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

2. 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.  

3. 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

4. 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 y
9 patients had > 1 scan

5. Who performed the scan?

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

7. Next day scans
All appropriate

8. 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

9. 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)

10. Reason for request

11. Other reasons

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

13. Lead to change n=16

14. Was the result written in the notes?

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

16. Pulmonary hypertension

17. 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

18. 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

19. 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

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

21. 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. 

22. 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

23. 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