Sponsored by Innovatus Imaging
Ultrasound is perhaps the most used imaging modality at health care facilities in the United States and its popularity continues to grow. ICE Magazine reached out to imaging leaders to find out more about ultrasound in this month’s Director’s Circle article. Leaders sharing their insights are:
- UC Health Vice President of Operations, Becky Allen
- University of Texas Medical Branch Senior Imaging Manager-Ultrasound and CT, Julie Dueitt
- UT Southwestern Imaging Systems and Services Technical Manager, Kim Pongsatianwong
- University Hospitals of Cleveland Radiology Manager, Amy Rutledge.
Q: What are the biggest challenges that sonographers face today?
Allen: The biggest challenges sonographers face today is the number of scans per sonographer that’s expected and the inpatient turnaround time from time ordered to time of final dictation within 24 hours. These challenges can lead to increased stress and burnout for our team members. Sonography is such a technologist dependent modality; we understand how important it is to provide flexible scheduling and work/life balance to keep the best of the best sonographers. We are fortunate to have many long-term sonographers.
Dueitt: Although sonography can be a very rewarding career, there are significant challenges that sonographers face. In fact, most of the challenges that sonographers face can be linked to the greatest challenge of all which is bodily harm – both mentally and physically. The top three challenges would be on-call abuse, performance of unnecessary exams, and ergonomics issues from scanning position, pressure and repetitive motion resulting in musculoskeletal injury. In fact, by their third year working in ultrasound, 45% of sonographers have musculoskeletal injury symptoms. In addition, many sonographers take calls all night long and are still expected to work the next day. This lack of sleep or broken up sleep can create a mental fog which not only affects the sonographer but has the potential to affect the patient. Lastly, on a normal day at work sonographers perform unnecessary exams (exams ordered after another testing method has already answered the question) and portable exams putting more physical stress on their bodies.
Pongsatianwong: One of the biggest challenges that sonographers face today is keeping up with rapidly advancing ultrasound technology and equipment. Manufacturers are designing innovative features and functionalities that are elevating the use of ultrasound in many exciting new ways to assist with diagnosing patients. It can be difficult to find the time to learn the latest equipment and techniques when there is a demanding workload with tight schedules. Meeting the demand for ultrasound services while maintaining accuracy and high image quality can be stressful in situations where there exists difficult patient body habitus and pathologies. However, making time to incorporate these new developments can help to streamline workflows and increase the throughput of patients.
Rutledge: One of the most significant challenges that the sonography profession faces is the increasing number of sonographers needed to address the changing demographics of the patient population. We have an aging population which coincides with an increased number of hospital admissions and directly impacts the utilization of diagnostic imaging. To manage demand in the post-COVID era, the profession will need an influx of new sonographers.
Q: What percent of your volume is performed via portables?
Allen: Twenty-five percent of the volume for the department is via portable mode. All ICU patients and NICU baby exams are performed via portable to keep them in the appropriate environment for healing. We try to limit the transport of patients from these areas as we know how difficult it is transporting patients and the resources involved.
Dueitt: Currently, about 10-15% of our volume is performed via portable ultrasound. This is higher than average when compared to many other facilities our size. Interestingly, this increase in portable exams is due to issues with the transportation of patients, not true need for the exam to be performed portably. If we only performed necessary portables that percentage would easily fall to 3-5%. When our transportation system cannot get patients to us in a timely manner, the sonographers opt to go portable in an effort not to delay patient care. Unfortunately, bringing a higher chance of musculoskeletal injury to themselves.
Pongsatianwong: Our hospital-based sonographers perform about 35% of our total inpatient volume via portables. Most of these are bedside exams, and we also provide ultrasound services during procedures in the OR and in post-op recovery rooms. We take into consideration the physical strain that performing portable examinations can have on a sonographer’s ability to adhere to proper ergonomics when setting guidelines on when to perform portable examinations.
Rutledge: University Hospitals Cleveland Medical Center performs approximately 13% of our ultrasound examinations portable. It is an average of 465 per month.
Q: How do you advise which vendor to choose when the ER wants one vendor, the radiologist another and the tech yet another?
Allen: We have a system wide POCUS committee that is responsible for setting the expectations on point-of-care purchases and use of ultrasound equipment within the system. The team met and invited all professionals across the system to trial multiple vendors. At the end of the trial, each provider voted on the top vendor for POCUS equipment. We then signed a strategic agreement with the vendor that had the most votes. This way, we standardized our POCUS fleet. As more and more providers are using ultrasound as a diagnostic tool, it was important to our system to have a standardized approach on how we purchase and use the equipment.
