Basic Obstetric POCUS

Chapter 4. Safety and Documentation

Ultrasound is one of the safest imaging modalities, especially for pregnancy. In addition to concerns about potential bioeffects, however, there are other factors to conside that affect safety. These factors might be overlooked without a good understanding of how ultrasound works (which was reviewed in the first few chapters). All of these factors can lead to incorrect clinical judgments, inappropriate use, infection exposure, and inaccurate documentation Lastly, we will review ways to monitor risks with quality assurance plans. This chapter will build on the previous concepts learned in the past 4 chapters.

SAFETY

By the completion of this section the participant will be able to:

Describe the difference between x-ray and ultrasound with respect to ionizing radiation
Cite the World Health Organization’s opinions from 2013 on the safety of ultrasound in pregnancy
Define pulsed versus continuous wave ultrasound and the safety concerns of each
Accurately define thermal index and mechanical index, and know their respective safety ranges for pregnancy
Locate TI and MI indicators on the ultrasound screen
Describe the differences in high-level and low-level disinfection, and accurately describe the appropriate method for each type of transducer
List the components for correct documentation of a POCUS exam
Describe protocols for safe ultrasound practice
Utilize standardized templates to develop quality assurance guidelines

Safety concerns for use of POCUS are related to 3 basic factors:

1. Potential bioeffects

2. Infection control (handwashing, equipment cleaning)

3. Accurate imaging/interpretation and effective communication of findings

Types of Imaging: Comparison of X-ray and Ultrasound

The two most common forms of imaging are Xray and ultrasound. Ultrasound has become more widely used in recent years due to its relative safety profile, but x-ray is still a necessary imaging modality for many indications. Ultrasound cannot substitute for x-ray for some diagnostics.

Figure 1. Differences between x-ray and ultrasound.

X-ray uses ionizing (electromagnetic) radiation.

Benefits of x-ray include greater definition of solid structures such as bones and joints. One definite advantage in women’s imaging, for example, is mammography, which detects solid lesions in the breast. Mammograms can detect earlier densities more easily than ultrasound. Ultrasound helps differentiate soft tissue structures from fluid-filled structures, which x-ray cannot. While mammography remains the gold standard for breast imaging, ultrasound can also be used to view soft or fluid-filled masses in the breast. The 2 modalities complement each other.

Although x-ray is generally considered safe, there has been concern that over time, with repeated exposure to ionizing radiation, there can be a cumulative adverse effect on the body over a lifetime.

Ultrasound uses sound transmission, which is non-ionizing and safer, especially for fetal tissues

Benefits of ultrasound include greater definition of soft tissue, such as abdominal and pelvic organs, and pregnancy. These are the systems most pertinent to this course.

Some disadvantages are its limitations with diagnosing bony structures adequately, so as stated before, ultrasound is not necessarily a substitute for x-ray.

Safety Regulations

Despite years of research on bioeffects of diagnostic ultrasound, there are potential safety concerns given the properties of sound described in earlier chapters. Sound waves have the potential for generating mild temperature increases, as well as miniscule mechanical vibrations – each of which have a small potential for damage to tissues. Obstetric applications are of most concern due to rapidly dividing and differentiating fetal tissues.

Radiologic and other medical societies across the world have closely examined safety of ultrasound for the past 3 decades and have published numerous papers and guidelines. Ultrasound machine manufacturers are required to display output of power generated by the transducer, allowing the provider to monitor for safety.

ISUOG (International Society of Ultrasound in Obstetrics and Gynecology) is one of the premier ultrasound organizations in the world. It issued a safety statement in 2003 summarizing the safety of ultrasound relative to ob/gyn application.

The World Health Organization also published a document describing safety and its conclusions are listed in Figure 2.

Figure 2. WHO guidelines on ultrasound safety.

The general consensus of all of these recognized organizations is this:

The use of diagnostic ultrasound generally accepted as safe at this time. There have been no updated concerns since the publication of these position papers.

B-mode and M-mode outputs are generally not high enough to produce ill effects.
Prudent use is recommended even though there may be no concern about most applications

WHY IS THIS IMPORTANT?

