quotes from the SVU office to share with you. As always, this webinar will be recorded and available online for attendees through the SVU website at no charge. Let's please take a moment to familiarize yourself with the GoToWebinar program we're using. Everyone should see a questions section along the side menu of your screen. It's near the bottom of the choices, just above chat. So please type in any questions that come to mind during the presentation. And then at the end of tonight's talk, we should have some time for discussion. Now, this next piece of news, I say every month. And still, Missy will get an email as soon as we're done with the webinar, looking for their CMEs. Where's my CMEs? So, listen up. To receive your CMEs from tonight's lecture, you need to wait for an email from the SVU office. It's gonna contain an evaluation. And you should get that email in seven to 10 business days. When you get it, complete the evaluation, and your CMEs will magically pop up. So, wait for that email. And that concludes our announcements. So, let's begin. Tonight, we are honored to have Marge Hutchinson as our speaker. Miss Hutchinson earned her nursing diploma at Lakewood School of Practical Nursing in Cleveland, Ohio, and her Bachelor of Science degree from Colorado State University in Fort Collins, Colorado. She is board certified by the American Registry of Diagnostic Medical Sonographers in both vascular technology and adult echocardiography. She's also credentialed by CCI, Cardiovascular Credentialing International, as a registered phlebology sonographer. Now, Marge joined the IAC in April of 2008, and serves as their director of accreditation for IAC vascular testing. Her experience includes more than 30 years in the field of peripheral vascular ultrasound, and 13 years in trans-thoracic echocardiography. Throughout Marge's career, she's served in a managerial and technical director capacity in the establishment and management of cardiovascular laboratories. Marge is an active member of ARMS, SVU, and CCI. Now, some of us may have communicated with Marge directly over the years during the accreditation application process for our own laboratory. And if so, you know from firsthand experience how knowledgeable and helpful Marge can be in helping us to be better at our craft. So, in my opinion, without paying for a lawyer, there's probably no one else better to advise us on the subject of vascular reporting. And again, we are very honored that Marge has agreed to spend some time with us this evening, giving us direction. Again, I encourage everyone to use the question feature and type in those questions that you have always wanted to ask the experts, and we'll get to them at the end of the talk. Okay, Marge, we're ready to know the truth about final reports. So, take it away. All right. Thank you so much for that introduction. I hope I can live up to all that stuff. So, it is true that I am old. I've been in this business a long time, I hope this is worth your time and thank you for coming this evening. I'm going to start off with a little bit of SVU business here. This is obviously the objectives. They're also in the slides. And the overview is a review of what is required for all vascular testing final reports. The value of quality, completeness, and timeliness. You're going to see that this is pretty important stuff at some point. I have no financial disclosures and I do disclose that I'm a full-time employee of the IAC. And so, all of my discussion tonight will be based on IAC standards and guidelines. I just want to tell you a little bit about the IAC. That stands for Intersocietal Accreditation Commission. And our mission is improving healthcare through accreditation. Every time we're all in the same room, board meetings, staff meetings, anything at all, we always keep this mission statement in front of us so that we can be sure that when we're making standards that we keep the mission about improving healthcare in the forefront. Now, the IAC is a non-profit professional organization. We are not a membership organization. We are funded solely by our applications. We have over 30 years of accreditation experience. Our board of directors are specialists in various medical fields. We have 41 medical societies that send representatives to our various boards throughout the whole IAC. We have over 14,000 accredited sites. We are managed by CMS as an accrediting organization for advanced diagnostic imaging. Now, that means nuclear, what else? CT, MR, those advanced diagnostic imaging items. Now, the IAC knows exactly what you're going through when you go through your accreditation because we do it too. We are ISO accredited and certified. And we really appreciate what you go through because it is a job for us to get there. Just a little visual here of the IAC, and the most important part is that it was started in 1990 with eight sponsors, and that was the vascular testing division. So we're proud to be the oldest ones in the organization. And we set the model. We were so successful in the way we wrote the standards and the application that other organizations came to the IAC and wanted to participate in our programs. The IAC programs for accreditation are dedicated to quality improvement and patient safety, and all support one common company mission. Now, I just want to tell you a little bit about the board of directors because they are the ones who create the standards. They're the ones who evaluate them, and they're the ones who bring their expertise to the table if things need to be changed. You see in red highlights that our board welcomes sonographers also to the table. In fact, to the point where our president right now is a sonographer, Susanna Robeson. I've known Susanna for many years, and she brings great expertise to this board and a different perspective than the physicians bring. And so even though we are sonographers, we do and can hold very important roles in the vascular testing division. So the standards and guidelines are pretty much our Bible. It's what we have to, we live by it. We make all of our decisions based on what says in the standards and everything that if somebody calls and asks a question, we refer to the standards to see what's the right answer to the question. Now, the current guidelines were published in August, and they will be required to be in compliance by November. There were not many changes in the last round, and I don't anticipate any changes to the standards for at least a year or so. So you want to grab a hold of this, go to our website. If you have downloaded or printed or something else, some other copy, get rid of it, because you want to follow the most current standards to avoid any delay issues. Now, the standards and guidelines, they're a minimum standard for accreditation of vascular testing facilities, minimum requirements. The thing to remember is that even if you're not accredited or you have no intention of being accredited, you can still review the standards and