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How to set up a community echocardiography service

The highest technical and clinical standards must be maintained in any community echocardiography service, writes Dr Strat Liddiard

The highest technical and clinical standards must be maintained in any community echocardiography service, writes Dr Strat Liddiard

Our practice in Poole has more than 10 years' experience in developing primary care cardiology. The lessons we have learned along the way are applicable to those GPs who are choosing to redesign services for patients with heart failure under PBC.

We began an in-house echocardiography service in 1994. The main driver for our decision was that we had the in-house skills to do so and perceived that there was a need for more cardiac imaging than the hospital services could supply. Fundholding savings were sufficient to acquire a machine and the mechanism was present for paying for the service.

The first requirement for any new service must be the availability and competence of people to provide the service.

At the time we set up our service, I was a clinical assistant in echocardiography at a local hospital and was thought competent to undertake imaging sessions on my own. My images were reviewed from time to time by cardiologists and deemed to be adequate from a medicolegal point of view and it was accepted that the level of expertise shown in this peer-review process acted as accreditation for primary care echocardiography.

Today, any technician or clinician performing echocardiography in the community would be expected to have an appropriate qualification, such as the accreditation in community echocardiography or the full transthoracic accreditation from the British Society of Echocardiography. Working in a local hospital or in conjunction with a local physician working in a relevant area of cardiology, for example heart failure, would be beneficial in reducing the isolation of providing specialist services in the community.

Possibly the best way to staff the service would be through a rotating post in community echocardiography, serviced by technicians on secondment from a hospital department who are then supervised by a GP with a special interest in cardiology or by a community cardiologist.

Under this model, the GP with a special interest would be accredited by one of the recommended courses (Middlesex or Bradford) and would also be expected to work in a relevant area of cardiology in a local hospital.

These may be onerous requirements to fulfil and would need a co-ordinated approach to the delivery of cardiac services across the primary–secondary care divide. This could be difficult to achieve in the current economic and political environment.

Choosing the right machine

If the difficulty of staffing your new service is solved, you will be faced with the problem of which machine to acquire. The first requirement is to determine what your needs are.

Although others may differ, I believe that any machine suitable for community use must have the ability to perform a full transthoracic echocardiographic study including assessment of left ventricular function and all four heart valves. To do this a machine will need to have M-mode, 2D imaging, colour Doppler and pulsed Doppler. A 2.5 to 3.5 MHz probe is a sufficient minimum.

In addition, facilities for recording samples of the images are necessary. This provides the opportunity to subject the images to review by a remote physician and acts as a record which is useful for comparison with later images and rarely for medicolegal matters.

In 1994 there were few options – a reconditioned hospital machine or a new Hewlett-Packard Sonos 100, which cost us approximately £60,000.

Today there is more choice. Machines from SonoSite, Acuson, Esaote and others can be purchased for between £12,000 and £40,000. Other factors to take into account include service contracts, reliability, portability, stability, use for other ultrasound imaging and personal preference.

Consideration must be given to the sort of service that is to be provided. Time has changed our understanding of the uses of echocardiography. In 1990 I offered a simple diagnostic service asking the referrer only to indicate whether or not they would have sent this patient to hospital had the community service not been available. There was no correlation between intention to refer and findings.

We now know that reasons can include:

• that the referring clinician believes the test will provide either a positive or negative diagnostic value, for example ruling out a significant valve lesion or demonstrating left ventricular dysfunction;

• to establish a baseline for future reference, for example in assessing left ventricular hypertrophy in newly diagnosed hypertensives with or without ECG changes;

• to determine treatment decisions in known disease, for example in atrial fibrillation, left atrial size is of importance;

• to prove that the heart is normal, for example, in adults with a history of a childhood heart disease with no corroborating evidence or elite athletes to exclude cardiomyopathy.

Whatever the reason for the test, a full echocardiographic examination should be undertaken including long axis, short axis, four chamber and if appropriate sub-costal views. All chambers and all valves should be examined.

There are certain conditions that are unsuitable for community echocardiography: any acute condition, paediatric patients unless the operator is specifically competent in paediatrics, and reviews of complex cardiology.

The original echocardiography service was for the 27,000 patients of my practice, through about one session per week.

In each session I would do eight echos, allowing 20 minutes each. Later the service was opened up to all Poole patients and is currently run by a technician working three sessions a week in the community. Referral is faxed or mailed.

Some clinicians advocate a referral system that insists on chest X-rays, blood tests and ECGs being done first. This is reasonable but misses the point of community-based investigation.

