requires an escort with them in order to take them home • Introductions and explanation of procedure given with time allowed for questions • Patient identification confirmed • Perform a pre procedure assessment (e.g. NPO 6 hours, allergies, trouble swallowing, dentures) • Obtain a medical history including any allergies, history of ulcers, hiatal hernia or swallowing

difficulties. • Have patient change into a gown—explain drooling during the procedure is normal and

suctioning will be performed as needed • Ensure a clear ECG signal for appropriate looping of digital images • Apply ECG electrodes for monitoring of vital signs throughout the procedure • Insert an IV line for administration of IV sedation and for access in case of emergency • Document patients room air saturation level and apply oxygen by nasal prongs if level below

96% • Have cardiologist performing the exam inform the patient of the procedure and associated risks

prior to obtaining a written consent • Position patient on left lateral side with chin tucked to chest

Procedure

• Cardiologist preps throat with Lidocaine gargle and spray to suppress gag reflex • IV sedation, preliminary dose given to relax patient - patient to remain awake in order to

swallow during intubation process • Cardiologist/anaesthetist will intubate the patient while the sonographer operates the

ultrasound machine controls • Maintain patient comfort during procedure - additional sedation is given as required and

ordered by the cardiologist

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• Patients may respond well to reassurances during the test • After all images have been acquired the cardiologist/anaesthetist will extubate the patient

Recovery

• Patient will be recovered according to the sedation type, dosage and effect • Separate recovery room with heamodynamic monitors and staff is preferred • Patient remains monitored and IV line patency is maintained until fully recovered • Airway, respirations, level of consciousness, heart rhythm and blood pressure will be monitored

post procedure, until patient can protect their airway and is hemodynamically stable (+/- 20mmg of pre-procedure MAP/BP)

• Utilize recovery assessment tools (such as Aldrete score) to assess level of readiness for discharge

• Written discharge instructions are given to patient and accompanying adult prior to discharge Potential Complications:

• Esophageal perforation: may require immediate surgery to repair • Life threatening arrhythmias: treated by cardiologist; ensure emergency cart is immediately

available • Respiratory distress: ensure emergency cart immediately available, including artificial airways

and recovery support staff such as anaesthetist; anaesthesia assistant; registered nurse (RN) trained in recovery post anesthesia

• Tracheal intubation: remove TEE probe, assess airway

Documentation

• Completed by the cardiologist and appropriate recovery support staff • Final report by cardiologist • Documentation of vitals and patient tolerance to procedure usually completed by sonographer

or RN • Full documentation of medications given: name, dose, time and effect • Documentation of comments made by patient pre and post procedure

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Insert Institution Logo at top of page Transesophageal Echocardiography (TEE)(Adult) Pre-printed Orders Patient Weight: Drug Allergies: Physician Orders:

• IV D5W to keep vein open • Lidocaine 2% viscous gargle - 30 ml for 30 seconds • Midazolam ______ mg IV for sedation prior to procedure • Midazolam 1 mg IV prn once • Contrast method: • None required: • Bolus method - description of technique____________ • Dilution method - description of technique____________ • IV drip method - description of technique_____________ • Administer bolus 10 ml of 0.9% agitated sodium chloride IV during procedure for shunt

visualization • Oxygen at 2 liters/minute by nasal prongs or continue on previous oxygen therapy • Monitor vital signs every 5 minutes throughout procedure and every 20 minutes until

patient meets discharge criteria • Discontinue IV prior to patient discharge • Patient to remain NPO for 2 hours post procedure

Physician signature _____________________________________ Physician name printed __________________________________ Date and time __________________________________________

Addressograph: Patient Name, Date of Birth, Gender, MRN (CR) Address, Referring Physician,

