Quality not expediency

Abstract

We read with interest the article on bedside ultrasound in a palliative care unit (Gishen & Trotman 2009). We agree that ultrasound can be an extremely useful investigation in palliative care patients. Its non-invasive, painless nature and the dynamic nature of scanning make it appropriate for all the purposes suggested in this paper. However, we would like to draw your attention to a number of points. First, there is no mention made to the recommendations made by the Royal College of Radiologists for Training in Ultrasound for the Medical and Surgical Specialties (Royal College of Radiologists 2005). These widely accepted guidelines are aimed to ensure high quality imaging services (or ‘best practice’) and support the minimal training requirements proposed by the European Federations of Societies for Ultrasound in Medicine and Biology. For the needs of the service suggested in the article, Level 1 training would be required – equivalent to a radiology registrar after 3 or 4 years of training. This level of training includes (for example) a knowledge of the physics underlying the technology of ultrasound so that artefacts can be differentiated from pathology. Ongoing training and clinical supervision by Level 2 or 3 standard practitioners is also necessary. Sufficient number of scans need to be performed – 40 scans in a 17-month period is arguably insufficient to maintain competence. Second, simply buying an ultrasound machine and ensuring its safety is inadequate. Some form of regular Quality Assurance, such as a service contract, is needed to ensure the machine can still produce diagnostic quality scans. No form of Quality Assurance is mentioned in the paper. This would increase the apparently cheap scan cost. On this point, we would like to make a recalculation. The discussion implies that many of these scans were simply done due to the easy availability of the scan. Removing the scans relating to paracentesis the cost per scan increases to almost £40, excluding all ongoing expenses. While we support the availability of easily accessible ultrasound services, particularly in the palliative care setting, quality must be paramount over expediency. Scans should only be performed by suitably trained individuals with an established clinical support structure. Such individuals should only use appropriate machines which are regularly maintained to ensure adequate scan quality. While such services are often most easily provided by a hospital-based clinical radiology department, this may not be most practical in a hospice remotely sited from the nearest hospital. With the advent of portable ultrasound machines, a peripatetic community-based ultrasound service is perfectly feasible. Indeed, in north Bristol, such a service providing GP surgeries with deep venous thrombosis ultrasound has been commissioned. We summarise by arguing that it would be a better use of resources to employ a professional peripatetic service than to mimic the service described in the paper by Gishen and Trotman (2009).