Ideal Ultrasound Machine Features for the Emergency Medicine and Critical Care Environment-2008

1. Compact size
   • Fits well in patient rooms with multiple tasks occurring
   • Width and depth of the machine should be kept to a minimum
   • Easily mobile - wheels should be high quality and multidirectional
   • Reasonable weight
   • While certain situations may benefit from true portability, most ED applications are best served by a well designed cart based system
2. Image quality and versatility
   • 2-D image quality is essential, especially in difficult/overweight patients
   • Quality across many applications:
     • General abdominal
       • High quality wide footprint probe
     • Pelvic/obstetrical
       • Endocavitary/transvaginal pelvic probe
     • Cardiac
       • True phased array probe capability with tissue harmonic imaging
     • Vascular, skin, soft tissue, lung, procedural
       • Versatile, broadband, high frequency linear transducers
   • Multiple live ports that allow easy switching between transducers on the same patient (at least 3, ideally 4 ports)
   • Ideal monitor articulates in all directions with bright flat screen viewable from multiple angles
3. Ease of use
   • Quick boot up time
     • Option for battery powered sleep
       • At least 2-3 hours of battery powered scanning
       • mechanism to allow notification that battery is running down
     • Cold-boot time is still very important
   • Straightforward "first grade" keyboard and screens. Backlit, large print, large buttons. Multiple users (as many as 60 or more in many residency programs)-means any small non-intuitive feature is magnified.
   • Consider "burying" more advanced features, ? pullout keyboard
   • Initial screen should be straightforward
   • Buttons that should be emphasized (and separate)
     • On/off
     • Start exam
       1. Patient info
       2. Examiner info
       3. Exam type
       4. Reason for exam
       5. Probe selection
     • Depth
     • Gain
     • Freeze
     • Measure
     • Calculations
     • Record (loop/still/video)
     • End Exam
       1. Exam findings
       2. Generate report
       3. Transmit report/images
4. Durability and service
   • The ED is a harsh environment but demands 24/7 uptime
   • Equipment and probes should be built and expected to survive being dropped, stepped on, bled and vomited on - crevices should be avoided, a sealed keyboard is very desirable
   • Probe holders should be stable, strong, easily cleaned
   • Parts that may be broken should be separate and easily replaceable
   • Service needs to be accessible and prompt 24/7
     • A call on Friday afternoon may be at the end of the service technician's week, but it is just the beginning of a weekend full of traumas for the ED
   • Option for affordable service
     • Either included service (five years) OR discounted price up front with service contract paid for yearly
     • Different pricing options allows options for negotiation with hospital
   • Windows based systems should be extensively tested and bulletproofed to avoid software malfunctions
5. Versatility in image archival options. EDs vary widely in how they review and archive images
   • DICOM should be standard on any machine, but alternative image archival options should be available
   • Still image options
     • Ability to print images
     • Ability to save still images on internal hard drive
     • Ability to export images in both DICOM and more widely usable format (jpeg, bitmap) to: external hard drive/jumpdrive/CD/DVD
     • Ability to incorporate images into reporting packages or an electronic medical record (EMR)
   • Video image archival options
     • Ability to save cineloops to hardrive
     • Ability to easily and quickly export both DICOM and more widely usable video formats to external hard drive/jump drive/CD/DVD
     • Ability to output multiple video formats to a recording device: coaxial, S-video, HDMI
     • On keyboard control and review of recorded images, i.e. for DVD recorder
     • Ideally, the option to record real time video (not loops) as direct digital information to a DVD. This would allow true video without analog loss that is immediately archived
   • Integration of image and image management with workflow (see below). Method for easily taking images and information off of machine and associated with patient info for external CQI/educational review.
6. Workflow and image reporting. Workflow is essential to running an effective emergency ultrasound program in terms of medicolegal documentation, reimbursement, quality assurance, and education. Customizability and non-proprietary systems are ideal.
   • Front end workflow: getting information into the machine regarding: who is doing the scan, who the scan is being done on, what type of scan is being done, and why.
     • Wireless interface with hospital ADT systems that allows all patient information to be matched and accurately entered with minimal user effort: ie, barcode reader, or selecting patient from list of patients in the department.
     • Customizability is extremely desirable. Different workflow environments may require certain elements prior to scanning, and have other options available. However other areas may only add to "noise" on an initial screen. The option to include (and require) elements at the director's discretion would be a significant advantage.
     • One possibility: Microsoft Access (or Filemaker for Mac users) type database structuring-ie, creating fields and designing a form that would allow customizable fields and formatting as well as flexible output.
   • Back end workflow: Getting information out of the machine and into the patient record and/or a database for CQI. Includes all front-end workflow elements as well as images and findings.
     • Again, customizable, non-proprietary-ability for director to structure which elements are required for a report of findings, with baseline findings designed per ACEP guidelines. Ability to generate a customizable, non-proprietary CQI database, with images/loops linked to records.
     • Ability to output (wirelessly) into printable and robust reimbursable medicolegal format, .pdf, etc.; ability to interface/ input into electronic medical record
     • Ability to take large amounts of information out of the machine and have it removed from the machine at that point - for example for a set of dates - ie, without having to individually highlight and delete.
     • The images should be able to be post processed allowing emergency image capture and then proper credentials applied to the image thereby preventing "unverified" image transfer
       • The necessary steps to get the patient into the radiology information system (RIS) and accessible via the DICOM worklist are time prohibitive in some emergency situations
       • In these situations, post processing of the images is required to attach at least the correct accession number
       • Other options discussed in the main document, such as bar coding, may help in these situations
7. DICOM and wireless connectivity. DICOM worklist access and image archival represent unique challenges in the emergency department setting. The emergency paradigm is different in that the machine will be used by multiple users, be taken to the bedside of the patient, and will not always be able to have correct demographics of the patient in emergency situations. The ideal solution is to have wireless communication between the ultrasound machine and DICOM servers.
   • The wireless communication should be compatible with recognized 802.11 wireless standards
     • The system should have the ability to communicate on both the 802.11a and 802.11b/g/n standards for maximum compatibility
     • The system should have a minimum of Wi-Fi protected Access (WPA) security features
     • "Medical grade" security enhancements are welcomed and encouraged
   • The wireless radio should be included and internal to the machine, either as an option or standard
     • External radios are currently the norm, but are subject to failure, theft, and in some cases are grossly underpowered (ie, USB radios)
     • The radio should be adequately powered so that only a minimal amount of wireless infrastructure will be required to maintain wireless reception
     • Setup should be easily accessible and user friendly to allow minimal setup and maintenance
   • Those with administrator privileges should be able to easily access, change, and repair the wireless settings preventing dependence on IT or PACS teams to fix these settings
     • The settings should be easy to import and export for those cases of "loaner" machines and upgrades
   • Should be configurable to an existing PACS system or a local computer server
     • In many situations non-traditional imaging specialists are excluded from access to the PACS.
     • Should be allowed an alternative configuration to archive to a local server
8. Other attractive features
   • Storage options, ie, drawer(s) for: sterile probe covers, special angiocaths, towels, gel, etc.
   • Battery powered gel warmer that recharges when machine is plugged in
   • Retractable or easily stored cords (preferably in a separate area for each probe).