Moderators: Rick Duncan and Gail Size

Rick Duncan (Apr 12, 2007 8:00:37 PM)
Hi everyone, we'll take just another minute for everyone to get on.

Rick Duncan (Apr 12, 2007 8:04:16 PM)
Okay, tonight we are honored again with Beverly Gorman, Technical Manager of the ICAEL.

Rick Duncan (Apr 12, 2007 8:04:23 PM)
Hi Bev.

Rick Duncan (Apr 12, 2007 8:04:48 PM)
We'll just go over some housekeeping before we start.

Rick Duncan (Apr 12, 2007 8:05:28 PM)
We invite everyone to join us every second and fourth Thursday for our scheduled chat sessions. Transcripts of past sessions are available from the chat page. Also, the Chat rooms are open every day. We encourage you to use them to chat with your colleagues.

Rick Duncan (Apr 12, 2007 8:06:05 PM)
A last comment - spelling goes out the door during these live events. We'll leave it to the spell-checkers to fix things before posting the transcripts of tonight's talk.

Rick Duncan (Apr 12, 2007 8:07:22 PM)
To introduce our guest, Beverly has been an RDCS since 1988. Her experience has taken her in many clinical settings to include both pediatric and adult echo.

Rick Duncan (Apr 12, 2007 8:07:42 PM)
She's also had experience as a clinical applications specialist.

Rick Duncan (Apr 12, 2007 8:07:57 PM)
Welcome, Beverly.

Beverly Gorman (Apr 12, 2007 8:08:35 PM)
Welcome and thank you for joining us tonight. My name is Beverly Gorman and I am the Technical Manager for the ICAEL. The topic of tonight’s chat is Echo Case Studies: Documenting Proof of Quality. Please stay online after the QA session, for an important announcement from the ICAEL.

Beverly Gorman (Apr 12, 2007 8:10:04 PM)
First let us review how many cases must be submitted. The required number of case studies is based on the total number of staff (physicians and sonographers) in the laboratory. For example, an office with 4 physicians and 2 sonographers would have a total of 6 staff members and would need to submit 6 cases. Representative case study requirements per testing section can be located on the ICAEL website www.icael.org click on the accreditation tab, then case studies.

Beverly Gorman (Apr 12, 2007 8:11:28 PM)
The cases must represent as many medical and technical staff members as possible, and no medical or technical staff member should be represented more than once if any other member of the laboratory has not been represented.

Beverly Gorman (Apr 12, 2007 8:12:11 PM)
All cases submitted must be abnormal. For Adult TTE: § LVDF cases are regional wall motion abnormalities. This type of study allows reviewers to evaluate the interpreting physician’s ability to recognize and report wall motion abnormalities of the left ventricle. § Aortic stenosis cases allows reviewers to assess both the sonographers ability to perform 2 D and spectral Doppler for adequate valve interrogation as well as the abilities of the interpreting physician.

Beverly Gorman (Apr 12, 2007 8:13:04 PM)
The Technical Director must submit one case. All cases should represent the laboratory’s BEST WORK.

Beverly Gorman (Apr 12, 2007 8:13:36 PM)
Please review Elements and Components of Examination Performance, which are in the Standards, Section 3 of the testing sections; Adult Transthoracic, Adult Transesophageal, Adult Stress, Pediatric Transthoracic, Pediatric Transesophageal and Fetal.

Beverly Gorman (Apr 12, 2007 8:14:31 PM)
The Pediatric Standards were recently revised by the ICAEL Board of Directors, please visit the ICAEL website www.icael.org for the most recent Standards. Changes to the Pediatric Standards are also one of the topics for the ICAEL April newsletter.

Beverly Gorman (Apr 12, 2007 8:15:25 PM)
In January 2006 the ICAEL Board of Directors revised the Adult Standards to include the Suprasternal notch view as a required view on all patients. Also, a transducer dedicated to the performance of continuous wave Doppler studies (Pedoff) must be available for each study. (The reviewers must see the dedicated CW probe (Pedoff) being used in aortic stenosis cases from multiple transducer positions. If we can’t see it we do not know it was done.)

