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| Neil MacLennan, MD, anesthesiologist at Aukland City Hospital in New Zealand, is placing an infraclavicular nerve block using a hand-carried ultrasound system from SonoSite Inc, Bothell, Wash. |
Using smaller and advanced technology, the newest portable ultrasound devices require little in the way of compromise while offering benefits that have physicians praising their value—in terms of both care and economy. Indeed, portable ultrasound has become a complementary standard to fixed systems in many health care institutions, but the newer technology has not superseded its larger counterpart.
“With hand-carried ultrasound, the goal is not to replace traditional systems,” says Tom Dugan, senior vice president of global marketing and US sales for SonoSite Inc., Bothell, Wash. “It is to enable physicians to perform procedures using ultrasound more efficiently and effectively, bringing the system to the patient rather than the patient to the system.”
Portable systems vary in their portability, from cart-based systems to hand-carried units. Naturally, smaller devices are easier to maneuver around a busy health care institution than are larger, more cumbersome units, even those that are cart-based.
Thomas Jefferson University Hospital and Medical School (TJU), Philadelphia, is a large teaching hospital with roughly 20 scanning rooms and 700 beds. According to Barry Goldberg, MD, director of the division of ultrasound in the Department of Radiology at TJU, “We perform a number of portable exams, and it’s much easier to move a smaller machine around than a bigger one, which is true whether you are a physician or a sonographer,” he explains.
Even though they can be awkward, carts not only help move larger machines, but also help carry the accessories that could be needed for an examination and to provide working space in the room for smaller devices. “You sometimes need three or four types of transducers, and then, even the smallest machine becomes not so easy to carry,” Goldberg says.
However, sometimes even a cart can be too much to manage, whether between offices or within the confines of a small, crowded room. In these cases, hand-carried ultrasound units provide greater maneuverability. Between the five hospitals where he sees patients, Greggory DeVore, MD, a maternal-fetal specialist at the Fetal Diagnostic Center, Pasadena, Calif, totes the Voluson i from GE Healthcare, Waukesha, Wis, which weighs 11 pounds. “All of the hospitals have different machines available with varying levels of image quality,” DeVore says. “By bringing my machine with me, I don’t have to compromise quality.”
Does Portability Entail Sacrifice?
DeVore believes that the newer portable ultrasound devices are nearly equivalent to fixed systems. “In the past, you paid the price for portability,” he says. “But new machines have helped to close the gap between portable and fixed systems.”
DeVore says that the biggest limitation to the equipment now lies with the transducers rather than the device. “There are higher-resolution transducers on fixed systems that are not yet available for portable ones. If we look at equivalent transducers, there is no difference between a portable system and a box system,” he says.
For the most part, physicians agree that portable ultrasound is extremely functional. “The higher-end machines often have technology that has not yet migrated to the smaller devices, but that is not to say that it [won’t do so] in the future,” Goldberg says. “Currently, it depends on the application. But for routine needs, the smaller portables are satisfactory.”
Stamatia Destounis, MD, clinical associate professor at the University of Rochester Medical Center, and attending physician at the Elizabeth Wende Breast Clinic, Rochester, NY, has found no limitations to her use of ultrasound. The facility uses equipment from a variety of vendors to conduct breast examinations and interventional procedures. “We don’t feel we’ve sacrificed anything,” Destounis says. “For superficial organs, such as the breast, visibility is good.”
Does Portability Cost More?
“The cost of portable systems varies from between $25,000 and $60,000, and you get the quality you pay for,” DeVore says. Low-end cart systems can be comparable in price, although, according to Dugan, high-end fixed systems can run in the low $200,000s.
Even if the systems are comparable in price, portability can save money in the long run. “A physician might work out of five different offices. If each office requires its own ultrasound system, that’s a large capital investment that sits idle while the physician is elsewhere,” DeVore notes. One portable ultrasound unit can serve all offices, reducing capital investment and increasing cost efficiency.
This same cost efficiency is seen in hospitals and clinics. “We currently have five radiologists that work at the clinic, and we are expecting to add one more,” Destounis explains. “But we don’t have a sixth permanent ultrasound room, so the new radiologist might act as a floater with a mobile unit, which will allow us to accommodate more patients in the building.”
Cost efficiency also is seen in the overall cost of ownership. More expensive systems tend to have more expensive service contracts, particularly if fees are based on the system price. Larger systems, even cart-based, also can result in ergonomic injury expenses, which have negative repercussions on the department’s bottom line. “As you move systems around, you get repetitive stress and work-related injuries, which you don’t see with a handheld system,” Devore says.
Is Smaller Faster?
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| “We don’t feel we’ve sacrificed anything… For superficial organs, such as the breast, visibility is good.” —Stamatia Destounis, MD, Elizabeth Wende Breast Clinic |
Greater maneuverability also can translate to faster throughput: Carts require more time to move through hallways and get on elevators as well as set up in the room. “It takes time to wheel a large machine in, unhook others to plug it in, create room near the patient, and conduct the examination in comfort. With a hand-carried system, it’s battery-operated. You can set it bedside immediately and probably decrease the examination time by 80%,” DeVore says. “A portable system that you pick up and take to the bedside provides an easy way to bring the machine to the patient.”
