UPDATE 2010:
Several important changes to ICAEL’s standards go into effect on December 1, 2010.

Reduced CME Requirements
The number of required continuing education credits relevant to echocardiography, attained during a three year period, has been reduced from 30 credits to 15, for both the Medical and Technical Directors.

Strengthened Language Related to Sonographer Credentialing
Though the standards include multiple pathways by which a technical staff member may document experience and training, the ICAEL encourages that all staff members acquire an appropriate credential in echocardiography within two years of completion of pathway B, C or D.  By 2014, the lab must have a process in place to ensure that all sonographers become credentialed.

Avoidance of Muculoskeletal Disorders (MSD)
A policy must be in place to address technical staff safety, comfort and avoidance of work related musculoskeletal disorders (MSD).

Enhanced Details Related to Timely Reporting of Examination Data
Routine inpatient echos must be interpreted by a qualified physician within 24 hours of completion of the examination.  Outpatient studies must be interpreted by the end of the next business day.  The final verified signed report must be completed within 48 hours after interpretation.

Multiple Enhancements to the Quality Assurance Section
Incorporation of Appropriate Use Criteria (AUC)
Appropriate Use Criteria (AUC) are developed and published by several medical specialty societies including the American College of Cardiology Foundation.  Such criteria are written to define “when to do” and “how often to do” a given procedure in the context of scientific evidence, the health care environment and the patient’s profile and a physician’s judgement.  The criteria are designed to examine the use of diagnostic and therapeutic procedures to support efficient use of medical resources, while also providing patients with quality, appropriate care.

Through the incorporation of AUC, the ICAEL Standards now require laboratories applying for accreditation to measure and evaluate the appropriate use of echocardiography in their practice as part of their ongoing quality assessment programs, to improve patient care.  It is important to note the laboratories are not required to achieve a defined percentage of the level of appropriate studies, nor will laboratories be judged based upon the results of their metrics.  Rather, the purpose of requiring measurement of appropriate use is for self-education of the facility and self-assessment of areas for improvement.

As part of the ongoing quality improvement program, facilities providing echocardiography imaging MUST incorporate the measurement of the appropriate use criteria published and/or endorsed by professional medical organizations(s). (such as ASE)

• Appropriate use MUST be measured in a minimum of 30 consecutive TTE, TEE and stress patients annually.  In addition to measuring appropriateness, a policy for ongoing monitoring of appropriateness for TTE, TEE and stress echocardiograms should be in place by 2012.
• Overall results MUST be documented.  The percententage of appropriate, inappropriate and uncertain indications for testing MUST be measured.
• A program for education and reporting MUST be developed and include:
• Patterns of adherence to AUC
• Baseline rates of adherence
• Goals for improvement of adherence to appropriate use criteria
• Measurement of improvement rate
• Confidential comparison reports on patterns of adherence in aggregate by ordering physician, ordering practice and interpreting practice

Documentation of measurement of AUC will be a mandatory requirement for accreditation effective January 1, 2012.

Echocardiography Conferences
Quarterly echo QA conferences MUST be held to review the results of variability, correlation and report timelines, to address discrepancies and to discuss difficult cases and laboratory issues.  Attendance by the medical and technical directors or their designees is required at all meetings.  All medical and technical staff are required to attend at least two of the four meetings.  Minutes of the meetings and attendance MUST be recorded.

Three Specific Categories of QA Measures Are Now Required

• Ejection Fraction, wall motion analysis and degree of regurgitation/stenosis MUST be assessed on a minimum of two cases per modality per quarter to be reviewed in quarterly conferences.  The cases must represent as many physicians as possible.  A policy for the medical director to address discrepancies MUST be in place.
• A minimum of 10 random reports per quarter evaluated for time of study performed and time of final report generation and report completeness.  The reports must represent as many physicians as possible.  A policy for the medical director to address discrepancies must be in place.
• Ejection Fraction, wall motion analysis and degree of regurgitation/stenosis will be correlated on a minimum of two per modality per quarter with other imaging modalities in quarterly conferences.  A policy for the medical director to address discrepancies must be in place.

Use of Contrast
Contrast is indicated for use when two contiguous segments are not visualized as it provides greater accuracy in determining left ventricular function.