set up your lab according to those standards. It really is the best practice for you to be in compliance to at least something that's documented. The intent of the accreditation process is twofold. It gives you the opportunity to review your facility, your laboratory, and then it gives us the opportunity for independent peer reviewers to look at your laboratory. So you get to figure it all out ahead of time, and then we come in and we do the evaluation and hopefully give you good feedback. Now, we'll get into the final report situation. I cannot stress enough, and if you don't go home with any other message but this one, never forget that medical records are legal documents. They are saved, they show up whenever anybody has a question about the care of their patient or a care of their family member. And so that's what this whole evening's talk is going to be about, is being sure that we're following certain standards. Now, there are legal ramifications that sonographers tend to kind of just brush off because they say that they are not that responsible, that the medical director or the doctor is responsible for everything that goes on. And for the most part, I think that might be true. However, there are several cases. This is just a few of them. In 2017, a sonographer was named in a malpractice case of lower extremity venous and the preliminary report said normal, though the sonographer found reduced flow in two veins. The study was interpreted by the physician as normal, and the jury found that the sonographer met the standard of care. So again, we're back to standards. It's all about what's the standard of care right now today. In 2017, a stat venous duplex ordered but was never performed. The patient died of PE the following day. The case did not meet the standard of care, so they become responsible for many damages and financial burdens. In 2014, a sonographer was named in a medical malpractice case of failing to diagnose breast cancer. The sonographer failed to scan over the area where the lump was located. The judge determined that the ultrasound person was 85% liable. The interpreting physician was 15% liable. So that's an interesting situation where in this case, both were sued and the sonographer was found to be more liable than the physician. And you know, the thing is, we get patients who come in all the time and they'll point to a spot on their leg and they'll say, hey, this is where it hurts, but it's nowhere near a vein or an artery or anything, and you're like, yeah, yeah, yeah. It would be of you to take a few minutes to put the probe over that spot that hurts them. The patient will be happy that you've looked at that and you never know what you're gonna find. I had an experience once where a guy came in and he said, it hurts right here. And he was a venous case, the venous was negative. I said, let me see that. Here he had in there a suture needle from a previous surgery, one of those curved deals. And it was just right in there, a little bit under the skin. And so it really is a value to listen to your patients and to do something about it. Now, I do have a personal story where when I was a young sonographer, I was sued for practicing medicine without a license. It was a two-week jury trial. We had been called to the emergency room to do a venous study on a 26-year-old pregnant female. And there was no DVT, but there was a mass behind her knee. And so when I gave the verbal report to the ER guy, he apparently decided that that was a Baker's cyst. And so we went back to the office, we sent out a preliminary report that clearly defined it as a mass. We measured it, we put color on it, we put Doppler in it. We did everything we could think of to document what that was. And so come to find out the lady had her baby, she still had leg pain, and she went to her doctor and they did a CT or an MR, whichever it was, I can't recall, and she had a cancer and she lost that leg. And so I was sued because it was documented in the record. The text said the patient has a Baker's cyst. And so it was, the moral of the story is that it was our documentation. We had written it all over. We had images to show what we were doing, what we called it. We called it a mass during the study. Our preliminary report called it a mass. Our final report called it a mass. But nonetheless, it was a very harrowing two-week process. We were found innocent by a jury. There was a jury there. And we were not, they weren't awarded any money from us, but it was very harrowing. And for anybody who thinks that the doctor's gonna take all the responsibility, no, we have to be responsible for our own actions. So there's some goals of the final report, and that is standardization, accuracy, timeliness, and completeness. We're gonna cover all these things in a little bit more detail. The important thing to know is that we make mistakes. You know, and in medicine, you're not really allowed to make mistakes. Everybody assumes that the medical staff, including sonographers and everybody's just perfect, but we make mistakes. And in 2023, here at the IAC, we looked at all of our applications that were submitted that year. And I don't have the number, but I think it was like 503 or something like that. And we found that 43% had inaccurate interpretations. 21% had missing required images. 9% were suboptimal technique. And 27% were missing findings. Now, this is big in my opinion, and especially 43 inaccurate interpretations. Now, these things can be very minor, and I'll show you some final reports later on where, yeah, it's minor, but nonetheless, it's wrong. And if that patient has a negative outcome and you have documented the wrong thing, that makes us responsible for that patient. So we wanna be really, really careful about all these things because we don't wanna become a statistic. Now, the medical documentation is a collection of printed, in quotation marks, information that provides an exchange of information from one medical professional to another. So that's us reporting to our interpreting physician, our interpreting physician reporting to the referring physician, and the referring physician reporting to the patient. So this is a laundry list of people that you're giving this information to. It's legal proof of patient care, like that one case that I mentioned a few minutes ago. They didn't do the venous study, and so there was no proof that they took care of the lady. It's supporting evidence of the event. It's communication of the patient's status or needs. Does this patient need more immediate care or more immediate attention than another patient? This is big here. It aids in preparing a patient's care plan. That's how they decide. What does the patient need to do next? Can we sit on it? Do they need another procedure? Do they need surgery? Those are the things that it's our job to help physicians make those decisions. And then, of course, it's a record of the care that we've given the patient. So again, another good reason to be accurate with