Dueitt: Choosing which vendor to go with is affected by several factors. Image quality, cost and perks are all relevant. Largely, image quality is comparable between most major vendors. Radiologists, sonographers and others may have preferences, but when it comes down to diagnostic images all major vendors deliver that. This leads me to put more emphasis on what the vendor is willing to give automatically without extra upgrades, and at what final cost. In this economy, and just like any other important purchase, you want more bang for your buck. My decisions always come down to the machines that come with the most options without extra purchase that will benefit our patients the most.
Pongsatianwong: When choosing a new machine to purchase, we solicit input from our radiologists and sonographers after demoing machines from several vendors. Our facility currently has 50 ultrasound units from 3 different vendors. These units include different models, software levels, and software functionalities. While our radiologists and sonographers have their personal preferences, it is expected that all our sonographers are competent using any of the equipment within our fleet. We typically do not encounter requests for specific vendors, but rather requests for specific tests. We have strategically installed software packages for tests like elastography and contrast-enhanced ultrasound on our machines based on clinic location and vendor availability.
Rutledge: The vendor selection process requires significant research and consideration. We have a strategic partnership with multiple vendors, eliminating much of the leg work. The configuration of the units purchased is discussed though our modality triad, which is a combination of radiologists, leadership and modality supervisors.
Q: What were some surprises from your most recent ultrasound purchase?
Allen: We were surprised by the ease of use and ergonomics of the most recent ultrasound purchases. The units are not the large, bulky hard to maneuver units from before. The security availabilities on the units were also a nice surprise so easy to lock down and can badge tap to get access to use. This allows us to see who is using the equipment.
Dueitt: I had two major surprises in my most recent ultrasound purchase. The first is that vendors, specifically the vendor I chose, are working much harder to ensure their service and new software patches are part of the package and not having to be an extra purchase. Of course, there are things they can’t help with without that service agreement but this specific vendor made it part of the deal that their new software upgrade that would be coming out three months later would automatically be put on our machines. They listened to what we felt was important and met us halfway. The second surprise I had was that a perk that I felt would be highly beneficial fell flat when implemented. This perk required buy-in from myself, the sonographers and the radiologists. Unfortunately, we failed to prioritize it’s possibilities and it didn’t work for us. That ultimately came down to myself and the radiologists having to log into an additional program each day as well as the sonographers logging into it on the machine and being comfortable on camera. This proved to be too much for us at this time.
Pongsatianwong: Our most recent ultrasound purchase was to upgrade our high-level disinfection systems. The improvement in the user interface and advancement in transducer tracking abilities have greatly streamlined our workflows, so that the technologists can spend more time on patient care and less time on documentation.
Rutledge: The technological advances made by our vendor partners were a pleasant surprise for me during our last ultrasound purchase. Advances such as one-touch image optimization and automation driving workflow efficiencies reduce scan time while AI supports advanced tools to assist in clinical decisions. These advanced technologies support our sonographers and radiologists while improving the care we provide our patients.
Q: How are you managing ultrasound procedure growth and staffing shortages?
Allen: We have had to turn to agency sonographers to help manage our staffing shortages and volume. We have been successful in having really good agency sonographers for the past year as we have been limited on the number of qualified candidates applying. This just recently changed, and we were fortunate to hire three new sonographers. I am hoping this is the change of candidates in the pipeline moving forward.
Dueitt: As more institutions begin tightening the belt financially and holding patients responsible for co-pays and deductibles up front, the use of ultrasound has been growing because it is so much cheaper than CT or MRI. The way we have managed this increase in procedures has been to extend outpatient hours during the week and to open outpatient hours on the weekends. Managing staffing shortages has taken a little more outside-the-box thinking. The pandemic really changed the health care landscape in regard to staffing. Many sonographers left their long-term jobs to take travel assignments because the money was just too hard to pass up. Finding people to fill open positions became a challenge. We have been successful in cross-training from within for CT and MRI but this isn’t as feasible for ultrasound. However, we have been able to cross-train some general sonographers into vascular procedures. I am a strong advocate for teaching so we always have students from the surrounding colleges. Keeping in contact with newly graduated students allows me to constantly have a pool to draw from since most ultrasound travel agencies prefer not to hire new graduates.