It is the responsibility of referring doctors to ensure they complete the tests that will provide them with the best information.

It is not the responsibility of the echocardiography service to provide prompts for those referring doctors to do so.

Questions to ask

I think that a referral form asking simple questions is sufficient. The questions I wish to know the answers to are:

• What are the known relevant medical conditions of this patient?

• What are the reasons for the investigation?

• Is the ECG normal, if not, what is wrong?

• What medication is the patient on?

• What question are you hoping to have answered?

The report itself is a matter of importance. It must contain all the relevant factual data that would not necessarily be understood by the referring GP, but would be understood if sent later to a cardiologist. The factual summary should also be translated into common English.

In addition the report may contain advice given according to the skill of the reporter or according to agreed templates. Common useful template advice includes:

• For significant structural abnormality ‘consider cardiology referral';

• For minimal structural abnormality, for example borderline aortic stenosis, ‘suggest repeat in x years';

• For mild regurgitant heart valves ‘recommend antibiotics for surgery'.

The success of the service also requires referring clinicians to be aware of how to use it. Training programmes, information drops, chances to see echocardiography being done and feedback on referral rates all help to inform and update clinicians.

Local protocols for the management of atrial fibrillation, asymptomatic heart murmurs and breathlessness could all channel patients into a community echocardiography service, ensuring its appropriate use and viability.

Overall the service should reduce unnecessary cardiac referrals but speed up the management of significant problems.

To maintain credibility, a regular audit of service and review of cases is necessary. In any case, audits and reviews should be done to observe changes in referral patterns and to be aware of evolving echocardiography techniques in real practice.

Costing the service should include space, light, heat, staff pay, and maintenance and replacement costs. The time taken to do an echocardiograph must include writing up time and is distinct from any time spent taking a history, examining or treating the patient.

If an echocardiograph is supplied as part of an advisory GPSI or consultant community service, then this should be recognised as different, and costed accordingly.

Increased referrals

PBC sets tariffs that will need to be observed, but remember that primary care echocardiography, if used appropriately,

will result in an increase in the number of referrals for imaging by up to 50 per cent. Echocardiography must maintain the highest standards of technical and clinical integrity to be of any value to primary and secondary care physicians and society at large.

A cut-price, cut-corners service has no part to play in the delivery of medical care in any developed country in the world. Mistakes will be made but they must be minimised and only by maintaining standards can that be achieved.

Dr Strat Liddiard is a GP in Poole,Dorset, and a national clinical lead on the NHS Heart Improvement programme

10 top tips on setting up a community-based echocardiography service

  • 1 Ensure the competence of the clinician or technician delivering the service – see the British Society of Echocardiography for accreditation details (see for more information)
  • 2 Choose a machine that has the ability to perform a full transthoracic echocardiographic study
  • 3 Also consider account service contracts, reliability, portability, stability, use for other ultrasound imaging and personal preference when choosing the machine
  • 4 Require referring doctors to write simple referral letters that explains what question they are seeking to have answered by the echo
  • 5 Ensure the echo report contains a factual summary that can be understood if it needs to be sent later to a cardiologist
  • 6 Exclude the following conditions for community echocardiography: any acute condition; paediatric patients, unless the operator is specifically competent in paediatrics; and reviews of complex cardiography
  • 7 Develop local protocols for management of atrial fibrillation, asymptomatic heart murmurs and breathlessness, to ensure appropriate use of the community service
  • 8 Carry out regular audit and review of cases
  • 9 Inform and educate referring doctors through information drops, feedback on referral rates and chances to see echocardiography being done
  • 10 Beware a cut-price service – the cost of space, light, heat, staff pay, maintenance and replacement costs, as well as time to write up the echo, must all be included

Skills-based framework for practitioners with a special interest (PWSIs) in cardiology

• A national framework of modular training for PWSI in cardiology in England was launched last month by the NHS Heart Improvement Programme, in voluntary agreement with key professional bodies.

• It is aimed at commissioners of cardiac services, current and potential cardiology PWSIs, and education training providers who want to use this approach to deliver local cardiology services.

• Cardiologist Dr Mark Dancy, who led the steering group that agreed the framework, says: ‘With the push to develop new enhanced services in the community using models such as PBC, adoption of this framework will help people aspiring to work as practitioners with special interests to develop transferable recognised qualifications to the benefit of the patients, practitioners and the wider NHS.'

He adds: ‘National qualifications will also help reassure commissioners that the practitioners they employ to provide enhanced services have appropriate training.'

• The document is available online via the NHS Heart Improvement Programme

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