By Ikegwuonu, NC; Nzotta, CC; Anyanwu, CE; Okpaleke, MS (2022).

Greener Journal of Medical Sciences

Vol. 12(1), pp. 145-150, 2022

ISSN: 2276-7797

Copyright ©2022, the copyright of this article is retained by the author(s)

https://gjournals.org/GJMS

 

 

 

 

Assessment of Ultrasound Quality Control Practices in Anambra State, Southeast, Nigeria.

 

 

1Nwamaka C. Ikegwuonu, 2Christian C. Nzotta, 2Chinedu E. Anyanwu and 2Michael S. Okpaleke

 

 

1 Radiology Department,  Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria.

2 Department of Radiography, Faculty of Health Sciences and Technology, College of Medicine, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria.

 

 

ARTICLE INFO

ABSTRACT

 

Article No.: 042622042

Type: Research

Full Text: PDF, HTML, EPUB, PHP

 

Background: Ultrasound equipment quality control (QC) checks ensure that faults are detected and corrected, to ensure optimal equipment performance for good clinical outcome. Ultrasound practitioners have an essential role in the QC of ultrasound scanners. This study was aimed at assessing QC tasks practiced by ultrasound practitioners in Anambra state, Nigeria, and their compliance to recommended standards.

 

Materials and Methods: This was a cross-sectional, questionnaire-based study carried out among 37 certified ultrasound practitioners. The hardcopy questionnaire made up of questions on QC practices according to recommendations of the American Association of Ultrasound in Medicine (AIUM) was used for data collection, and included questions on: cleanliness, infection control and safety tasks, and image display and performance tasks. The obtained data were analyzed using descriptive statistics.

 

Results: The ultrasound practitioners showed good compliance (86.1% - 100%) to infection control QC tasks of cleaning  transducer, console and monitor of gel and body fluid; good compliance to equipment physical/mechanical safety tasks (61.1% - 83.3%), but poor compliance to image display and performance tasks (0 – 30.6%). Their compliance to the recommended frequency of practice for these QC tasks was generally poor (0% - 19.4%), except for transducer cleaning after each patient (91.7%) and immediate cleaning of spilled body fluid (100%). All phantom tasks had zero practice among the practitioners. Though none of the facilities had a QC programme in place, in addition to poor awareness (33.3%, n= 12)) of recommended QC tests by the practitioners, most (94.4 %, n=34) of the practitioners believed that ultrasound quality control was beneficial.

 

Conclusion: Except for the phantom-based tasks which had zero practice, other quality control tasks were practiced by the ultrasound practitioners, and in varying degrees, but most times not according to the recommended standards.

 

Accepted:  26/04/2022

Published: 30/04/2022

 

*Corresponding Author

Nwamaka C. Ikegwuonu

E-mail: ncikegwuonu@ nauthnnewi.org.ng, zubeamaka@ yahoo.com

Phone: +2348033950499

 

Keywords: Ultrasound, Quality control, Image quality.

 

 

 

 


Abbreviations: (IPEM) Institute of physics and engineering in medicine; (RCR) Royal College of Radiologists; (ACR) American College of Radiology; (AAPM) The American Association of Physics in Medicine; (EFSUMB); European Federation of Societies for Ultrasound in Medicine and Biology.

 

 

INTRODUCTION

 

Ultrasound equipment undergoes deterioration as a result of usage and normal aging process. Its delicate parts can be physically damaged by improper use and handling  [1]. Transducers may be accidentally dropped, wheels may be run over cables, dust or fluid may accumulate on the machine and its electrical boards, connecting ports may become loose, cracks may appear on the knobs due to pressure of touch etc. These factors collectively affect the imaging performance of an ultrasound system. Some changes in performance may be obvious and usually noticed by the operator; however, others may occur subtly over time and usually go unnoticed, while some other problems may go unnoticed because they are masked by patient anatomy [2]. Regular quality control checks are essential in detecting fault that may affect equipment performance. Ultrasound QC is aimed at ensuring proper equipment functionality, clinical usage safety within internationally accepted limit, and performance consistency over time [3]. Ultrasound quality assurance (QA) guidelines and recommendations have been developed by regulatory bodies like AIUM, IPEM, RCR, ACR, AAPM, EFSUMB which if applied, will help in maintaining high equipment performance for better diagnostic accuracy. A substantial effort has been made to determine the most pertinent tests, the recommended frequency of testing, the most useful phantom design(s) and acceptable measured values [2]. Some QA procedures are those that are routinely carried out under good clinical practice, and consist of regular safety and cleanliness checks as well as more detailed checks of image display and performance which are best done using a phantom or a test object [4]. Ultrasound practitioners have an essential role in the QA of ultrasound scanners [5]. A clean and hygienic equipment including transducers, control panel, monitor, and peripherals is mandatory each time before a patient is scanned [3].  In addition, adopting infection control procedures ensures that the risk of infection to patient and staff are minimized [5]. Visual inspection of scanner’s physical components ensures that damaged components that may pose electrical safety risks are identified and replaced.  QC tests using phantom or test object can provide insight to specific performance characteristics of an ultrasound scanner [2]. The operator of the ultrasound equipment should monitor its optimal operation and immediately report any deficiency or fault for repairs [1].

