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The Role of the Nurse in Clinical Echocardiography
SPECIAL ARTICLE
The Role of the Nurse in Clinical Echocardiography Gregory Gilman, RN, RDCS, FASE, Janice M. Nelson, AN, RN, Amy T. Murphy, BSN, RN, Glenda M. Kidd, RN, Vicky L. Stussy, RN, and Kyle W. Klarich, MD, FACC, Rochester, Minnesota
Echocardiography plays an important role in the practice of clinical cardiology. As echocardiographic practice has evolved, the addition of nursing personnel to the echocardiography team has enhanced the assessment and diagnosis of cardiovascular disease. Specifically, nurses monitor patients during
Echocardiography is an important component in
the assessment and diagnosis of cardiovascular disease.1 The addition of nursing personnel to the echocardiography team has advanced the use of echocardiography. We review the contribution of registered nurses to the practice of clinical echocardiography. The Evolution of the Nurse’s Role in Echocardiography Nursing encompasses autonomous and collaborative care of patients of all ages and in all settings, whether sick or well, in families, groups, and communities. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy, management of health systems, and education are also key nursing roles. At Mayo Clinic in Rochester, Minn, nurses have been members of the echocardiographic and hemodynamic laboratory team for nearly 2 decades. In our experience, the migration of nurses from the bedside to the clinical echocardiography setting has been the result of numerous forces. During the late 1980s, some members of the nursing staff trained as cardiac sonographers and also monitored patients undergoing transesophageal echocardiography (TEE) under the supervision of echocardiologists. In the early 1990s, nurses with expertise in critical care nursing and exercise testing found a demand for their skills not only in performing stress imaging but also in monitoring stress tests in this
From the Division of Cardiovascular Diseases, Mayo Clinic. Correspondence: Kyle W. Klarich, MD, FACC, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. 0894-7317/$30.00 Copyright 2005 by the American Society of Echocardiography. doi:10.1016/j.echo.2005.03.030
transesophageal and stress examinations and establish intravenous access for sonicated saline, microsphere contrast, and medication administration. We describe the involvement of nurses in the practice of clinical echocardiography. (J Am Soc Echocardiogr 2005;31:773-7.)
subspecialty of echocardiography. This period predated establishment of the echocardiography program in the Mayo School of Health Sciences, Mayo Clinic College of Medicine, Rochester, Minn. As the needs for patient monitoring, establishing intravenous access, and administering medications became integral parts of many echocardiographic procedures, nurses trained as cardiac sonographers were recognized as a valuable resource in the echocardiographic laboratory. Soon demand exceeded availability of nurse sonographers in the daily operations of the laboratory. Simultaneously, increasing demands on physicians to perform patient monitoring and medication administration began to impede the growth of the echocardiographic practice. To accommodate the demands of the practice, in 1994 the leadership of our echocardiographic and hemodynamic laboratory decided to add registered nurse positions to the echocardiography laboratory staff. Prerequisites to employment included a background in intensive care nursing and advanced cardiac life support certification. Nurses were trained to monitor patients during TEE and, later, stress echocardiography. By freeing the physicians’ time and enabling a greater number of patient examinations per physician, the laboratory provided greater access for the growing population of patients in need of diagnostic testing. Our nurses serve two distinct patient groups: hospital inpatients and clinic outpatients. Although most patients are in stable condition while in the laboratory, nurses with a background in critical care nursing are ideally suited to meet the needs of and anticipate the potential problems that face these patients at high risk. The Role of the Nurse in TEE The clinical application of 2-dimensional TEE began in the late 1980s.2 TEE is performed when a detailed structural and functional evaluation of the heart is
773
774 Gilman et al
