CARDIOLOGY CLINICAL STREAM
Draft Model of Service Delivery: Cardiac Echosonography
August 2009
SERVICE OVERVIEW ............................................................................. 3
Overview of Current Issues .................................................................................................................. 3
CURRENT SERVICE PROVISION OVERVIEW ........................................... 4
Armidale .............................................................................................................................................. 4
Belmont ............................................................................................................................................... 4
John Hunter ......................................................................................................................................... 4
Maitland............................................................................................................................................... 5
Tamworth ............................................................................................................................................ 5
Taree .................................................................................................................................................... 5
Workforce ............................................................................................................ 5
The Ideal Echo Workforce.................................................................................................................... 5
Labour Market Overview ..................................................................................................................... 6
Award Profile of Echo Technicians....................................................................................................... 7
Support workforce requirements ...................................................................................................... 10
Information Technology Reporting Systems...................................................................................... 10
Echo Report Validation Process ......................................................................................................... 10
Equipment ...........................................................................................................11
Funding ...............................................................................................................11
RECOMMENDATIONS......................................................................... 11
Service Provision Model .................................................................................................................... 11
Cardiac Technician Training ............................................................................................................... 12
Information Technology .................................................................................................................... 12
Funding Models ................................................................................................................................. 12
Service Overview
Cardiac echo is an essential part of diagnostic services for Cardiovascular Medicine, and is widely used
by all services within Hunter New England Area Health (HNEH). Whilst there has been a service plan
developed for Cardiology and Cardiac Surgical Services within the HNEH, little thought has been
documented on the development of an area wide cardiac echo service. Currently the echo service has
developed and been funded in a variety of forms across various facilities with little standardisation of
practice, technology or service provision.
The most important cardiological investigation modality following consultation with ECG, CXR and
basic blood tests is cardiac sonography. It is arguably more important than exercise stress testing and
certainly more important than cardiac catheterisation. It is used for the assessment of patients
presenting with breathlessness, valvular heart disease, ischemic heart disease and hypertension. It is
also necessary for the assessment of patients with potential drug toxicity, such as patients treated
with anti cancer drugs and certain antipsychotic medication.
This paper is designed to help define our present position with provision of service and possibilities of
development of the service.
Overview of Current Issues

The provision of equipment to provide echo services is presently inadequate. Equipment within
the area has been sourced from a variety of providers. Funding has been difficult to obtain from
DOH sources leading to a lack of forward planning for replacement. Funding in the lower Hunter
has been supported almost entirely from Staff Specialist Trust Funds. This model is barely
sustainable there and probably as it stands unsustainable in parts of the area without Staff
specialist support, unless the model is changed.

The provision of trained staff, including Consultants and Technicians is and will continue to be a
challenge.

Space, nurse, clerical support, and clinical support services are continuing issues.

Support and training for other services that provide echo are necessary. These Areas include
Paediatrics, Intensive Care, Anaesthetic services, and Emergency Departments

A commitment to outreach services is necessary for communities unable or not willing to attend
large centres.
Current service provision overview
Armidale
The Hospital provides inpatient and outpatient care, has an active ED and is a referral centre for more
complex patients from surrounding Hospitals. It has a CCU and Medical Service, but at present does
not have a Cardiologist. It has an active surgical service and Obstetric facilities. Echo services are
provided by a visiting private service, and occasional studies can be performed on a Portable Echo
machine in emergency, which is mainly for urgent triage use but has been used by Visiting
Cardiologists. Service provision is hampered by limited quality of images, difficult archiving, visiting
service provided on a _____ basis, ____images available for review as well as no dedicated funds for
renewal or plans for tech training.
Belmont
A District Hospital with close proximitry to the HNEH main tertiary referral hospital, Belmont services
include an ED, HDU/CCU, elective and some urgent surgery and outpatients. The hospital is staffed by
Cardiologists, general physicians, specialist and general surgeons. Belmont presently has a dedicated
inpatient echo service of 2 to 3 sessions per week, mainly used by patients in CCU with MI or CCF, and
for general medical patients with CCF, CVA and valvular heart disease. One vivid 4 machine bought
through hospital funds (after a major upheaval in services, part of which was a perceived delay in
appropriate patient care due to lack of echo facilities), used for inpatients and occasional outpatients.
No plans for scheduled replacement. Probable insurance rate about 30 to 40 %, images read by
Cardiologist at JHH.
John Hunter
Major Teaching Hospital, with Cardiology Dept, invasive and non invasive, CCU, Cath Lab, Angioplasty,
valvoplasty, closure devices, EPS, Cardiac surgery, Major centre for paediatrics including NICU
3 Vivid 7 GE machines (1 OPD, 2 IP), 1 Vivid I GE (portable) used in CSU, wards, teaching in Uni,
outreach clinics (Moree), and also Awabakal clinic (yet to be established). Machines are leased by
HNEH from facility fee raised on insured inpatients and referred outpatients. Cost recovery and
viability and potential for service expansion unknown, because of difficulty in tracking actual charging.