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Transesophageal Echocardiography (TEE) Patient Information Guide What is a Transesophageal Echo? Transesophageal Echo (TEE) is a test that allows your doctor to record images of your heart from inside your esophagus, or food pipe. These images will help your doctor identify and treat problems with your heart. This technique offers an alternative method of obtaining images of the heart rather than through the chest wall. Getting ready: • You will be reminded of your appointment by phone one or two days before your scheduled test • You will need to be fasting 6 hours before the test, this includes nothing to eat or drink • During the test you will receive sedation and you will need someone to drive you home afterwards. • You will not be able to drive a motorized vehicle for 24 hours following the test. During the TEE procedure: • When you arrive for your test, you will change into a gown and then be taken to the procedure

room. • Before the test you will be asked to gargle with an anesthetic solution which will begin to freeze

your throat. Then your throat is sprayed with an anesthetic to freeze it further. • You will have an intravenous started in your arm. You may be given a mild sedative through the

intravenous to help you relax. Then you will be asked to lie on your left side. • The doctor will gently insert the TEE probe into your mouth. You will be asked to swallow the probe

as it is slowly guided into your esophagus. The probe is lubricated to help it slide easily. • You may feel the doctor moving the probe, but is should not hurt or interfere with your breathing.

Your heart rate, blood pressure and breathing will be monitored throughout the test. • The TEE probe, which has a camera in it, will be in the esophagus for approximately 15 to 20

minutes. • After the procedure is over, recovery will take 1 to 2 hours depending on the effect of the sedation. • The total length of time in the echo lab is approximately 2 to 3 hours before being discharged home. After the TEE procedure: • You may have some difficulty swallowing right after the test. This will go away in a few hours • You can eat and drink again when your throat is no longer numb. This will be approximately 2 hours

after the procedure. • It is common to have a sore throat for a day or two after the test. • Do not drink alcohol for the next 24 hours. • Someone must accompany and drive you home, and stay with you the first night after the

procedure. • You should avoid eating salad for the first meal after the test as the lettuce may become stuck in

your throat. • You will receive a follow up phone call from the Echo Lab within 24 to 48 hours after the test. • It is important that you keep your follow-up appointment.

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If patients have any concerns or questions after the test, please direct them to call the Echo Lab at __________________ or go to the nearest emergency department for examination.

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Transesophageal Echocardiography (TEE) Procedural Sedation Purpose To provide guidelines that promotes safety and best practice for patients receiving conscious sedation for a transesophageal echocardiography procedure.

Description Conscious Sedation: Increasingly patients are receiving short-term conscious sedation and analgesia for invasive diagnostic procedures. Advantages of conscious sedation and analgesia include a short rapid recovery, early ambulation, and the preference for patients to experience light sleep while maintaining adequate cardio-respiratory function and the ability to respond to verbal or tactile commands. It is impossible to predict individual responses to sedation, therefore specific post procedural monitoring of each patient is required. Sedation Levels (ASA – American Society of Anesthesiologists)

ASA Levels of Sedation

Minimal (anxiolysis)

Moderate (conscious sedation)

Deep General Anesthesia

Responsiveness Normal response to verbal stimuli

Purposeful response to verbal or tactile stimulation

Purposeful response after repeated or painful stimulation

Unarousable even with painful stimulation

Airway Unaffected No intervention required

Intervention may be required

Intervention often required

Spontaneous ventilation

Unaffected Adequate May be inadequate

Frequently inadequate

Cardiovascular function

Unaffected Usually maintained

Usually maintained

May be impaired

Most common level for the performance of a TEE

Procedure Staff Responsibilities: • Able to differentiate the different levels of sedation • Full explanation must be provided to patient with time to answer questions • Must acquire written consent to proceed with test • Patient safety and comfort a priority • Emergency equipment (crash cart) is located in the procedure room • Must know how to activate a code blue

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• Vital signs are monitored and documented by a dedicated and qualified staff member • Documentation of all medications given (name, dose, time and effect) • Able to identify adverse reactions • Able to assess for airway patency and identify life-threatening arrhythmias • BCLS certification maintained • The regulated health care professional (RN, Anesthetist Assistant) responsible for monitoring of the

patient during and after the procedure may not leave the patient unattended at any time; they cannot assist with any procedure that distracts them from the monitoring of the patient