indicated, and it has become important in the evaluation of patients with cardiovascular diseases.3 Common indications for TEE are to rule out native or prosthetic valvular endocarditis, assess the degree and cause of valvular regurgitation, determine a potential source of embolus, and rule out cardiopulmonary shunting. Increasingly, we use TEE to assess patients before cardioversion and radiofrequency ablation for atrial fibrillation and to monitor and guide percutaneous procedures such as deployment of atrial septal closure devices. The history of the nurse’s role in TEE is not well documented. Originally described as the “role of the sonographer assistant,”4 a safe and legally compliant state-of-the-art TEE program requires administration of intravenous conscious sedation and periprocedural patient monitoring, with complete documentation of all patient care activities. Patient education promotes a safe, comfortable environment and diminishes patient anxiety. The professional registered nurse is best suited to complete these vital aspects of a successful TEE program. TEE may be done in an outpatient or inpatient laboratory setting, at the patient’s bedside, or in the cardiac catheterization suite. The nurse reviews the order for the TEE from the referring physician to confirm the correct patient identification on the order, determines contraindications of performing the TEE, and makes the initial assessment of the appropriateness of TEE for the patient’s specific condition. This review requires a working understanding of the strengths and limitations of TEE and a detailed look into the patient’s history, paying special attention to cardiac history, gastrointestinal tract abnormalities or procedures, prior complications with sedation, medication allergies, and the patient’s current medication regimen. Any concerns regarding the examination are presented to the physician performing the examination. The nurse prepares esophageal intubation supplies and confirms the availability of emergency airway equipment. During the examination, the nurse assists the physician by administering medications and providing direct patient care. Emphasis is placed on managing the patient’s airway and proper positioning of the patient to minimize risk of aspiration. Moderate sedation allows the patient to maintain and protect his or her own airway and to respond to commands given verbally by the nurse or physician. Hemodynamic and neurologic monitoring continues through the recovery period until the patient has returned to presedation status. The nurse documents the procedure activities, medication administration, and patient assessment, adhering to institutional and Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) guidelines. Our laboratory now uses a 24-hour on-call
Journal of the American Society of Echocardiography July 2005
nurse to accommodate conscious sedation for emergency inpatient TEE. The Role of the Nurse in Stress Echocardiography Articles referring to the diagnostic potential of exercise stress echocardiography date back to the late 1970s and early 1980s.5-7 Esophageal atrial pacing and pharmacologic stress echocardiography were developed for patients in need of functional assessment for coronary artery disease but unable to exercise. The safety and diagnostic value of pharmacologic stress echocardiography was initially explored in the early 1990s.8,9 Historically, the nurse’s role in administering these diagnostic tests was not well documented until 1998, when Bremer et al10 described the role of the nurse in monitoring dobutamine stress echocardiographic examinations. They demonstrated the safety of implementing a stress protocol during which nurses monitored dobutamine stress echocardiography and a physician was immediately available but not present in the room during the stress test and dobutamine infusion. Currently, exercise and pharmacologic stress echocardiography is important in the clinical management of coronary artery disease. In addition to the nurse, the stress echocardiography team consists of a supervising physician, an imaging sonographer, and an electrocardiography (ECG) technician. Nurses are involved in various stages of the examination, beginning with completing a detailed review of the medical history, performing a patient interview to rule out any contraindications for the examination, and confirming that the correct test will be performed on the correct patient. A registered nurse can establish intravenous access and administer medications that are required in some exercise and all pharmacologic stress examinations. The nurse tells the patient what to expect during the examination and during the recovery period. Finally, documentation of the patient’s experience, including all pertinent hemodynamic and ECG parameters, any medications administered, and the necessary patient education related to the examination, is completed by the nurse in compliance with institutional and JCAHO guidelines. The American College of Cardiology, American Heart Association, and American College of Physicians recognize stress echocardiography as an important alternative to standard exercise ECG.11 The need for nurses in the stress laboratory has increased correspondingly. Historically, the annual demand for stress echocardiography has been increasing steadily, and during the past 3 years our laboratory has experienced a markedly increased rate of referrals. We have met this need by adding nursing personnel through planned staffing increases.
Journal of the American Society of Echocardiography Volume 31 Number 7
Gilman et al 775
The Role of the Nurse in Pediatric Echocardiography
requirements related to contrast and saline administration.
