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Looking Ahead – The Future of Vascular Ultrasound

05-11-2023

As the emphasis on cost-effective and patient-friendly imaging solutions, as well as excellence in vascular care continues, there has been a shift in the ultrasound market, bringing vascular ultrasound into the limelight. Historically, vascular ultrasound capabilities have been grouped together under the overarching bucket of “cardiovascular imaging.” As the population ages with an increasing number of comorbidities, there has been increased market interest in vascular-specific imaging and minimally invasive diagnostic methods.

With this emphasis on vascular excellence, the Mindray team recently met with some of the leading experts in vascular ultrasound to gauge the current market, reflect on the current challenges and demands, and discuss the future of vascular ultrasound. In this blog, you’ll gain insights from:

  • Marybeth Georges RVT, BS
  • Tony Smet RVT, RDMS, BS
  • David Barry RVT
  • Laurie Lozanski RDMS, RVT, RVS, FSVU, BS
  • Leni Karr RVT, BS

Describe the current state of the workforce in the vascular industry, including issues that impact your staff.

Marybeth Georges RVT, BS: I consider all of the problems that we have in our field, including burnout and definitely the understaffing trend. I think there’s this expectation that we can do more some days, but it all depends on staffing and the types and difficulty of the exams we’re doing at that particular moment. I don’t think that there’s a lot of understanding from outside of the vascular world as to what our job entails, nor how hard it is physically.

I feel like we’ve had a major shortage lately in the workforce, and overall, it’s just a lack of available, skilled people on staff to ensure an easier and more productive workday. Our institution struggles with staffing quite a bit. Another challenge we face is the learning curve with new technologists as they learn how to navigate complex disease states. The training period impacts our team as a whole. In other words, we may have the bodies and the people to scan the patients, but they don’t necessarily have the knowledge of how to approach all exams and conditions yet.

Tony Smet RVT, RDMS, BS: My experience is that we had a period at the beginning of COVID-19 where a lot of the pillars of the vascular technology community retired. They were not necessarily high-volume workers but experienced trainers who knew how to do things well. Many of those people retired due to COVID fears, while others left the industry altogether.

David Barry RVT: Unfortunately, a shortage in staffing is our primary issue. We simply cannot find adequate, qualified staff members on a consistent basis, regardless of where I advertise. Either we don’t get applicants at all, or we attract new graduates without any experience. Worst-case scenario, we get applicants I wouldn’t hire. New graduates have increased their salary expectations so much, they’ve managed to price us out of the market!

Laurie Lozanski RDMS, RVT, RVS, FSVU BS: Speaking from my own experience, we might have two openings, but we’re just not receiving any applicants. Staff shortages continue to be an issue within many facilities… We’re currently awaiting graduates to complete degrees in their ultrasound program to fill positions. Another big issue I’ve seen is ergonomics, especially post-COVID. I’ve observed a lot of sonographers go through severe burnout, so it’s important to help keep techs healthy and make things as safe as possible to reduce work-related fatigue and injuries. One way we try to do that is to oversee workflow – we want to do portables for the right reasons and assign two bedsides per tech, per day whenever possible. Even with the best equipment, it’s still taxing for techs to contort themselves to treat their patients.

Leni Karr RVT, BS: I work in a couple of different places; both are hospitals. In the past, I have also taught students that are going into the field. Overall, I am very concerned about burnout and understaffing.

Currently, there isn’t a large pipeline of people in vascular diagnostic imaging careers… While many people can do the “bread-and-butter” carotid and “rule-out DVT” exams, when it comes to more advanced or detailed evaluations, the question becomes, “Do we have robust quality educational offerings and student volume feeding those roles and do they possess the skills to learn quickly”? Even then the question arises if someone is trainable, is there even time and bandwidth to get people up to speed? It’s a multilayered concern.

Unfortunately, a shortage in staffing is our primary issue. We simply cannot find adequate, qualified staff members on a consistent basis, regardless of where I advertise. Either we don’t get applicants at all, or we attract new graduates without any experience. Worst-case scenario, we get applicants I wouldn’t hire. New graduates have increased their salary expectations so much, they’ve managed to price us out of the market!”– David Barry RVT

What recent challenges or changes in the vascular world have you observed?