your final reporting is because these are all legal documents, and they can be called upon at any time for any reason. Now, the final report must contain information so that a healthcare professional who's unfamiliar with the case is provided adequate information regarding the indication of the exam, the million-dollar question, why is the patient even there, the type of exam performed, and the results of the diagnostic study. Now, this is one situation where this is why we don't wanna use a bunch of vascular or vascular testing languages or abbreviations or catchphrases or anything like that because this report may be going to somebody who's not familiar with our language. And so we need to be very clear when we're writing our reports what we're saying and why we're saying it. The final report must accurately reflect the content of the exam and the results of the exam. You can't report something if you don't have an image to support it. And if you have an image of something, you must report it. Again, it all goes back to accuracy and completeness. You want to be able to share your findings with that patient's caregivers. And this is the way we do it through our final report because chances are, the reading physician may or may not see the patient. The only person seeing that patient sometimes in the practice is the sonographer. So we have to be very complete with what we pass on. The final report must be standardized. And we're going to see some images about this later on. It has to be interpreted with standardized criteria and a standardized report format. It must be signed and dated by the interpreting physician. And if they're an accredited facility, that physician must be listed in the application. We cannot allow the physicians who are not listed in the application to read our studies because we don't know if they're qualifications. We also have to use standardized criteria so that everybody's using the same criteria. And the format has to be the same every single time. And that, again, helps us communicate to the referring physician exactly what's going on with the patient. The interpretation, it has to be, there has to be an adequate description of the exam performed. And that's why we say that we've done, you know, duplex ultrasound with color Doppler or Doppler, or we just explain all the different parts of the exam. We have to document measurements, images, recordings, all exam content. You can't leave out chunks of what we've got. We've got to share everything we find. A description of all positive and negative findings. And this again goes back to the old adage, and we're going to see this again, where if you don't report it and you don't write it down, then chances are when it goes to court or something, it's going to be considered not done. And they're going to say, where's the left leg? And you're going to say, well, it was normal. I didn't write anything about it. And that's not going to fly. You have to document whatever's normal, whatever's abnormal. If the disease is present, you have to talk about, to the best of your knowledge, the location, the extent, and the severity. Those are the three main things that are very obvious to all of us that are doing the scanning. Incidental findings. You have to document it. You don't have to interpret it. You just have to document. Like for instance, in my case, there was a mass behind the knee that measured this. There was no Doppler. There was no color flow. It was non-compressible, those kinds of things. You have to tell somebody what's there and let somebody else, some other physician, if yours doesn't recommend it, to do something about it. If the exam is technically limited, suboptimal, or incomplete, you have to document that. Because again, if you don't write it down, it's not done. So if it's a limited exam and you can't do some of the lengths of the vessel that you're looking at, you have to document that because otherwise they're gonna say, oh, why'd you skip this part of the vessel? That's where the disease was. So you wanna be very careful about that. If the patient's had a previous exam, you need to compare this exam to that exam. And that's pretty easy. You just pull it up and your doctor can make a comparison. And then you wanna take all this information and you wanna put it in a summary of exam findings. And keep in mind, this is simple. It can either be normal left and whatever on the right, or however you wanna word it. It doesn't have to be a big, huge paragraph because we've already done that part. Always remember, though, the point of the patient being there is the indication for the exam. And we wanna be able to answer that question. For instance, if the patient comes in with claudication or a BRUI or something like that, we wanna do the test and we wanna be able to either say, yes, here's why the patient is claudicating. Yes, here's the reason for the BRUI and those kinds of things. So always keep in mind when you're doing the test why the patient's there. And sometimes you might have to look for. Now, I encourage you to have your reports typed. We do, on occasion at the ICC, handwritten things. Not crazy about that kind of stuff because, again, you all know, handwriting is very difficult to read, especially those folks that are still using cursive. You have to use accurate grammar. You wanna sound like you know what you're talking about. The final report has to have the patient ID, has to have the date of service. Again, the indication for the exam. That keeps coming up. And the interpreting physician must sign it, at least electronically, and date the signature. And this is how we at the ICC evaluate the timeliness of the report, is by the date of the signature. So, again, all these things are safeguarding you and giving good feedback to the physician regarding his patient, his or her patient. Defense of documentation. You have to be objective. Chart the facts only. You don't wanna say, hey, this is the way it is, but I think it might be this. That's not our job, that's not our place. Do not document findings that another sonographer reports to you. If somebody comes to you and says, hey, I saw that lady three weeks ago, and she had this, this, and this. And you do your study, and maybe you don't see this, this, and this, but yet you document it because somebody saw it, supposedly. Don't document findings that aren't true. You wanna be very, very truthful and honest. You wanna sign your own name to your own studies. Don't do anybody any favors. Don't sign off on anybody else's work. And then, of course, you want to do your charting when the information is very fresh in your mind. And I know a lot of times the schedules don't permit that kind of thing. I know in my day, the studies just piled up in the corner and at the end of the day I sat down and did all my work. So try and get into a routine where you're actually looking at your studies, writing your reports, making your comments, looking at your numbers, whatever it is. Try to