Pediatric echocardiography is a subspecialty of cardiac ultrasonography. Assessment of patients between the ages of 2 and 24 months is especially challenging in the echocardiography laboratory. These patients often require sedation to minimize movement during the examination. JCAHO guidelines state that the person performing the cardiac imaging must not be the same person responsible for monitoring the patient during sedation. Therefore, a registered nurse trained in the administration of moderate sedation and certified in pediatric advanced life support is a valuable member of the pediatric echocardiography team. In addition, the nursing staff educates and reassures the patient’s parents to reduce their anxiety during their child’s examination. Sedatives may be administered to the pediatric patient either orally or nasally. Baseline and routine blood pressure measurements, continuous monitoring of consciousness, and ongoing assessment of respiratory and heart rate are required until the patient’s status has returned to baseline. At that point the patient’s care can be returned to the parents. Allergic reactions to commonly used sedation medications are rare. Respiratory compromise is the most likely adverse complication during pediatric sedation, although the nurse must be prepared to react to any emergency situation.
The Role of the Nurse in Research
The Role of the Nurse in Contrast Echocardiography Microsphere contrast agents can help delineate cardiac structures, enable the semiquantification of myocardial perfusion, and enhance Doppler signals. Agitated saline contrast injections are used during echocardiographic examinations to enhance Doppler signals and to determine the presence and severity of intracardiac and pulmonary shunts. During the past decade, the emergence of microsphere contrast agents and sonicated saline in the practice of echocardiography has increased the need for registered nurses during echocardiography. Categorized as a medication, contrast agents must be administered intravenously according to an established protocol under the direct or standing order of a supervising physician. The nurse discusses the risks and benefits of using intravenous contrast, obtains consent from the patient to place an intravenous line if not already present, administers the contrast agent or sonicated saline, assesses for adverse reactions, and documents the procedure according to institutional policy. By involving a nurse in this process, the physician and sonographer can focus on the examination. The nurse’s role also meets all legal and JCAHO
It has been our experience that echocardiography laboratory research requires the participation of nurses in the same manner as in the clinical echocardiography practice. In addition, protocol testing of new pharmacologic stress medications and the application of new echocardiographic devices have required specialized nursing care of patient participants. Aside from the technical and holistic support previously discussed, nurses have expanded their role to become study coordinators. Nursing training and experience enable nurses to oversee many administrative and patient assessment tasks required for the completion of protocols as outlined by federal guidelines for patient-oriented research. Specialty Training of Nurses in Echocardiography Although establishing intravenous access, administering medication, and hemodynamic monitoring are common nursing activities, certain idiosyncrasies of laboratory protocols require a period of orientation. In addition, although nurses with cardiovascular experience would be best suited for a position in an echocardiography laboratory, interpretation of 12-lead ECGs and monitoring stress and TEE examinations also requires specialized training. Mentorship of new nursing staff by experienced nursing staff provides an environment where laboratory protocols can be most effectively presented. Written materials help establish orientation objectives and projected completion times. Traditionally, orientation is accomplished by observing nursing functions, then demonstrating proficiency under direct supervision. Orientation periods vary depending on the experience of new staff members. The Role of the Nurse in Continuing Education Our echocardiographic and hemodynamic laboratory has recognized the value of continuing education to maintain state-of-the-art standards of practice. Continuing medical education programs cover pharmacologic advances, advanced stress echocardiographic testing, and ECG analysis. In addition, issues regarding nursing practice within the laboratory are communicated to the nursing staff during monthly staff meetings. Our nurses have joined the faculty of the Diagnostic Medical Sonography Program in the Mayo School of Health Sciences, Mayo Clinic College of Medicine, Rochester, Minn. Courses concerning cardiopulmonary anatomy, cardiopulmonary pharmacology, and
776 Gilman et al
Figure 1 Number of common echocardiographic procedures involving nursing support performed at Mayo Clinic, Rochester, Minn, between 1999 and 2003.
