Ultrasound Prioritization

Effective Date: May 30^th, 2018.

Recommendations and Topics

Scope
Background
Prioritization of Potential Diagnoses
Abdomen and Pelvis
- Overview
- Notes and Alternative Tests
Pediatrics
- Overview
- Notes and Alternative Tests
Obstetrics and Gynecology
- Overview
- Notes and Alternative Tests
Musculoskeletal/Extremity
- Overview
- Notes and Alternative Tests
General
- Overview
- Notes and Alternative Tests
Vascular
- Overview
- Notes and Alternative Tests
Resources

Scope

This guideline summarizes suggested wait times for common indications where ultrasound is the recommended first imaging test. The purpose is to inform primary care practitioners of how referrals are prioritized by radiologists, radiology departments and community imaging clinics across the province. This guideline is an adaptation of the British Columbia Radiological Society (BCRS) Ultrasound Prioritization Guidelines (2016). Management of the listed clinical problems is beyond the scope of this guideline. However, in some cases, notes and alternative tests are provided for additional clinical context. Primary care practitioners are encouraged to consult a radiologist if they have any concerns or questions regarding which is the appropriate imaging test to choose for a particular problem.

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Background

The BCRS Ultrasound Prioritization Guidelines (2016) were developed to provide imaging departments with a consistent, provincial approach to prioritizing commonly ordered ultrasound tests according to suggested maximum wait times. The Guidelines were developed by consensus and are based on best BC expert opinion with representation of radiologists from across the province. Several considerations apply:

These are guidelines, and as such, are designed to apply in general terms. They are not intended to replace clinical judgement or physician-to-physician discussion.
Prioritization levels were selected to match other similar guidelines for CT and MRI and are typically assigned by radiologists rather than referring physicians.
These guidelines should not be applied rigidly to each case, as varying clinical factors may shift a particular indication from one priority level to another.
Access to ultrasound and the ability to respond to emergent/urgent ultrasound requests will depend on local availability.
The clinical topics included in this guideline represent broad examples, and do not encompass all possible scenarios or all requirements for ultrasound examinations.
These guidelines do not apply to inpatients or emergency room patients.

Priority Level Definitions

The priority levels defined below (Table 1) are in alignment with the Canadian Association of Radiologist's national designation Five Point Classification System¹.

**Table 1: Priority Level Definitions**
Priority Level	Clinical Example	Maximum Suggested Wait Time
P1	An examination immediately necessary to diagnose and/or treat life-threatening disease. Such an examination will need to be done either stat or not later than the day of the request.	Immediately to 24 hours
P2	An examination indicated within one week of a request to resolve a clinical management imperative.	Maximum 7 calendar days
P3	An examination indicated to investigate symptoms of potential importance.	Maximum 30 calendar days
P4	An examination indicated for long-range management or for prevention.	Maximum 60 calendar days
P5	Timed follow-up exam or specified procedure date recommended by radiologist and/or clinician.

Source: Adapted from the Canadian Association of Radiologists National Maximum Wait Time Access Targets for Medical Imaging.

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Prioritization of Potential Diagnoses

The following potential diagnoses, where ultrasound is the recommended first test, are grouped according to system and then further subdivided into priority levels. For each system an overview table is presented followed by a more detailed table outlining additional notes and alternative tests where appropriate. Refer to Appendix A: Ultrasound Prioritization Guideline Summary for a one page summary of all potential diagnoses and prioritizations. Referring practitioners may consider noting the priority directly on the requisition.

Abdomen and Pelvis

**Abdomen and Pelvis: Overview**
P1	P2	P3	P4	P5
Immediately to 24 hours	Max 7 calendar days	Max 30 calendar days	Max 60 calendar days	Specified date
Acute abdominal pain (e.g., appendicitis, cholecystitis) Acute post-transplant assessment Splenic rupture Septic renal colic/focal pyelonephritis Acute painful hernia, (obstruction, strangulation, or ischemia suspected) Intra-abdominal abscess Painful jaundice Testicular torsion/epididymitis Testicular rupture Priapism	Acute painful hernia, (obstruction, strangulation, or ischemia not suspected) Painless jaundice Pancreatitis, complications Painless hematuria Renal colic Acute renal failure New testicular mass New painless abdominal or pelvic mass	Acute painless hernia/chronic hernia (if diagnosis in doubt) Extra-testicular mass Cholelithiasis New pulsatile abdominal mass Renal stone burden	Chronic abdominal pain/bloating Abnormal liver function tests/known chronic liver disease Pre-transplant work-up Scrotal or pelvic ultrasound as part of workup for varicocele embolization/ uterine artery embolization Peyronie’s disease	Known abdominal aortic aneurysm (AAA)/ endovascular abdominal aortic aneurysm repair follow-up

