Echocardiography in PCCU J Murphy Supervisors – R Thomas & R Talekar

Background Historically the echocardiography service was provided to PCCU by radiologists and cardiac ultrasongraphers. This service now includes paediatricians with an expertise in cardiology (PEC). This service evaluation aimed to look at whether the service can be improved/ used more effectively/used more efficiently.  

Background Aim: To determine if the current echocardiography service provided to PCCU is being used appropriately and if this service is fulfilling the need. Objectives: Evaluate the quality and quantity of requests Assess the quality of the information obtained Determine how the results affect clinical practice Review the quality of reporting in pulmonary hypertension

Data Collection 3 month period 1/11/2016 – 31/1/2017 Data collected retrospectively Cases identified via ICE reporting system and during handovers. 47 ECHOs in this time period Age range 12d 18y 9 patients had > 1 scan

Who performed the scan?

When were the scans done? Known CHD LRTI 1 Difficulty weaning ventilation, known VSD, ? PHTN 1 murmur 3 + PEC review

Next day scans All appropriate

OOH/In hours 4 OOH Diagnosis of shock ?coarctation suspected cardiac anomaly Shock on vasoactive drugs Post heart transplant Septic Shock - shock on vasoactive drugs Influenza A pneumonitis post BMT

Was there a clear clinical question? Examples of No - near fatal asthma 80mls/kg . Met acidosis. Lactate 5. On adrenaline. No -LV outflow obstruction increased resp distress No- known T21 with atrial communication episode of profound bradycardia Profound desaturations on ventilator (? Function)

Reason for request

Other reasons

Did the echo lead to change? Support current management Used in conjunction with all the other clinical information

Lead to change n=16

Was the result written in the notes?

Was the echo result d/w the family? Documented as being discussed on 8 occasions.

Pulmonary hypertension

Minimum standards 1. TR measurements 2. Gradient between RV - RA in mmHg 3. RV appearance - dilatation 4. RV function Indirect signs of pulmonary hypertension: 5. IVC filling 6. Shape of IV septum 7. Pulmonary regurgitation Rob Tulloh presented these standards at royal colleg In the BSC guidelines

requests for diagnosis 2y 8m Shock on vasoactive drugs LRTI and resp failure 4m requiring ++ 02 bronchiolitis 2m ? For ECMO VSD difficulty weaning ventilated CF 17y On inotropes and NO Flu A pneumonitis Max NO Pulmonary haemorrhage Hypoxic resp failure - maximal support 7 requested for diagnosis

4 follow up scans 2m old Bronchiolitis + ARDS turbulent course 1.On NO – reassessment ? Improvement 2 & 3.On sildenafil – to assess pressures 4. Acute deterioration ? Worsening of PHTN Follow up scans over a 1 month period

Reported Yes No Minimum standards met completely on 3/11 occasions = 27% 2 scans difficult due to oscillator

Discussion 38% of scans for function or filling - ? Role of PICU consultants performing scans 20% no clear clinical question – educations for registrars/ANP Only 49% of the time results written contemporaneously in the notes 37% of the time it lead to change 40% supported current management The reason Pec's reports go into notes is that it's a clinical opinion and not just an echo report. Also we looked at writing the report on same sheet that radiologists write but they have admin person who types and uploads their report onto PACS. : That is something some ICU's offer (I am sure you know) and Adult ED consultants have short courses that specifically teach this. 

Recommendations and actions Improved triaging of requests Action The requests are now being returned if more information is required or if the scan is not felt to be appropriate Education/Training for the radiologists Teaching sessions 1x per month for the radiologists – 2 sessions have gone ahead on pulmonary hypertension Added to the radiology risk register : That is something some ICU's offer (I am sure you know) and Adult ED consultants have short courses that specifically teach this.  Therefore using the service approt i.e. recent scan – what extra information is expected to be found on a repeat scan

Recommendation Education for those interpreting the reports Action All radiologists write on the report ‘this a factual report and needs to be correlated clinically’ to ensure the interpreter will ask for assistance in interpreting the report PCCU consultants to learn to scan for function and filling This remains under discussion Pulmonary hypertension report template In progress