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The
mission of vascular laboratory
accreditation is built upon assuring high quality patient care
through evaluation and assessment of the entire process which
goes into noninvasive vascular patient testing. There are three
key components to this process: (1) testing should be performed
by qualified, trained technologists / sonographers following
a consistent protocol; (2) interpretation should be done by
qualified, trained physicians using consistent diagnostic criteria;
and (3) findings based on the test results and these criteria
should be regularly validated by comparison with another accepted
technology. If any one or more of these links in the chain are
weak, the entire process is at risk for leading to inappropriate
patient management. The best technologists working with the
most dedicated physicians cannot by themselves completely assure
that patient care decisions based on their findings will be
the appropriate ones. Quality assurance programs are designed
to address item (3) above - the ongoing validation of testing
procedures and diagnostic criteria.
The
importance of quality assurance was recently underscored by
a presentation at the annual meeting of the Society For Vascular
Surgery in Chicago in early June. We (like most busy vascular
laboratories around the country) are often referred patients
for surgical evaluation for carotid endarterectomy based upon
the results of a carotid duplex ultrasound examination done
at another facility. We reviewed 174 asymptomatic patients referred
over a 2-year period for carotid surgery because of duplex ultrasound
findings in non-accredited vascular laboratories, with evaluation
of changes made in clinical management after the examinations
were repeated in our accredited laboratory. Discordant findings
of no overall clinical significance were found in 54 arteries
(16%). Clinically significant differences in findings were noted
in 123 arteries (35%) in 107 patients (61%). The vast majority
of these errors were the result of incorrect or inappropriate
interpretation of the test results (104 arteries in 94 patients,
88% of the total errors) which in most cases ascribed a severe
or critical stenosis where none existed. In 88 patients (51%),
an unnecessary carotid endarterectomy was avoided. The common
theme exhibited by all the outside laboratories was the lack
of any quality assurance program which would have identified
the reasons for these errors and provided the laboratories the
data necessary to adjust their criteria; without this ongoing
feedback and data the errors simply perpetuate themselves and
may lead to a surgical procedure when none is indicated.
Yes,
a quality assurance program requires some additional time and
energy to implement in a typical vascular laboratory environment
which already seems stretched to the limit. Yes, it sometimes
can be difficult to acquire the correlating data necessary for
a quality assurance program, particularly in those laboratories
which are not affiliated with a hospital and do not have direct
access to other imaging studies. But consistent with the goal
of high quality patient care, quality assurance is an essential
part of the process so that, yes, a quality assurance program
can reinforce existing practices or provide a mechanism for
the early detection of a need for change, and most important,
lead to the secure knowledge that vascular laboratory findings
will help implement the correct decisions regarding patient
care and management.
Phillip
J. Bendick, PhD, RVT,serves as a consultant to the ICAVL
Board Of Directors and is employed by the Peripheral Vascular
Diagnostic Center, William Beaumont Hospital, Royal Oak, Michigan.
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