IAC Echocardiography Stress
Add-on Supplement

An additional testing area (or areas) may be added to a facility’s current accreditation at any time during the three-year accreditation cycle. Accreditation is granted only for the specific testing areas for which a facility has applied and submitted an application. Though facilities may be performing other testing in the facility, those areas are not covered under the accreditation until an application for the specific testing type is submitted and granted accreditation. The following form is to be used for supplemental testing only. If your facility is not currently accredited in Echocardiography, please contact the IAC.

Please answer all questions, required attachments will be indicated by the  symbol. Case studies requirements are listed on page two.

Name of institution (as listed in the IAC Accreditation Agreement):

(This institution name will be tracked in the IAC database and will receive all IAC correspondence)

Department:

Street Address 1:

Street Address 2:

City:

State: Zip code:

Location of echocardiography facility:

Hospital (number of beds: )

Private Office

Freestanding imaging center

Independent facility

Other (specify):

1)Is there a written policy in place that addresses the facility’s protocol for handling acute medical emergencies?(Applicable Standard: 4.1.4A)
Yes No

2)Enter how many minutes are allotted for each of the following echocardiogram procedures from patient encounter to patient departure in the facility(Applicable Standard: 1.4.3B):
Exercise stress echocardiogram:
Pharmacologic stress echocardiogram:
Doppler stress echocardiogram:
 Submit a copy of the facility-specific, step-by-step stress Echocardiography protocol.
(Applicable Standard:3.6A)

3)How many personnel are routinely present during stress echocardiograms?
(Applicable Standard: 3.6.4B):

4)Are all personnel supervising cardiac stress procedures certified in basic life support?
(Applicable Standard: 3.6.5B):
Yes No
If no, please explain:
 Submit a copy of attestation demonstrating the appropriate training and competence as outlined in the American College of Cardiology/American Heart Association Clinical Competence Statement on Stress Testing if non-physician personnel supervise stress procedures (e.g.,nurse, nurse practitioner, physician’s assistant).(Applicable Standard: 3.6.3B):

5)Is a person certified in ACLS is on site during all cardiac stress procedures?
(Applicable Standard: 3.6.6B):
Yes No
If no, please explain:

6)Which sites should be included in the add-on testing area?

Stress Echocardiography Case Studies:

  • The required stress case studies are now based on the total number of staff (medical and technical) that perform stress echo in an applicant facility. Following are the required number of stress case studies per base facility:
  • 5 or fewer staff = 4 cases per facility
  • 6 to 8 staff = 6 cases per facility
  • 9 to 15 staff = 8 cases per facility
  • 16 to 25 staff = 10 cases per facility
  • Greater than 25 staff = 12 cases per facility
  • Multiple Sites: 1 stress echocardiography casefrom each applicant site must be submitted.
  • Any one of the following types of cases is acceptable for submission; abnormal wall motion at rest, inducible wall motion abnormality with stress or a stress case using contrast (may be normal or abnormal).
  • Cases must represent as manyCURRENTstaff as possible.When submitting case studies, do not duplicate staff members (medical and technical) until all staff have been represented at least once.
  • Cases submitted with the application must not be independently performed by sonographer or physician trainees.
  • One case study must be submitted from the Technical Director.
  • Medical Director must be represented.
  • All cases must be selected from within the past 36 months from the date of application filing.
  • Submit only BEST cases. Rest and post images must be submitted in a side by side format.

IAC Echocardiography Stress Add-On Supplemental Form 1

Reviewed 9/2016