Beverly Gorman (Apr 12, 2007 8:16:30 PM)
Common pitfalls - Transthoracic Echocardiograms:

• Incomplete studies
• Not all standard views obtained
• Not all standard Doppler evaluations performed, (inadequate interrogation of AS)
• Location and performance of measurements not shown.
• Protocol sequence not followed
• Poor technique
• M-mode measurements taken off axis (inaccurate)
• Poor Doppler technique (not aligned with flow)
• Poor system settings (gains).

Beverly Gorman (Apr 12, 2007 8:17:09 PM)
Common pitfalls - Transesophageal Echocardiograms:

• Incomplete studies Ø Not all standard views obtained
• Not all standard Doppler evaluations performed
• Protocol sequence not followed.

Beverly Gorman (Apr 12, 2007 8:18:54 PM)
Common pitfalls – Stress Echo:

• Poor endocardial definition
• Pre and Post exercise images not displayed side-by-side
• Off axis or foreshortened images
• Timer not visible or improper use of timer
• Must be abnormal .

Beverly Gorman (Apr 12, 2007 8:19:36 PM)
Submit only your best cases.

Beverly Gorman (Apr 12, 2007 8:20:26 PM)
Use the following list of questions to select your Adult TTE cases for submission. These are the actual questions that the reviewers use to evaluate the studies submitted for accreditation, if you answer all of the questions below, yes, it is a case you should submit with your application.

Beverly Gorman (Apr 12, 2007 8:21:02 PM)

• Are the 2D and/OR M-mode measurement of the LVIDd performed accurately?
• Is at least 3/4 of the endocardium clearly defined in the four standard views?
• Is the Apical 4 Chamber NOT foreshortened?
• Is the mitral inflow Doppler accurate (parallel to flow with complete spectral envelope)?
• If TR is present, is a complete TR envelope aggressively sought from more than one view?
• Are AI and MR evaluated for (with color flow) in at least 2 planes?
• For views obtained, are at least 5 cardiac cycles of each 2D, M-mode and Doppler view taped/acquired?
• For views obtained, is caliper location (in 2D and/or M-mode AND Doppler meas) shown on tape OR print?
• Does the study include all ICAEL standard 2D OR M-mode measurements?
• Does the study include all ICAEL standard views?
• Does the study include all ICAEL standard Doppler flow evaluations?
• Does the study include all components (2D views, 2D/M-mode and Doppler meas) of the lab's own protocol?
• Does the study adhere to the lab's sequence as written?

Beverly Gorman (Apr 12, 2007 8:22:49 PM)
A list of questions for Stress Echo, Adult TEE, Pediatric TTE, TEE and Fetal will be available by contacting me at the ICAEL office, 410-872-0100 or gorman@intersocietal.org.

Rick Duncan (Apr 12, 2007 8:23:33 PM)
Okay, I think that Bev is ready for your questions.

Rick Duncan (Apr 12, 2007 8:23:48 PM)
Please send your questions by typing in the field below.

Email (Apr 12, 2007 8:28:33 PM)
The pedoff regulation has put a particular strain on our ability to find good case studies. With the advancement of other transducers why was pedoff added as a standard in 2006 instead of keeping its use as an option as before?

Beverly Gorman (Apr 12, 2007 8:28:33 PM)
In January 2006 the Board of Directors revised the Standard to include the use of the Pedoff, it enables you to obtain higher velocities. A complete explanation is available on our website, in a past newsletter.

DeDe (Apr 12, 2007 8:29:29 PM)
Will you be cutting down the amount of views required for the cases? It is really a lot and makes for a long study.

Beverly Gorman (Apr 12, 2007 8:29:29 PM)
No, I do not think that views will be eliminated.

Cassie (Apr 12, 2007 8:30:02 PM)
Can I use one patient for a LV and Aortic Stenosis case study?

Beverly Gorman (Apr 12, 2007 8:30:02 PM)
No, you will have to submit it as either an AS case or LVDF.

Cassie (Apr 12, 2007 8:30:44 PM)
What if all my patients are old and my studies are "not the best" ---

Beverly Gorman (Apr 12, 2007 8:30:44 PM)
We understand that some patients are technically difficult, but always try to submit your best work.

shavatt (Apr 12, 2007 8:31:09 PM)
Who do we make the check out to? :)

Beverly Gorman (Apr 12, 2007 8:31:09 PM)
To me! No, to the ICAEL.