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**Abdomen and Pelvis: Notes and Alternative Tests**
Priority Level	Potential Diagnosis	Notes and Alternative Tests
P1	Acute abdominal pain (e.g., appendicitis, cholecystitis,)	Choice of first-line test will depend on likely origin of pain and suspected clinical diagnosis, for example: If acute pancreatitis, suggest CT If bowel ischemia, suggest CT If ultrasound is equivocal for appendicitis, consider CT or MRI CT is not recommended for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option (Choosing Wisely Radiology recommendation)
	Acute post-transplant assessment	CT for liver transplant if ultrasound inconclusive
	Splenic rupture	CT is typically ordered as first-line imaging for trauma In pediatric and pregnant population, consider ultrasound as first-line
	Septic renal colic/focal pyelonephritis	In pediatric, young female and pregnant population consider ultrasound as first-line CT KUB (kidney/urinary/bladder) can be first-line for renal colic
	Acute painful hernia (obstruction, strangulation, or ischemia suspected)	If concern for bowel obstruction, consider plain film prior to ultrasound If ultrasound is inconclusive, CT can be used
	Intra-abdominal abscess
	Painful jaundice
	Testicular torsion/epididymitis
	Testicular rupture	Associated with an episode of preceding scrotal trauma
	Priapism	Typically referred by urology or emergency department to elucidate cause
P2	Acute painful hernia (obstruction, strangulation or ischemia not suspected)	If ultrasound is inconclusive, CT can be used For acute painless hernia, ultrasound is not recommended
	Painless jaundice	CT is recommended for characterization if a mass is seen on ultrasound in the liver or pancreas
	Pancreatitis, complications	To assess for fluid collections and to identify any underlying causes such as gallstones and/or common bile duct stones
	Painless hematuria	Includes microscopic and macroscopic hematuria Negative ultrasound still requires follow-up (consider CT)
	Renal colic	Ultrasound is first-line imaging test in pediatric patients and pregnant women Consider CT KUB (kidney/urinary/bladder) as first-line test in adults
	Acute renal failure	To rule out obstructive uropathy
	New testicular mass
	New painless abdominal or pelvic mass	CT is often considered first-line in this situation except in pediatrics In rural and remote areas where CT may not be available, ultrasound is the first choice modality
P3	Acute painless hernia/chronic hernia	Generally no imaging is required, ultrasound may be ordered if diagnosis is in doubt
	Extra-testicular mass	For example, to differentiate hydrocele, varicocele, epididymal cyst
	Cholelithiasis
	New pulsatile abdominal mass	Suspect previously undiagnosed abdominal aortic aneurysm (AAA)
	Renal stone burden	May be supplemented with CT KUB (kidney/urinary/bladder) or KUB radiograph as needed
P4	Chronic abdominal pain/bloating	If associated symptoms suggest potential malignancy, consider P3
	Abnormal liver function tests/ known chronic liver disease	Includes non-alcoholic fatty liver disease (NALFLD) or other causes of chronic hepatitis Includes screening for hepatocellular carcinoma (HCC) in patients with known Hep B/C or other risk factors Interval follow-up may be recommended based on hepatology guidelines²
	Pre-transplant work-up	As indicated by pre-transplant orders Urgency may be dictated by anticipated surgery date
	Scrotal or pelvic ultrasound as part of workup for varicocele embolization/ uterine artery embolization	Typically referred by specialists prior to procedure
	Peyronie’s disease	Typically referred by specialists
P5	Known abdominal aortic aneurysm /endovascular abdominal aortic aneurysm repair follow-up	CT can be an alternative imaging test or if ultrasound is technically challenging Timed follow-up, usually done yearly or per advice of vascular surgeon