When scanning a woman in pregnancy, you must be able to explain the general safety of ultrasound. There are many misconceptions even among societies where pregnancy ultrasound is commonplace.

Acoustic Output is the term used to describe the amount of energy or power generated by the ultrasound beams. It is often presented as a gradient from the least to the most energy output.

B-Mode or 2D creates the least amount of energy. Color Doppler is in between Spectral Doppler (pulsed and continuous wave Doppler) which produces the highest energy. As you recall from prior chapters, this is because the beam is narrowly focused at a very small area of a blood vessel, causing the potential for tissue damage at that area due to intensity. This is summarized in Figure 3. below.

Figure 3. Acoustic output gradient based on mode.

When discussing the safety aspects of ultrasound, understanding the effect of an ultrasound beam on body tissue is vital. Bioeffects of ultrasound are categorized as either thermal or mechanical, and both are important concepts to understand.

Thermal Effects

The thermal effect of ultrasound pertains to how much heat can be potentially generated by applying the ultrasound beam to tissue.

Of primary concern is that ultrasound waves send energy into the body, most of which is converted into modest amounts of heat. Generally, this heat is dispersed through the tissue evenly. However, if focus is applied to viewing a structure, aiming that beam at the structure for an extended period can increase the temperature to a degree that may not be safe.

Some ultrasound settings are capable of producing temperature increases of greater than 1° C (or 2° F) at soft tissue/bone interfaces if the focal zone of the transducer is held stationary.

KEEP IN MIND: With 2D imaging, intensities are not sufficient to produce measurable heating of tissue unless there is prolonged exposure.

Figure 4. Thermal effects monitored by ultrasound operator.

The principles described in Figure 4 are important to learn:

—Thermal Index (TI) expresses the potential for a rise in temperature at the ultrasound beam’s focal point. It describes the relative absorption of ultrasound energy by body tissue converted to heat

Tissue with the lowest absorption and conversion to heat:

1. Fluid-filled tissue

The highest absorption and conversion to heat occurs in:

1. Bones

2. Tissue closer to the transducer

3. The focal zone (where the focus of the beam is directed)

4. Static scanning - directing the beam at a specific area for a prolonged period of time. (Example: holding a hot iron in place too long instead of moving it around). This is also known as transducer dwell time.

Transducer dwell time

Temperature increases can be minimized by minimizing transducer dwell time. Transducer dwell time (or dwell time) is defined as the total time that a structure is continuously exposed to the active ultrasound beam during an ultrasound examination. When you ‘freeze’ an image, this stops the transmission of the sound beam. That means you can keep your transducer in place to hold the scanning position without unnecessary exposure.

2 Facts to remember:

The closer the object to the transducer the greater the energy
the smaller the area the beam is hitting, the greater the energy and intensity.

Thermal index is divided into three categories, having to do with the type of tissue you are planning to scan. When scanning either an early pregnancy or a late pregnancy, it is important to confirm that the TI is at the appropriate setting.

Figure 5. Types of thermal index indicators

TI categories are automatically selected by the machine when you select the application you want to use. For example, if you select “first trimester” as the type of scan you want to perform, the machine will automatically creat the TI for TIS (soft tissue) to minimize the energy directed to a small fetus.

TIS – Thermal index for soft tissue

1. Assumes that only soft tissue is being imaged

2. Usually used up to 10-12 weeks’ gestation

TIB – Thermal index for bone

1. Assumes bone is present at the depth where intensity is greatest

2. Adjusts settings to protect bone

TIC – Thermal index for cranial bone

1. Not displayed in ob settings

2. Assumes the cranial bone is very close to the probe itself

WHY IS THIS IMPORTANT?

You need to be aware that earlier gestation should be viewed with lower TI settings to avoid affecting tiny structures. You also can feel safe in using a TI setting for bone if the pregnancy is in a later trimester.

Figure 6. provides general time limits for scanning, showing that the higher the thermal index, the less time you should spend performing the exam.

Figure 6. Recommended scanning time limits based on TI.

