Organization of Pediatric Echocardiography Laboratories: Impact of Sonographers on Clinical, Academic, and Financial Performance

Abstract

Echocardiography has evolved the first-line imaging for diagnosis and management of pediatric and congenital heart disease all over the world. While it recognized as essential component of pediatric cardiac care delivery, organization of pediatric echocardiography services is very heterogeneous across the world, mainly related to significant differences in material and human resources in heterogeneous health care systems. In this paper, we focus on the role of pediatric sonographers, defined as expert technicians in pediatric echocardiography. While in some services sonographers are an essential part of the organizational structure, other laboratories operate only with physicians trained in echocardiography. The impact of sonographers on clinical, academic and financial performance will be discussed. Two organizational models (with and without sonographers) will be compared, and the advantages and disadvantages of each model will be evaluated. Different models of care provision are possible and decisions on organizational models need to be adjusted to the demands and available resources.

Keywords: congenital heart disease; laboratory management; pediatric cardiology; pediatric echocardiography; sonographers.

FIGURE 1

World map representing the countries (in green) operating with a predominant sonographer model in the acquisition of pediatric echocardiograms. Applies to 11 countries to date.

FIGURE 2

Sonographer-based scanning system at the Hospital for Sick Children of Toronto, Canada. (A) The sonographer reviews the patient echocardiography order and previous echo images to determine the appropriate scanning protocol. (B) The sonographer obtains the patient height and weight for growth and z-score calculations. (C) For an outpatient or mobile inpatient, the sonographer brings the patient into the echo scanning room. For a non-mobile inpatient, the sonographer brings the machine to the patient bedside. (D) If the sonographer is with a trainee (fellow or student), both complete the image acquisition. (E) Without a trainee the sonographer completes the image acquisition alone. (F) After image acquisition, the sonographer reviews them and completes a preliminary echocardiography report, including necessary measurements, findings, conclusions, and diagnostic coding. (G) The sonographer then reviews the images and report with a pediatric cardiologist. (H) The cardiologist determines whether any additional images need to be acquired. (I) If yes, the sonographer or cardiologist will acquire additional images. (J) If no, or following the additional images, the cardiologist finalizes the echocardiography report.

FIGURE 3

Physician-based echocardiography system at the University Hospital of Bordeaux, France. (A) The physician assesses the echocardiogram indication for his patients. (B) If the physician is not a cardiologist, he usually discusses with the heart team to validate the indication. (C) For the outpatients followed up in cardiology clinic, the echocardiogram is done by the cardiologist during the consultation. (D) About inpatients, the inward cardiologist staff and trainees manage the TTE indication and scanning during the hospitalization. (E) The interpretation of the images is done in real time and the report is noted with the patient’s daily notes, or in the consultation letter for outpatients.

FIGURE 4

Health expenditures as a proportion of the Gross Domestic Product (GDP) in 2019. Source: 2019 OECD Health Statistics; WHO Global Health Expenditure Database.

FIGURE 5

Strengths, weaknesses and common objectives for the sonographer and the physician systems.