We have all been there… It’s another day of a growing number of referrals and fewer staff to get the work done. We are already working through lunch, and squeezing in the extra inpatient that the wards are screaming for. Despite this, we just aren’t winning – more tests are being requested than we can get through in a day… and now another staff member has called in sick for the rest of the week. This nightmarish scenario is the everyday scenario for many sonographers. Faced with this situation, there are really only three options available:
- Let the waiting list grow. This is not sustainable in the long run. Patients will suffer by waiting longer and longer to access services. For many labs, the pandemic already pushed out wait times. The consequence of lengthening waitlists is increased in sonographer burnout (which then worsens the staffing shortage), and patients not accessing services that could have life-changing outcomes for them. Waitlists for testing can be a little like credit card debt, it sneaks up on you until one day you can’t make the repayments. All of a sudden the waitlist can blow out from being able to perform an echo the next day, to next week, to next year (which many labs saw during the peak of Covid-19). It is important to keep an eye on this and manage the situation before it becomes out of control.
- Scan faster. This doesn’t work either. You are a quality sonographer and you are only interested in quality echos. You are already scanning fast, and you have trimmed off what you can, but this has a finite limit. Remember our bookings should be 45-60min for a comprehensive examination (see ASE quality recommendations). Yes, some patients will be scanned quicker, but many won’t. Decreasing the scan time so that more studies can be scanned only leads to damage, burnout, and missed diagnoses. A musculoskeletal injury caused by high-volume scanning leads to very low-volume scanning quickly. Don’t do it and stay safe friends!
- Triage the list to prioritize the patients in most need, or who will benefit the most from a timely echo. This allows us to maintain the high standards of the quality echo lab, scan safely to minimize sonographer injury or burnout, and get through the work based on clinical need. It doesn’t remove the waitlist, but it does make sure the list isn’t worsening outcomes for the patients.Triage is hard. It takes senior knowledge and experience to be done effectively and represents a significant level of responsibility. The goal of triage is to allocate the very limited resources available to provide a service and ensure the patients that are in most need of an echo are able to access the service in a timely manner. But this needs to be done properly.
So here are my tips to improve the triage process.
Use the ASE appropriate-use criteria (UAC) to help identify requests that might not be truly indicated. An example would be “transient fevers” in a patient without bacteremia or murmur. It’s really important that we don’t use this as an excuse to just bin the request though – talk with the requesting Dr and communicate the expected timing (or delay) of the test. This also opens the path for discussion giving the Dr the chance to add any extra information that might either help you triage, or help the sonographer to assess the patient properly. For example, it might be that the patient has had positive cultures, and the referring doctor has failed to communicate this. It takes time, but this is an important teaching moment for the requesting doctor. This must be done tactfully (and in some instances may need to be a discussion between Drs) but it has a huge payoff for everyone, especially the patient. No one wants to do unnecessary tests, and the patient wants the shortest diagnostic pathway to improve their outcomes. Just remember, that some echo referrals that at first glance seem contraindicated may actually be just a poorly completed request form. Think about this from the referrer’s perspective. They are trying to convey what they think is the most important clinical detail to the sonographer, but this is always only a tiny part of the patient’s story and it could be that the Dr just hasn’t used the right “keywords” to order a test. For example, a referral that says “pre-op assessment” which by itself is not indicated according to the AUC criteria, but had it been worded as “pre-op assessment, new-onset AF” then it would; the actual referral hasn’t really changed but the level of indication increases significantly, according to AUC guidelines. Education of referring Dr base, particularly junior medical officers when they start is highly rewarding.
Are the referral details complete? Do you know what you need to know to make a decision? Effective triage assumes that you are able to compare two patients and prioritize one over the other. We have all scanned a patient with the request “Assess function” only to find they have had major cardiac surgery in the past and new onset dyspnoea. If the referral is vague or seems incomplete, then it is worth checking if you have the whole story.
Use a mentor process with either the cardiologist or an experienced lab supervisor who is skilled in triaging. If you don’t understand WHY a test was prioritized (or pushed back), then ask. Triaging is way too complex to just be a list of standing orders on an information sheet. Use the network around you. This includes the Echo Guru community! And remember “If the answer isn’t clear, it is clearly a teaching moment”.
Most importantly, work within your scope of practice. Triage is not a power trip. It is a high level of responsibility and you have a duty to work within your abilities. There is no shame in asking for help, and even less shame in saying that you are not sure how to prioritize in a given scenario. This is not a role for junior sonographers. I often see injured sonographers asked to prioritize a list, when they are just nowhere near that level of responsibility yet. Remember, a patient will have a test, or have access delayed based on the triage process – this can have big consequences – take the responsibility seriously!!
You might have noticed an overarching theme in these tips… triaging is all about communication. Learning to triage effectively takes time to do well, but is worth every second of effort. It is an investment in education and will save loads more time in the long run. Most importantly it makes sure that the patients who need an echo will be prioritized for the service.
Finally, make use of the resources available from our professional associations and societies. Guidelines from the American Society help direct us with AUC and form a basis for when an echo is indicated or not.
The British Society of Echo has some fantastic resources on triaging. They also have an auditing tool available to help track the impact of triaging in the lab.
American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American College of Chest Physicians, Douglas, P. S., Garcia, M. J., Haines, D. E., Lai, W. W., Manning, W. J., Patel, A. R., Picard, M. H., Polk, D. M., Ragosta, M., … Weiner, R. B. (2011). ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography, 24(3), 229–267. https://www.onlinejase.com/article/S0894-7317(10)01046-1/fulltext
Bennett, S., Stout, M., Ingram, T.E. et al. Clinical indications and triaging for adult transthoracic echocardiography: a statement by the British Society of Echocardiography.Echo Res Pract 9, 5 (2022). https://echo.biomedcentral.com/articles/10.1186/s44156-022-00003-8