Marybeth: Being that we’re a fairly large lab, we have our own unique set of challenges. We have about 16 sonography technologists total, and on an average day, we aim to have between 9 and 10 techs – and then there are some days obviously we don’t have enough staff. We have about two to three lead techs a day, and then the rest are new. There are a lot of burdens on the older senior techs to train, check over things, and do some of the routine procedures and related tasks. The training period is one of the biggest challenges for our team. I think a lot of labs will be seeing that.

Now, especially post-COVID, many people have either transitioned out of the field or have recently entered into the field. As a result, you’ll see new people coming in and showing others how to do things to the best of their ability, whether it’s based on their general vascular knowledge or machine knowledge.

Tony: Before COVID, many medical practices were taking on new sonographer students, but training was canceled because they didn’t want the liability of people getting sick or exposed to the coronavirus. As a result, it put a lot of stress on the sonographers left behind. They’re overworked and understaffed as people shift from the industry, yet the workload continues to increase. Although I speak for my facility, these problems seem to be the national norm. Even the pay rate has impacted the landscape of the vascular workforce.

Laurie: Right now, we’re interviewing new surgeons in our facility who are interested in adding exams we’d previously not had much call for, such as transcranial studies.,I’ve also seen an upswing in transcranial referrals from other services, whereas there wasn’t much TCD/TCI before in our Institution; it ebbs and flows and was dormant for a while. We’ve also been asked to do more abdominals recently.

Leni: Because of burnout, there’s more attention being spent on musculoskeletal issues, work-related problems, ergonomics, etc. I anticipate we will likely see more organizational “best practices” based around these issues. My concern is more about addressing burnout directly and filling those jobs with people that have quality education.

Those who are managing labs may recognize that you need to provide time for people to mentor the next wave yet still be challenged to justify or approve it for various reasons. I’ve seen or heard of many labs suffer recently simply because so many people are out sick, and then feel the need to return when they’re not healthy. Then we have holidays to cover, and people haven’t taken a vacation because they have used all their sick leave for PTO and don’t have the capacity, or energy, to train students (if they have them) because they’re so busy.

The way I see it, there is consistently a lot of room for operational efficiency. Where you (equipment manufacturers) come in is your ability to promote education, ergonomics, and workflow or just simplifying the whole workflow process. These little things add up all day long, and they really matter to the sustainability and growth of a quality service.

Being that we’re a fairly large lab, we have our own unique set of challenges. We have about 16 sonography technologists total, and on an average day, we aim to have between 9 and 10 techs – and then there are some days obviously we don’t have enough staff. We have about two to three lead techs a day, and then the rest are new. There are a lot of burdens on the older senior techs to train, check over things, and do some of the routine procedures and related tasks. The training period is one of the biggest challenges for our team. I think a lot of labs will be seeing that.
Now, especially post-COVID, many people have either transitioned out of the field or have recently entered into the field. As a result, you’ll see new people coming in and showing others how to do things to the best of their ability, whether it’s based on their general vascular knowledge or machine knowledge.
”– Marybeth Georges RVT, BS

Are there any current trends in the vascular market related to equipment manufacturing?

Marybeth: For the sake of size, ease of use, mobility, and overall ergonomics, I’ve noticed people in my institution will always favor portable machines – the smaller and more compact, the better. In fact, portable sonography machines are our go-to. When you work in this industry, having a more compact and lightweight machine with a platform that can move and swivel is a big deal.

I’ve been working within the vascular field for 17 years, and when I began, we were using ATLs that were giant back-breakers – definitely not mobile-friendly! As far as ergonomic trends that have enabled sonographers to do their job more efficiently and with less physical strain, the industry has grown by leaps and bounds. Ergonomically engineered, mobile machines are crucial in labs – especially in large hospitals where you’re going portable multiple times a day, and half your patient load entails portable exams in the ICUs, COVID patients, and other similar scenarios. Having an ergonomically friendly machine with features you can manipulate and adjust so that you can get what you need on the go and not question yourself is very important to me.

Regarding engineering trends such as image quality, the sensitivity of machines has improved drastically. For example, being able to flip between different probes and go from a linear to a curve to a superficial probe is a game-changer during exams. It’s crucial to have all those tools at your fingertips and to utilize what you have at any given moment.

