NCSS Practice Policies and Procedures for Use of Diagnostic Ultrasound

Use of the Ultrasound Machine at NCSS is restricted to registered Medical practitioners with at least FRACS qualification and attendance at ‘Ultrasound for Surgeons’ course. Assistance with supporting procedures (patient positioning, entering data, infection control procedures etc  may also  be provided by the practice nurse or the practice enrolled nurse, both of whom are required to be registered with the Nursing and Midwifery Board and have been given adequate on the job training.

Evidence must be provided of above qualifications and a register is kept of relevant expiry dates and registration numbers. (see appendix B)

NCSS is not a diagnostic imaging practice, it is a surgical practice which provides the opportunity for  ultrasound examination where deemed appropriate by the surgeon. The integration of ultrasound into the surgeon’s practice provides improved patient service and is a valuable addition to the surgeon/clinician’s diagnostic and follow-up armamentarium.  As such our only equipment is one Sonosite M-Turbo ultrasound machine. 

All equipment in the practice is to be serviced and maintained according to the manufacturer’s specifications.

In the specific case of the current machine, there is no recommended maintenance schedule, as per information supplied by Sonosite.

As NCSS is not a Diagnostic Imaging Practice and we do not have any equipment which produces radiation we do not require a radiation management plan.

NCSS is committed to maintaining the highest levels of safety for our staff and patients by complying with recognised infection control standards and precautions.  As such NCSS has a whole practice infection control policy (click on this link to see the Infection ControlPolicy ../content/default.aspx?cid=705&fid=699 ).  In adition, with particular relevance to use of the ultrasound, the following principles must always be applied:

• patients are to be examined on examination couch which is covered by clean paper designed for the purpose.
• after each patient- ultrasound event the transducer is to be cleaned thoroughly with alcohol based sterilising solution.

Diagnostic imaging procedures are only undertaken at NCSS where there is an identified clinical need and where the practitioner interpreting the image is permitted to self-determine the service for which a Medicare benefit is payable under the act.

a decision to offer ‘in rooms’ diagnostic ultrasound to patients may be made by the treating surgeon when it is felt that the information obtained will benefit the overall management of the patient.

A full history must be taken prior to the decision to offer ultrasound examination.

Patients who are offered diagnostic ultrasound will be required to sign the NCSS Diagnostic Ultrasound Consent form (Appendix A)

Ultrasound images must be documented and recorded according to the following guidelines.

Record

• patient details
• site including- side examined ( if applicable) and for breasts , clockface position and distance from nipple
• plane scan
• size of lesion
• all appropriate images

Images are to be captured and stored in the patient’s electronic medical record.  These are stored and backed up daily by the practice server. An additional copy is to be made and stored on USB.

As NCSS is not a diagnostic imaging practice we do not advertise the availability of ultrasound at the practice. It is up to the treating surgeon to determine the need for ultrasound examination. Once this need is determined the surgeon explains why it is needed and the patient is provided with the practice Ultrasound information and consent sheet (Appendix A).

NCSS is committed to ensuring that all patients are correctly identified when attending our practice.

Any ultrasound images that are produced must show:

• patient’s full name
• date of birth
• sex
• specific location

All mismatching events are considered serious and must immediately be reported to the practice manager. The practice manager will investigate where the break down occurred and is responsible for designing and implementing corrective actions, recording the mismatching event and the actions taken.

NCSS does not administer medications for any ultrasound procedures performed at the practice.

As NCSS is not a diagnostic imaging practice our protocols relate solely to the use of the Sonosite ultrasound machine.   All ultrasounds performed within the practice are self-determined. The reason for and the findings of the examination are to be included in a report and sent to the referring practitioner.

NCSS is committed to ensuring that management of feedback and complaints is consistent with the principles of open disclosure and fairness, accessibility, responsiveness, efficiency and integration.

To do this we use two methods for receiving and recording feedback and complaints:

• a customer feedback/complaints form (Appendix F), and
• a complaints handling register (Appendix G)

If a complaint is received by the practice, the complainant must be advised of this policy and procedure and expected resolution times. If the complaint is about a matter which can be resolved immediately without reference to others, then the staff member is expected to take the necessary action. Staff members are to seek clarification from the Practice Manager where required.

Corrective action will take place as soon as possible. Staff members must ensure the complaint or feedback is recorded on the feedback/complaints form and included on the complaints handling register.

The Practice Manager carries the ultimate responsibly for NCSS’ Safety and Quality Manual and is responsible for reviewing this document, in consultation with the other co-authors, annually. Staff may submit improvement modification requests at any time, however only the practice manager can make changes to these policies.

The Practice Manager ensures all staff are informed and educated regarding any changes to this document.

Ultrasound uses soundwaves to produce images. The soundwaves are transmitted into your body from a small handpiece called a probe. Some of these waves are reflected and are processed by the ultrasound machine to form pictures. These pictures are shown on a tv screen and are recorded.

Ultrasound has been around for more than 60 yrs and studies have shown that it is a safe technique with no harmful side effects

NCSS Consent for Diagnostic Ultrasound.

I,                                                             , DOB

Consent to the performing of  ultrasound imaging on my                                                              .

I also consent for information obtained from this imaging to be stored and treated according to the same principles as my other information stored by this practice

Costs: I understand that this procedure is in addition to my normal consultation and that I will be charged for this procedure in addition to the normal cost of my consultation.

Signed                                                                                                  date:

Please click here to view our Infection Control Policy >>