Joint guidance from the British Society of Echocardiography (BSE) and the British Congenital Cardiac Association (BCCA)
Where an echocardiographer normally working with adult patients is requested to perform an emergency study for a paediatric patient they should be supported by the following recommendations:
General principles
- For all paediatric patients the primary assessment and treatment pathway should be clear and regional guidance is usually available from the relevant congenital heart disease (CHD) network or local level 1 or 2 cardiology unit. It is expected that this primary care pathway will be followed for the vast majority of patients.
- This guidance relates to urgent / emergency situations where local echocardiography typically performed by a Paediatrician with Expertise in Cardiology (PEC) is not available in an appropriate timeframe and echocardiography is key to guiding clinical management.
- The local paediatric team and on call paediatric cardiologist should discuss whether it is appropriate to transfer the patient to the cardiology centre for complete evaluation. With patients around the age of transition (16-18 years old), depending on the clinical scenario, it may also be appropriate to discuss the patient with the local adult cardiology team and/or respective adult CHD team.
Patient age
This guidance principally applies to patients aged eight and above. Assessment of neonatal patients is not included in this guidance.
Emergency studies in patients aged between infancy and eight years of age may be undertaken. This should only be in circumstances where the image acquirer feels adequately skilled and is supported by the responsible clinical team.
This guidance is solely aimed at urgent and/or emergency situations and does not mandate that any echocardiographer should perform imaging in any patient not within their usual practice age-range. In non-emergency situations, an alternative pathway to access imaging needs to be sought.
When the study may be requested
Following discussion of the patient with the regional cardiology team (if this is possible in view of the clinical urgency), the study should be requested by an attending consultant paediatrician who has seen the patient and made the decision that emergency echocardiography is necessary. The guiding principle is that the clinician ultimately responsible for the patient’s care must be involved in the request and clinical discussion with the paediatric cardiology team will inform the questions and data required from the targeted scan. If specific images are required, the responsible clinician should request them in direct conversation with the image acquirer who will perform the scan.
The study should be requested to answer a specific urgent clinical question and may often relate to a functional assessment and/or a targeted scan (for example, to look for a pericardial effusion). Adult practitioners should not be expected to perform a sequential comprehensive dataset or assess anatomy in congenital heart disease patients. Children who are stable in the outpatient or ward setting should be reviewed in the cardiology clinic as is normal practice.
Image acquisition
Arrangements should be clear for how the images will be reviewed by the responsible clinician / cardiologist involved in discussion of the case. The acquired images should be adequate to answer the clinical question and guide immediate management. In many cases this will be concurrent with a Level I adult BSE echocardiography dataset1. In some cases, further specific images may be required and this should be guided by the responsible clinician in discussion with the echocardiographer.
Reporting
The study should be acquired, uploaded, and initially reported by the performing echocardiographer according to local standard operating procedure.
Imaging should then be transferred according to CHD network guidance or as locally available to the regional paediatric cardiologist involved in primary discussion around clinical care. They will further discuss findings and plan management with the clinician ultimately responsible for the patient’s care. Where there is uncertainty or further evaluation is required, repeated assessment by a paediatric echocardiographer or evaluation in clinic will be planned.
The report should contain a clear documentation that the assessment as been made in an urgent/emergency situation by an echocardiographer not accredited in paediatric/congenital echocardiography. Skills of the echocardiographer may be noted: for example, 'Accredited with the BSE in adult transthoracic echocardiography'.
References
- Hindocha R, Garry D, Short N, Ingram TE, Steeds RP, Colebourn CL, Pearce K, Sharma V. A minimum dataset for a Level 1 echocardiogram: a guideline protocol from the British Society of Echocardiography. Echo Res Pract. 2020 Jun;7(2):G51-G58. doi: 10.1530/ERP-19-0060. Epub 2020 Jun 1. PMID: 36472200; PMCID: PMC7354713.
Claire Colebourn, Daniel Augustine, Jude Skipper, Rakhee Hindocha, Caroline Jones and Andreas Hoschtitzky December 2022