Tony: I’ve been seeing a lot of software that makes our lives easier – there’s been many shifts, from the quality of images to more of the QOL (quality of life) improvements in technology. With regard to the differentials among vendors, some of these developments are good – and some are not so good. Mindray is definitely a forerunner when it comes to cutting-edge technology and ergonomics in ultrasound. I sometimes worry too much about my reliance upon technology, as it’s become more and more common for proprietary software to do all the heavy lifting. I fear that people won’t be able to teach or prepare sonographer students during their training period properly.

David: We’ve been trying to streamline testing using ABI (Ankle Brachial Index) ultrasound equipment, so we don’t have to do as many exams. That way, if we get an abnormal ABI, we go into full segmental pressures. We’re trying to improve upon what we can do and not be inundated with just study after study. I think that’s the industry trend that everybody’s leaning towards.

I’ve been seeing a lot of software that makes our lives easier – there’s been many shifts, from the quality of images to more of the QOL (quality of life) improvements in technology. With regard to the differentials among vendors, some of these developments are good – and some are not so good. Mindray is definitely a forerunner when it comes to cutting-edge technology and ergonomics in ultrasound. I sometimes worry too much about my reliance upon technology, as it’s become more and more common for proprietary software to do all the heavy lifting. I fear that people won’t be able to teach or prepare sonographer students during their training period properly.”– Tony Smet RVT, RDMS, BS

Has your procedure mix changed? For instance, have you seen any recent exam types increasing or decreasing in number?

Marybeth: Yes, absolutely. The number of venous exams that we do has almost doubled in the past few years. One of the trends I see a lot more of is TCIs (Transcranial Imaging exams). I think those are a big trend among neurologists as well as vascular surgeons. We went from a Transcranial Doppler that was a blind study to imaging those vessels intracranially. Transcranial imaging has really surpassed a lot of other modalities.

We also see a lot more abdominal cases, especially renal ultrasounds – overall, I’ve noticed that abdominal scans have become more prevalent in our vascular labs. With vastly improved equipment, we don’t have as many limitations as we had before – our machines are better and are capable of penetrating deeper. Now we can detect endoleaks with duplex, whereas people used to get CTs first. Working with correlated modalities enables greater accuracy, elevating the popularity of abdominal scans as a superior way of screening. In the past, CTs with contrast limited physicians, but now they’re able to look at demonstrated EVARs (Ultrasound evaluation of endovascular aortic aneurysm repair) on a duplex with routine follow-ups. This trend has really benefitted clinicians and patients alike.

Nowadays, most of your dedicated vascular labs will do your renals, mesenteric, and other similar exams. Looking ahead, I think transcranial imaging will continue to expand in popularity and frequency, and you’ll see more of a trend away from transcranial doppler.

Tony: I see more imaging – more duplex imaging and less use of ABI/PPGs and exercise/physiological testing is almost gone. We’ve also been doing more thoracic outlet imaging. For some of these tests, that’s a good thing. Because there are so many false positives with physiologic testing, these exams require due diligence – the more imaging, the more accurate the results.  It’s easier to interpret the results using imaging modalities.

David: In recent years, we have been using lower extremity arterial (LEA) evaluations more frequently, combined with duplex and ABIs exercising as our ultrasound modalities of choice.

Laurie: I’ve noticed a rise in duplex ultrasonography (DUS) for evaluating patients with superficial venous insufficiency (SVI). As a result, we’ve had to invest in some cuff inflators. For example, we recently had nine bilateral reflux studies in one day. Each leg takes us one hour – that’s 18 hours of work! We usually try to have 10-11 sonographers to cover the workload, but staffing shortages can sometimes pose challenges.

I’ve also seen a correlation between imaging trends and the frequency at which they’re being conducted. In other words, as certain types of imaging are becoming more widely accepted like endovascular stent duplex scans, the more we’re seeing them in practice. Depending on the surgeon, instead of a pre-op CT scan, patients may have an in-suite angiogram instead before surgery instead, which puts extra pressure to perform a reliable duplex scan before scheduling time in operating room.