Some studies in Nigeria have shown poor quality control practices among ultrasound practitioners [6,7].  This study was therefore aimed at assessing the quality control practices carried out by ultrasound practitioners in Anambra state, Nigeria.

 

 

MATERIALS AND METHODS

 

This was a descriptive cross-sectional study carried out among 37 certified ultrasound practitioners practicing in the 25 ultrasound facilities  in Onitsha, Awka, and Nnewi, Anambra State. An ethical approval (NAUTH/CS/66/VOL.11/035/2018/031) for this study was obtained from the Human Research and Ethical Committee of the Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria. The entire procedure of the study was adequately explained to the participants and their consent was duly sought and obtained. All the information obtained was treated with confidentiality and used for the purpose of this study only. A questionnaire was used to obtain information from the participants. The questionnaire was validated using content validity, while its reliability was tested using test-retest method; the cronbach’s alpha reliability coefficient being 0.804. The questions were about electrical safety, cleanliness and infection control, image display and performance, according to AIUM recommendations. Questions to determine the priority given to ultrasound QA were also included and bothered around the availability of formal QA in place, awareness of ultrasound QC, frequency of QC actions and availability of tissue-equivalent phantom. Opinion on the usefulness of ultrasound QC was equally sought. A total of 37 Questionnaires were self-distributed to the ultrasound practitioners working in the selected centers.  Thirty-six (36) were filled by the respondents and collected back by the researcher, giving a 97% return rate. Data were analyzed using a statistical package for social sciences SPSS version 22. Non-numeric performance parameters and quality control practices by ultrasound practitioners were expressed using simple descriptive statistics (mean, frequency and percentages).

 

 

RESULTS

 

The results of the ultrasound practitioners’ quality control practices revealed that the tasks of cleaning of ultrasound machine or room, and wiping gel off transducer after each exam had the highest mean score of 1.00 each respectively, while checking power cords and picture archiving had the least mean score 0.09 (Figure 1). Tasks involving use of phantom had zero score (figure 2)

 


 


Fig 1: Pattern of Compliance to Cleanliness, Infection Control and Safety tasks

 

 

Fig 2: Pattern of Compliance to Image Display and Performance Tasks

 

 

 

 


Most 94.4 % (n=34) of the practitioners believed that ultrasound quality control is beneficial and a small proportion of them, (33.3%, n=12) were aware of quality control test (Table 1). The majority of the ultrasound practitioners (61.1% -100%) had good quality control tasks of equipment cleanliness, infection control and safety practice. Only a few (0 -19.4%) had compliance with the recommendation of the AIUM [4]. A large proportion (86.1%) of the ultrasound practitioners had good dust cleaning practices (Table 2). The results of the ultrasound practitioners’ practice of QC towards image display and performance, revealed that only a few (0-30.6%) practiced QC tasks for image display and performance while their adherence to the frequency of practice was poor (0% - 2-8%) (Table 3).

 


 

 

Table 1: Frequency Distribution for Quality Control Demographic Characteristics for the Ultrasound Facilities and Practitioners Studied

Quality control related question

Frequency of positive  response

Is any quality assurance programme in place?

0%

Any baseline tests carried out the ultrasound machines?

0%

The facility owns a QC phantom?

0%

Awareness of different QC tests

33.3% (n=12)

Is ultrasound QC of any benefit?

