Q4 Quality Review 2011

Summary of Q4 concerns

• Review prior related studies and comment about your findings relative to the previous studies. 
• Document if you cannot reproduce prior findings
• Measurements:  Choose the longest axis and measure the AP in the same image (except the kidney and spleen), the transverse should be measured 90 degrees from this plane.

Image Checklist:

1. Have I taken an appropriate history on behalf of the radiologist?
2. Correct Preset?
3. Correct Transducer and frequency for application?
4. Proper use of technology?  (Harmonics, Compounding, RTAF's, etc.)
5. Does pathology display diagnostic markers?  (shadow, posterior enhancement, etc.)
6. Is the image balanced from top to bottom?  (TGC)
7. Is the image zoomed usefully?  (Not too small and not too "pixelated")
8. Is there something odd in my image that is not associated with the structure of interest?
9. Have I created something in my image that is not real?  ("Imaginoma")
10. Do my images tell the story?

Fetal Heart - What Do I Image?

• 4 Chamber - Always
• LVOT, RVOT and 3 Vessel View - A good attempt made
• Image of Stomach must follow or immediately precede the image of the 4 chamber heart
• Stomach must be included in cine clip of Situs - also including the 4 chamber
• Cine clip of beating heart is not required (except in Seattle) but is helpful to identify valve insertion and VSD/ASD.  For still images of these remember to modify settings for best frame rate.
• Do NOT use spectral Doppler for fetal heart rate.
• Proper algorithm for fetal demise:
• 2D M-Mode (I like to use color M-Mode but the use of color will increase the MI)
• 2D cine clip usually in 4 chamber
• Color Doppler cine clip if 2D is ambiguous
• If you still can't get it, call the radiologist. 
• Zoom to a useful size

Take Home Message:

Communicate what you know and what you have seen or couldn't demonstrate so the radiologist knows what you were thinking.  If it is not on the online form it is assumed you didn't ask, didn't know or didn't try.  

Q3 2011 Image Quality Update

• Limited versus Follow Up on OB - Limited (76815) is used to look specifically at things like viability, fluid volume or fetal position and is usually done from the ED.  Follow Up (78616) is used for following  biometry and anomalies.  
• Chorionicity and Amnionicity of Multiples - Be sure to document # of placentas, membranes and fetuses especially if not previously documented.  Labeling fetuses begins at the first presenting fetus at the cervix and increases to the fundus starting with "A".  Draw the fetuses on the online form.
• When dating multiples choose the largest on the first ultrasound.  
• Take the general AFI of the uterus and the largest pocket in each sac.  
• Document the placental cord insertion with and without color Doppler
• Ovarian cyst measurements should include the wall or rind.  
• The gallbladder box on the online form is intended for a comment not a measurement.  Use "wnl" or "stones" and put further comments in the Findings portion.  
• If a cervix is less than 3 cm please don't leave as routine and check with the reading radiologist.  
• Document lower tip of placenta in relation to the internal cervical OS.  

• I suggest taking a cine clip if it cannot be documented with one image and at least comment that the placenta is not near the cervix.

Zoom and frame fetal heart images appropriately

Good

Poor

Fetal Kidneys

Clearly demonstrated and appropriate size.

Good

Poor

Head Measurements  
Keep anatomy symmetrical

Poor

Good

Posterior Fossa 

Good Posterior Fossa.  Clean images and clear anatomy.  Don't push the transducer beyond it's limits

Orientation of Uterus

Line up the long axis of the structure not necessarily on the patient.

Color Doppler 

Color Doppler should have been done on thickened endometrium.

3D Uterus for IUD placement???

Should we or should we not?  That is the question!

Measurements:

Compare the sonographer's measurements to the radiologist's measurements.  Include the fibroids in the overall measurement.









Did I really just do that???

Spine and kidneys not imaged, but checked off as normal.

Follow up recommended due to poor visualization of the spine. Spine not imaged on current exam. Oops! (read prior OB reports)

Incorrect Uterine volumes, no uterine volumes.

Right and left ovarian measurements transposed.

Fibroids well documented but not drawn on on-line form.

No Doppler of left testicle.

No cine sweeps of the thyroid, uterus, ovaries, pathology.

Look at previous studies and be sure to reproduce and or comment on previously seen pathology.

Sick Gallbladders

These need to be addressed!  Don't let them sit over the weekend. 

Here is what we are looking for in an image of the cervix.  Must see the internal and external OS, the endocervical stripe and a symmetrical uterine wall around the internal OS.  If all of these structures are not seen then you must do a transvaginal exam.

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