Leni Karr:  We did see a lot more venous studies with COVID, and generally the current trend request is for more information on exams that aren’t inhibited by reimbursement. I would also say there is a significant increased interest in more scanning of the vasculature of the foot, the anatomy of the foot, and integrating images in your worksheet.

Opportunities to provide visual information on findings that could influence procedural planning or patient management are typically met with positive feedback. I think we’ll see more of that, especially with CLTI patients and other studies with increased  endovascular options, such as AV fistula creation.

We did see a lot more venous studies with COVID, and generally the current trend request is for more information on exams that aren’t inhibited by reimbursement. I would also say there is a significant increased interest in more scanning of the vasculature of the foot, the anatomy of the foot, and integrating images in your worksheet.
  Opportunities to provide visual information on findings that could influence procedural planning or patient management are typically met with positive feedback. I think we’ll see more of that, especially with CLTI patients and other studies with increased  endovascular options, such as AV fistula creation.
 “– Leni Karr RVT, BS

What is the single biggest challenge within a vascular technologist’s daily routine?

Marybeth: I believe it changes periodically depending on each lab. in our institution, one of our biggest obstacles is just being able to keep up with our orders. Having enough staff on hand to perform them is often a challenge. For example, some days, we may have an extra machine, but we don’t have an extra person to go scan that patient. I’m going to say more staffing is probably one of the biggest issues, along with coding and reimbursement. Overall, I also think modern ergonomics are a thousand times better than they were 15 years ago. When I first started working in the field, the probes were gigantic – you couldn’t move your screens; you couldn’t adjust things to your preference the way you can today. I truly appreciate all of those improvements because, having been through them, I can attest we’ve come a long way since then.

Tony: I know that it’s been a big challenge as a whole within the vascular field. Within the vascular laboratory, the bundling of procedures has really reduced reimbursements. For example, it’s pretty standard for patients who have an arterial Doppler ultrasound not to be reimbursed at all if it is accompanied by imaging. As a result, labs are becoming discouraged from doing non-invasive testing. The billing system in America really does impede good patient care. The margins are so thin for vascular labs that it’s very hard for small practices to compete with hospitals and larger facilities, as we just don’t have the volume or multiple income streams.

Another obstacle I’ve noticed within smaller practices is that they need to be thrifty, mobile, and agile if you will. You see some staff sacrificing quality and hiring more people to do billing, so they don’t have a revenue problem. Smaller practices have to invest more time and money into insurance billing and practices to maximize their reimbursements. For example, in one private practice I worked in, we had to hire another person within our billing staff, leaving us with a financial deficit for new equipment or other existing staff members’ salaries. Money was being spent on fixing things rather than buying new equipment. Those are some of the challenges I’ve observed in smaller practices.

David: Other than the staffing shortage, which is a huge deal, the market is not what it used to be a year ago – the overall work ethic changed dramatically compared to when I started in this industry. While it may be a generational thing, it seems to have accelerated exponentially post-COVID.

I try to take a big-picture approach myself. In the past, I’d probably be a bit more boisterous about how I managed and dealt with staff members and issues in general. I try to be a bit more forgiving and empathetic, but overall, I hope I do a good job taking care of my staff. Taking care of your team – not just your immediate manager – it’s got to go way beyond that in the workforce. Industry leaders also need to be willing to listen to the real problems, not just bury them.

When comparing private practices to hospitals, there are definitely some noticeable differences and unique challenges specific to each scenario. The big one is financial – hospitals contract sonographer techs and simply don’t want to pay for anything, equipment or otherwise. However, when you come from private practice, they’re a little bit more lenient and are usually more willing to spend money on getting equipment than the hospital. We have a hospital equipment need right now, and they don’t want to do anything about it.

Laurie: Right now, ergonomics is a hot topic, as many sonographers suffer from chronic pain due to work-related conditions. I believe our profession is currently conducting a cross-modality research project regarding work-related musculoskeletal disorders.  Past research has shown that 80% of the sonographer population suffers from pain or some type of injury. Due to the repetitive nature of movements and length of exam, we’ve also discovered that work-related injuries are most prevalent for sonographers administering cardiovascular ultrasound examinations.