94.4% (n=34)

 

 

Table 2: Frequency Distribution for Practitioners that Practice AIUM-Recommended Quality Control and their Compliance to Recommended Frequency: Cleanliness and Safety.

Task

% (n) of practitioners that practice QC task

% of compliance according to AIUM-recommended  frequency.

AIUM recommended frequency

 

Cleaning transducer after each patient.

100% (n=36)

91.7% (n=33)

      Multi-daily

 

Immediate cleaning if spillage of body fluid or hazardous material.

100% (n=36)

100% (n=36)

      Multi-daily

 

Cleaning control panels of gel after each patient, if necessary.

88.9% (n=32)

 0% (n=0)

      Multi-daily

 

Monitor cleaned of dust, gel and streaks.

86.1% (n=31)

19.4% (n=7)

      Daily

 

Check operation of switches and knobs on machine console.

83.3% (n=30)

19.4% (n=7)

      Daily

 

Check transducer  cables, housing, and surface for cracks damage

80.6% (n=29)

 

19.4% (n=7)

      Daily

 

Generally check machine for dents and other damage.

61.1% (n=22)

2.8% (n=1)

    Weekly

 

Thoroughly clean machine console and other equipment in the room.

36.1% (n=13)

5.6% (n=2)

     Monthly

 

Check power cords and PACS connections for damage

8.3% (n=3)

0% (n=0)

     Daily

 

Cleaning machine console air filters.

2.8% (n=1)

2.8% (n=1)

    Weekly

 

 

 

 

 

 

Table 3: Frequency Distribution for Practitioners that Practice AIUM-Recommended Quality Control and their Compliance to Recommended Frequency: Image Display and Performance.

 

Task

% (n) of practitioners that practice QC task

% of compliance according to AIUM-recommended  frequency.

AIUM-recommended frequency

 

Checking brightness and contrast controls match

30.6% (n=11)

0% (n=0)

Daily

 

Checking display of gray bars

11.1% (n=4)

0% (n=0)

Daily

 

Checking image gray level match

19.4% (n=7)

2.8% (n=1)

Daily

 

Examine images for streaks

11.1% (n=4)

2.8% (n=1)

Daily

 

Check image uniformity using  phantom

 0%  (n=0)

0% (n=0)

Daily

 

Check maximum depth of visualization using phantom

0% (n=0)

0% (n=0)

Annually 

 

Check target contrast and imaging resolution

0% (n=0)

0% (n=0)

Annually

 

Check distance measurement accuracy using phantom

 0% (n=0)

0% (n=0)

Annually

 

 

 


DISCUSSION

 

Results from our study showed that none of the facilities had a formal QA program in place. This finding is consistent with the report of BMUS [8], which stated that many clinical ultrasound services have no formal QA program. We therefore infer that quality assurance is not prioritized in these facilities. In addition, there is poor awareness among the ultrasound practitioners about the quality control tests to be carried out on the ultrasound equipment, nevertheless, most of the practitioners acknowledged the benefits of ultrasound quality control.

In our study, quality control tasks of equipment cleanliness, infection control, and safety have good practice compliance by most of the practitioners, but their compliance to the recommended frequency of practice was generally poor, except for the cleaning transducer of gel after each patient, and cleaning spilled fluid, both which has excellent compliance. Also, except for the scanners’ monitor which had good dust-cleaning practice compliance by the practitioners; other tasks of cleaning equipment of dust have poor practice compliance among the practitioners. Tasks for image display and performance by the ultrasound practitioners were found to be poorly practiced, while their adherence to the frequency of practice was even poorer. We found that all phantom-based tasks had zero compliance, likely due to absence of QC phantom in all the facilities. Our findings of poor compliance to some QC practices and poor compliance to their recommended frequency of practice may not be unconnected with poor awareness of QC tests noted among the ultrasound practitioners. However, despite the poor awareness of QC tests, some of the practitioners showed excellent compliance to some of the recommended QC practices, likely as a result of good clinical practice, infection control consciousness and equipment care. The is in agreement with the AIUM [4], which stated that some QA procedures were those that are routinely carried out as good clinical ultrasound practice, and the BMUS [8], which noted that some elements of QA were not time-consuming and would already be carried out in departments complying with local infection control and equipment management requirements. Poor compliance to some QC tasks in this work may also be because of the lack of a formal QA program in the facilities, which may lead to a lack of commitment to QC.