do it when that stuff is fresh in your mind and not like eight hours later because something's gonna get missed. So a simple summary about medical record. It really is the most important element to prevent and minimize the consequences of liability in a malpractice suit. Again, it is that bit of information, it is that final report that's going to safeguard you. And I don't mean to be scary and I don't mean to always talk about defensive documentation, but you gotta do the right thing and you gotta do the right thing for the patient. And we know, statistically we know that we make mistakes so we just have to be more diligent. The accuracy of the interpretation, you have to have diagnostic criteria, that's a single set of written validated diagnostic criteria. It has to be based on published reports. We do kind of allow people to still use internally validated criteria. Although so many people have kind of changed all the criteria to match whatever they want without doing a scientific project about it. So we're not real great about wanting people to use their own criteria unless they can prove that they've done the research. Remember, you have to use the criteria as it is written. You can't use a little bit of strangeness and a little bit of blues and a little bit of this and a little bit of that. You have to pick which one you're gonna use and you gotta stick with it because that's the way you get the accurate impression of the findings. Remember, you must interpret the presence or the absence of disease. You have to document its severity, location, extent and whenever possible etiology, although that's a little bit more tricky. Particularly in lower extremity and upper extremity, I assume, in lower extremity arterial cases, you have to document where the disease is. You just can't say ABI says moderate disease. You have to tell us where it is, how severe it is and that's all part of your diagnostic criteria. Don't be afraid to use your criteria. So let's do a little review and look at some examples I have here. So these are all cases, these are all final reports that were submitted for accreditation and I'm sure you all know that we allow you to cherry pick your cases. We allow you to go through all the cases you have and find the best ones that are most compliant to the standards. Yeah, scoot this thing over so I can see. So this case, this case, they're talking, it's a carotid study and on the right, they're talking about velocity 377, ratio 6.3 and then they'll talk a little bit about the external. Remember, if you're gonna talk about externals in your interpretations, you have to have criteria that supports it. Now you can talk about externals, you can talk about mosaic patterns of color, we can talk about plaque that we may or may not see there but if you're gonna interpret it, you gotta have the criteria and there is some published criteria out there. It really doesn't shed a lot of value on the patient's healthcare though. On the left side of this interpretation, we see that it's the common, the external is 162 and the ratio is 1.72 on the left. Now we go down here to the assessment and again, it's one of those organizational things, those standardization things. So when you read the assessment, you would think that it would say on the right, 40 to 59, on the left, 80 to 99 but it's backwards. It says left first and then right and we don't wanna do that, we don't wanna confuse our referring physicians. So if we're talking about right first, we should interpret right first and then left. So it's really just a standardization thing that can be confusing and can unfortunately afford the patient a little bit of maybe an extra study or something because now the referring physician might not know what the heck we're talking about. The next one is a venous study and the duplex of the right groin. So they're talking about the contralateral side, that's fine. The venous duplex of the left reveals all these things. It's non-compressible and contains mildly echogenic intraluminal thrombus. There's no color flow and no Doppler signal within the mid distal superficial femoral, we don't call it superficial anymore. Femoral vein, popliteal, tibial peroneal trunk, PT peroneal indicative of acute deep vein thrombosis. Okay, so then we come down here and it says the left common femoral and all the other vessels are visualized and compressible. There's color flow, it's spontaneous, blah, blah, blah. So the question here is, is it right? Is it left? Is it non-compressible or is it compressible? And these are true cases that were sent to us as part of an accreditation. And you see how simple, of course we can look at this and say, come on Marge, that's not what they meant to say. And I know that's not what they meant to say, at least I hope so, but they have to correct it. And the thing to get around all this stuff, of course, is the QI tool. And maybe we'll have some time to talk about that. The next one is again, very simple error, right lower, Jeremy Venus duplex. Now I don't know where Jeremy came from. I don't know if that's the patient's name. I don't know how that got in there, but apparently nobody looked at this final report before they sent it out and before they sent it to us. And it had this very odd something thrown in there. So the mildest, slightest little things can really make your reports look unprofessional. All right, let's look at this one. This carotid study, right findings are total occlusion of the right internal carotid artery. And then he goes on to talk about Doppler and blah, blah. The left 16 to 49% stenosis of the left internal carotid. And then the interpretation is right carotid 16 to 49, left carotid 50 to 79. Now I don't exactly know where this all came from, but I can tell you that if the right's occluded, chances are it's not 16 to 49. And if the left is 16 to 49, chances are it's not 50 to 79. So again, you look at these things and you're like, well, that's kind of crazy. Why would, how did this ever get through? But I think that's the issue is we don't read these things that often or we don't run them through the quality improvement tool or anything like that. I would certainly suggest that everybody just pull random cases, maybe 10 a month or something and read the final reports. If you don't have somebody who's reading these reports before they go out, somebody needs to do some kind of a random project about it. The next one, they did the right leg, they did the left leg. And then they said the right GSV is positive for reflux. But the problem is it's on the left leg interpretation. And I suspect what happened is it somehow, not sure how, but somehow it got stuck in there by mistake because it's almost the exact same thing that the right leg says. And so why or how that got there, I don't know, but I do know it's a mistake and I know it's bad and I know somebody should have caught that. Here's another one, GSV, it's compressible, it's spontaneous, it's phasic, it augments. Is there reflux? Yes. And