Studies are reviewed by Cardiologist and trained techs, one in training, recently trained Advanced
trainee in ICU, Cardiology advanced trainees rotate through.
Training in TTE and Transoesophageal echo.
1 IE 33 Philips dedicated Pediatric echo machine, totally funded by paediatric funds, no plan for how
to budget for service, used for general (abdominal and heads studies mainly) and for Paediatric
Cardiac echo, in ward patients and in NICU. Technical service provided by Cardiologists (GW, BB, NC
and ST (in training) and Lynn Bull. Physiological studies by one neonatologist.
1 IE 33 Philips dedicated to Cardiac Surgery used for cardiac surgery patients, paid out of Surgery
funds. Revenue stream is small. Have up to date 3Dimensional TOE probe, important for valve repair,
and valve assessment.
Maitland
Regional Centre with active CCU and staffed by 2 Cardiologists, general Physicians, general and
specialist surgeon, active ED. 1 IE33 and one lesser configured machine as backup, 1 tech / trainee
(part time 3 days per week). Resulting studies are read by Cardiologists.
Tamworth
Rural referral centre, with general physicians, specialist and general surgeons, Active ICU and Cardiac
diagnostic services. Two cardiologists on site with probably need for more. One cardiology advanced
trainee position on site. IMET initiative. 1 failing ancient System 5 GE machine fully owned no funds to
replace, no capacity to digitally store or review images, no present tech in the hospital, although one
attends private practice. No dedicated area to image patients.
Taree
Rural referral centre, with general physicians, and specialist and general surgeons, ICU, CCU and ED.
1 Phililps 5500 (Old Technology) Visiting service by GW and BB. Onsite service by Sanath
Wickremesinghe and Dan Connor. No tech, Private out patient service run by Dan Connor in Private
(Mayo Hosp) significantly removed from MBH. TOE service provided in OT usually for inpatients
Workforce
Echo services are workforce intensive in nature. They are very reliant on the skills of the person
performing the scan and subsequently the interpreter of the scan. The study needs to be performed
with knowledge of the types of condition that the patient may have, so that particular effort is
directed to ensuring that as much information is acquired to help to arrive at the correct diagnosis.
The Ideal Echo Workforce
The perfect tech will have superb imaging skills and a good understanding of the pathophysiology of
the conditions likely to be producing the symptoms of which the patient is complaining. They will be
able to glean from the patients’ notes the question that should have been asked, with often sketchy
information provided on the request form. It takes a lot of time to train a good technician, and most
of the technicians have been trained in the public system.
It is difficult to retain techs in the public system, because of the fixed wages available, and the
competitive wages available in the private system. We do provide a stimulating and interesting
environment for techs and in the past have supported their training financially, although recently this
has been a struggle. We have also sent techs to meetings, which has improved loyalty. We have lost
techs due to perceived lack of appreciation of their work, and this attitude may also exist in the
private world as well.
Labour Market Overview
To become an accredited sonographer, persons with an appropriate degree (for example, in medical
imaging, nursing, health or science) can undertake a relevant two-year diploma through a university
or the Australian Society of Ultrasound in Medicine. Most courses require students to be employed as
sonographers and therefore most students will be experienced sonographers by the time they
graduate. It is important to note that cardiac sonography procedures do not attract a Medicare rebate
unless the sonographer is accredited.
Many of the larger public and private hospitals attempt to meet their own need for sonographers by
offering training to those of its medical imaging staff who are interested in entering the specialisation.
The number of persons completing relevant courses averaged 65 a year in the three years to 2005
which represents a training rate of 5.7 per cent a year based on estimated employment of 1000 to
1100. There are no precise figures on supply to the occupation from interstate and overseas
immigration. However, data from the Australian Sonographer Accreditation Registry suggest that
supply from sources other than local graduations averaged 38 a year between 2002 and 2005. The
number of newly-accredited sonographers in NSW increased to 105 in 2006 but it is unclear how
many of these would be working predominantly in NSW (DEEWR, 2007).
Shortages were evident in both the public and private sectors in Sydney and regional NSW. The
majority of advertisements attracted few responses and these were mostly from current student
sonographers or from science and health professionals wishing to become student sonographers.
Positions requiring specialised skills in areas such as cardiac or vascular sonography proved
particularly difficult to fill. In a typical example, one prominent public hospital advertised for three
cardiac sonographers but only attracted one applicant who was recruited despite the need to provide
her with further training (DEEWR, 2007).