• Monitoring includes: observing skin color, level of consciousness, rate and depth of respiratory rate • Patients are at a higher risk of respiratory depression within 5 to 20 minutes after receiving IV

sedation • Oxygen saturation monitor id maintained throughout the procedure • Cardiologist performing the test is responsible for sedation dosage and writing the order for

administration • Start with the lowest dose of sedation and repeat to achieve patient comfort • Cardiologist performing the test must be made aware of the patient’s status throughout the test • Staff should always be aware of length of test and patient comfort level • Appropriate recovery time with continuous monitoring and IV site, until patient stabilized • If Flumazenil or Naloxone required to reverse the effects of the sedation, the patient should

continue to be monitored for an additional 2 hours • Patient must be discharged with an accompanying adult

Recovery To assess the recovery status of the patient after discontinuation of the sedation. Aldrete Score

Score 2 1 0 Respirations Able to take a deep

breath and cough Dyspnea/shallow breathing

apnea

Oxygen saturation Maintains > 92% on room air

Needs oxygen inhalation to maintain > 90 %

Saturation < 90% even with supplemental oxygen

Consciousness Fully awake Arousable on calling Not responding Circulation B/P +/- 20 mmhg

pre test B/P +/- 20 to 50 mmhg pre test

B/P +/- 50 mmhg pre test

Activity Able to move all extremities

Able to move 2 extremities

Able to move 0 extremities

The Aldrete score should be completed every 15 minutes until the patient reaches a score of 8 to 10 prior to discharge. There are different scoring methods available on line:

• Modified Observers Assessment of Alertness • Ramsey Score

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Transesophageal Echo (TEE) Probe Maintenance, Sterilization and Storage Note: Care of TEE Probes should follow manufacturer’s specifications, including Medical Device Reprocessing guidelines according to Public Health Ontario guidelines which may include the following: Maintenance:

• Probe checks completed regularly by qualified biomedical personnel according to manufacturer’s specifications.

• Check for bite marks, crystal deterioration, and control mechanism functions. • Log book should be kept to document frequency of checks.

Sterilization of TEE probe:

• Written procedure must in place for care and handling of the TEE probes. • Gloves are worn when handling probes. • Immediately after use, the probe should be washed with soapy water, rinsed off,

and patted dry before immersing in the sterilization fluid. • Probe should soak a set amount of time as directed by the type of sterilization

solution being used. • When removed from solution, probe should be rinsed off and patted dry before

putting away. • Ensure sterilization room is well ventilated and away from the scanning room. • Always have process of probe sterilization reviewed by an infection control

specialist. • Solution should be changed as suggested by the manufacturer; maintain record

with the date and initials of staff that changed the solution. Storage:

• TEE probe should be stored in an area where it can hang. • Place a foam sleeve over the camera end of the probe to prevent damage to the

crystals. • TEE probe should be transported in either a carrying case or clean pillow case to

prevent unnecessary banging of the probe. • After each TEE, there should be a logbook to document the date, patients MRN

number, the Serial Number of the TEE probe used and the staff involved in the care of the probe, for infection control purposes.

Reference: http://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdf

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Section 3: Standards for Reporting of Echocardiographic Examinations

Required Documents

1. Standardized Report for Adult Transthoracic Echo

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Standardized Report for Adult Transthoracic Echo ASE recommendation Comprised of: 1. Demographics 2. Echo evaluation 3. Summary Demographics 1. Patients name 2. Date of Birth 3. Gender 4. Indication for test 5. Height 6. Weight 7. Blood pressure 8. Referring physician 9. Interpreting physician 10. Date of study 11. Location of the patient (inpatient or outpatient) 12. MRN or CR number 13. Sonographer’s Name Echocardiography and Doppler Evaluation A. Cardiac Structures

The following cardiac and vascular structures should be evaluated and described 1. Left ventricle 2 Left atrium 3 Right ventricle 4 Right atrium 5 Aortic valve 6 Mitral valve 7 Tricuspid valve 8 Pulmonic valve 9 Pericardium 10 Aorta 11 Pulmonary artery 12 Inferior Vena Cava 13 Pulmonary veins

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Imaging of all structures may not be possible – it is important the report includes a comment that imaging was suboptimal. It is important that the report comments on the crucial findings as required by the indication for the test. B. Measurements 1. LV size, wall thickness and function 2. LA size and volume 3. Aortic root dimension 4. Valvular stenosis – severity, gradients and areas 5. Subvalvular stenosis – severity 6. Valvular regurgitation – severity, quantitative measurements 7. Prosthetic valves – transvalvular gradient, EOA and description of regurgitation 8. Shunts – severity, location, QP;QS ratio, diameter of defect C. Descriptive Statements

A descriptive statement of each of the cardiac structures listed and all pathology identified.