this is the left leg, left GSV, and then come over here and it says the left GSV is not visible due to prior ablation. Again, it's just a lack of attention to detail. But think about this, if this case went to court and it says this and then it says not visible due to ablation, what's that going to say about us and our work and our business? I mean somebody's not paying attention. Here's another one, the right post-exercise ABI is 1.06 and the left is 0.4. And the interpretation is the post-exercise ABI is moderately to severely reduced on the right and remains normal on the left. Again, I can imagine you're saying to yourself these are stupid mistakes and they should not have been done. But not only were they done, but they were submitted for accreditation review, which that's a little scary. Here's another case where the ABI is like 1.0 on the right and 1.2 on the left. And you know you just got to look at these waveforms. I mean if you're doing a study and the waveforms don't match the numbers and vice versa, you got to keep working at it. You know you got to make some sense out of it. Hold on one second, let's go back here. So look at these waveforms. I mean those do not reflect, those are normal ABIs, but those waveforms are not normal. And if they are normal, if you can see those itty-bitty little deals, it's not very well done. You got to make those waveforms so that A, the doctor can read them, and B, they reflect your findings of your ABI. Everything's got to make sense in these studies. Now this is, I thought this was interesting. The exact same laboratory, two patients, both had a 0.7 on the right and a 0.7 on the left. Now if that's the case and they're relatively the same ABIs, there should be some reason why the waveforms are so different. And there should be an explanation in the final report on, you know, what's going on with these waveforms. Let's try and get waveforms that reflect what we find. And how about this one? Normal ABI on the right and a mild decrease on the left. But look at those waveforms. I mean if somebody, if those are my waveforms, I'd be like, wait a minute, what's going on here? So we have to, again, we have to be careful. How about this one? The study was of adequate technical quality. Well, in my mind that's not very adequate, you know, especially these lower, well, none of them actually. There's like one good waveform there. There is a normal triphasic waveform throughout the left lower extremity. Normal triphasic waveforms. I don't know. I'd have to, I'd have to differ. And then here's a very simple mistake. The right vertebral artery is 82.7 centimeters per second. The left is 36.9. And it's interpreted elevated velocity is seen in the left vertebral artery suggesting greater than 50% stenosis. Well, that's not true because the left vertebral artery is less than the right. And who knows if they have criteria to support that. So we'll just leave that one as it is. Let's see. How about this one? Abnormal results suggest a significant peripheral arterial disease of the left. I don't know. You be the judge. You tell me. Is the right, is the right normal and the left abnormal? I don't think so. And here's one more. Following our diagnostic criteria. Nowhere in the chart up here does it say quite severe. We cannot add these kind of, this kind of language. Moderate, mild, severe if it's not part of the diagnostic criteria. So we have to stick to that because that is validated. These are validated numbers and we have to, we have to support those and we have to stick to what it says. This, I don't know. I don't know what to say about some of these. These are normal ABIs and not so normal waveforms. So make it make sense. Figure it out. This is an interesting report where the numbers are blank. There's no numbers in there. They're just a bunch of blanks. Somebody didn't fill in the drop-down boxes well enough. And of course here they're talking about, they're talking about external stenosis and they're even talking about diameter reduction. So that's interesting wherever that information came from. Here's a good one. The deep venous system includes the subclavian axillary brachioradial ulnar, basilic, and cephalic. Let's keep our veins straight. Let's know what's deep and let us know what's not deep. Be accurate. We're the experts in this field. We should be accurate with with what we're saying in our documentation. Again, basilic, cephalic are not deep veins. Here's a good one. We did a left lower extremity study. All the findings were on the right and all the conclusions on the right. Now I'm sure that this is a very simple drop box kind of thing where it drops down. Somebody picked the wrong, the wrong leg. But you know, it gets us in trouble. These kinds of things are wrong. They're errors. We don't want these to end up in court. Here's another one. Venous, left upper extremity, and then the procedures. The right upper extremity, and then the impression is the left subclavian. So let's get our left and right figured out. Let's just pay more attention to what we're doing. I know we're all busy. I know we're all in a hurry, but we got to think about what we're doing. And we have to do some QI on these things and make sure they're right. Now here's an upper extremity. No, lower. I'm sorry. It's a lower extremity. The venous on the right is compressible. The left is non-compressible. Yet the findings are the left is suddenly compressible now. So again, I'm sure it's all this electronic drop-down box, final reporting kind of system. But we can't hurry through it. We have to take our time and we have to be accurate. If you do preliminary reporting, you have to have a policy. Cover yourself. This is a patient safety issue. You don't want to say something in a preliminary report that may or may not be true. If you're not sure, talk to your doctor. And be sure that if you are the technical director of a facility and you want your text to give preliminary reports, be sure that they're experienced and trained and that you can have a level of comfort and when they're reporting things that they're accurate and they're reporting them properly. As a final word, if it's not documented, it never happened. And that's part of the whole legal thing. You don't write it down, it didn't get done. The other point of it is if it's not documented correctly, it's wrong. Now you can't go into court and can't say, oh geez, I saw, I meant right, I didn't mean to put the left leg in it, that's the right leg, of course that's the right leg. Well, you know, you're gonna be held accountable. And again, I'm not doing all this to scare you, I'm doing all this to show you that we make mistakes. But it's best if we find them in the way we review them. And if you, you know, do a little QI program in your facility, pull 10 or 12 charts a month, read through the final reports, make sure that they make sense, make sure that they're reporting the right things, and I bet you'll be shocked at what you find. So that's