Advancing patient safety with ultrasound

The first hand-held ultrasound system, developed by SonoSite, over ten years ago, was initially designed for use on the battlefield. Since then, the role of pointof- care ultrasound has expanded across a range of disciplines on the “frontline” of the health service – from critical care, cardiology and rheumatology, to anaesthesia, palliative care and orthopaedics. It now plays an important role in improving the safety of procedures, reducing patient transfers around the hospital, cutting the risks associated with moving very ill patients, as well as helping in the fight to minimise the spread of infection. At the same time, hand-carried, point-of-care ultrasound has freed up space, time and staff in radiology departments – allowing sonographers to concentrate on specialist applications requiring their expertise.

Safer catheter placement

The expanded role of ultrasound has, in part, been driven by NICE guidelines, which recommend that ultrasound is used to guide vascular access in order to prevent complications. In a report, published in 2002, NICE highlighted the fact that although experienced operators using surface anatomical landmarks can achieve relatively high success rates with few complications, failure rates for initial central venous catheter (CVC) insertion were reported to be as high as 35%.1 The guidelines pointed out that the most common complications associated with CVC placement are arterial puncture, arteriovenous fistula, pneumothorax, nerve injury and multiple unsuccessful attempts at catheterisation, which delay treatment. The risks and the consequences of complications vary substantially across different patient groups depending on the patient’s anatomy (for example, morbid obesity, cachexia, short neck, or local scarring from surgery or radiation treatment), the circumstances in which CVC insertion is carried out (for example, for a patient receiving mechanical ventilation or during emergencies such as cardiac arrest) and co-morbidities (for example, bullous emphysema or coagulopathy).1 Consequently, the NICE guidance recommended that two-dimensional imaging ultrasound guidance should be used as the preferred method for insertion of CVCs into the internal jugular vein. The use of ultrasound guidance should be considered in most clinical circumstances where CVC insertion is necessary, either electively or in an emergency situation, while all those involved in placing CVCs using ultrasound should undertake appropriate training to achieve competence. “The NICE recommendations on ultrasound guided vascular access have taken around six years to become adopted on a mainstream basis, and still some Trusts have not yet been able to fully comply with the guidelines due to financial constraints,” commented Tracey Byard, SonoSite’s UK country manager. “Trusts cannot afford not to use ultrasound guidance. If something goes wrong, they are likely to face litigation issues. In the event of an investigation into a patient safety incident, they will be asked: ‘Was ultrasound available? Was the proficient at using it and was ultrasound actually used?’ Lawyers will be aware of the NICE guidelines and will want to know why they were not adhered to.” Paediatricians at Southampton General Hospital are currently using SonoSite’s M-Turbo point-of-care ultrasound system to improve the safety of vascular access procedures, while ultrasound is also used to assess and monitor patients in the hospital’s dedicated paediatric intensive care unit (ICU) and during transport. Dr Gareth Jones, a consultant paediatric intensivist and anaesthetist at the hospital, explained the benefits of using bedside ultrasound for children: “Vascular access in small children can be a major challenge, and the development of point-of-care ultrasound has significantly helped in the placement of central lines in these potentially difficult patients. It has also helped us to develop our PICC line service, allowing us to target veins in the upper arm that were not accessible using conventional techniques. The large screen and image quality of the instrument ensure these lines are accurately placed, minimising risk for very young patients. “The portability of the system also means that it can be used during our patient retrieval service; it can easily be taken in the ambulance or air ambulance to aid assessment and monitoring of critically ill young patients during transport from our satellite hospitals.” Ultrasound guidance is also crucial to improving the safety of other invasive procedures, such as suprapubic catheter insertion, which carries some risk of complications including peritoneal perforation (with or without bowel perforation), infection and haematuria. In July 2009, The National Patient Safety Agency (NPSA) issued a Rapid Response Report on “Minimising risks of suprapubic catheter insertion”, as a result of an incident, in September 2008, where a patient’s bowel was perforated during the insertion of a suprapubic catheter. The incident, which was identified via the Reporting and Learning System (RLS), prompted a formal search for further incidents relating to the insertion of a suprapubic catheter. The NPSA found that three incidents causing death, and seven causing severe harm, were reported between September 2005 and June 2009, while nine of these incidents resulted in a bowel perforation. The safety alert suggested a number of actions should be taken to reduce the risks of this procedure. Included in the recommendations was the comment that: “The use of ultrasound is a safer method for suprapubic catheterisation especially in complicated patients such as those with large body habitus, abdominal adhesions, and in uncooperative patients”.