Email (Apr 12, 2007 8:31:59 PM)
What views are we to do with our Pedoff transducer?

Beverly Gorman (Apr 12, 2007 8:31:59 PM)
The standard views for the Pedoff are right sternal boarder, suprasternal notch, and apical.

Ksy (Apr 12, 2007 8:32:54 PM)
what if my lab really does not have any abnormal aortic stenosis -- we are private practice.

Beverly Gorman (Apr 12, 2007 8:32:54 PM)
An aortic velocity of 2 m/sec or greater is considered AS and can be submitted.

Ksy (Apr 12, 2007 8:33:27 PM)
What if all my LV Dysfunctions are global can I submit those with a note?

Beverly Gorman (Apr 12, 2007 8:33:27 PM)
No, we require cases with regional wall motion abnormalities.

Rosario (Apr 12, 2007 8:34:34 PM)
Where can my docs get Category 1 without attending a course.

Beverly Gorman (Apr 12, 2007 8:34:34 PM)
There are online courses, and the ASE even has a CD that you can purchase of the last meeting in Baltimore.

Email (Apr 12, 2007 8:35:05 PM)
Do we really need a TABLE in the final report -- can we attach a copy of the tech's table or the sony print from the machine?

Beverly Gorman (Apr 12, 2007 8:35:05 PM)
The report needs to include a table of measurements.

Email (Apr 12, 2007 8:35:39 PM)
If one tech does say a four chamber then goes back and does Doppler vs one tech doing each chamber and Doppler to follow - is that ok, or do we have to do everything the same way?

Beverly Gorman (Apr 12, 2007 8:35:39 PM)
Everyone in the laboratory must follow the lab protocol sequence.

summer (Apr 12, 2007 8:37:36 PM)
Can you tell me exactly what are the components of final exam?

Beverly Gorman (Apr 12, 2007 8:37:36 PM)
Examination components are in the Standards under the specific testing section, which can be located on the ICAEL website, under the Standards tab.

Email (Apr 12, 2007 8:39:15 PM)
What structures need to be commented on in the final interpretated and do you have a sample in the Webcasts on the ICAEL site?

Beverly Gorman (Apr 12, 2007 8:39:15 PM)
The Standards include a complete list of what needs to be included in the final interpretation.

Gail (Apr 12, 2007 8:39:50 PM)
Do we have to do all those views with the pedoff?

Beverly Gorman (Apr 12, 2007 8:39:50 PM)
At least 2 of the views must be included in your cases.

Gail (Apr 12, 2007 8:41:41 PM)
Any two? Our choice?

Beverly Gorman (Apr 12, 2007 8:41:41 PM)
Yes, but if one of them is not adequate, try the third.

Rick Duncan (Apr 12, 2007 8:42:47 PM)
I believe that Bev has an announcement that you will be the first to hear.

Beverly Gorman (Apr 12, 2007 8:43:06 PM)
Well I think that is all of the questions, so are you ready for the ICAEL announcement?

Rick Duncan (Apr 12, 2007 8:43:15 PM)
Yes.

Beverly Gorman (Apr 12, 2007 8:45:14 PM)
Majority of Attachments No Longer Required with Every Application Submission Beginning with the August 1st application deadline, laboratories will no longer submit the following attachments as part of their applications for accreditation or reaccreditation: ·

• Medical licenses for all physicians
• Credential cards for all sonographers
• Policy for the method and frequency for replenishing emergency supplies
• Infectious disease policy
• Transducer cleaning policy
• Policy for handling acute medical emergencies
• Maintenance agreements for all ultrasound equipment
• Patient assessment and monitoring policies and forms for Stress and TEE
• Conscious sedation policy for TEE
• TEE transducer cleaning policy
• Continuing Medical Education (CME) documentation

In lieu of requiring all laboratories to submit these attachments, the ICAEL will randomly audit a statistically valid percentage of the applications received each quarter and require only that select group to submit the documentation.

Beverly Gorman (Apr 12, 2007 8:46:45 PM)
Laboratories randomly selected to submit the attachments will receive notification via certified mail, addressed to the medical and technical directors of the laboratory. Subsequently, the selected laboratories will be given 45 days to return the required attachments to the ICAEL office for review. Failure by the laboratory to provide the ICAEL with the documentation within 45 days of such request during the accreditation review process will result in postponement of the accreditation decision.