When performing ultrasound we have learned that we can select a certain mode of scanning that allows us to see certain structures. Each of these modes has a different capacity to send energy into the body with the sound wave. It is these intensities that have the most relevance for thermal effects. Figure 7 compares the relative power or strength based on the type of mode selected. As you can see, B-mode (or 2D -mode) creates the least amount of energy that can cause thermal effects. Next is Doppler, which primarily means color Doppler. It generates a higher amount of power. The highest is the use of pulsed Doppler (spectral Doppler) which is used infrequently in POCUS. There are certain indications for its use and we will discuss these in later chapters.

Figure 7. Average intensity comparison by modes of ultrasound.

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Figure 8. Thermal effects summary

Non-Thermal Effects (Mechanical Effects)

Ultrasound energy waves affect tissue by creating energy waves in the form of sound. This energy causes vibration of tissue which is considered mechanical in nature. The measure of these effects is described as the Mechanical Index or MI. Remember the principle that the sound wave causes tiny movement of particles in its path. These vibrations are minute and typically innocuous, but at the cellular level there can be significant impact.

Figure 9. Non-thermal bioeffects of ultrasound

Non-thermal or Mechanical Effects

Ultrasound energy waves create effects in tissue that are considered mechanical in nature, and are described as the Mechanical Index or MI. Remember the principle that the sound wave causes tiny movement of particles in its path. These vibrations are minute and typically innocuous, but at the cellular level there can be significant impact.

Mechanical effects caused by the pressure of sound waves passing thru or near areas with gas or air pockets, causes tissue motion or vibration. This vibration can result in “mini-explosions” (collapse) of air or gas bubbles in tissue, and this is called ‘cavitation’. Cavitation itself is used for a variety of medical purposes, including use as a contrast agent for tumor identification. In theory it is potentially harmful for delicate fetal tissue, but in the safety range used for obstetric ultrasound, there has never been evidence of real damage occurring to a fetus. In obstetrics the risk is considered potential, but awareness of that potential is necessary.

Output display

The output display is the place on the ultrasound screen that shows the numerical value for both thermal and mechanical effects.

The MI and TI are usually located at the top middle or top right of this screen, but on some machines can be found in the upper right corner or right side of the screen.

Figure 10. Output display location on the screen

ALARA

NOTE: The overall goal in ultrasound is to get the best image while using the least amount of energy in the least amount of time.

ALARA is a term that is widely used in the field of imaging. It was originally used for acknowledging safety risks of x-ray exposure, but was adopted as an acronym appropriate for ultrasound as well. This acronym is the hallmark of imaging safety awareness. It is a common test question and helps one to be mindful of ultrasound safety. It stands for “As Low As Reasonably Achievable” and it has to do with energy of beams and scan time (transducer dwell time).

NOTE: This acronym needs to be memorized: It will be referred to and asked throughout this course.

Figure 11. Definition of the ALARA principle

This is a summary of how to achieve ALARA:

—Use lowest power to achieve a satisfactory image

—Use the least amount of time to acquire the necessary image

—Use power or Color Doppler only as necessary and RARELY in first trimester

—Do not use pulsed Doppler in OB since it creates the most amount of energy

—TI (Thermal Index) should be < or = 1.0 in pregnancy. Typically displayed at the top of the screen on the display

—MI (Mechanical index) should also be < or = to 1.0 in pregnancy

DOPPLER ULTRASOUND

Doppler imaging

The physics of Doppler imaging are a bit more complex to describe, but what you need to know is that it is a useful mode used to measure moving fluid or particles. It is used primarily to either detect the presence of blood flow to living tissue, or to detect the rate and direction of flow in structures such as critical blood vessels.

Use of Doppler (even color Doppler) raises safety concerns for early pregnancy due to its higher energy/intensity. With Doppler the potential for thermal effects is greater due to increased number of pulses sent to an area, and narrow focus of the beam. Power or Spectral Doppler utilizes a specific window, or “gate”, used to both narrow and focus on the field of investigation. Color flow uses a window to view an area or structure, but it does not create as small or focused gate. Doppler ultrasound uses more frequent pulses of sound waves, which increases the overall level of tissue exposure to energy. Based on current evidence of potential harm to early gestation, most ultrasound societies do NOT recommend routine use of doppler prior to 10 weeks’ gestation.

