Published on Policy & Guidance Document Library (http://doc-lib.sor.org) | Published on 1st October 2008

Guidelines For Professional Working Standards: Ultrasound Practice

Guidelines For Professional Working Standards: Ultrasound Practice [1]

The minimum qualification for non-medical sonographers to practise in the UK is a Postgraduate Certificate in Medical Ultrasound or equivalent as recommended by the Consortium for the Accreditation of Sonographic Education (CASE)(1). Individuals without a recognised qualification, including student sonographers, should always be supervised by qualified staff.

The sonographer should:

An ultrasound examination should not be carried out unless a valid request has been received. The request should include such clinical details as are relevant to the examination, clear identification of the person requesting the examination and to whom the report should be directed.

Sonographers are strongly advised to register on the National Voluntary Register for Ultrasound Practitioners in support of practice regulation(2)(3)

References

  1. Consortium for the Accreditation of Sonographic Education. (2000) CASE Accreditation Handbook. London: CASE.
  2. http://www.ukasonographers.org [2]
  3. http://www.sor.org [3]

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1.1 Safety Of Medical Ultrasound

“...Diagnostic ultrasound has been widely used in clinical medicine for many years with no proven deleterious effects. However, if used imprudently diagnostic ultrasound could be capable of producing harmful effects. The range of clinical applications is becoming wider, the number of patients undergoing ultrasound examinations is increasing and new techniques with higher acoustic output levels are being introduced. It is therefore essential to maintain vigilance to ensure the continued safe use of ultrasound(1)...”A broad range of ultrasound exposure is used in the different diagnostic modalities currently available. Doppler imaging and measurement techniques may require higher exposures that those used in B- and M-modes, with pulsed Doppler techniques having the potential for the highest levels.

Modern equipment is subject to output regulation. Recommendations related to ultrasound safety included in this publication assume that the equipment being used is designed to international or national safety requirements and that it is operated by competent and trained personnel.

It is the responsibility of the sonographer to be aware of and apply the current safety standards and regulations(2) and to undertake a risk/benefit assessment for each examination.

The sonographer should be responsive to:

References

  1. http://www.efsumb.org/ [4] - Committees - Safety Committee (ECMUS) - Clinical Safety Statements
  2. http://www.bmus.org/ [5] - Ultrasound Safety - Ultrasound Safety & Guidelines - BMUS Safety Guidelines
  3. Barnett, S. B. and ter Haar, G., (2000). Guidelines and recommendations in The Safe Use of Ultrasound in Medical Diagnosis, ter Haar and Duck FA (ed). London: British Institute of Radiology
  4. ISUOG Safety statement 2003 (access for [temporary] members only) http://www.isuog.org/EducationAndTraining/StatementsandGuidelines/Statem... [6]
  5. Routine Ultrasound Screening in Pregnancy; Protocol, Standards and Training. Supplement to Ultrasound Screening for Fetal Abnormalities; Report of the RCOG Working Party. July 2000. RCOG Press

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1.2 Ultrasound Equipment And Quality Assurance Testing

The sonographer is expected to:

The stated aim of quality assurance procedures applied to ultrasound equipment is to ensure consistent and acceptable levels of performance of the imaging system and image recording facilities. Most quality assurance protocols focus on the consistency of specific features of image quality over time. The acceptability of image quality may not be apparent from measurable changes in the parameters tested. The issue of what constitutes unacceptable equipment performance is still very difficult to assess objectively. In the absence of nationally accepted performance standards for ultrasound equipment, local and subjective evaluation is required.

This programme should include a policy on:

A quality assurance programme should be developed in discussion with medical physics or service engineers, for each individual machine. This should be based on its clinical uses, the modes and functions utilised, the transducer types and frequencies and the auxiliary equipment attached. The programme should indicate clearly the limits of acceptability for each test, what and by whom action should be taken when these are exceeded.

The sonographer’s responsibilities in relation to the ultrasound equipment should include:

References

  1. MHRA Device Bulletin DB2006(05) “Managing Medical Devices: Guidance for healthcare and social services organisations”, Nov. 2006. Available at www.mhra.gov.uk/Home [7] - Publications - Safety guidance - Device Bulletins

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1.3 Ultrasound Examination Procedures

Relating to all ultrasound examinations, the sonographer should be aware of locally agreed standards of practice and current guidelines of other professional bodies and organisations.

The following points should be considered for all ultrasound examinations:

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1.4 Communication

Whilst undertaking any ultrasound examination and working in accordance with locally agreed practice, the sonographer should:

* Refer to Section 1.5
+ Refer to Section 1.6

References

  1. The Royal College of Radiologists (2005) Standards for Patient Consent Particular to Radiology. London: The Royal College of Radiologists.
  2. Mental Capacity Act 2005.
  3. National Patient Safety Agency, February 2007: Early identification of failure to act on radiological imaging reports.

