“There’s a ghost in the library”
Documentation in medicine has transformed in the last 10 years: notes no longer scatter across the floor to reveal hurriedly scribbled ward rounds without signature or ownership. In the digital era, we can proudly say that ‘if it wasn’t written down it didn’t happen’. By extension, in the modern world of acute echocardiography, if it wasn’t ‘uploaded and reported’, it didn’t happen. These ‘ghost studies’ roam hospital corridors ready to interfere with patient care in maverick ways. All we are left with clinically is a rumour that a study possibly happened. There should be zero ‘ghost studies’ in our library. But, evidently, the ghosts are yet to be busted.
“I ain’t afraid of no ghosts”
Work-flow in outpatient echocardiography departments lends itself to the process of performing and reporting in tandem. By the time the patient has left the department, the report is written, images archived and, if needed, an on-hand senior opinion sought. The audit cycle is clear and tight.
In the world of acute care echocardiography, that focus changes from a cycle of ‘perform-upload-report’, to ‘perform-decide-act’.
“Don’t cross the streams!”
Governance must sometimes come second to patient care. Some echo findings are so time-critical that it is life-saving not to carry on and finish the study. In a recent case from our clinical practice, the life of a 37-year-old peripartum woman depended upon not finishing the study, and instead putting the probe down and picking up the thrombolysis. But what really saved her life was governance. After thrombolysis, the study was continued. It demonstrated ongoing life-threatening right heart dysfunction. Thrombolysis alone was not enough. Governance drove her care into the interventional laboratory, and her life was saved by emergency clot retrieval from both pulmonary arteries.
The high-profile case of the 17-year-old amateur boxer, Christian Hobbs, who died of unrecognised acute myocarditis in 2017, underlines this point precisely. The senior coroner who heard Christian’s case, issued a section 28 to several medical bodies demanding to know why the loop failed to close on key acute care investigations as they happened during his attempted resuscitation.1 The signs of cardiogenic shock were there to be seen, but the loop wasn’t closed in time. There can be no starker description of how governance saves lives in real-time.
“Why worry, each one of us is carrying an unlicensed nuclear accelerator on our back”
This is not a single specialty issue. This warning applies to cardiology, acute medicine, critical care, pre-hospital care, emergency medicine, and any clinical setting where sick patients present and echocardiography is used to guide emergency care.
2025 data from Seskatchewan in Canada, describes a 0% baseline upload rate of point-of-care ultrasound studies (PoCUS) performed in acute medicine in a single large centre.2 A second 2025 publication, looking at ghost-imaging rates for PoCUS studies in acute trauma patients across four major trauma centres in the US, was up to 93.2% in some centres.3
There are no balancing studies in the literature describing excellent rates of upload and reporting in acute ultrasound and echocardiography services. The dangers are clear and the time for change is now.
“I’m fuzzy on the whole good/bad thing”
Effective governance in the acute setting needs to be individualised to its location. Governance of an outpatient service does not map directly to governance in an acute setting … one size plasma proton beam will not trap all ghosts!
There are, however, translatable principles, such as those described by the excellent British Society of Echocardiography (BSE) Echo Quality Framework.4 The power of these governance principles is that they form a basis for framing bespoke ‘intelligent enquiry’ into an individual service. I have found them most effective when used in this flexible way, and not as prescriptive protocol. Learning to govern the Oxford Critical Care Echocardiography Service over the last 18 years has taken me from a governance approach of ‘counting things’, to a destination approach of ‘noticing things’, linked directly to action.
There are some very practical issues around the governance of an acute echocardiography service which make governance harder:
- Equipment faces a daily battle for survival in a harsh environment.
- Uploading points and reporting stations are not always available where the patient is being cared for: therefore, the importance of uploading and reporting directly after the study has had its clinical effect needs to be hard-wired into the whole team.
- The team rotates quickly and new team members need to be kept quickly and fully up to speed with the governance process.
- Team members need to know how to access immediate senior support to ensure studies are reviewed in a timely way: this needs to happen in 100% of cases to avoid technical imaging difficulty driving deliberate ghosting of a study.
- Individual education is vital because imaging results matter immediately, not after a scheduled multi-disciplinary team (MDT) meeting.
- Team cohesion needs to be maintained, even where a service runs ‘without walls’.
“Who you gonna call?”
I found that the single most powerful step towards meeting this unique governance challenge is to appoint a governance lead with the curiosity, time, and freedom to observe their service intelligently: not just to count things, but to ‘notice’ things, plan and act in a way that works for their service and their patients.
An acute echo governance lead prevents equipment damage and failure, team dissipation and high-risk individualised practice. Without a governance lead, uploading rates fall away because no one is watching, reporting rates vary, and care quality drops because there is no port of call for urgent queries. The service fades away leaving patients exposed.
The existence of the governance lead itself is powerful: further effective governance interventions do not need to be complex. One of the most effective interventions I make in my own service is the weekly review of a case at random from start to finish. I review each step in the governance chain, and address issues as they arise. It often gives me the opportunity to deliver a compliment to a team member who has elevated patient care through tight governance; positive feedback is an immensely powerful governance intervention.
Data from the two studies above tell a similar story. Upload rates were lowest in the trauma cohort when findings were declared to be normal.3 Upload rates rose from 0 to 70% in the Seskatchewan cohort with an educational intervention taking the residents through the process of upload: operators simply didn’t know how to upload, or fully appreciate the importance of reporting ‘normal’.2
Acute echocardiography services ‘without walls’ are developing rapidly. They are vital to patient care and will become the norm in every acute specialty. We have a unique opportunity to angle our united multi-specialty efforts towards excellence, and this conversation needs to be an international one. Let’s go and bust some ghosts.
Conflicts of interest
None declared.
Funding
None.
References
1. Heming D. Christian Hobbs: prevention of future deaths report. London: Courts and Tribunals Judiciary, 7 April 2025. Available from: https://www.judiciary.uk/prevention-of-future-death-reports/christian-hobbs-prevention-of-future-deaths-report/ [accessed January 2026].
2. Kolbenson L, Salman T, Oro A, Olszynski P. Seeing ghosts: a quality improvement intervention to decrease phantom scanning through increased image archiving of POCUS by internal medicine residents. POCUS J 2025;10:11–18. https://doi.org/10.24908/pocusj.v10i01.17775
3. Boivin Z, Dwyer KH, Pare JR et al. Prevalence of ghost scans in point-of-care ultrasound for trauma patients: a multicenter study. Am J Emerg Med 2026;99:354–8. https://doi.org/10.1016/j.ajem.2025.10.043
4. British Society of Echocardiography. About the Echo Quality Framework (EQF). Available at: https://www.bsecho.org/Public/Public/Accreditation/Departmental-accred/About-EQF.aspx
