Echo triaging works. How to use international guidelines

Abstract

Abstract Introduction Transthoracic echocardiography (TTE) is the first-choice non-invasive imaging modality for the assessment of cardiac structure and function due to its wide availability, speed, cost-effectiveness and reproducibility. Therefore, there is exponential increase in demand in TTE across all specialties in medicine and surgery. Hence, it is important to carefully triage patients according to current international guidelines. Purpose To reduce inappropriate TTE scans by using guideline driven indications in triaging echo scans in the UK tertiary hospital. Methods Strict list of guidelines driven indications adapted to local practice was used for triaging echo requests which included both inpatient and outpatient TTEs. The 4 objectives: appropriateness, completeness of requests as well as impact of performed studies on the follow-up and patient management plan were assessed before and after implementation of new triaging tool. To ensure similar working and staff environment was sustained we studied the pattern of referrals in the same month of the year- September. The triage process was conducted by accredited physiologists. The same month was chosen to reflect true change of practice. Change in patient management and follow up were evaluated for a minimum duration of 6-months. Results Overall there were 1112 TTEs performed in September 2022 and 1081 - in September 2023. Prospective TTE referral triaging began in March 2023. We have studied and analyzed above criteria retrospectively. In 2022 there were 18% inappropriate requests; 37% of requests lacked sufficient clinical information and 10% of studies did not lead to change in management plan according to clinical letters. There was also high proportion of inappropriate requests for inpatients (9%). Within 6 months of implementation there was a significant improvement in the appropriateness (82% vs. 99%, p<0.001), with increase in supply of adequate clinical information (63.4% vs. 86.1%, p<0.001). However, there was no significant change using TTE study results in changing patient management (10%). All inpatients had 100% appropriate requests. Conclusion The implementation of triage criteria resulted in a significant improvement in TTE referrals: both in appropriateness and completeness of requests. However, some clinicians did not use echo in patient management plan. Future research on lack of use of TTE results in clinical practice might help to utilize the limited echo capacity to full.