all I have tonight. I believe there might be some Q&A. Laurie? Yes, we do. We have some questions coming in already. I'll share the first one. Going back to your story about the incidental findings, there's a couple questions around that. So, like, should, the question is, should we never call a baker's cyst or a baker's cyst, or should we say in a conclusion, you know, it's possibly a baker's cyst versus some other etiology? What would your advice be on that point? Yeah, I definitely, definitely would never call it a baker's cyst. I don't care if you've been in radiology and you've seen a million baker's cysts. You're not in radiology now, you're in vascular. I think you should describe what you see, the size of it, that maybe it's translucent, maybe it's compressible, maybe it's not, there's no Doppler, there's no color, but the minute you diagnose that, you buy yourself some trouble. If the physician wants to say it, that's on them, but as a technologist, I would never recommend giving an interpretation of something. And to stay on that same point, where would be the appropriate place to communicate incidental findings? Like, would, should you do it in the interpretation, impression, or do you want to keep it separate from all the work that we do and maybe just put it in a comment section, let's say? Yeah, no, I would definitely put it in the impression or the interpretation, you know, the ending piece, because physicians, say, for instance, like family physicians, they must get a hundred reports of things that are going on with their patients, and I would bet that they're not going to sit there and read through, you know, this is the test we did, these are the findings, this is this, they're going to go right to the bottom, what the interpretation is, and that's where they need to see it, because that's where, basically, all the important stuff is, the interpretation. So it's got to be in a place where they can be informed and do something about it if they're so inclined. And now that online patient portals like MyChart have become so popular, like, does that affect the way we write our vascular reports? Being more mindful of health literacy, or, you know, sometimes you would say something that made the test difficult, and you don't want to insult the patient. These reports, you know, before they even get back to talk with their doctor, so what's your plan? Yeah, well, you know, the thing is, at the end of the day, you have to be honest and truthful, and, you know, I mean, even if, say, for instance, you have a very huge obese patient and you couldn't see what you wanted to see, the patient knows they're obese. I mean, you know, you can say, you know, unable to visualize whatever due to body habitus, everybody knows what that means, but I think you still, whether, you know, I mean, come on, it's the details, it's the data, and you have to document that. And the patient, you know, I mean, I hate to be cold-hearted towards the patient, because I'm a patient myself, but you got to do the right thing, you got to document the appropriate findings. Okay, and one question is coming in about some labs not doing compressions for lower extremity exams, and then they state that there's no DBT visualized. Should that be acceptable? What are your thoughts? They're not doing compressions in a venous study? Right, like, would you ever allow a protocol for a lower extremity venous, let's use that, that would, you know, not require compressions that, you know, maybe you're just documenting based on the Doppler waveform? No, no, that makes absolutely no sense to me. Compression is the baseline part of the exam, you have to do the compression. I would hope nobody would be doing that, and if you are, maybe you want to reconsider your protocol. And again, if you're not accredited, you can still use our standards, and the standards are very clear about required compression images, and so, yeah, no, you have to do compression on veins. How would you ever, because the color can often override something, so yeah, don't do that anymore. Yeah, I agree. If you want a quality vascular exam, you should at least be familiar with some standards that are pretty easy to access online. And, you know, the other thing is, is that should you end up in court, they're going to, like they did when I was there, they're going to hand you the standards, and they're going to say, did you do all this? And you're going to say, yes, sir, I did, and your study better reflect that. So even if you're not accredited, to have some kind of a formalized standard that you're following will save you. First of all, it will be the best thing to do for the patient, and it will save you legally. So there's nothing wrong with using the standards for your own sake. Okay. What is your opinion on DCA stenosis, for example? Like, should you be documenting diameter reduction? Or, and where would you do that? Like, should we be reporting that in the impression, like a 50 to 99%? Or just keep the impressions focusing on the ICA or REGIBO, for example? Yeah, that, like I said, there is external carotid interpretation, I mean, diagnostic criteria out there. And there is common carotid artery out there. But the main interest and the main reason why your patient's there is, is there a problem with their internal? And if you don't have that, if you don't have that published criteria for those other vessels, we don't want you to report, we certainly don't want you to report diameter reduction. And we certainly don't want you to report percent stenosis, because the data just isn't there. And the thing of it is, it doesn't really matter, like your external, like, chances are that the physician's not going to be that concerned about 50 to 99% of the external. Now, certainly, there are occasions where the patient may have no internals or something like that, where, where maybe that makes sense. But as a general rule, we are very happy to have you discuss the external, what you see, the blood flow, but to actually document the velocity, and put a percent stenosis to it, we don't really prefer to see that. I'm just thinking of maybe one scenario, like what if a patient's referred because they're attending Herta Brewery, and you know, the ICA is fine, but the ECA has a stenosis, would it be appropriate, maybe, to explain the reason the patient is coming to the vascular lab? I think that's a good point in that the patient's coming because they have a brewery, and it appears to be that the brewery is coming from the external. And you can say that there's pathology there, you can say there's plaque there, you can say there is a change in the flow pattern, maybe. You know, you can say all kinds of descriptive things about what's going on there. But we cannot put a percent stenosis, nor can your doctors unless you have the criteria. And I think at one time, I remember the rule was, it's better to report a range, in your impression at least, than, you know, it's a 62% stenosis. Yeah, well, any validated