In the Hunter New England Area Health Service (HNEH) the majority of cardiac sonography in the
public health system takes place at the John Hunter Hospital. Additional services are provided at the
Calvary Mater Hospital, Belmont Hospital and Maitland Hospital. Cardiac Sonography in the HNEH is
undertaken mainly by cardiac technologists; however in areas where access to cardiac technologists
with appropriate skills is limited radiographers and medical officers perform cardiac sonography
Award Profile of Echo Technicians
The NSW (Public) Health Employees State Award states the following:
1) Cardiac Technician - means a person who performs ECGs, Exercise Stress Testing and Holter Loop
Recorders.
2) Cardiac Technologist - Grade 1 - means a person who has attained a Bachelor of Science Degree
or qualifications or competencies deemed equivalent by the employer and may be required to
perform ECGs, Exercise Stress Testing, Holter-Loop event recorders as well as VVI pacemakers,
dual chamber pacing/cardiac catheter and Implantable Cardiac defibrillators (ICDs).
3) Cardiac Technologist - Grade 2 - means a person who has attained a Post Graduate Degree in
Sonography or qualifications or competencies deemed equivalent by the employer and performs
Cardiac Sonography or Electrophysiological Studies (EPS).
4) Senior Cardiac Technologist - means a person who can perform all duties of Cardiac Technologist
Grade 1 and assists the Chief Cardiac Technologist with management, either through;
Undertaking supervisory duties in a Deputy or Second in Charge role overseeing other Cardiac
Technicians and/or Cardiac Technologists; and/or have responsibility for the day to day running
of a discreet function within the department.
5) Chief Cardiac Technologist - means a person who can perform all the functions of a Cardiac
Technologist and who is responsible for the management of the department including the
development of operational protocols.
Cardiac Technologist Grade 2: Current Active Staff all HNE at 26/3/09
Employee Base Cost Code
Award Code Description
Description
Award Profile Description
Cardiac Technologist Grade
Cardiology - C.S.U. ~John
2
Hunter
ECG
Cardiac Technologist Grade
Cardiology - C.S.U. ~John
2
Hunter
ECG
Cardiac Technologist Grade
Cardiology - C.S.U. ~John
2
Hunter
ECG
Cardiac Technologist Grade
Cardiology - C.S.U. ~John
Heart/Lung Tech &
2
Hunter
Assistant
Cardiac Technologist Grade
Cardiology - C.S.U. ~John
2
Hunter
ECG
Cardiac Technologist Grade
Cardiology - C.S.U. ~John
2
Hunter
ECG
Cardiac Technologist Grade
Cardiology - C.S.U. ~John
Heart/Lung Tech &
2
Hunter
Assistant
Cardiac Technologist Grade
Cardiology - C.S.U. ~John
Heart/Lung Tech &
2
Hunter
Assistant
Grand Total
Source: HNE Business Objects
Tota
l
1
1
1
1
1
1
1
1
8
One of the main reasons that retention of echo techs is problematic is due to remuneration
differences between public award rates and private pay rates. The table below indicates NSW State
award pay rates
Cardiac Technologists Award Rates from the Health Employees State Award
Grades
Rate from
Rate from
Rate from
Grade 1
1.7.2008
1.7.2009
1.7.2010
Year 1
917.90
953.70
990.90
Year 2
952.30
989.40
1,028.00
Year 3
1,010.90
1,050.30
1,091.30
Year 4
1,080.10
1,122.20
1,166.00
Year 5
1,154.80
1,199.80
1,246.60
Year 6
1,228.40
1,276.30
1,326.10
Year 7
1,288.00
1,338.20
1,390.40
Year 8
1,329.60
1,381.50
1,435.40
Year 1
1,288.00
1,338.20
1,390.40
Year 2
1,329.60
1,381.50
1,435.40
Year 3
1,430.10
1,485.90
1,543.90
Senior Cardiac
Technologist
Year 1
1,430.10
1,485.90
1,543.90
Year 2
1,478.00
1,535.60
1,595.50
Chief Cardiac
Technologist
Year 1
1,519.20
1,578.40
1,640.00
Year 2
1,685.70
1,751.40
1,819.70
Grade 2
Source: NSW Health
As stated above there are a number of programs to facilitate training in echocardiography at various
institutions. The program is at graduate diploma level and is offered by universities and professional
groups. Most techs will be capable of working by themselves to do the scanning, with occasional input
from a Cardiologist or a more senior tech.