Beverly Gorman (Apr 12, 2007 8:47:17 PM)
To continue to ensure the integrity of the accreditation program, the medical director of each applicant laboratory will be required to sign, and have notarized, the Random Audit Acknowledgment/Consent document, agreeing to maintain accurate and current documentation in a file on site at all times, in a manner that is consistent with any reasonable policies and procedures established by the ICAEL. In addition, by signing the Random Audit Acknowledgment/Consent, the laboratory’s medical director will be providing consent for the laboratory to be audited at any time.

Beverly Gorman (Apr 12, 2007 8:48:19 PM)
The signed and notarized Random Audit Acknowledgment/Consent is required with each application submission and can be downloaded from the ICAEL web site at www.icael.org.

Beverly Gorman (Apr 12, 2007 8:48:47 PM)
The ICAEL Board of Directors adopted this new policy to make both the application and review processes more efficient for applicant laboratories, as well as for the in-house and peer reviewers. Any questions about this new policy should be directed to the ICAEL at 800-838-2110 or by email, using the online staff directory published at www.icael.org.

Beverly Gorman (Apr 12, 2007 8:49:05 PM)
Attention United Healthcare Providers . . . All freestanding facilities and physician offices performing Echocardiography must apply for accreditation by March 1, 2008. Will your lab be ready?

Beverly Gorman (Apr 12, 2007 8:49:32 PM)
The ICAEL is strongly encouraging laboratories to submit their applications within 2007 to ensure compliance.

Rick Duncan (Apr 12, 2007 8:50:31 PM)
Are there any more questions for Beverly?

Nikki (Apr 12, 2007 8:54:45 PM)
Is there a recommended percentage for case correlation? 100% of AS cases, at least 75%? etc.

Beverly Gorman (Apr 12, 2007 8:54:45 PM)
No, the ICAEL does not require a certain percentage, or number.

Guest (Apr 12, 2007 8:55:19 PM)
Is this new information on the website?

Beverly Gorman (Apr 12, 2007 8:55:19 PM)
It will be very shortly, and it will also be in the next newsletter.

Guest (Apr 12, 2007 8:55:35 PM)
This mean if we are submitting for August 1 this new information is effective right?

Beverly Gorman (Apr 12, 2007 8:55:36 PM)
Absolutely.

Scott (Apr 12, 2007 8:56:30 PM)
How many will be monitored?

Beverly Gorman (Apr 12, 2007 8:56:30 PM)
It will be a range, depending on the volume of applications.

Gail (Apr 12, 2007 8:56:57 PM)
How many correlations should we do?

Beverly Gorman (Apr 12, 2007 8:56:58 PM)
As many as you can.

Scott (Apr 12, 2007 8:58:02 PM)
What percentage?

Beverly Gorman (Apr 12, 2007 8:58:03 PM)
It depends, anywhere from 10 to 50%.

kl (Apr 12, 2007 8:58:22 PM)
Will medicare follow what united health care is gong to do?

Beverly Gorman (Apr 12, 2007 8:58:22 PM)
I do not know.

Nikki (Apr 12, 2007 9:00:44 PM)
If you have a main lab, and multiple other facilities, does ICAEL want the floor plans, etc of each lab, or just the core lab?

Beverly Gorman (Apr 12, 2007 9:00:44 PM)
We do not want floor plans, the ICAEL recommends that the lab is 150 sq ft.

Rick Duncan (Apr 12, 2007 9:01:33 PM)
We thank Beverly for being here.

Rick Duncan (Apr 12, 2007 9:02:03 PM)
Thank you everyone.

Rick Duncan (Apr 12, 2007 9:02:32 PM)
The transcript will be available soon so check back with Echo-Web.

Beverly Gorman (Apr 12, 2007 9:02:42 PM)
Thank you for joining me tonight. Please contact me at the office with further questions. Have a good evening.

Rick Duncan (Apr 12, 2007 9:02:45 PM)
Thanks for attending!

Rick Duncan (Apr 12, 2007 9:02:51 PM)
Thanks, Bev!

Beverly Gorman (Apr 12, 2007 9:03:00 PM)
Thank you Rick and Gail.

Rick Duncan (Apr 12, 2007 9:03:07 PM)
Good night everyone. Thanks for being here.