I’ve also noticed that many labs are unwilling to work with ultrasound schools and serve as clinical sites for training. When you volunteer to be a clinical site, getting new staff on-board can be expedited if you are able to employ one of your clinical students at the end of their training.  Clinical experiences can be a bridge to hiring a new technologist already familiar with your Lab who requires less training, but it’s not common in our industry. Even though you think the internship is painful, you’re training someone to do a good job for your office or your friend’s office – it’s just hard to get administration and staff within many labs to take on the challenge of training vascular sonography interns.

“Right now, ergonomics is a hot topic, as many sonographers suffer from chronic pain due to work-related conditions. I believe our profession is currently conducting a cross-modality research project regarding work-related musculoskeletal disorders.  Past research has shown that 80% of the sonographer population suffers from pain or some type of injury. Due to the repetitive nature of movements and length of exam, we’ve also discovered that work-related injuries are most prevalent for sonographers administering cardiovascular ultrasound examinations.I’ve also noticed that many labs are unwilling to work with ultrasound schools and serve as clinical sites for training. When you volunteer to be a clinical site, getting new staff on-board can be expedited if you are able to employ one of your clinical students at the end of their training.  Clinical experiences can be a bridge to hiring a new technologist already familiar with your Lab who requires less training, but it’s not common in our industry. Even though you think the internship is painful, you’re training someone to do a good job for your office or your friend’s office – it’s just hard to get administration and staff within many labs to take on the challenge of training vascular sonography interns.”– Laurie Lozanski RDMS, RVT, RVS, FSVU, BS

What does the future hold for the vascular industry?

Marybeth: I think for a lot of people, there’s a lot more job-jumping – these days, people are trying to find different places to work, whereas years ago, once you were working within a lab, you’d stay there for an extended period of time and gain on-the-job, impactful experiences intended to span the rest of your career. I think today’s hospital setting itself is way more challenging. I’ve seen a lot of people shy away from the more difficult things, and that’s why the teaching component during training is so crucial. Within our particular field, we need to ensure we’re teaching our people every day since the industry is constantly changing. We now do procedures; we go into the OR and do venous ablations with our doctors. The scope of today’s sonographer goes way beyond just scanning.

Looking ahead, I think would-be techs need to realize that there’s way more entailed within our line of work than a quick ultrasound exam. As we discussed earlier, there’s a big learning curve for techs in training – they need to stay on top of their CMES; meetings and new developments in our industry are key. Events such as the SVU annual conferences are great resources, providing valuable insight into what’s out there. They allow techs to see what they can bring to their own labs, introducing new market industry trends and technologies, as well as different clinical protocols and ways of doing things.

Tony: I think something else we’ll probably be seeing in the future is a small evolution of physiological equipment, such as pneumatic cuff inflators for patients suffering from venous insufficiency. There are also new PPG (photo-plethysmography) systems being developed. These devices are extremely costly, so it would be great if some of these machines were integrated into imaging platforms. I also foresee arterial/physiological machines will be relied upon much less, whereas other ultrasound modalities will become more popular in the vascular market.

David: I think one of the biggest challenges in our industry is a shortage in staffing. According to the recent studies I’ve seen, approximately 25% of entities in the vascular market are adequately staffed, equating to another 75% not adequately staffed. This trend continues to put more burden on everybody else and more work-related burnout; I just don’t know how we’ll keep up with it. I keep telling my management team: unless you take care of your staff, you will start losing them. I’ve lost two within the last three months. Based on this current climate, I can’t reiterate enough how important it is to keep lines of communication open with your staff. Listen to them; acknowledging their concerns really goes a long way. Even if you can’t solve their problems, remember that sometimes people want to be heard.

Laurie: When we were coming out of COVID-19, there were many restrictions, but we’ve equaled out again. In the past, we didn’t have a cuff inflator or a proper flow lab and were missing other essential equipment. We’re currently in the process of planning more sites at our facility. We probably do 50% of our volume at the main campus on an outpatient basis. Offsite, we might contribute 5-10% of our volume since we don’t have as many machines or rooms and are sharing space and equipment. In this industry, your resources truly limit how much you can grow or offer.

Lastly, one of our main challenges is balancing requests and conveying them to the engineers to prioritize the demands required from the sonography industry. The more we hear from our customers, the more we can establish what the priorities are for the clinicians.