Current Programs in Ultrasonography at 26/3/09
Conferring Body (Please Click Hyperlink)
ASAR Accredited Qualifications
Diploma of Medical Ultrasonography (Cardiac)
Australasian Society for
Diploma of Medical Ultrasonography (General)
Ultrasound in Medicine (ASUM)
Diploma of Medical Ultrasonography (Vascular)
Diploma of Medical Ultrasonography (Obstetric)
Graduate Diploma of Applied Science (Medical
Charles Sturt University
Ultrasound)
Master of Applied Science (Medical Ultrasound)
Post Graduate Diploma in Medical Imaging
Science — Ultrasound (for students enrolled prior
Curtin University of Technology
to 1/1/2000)
Master of Medical Sonography, incorporating the
Graduate Diploma
Monash University
Graduate Diploma in Medical Ultrasound
Master of Medical Ultrasound
Graduate Diploma in Applied Science (Medical
Ultrasound)
Master of Applied Science (Medical Ultrasound)
Queensland University of Technology
Graduate Certificate in Applied Science (Breast
Ultrasound)
Graduate Diploma in Cardiac Ultrasound
Master of Cardiac Ultrasound
Graduate Diploma (Sonography)
RMIT University
Graduate Diploma of Ultrasonography
Master of Applied Science (Sonography)
Graduate Diploma of Health Science (Medical
Sonography)
Graduate Diploma of Health Science with
University of Sydney— Cumberland Campus
Certificates of Specialisation in Vascular
Sonography
Graduate Diploma of Health Science with
Certificates of Specialisation in Cardiac
Conferring Body (Please Click Hyperlink)
ASAR Accredited Qualifications
Sonography (for students enrolled prior to
31/3/2006 and students enrolled after 8/3/2009)
Master of Health Science (Medical Sonography)
Master of Health Science with Certificates of
Specialisation in Cardiac and Vascular Sonography
(for students enrolled prior to 31/3/2006 and
students enrolled after 8/3/2009)
Source: Australian Sonographer Accreditation Register (ASAR).
http://www.asar.com.au/programs.html
Support workforce requirements
Service provision requires the care of patients who are in an unstable state, and sometimes it is
necessary to have a nurse or a doctor in attendance. Many patients scanned are relatively immobile
due to severe respiratory, cardiac or neurological disease and many are very obese, and may require a
porter to move them about adequately. There have been continuing problems getting patients to the
Echo Lab, let alone having support staff available to help position the patient for optimal scanning.
During a scan , the patient will ideally lie in at least 4 quite separate positions ( L lateral, supine, R
lateral and sitting upright with head back, and “ minor “ adjustments to position are frequently
necessary). Adequate and rapid availability of support staff is essential to use these people properly,
but is very difficult to obtain in many of our clinical environments.
Information Technology Reporting Systems
The technicians and advanced trainees will perform the echo and then construct a draft report onto a
computer based reporting system presently Prosolv, which is available in JHH, Maitland, Newcastle
Mater, Belmont for entering data, and images and reports can be reviewed throughout the area, from
any computer on the HNEH network, which is a huge advance from the previous tape based system.
Images from Armidale, Tamworth and Taree cannot be entered due to both the machines and the
lack of licences for Prosolv workstations in those areas. This lack will have a significant impact on the
level of support that can be provided to those centres.
Echo Report Validation Process
All echoes performed by techs and advanced trainees should be checked by a consultant Cardiologist
or Physician with accredited expertise in echo. These consultants are out of necessity involved in
training of new cardiology and echo trainees, and in helping the existing trainees updating and
maintaining skills. They are also responsible for their own and other physician continuing education in
cardiac sonography. It is important that dedicated high speed echo work stations be available to the
techs and the consultants, for these purposes.
Equipment
Present equipment management arrangements have not been highly coordinated and are ad hoc.
There are a number of machines placed without a service or renewal plan. To lead such a process and
to maintain a high level of enthusiasm for the service, we need to provide high end machines for
diagnosing and treating the most difficult patients and for research and teaching. Without this
commitment, our service will deteriorate. We will be one of the 2 major referral centres for neonatal
care which includes a big commitment from Cardiology. We need to commit significant resources to
this, including advanced 2D and 3D echo. At a broad level our equipment in the area is presently
inadequate to provide services as they are required. It is clear that we must replace or improve
equipment in Tamworth, Taree, John Hunter, and Armidale as soon as possible.
Funding
An agreed long term funding model is needed for services throughout the area. If this is not
established the risk is that an unfair distribution of resources will result with inequality of service
distribution as exists at present. Appropriate funding will result in improved patient care over the
area, and a large part of this would be due to staff satisfaction improving.
Recommendations
Service Provision Model
RRH
3 days per week base
4 days per month
Community hospital/MPS
4 days per month
district hospital




Reporting by trained General Physician/Cardiologist via CAP (Kodak system)
Negotiate clinic infrastructure with site to support service
Professional link across HNE echo team for professional
development/extended leave relief
Link with outreach cardiology clinics as available.
Cardiac Technician Training
Information Technology
Funding Models