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Pediatrics

**Pediatrics: Overview**
P1	P2	P3	P4
Immediately to 24 hours	Max 7 calendar days	Max 30 calendar days	Max 60 calendar days
Pyloric stenosis Intussusception Clinically suspicious intra-abdominal/ pelvic mass	Increasing head circumference (hydrocephalus) Biliary atresia as the cause of neonatal jaundice	Follow-up antenatal hydronephrosis	Developmental dysplasia of the hip (DDH) Spine ultrasound (prior to 5 months of age) Urinary tract infection Chronic liver disease Renal anomaly

**Pediatrics: Notes and Alternative Tests**
Priority Level	Potential Diagnosis	Notes and Alternative Tests
P1	Pyloric stenosis
	Intussusception
	Clinically suspicious intra-abdominal/pelvic mass
P2	Increasing head circumference (hydrocephalus)	Providing the fontanelles are still open
P2	Biliary atresia as the cause of neonatal jaundice	When jaundice is refractory or severe Usually requested by pediatrician
P3	Follow-up antenatal hydronephrosis	Refer to Associated Documents - BC Children’s Hospital Antenatal Hydronephrosis Imaging Guideline
P4	Developmental dysplasia of the hip (DDH)	P4 provided that requisition is sent in at birth, exam should be completed by 4-6 weeks If requisition is sent later, DDH may become a P2 or P3 exam so that exam is completed by 4-6 weeks
	Spine ultrasound (prior to 5 months of age)	Typically for dysraphism or cord tethering
	Urinary tract infection (UTI)	For recurrent UTIs, to rule out or confirm bladder problems
	Chronic liver disease	Or for cystic fibrosis liver evaluation
	Renal anomaly

Obstetrics and Gynecology

**Obstetrics and Gynecology: Overview**
P1	P2	P3	P4
Immediately to 24 hours	Max 7 calendar days	Max 30 calendar days	Max 60 calendar days
Ectopic pregnancy Threatened abortion Embryonic/fetal demise Placental abruption Vasa/vena previa Pre-term labour to determine cervical length Acute pelvic pain of suspected gynecological cause (e.g., query ruptured cyst, pelvic inflammatory disease, ovarian torsion)	Medical abortion Polyhydramnios Oligohydramnios Follow-up of oligohydramnios (unless otherwise specified) Intrauterine growth restriction Post-dates fluid assessment Intrauterine device localization with pain	Post-menopausal bleeding Follow-up possible fetal abnormality from routine detail scan High-risk pregnancy Pelvic mass Intrauterine device localization without symptoms or bleeding	Dysfunctional uterine bleeding e.g., fibroids, adenomyosis Follow-up placental location Adnexal cyst follow-up (unless otherwise specified) Fetal detail exam (unless otherwise specified)

**Obstetrics and Gynecology: Notes and Alternative Tests**
Priority Level	Potential Diagnosis	Notes and Alternative Tests
P1	Ectopic pregnancy	Indicated if clinically suspect pregnant, positive beta human chorionic gonadotropin (BHCG), or pain and/or bleeding regardless of BHCG level
	Threatened abortion
	Embryonic/fetal demise³
	Placental abruption
	Vasa/vena previa
	Pre-term labour to determine cervical length	Endovaginal ultrasound to be used if a transabdominal scan is inconclusive
	Acute pelvic pain of suspected gynecological cause (e.g., query ruptured cyst, pelvic inflammatory disease, ovarian torsion)	MRI can be used in selected cases if ultrasound is inconclusive and if locally available
P2	Medical abortion	To confirm intra-uterine pregnancy and gestational age prior to medical abortion⁴
	Polyhydramnios
	Oligohydramnios
	Follow-up of oligohydramnios	AFI (amniotic fluid index)/fluid volume unless otherwise specified i.e. patient has regularly scheduled checks for AFI
	Intrauterine growth restriction (IUGR)	Consider P5 as necessary
	Post-dates fluid assessment	Consider P5 as necessary
	Intrauterine device (IUD) localization with pain
P3	Post-menopausal bleeding	Negative ultrasound should not interfere with further investigation to exclude malignancy
	Follow up possible fetal abnormality from routine detail scan	Generally as suggested by perinatal specialist
	High-risk pregnancy	Follow-up amniotic fluid is P3 unless otherwise specified by radiologist and/or clinician (i.e. P2)
	Pelvic mass	Masses detected on pelvic exam include causes such as ovarian cysts and fibroids If symptomatic consider higher priority
	Intrauterine device (IUD) localization	If without symptoms or bleeding
P4	Dysfunctional uterine bleeding e.g., fibroids, adenomyosis
	Follow-up placental location	If follow-up recommended, not indicated before 32 weeks. If the ultrasound is performed earlier (28-32 weeks) and placenta is found to be low lying, the ultrasound should be repeated at 32 weeks given the significant rate of growth between 28 and 32 weeks.
	Adnexal cyst follow-up (unless otherwise specified)	Interval follow-up may be recommended based on the Society of Radiologists in Ultrasound guidelines⁵
	Fetal detail exam (unless otherwise specified)