criteria that you look at is going to be a range. And that's because, you know, based on the work that we did at the IAC on carotid interpretations and diagnostic criteria, it is hard to come up with even the categories, even the cut points. It's very hard. There's no way somebody's going to be able to say 69% or this percent or that percent. You just scientifically cannot do it. Okay, I'm going to throw in a question that just came in. With such responsibility and legal impacts, why is it expected for vascular sonographers to provide preliminary reports? Yeah, well, you know, this is an age old issue. And for those of you who do vascular and echo, you know, the echo people are not allowed to do preliminary reporting at all, to anybody, except their own reading physician. However, I think historically, the vascular techs gave preliminary reports because of the DVT issue, where they felt as though the patient needed to be seen and maybe have more immediate treatment. And I think, I think that's where it came from. And so that's why I stress, you know, if you're going to give preliminary reports, make sure that the person that you're allowing to do it is qualified and experienced enough to do that, because that's a serious, that's a serious responsibility. But yet, in the interest of caring for the patient, I think I think it's something that we have to do. There are some standards that require us to do extra documentation for those kinds of situations. Because you don't want to call up a critical findings report and give it to the secretary, and it never goes anywhere. So there are some, there are some standards to, to follow when you talk about critical findings and those kinds of things. But I think, I think quite honestly, I think it's a good thing for us to be able to give reports, we just have to be sure that who's doing it is qualified. Great. Okay, going back to the question we talked about earlier about a venous duplex with no compression. So what about a scenario if you, you know, like, it's not your general practice to not perform compressions, but you just couldn't in that situation, like, the patient was just in too much pain. So can you color instead, you know, just say that you have wall-to-wall color filling and, and then in those instances, just report based on your Doppler waveforms? Yeah, I think you covered it nicely. First of all, you have to document why you didn't do it. The patient was in severe pain, the patient was, had too much edema, and you couldn't get the compression in. You have to document that, why you didn't do the main part of the test. And then you can add to it, well, color flow, maybe you have to do a little more Doppler than, than is normally required to get a feel for what's going on in there. I think that makes perfect sense. And we all know we're going to find patients that aren't going to tolerate the compressions. And we just have to, we just have to document every little detail in that case. Because if that patient comes up with something, somebody is going to come to you and say, hey, why didn't you find this? And, you know, after the fact, it's not going to be worth it, you have to document it in the final report. Okay, and this is sort of related, but it has to do with arterials. And when you have falsely elevated ABIs or non-compressible ABIs, so, you know, is it, should you still require, are you still required to report severity, location, and extent? Can you just base it on maybe PVRs and, you know, the waveform patterns instead? I think you certainly can, because at that point, all you've got is the waveforms. I would highly encourage people to start doing toe pressures and TBI and that kind of thing. I believe there was even a article in the most recent journal about this. And that has been a very valuable component to people who have non-compressible ankle vessels. So, you know, think about it, think it all through, do everything you can. But primarily, yes, in that case, it's going to be those waveforms. And you got to have good waveforms. You can't have some of the waveforms like I showed you, because they're not diagnostic, who knows what they show. So you really got to concentrate on getting good waveforms and the TBI. Okay. Marge, if the technologist types something in the prelim and the reading MD agrees with the statement, can the physician simply copy and paste the text statement into the final interpretation? Or, you know, should they rewrite it? Yeah, well, if you're cutting and pasting, don't tell us about it, because we don't really want that to happen. We really don't want the text to do an interpretation. If there's a section for tech comments, it could be about the case, about the exam, but it cannot include interpretation. So technically, there shouldn't be anything for the doctor to cut and paste. We really do want, and I think it's the expectation, that the doctor will look at the data and do the interpretation. We don't really want to know if they're just cutting and pasting. We really don't want to know if the techs are doing the interpretation. Okay, I'm sure that never happens, so don't worry about it. I'm sure. Here's a question that sounds like it has to do a little bit with billing. Can you speak to how IAC, in developing the standards, balanced a comprehensive best practice exam against being practical and realistic? You know, particularly, there might be barriers, like fee payments to facilities that don't reflect the time that's required for the actual exam. Yeah, good question. I can tell you that the IAC, and in particular, the individual division boards of directors, they make recommendations for the standards based on the best practice for patient care and patient outcomes. We do not consider billing and all that. We may talk about billing, but we don't consider, we don't consider whether people are going to get paid $100 or $200 or whatever. We look at the patient and we decide what's the best practice for the patient, and I'm sure you see that you can appreciate this in the whole arterial duplex requires an ABI. Well, I'm sorry that the ABI doesn't get individually paid for, but that has to be part of your duplex protocol. And, you know, that's a big example, that the board wants us to do what's best without concern. We don't concern ourselves with payment or policy or billing or anything like that. Understood. What would be the best way to fix a report that's incorrect and been signed off on by a physician like some of the ones that you showed us? If there's an issue with laterality, do you do an addendum and you unlock it, revise it, correct it, final? What's your opinion? Yeah, if it's already done, I would say don't unlock it and correct it after the fact. I would say write an addendum and document the date and time that you're writing the addendum, which may be, you know, a couple days later or whatever, date it, write the correction, explain the correction, you know, laterality error or something like that, and, you