basic ECG analysis are part of the standard curriculum. Preparation of educational materials from a nursing perspective has enriched the sonography student’s preparation for a future collaborative role with nursing staff in echocardiography and developing skills to enhance patient interaction and care. In addition, nursing staff participates in annual educational sonography conferences, describing the various nursing roles that are integral parts of our echocardiography practice. The Impact of Nursing Participation on the Practice of Clinical Echocardiography In this article, we have described the various roles of the professional nurse in the practice of clinical echocardiography. To illustrate the effect that nursing participation has had on the evolution of clinical echocardiography and the various echocardiographic subspecialties, we analyzed our past patient procedures (Figures 1 and 2). Our steady growth in nurse-supported procedures represents the increasing demand for subspecialty echocardiography procedures. We are expanding our nursing staff to meet the current needs and prepare for the anticipated growth in these subspecialty procedures. Future Directions of Nursing in Echocardiography With the recent recognition of nurses by the American Society of Echocardiography (ASE), the nursing profession now has an official affiliation with an international echocardiography organization. Our institution has fully supported the participation of our nurses in the ASE. Future involvement in the planning and implementation of nursing activities in the field of echocardiography is promising. We
Journal of the American Society of Echocardiography July 2005
Figure 2 Total number of selected echocardiographic studies performed at Mayo Clinic, Rochester, Minn, involving nursing support between 1999 and 2003. TEE, Transesophageal echocardiography.
anticipate future publications describing the activities of nurses in echocardiography in both the cardiology literature and in nursing journals. The practice of echocardiography offers nurses a career choice that both aids the patient and rewards the practitioner.
REFERENCES 1. Cheitlin MD, Alpert JS, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, et al, for the Committee on Clinical Application of Echocardiography. ACC/AHA guidelines for the clinical application of echocardiography: a report of the American College of Cardiology/American Heart Association task force on practice guidelines; developed in collaboration with the American Society of Echocardiography. Circulation 1997;95:1686-744. 2. Freeman WK, Seward JB, Khandheria BK, Tajik AJ. Transesophageal echocardiography. Boston: Little, Brown and Co; 1994. p. 1. 3. Chee TS, Quek SS, Ding ZP, Chua SM. Clinical utility, safety, acceptability and complications of transesophageal echocardiography (TEE) in 901 patients. Singapore Med J 1995;36: 479-83. 4. Mays JM, Nichols BA, Rubish RC, O’Meara KW, Koverman PA. Transesophageal echocardiography: a sonographer’s perspective. J Am Soc Echocardiogr 1991;4:513-8. 5. Autenrieth G, Angermann C, Goss F, Bolte HD. Stress echocardiography in patients with coronary heart disease [in German]. Verh Dtsch Ges Inn Med 1977;83:231-6. 6. Feigenbaum H. Future applications for the evaluation of ventricular function using echocardiography. Am J Cardiol 1982;49:1330-6. 7. Simard M, Heng MK, Udhoji VN, Weber L. Exercise twodimensional echocardiography: a technique for improving ultrasound images during exercise stress. Clin Cardiol 1983; 6:318-26. 8. Picano E, Lattanzi F. Dipyridamole echocardiography: a new diagnostic window on coronary artery disease. Circulation 1991;83:III19-26.
Journal of the American Society of Echocardiography Volume 31 Number 7
9. Sawada SG, Segar DS, Ryan T, Brown SE, Dohan AM, Williams R, et al. Echocardiographic detection of coronary artery disease during dobutamine infusion. Circulation 1991;83:1605-14. 10. Bremer ML, Monahan KH, Stussy VL, Miller FA Jr, Seward JB, Pellikka PA. Safety of dobutamine stress echocardiography supervised by registered nurse sonographers. J Am Soc Echocardiogr 1998;11:601-5.
Gilman et al 777
11. Quinones MA, Douglas PS, Foster E, Gorcsan J III, Lewis JF, Pearlman AS, et al, for the American Society of Internal Medicine Task Force on Clinical Competence. ACC/AHA clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians. J Am Coll Cardiol 2003;41:687-708.
