Patient satisfaction and incidence of adverse events during a trial of sonographer administered musculoskeletal injections

Increases in demand for therapeutic ultrasound‐guided musculoskeletal injections have led to longer waiting times for appointments. With the right training, sonographers are well placed to perform these low‐risk procedures. This study evaluated the effect of musculoskeletal injections administered by trained sonographers with respect to patient safety and satisfaction.


| INTRODUCTION
The demand for therapeutic ultrasound guided musculoskeletal injections (TUGMIs) in medical imaging departments has increased over the last decade. 1 These injections are usually prescribed for patients with musculoskeletal (MSK) conditions to relieve local pain and inflammation, and may be administered intra-articularly, peri-articularly or within specific soft tissues. 2 TUGMIs are commonly used to manage conditions such as inflammatory and non-inflammatory arthritides and musculoskeletal conditions across multiple anatomic areas, such as the shoulder, elbow, wrist, knee, ankle, hands, feet, and hip. These conditions are common clinical presentations in Australia with an estimated 29% of Australians reporting a musculoskeletal condition in 2017-2018, and 15% suffering from arthritis. 3 The increased demand for TUGMIs may be the result of a shift from medical practitioners performing anatomically guided MSK injections (without imaging guidance) to referring patients to imaging departments for injections guided by medical imaging modalities, such as ultrasound. 4 While studies have shown comparative effectiveness between ultrasound-guided and anatomically-guided injections of the shoulder, 5,6 others have demonstrated improvements in accuracy as well as clinical outcomes at least as good as anatomically-guided MSK injections for several injection sites with the use of ultrasound guidance. 7 The shift to secondary referrals may reflect increasing awareness of the evidence that TUGMIs can provide improved accuracy and effectiveness than anatomically guided MSK injections, or be a coping strategy as the workload of general practitioners increases. 8,9 This increased demand for TUGMIs has coincided with an expanded volume and complexity of workload for radiologists, secondary to the emergence of other interventional procedures that they are required to undertake. 1 In regional and rural/remote areas of Australia this demand is further compounded by radiologist accessibility problems, with these communities' having fewer radiologists than are required for their populations. 10 All of these factors have the potential to contribute to longer waiting times for patients requiring a TUGMI, increasing the time they have to suffer pain. 4 This has been shown to diminish the quality of the patient's healthcare experience, treatment and health outcomes. 11 With the increasing demands on health services, such as TUGMIs, health and medical professionals need to work collaboratively to identify evidence-based effective and efficient solutions that support improved access for patients, while ensuring patient safety and highquality health outcomes. Professional role substitution, using allied health professionals in roles traditionally undertaken by medical practitioners, has been effective in improving patient access to health services while releasing medical specialists to see more complex patients. 12 Evidence suggests that these extended scope of practice roles for allied health practitioners are a cost-effective and consumer-accepted solution to improve patient outcomes for services under strain. 13 As a solution to the increased demand for TUGMIs, sonographers could perform these low-risk procedures as an extension of their current scope of practice. Sonographers are well placed to undertake this professional role substitution as they commonly work with radiologists in medical imaging departments and have expert skills in ultrasound technology. In the United Kingdom, sonographers are already performing these procedures, and role extension has resulted in reduced waiting times, and improvements in patient care and service provision without loss of therapeutic efficacy. 1,14 The success of this role substitution has been underpinned by the support of local medical clinicians, formal risk assessment, structured supervised practical training, theoretical study, and on-going professional and service audit for practice and outcome. 14 In 2014, the Queensland Government Ministerial Taskforce on Health Practitioner Expanded Scope of Practice final report recognized that training sonographers to perform MSK therapeutic steroid injections was a possible extended scope of practice that would build capacity in the health system and reduce outpatient department waiting time. 15 In support of this, the Australasian Sonographers Asso-

| Participants
All patients who presented to these three radiology clinics with a referral for a TUGMI were approached to volunteer for the study. 3. Whether they would they recommend the service. 4. Whether they would be happy to have the service again by the sonographer.
All patients were also offered the opportunity to provide open text responses to the question "Can you think of anything that could be done to improve the injection service?" This survey was available in hard copy or as an e-survey using a commercially available on-line survey tool (Survey Monkey©). The hard copy paper version was available to be completed in the waiting room post-injection, while the e-survey could be emailed out to the patient to be completed electronically. The choice of completing a paper versus e-survey was offered to each patient.

| Adverse events
Adverse events were recorded at two time points in the patient journey. Immediately following the injection, the occurrence of any adverse event was reported by the sonographer, and all patients who agreed to participate in follow-up interviews were contacted by the researcher by telephone 7-10 days following the injection. The interviewer followed a script to guide the patient through their reporting of any adverse reactions they had as a result of the injection.