In the Elizabeth Wende Breast Clinic, portable ultrasound has made the examinations more accessible. “If you have a technologist who can perform the exam and a radiologist who can interpret it, portable ultrasound allows a faster, appropriate diagnosis,” Destounis says.
Ultrasound also can have a direct impact on care delivery, particularly with small devices designed with a focused use, which provides guidance for vascular access. “Small machines routinely are used by nurses, interventionalists, and even anesthesiologists to get into vessels to put lines and catheters in. It’s certainly much quicker and safer,” Goldberg says. The single purpose means one transducer, so portability is maximized.
“We’re seeing the same [use] in anesthesia with nerve blocks—ultrasound assists with finding the nerve. In orthopedics, it can help locate the joint,” says Goldberg, who notes that these are specialized areas in which ultrasound has not traditionally been a part of routine care. “There is no question that the use of ultrasound has increased in single-focus areas,” he adds.
Economic Implications
Portable Ultrasound Sales Figures |
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2003…. $160 million |
In addition to providing radiology with a highly flexible tool, portable ultrasound has definitely fueled the movement of the modality out of the department and into the hands of other clinicians, and the outlook is for further penetration.
The American Institute of Ultrasound in Medicine (AIUM), Laurel, Md, reports that worldwide sales were $160 million in 2003 and are expected to grow to $1 billion by 2010.1 In its 2004 conference report, the AIUM suggests that the miniaturization of ultrasound was inevitable and that the “concept of an ‘ultrasound stethoscope’ is rapidly moving from theory to reality.”1
According to SonoSite’s Dugan, “It’s still very early in the curve of these expanded applications. As a physician, you now have a way to see things you normally wouldn’t be able to see. You can look into the body without using radiation to get a quick sense of what you’re doing, how you’re doing, or how the patient is. In the hospital, portable ultrasound is used for everything—nerve blocks, echo exams, breast biopsies. There is still a tremendous number of ways where its use can grow.”
Procedures Commonly Performed with Portable Ultrasound |
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Looking at the focused abdominal sonography for trauma (FAST) examination as an example, Dugan notes, “FAST is used to determine an ER patient’s status and treatment course. Despite the recommendation for its use, it’s still not fully utilized,” Dugan says, blaming a lack of training rather than ability.
In the hospital setting, the use of portable ultrasound at the point of care has proven economic benefit in its ability to streamline and improve care as well as potentially reduce length of stay.
For instance, the cost savings seen as a result of placing a central line using ultrasound guidance are often indirect but impact both care and the bottom line. “With ultrasound guidance, you need to needlestick the patient only once. You don’t need to bring in a portable x-ray machine afterward to verify that the line is in the right place,” Dugan explains. Fewer needlesticks could reduce the risk of patient infection, preventing a hospital stay from being extended.
Ultrasound also can be used to direct a more accurate course of treatment, for instance, when used to image abnormal fluid concentrations at an injury site. And it can result in faster care, such as the ability to image and set broken bones at bedside.
Practice Implications
But what are the implications for radiologists—who already have seen much of their ultrasound volume shift to other clinicians—for the movement of ultrasound to the point of care?
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| “In fact, over time, as the modality gets out into the community to smaller practices—internists, generalists, and so on—there will be an increase in referrals to more sophisticated centers when those who are just doing it as a preliminary examination see things that they don’t quite understand.” —Barry Goldberg, MD Thomas Jefferson University Hospital and Medical School |
According to Goldberg, the implications are entirely positive. Ultrasound should be expected to remain a tool of radiology since it is part of the total imaging evaluation of patients. “In fact, over time, as the modality gets out into the community to smaller practices—internists, generalists, and so on—there will be an increase in referrals to more sophisticated centers when those who are just doing it as a preliminary examination see things that they don’t quite understand,” he believes. “The complexity of ultrasound procedures done for diagnosis and treatment will go up as the large group of nonradiologists perform ultrasound and obtain information to confirm or for which they don’t really have the knowledge to decide what to do next.”
Training is key to maintaining the safety of portable examinations as their applications expand outside of radiology. “As the modality evolves, the first people performing the exams may not be as adequately trained as needed, but courses now and efforts by the various societies are making sure the members are properly trained,” Goldberg says.
The AIUM has been collaborating with industry organizations to develop evidence-based guidelines as well as an accreditation program for the safe use of portable ultrasound, intended primarily to benefit older physicians. New physicians are often exposed to the technology during medical school and/or residency, where ultrasound is beginning to be as common as the stethoscope.
Renee DiIulio is a contributing writer for Axis Imaging News.
Reference
- Greenbaum LD, Benson CB, Nelson LH, et al. Proceedings of the compact ultrasound conference by the American Institute of Ultrasound in Medicine. J Ultrasound Med. 2004;23:1249–1254. Available at: http://www.jultrasoundmed.org/cgi/content/citation/23/10/1249. Accessed June 1, 2006.