The Role of the Nurse in Clinical Echocardiography Gregory Gilman, RN, RDCS, FASE, Janice M. Nelson, AN, RN, Amy T. Murphy, BSN, RN, Glenda M. Kidd, RN, Vicky L. Stussy, RN, and Kyle W. Klarich, MD, FACC, Rochester, Minnesota
Echocardiography plays an important role in the practice of clinical cardiology. As echocardiographic practice has evolved, the addition of nursing personnel to the echocardiography team has enhanced the assessment and diagnosis of cardiovascular disease. Specifically, nurses monitor patients during
Echocardiography is an important component in
the assessment and diagnosis of cardiovascular disease.1 The addition of nursing personnel to the echocardiography team has advanced the use of echocardiography. We review the contribution of registered nurses to the practice of clinical echocardiography. The Evolution of the Nurse’s Role in Echocardiography Nursing encompasses autonomous and collaborative care of patients of all ages and in all settings, whether sick or well, in families, groups, and communities. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy, management of health systems, and education are also key nursing roles. At Mayo Clinic in Rochester, Minn, nurses have been members of the echocardiographic and hemodynamic laboratory team for nearly 2 decades. In our experience, the migration of nurses from the bedside to the clinical echocardiography setting has been the result of numerous forces. During the late 1980s, some members of the nursing staff trained as cardiac sonographers and also monitored patients undergoing transesophageal echocardiography (TEE) under the supervision of echocardiologists. In the early 1990s, nurses with expertise in critical care nursing and exercise testing found a demand for their skills not only in performing stress imaging but also in monitoring stress tests in this
From the Division of Cardiovascular Diseases, Mayo Clinic. Correspondence: Kyle W. Klarich, MD, FACC, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. 0894-7317/$30.00 Copyright 2005 by the American Society of Echocardiography. doi:10.1016/j.echo.2005.03.030
transesophageal and stress examinations and establish intravenous access for sonicated saline, microsphere contrast, and medication administration. We describe the involvement of nurses in the practice of clinical echocardiography. (J Am Soc Echocardiogr 2005;31:773-7.)
subspecialty of echocardiography. This period predated establishment of the echocardiography program in the Mayo School of Health Sciences, Mayo Clinic College of Medicine, Rochester, Minn. As the needs for patient monitoring, establishing intravenous access, and administering medications became integral parts of many echocardiographic procedures, nurses trained as cardiac sonographers were recognized as a valuable resource in the echocardiographic laboratory. Soon demand exceeded availability of nurse sonographers in the daily operations of the laboratory. Simultaneously, increasing demands on physicians to perform patient monitoring and medication administration began to impede the growth of the echocardiographic practice. To accommodate the demands of the practice, in 1994 the leadership of our echocardiographic and hemodynamic laboratory decided to add registered nurse positions to the echocardiography laboratory staff. Prerequisites to employment included a background in intensive care nursing and advanced cardiac life support certification. Nurses were trained to monitor patients during TEE and, later, stress echocardiography. By freeing the physicians’ time and enabling a greater number of patient examinations per physician, the laboratory provided greater access for the growing population of patients in need of diagnostic testing. Our nurses serve two distinct patient groups: hospital inpatients and clinic outpatients. Although most patients are in stable condition while in the laboratory, nurses with a background in critical care nursing are ideally suited to meet the needs of and anticipate the potential problems that face these patients at high risk. The Role of the Nurse in TEE The clinical application of 2-dimensional TEE began in the late 1980s.2 TEE is performed when a detailed structural and functional evaluation of the heart is
773
774 Gilman et al
