Archiving in Qpath Defining Adequate

Transcription

1 General Archiving Information for QPath Users As you become familiar with Qpath and how to archive your clips you will want to be sure you are capturing good quality clips for review. The properly captured, labelled and archived clips will be useful for tracking your studies, increasing your qualifying scan numbers (ie OB) and providing high quality educational clips for the POCUS program and your individual portfolio. We are all aware that at times, the probe goes on quickly and is quickly set aside to continue your management of the acutely unwell patient. This is absolutely understood. In these cases, quick clips of the pathology suffice, although we d encourage you to capture the interesting positives as soon as time allows. At other times, you are actually creating a record of what you see and act on, and here it is really beneficial to aim to achieve a minimum standard for a good quality clip. This is what we are trying to outline in this document. This is especially important for our trainees as some studies will be available for offline review, and they must meet these standards to be considered in their scan totals. As always, if you are unable to generate an adequate image, please submit your study and document your interpretation as indeterminate. It is just as important to be confident in calling indeterminates as it is in calling positives or negatives. It is also the safe default position when you are not certain you have seen enough to make a negative call. By archiving all studies

2 (including indeterminates) we can get a better sense of the true scope of POCUS here at LHSC. Although not our primary objective, it should be noted that even an indeterminate image may still qualify for the H100 OHIP code if landmarks are identifiable. As a reminder, at LHSC we archive CLIPS rather than STILL images. Once an interpretation is entered on the ultrasound unit (see tutorial at a still image of the text must be captured by hitting the SAVE button (before closing out the study by hitting A/B). Interpretations and reports entered on Qpath are the preferred method of properly documenting your studies and is a REQUIREMENT for all trainees. Probe Selection As this document pertains to the basic indications for POCUS, it is acknowledged that either the curvilinear or phased array probe may be used. When used, the phased array probe will require the proper preset to be selected (either abdominal or cardiac) depending on the indication for the study (selected with the EXAM button on the Sonosite machines). Failure to use the proper preset will generate inferior quality images, reverse probe markers at times, and is a source of frustration for new users. Positive studies Archiving quality is especially important in a QA program where your studies will be overread by another POCUS user. In order to truly call a study negative, these minimum requirements should be met or a call of indeterminate should be considered. However, once a positive study is identified - feel free to stop sweeping with the probe and take some clips of the pathology without probe movement. This really increases the educational yield and makes for some solid clips for others to use in training, education and review.

3 Aorta An adequate image will show the vertebral body and its acoustic shadow along with a full view of the outer echogenic wall of the aorta. Ideally this interposition will be centered in the field of view (see image below). ie spine centered at 6 o clock * Bonus - It is always nice to see a still image with the caliper notation of maximal aortic size when the aorta approaches or exceeds the upper limits of normal (3cm). Adequate vertebral body midline adjacent aorta centered in screen Bonus - calipers Inadequate cannot see vertebral body uncertain of aorta depth too shallow Archived Clips Ideally the entire aorta is seen from xiphisternum to bifurcation and is captured in 1-3 clips. If you are having difficulty, please submit up to 3 clips and document your bedside interpretation (ie negative, positive or indeterminate). It is possible that your submitted clips look great (and possibly even appear determinate individually) yet at the bedside you were unable to visualize the entire aorta. In this case there should be an indeterminate interpretation acknowledged.

4 Cardiac (subxiphoid/subx) An adequate image will ideally show the entire outline of the heart, including the apex. * Bonus - As practitioners/trainees become more familiar with the phased array probe, this is the ideal probe to be using for this portion of the study (and can be used for all other portions of the bedside assessment of basic indications). Careful note needs to be made of probe presets and screen probe marker positions. Adequate majority of heart/pericardium visualized and centered in field of view sweep SLOWLY through near field (inferior) pericardium Inadequate cannot identify majority of heart/pericardium depth too shallow no interpretation noted (in this case it would be indeterminate) Archived Clips Adequate clips must include the majority of the heart, and be swept SLOWLY from anterior to posterior. Again, 1-3 clips should be archived. If obscured by stomach gas, a reasonable goal is to see the majority of the inferior (near field) pericardium - marked by an approximation of the interventricular septum meeting the apex.

5 OB/Pelvic Assessment Adequate An adequate image will ideally show the the sonographic landmark of the bladder with the immediately adjacent solid organ density of the uterus (easier in longitudinal plane) * Bonus - As training advances, endovaginal clips are encouraged. Bladder identified in scan Outline of the uterus including fundus (longitudinal) Image of the area of interest (endometrial stripe or decidual reaction/gs/ys/fp) Inadequate cannot outline uterus depth too shallow interpretation here incorrect based on image Archived Clips Negative studies must include a SLOW sweep throughout the entire uterus in TWO orthogonal planes (ie longitudinal AND transverse for trans-abdominal, or sagittal AND coronal in trans-vaginal). In a positive study, a subsequent zoomed in image to identify a yolk sac, fetal pole or FHR is appropriate.

6 FAST (Focused abdominal sonography in trauma) ** A minimum of 3 clips (RUQ/LUQ/Pelvis) are required for an adequate FAST examination. In the RUQ and LUQ scans, the sonographic landmark of the double density of the kidney and the area of interest (hepatorenal interface or the splenorenal interface) must be seen. In addition, the tips (near field and far field reflections) of the liver and spleen and the interface of the spleen and diaphragm (the six to nine - subdiaphragmatic view) must be seen. Adequate RUQ (areas seen in clips) interface in mid screen entire interface identified tips (reflections) seen Sweep at this point = excellent Inadequate RUQ Majority of interface not identified May improve with sweeping/centering Note excellent near field reflection Adequate LUQ Interface well identified tips (reflections) seen Subdiaphragmatic View May require 1-2 clips * Note - These images are ideal - aim to find all key areas while sweeping slowly. Archive representative scan (1-3 clips).

7 In the pelvis both longitudinal and transverse views identifying the bladder and documenting sweeps through the rectovesicular pouch (male) and the rectouterine and uterovesicular pouch (female) are required. Inclusion of the pelvic views maximizes sensitivity in hunt for traumatic free fluid, and is a necessary component of a FAST exam. ** It is recognized that the pelvic views are often indeterminate owing to an empty bladder, and in this case documentation of such can be made, along with an overall call of the study. ie pelvis indet, Abdo - no FF Adequate Pelvic Views (Male) Note - See OB for Female