Despite concern, color Doppler causes less overall energy exposure than power or spectral doppler imaging if used judiciously. ISUOG recommends no longer than 5-10 minutes using Doppler scanning.

Power or spectral Doppler is another form of Doppler imaging that utilizes more intensity than color Doppler since it is more concentrated, so it will not be described in this chapter.

It is important to remember the following regarding Doppler:

1. Doppler (spectral, power and color flow imaging) ultrasound should not be used routinely in first trimester.

2. Doppler ultrasound may be used for certain clinical situations such as to confirm a loss of cardiac blood flow in a fetal demise.

3. When performing Doppler ultrasound, the displayed thermal index (TI) should be less than or equal to 1.0 and exposure time should be kept as short as possible (usually no longer than 5-19 minutes, not exceeding 60 minutes).

Infection Control: Handwashing

This cannot be overemphasized! Between every patient the midwife must wash hands or use a hand sanitizer! Since you will be touching the machine and the patient, there is great potential for spreading microorganisms.

Figure 12. Wash your hands between patients

Infection control: Transducer Cleaning

Infection control is a critical concern for both the woman you are scanning and for the practitioner. Transducers should be carefully inspected before use to be certain they are free of any debris or fluid. Transvaginal probes should be covered with an appropriate sheath. Both types of transducer need to be wiped clean with a soft cloth prior to the disinfecting process in order to remove any body fluids or gel. The cord should also be wiped down.

Transducer Disinfection

Figure 13. Transducer cleaning

Each machine manufacturer provides a list of recommended products for their equipment. After disinfecting, the recommendation is for probes to be stored in a clean utility area, or close to the ultrasound machine. Keep the clean probe covered with a cloth or keep it in a protected bin. Do not use alcohol or bleach on the rubber or silicone part of the probe that comes in contact with the skin (called the acoustic matching layer) since it can destroy that layer.

Other Safety Considerations

Other safety considerations include regular inspection and cleaning of all parts of the machine, including:

Figure 14. Other safety considerations - machine component integrity

Be aware of the following (listed in Figure 14)

1. Non-functioning parts

2. Cords

3. Regular inspection and cleaning

4. Keep off the floor

5. Avoid draping cords over patients while scanning whenever possible

COVID Safety Concerns

Since the onset of the COVID-19 pandemic, all medical facilities had to develop rigid infection control policies. Specific COVID-19 guidelines were implemented during this pandemic, and in many places remain in place. These However, basic infection control is to be followed regardless of setting.

Another aspect of safety has to do with accurate documentation and communication. Safety concerns follow the patient throughout the consultation and referral process, and appropriate documentation provides that.

DOCUMENTATION

This section reviews general guidelines for documenting a standard ultrasound exam, as well as essential components of documenting for point-of-care ultrasound. There is overlap between the two, but there are fewer detail components with a POCUS since typically fewer structures are being assessed.

Documentation objectives

By the completion of this Section, the participant will be able to:
List the essential components of documentation for any ultrasound exam performed
Describe the importance of text annotation on an image and how that can impact clinical management
Define a “critical finding” and the importance of obtaining consultation or referral in those cases
Review a report generated by a radiologist and locate critical findings

This course is about point-of-care ultrasound, or bedside ultrasound, done for a specific purpose in expediting clinical decisions. With standard ultrasound, there are typically at least two separate individuals involved – the woman’s provider and the one performing the ultrasound. This requires critical communication between providers.

With POCUS, the provider is likely the one to be performing the ultrasound. This does not mean that documentation is unnecessary. Accurate recording of the POCUS exam is just as critical for others who will be caring for the woman, especially if she is referred to a consulting provider or physician.

With POCUS is just as critical to provide all the information possible, especially since the burden of clinical decision-making and care management depends on the scanner, who must justify the assessment and subsequent plan. It is even more critical if referral to another provider is made, so that complete information can be sent quickly.