indicated, and it has become important in the evaluation of patients with cardiovascular diseases.3 Common indications for TEE are to rule out native or prosthetic valvular endocarditis, assess the degree and cause of valvular regurgitation, determine a potential source of embolus, and rule out cardiopulmonary shunting. Increasingly, we use TEE to assess patients before cardioversion and radiofrequency ablation for atrial fibrillation and to monitor and guide percutaneous procedures such as deployment of atrial septal closure devices. The history of the nurse’s role in TEE is not well documented. Originally described as the “role of the sonographer assistant,”4 a safe and legally compliant state-of-the-art TEE program requires administration of intravenous conscious sedation and periprocedural patient monitoring, with complete documentation of all patient care activities. Patient education promotes a safe, comfortable environment and diminishes patient anxiety. The professional registered nurse is best suited to complete these vital aspects of a successful TEE program. TEE may be done in an outpatient or inpatient laboratory setting, at the patient’s bedside, or in the cardiac catheterization suite. The nurse reviews the order for the TEE from the referring physician to confirm the correct patient identification on the order, determines contraindications of performing the TEE, and makes the initial assessment of the appropriateness of TEE for the patient’s specific condition. This review requires a working understanding of the strengths and limitations of TEE and a detailed look into the patient’s history, paying special attention to cardiac history, gastrointestinal tract abnormalities or procedures, prior complications with sedation, medication allergies, and the patient’s current medication regimen. Any concerns regarding the examination are presented to the physician performing the examination. The nurse prepares esophageal intubation supplies and confirms the availability of emergency airway equipment. During the examination, the nurse assists the physician by administering medications and providing direct patient care. Emphasis is placed on managing the patient’s airway and proper positioning of the patient to minimize risk of aspiration. Moderate sedation allows the patient to maintain and protect his or her own airway and to respond to commands given verbally by the nurse or physician. Hemodynamic and neurologic monitoring continues through the recovery period until the patient has returned to presedation status. The nurse documents the procedure activities, medication administration, and patient assessment, adhering to institutional and Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) guidelines. Our laboratory now uses a 24-hour on-call
Journal of the American Society of Echocardiography July 2005
nurse to accommodate conscious sedation for emergency inpatient TEE. The Role of the Nurse in Stress Echocardiography Articles referring to the diagnostic potential of exercise stress echocardiography date back to the late 1970s and early 1980s.5-7 Esophageal atrial pacing and pharmacologic stress echocardiography were developed for patients in need of functional assessment for coronary artery disease but unable to exercise. The safety and diagnostic value of pharmacologic stress echocardiography was initially explored in the early 1990s.8,9 Historically, the nurse’s role in administering these diagnostic tests was not well documented until 1998, when Bremer et al10 described the role of the nurse in monitoring dobutamine stress echocardiographic examinations. They demonstrated the safety of implementing a stress protocol during which nurses monitored dobutamine stress echocardiography and a physician was immediately available but not present in the room during the stress test and dobutamine infusion. Currently, exercise and pharmacologic stress echocardiography is important in the clinical management of coronary artery disease. In addition to the nurse, the stress echocardiography team consists of a supervising physician, an imaging sonographer, and an electrocardiography (ECG) technician. Nurses are involved in various stages of the examination, beginning with completing a detailed review of the medical history, performing a patient interview to rule out any contraindications for the examination, and confirming that the correct test will be performed on the correct patient. A registered nurse can establish intravenous access and administer medications that are required in some exercise and all pharmacologic stress examinations. The nurse tells the patient what to expect during the examination and during the recovery period. Finally, documentation of the patient’s experience, including all pertinent hemodynamic and ECG parameters, any medications administered, and the necessary patient education related to the examination, is completed by the nurse in compliance with institutional and JCAHO guidelines. The American College of Cardiology, American Heart Association, and American College of Physicians recognize stress echocardiography as an important alternative to standard exercise ECG.11 The need for nurses in the stress laboratory has increased correspondingly. Historically, the annual demand for stress echocardiography has been increasing steadily, and during the past 3 years our laboratory has experienced a markedly increased rate of referrals. We have met this need by adding nursing personnel through planned staffing increases.
Journal of the American Society of Echocardiography Volume 31 Number 7
Gilman et al 775
The Role of the Nurse in Pediatric Echocardiography
requirements related to contrast and saline administration.
