Ultrasound-Guided Vascular Access: Out of Plane Approach

out of plane approach
Diagram and ultrasound images: Adapted from Chapter 19, Emergency Ultrasound Ed. 2, James Mateer MD, editor

The short-axis or out of plane approach is the technique used to visualize the vein in a cross-section while inserting the needle perpendicular to the beam axis.

In this view, the needle is only visible at the point where it crosses perpendicular to the beam path.  Therefore the entire needle shaft and tip are not seen with this technique.

The vessel is positioned in the center of the screen.  The needle is positioned at the center of the transducer at a 45 degree angle.  Based on the Pythagorean Theorem, the needle punctures the skin at the same distance from the transducer as the depth of the vessel.

For example: if the vein is 1 cm below the skin surface, the needle should puncture the skin 1 cm away from the transducer (toward the operator) at a 45 degree angle (noble, nelson 281).

The needle is seen as a bright dot with a black shadow or reverberation artifact.  The operator must angle the sound beam or slide the transducer to ensure the needle tip (not the needle shaft) is being visualized.

To learn more about Ultrasound-Guided Vascular Access: Out of Plane Approach, check out upcoming that will provide hours of .

 

References

Ma, OJ, MD,James R. Mateer, MD, RDMS, Michael Blaivas, MD, RDMS, et al. Emergency Ultrasound, 2nd Edition. McGraw-Hill: 2007

Noble, V., Nelson, B. Manual of Emergency and Critical Care Ultrasound, 2nd ed. New York. Cambridge University Press: 2011

Ultrasound Lab Accreditation 101

By: Trisha Reo, RVT, RDMS

Achieving and maintaining accreditation status

Accredited Lab for SonographyAs the Technical Director of Vascular Ultrasound Services at my facility, I have personally experienced the tedious processes of achieving and maintaining accreditation status. Achieving vascular lab accreditation status in ultrasound requires compliance with requirements regarding ultrasound image quality and consistency, exam protocols, quality assurance and continuing medical education. In my professional opinion, ultrasound lab accreditation is a necessary evil that ensures quality diagnostic care and improves patient outcomes. Professional societies, such as the SDMS, agree that accreditation is a staple of a quality diagnostic ultrasound lab (here is the link to an excellent article on accreditation). Although this process can be overwhelming if you are new to it, the ultrasound resources you need to be successful are readily available to you. Read on for some hints and helpful suggestions to get you better prepared.

Five Steps to a Successful Accreditation Application:

  1. Download or request a copy of the application requirements (visit AIUM, ACR, or Intersocietal ). This is your road map. Review it, learn it, know it, and follow it! If you do each step in this application, you are on the road to success!
  2. Download and implement the suggested professional ultrasound exam guidelines from the website of the organization you are applying for accreditation with. If you have any trouble locating these guidelines, call the organization and ask for assistance in obtaining these. And remember, these are suggested ultrasound protocols! You do not have to follow them verbatim but your protocol should at least include the listed ultrasound images.
  3. Designate a physician to be your lab’s Medical Director and involve them. It is important to seek and consider their professional opinion throughout this process!
  4. Communicate the ultrasound guidelines, CME requirements and expectations during this process to your technical staff. This will alleviate any confusion they may have about the changes the department is making. Have multiple CME resources available to them to encourage compliance. Visit Gulfcoast Ultrasound Institute for access to multiple online and textbook CME resources.
  5. Submit an application that reflects only your best work and be sure it is organized. Remember, the application you submit will represent your facility and department, so make sure your application highlights your labs strengths and abilities!

Performing a Venous Imaging scanFollow the above steps and you are on your way to achieving ultrasound lab accreditation! There is nothing easy about this process but, it is well worth the hard work you will put into it.

Don’t be afraid to call or email the organization you are seeking accreditation from if you have any questions or find yourself lost during the process. They are there to help you in any way they can.

Good luck and happy scanning!

Certifications, Reimbursement and Lab Accreditation Updates

EchocardiographyEver changing certification, lab accreditation and reimbursement standards for echocardiography and vascular ultrasound can be confusing and hard to keep up with. To help out we’ve bundled it up, listed useful links to the right resources and summarized the key points to help answer all those burning questions.


Recertification:

Did you know; if you currently hold a certification from the ARDMS (American Registry of Diagnostic Medical Sonographers) you will not be required to begin taking the recertification exam until 2019 and will not have to pass it until 2022?

This includes all RDMS, RVT and RDCS registered Technologists. For all new certifications earned after January 1, 2012, you will have to take your recertification exams starting 10 years after you have acquired your credential.
* for more information regarding recertification and credentialing, please visit www.ardms.org


Reimbursements:

Did you know; reimbursement requirements for Medicare varies from state to state?

Several states require either lab accreditation and/or sonographer/physician credentialing for reimbursement. This applies to echocardiography and non-invasive vascular studies.

Full policy details and individual state reimbursement directive can be found on the Centers for Medicare & Medicaid (CMS) website.

To find a payment policy, go to www.cms.gov/mcd/overview.asp and follow these instructions:

  1. Click on Advanced Search
  2. Under Search by Document Type, check Local Coverage Documents
  3. Under What documents types do you want to search for? Check All Policies (LCD) and then Final Policies
  4. Select Geographic Area (State) AND/OR Contractor Criteria
  5. Type the testing area you are searching for (i.e., noninvasive vascular) or the LCD ID # into Enter Keyword(s) box and choose Title
  6. Click Search by Type box
  7. A page will appear asking you to accept the Terms & Conditions, Click Agree
  8. A new page will open with your search results

Additional information on reimbursement for individual states can found on the ICAVL website for vascular reimbursement and the ICAEL website for echocardiography.


Lab Accreditation:

Did you know; by 2017 ICAVL (Intersocietal Commission for the Accreditation of Vascular Laboratories) requires all technical staff to be registered to comply with lab accreditation?

Appropriate credentialing: RVT (Registered Vascular Technologist) from the ARDMS, RVS (Registered Vascular Specialist) from CCI or RT (VS) (Registered Technologist Vascular Sonography) from the ARRT.

Additional information on credentialing can be found at www.ardms.org, www.cci-online.org , or www.arrt.org

Did you know; that ICAEL (Intersocietal Commission for the Accreditation of Echocardiography Laboratories) is changing their physician requirements?

All physicians who do not have level 2 or 3 echocardiography training must pass the NBE (National Board of Echocardiography) by 2015 to comply with ICAEL accreditation. The purpose of the NBE is to establish the domain of the practice of echocardiography for the purpose of certification, assess the level of knowledge demonstrated by a licensed physician practitioner of echocardiography in a valid manner, enhance the quality of echocardiography and individual professional growth in echocardiography, formally recognize individuals who satisfy the requirements set by the NBE, and serve the public by encouraging quality patient care in the practice of echocardiography.

For more information on the NBE please visit www.echoboards.org

Training Level

Cumulative Duration
of Training

Minimum Number of
Examinations Performed

Minimum Number of
Examinations Interpreted

Level 1

3 months

75

150

Level 2

6 months

150 (75 additional)

300 (150 additional)

Level 3

12 months

300 (150 additional)

750 (450 additional)

Additional information on reimbursement for individual states can be found on the ICAVL website for vascular reimbursement and the ICAEL website for echocardiography.