The POCUS exam does not end when the patient leaves the facility. Documentation and communication remains a critical piece to complete the study.

Point-of-care ultrasounds, especially in obstetrics and gynecology, are often done under conditions of urgency. This makes it a challenge for those performing POCUS exams to take time to accurately document in a meaningful manner. A rapid ultrasound causes a necessary interruption in workflow; this interruption has been a subject of research in recent years to learn ways of expediting saving and transferring information. POCUS images and reports are considered legal documents, just like anything else that is part of the patient’s medical record. This protocol may vary depending on local or institutional procedures. Even in regions that do not have elaborate medical records systems, at the very least, a copy of a written summary should be documented in the patient’s paper record. It is also helpful to have a logbook of all the scans done in a particular patient unit, such as an obstetrical ward.

Most large institutions provide digital recording and archiving into their data systems and electronic medical records. But even with this technology, there are still reporting deficiencies with the use of POCUS. Two studies (Nomura and Aziz) involving emergency department (ED) physicians, showing documentation discrepancies resulted in protocol changes. Aziz concluded: “…accurate documentation of POCUS is essential, especially in cases where POCUS has been used to change management, facilitate decision making or been used to compare clinical status across time. Poor documentation affects the quality and safety of patient care as verbal handovers can be misconstrued or the information not given which also has medicolegal implications…”

Essential Documentation

Since the POCUS exam is usually a brief exam, there does not need to be the level of detail that is required for a standard diagnostic scan. However, there are essential components and principles for efficient but essential information.

Essential Components:

Patient name and other identifying information
Facility’s identifying information (where the scan was done)
Date of ultrasound exam
Indication (reason for the exam)
Type of exam (transabdominal or transvaginal)
Exam description and impression or interpretation
Images (normal and abnormal) to be recorded in retrievable format
Plan, Management of care (recommendations)
1. Communication between the ultrasound provider and any healthcare provider should be clear, timely, and in a manner that minimizes potential errors.
Maintenance of patient confidentiality

In addition to the above, the SDMS (Society of Diagnostic Medical Sonography) published a similar list of components for ultrasound documentation, with the recommendation documentation must be in accordance with collaborating physicians, facility policies and other protocols within the practitioner’s setting. In other words, the report needs to be formatted to be usable in the current medical record system, or formatted for easy interpretation by the referral facility.

Figure 15. Essential Documentation worksheet for POCUS extrapolated from AIUM guidelines.

Figure 15 (above) is a worksheet template that condenses the essential documentation components for point-of-care ultrasound.

In summary, the essentials for documentation for a POCUS exam are:

Patient name and identifying information
Date of ultrasound exam
Relevant clinical information
Specific ultrasound exam indicated or intended
Name of provider requesting and performing exam
Type of transducer used (transabdominal, transvaginal)
Use of appropriate sonographic terminology
Size descriptions should include specific measurements (not “large” or “small”)

Documentation Templates

Figure 2 shows an example of one type of POCUS ultrasound report. POCUS templates can be developed or modified to fit your practice setting. Other sample reporting templates will be provided in subsequent courses. Some electronic records systems allow providers to create their own templates; others may have pre-developed templates specific to the type of exam. You can make a generic template to describe any pregnancy exam, or you can create one that is specific for a certain type of pregnancy exam (such as a biophysical profile).

Figure 16. Sample documentation template for early pregnancy ultrasound

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Accurate annotation on the Image

In addition to a written report describing the ultrasound, each image needs to be correctly annotated. It should never be assumed that the person viewing your image will readily know the structure you are viewing or its orientation. This is something we described briefly in a previous section, but the following slides will give examples of why we need to do this.

Figure 17. Annotation on the image.

Figure 18. Example of incomplete GYN image annotation

In this image we see a round, hypoechoic structure. We do not have any annotation on it, however to let us know what it represents or where in the body it is located. It could represent a cyst in the neck, an ovarian cyst, or even an empty gestational sac. We also do not know if this view is long (sagittal) or transverse. These are all critical differences! This image has no interpretive value without annotation.