| Protocol
Patients were provided with a patient information sheet about the study, by the clinic receptionist and invited to ask the sonographer/ radiologist questions to clarify any issues. Patients were free to choose to have the injection performed by the radiologist or the sonographer. If the patient chose to have the injection from the radiologist, they were excluded from this study.
If the patient chose to have the injection performed by the sonographer, they were provided with a consent form that they were requested to sign. In this consent form they were also asked to provide their contact details if they consented to be followed up within 10 days by telephone to assess for longer term adverse events.
The patient was then screened using a pre-administration checklist that reviewed their suitability for the procedure through clearing common contraindications and precautions to the injection. Any patients identified as being at risk were referred to the radiologist for further discussion as necessary.If the patient provided informed consent and was deemed low risk from the pre-administration checklist they were imaged and injected by the sonographer. Only corticosteroids/local anesthetic were administered, based on the referral request and condition.
Following the injection, the patient was requested to remain in the waiting area for at least 15 minutes to ensure there were no acute adverse events from the injection. During this time, they were offered the choice of a paper copy patient satisfaction questionnaire or to provide contact details so a link to the on-line version of the satisfaction questionnaire could be emailed to them. With immediate adverse events recorded by the injecting sonographer, the survey completed by patients at this stage captured their satisfaction with their treatment throughout the procedure, as well as their willingness to return to the same department for future treatments.
The patients who agreed to the follow up interview were contacted by telephone up to 10 days later by a researcher and the incidence of adverse events were reported using a structured interview script to reduce interviewer bias.
All paper copy questionnaires were sent back to the research team using a pre-paid addressed reply envelope. Upon receipt of the patient datasheet the researchers contacted the patient via telephone for an interview regarding adverse events experienced by the patient 10 days after their injection and their satisfaction with the service.

| Statistical analysis
All hard copy data was manually transferred, and all electronic survey data downloaded, into a spreadsheet for analysis using MedCalc©

| RESULTS
A total of 884 patients were invited to participate in the study between June 2020 and July 2021, of which 823 (93%) consented to participate (Table 1). Data was only available from 804 patients, as 19 participants who provided signed consent and asked for on-line surveys did not respond to the email invitation. Due to the anonymous nature of data collection, it was not possible to identify and follow up these patients. Data on the body area injected with the TUGMSI was available from 687 patients.

| Patient satisfaction
Patient satisfaction immediately following injection is presented in Table 2. Analysis of the effect of age/previous experience with injections and patient satisfaction data was analyzed using the Kruskal-
Wallis test (H-test). No significant relationship (P > .005) was found between any of the patient satisfaction results and age or if the patient had any previous experience with injections (Table 3).
The open text responses were thematically analyzed to explore  Were the details of the injection process explained adequately? Were you provided with enough information about monitoring any potential reactions from the injection? 1. "Less of a wait to get into see sonographer for injection." 2. "From seeing the dr I had to wait 3.5 weeks to get the injection. During that time I have been in an extreme amount of pain. No radiology clinics were able to provide an earlier appointment." 3. "Waiting list time is very long for injuries that can become permanent. This is a major issue." 4. "It is apparent that there are more sonographers needed at this practice to meet the demands placed on this service. There is currently a 3 month waiting list for appointments."

| Patient safety
Data on the incidents of adverse events immediately following injection (as reported by the sonographer) was available from 823 patients. Adverse events were reported for four patients (<1%) ( Table 4) A total of 110 (n = 110) patients agreed to participate in the follow up interviews and were contacted by telephone up to 10 days following the injection. Adverse events were reported by nine patients (8%) ( Table 5).

| DISCUSSION
The results of this study, undertaken in a large group of patients attending three radiology clinics who were piloting sonographer In a client centered

| CONCLUSION
The findings from this study indicate that the sonographer administered ultrasound-guided MSK injection service provided a quality health-care service model as viewed from the patients' perspective.
Patient satisfaction was high, and the risk of adverse events were no worse than that reported in the literature.
The high level of satisfaction from the patients who attended the service may reflect the use of experienced and specially trained sonographers in the three radiology clinics. As an extended scope of practice, it is important that the sonographers who are involved in providing the service have the appropriate level of experience, support, and training to undertake the role. The high level of satisfaction of the patients suggest that this service should be extended and expanded to address patient concerns regarding long waiting times.
It was beyond the scope of this study to measure a direct comparison between sonographer administered TUGMSIs and those performed by other medical and health practitioners. Future Australian studies are called for which directly compare patient satisfaction and outcomes directly between TUGMSIs performed by appropriately trained sonographers and those performed by radiologists. Further exploration into health service outcomes, with clinical audits of practice, and education and training models for extending the scope of practice for sonographers will also be beneficial.

ACKNOWLEDGMENTS
The authors would like to acknowledge the support provided by the Australasian Sonographers Association in the development of this study.

CONFLICT OF INTEREST
Kerry Thoirs is an editorial board member for Sonography and coauthor on this article. This co-author is not involved in the peer review process; management of the peer review process and decision-making for this article. These instead were handled by a Handling Editor who is not a co-author on this article.