Phantoms are used to carry out measurable parameters in the ultrasound scanner and help to reveal system defects that may otherwise not be identified and which can affect patients’ diagnoses. However, QC phantoms are usually expensive and this may have discouraged their procurement by the facilities we studied, and thus zero compliance to all phantom-based tests. In addition, evidence of a current QA certification is not required for setting up and continuing an ultrasound practice in Nigeria, so the facilities may not readily commit funds for something that has no legal threats. This agrees with Ward and Stanton [9] who noted that time and resources may not be prioritized to something that is not legally required. The ultrasound operators however believed that ultrasound QC was beneficial. A good practice of quality control in ultrasound is beneficial for improved clinical outcomes.

 

 

CONCLUSION

 

This study revealed that ultrasound practitioners in Anambra state undertake the various recommended ultrasound quality control tasks in varying degrees but not according to recommended frequency of practice. QC tasks involving the use of phantom was entirely lacking among the practitioners. This may result in use of equipment with possible compromised performance, which may affect clinical outcome.

 

Conflict of interest: None was declared among the authors.

 

Funding sources: None

 

Acknowledgment: Not applicable

 

 

REFERENCES

 

1)     Grazhdani, H., David, E., Spagnolo, V.O., Buemi, F., Perri, A., Orsogna, N., Gigli, S, Chimenz, R . Quality assurance of ultrasound systems: current status and review of literature. Journal of Ultrasound, 2018;  27(3), 173-182.

 

2)     Kofler, J.M. Quality assurance of ultrasound imagers: Procedures, expectations and philosophies. The American Association of Physics in Medicine (AAPM), 43rd Annual Meeting, 2001, P.5.; Retrieved from: https://www.aapm.org/meetings/2001AM/pdf/7194-74902.pdf. (Accessed on: 22/07/17).

 

3)     Kollmann, C., deKorte, C., Dudley, N.J., Gritzmann, K. and Evans, D.H. (2012). Guidelines for technical quality assurance (TQA) of utrasound devices (B-Mode)-version 1.0. EFSUMB Technical quality assurance group.US-TQA/B. Ultraschall in Medicine, 33, 544-549.

 

4)     American Institute of Ultrasound in Medicine. (2008). Routine quality assurance for diagnostic ultrasound equipment. American Institute of Ultrasound in Medicine, AIUM, Routine Quality Assurance of Clinical Ultrasound Equipment Subcommittee. USA: Laurel MD.

 

5)     Dudley, N., Russell, S., Ward, B. and Hoskins, P. (2014). British Medical Ultrasound Society guidelines for the regular quality assurance testing of ultrasound scanners by sonographers: BMUS Working Party. Ultrasound, 22(1), 8-14.

 

6)     Eze, C.U., Eze, C.U, Asogwa, C. A survey of quality of sonographic practice. British Journal of Healthcare Management, 19(3), 2013:124-128.

 

7)     Sidi, M., Sani, G.M., Ya’u, A.Zira, J.D, Loshugno, S.S,  Luntsi, G. The current status of ultrasound practice in Kano metropolis, Nigeria. Egyptian Journal of Radiology Nuclear Medicine. 2021;  52, 212.  https://doi.org/10.1186/s43055-021-00509-x (Accessed on 13/9/21).

 

8)     British Medical Ultrasound Society. (2015). Guidelines for professional ultrasound practice. Society and College of Radiographers and British Medical Ultrasound Society. P. 9. Retrieved from: https://www.bmus.org/static/uploads/resources/SCoR__BMUS__Guidelines_Amend_Mar_2019_final_DecHwyx.pdf. (Accessed on: 25/08/17).

 

9)     Ward, A.M, Stanton, M.T. Quality assurance in Irish ultrasound departments. Poster presentation (poster No:B-0715) to the European Society of Radiology.2016. Retrieved from:  https://doi.org/10.1016/B978-0-08-102216-0.00003-5. (Accessed on: 22/03/2017)

 


 

 

 

Cite this Article: Ikegwuonu, NC; Nzotta, CC; Anyanwu, CE; Okpaleke, MS (2022). Assessment of Ultrasound Quality Control Practices in Anambra State, Southeast, Nigeria. Greener Journal of Medical Sciences, 12(1): 145-150.