know, make the proper interpretation corrective and do that. I would certainly not suggest changing something once it's been done. Okay. Should you report everything about the ILLIAC level all at once and then the femoral level, like, from the top down, or do you want to hear first all about the compressions and the Doppler waveforms of each segment? Yeah, I think that's an individual facility's decision how you want to do it. It's just that when you make that decision, everybody's got to follow it. Everybody's got to do it the exact same way every single time, because if you switch things up, the referring physicians are going to get confused, because then they're going to have to read every single report because they're not going to know, they're not going to know which one they're getting. So you do you, whatever works for you and your facility and your physicians and your technologists, just be sure that it's in the protocol and that you follow the protocol and you do it the same way every time. Marge, what's the time frame to finalize an exam on the current guidelines? Business days. You kind of cut out. I'm sorry, two business days, and so you, if you do it on a Friday afternoon, we'd like to see it Monday afternoon. If there's a holiday in there, you kind of get some dispensation for that because the docs might not be around interpreting on holidays, but generally it's two business days. Okay, we're going over. Missy, should I keep going? There's a couple more questions, or do we want to wrap it up? You can keep going if you wish. It's up to Marge. We can send Marge the questions as well, answer them by email. Yeah, let's do a couple more. How about, does the Doppler obtained on the parks machine need to be at 30 degrees or less? I don't know. I'm not familiar. I'm not familiar with that, with the equipment anymore. Yeah, I'll just chime in. You just want to get your parks machine to give you the best quality signal. So, you know, whether that's at 30 degrees or 60, that's my take on it. Right. That's good advice. Should the finding section give an impression of the disease or just be descriptive? You know, not hyper-echoic and then just leave the, you know, acute DBT for the impression section. Yeah, yeah, just like that. The findings should just be the findings. And oftentimes that is done by the technologist. So, you do not want to give the impression that the technologist is just doing it for the sake of it. So, you do not want to give the impression that the technologist is just doing the interpretation. And then the finding section is by itself. And then the interpretation or the impression or whatever you want to call it should include what you found, the disease. Okay. When you're reviewing applications, do you ever ding a lab for using too much technical jargon? Unless it is, like, stuff that doesn't make sense. You know, we all kind of are familiar with what something should say and, you know, what makes sense. So, if there's a whole bunch of stuff, then we may say something. We may give a suggestion of something. But I don't think, I can't imagine that we would delay them for too much information. Okay. Should we augment a leg with DDT? That's a really good question. In my experience, my answer would be yes. I think any, I think the policy has to be made within your facility. And you all have to agree on it. And you all have to comply. So, if your medical director and your medical staff say, no, no, no, no compression of DDT, then that's the policy. And as long as that's the way it's written, you're fine to do however your doctors want you to do it. There is some flexibility that we allow the doctors to be doctors. And they can make medical decisions on how you do things. You just have to be sure that it's documented that that's the way you do it. Okay. I'm just looking through. We have a lot of questions. And look at that. We're like, we're way past our time and everybody's still hanging on. So, I appreciate that. Well, Laura, I can interject that if, you know, we're always available at the IEC to take your questions. So, you can always call us. And I believe I heard Missy say that you can send me a list of the unanswered questions. So, and I'll email you back with the answers. And so, your questions will not just go to the wasteland. We'll take care of it. It does seem like your talk has inspired some of our audience to show this to the staff and check reports daily to make sure we're not making these little errors. Yeah. So, all very, very good. And how would a SNAGFR become involved with the IEC if they're interested in working with the society? Well, you start off by, you know, talking to the director of whatever division you're interested in. And then, of course, you submit all your information and we discuss it. And, you know, it's hard to get into the IEC as a reviewer and that kind of thing because that's a very finely tuned process. But certainly, I think an email to the respective director for your division, whichever one you're interested in, you know, and let them know your interest and your experience and your training and that sort of thing. Okay. Here's, we'll do one more. Okay. If a patient has significant edema, for example, do you have to list out all the veins that you weren't able to see because of this edema? Or what advice would you give? Yeah. I mean, I would like to see especially the veins, the sites that are listed in the standards to be listed. However, a blanket statement that they say, for instance, the femoral vein from groin to distal thigh was not visualized, that's pretty descriptive. So it really, again, is the policy of the facility, how they want to do that. But more information, as long as it's accurate is better. Okay. All right. Thank you, Marge. And thanks everyone for joining us tonight. Before we sign off, I just want to remind everybody one more time, the webinar is recorded. And Missy just wrote a comment to one of our audience members that the on-demand version for this webinar will be available within seven to 10 business days. So you can rewatch it if you missed anything. And again, don't email Missy looking for your CMEs in the next two minutes. You have to wait seven to 10 business days. Wait for that evaluation, fill it out and your CMEs will appear. We have two webinars coming up in October. The very next webinar is scheduled for Tuesday, October 8th. Right now, the topic is going to be human analysis access. And our speaker will be Matt Allen from Santa Fe College in Gainesville, Florida. And then we're going to follow that webinar with a talk in advanced digital evaluation on Wednesday, October 23rd. That's going to be given by Shannon York of Sky Vascular. So we hope to see you guys back in October. Until then, take care, stay well. Thank you, everyone.

GoToWebinar

CME credits

Marge Hutchinson

peripheral vascular ultrasound

echocardiography

IAC standards

defensive documentation

final reports

Q&A session

non-compressible vessels

SVU webinars