Pongsatianwong: We have employed creative scheduling options, including part-time, per-diem, and contract sonographers to optimize coverage during peak demand periods and difficult-to-fill shifts. We have also established partnerships with nearby ultrasound educational programs to provide clinical placements for students which will help address staffing shortages in the long term by contributing to the education and training of future sonographers. We introduced an imaging tech trainee position at our hospital, enabling us to bring students on board and initiate their institutional onboarding before they graduate. They continue training under the supervision of a registered technologist, and it has proven to be a win-win situation since we implemented the program.
Rutledge: This is a complex time in health care where we have to manage increasing volumes while combating staffing shortages. One area we have tried to concentrate our efforts is employee retention. Our organization recently implemented additional regular compensation (ARC) for Cleveland Medical Center, the quaternary care academic medical center. Leadership recognizes that the academic medical center has the most acute patient population along with some of the highest vacancy rates. These factors impact the retention of current caregivers and recruitment of new team members. We have also created unique programs where we offer students in imaging modalities a sign on bonus, which pays out when they reach milestones in their careers.
Q: Ergonomics has become a big issue with ultrasound. Have you done any special training or purchased any special equipment?
Allen: We have not had an issue with ergonomic injuries to our sonographers. We have purchased ergonomic chairs a few years ago. I think the newer equipment has also helped with this as well.
Dueitt: We created a process improvement plan to help combat musculoskeletal injury in our sonographers. I purchased exercise bands that stay in the department so that the sonographers can stretch and exercise between patients. The suggested exercises are also posted in the department as a guide specific to strengthening the pertinent muscle groups either with exercise bands or sitting in a desk chair. In addition, we purchased ergonomic sonographer scan chairs that give support where most needed for the sonographer.
Pongsatianwong: We highly value a vendor’s ergonomic features when evaluating new equipment for the department. Height adjustability, transducer and cord weights, and moveability of the console are some of the qualities we consider as they greatly impact the effect on a sonographer’s body. To assist with venous reflux studies, we have an augmentation device to decrease the repetitive motions necessary for the exam. We also annually host a CME for our staff about proper ergonomics and how to prevent musculoskeletal-related injuries.
Rutledge: The causes of work-related musculoskeletal injuries among sonographers are multifactorial, thus, require multiple varied solutions to reduce the risk. Having an ergonomic workstation plays a major role in mitigating these injuries, ultrasound systems with a floating user interface and a full range of motion allows sonographers and physicians to position the operator’s console at an ergonomic height and position. Backlighting on keyboards used to reduce eyestrain. Scheduling a variety of exam types helps reduce repetitive motion injuries. Also, education for sonographers is key. We recently offered a vendor sponsored educational class on ergonomics in sonography and it has been a topic at our annual ultrasound symposium.
Q: What else should ICE Magazine readers know about ultrasound?
Allen: Ultrasound is a fantastic modality that can be used for many reasons. It is essential to have a plan for the POCUS needs within your facilities. Standardize your equipment and make sure to have a process for credentialing providers, space to store those images and proper billing. For radiology departments, the key to a successful ultrasound department is to hire the absolute best sonographers. Without top notch sonographers, it makes it extremely difficult on the radiologist.
Dueitt: That’s a dangerous question to ask a sonographer! There are so many things! Most importantly, sonographers don’t “just take the pictures.” Ultrasound is a highly user-dependent modality in which the sonographer plays a lead role in the actual diagnosis which stands apart from other modalities. I think everyone should also know that ultrasound is not only about looking at babies in the womb, as awesome as that part is. Ultrasound is used to provide diagnostic information from almost every part of the body from head to toe and is in a state of constant change. When I first was a sonography student, we were told that we would never look at bone, lung or intestine. Now, 17 years later, ultrasound can identify fractures in bone, pneumothorax, and can evaluate for inflammatory bowel disease.
Rutledge: The ultrasound profession is dynamic and ever changing. Medicine is constantly evolving, but medical imaging is advancing at a rapid pace as well. Advancing technologies, improved techniques and innovative best practices will allow this profession to experience continual growth.
Pongsatianwong: The continuous introduction of new innovative features and functionalities is revolutionizing the application of ultrasound in diagnosing patients. Developments in technology to decrease the limitations of ultrasound, such as those to lessen artifacts caused by bone and air, are in the works and uses for contrast enhanced ultrasound continue to be discovered. Because ultrasound is largely dependent on a sonographer’s skillset, it is vital for institutions to invest in the continued education of sonographers as our field continues its upward trajectory.
This month’s article was sponsored by Innovatus Imaging. For more information on this company, visit innovatusimaging.com.