Summary

The echo report will include a summary or conclusion related to the indication provided in the referral. This will emphasize abnormal findings and comparison to previous studies that are available.

Descriptive statements/measurements and comments can be found on line at www.asecho.org

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Section 4: Standards Regarding Laboratory Type and Personnel Involved in Echocardiographic Examinations

Required Documents

1. Reporting Responsibilities

Additional Templates

1. Echo Lab Staff Responsibilities 2. Echo Nurse Responsibilities 3. Training and Education Protocols

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Reporting Responsibilities Written policies and procedures are required to be in place for the following reporting systems and processes. Reporting systems and locations:

• Workstations located in the reading room of the Echo Lab. • Offline storage of completed exams.

Echocardiologist reporting:

• Monthly schedule with the reporting physician for each day. • Responsible for reviewing and reporting of all studies in a timely manner. • Responsible for giving preliminary reports if required. • Responsible for making amends to the studies as required. • Responsible for signing of the preprinted orders.

Sonographer reporting:

• Responsible for completing the preliminary information and technical report in the system (i.e. wall motion scoring, contrast use).

• Full documentation during special procedures. • Role of the sonographer is to perform the study and document observations. • Sonographer is unable to provide any information directly to the patient. • Inpatient charts must have documentation indicating that the test has been completed with date

and initials of sonographer. Reporting times:

• Urgent, stat, and ASAP studies are reported immediately by the echocardiologist, which may include a verbal report.

• Critical care areas are reported the same day as the test. • Inpatient TTE tests are reported within 24 hours. • Outpatient studies are reported within 48 hours.

Distribution:

• Completed by the clerical staff and medical records personnel, printed and mailed. • Reports are faxed upon request.

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Echo Lab Staff Responsibilities Medical Director:

• Represent the group in divisional and hospital discussions • Assessment of need and suitability of current equipment • Monitor purchase processes and prepare business cases • Provide sonographer reviews and create a feedback process • Participate in recruitment of new staff • Design and update report format with ITS staff • Ensure supervision of the lab • Create a training program for the cardiac fellows • Ensure QA initiatives are in place and ongoing • Create a physician on call and reading schedule

Technical Director/Sonographer:

• Organize and attend staff meetings • Create a daily assignment for the sonographers • Maintain policies and procedure manual • Oversee regular maintenance of equipment • Participate in recruitment of new staff • Oversee sonographer student clinical placements • Organize on call schedule • Create and distribute monthly statistics • Prioritize inpatient studies • Monitor ongoing QA practices (i.e. appropriateness of indications, completed requisitions)

Sonographers:

• Certified in adult echo and maintaining required CME credits • Demonstrate proficiency in the performance of 2D imaging, m-mode and Doppler • Effectively communicate and interact with patients • Well versed in medical terminology • Demonstrate knowledge and understanding of ultrasound physics, instrumentation, tissue

characteristics and measurement of blood flow • Aware of proper infection control and safety standards • Maintain patient privacy and confidentiality • Operate within their scope of practice • Must use independent judgment and problem solving for optimal outcomes • All studies are completed unless focused study preapproved • Prioritize inpatients (stats, critical care areas, TTE more than 1 day old then all others) • Prioritize indications • Immediate response to stat requests • Review policy and procedure manual and aware of expectations • Clean, stock and care of equipment and rooms

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• Ensure hand hygiene between patients and at completion of shifts ECG Technician:

• Strong knowledge of arrhythmias • Report equipment problems • Prioritize patient safety • Review policy and procedure manual

Clerical Staff:

• Enter patient data into the system • Accession studies • Greet patients and register • Order supplies and stationery • Attend staff meetings, when available

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Echo Nurse Responsibilities Training:

• Specialized training to assist with dobutamine stress echoes, transesophageal echoes, contrast and agitated saline injections.