 

Additional Reading

• http://www.npsa.nhs.uk [8]
• http://www.dh.gov.uk [9]
• http://www.rcr.ac.uk [10]


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1.5 Informed Consent For Ultrasound Examination

Valid consent must be obtained before starting any ultrasound examination or procedure. Healthcare professionals who do not respect the right of a patient to determine what happens to their own body in this way may be liable to legal or disciplinary action. The consent process is a continuum beginning with the referring health care professional who requests the ultrasound examination and ending with the sonographer who carries it out. It is the responsibility of the referring professional to provide sufficient information to the patient to enable the latter to consent to the ultrasound examination being requested. It is the responsibility of the sonographer to ensure that the patient understands the scope of the ultrasound examination prior to giving his or her consent.

Verbal consent must be obtained for all examinations. Additional verbal consent should be obtained where a student sonographer undertakes part or all of the ultrasound examination under supervision.

Consent for those of an intimate or invasive nature should be recorded in the ultrasound report. (Refer to Section 4.4).

Local schemes of work should clearly state which examinations require written consent.

Literature which explains the scope of the examination clearly and accurately should be made available to patients prior to the ultrasound examination.

Additional Reading

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1.6 Intimate Examinations

The definition of an intimate examination may differ between individual patients for ethnic, religious or cultural reasons. In addition, some patients may have a clear preference for a health carer of specific gender due to their ethnic, religious or cultural background, because of previous experiences or in view of their age. Where possible such individual needs and preferences should be taken into consideration.

When conducting an intimate and/or invasive examination, the sonographer should:

Patients should not be asked to remove clothing unnecessarily - when required private, warm, comfortable and secure facilities for undressing and dressing should be provided. Care should be taken to ensure privacy in waiting areas used by patients not fully dressed in their own clothes. During the ultrasound examination only those body parts under investigation should be exposed.

Care must be taken to maintain confidentiality when non-health care personnel are nearby.

Patients should be offered the opportunity to have a chaperone, irrespective of sonographer gender and examination being undertaken.

A record should be made in patient records when chaperones are offered and used, and when they are declined. The record should include the name and designation of the chaperone. Chaperones should normally be members of the clinical team who are sufficiently familiar with the ultrasound examination being carried out to be able to reliably judge whether the sonographer’s actions are professionally appropriate and justifiable.

For professional integrity and personal safety the sonographer should give equal consideration to their own need for a chaperone irrespective of the examination being undertaken or the gender of the patient. The patient’s privacy and dignity should be maintained throughout the examination which should be conducted without interruption. Only personnel necessary for carrying out the ultrasound examination should be in the room during intimate examinations.

It is good practice to ensure that both hand washing and equipment cleaning are carried out in full view of the patient at the beginning and at the end of the intimate examination to reassure him or her that effective infection control procedures are being applied.(1)

References

  1. http://www.dh.gov.uk/en/AdvanceSearchResult/index.htm?searchTerms=hand+w... [17]

Additional Reading

• RCR (1998) Intimate examinations. BFCR (98) 5. London, Royal College of Radiologists.
• http://www.rcr.ac.uk/index.asp?PageID=310&PublicationID=73 [16]
  
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1.7 Ergonomic Practice

Prevention and Management of Work Related Musculoskeletal Disorders

Work related musculoskeletal disorders (WRMSD) are becoming increasingly associated with ultrasound practice. This is due to two major factors - escalating patient referrals and the increasing body mass index of the population. It is important that sonographers take care of their posture and working environment whilst scanning. Employers have a duty of care to their employees and should be guided in ways to avoid potential work related injuries, i.e. by supplying equipment fit for purpose and being realistic about time management1. Departmental guidelines should include strategies to minimise the risk of WRMSD, including appropriate management of workload. (Refer to Section 1.8).

The risk of WRMSD can be reduced by:

Managing the Obese Patient

In order to reduce the likelihood of the sonographer developing WRMSD and/or exacerbate the condition when present, multiple repeat examinations of obese patients/patients should be avoided. Clinical obesity is defined as a body mass index (BMI) >35. Where inadequate visualisation is due to clinical obesity of the patient, one repeat examination only should be offered.

Should the examination remain incomplete at the second attempt, the sonographer should record in the report that the examination could not be completed, due to increased patient BMI and that no further appointment has been given. (Refer to Section 2.5).

The sonographer should be aware of the recommended weight limits for various examination couches and ensure appropriate equipment is available or make suitable arrangements when necessary.

References

  1. Health & Safety at Work Act (1974)
  2. http://nscfa.web.its.manchester.ac.uk/cms.php?folder=94#fileid367 [18]

Additional Reading

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1.8 Guidance On Ultrasound Examination Timings

In the context of this section, the examination is defined as the following: Assessing the ultrasound request, introductions, explanation and consent, the ultrasound procedure, discussing the findings with the patient, writing the report, archiving the images and attending to the aftercare of the patient including arrangements for further appointments and/or investigations.

The sonographer has a professional responsibility to ensure that the time allocated for an examination is sufficient to enable it to be carried out competently. It is critical to patient management that no ultrasound examination is compromised by departmental and/or government targets.

