I am often asked, “How long should an echo take??”.
Trainee sonographers want to know if they are on track, overworked sonographers often ask before approaching management to address workplace issues, practice managers are interested in the answer to aid with rostering and timetabling. I am interested in the answer as I campaign for improved quality of our scans. Patients are interested in the answer to know how long they are going to be stuck in our room…. There seems to be an endless number of reasons for asking the question, and unfortunately the answer upsets more people than it pleases.
The truth is that it takes as long as it takes. Not very helpful advice, I know… So I guess the real question that we should ask is, what is a reasonable allocated booking time for a routine adult transthoracic echo?
The literature doesn’t offer a lot to help guide us. The American Society of Echocardiography (ASE) recommendation is that we should allow 45-60 minutes for a normal routine echo with longer time required for complex valvular pathology or reporting.
Many factors will influence the duration of a scan…….patient compliance, body habitus, difficulty in obtaining a window and complexity of pathology… Obviously we can’t predict which patients are going to need longer to obtain images at the time of booking, so allocated slots will represent an average of scan times over a variety of patients and pathologies. Some scans will be completed well under the allocated slot, and some will run overtime. We also need to consider what is expected as part of the scan. Advanced measurements (such as 3D volumes, contrast, strain imaging etc) will require an additional allocation of time. It is also unreasonable to expect student or trainee sonographers to scan within this time frame either.
I should also add at this point that I strongly advocate performing all measurements online whilst the patient is still present. This is a whole other discussion topic altogether! There are many exceptions to this rule (acutely ill pt for example) but measurements while the patient is still present really should be the routine. I therefore expect that in the allocated time, all measurements have been performed, checked for accuracy, and a report written.
The expectation of level of reporting will vary between institutions also, ranging from no report or a simple worksheet with tick boxes all the way through to finished formatted report ready for a final check by a reporting physician. Differences in efficiency in reporting packages also confound this aspect of the examination. In my practice, I allow 10 minutes to complete the report, which normally leaves enough time to stretch the legs and have a short break before starting the next patient. This would also include a side-by-side comparison with previous images if indicated (or available).
Now I know I have lost more than half of my readers by now… 60 minute slots!!! That’s ridiculous!! So let’s look at it differently… What if we have a 30 minute booking time? The time to report is a constant, and I’ll even assume that on average you are twice as fast at reporting than I am, that takes us down to 25mins. On average we lose 5-10 minutes in setting up packing up and cleaning up after a patient (lets say you can get a patient into your room, explain the test, wait for them to get undressed and onto the bed, and then packed up again at the end in 5 minutes). This would include introduction and explanation (consent) for the procedure. That leaves us less than 20 minutes to actually scan the patient. Looking through standard suggested protocols, I would estimate that 80 clips is an average number of clips (the standard protocol in my institution is closer to 100 clips). This means that we have about 15 sec to find an image, optimise, measure and clip before moving on to the next image. That doesn’t leave a lot of time for adequately panning through the valves, controlling patient breathing to optimise the images or struggle to find any windows. Even after many years scanning, I still struggle to find windows or struggle to see endocardium. I would agree that I can acquire all the necessary clips and measurements in a normal patient in 30 minutes, but no one can put hand to heart and say that they honestly panned adequately through the images or gone looking for an alternate (and possibly better) window. I could take 80 pictures in 30 minutes, but I can’t properly assess the heart in that time.
My personal view is that we should allow no less than 60 minute slots for booking times. Some scans will be finished sooner and some will go a little later…. But any faster and we run the real risk of missing pathology, causing injury to ourselves or not allowing enough time to actually stop and listen to our patients. Talking with patients gives important clues that may not be in the request form, and is one of the more pleasant aspects to our profession. Finding the correct answers takes time. If our only goal is to press the clip button 80 times, then we don’t deserve the money we earn. We are professionals and we need to take responsibility for ensuring we adequately (thoroughly) assess the heart and perform a comprehensive examination.
A little controversial, but best we clear that one up from the start… happy scanning!