• If contrast is used, there must be a written policy for the use of contrast agents.
• If contrast is not able to be used there must be a policy for alternative imaging
• Contrast should be used in the presence of poor endocardial border definition for quantification of chamber dimensions, volumes, ejection fraction and assessment of regional wall motion.
• Poor endocardial border definition is defined as the inability to detect two or more contiguous segments in any three of the apical views.
• Contrast should also be used to assess conditions such a hypertrophic cardiomyopathy or when left ventricular thrombus is suspected.

Patient Demographics
The demographics of height, weight, gender and blood pressure are now required elements of the standardized report.
To learn more go to: icael.org/icael/main/standards.htm

QUESTION:
What do reviewers look for in an adult transthoracic case study?

ANSWER:
They look to make sure that the lab’s protocol is followed and that all the studies are performed in the same sequence.  They answer the following questions: Are the views on-axis? Is the Doppler parallel to blood flow? Are the measurements performed correctly?  Is the pedoff probe used from 2 or more windows when aortic stenosis is greater than 2 m/s.  Are the apical views foreshortened?

QUESTION:
What is the number of case studies that our lab needs to submit?

ANSWER:
The required TTE case studies are based on the total number of staff (docs and techs) in an echo lab.  Following are the required number of case studies per base laboratory:

ADULT TRANSTHORACIC:

• 5 or fewer staff = 4 cases per lab (2 AS, 2 LVDF)*
• 6 to 8 staff = 6 cases per lab (3 AS, 3 LVDF)*
• 9 to 15 staff = 8 cases per lab (4 AS, 4 LVDF)*
• 16 to 25 staff = 10 cases per lab (5 AS, 5 LVDF)*
• Greater than 25 staff = 12 cases per lab (6 AS, 6 LVDF)*

*LVDF are cases of regional wall motion abnormalities, not global LV dysfunction or diastolic dysfunction cases. AS cases must be native valvular AS with a velocity of at least 2 m/sec.

• All cases must be abnormal.
• Cases must represent as many staff as possible. When submitting case studies, do not duplicate staff members (medical and technical) until all staff have been represented at least once.
• One case study must be submitted from the Technical Director.
• Medical Director must be represented.
• All cases must be complete examinations and not limited or followup exams.
• All cases must be selected from within the past 12 months from the date of application filing.
• Submit only BEST cases.
• Laboratories are required to send printed final reports.

ADULT STRESS

• The required stress case studies are now based on the total number of staff (medical and technical) that perform stress echo in an applicant laboratory. Following are the required number of stress case studies per base laboratory:
• 5 or fewer staff = 4 cases per lab
• 6 to 8 staff = 6 cases per lab
• 9 to 15 staff = 8 cases per lab
• 16 to 25 staff = 10 cases per lab
• Greater than 25 staff = 12 cases per lab
• All cases must be abnormal (positive stress cases, or cases with a regional wall motion abnormality at rest).
• Cases must represent as many staff as possible. When submitting case studies, do not duplicate staff members (medical and technical) until all staff have been represented at least once.
• One case study must be submitted from the Technical Director.
• Medical Director must be represented.
• All cases must be selected from within the past 36 months from the date of application filing.
• Submit only BEST cases. Rest and post images must be submitted in a side by side format.
• Laboratories are required to send printed final reports.

ADULT TRANSESOPHAGEAL:

• One representative Adult TEE case and its final report for each physician that performs TEE.
• 1 case per physician that includes an indication or finding of a greater than mild mitral regurgitation or source of emboli. Of the total submitted, at least one case must demonstrate a finding of greater than mild mitral regurgitation.
• All cases must be selected from within the past 12 months from the date of application filing.
• Laboratories are required to send printed final reports.

QUESTION:
Does it matter if I get my echo credentials through the American Registry of Diagnostic Medical Sonographers  or through Cardiovascular Credentialing International (RCS)?

ANSWER:
No.  Cardiovascular Credentialing International (CCI) and the American Registry of Diagnostic Medical Sonographers (ARDMS) are equally recognized for their cardiac sonographer credentials by the ICAEL and by the American Society of Echocardiography (ASE).