A transvaginal ultrasound exam is a common procedure performed thousands of times every day in the United States. A TVUS (transvaginal ultrasound) may be required for many applications such as pregnancy monitoring, fertility treatment, routine screenings or diagnosis. Today we'll review five tips to keep your endovaginal exams safe and comfortable for your patients. We will be talking about regular scans that do not involve invasive acts (invasive acts: biopsies, aspirations or treatment deliveries)
Ultrasound grows in popularity from year to year, mainly due to its low-cost of acquisition and operation (compared to other imaging modalities), its ease of use, and its absence of danger for both patients and professionals.
Even if ultrasounds don't expose the patient to ionizing radiation, they are not exempt of danger. Spread of infections and cross-contamination (contamination of the transducer by the patient and vice versa) are the most critical risks encountered when performing an endovaginal ultrasound exam. According to CDC, Healthcare Associated Infection (aka Hospital Acquired Infection - HAI) account each year for $35 to $45 billion in extra cost to our healthcare system.
Fortunately, there are ways to reduce the risks associated with transvaginal or transrectal ultrasound. Let's jump right into it.
Tip #1: Use an appropriate ultrasound cover
As obvious as it seems, the probe cover is not an option here. And by probe cover, we mean products designed and labeled as so, no cut gloves or other DIY fancy solutions! You can use condoms, but they must be non-lubricated and non-medicated (lubricants and other coatings can carry infectious agents).
11% of the practitioners do not use a proper ultrasound cover.
For instance, in a recent study conducted by the European Society of Radiology (ESR), it was found that 11% of the respondents (A total of 946 practitioners) do not use a proper ultrasound cover every time they perform an endocavity exam (whether it is transvaginal or transrectal). While these results come from Europe (Mostly UK, France, Itlay and Spain), we can bet we would obtain similar conclusions in the USA.
Let us mention that endocavity probes are Semi-critical devices that are in contact with mucous tissues. As a result, medical professionals must use an ultrasound cover for all their endocavity procedures. The cover doesn't have to be sterile, although it is preferred when dealing with a "risky patient". Not to mention that one must never reuse a cover! Also, you might want to use latex-free covers to accommodate allergic patients and practitioners.
Tip #2: Wear gloves
Now that your patient and your transducer are protected, let's talk about you. You should be wearing gloves throughout all the procedure, from the moment you cover your probe to the moment you take it off. No need for sterile gloves though. However, you may also want to use latex-free gloves, for the same reasons as explained above. The gloves will keep your hands from body fluids, and will also protect the handle of the transducer.
At the end of the endocavity ultrasound exam, be sure to remove the probe cover before taking off your gloves. Pay attention not to contaminate the transducer with the soiled gloves or with the cover. Dispose of them immediately, following your facility's guidelines. Finally, never reuse, wash or re-sterilize your gloves.
Tip #3: Use sterile ultrasound gel
When it comes to ultrasound gel, the ESR survey points out that 35% of practitioners use refill bottles for a transvaginal ultrasound exam. While using a refill bottle is no big deal, these are more likely to host microorganisms compared to single use containers. If you use refill bottles, make sure to change your bottle on a regular basis, and to discard gel that may have been in contact with air for too long.
The remaining 65% of practitioners use either sterile gel (30%) or single-use bottles (35%). Even if the sterile gel is more expensive, it suits endocavity procedures for two reasons:
- It won't carry any pathogen that may cross the physical barrier (cover)
- The gel container cannot get contaminated by the probe or the patient because you discard it right away. As a result, there is no risk of infecting another patient with a mishandled gel bottle. The same applies to single-use bottles.
Even though you can use refill bottles when following a strict hygiene protocol, we still recommend the utilization of sterile gel for an endocavity ultrasound exam.
Tip #4: Clean & Disinfect your probe between each patient
As mentioned above, your endocavity transducer is a Semi-Critical device. That being, it must be cleaned, and then High-level disinfected between each patient.
According to the ESR, 11% of the responders would clean or disinfect their probe at the end of the patient list only! Another 69% of the practitioners would only clean the probe with a soft tissue, and perform a low-level disinfection with a wipe or foam. Finally, only 18% of the physicians carry-out a proper high-level of disinfection after each patient.
CDC and AIUM have issued the following guidelines for cleaning and disinfecting endocavitary probes:
- Remove the remaining gel with a soft tissue
- Clean the probe with a low-level disinfection spray or wipe (prefer alcohol-free chemicals that won't damage your transducer)
- Dry the probe and make sure no soil or chemical remains, as they can interfere with the disinfection process
- Soak your ultrasound transducer in the high-level disinfectant. The most popular compounds are the glutaraldehyde, the peracetic acid, and the hydrogen peroxide. Each disinfectant being different, refer to the manufacturer's recommendation for soaking time.
The main drawback here is the time required for soaking, usually 20-30 minutes. That is the reason why so little facilities comply with the disinfection guidelines. Yet, high-level disinfection must be a no-brainer after each transvaginal or transrectal ultrasound exam. You should allow a 30-minute window between each patient to reprocess your equipment.
Tip #5: Store your transducer properly between each ultrasound exam
The final step for keeping a probe clean and free from microorganisms is to store it appropriately. Right after the disinfection cycle, you must store your transducer in a way to avoid recontamination. Hence, The Joint Commission (aka JCAHO or TJC) has issued guidelines for when your device is not in use: "Store the device in a manner that will protect from damage or contamination and that is consistent with national guidelines and manufacturers' recommendations such as hanging vertically in a cabinet and storing in a clean environment"
Store the device in a manner that will protect from damage or contamination.
A few options are available here. One of them is to protect the probe with a dedicated cover when not in use.
Probe storage covers
The probe storage covers are larger than exam covers; allowing for easy insertion and better protection of the transducer and the handle. They generally feature a dedicated area to put on the disinfection label. Such storage covers are non-sterile but will do the job of keeping your ultrasound probe clean between two examinations.
However, you can't use them as an exam probe cover: they are too loose and will give a poor image quality. Likewise, we don't recommend using a regular probe cover to store your probe. I recently visited a practice where the probe cover was used for storage, and then directly used for the exam. I don't know exactly how long the cover remained in the open air, but I wouldn't have liked to be the next patient! Plus, you don't want to be this facility when the Joint Commission knocks at your door.
Probe storage cabinets
Another option, though more expensive, would be to equip your facility with a storage cabinet. It will allow you to hang your probe vertically (which is what manufacturers recommend), keeping it from damages. Positive pressure and filtered air inside the cabinet will keep the contaminants away from your devices. You can certainly combine an ultrasound probe storage cover with a storage cabinet.
Your probe is disinfected and kept in a clean environment. You are now ready to go for your next endocavity ultrasound exam!