Pediatric echocardiography is a subspecialty of cardiac ultrasonography. Assessment of patients between the ages of 2 and 24 months is especially challenging in the echocardiography laboratory. These patients often require sedation to minimize movement during the examination. JCAHO guidelines state that the person performing the cardiac imaging must not be the same person responsible for monitoring the patient during sedation. Therefore, a registered nurse trained in the administration of moderate sedation and certified in pediatric advanced life support is a valuable member of the pediatric echocardiography team. In addition, the nursing staff educates and reassures the patient’s parents to reduce their anxiety during their child’s examination. Sedatives may be administered to the pediatric patient either orally or nasally. Baseline and routine blood pressure measurements, continuous monitoring of consciousness, and ongoing assessment of respiratory and heart rate are required until the patient’s status has returned to baseline. At that point the patient’s care can be returned to the parents. Allergic reactions to commonly used sedation medications are rare. Respiratory compromise is the most likely adverse complication during pediatric sedation, although the nurse must be prepared to react to any emergency situation.
The Role of the Nurse in Research
The Role of the Nurse in Contrast Echocardiography Microsphere contrast agents can help delineate cardiac structures, enable the semiquantification of myocardial perfusion, and enhance Doppler signals. Agitated saline contrast injections are used during echocardiographic examinations to enhance Doppler signals and to determine the presence and severity of intracardiac and pulmonary shunts. During the past decade, the emergence of microsphere contrast agents and sonicated saline in the practice of echocardiography has increased the need for registered nurses during echocardiography. Categorized as a medication, contrast agents must be administered intravenously according to an established protocol under the direct or standing order of a supervising physician. The nurse discusses the risks and benefits of using intravenous contrast, obtains consent from the patient to place an intravenous line if not already present, administers the contrast agent or sonicated saline, assesses for adverse reactions, and documents the procedure according to institutional policy. By involving a nurse in this process, the physician and sonographer can focus on the examination. The nurse’s role also meets all legal and JCAHO
It has been our experience that echocardiography laboratory research requires the participation of nurses in the same manner as in the clinical echocardiography practice. In addition, protocol testing of new pharmacologic stress medications and the application of new echocardiographic devices have required specialized nursing care of patient participants. Aside from the technical and holistic support previously discussed, nurses have expanded their role to become study coordinators. Nursing training and experience enable nurses to oversee many administrative and patient assessment tasks required for the completion of protocols as outlined by federal guidelines for patient-oriented research. Specialty Training of Nurses in Echocardiography Although establishing intravenous access, administering medication, and hemodynamic monitoring are common nursing activities, certain idiosyncrasies of laboratory protocols require a period of orientation. In addition, although nurses with cardiovascular experience would be best suited for a position in an echocardiography laboratory, interpretation of 12-lead ECGs and monitoring stress and TEE examinations also requires specialized training. Mentorship of new nursing staff by experienced nursing staff provides an environment where laboratory protocols can be most effectively presented. Written materials help establish orientation objectives and projected completion times. Traditionally, orientation is accomplished by observing nursing functions, then demonstrating proficiency under direct supervision. Orientation periods vary depending on the experience of new staff members. The Role of the Nurse in Continuing Education Our echocardiographic and hemodynamic laboratory has recognized the value of continuing education to maintain state-of-the-art standards of practice. Continuing medical education programs cover pharmacologic advances, advanced stress echocardiographic testing, and ECG analysis. In addition, issues regarding nursing practice within the laboratory are communicated to the nursing staff during monthly staff meetings. Our nurses have joined the faculty of the Diagnostic Medical Sonography Program in the Mayo School of Health Sciences, Mayo Clinic College of Medicine, Rochester, Minn. Courses concerning cardiopulmonary anatomy, cardiopulmonary pharmacology, and
776 Gilman et al
Figure 1 Number of common echocardiographic procedures involving nursing support performed at Mayo Clinic, Rochester, Minn, between 1999 and 2003.