• Review of policy and procedure manual. • Orientation period to learn routine and begin working independently.

Dobutamine stress tests:

• Preparation of IV bags with the medication. • Start intravenous line. • Review the dosage chart for correct infusion rate. • Review the 12 lead ECG. • Monitor IV site for extravasation. • Document the medication(s), the dosage(s), the time(s), of administration, prescribed rate(s),

route(s), and patient response(s) to the medication(s). • Identification of side effects of medications. • Assessment of and reporting patient symptoms to physician. • Knowledge of location of crash cart. • Inject contrast as ordered. • Knowledge of cardiac arrhythmias. • Patient assessment prior to discharge. • Documentation of care provided.

Transesophageal Echo:

• Preparation of sedation prior to test. • Start an intravenous line. • Review inpatient chart for medical history prior to test. • Monitor patient’s response to procedure and sedation as well as document vitals during the test. • Inject agitated saline as required. • Knowledge of location of crash cart and use of emergency equipment.

Contrast:

• Start an intravenous line. • Inject contrast followed by a flush. • Assess patient for adverse reaction.

Agitated Saline:

• Start an intravenous line. • Draw up, agitate, and inject saline.

Other duties (i.e. obtaining verbal or written consent, explaining the procedure, answering questions) may be completed by the nurse or the sonographer.

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Training and Education Protocols New Sonographer Training and Education • Must have graduated from a qualified institution and show certification has been completed. • Upon hiring there will be a 3 month probation period. • New staff will be supervised by a senior sonographer - shadow for 1 week while learning the

“Imaging and Measurement Protocols” for the lab. • Will start scanning with minor assistance until approved to work independently. • The new sonographer will receive continuous feedback from the reading cardiologists. • After completion of the probation period and demonstration of competence in doing adult TTE -

there will be the option to start participating in the stress procedures, assist with TEEs and participate in pediatric training.

• All sonographers must obtain the required CME credits (30 credits in 3 years) to maintain certification.

• The department will support CME by providing echo rounds once a week and attendance to echo conferences on a rotation basis.

• The sonographer is responsible for keeping a record of their CME credits. Student Sonographer Training • All senior sonographers are expected to participate in the training of students. • Sonographer students will do a 3 month placement working full days. • A handout will be given upon arrival outlining Procedure and Measurement expectations. • The student will be paired with a senior sonographer each day and will observe the routine and

attend orientation during the first week. • During the first month the student will start with 2D imaging of all the planes until comfortable,

then incorporate color Doppler. • The senior sonographer will review all images and provide instruction on how to maximize image

and color quality - and discuss all pathology as seen on each test. • The second month the test will include Doppler and Diastology – performing full tests with

assistance and receiving feedback on every aspect of their tests. • The third month the student will work independently performing complete studies - asking for

assistance as required - all studies will be reviewed by a senior sonographer before the patient is discharged from the lab.

• If needed the senior sonographer will add additional images. • The student will be given time to receive feedback on their work by the reading cardiologists. • The student will perform adult TTE and assist with TEE tests during their training. • The student will be provided the opportunity to observe stress tests, pediatric and fetal tests

however will not receive training. • The clinical supervisor will provide reviews and evaluations as outlined by the Mohawk manual

during and at the completion of the program.

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Cardiac Fellow Training Program Fellows will be trained in adult TTE in three stages. Stage 1:

• The trainee will learn the basic aspects of cardiac ultrasound. • Will work directly with a senior sonographer. • Initially the trainee will observe the sonographer and after a short period of time, will image the

patient after the sonographer has done a complete study. • An expectation of quality of 2D imaging before they can proceed to Doppler.

Stage 2:

• The trainee will work independently with minimal assistance if needed. • Three to four patients a day will be scheduled - with the trainee performing a complete study on

each with assistance as needed. • An expectation of 50 complete studies done to complete stage 2.