The allocated appointment time for specific ultrasound examinations will vary depending on their type and complexity. It may also be influenced by the expertise of the sonographer and/or training commitments within the department. In addition the duration of the examination will be further influenced by the scan findings and/or the condition of the patient.

It is recommended that the minimum time allocated for an ultrasound appointment is no less than 15 minutes. In order to provide adequate practical training without compromising the examination, it is recommended that the allocated time where training is being undertaken should be doubled. The following recommendations in Table 1 have arisen from a series of consultation workshops with UKAS members. They are offered for guidance purposes and represent minimum allocated appointment times. They are illustrative only, and not exhaustive.

Additional Reading

 

Table 1. Recommended Examination Timings


Allocated Appointment Time Ultrasound Examination Example
15 minutes Follow up of screening for abdominal aortic aneurysm
Follow up of screening for endometrial hyperplasia
20 minutes Pregnancy dating
3rd trimester review
Referral for gall bladder disease
Referral for urinary tract pathology
Referral for testicular lump
Referral for thyroid mass
Follow up of known liver disease (eg: cirrhosis / hepatitis)
Follicular tracking for assisted reproductive techniques
Referral for gynaecological indications
Peripheral vascular referrals (eg: DVT / carotid stenosis)
30 minutes 1st trimester pregnancy screening (nuchal translucency)
2nd trimester routine anomaly screening
Paediatric / neonatal referrals
Investigation for diffuse liver disease
Investigation for portal hypertension
Breast Referrals
Cardiac Referrals
45 minutes Interventional procedures - biopsies, contrast, fetal therapy
Known twin pregnancy including 1st trimester screening
60 minutes Bedside examinations (total time away from department)
Intra-operative procedures

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1.9 Medico-Legal Issues

The place of work should have a written set of guidelines that accurately describes the range of ultrasound examinations undertaken. Their content should address the ultrasound examinations, their reporting and the appropriate referral pathways for patients with normal and abnormal ultrasound findings. The details in the guidelines should be such that a new staff member, having read the guidelines, could carry out and report these examinations and appropriately refer the patient after the examination to the expected standard. Guidelines should be updated regularly and their review date should be included in their content. Superseded guidelines should be kept on file permanently.Records are currently required by law to be kept for a number of years as specified by individual institutions.

The following guidance should be considered:

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1.10 Ultrasound Screening Procedures

It should be noted that ultrasound screening programmes may differ across the four countries of the UK and sonographers should contact the relevant Health Departments for current advice. Screening programmes should follow the principles laid down by the World Health Organisation1. There are several ultrasound screening programmes based on local practice, research evidence or national guidance currently offered in the UK. These include:

Provision of an ultrasound screening programme requires the same level of competence, understanding, consent and patient care as any other ultrasound examination.

Pregnant Women Declining Antenatal Ultrasound Screening

At the current time, all women should be offered antenatal ultrasound screening for Down’s syndrome and fetal anomalies as part of their maternity care.2,3,4

Prior to attendance at the ultrasound department, all women should be provided with appropriate information, based on national and local guidelines, about the screening test in order to make an informed choice on their care.(1)(2) (Refer to Section 1.5).

Some women may choose to decline screening and/or any ultrasound examination during pregnancy.

In cases where a woman declines ultrasound screening, the sonographer is advised to:

If the sonographer has any reason to query either the clinical request for screening, the woman’s knowledge of the procedure and risks involved or a request from a woman for part-screening (chromosomal or structural), the sonographer should contact the referring health care professional for clarification.

Depending on local protocols related to giving patients relevant and appropriate information, women who are undecided about ultrasound screening could be given the following:

''...In order to confirm your pregnancy, to take measurements to provide you with an expected date of delivery, confirm that your baby’s heartbeat is present and establish the site of the afterbirth, various views of your baby must be obtained. The sonographer will need to take a detailed look at your baby and obtain various ultrasound images whenever you attend for your scan(s).

If we identify any unusual findings in any of these images - which might include for example a twin pregnancy, the fact that your baby has died, or that an abnormality is present - we are professionally obliged to inform you. We are also obliged to inform your midwife or medical practitioner of these findings in a written report.

By consenting to any ultrasound scan ‘to check your baby or provide details of your dates’, you should accept the above statement related to the sonographer’s professional practice code. If you find this unacceptable then you may wish to consider declining your scan appointment...''

You are advised to refer to the relevant sections in this publication for additional guidance on specific ultrasound examinations and techniques applied in health care screening.

References

  1. Wilson, J.M.G. and Junger, G. (1968) Principles and Practice of Screening for Disease: WHO available at http://whqlibdoc [22]. who.int/php/WHO_PHP_34pdf
  2. http://www.nsc.nhs.uk [23]
  3. http://www.screening.nhs.uk/downs/home [24]
  4. http://www.screening.nhs.uk/fetalanomaly/home [21]

 

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