**Musculoskeletal/Extremity Overview**
P1	P2	P3	P4	P5
Immediately to 24 hours	Max 7 calendar days	Max 30 calendar days	Max 60 calendar days	Specified time
Deep vein thrombosis Septic arthritis/toxic synovitis Abscess	Acute tendon tears	New palpable neck/thyroid mass New palpable extremity mass Acute rotator cuff tear	Synovitis/arthropathy follow-up Tendinopathy, chronic shoulder pain, non-operative rotator cuff tear Bursitis Chronic palpable mass Multi nodular goiter Carpal tunnel syndrome or other neuropathy Baker’s cyst	Follow-up of soft tissue mass

**Musculoskeletal/Extremity**

**Musculoskeletal/Extremity: Notes and Alternative Tests**
Priority Level	Potential Diagnosis	Notes and Alternative Tests
P1	Deep vein thrombosis	Correlate with D dimer if available
	Septic arthritis/toxic synovitis	If effusion present, may prompt fine needle aspiration
	Abscess	To confirm presence of fluid and exclude solid mass
P2	Acute tendon tears	Typically achilles or biceps require emergent surgery or management Except rotator cuff tears which typically are not surgical Unless specified under P4
P3	New palpable neck/thyroid mass	Thyroid ultrasound scan is not routinely recommended in patients with abnormal thyroid function tests, unless there is a palpable abnormality of the thyroid gland (Choosing Wisely Endocrinology and Metabolism Recommendation)
	New palpable extremity mass	To determine if the mass is cystic or solid If suspicious features on clinical exam or sonograph, CT or MRI may be recommended
	Acute rotator cuff tear	As part of orthopedic referral or pre-surgical MRI is an alternative test usually suggested by a radiologist if ultrasound is inconclusive, or ordered by a surgeon
P4	Synovitis/arthropathy follow-up	Typically ordered by rheumatologists for patients on biologics for inflammatory arthritis
	Tendinopathy, chronic shoulder pain, non-operative rotator cuff tear
	Bursitis
	Chronic palpable mass	E.g., differentiate lipoma, sebaceous cyst, or other
	Multi nodular goiter	Follow-up studies can be used to confirm stability
	Carpal tunnel syndrome or other neuropathy	May be useful if other diagnostic tests are equivocal Usually requires specialist referral
	Baker’s Cyst	To confirm diagnosis and exclude alternate etiology
P5	Follow-up of soft tissue mass	To confirm stability

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General

**General: Overview**
P1	P2	P3	P4	P5
Immediately to 24 hours	Max 7 calendar days	Max 30 calendar days	Max 60 calendar days	Specified time
Abscess	Cancer staging or metastatic workup New suspicious palpable mass			Follow-up of breast mass

**General: Notes and Alternative Tests**
Priority Level	Potential Diagnosis	Notes and Alternative Tests
P1	Abscess
P2	Cancer staging or metastatic workup	CT is often the preferred modality
P2	New suspicious palpable mass	E.g., new breast or lymph node mass
P5	Follow-up of breast mass	To confirm stability. For additional guidance refer to BI-RADS⁶.