basic ECG analysis are part of the standard curriculum. Preparation of educational materials from a nursing perspective has enriched the sonography student’s preparation for a future collaborative role with nursing staff in echocardiography and developing skills to enhance patient interaction and care. In addition, nursing staff participates in annual educational sonography conferences, describing the various nursing roles that are integral parts of our echocardiography practice. The Impact of Nursing Participation on the Practice of Clinical Echocardiography In this article, we have described the various roles of the professional nurse in the practice of clinical echocardiography. To illustrate the effect that nursing participation has had on the evolution of clinical echocardiography and the various echocardiographic subspecialties, we analyzed our past patient procedures (Figures 1 and 2). Our steady growth in nurse-supported procedures represents the increasing demand for subspecialty echocardiography procedures. We are expanding our nursing staff to meet the current needs and prepare for the anticipated growth in these subspecialty procedures. Future Directions of Nursing in Echocardiography With the recent recognition of nurses by the American Society of Echocardiography (ASE), the nursing profession now has an official affiliation with an international echocardiography organization. Our institution has fully supported the participation of our nurses in the ASE. Future involvement in the planning and implementation of nursing activities in the field of echocardiography is promising. We
Journal of the American Society of Echocardiography July 2005
Figure 2 Total number of selected echocardiographic studies performed at Mayo Clinic, Rochester, Minn, involving nursing support between 1999 and 2003. TEE, Transesophageal echocardiography.
anticipate future publications describing the activities of nurses in echocardiography in both the cardiology literature and in nursing journals. The practice of echocardiography offers nurses a career choice that both aids the patient and rewards the practitioner.
REFERENCES 1. Cheitlin MD, Alpert JS, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, et al, for the Committee on Clinical Application of Echocardiography. ACC/AHA guidelines for the clinical application of echocardiography: a report of the American College of Cardiology/American Heart Association task force on practice guidelines; developed in collaboration with the American Society of Echocardiography. Circulation 1997;95:1686-744. 2. Freeman WK, Seward JB, Khandheria BK, Tajik AJ. Transesophageal echocardiography. Boston: Little, Brown and Co; 1994. p. 1. 3. Chee TS, Quek SS, Ding ZP, Chua SM. Clinical utility, safety, acceptability and complications of transesophageal echocardiography (TEE) in 901 patients. Singapore Med J 1995;36: 479-83. 4. Mays JM, Nichols BA, Rubish RC, O’Meara KW, Koverman PA. Transesophageal echocardiography: a sonographer’s perspective. J Am Soc Echocardiogr 1991;4:513-8. 5. Autenrieth G, Angermann C, Goss F, Bolte HD. Stress echocardiography in patients with coronary heart disease [in German]. Verh Dtsch Ges Inn Med 1977;83:231-6. 6. Feigenbaum H. Future applications for the evaluation of ventricular function using echocardiography. Am J Cardiol 1982;49:1330-6. 7. Simard M, Heng MK, Udhoji VN, Weber L. Exercise twodimensional echocardiography: a technique for improving ultrasound images during exercise stress. Clin Cardiol 1983; 6:318-26. 8. Picano E, Lattanzi F. Dipyridamole echocardiography: a new diagnostic window on coronary artery disease. Circulation 1991;83:III19-26.
Journal of the American Society of Echocardiography Volume 31 Number 7
9. Sawada SG, Segar DS, Ryan T, Brown SE, Dohan AM, Williams R, et al. Echocardiographic detection of coronary artery disease during dobutamine infusion. Circulation 1991;83:1605-14. 10. Bremer ML, Monahan KH, Stussy VL, Miller FA Jr, Seward JB, Pellikka PA. Safety of dobutamine stress echocardiography supervised by registered nurse sonographers. J Am Soc Echocardiogr 1998;11:601-5.
Gilman et al 777
11. Quinones MA, Douglas PS, Foster E, Gorcsan J III, Lewis JF, Pearlman AS, et al, for the American Society of Internal Medicine Task Force on Clinical Competence. ACC/AHA clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians. J Am Coll Cardiol 2003;41:687-708.