Let’s say a cyst is annotated as a right ovarian cyst, and she returns in 6 weeks for a follow up. At that time, a cyst that looks identical to the previous one is seen; but this time it is noted on her left side. This could mean that an error was made on the previous scan, or the first one resolved and now she has one on the other side. Without full annotation and documentation, it would be difficult to decide.

Figure 19. Example of incomplete OB image annotation

Figure is an example of an obstetric scan. The green dot marker indicates that the baby’s head is pointed either to the mother’s head or her right side. But without any additional information we cannot tell from the image. This additional documentation may not matter if the person scanning understands the orientation he or she is using. However, the next provider that sees this woman needs to be certain of the position of the baby, say, for labor management. If the baby is breech during labor, then a vaginal delivery is possible in some cases. If the baby is in transverse lie, this changes the management, likely necessitating a C/Section. If this image has appropriate annotation on it (orientation to the mother), there is proof of the baby’s real position at the time she was scanned.

Figure 20. Correctly annotated GYN image

The image in Figure 20 (above) was correctly annotated – it is easy to see where the structures are since they are labeled. Long or Sagittal was not annotated; however, this view of the uterus can only be obtained in a sagittal plane, so the sonographer did not deem it necessary to write it out.

Critical Findings

When a point-of-care ultrasound is done and an abnormality with serious or urgent implications (such as a suspected ectopic pregnancy) is suspected, a reliable referral mechanism is ESSENTIAL for sending a woman to a more senior provider or physician.

This means also that in your study of ultrasound it is critical that you become so familiar with what is normal, an abnormality will be clearly identified when seen. This course does not teach how to diagnose ,but instead provides the learner with the skill to identify and describe abnormalities and consult or refer.

Figure 21. Critical findings documentation

When referring or consulting for an urgent clinical situation, it is essential that you document the conversation (including date and time) with that provider, as well as the recommended follow-up as instructed to the patient. This allows you to demonstrate that the woman’s condition and management were fully explained and documented.

Reading a Standard Ultrasound Report from Radiology

In addition to learning ultrasound principles in order to provide POCUS, this course gives you additional knowledge to be able to read, understand, and interpret reports sent from a radiology practice.

This is a sample of a report from a radiologist on a patient being scanned for a biophysical profile. In the subsequent course on 2nd and 3rd Trimester Obstetrics, the amniotic fluid index was 31 cm, which indicates an abnormality known as polyhydramnios. Although this sonographer verified the fluid level, he or she did not indicate that the referring provider was advised of this abnormality.

Figure 22. Example of critical findings report

In general, if the interpreting provider believes that delay in the results of the ultrasound examination would have an adverse effect on the patient’s outcome, direct communication (verbal or electronic) should occur between the person doing the exam and the consulting provider. It also works in the reverse - if a radiologist or sonographer determines an abnormality, the imager should contact the midwife or OB provider directly with critical information.

Figure 23 is a sample of a report from a radiologist on a patient being scanned for a biophysical profile. The amniotic fluid index was 31 cm, which indicates an abnormality known as polyhydramnios (which will be reviewed in the chapter on biophysical profile). Although this radiologist verified the fluid level, he or she did not indicate that the referring provider was advised of this abnormality.

Critical Findings Report

Figure 23 is an example of a sonogorapher’s report and documentation of a critical finding. This radiologist completed all the essential elements for a critical exam, including an image of the suspicious area, and her overall impression. In THIS report she noted that she discussed the findings with the provider, along with the date and time.

Figure 23. Example of critical findings report with follow up indicated

This report was generated by the ultrasound machine. The information was derived from what was input into the computer before and during the exam:

Patient information
Provider information
Date and time of scan
Place of exam
The indication for the exam (BPP)
Measurements taken
Other descriptions and annotations by the sonographer
Biophysical profile information recorded during the scan
Comments at the end were entered by the sonographer, writing out his/her impressions

QUALITY ASSURANCE

Quality assurance is a topic that is often avoided because of its perception as being disciplinary (singling out individual performance errors). However, quality assurance is essentially a way to provide the highest quality of care by monitoring for ways to improve care. It has become a standard part of almost all medical practice in many countries and regions. It should be designed to make nonbiased evaluations of individual/team performance or systems of care.