Vascular

**Vascular: Overview**
P1	P2	P3	P4	P5
Immediately to 24 hours	Max 7 calendar days	Max 30 calendar days	Max 60 calendar days	Specified time
	Carotid ultrasound with acute stroke/ transient ischemic attack symptoms		Carotid doppler screening	Follow-up of prior carotid surgery or stenting

**Vascular: Notes and Alternative Tests**
Priority Level	Potential Diagnosis	Notes and Alternative Tests
P2	Carotid ultrasound with acute stroke/transient ischemic attack symptoms	CT head and computed tomography angiography (CTA) is obligatory for acute stroke assessment but carotid ultrasound is a useful supplementary test Carotid ultrasound may be used to clarify the degree of stenosis if a large amount of calcified plaque is present on CTA limiting assessment or if a bruit has been heard
P4	Carotid doppler screening	For patients with high risk factors or bruit
P5	Follow-up of prior carotid surgery or stenting

Resources

Canadian Association of Radiology Diagnostic Imaging Referral Guidelines (2012)

www.car.ca/en/standards-guidelines/guidelines.aspx

American College of Radiology Appropriateness Criteria

www.acr.org/Quality-Safety/Appropriateness-Criteria

Society of Radiologists in Ultrasound

www.sru.org

Choosing Wisely Radiology Recommendations:

Radiology: choosingwiselycanada.org/radiology/

Endocrinology and Metabolism: choosingwiselycanada.org/endocrinology-and-metabolism/

Appendices

Appendix A - Ultrasound Prioritization Guideline Summary (PDF, 126 KB) https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/ultrasound-summary.pdf

Associated Documents

The following documents accompany this guideline

BC Children’s Hospital Antenatal Hydronephrosis Imaging Guideline:

References

Canadian Association of Radiologists National Maximum Wait Time Access Targets for Medical Imaging (MRI and CT).
Heimbach J, Kulik LM, Finn R, et al. AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology. 2017; Jan 28. [Epub ahead of print].
Doubilet PM, Benson CB, Bourne T, et al. Diagnostic Criteria for Nonviable Pregnancy Early in the First Trimester. N Engl J Med. 2013;369:1443-1451.
Cotescu D, Guilbert E, Benadin J et al. Medical Abortion. J Obstet Gynaecol Can 2016;38(4):366-389.
Levine D, Brown D, Andreotti RF et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Ultrasound Quarterly. 2010;26(3):121-131.
Mendelson EB, Böhm-Vélez M, Berg WA, et al. ACR BI-RADS® Ultrasound. In: ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology; 2013.

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This guideline is based on expert BC clinical practice current as of the Effective Date. This guideline was developed by the Guidelines and Protocols Advisory Committee based on the British Columbia Radiological Society Ultrasound Prioritization Guidelines (2016), and approved by the Medical Services Commission.

The principles of the Guidelines and Protocols Advisory Committee are to:

encourage appropriate responses to common medical situations
recommend actions that are sufficient and efficient, neither excessive nor deficient
permit exceptions when justified by clinical circumstances.

Contact Information
Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
Victoria BC V8W 9P1
E-mail: hlth.guidelines@gov.bc.ca
Web site: www.BCGuidelines.ca

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.

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Ultrasound Prioritization

Recommendations and Topics

Scope

Background

Priority Level Definitions

Table 1: Priority Level Definitions

Prioritization of Potential Diagnoses

Abdomen and Pelvis

Abdomen and Pelvis: Overview

P1

P2

P3

P4

P5

Immediately to 24 hours

Max 7 calendar days

Max 30 calendar days

Max 60 calendar days

Specified date

Abdomen and Pelvis: Notes and Alternative Tests

Priority Level

Potential Diagnosis

Notes and Alternative Tests

P1

P2

P3

P4

P5

Pediatrics

Pediatrics: Overview

P1

P2

P3

P4

Immediately to 24 hours

Max 7 calendar days

Max 30 calendar days

Max 60 calendar days

Pediatrics: Notes and Alternative Tests

Priority Level

Potential Diagnosis

Notes and Alternative Tests

P1

P2

P3

P4

Obstetrics and Gynecology

Obstetrics and Gynecology: Overview

P1

P2

P3

P4

Immediately to 24 hours

Max 7 calendar days

Max 30 calendar days

Max 60 calendar days

Obstetrics and Gynecology: Notes and Alternative Tests

Priority Level

Potential Diagnosis

Notes and Alternative Tests

P1

P2

P3

P4

Musculoskeletal/Extremity Overview

P1

P2

P3

P4

P5

Musculoskeletal/Extremity

Musculoskeletal/Extremity: Notes and Alternative Tests

Priority Level

Potential Diagnosis

Notes and Alternative Tests

P1

P2

P3

P4

P5