Stage 3:

• Emphasis shifts from the technical performance to the interpretation side of doing studies. • The trainee will be in the lab for a full day and will interpret studies as they are being performed

– while technically doing one or two studies a day to maintain their skills. • The trainee will be evaluated on both technical abilities and interpretation skills. • The trainee will keep a log of all studies performed and interpreted.

Specialized Training After completion of the first 3 stages of their training, fellows will proceed to specialized training in TEE or pediatrics or research. Expectations of Application for all Training Programs 1. Assessment of left ventricular function and wall motion. 2. Assessment of valvular stenosis and regurgitation. 3. Pericardial disease. 4. Aorta pathology – able to assess ascending, transverse, descending and abdominal aorta. 5. Valvular prosthesis – familiar with common types of prosthetic valves. 6. Intracardiac masses – identify and differentiate between different types of masses. 7. Adult congenital heart disease – able to detect congenital defects commonly found in adults.

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Section 6: Continuing Quality Assurance in the Echocardiographic Laboratory

Additional Templates

1. Quality Assurance

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Quality Assurance Purpose To outline the quality assessment practices used in the echo laboratory to ensure best practice. Test result analysis:

• Test results of all echo studies can be correlated with another modality, (e.g. an echo with a mass can be validated by CT or MRI).

• All positive stress studies that proceed to an angiogram can have the results of both exams compared to see if the findings correlate.

• Echo studies can be reviewed by an affiliate lab that can blindly read a study, followed by a comparison of the results of the two interpreting physician reports.

Policy and Procedure manual:

• A manual outlining all practices and procedures is accessible to all staff members. • Contents should be clear and concise; the manual should be updated on a regular basis to

ensure current information is available. • Should include step-by-step instructions for all modalities performed in the echo lab and

include emergency responses to address unexpected events. • Provide a mechanism where referring physicians have a method of providing input to improve

quality of services provided. Requisitions and Reports:

• Requisitions are thoroughly completed and indications are reviewed for appropriateness by the physician.

• Policies are in place to ensure reports are completed in a timely manner and distributed. • QA assessment conducted on a regular basis to assess when a requisition was received, when

the test was completed, when the report was distributed and received by the ordering physician.

• Ongoing assessment of wait times for each modality performed in your establishment. Staff:

• All staff should have current registration and CME credits. • All staff should be able to perform a complete and thorough examination in a reasonable length

of time with minimal discomfort to the client. • Staff trained to inspect machines and probes at the end of the day for cracks in the transducer

heads, loose buttons. • All staff are knowledgeable on the use of appropriate disinfectant wipes and transducer

cleaning sprays as approved by the manufacturers, to clean equipment between patients.

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Special Procedures:

• Facilities performing TEE shall have an infection control log book that documents probes used per patient for all TEE procedures.

• Potential follow-up phone call to the client within 24 to 48 hours after the procedure to obtain feedback on their experience, and check for adverse reactions that occurred following discharge.

• Regular infection control and safety specialist inspections to ensure best practices and safe environments.

Communication:

• Minutes kept from department staff meetings and communication logbook kept in a central area for staff reference.

• Describe practice in place for communicating critical findings to appropriate sources. Study Content:

• Describe the lab practice of the completeness of studies and what is done to ensure the procedures are updated and current.

• Randomly pick studies for review by colleague for quality, completeness and consistency. • Review preliminary reports completed by sonographer for completeness. Inter and intra

observer variability process to identify needs for adjustments or updating. Room Standards:

• Review of room sizes to determine if large enough for the procedure that is being performed with adequate space for additional staff in case of an emergency situation.

Maintenance:

• A dedicated specialist in biomedical engineering to clean the filters on the machines on a regular basis and to address issues not requiring a vendor specialist.

• Maintenance logbook with dates and services completed. • Information Technology specialist to service the computer connectivity and image storage.

97

4100 Yonge St., Suite 502,

Toronto, ON M2P 2B5

tel 416.512.7472

fax 416.512.6425

www.ccn.on.ca

© Copyright 2015 Cardiac Care Network.