Figure 24. Essentials of quality assurance.

All medical procedures must demonstrate ongoing assurance of quality to fulfil the mission of providing the best and safest care to all women.

Guidelines for monitoring quality indicators related to standard ob/gyn ultrasound also apply to point-of-care women’s ultrasound.

Protocol Development

Before implementing any new medical procedure, safety can be reassured by the development of protocols, which are simply written steps or guidelines. In this section a sample protocol will be provided as a template for adaptation to a practice site using women’s health POCUS. Safety is assured by development of protocols.

Protocols establish:

Indications for POCUS exam
Who may perform POCUS exam
Required training or certification
Specific types of POCUS that may be performed (gyn, first trimester, second-third trimester, BPP, etc)
Documentation protocol (format)
Reporting and referring mechanisms

Figure 25. Protocol development

Quality Assurance Flow Examples

The following section provides samples of quality assurance protocols that can be useful as templates.

Figure 26 presents a diagram illustrating a QA process that was developed by Dowdy and implemented for a practice in the United States for nurse midwives in private practice. This is only an example of how a quality assurance analysis might be done for midwives using POCUS.

Figure 26. Quality assurance flow chart example

Figure 27 (below) presents a template for a QA list for reviewing the image quality of POCUS scans for both transvaginal and transabdominal scans

Figure 27. Example of a skills checklist as a QA process

Figure 28. Recommended quality review for fetal biometry images

Documentation QA

In addition to reviewing images, another aspect of QA is to review accuracy of POCUS documentaiton. The following components are listed for use in reviewing POCUS records:

Use of appropriate anatomic and sonographic terminology
Description of anatomic location and laterality
Image orientation described, when appropriate
Accurate numeric measurements – avoid using descriptors like “large’ or “small”
Indication for the exam
output display documented or indicated on image
Exam limitations (body habitus, pt refusal, etc)

Table 1 presents a summary of common deficits identified during a QA evaluation of a POCUS exam. This table may also serve as a template for quality assurance review.

Table 1. Terms to use when reviewing and evaluating POCUS exams for QA purposes

Term	Definition
Incomplete study, missing operator	Study does not contain information on who performed the exam
Incomplete study, missing documentation	Study does not have a complete interpretation report
Incomplete study, missing images	Study does not have complete images
Incomplete study, missing patient identifiers	Study does not contain patient identifiers
“Phantom or ghost scan”	Study is not documented in the medical record or have archived images; when audited it does not exist. It is inadequate to write a simple notation in the record summarizing the exam

In summary, the essentials for documentation for a POCUS exam are:

Patient name and identifying information
Date of ultrasound exam
Relevant clinical information
Specific ultrasound exam indicated or intended
Name of provider requesting and performing exam
Type of transducer used (transabdominal, transvaginal)
Use of appropriate sonographic terminology
Size descriptions should include specific measurements (not “large” or “small”)

SUMMARY

—Ultrasound is a safe imaging modality since it uses non-ionizing radiation; however, there are certain safety precautions to observe

—International ultrasound organizations have established safety parameters for the use of medical ultrasound

—ALARA is the acronym used to define minimal ultrasound exposure for patients: As Low As Reasonably Achievable

—Machine safety parameters to be monitored include: thermal and mechanical indicators

—Infection control assures protection for both patient and provider and includes minimal standards for cleaning environment and equipment.

—Quality assurance is an essential component of an ultrasound program, and assures competency for imaging providers as well as patient safety

YOU MAY NOW TAKE THE QUIZ AND MOVE TO THE NEXT CHAPTER. YOU WILL NOT BE ABLE TO OPEN THE NEXT CHAPTER UNTIL YOU COMPLETE AND PASS THE QUIZ. YOU WILL HAVE AS MANY TRIES AS YOU NEED TO GET ALL THE ANSWERS CORRECT!

GULU Midwives Basic Obstetric POCUS

Chapter 5. Safety and Documentation