ICUS Review Finds No State Law Explicitly Bans Credentialed Sonographers From Administering Ultrasound Contrast
The International Contrast Ultrasound Society (ICUS) has released a comprehensive review of statutes and regulations covering all 50 U.S. states and the District of Columbia, challenging a commonly cited interpretation that state laws prohibit trained and credentialed sonographers from placing intravenous (IV) lines or administering ultrasound contrast agents during contrast-enhanced ultrasound (CEUS) examinations.
The report examines the legal and regulatory framework surrounding the practice of sonography and related healthcare professions, with a particular focus on venipuncture and the administration of ultrasound contrast agents, also known as ultrasound enhancing agents. According to ICUS, the review found that most states do not specifically regulate the practice of sonography and that no state statute reviewed expressly prohibits trained and credentialed sonographers from performing these activities.
The findings could have implications for hospitals, imaging centers and physician practices that have established internal policies restricting sonographers from initiating IV access or administering ultrasound contrast. ICUS said such restrictions may sometimes be attributed to perceived state-law requirements even when the relevant state statutes do not expressly impose such a prohibition.
The organization emphasized that its review is intended to clarify the distinction between what state law requires and what individual healthcare institutions may choose to permit through their own policies, credentialing processes and clinical procedures.
Review Examines Sonography Regulations Across the United States
ICUS undertook the review following repeated concerns from sonographers, physicians and patients regarding access to CEUS examinations. According to the organization, some CEUS procedures may be delayed or denied when hospital policies require nursing personnel to initiate IV access or administer contrast, particularly when nursing staff are unavailable to perform those tasks promptly.
The review sought to determine whether such restrictions were based on explicit state laws and regulations or instead reflected institutional policies and interpretations of professional scope of practice.
The findings indicate that most states do not have dedicated statutes regulating the practice of diagnostic medical sonography. Instead, educational requirements, professional competencies and standards of practice are frequently shaped by national credentialing organizations and professional societies.
Among the organizations cited by the report is the Society of Diagnostic Medical Sonography (SDMS), whose Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer includes venipuncture and administration of ultrasound contrast agents within the activities that appropriately trained sonographers may perform under suitable supervision.
ICUS said this distinction is important because the absence of a state-specific sonography law does not necessarily establish that a particular procedure is prohibited.
No State Statute Found to Expressly Prohibit the Practice
One of the central findings of the ICUS review was that investigators did not identify a state statute expressly prohibiting trained and credentialed sonographers from placing IV lines or administering ultrasound contrast agents.
The report also identified at least four states where state-level provisions affirmatively support the practice.
Ohio authorizes the activities through statute, while New Hampshire, New Mexico and North Dakota incorporate the national sonography scope of practice into state regulations, according to the review.
These findings provide examples of different approaches to defining professional activities across jurisdictions. At the same time, ICUS noted that the regulatory environment remains subject to change and that healthcare professionals and institutions should review requirements applicable to their own jurisdictions.
Dr. Jordan Strom, an ICUS board member who helped facilitate the study, said the review was prompted in part by the consequences of interpreting the absence of specific legislative language as an outright prohibition.
Strom is an Associate Professor of Medicine at Harvard Medical School, Director of the Echocardiography Laboratory at Beth Israel Deaconess Medical Center in Boston, Massachusetts, and Co-Director of the Center for Clinical Outcomes Research at the Richard A. and Susan F. Smith Institute for Evidence, Innovation, and Policy.
According to Strom, interpreting legislative silence as a prohibition could have broad implications for sonographers because sonography is not specifically regulated through dedicated statutes in most states.
The review, he said, challenges the frequently repeated assertion that state law prevents appropriately trained sonographers from administering ultrasound contrast agents.
Distinguishing State Requirements From Institutional Policies
A major issue highlighted by ICUS is the distinction between legal requirements and institutional policies.
Hospitals and other healthcare organizations can establish credentialing standards, competency requirements, supervision procedures and internal policies that are more restrictive than the minimum requirements established by state law. Such policies may be developed for a variety of reasons, including risk management, staffing structures, institutional preferences and interpretations of professional responsibilities.
However, ICUS said healthcare providers may benefit from determining whether a restriction attributed to “state law” is actually contained in a statute or regulation or instead originates from an internal institutional policy.
The organization said this distinction may be particularly relevant when nursing staff are unavailable to perform IV-related procedures during CEUS examinations.
“If legislative silence is interpreted as a prohibition, sonographers would not be able to perform their jobs in most states,” Strom said.
He added that the review was intended to address concerns that patients may lose timely access to CEUS because of institutional policies rather than explicit legal requirements.
ICUS stressed that its findings do not mean every sonographer is automatically authorized to perform venipuncture or administer contrast at every healthcare facility. Appropriate education, training, credentialing, competency assessment, supervision and institutional authorization remain important considerations.
Nursing Scope of Practice Was Not the Focus
The report also drew a distinction between sonography regulations and nursing scope-of-practice rules.
ICUS said its review did not evaluate state nursing board rulings or nursing scopes of practice that authorize nurses to establish IV access or administer contrast agents. The organization noted that nursing boards generally regulate the nursing profession and are not responsible for establishing the scope of practice for unrelated healthcare professions.
As a result, nursing regulations were outside the principal scope of the ICUS analysis.
The distinction is relevant because healthcare institutions may rely on nursing personnel to perform IV placement and contrast administration even when appropriately trained sonographers could potentially perform those activities under their professional scope and institutional credentialing policies.
CEUS Provides a Non-Ionizing Imaging Option
The regulatory discussion comes as CEUS continues to be used in a range of diagnostic applications.
Contrast-enhanced ultrasound involves the intravenous administration of microbubble ultrasound contrast agents, which improve the visualization of blood flow and tissue perfusion. The technology can provide clinicians with real-time information that may assist in the detection, characterization and monitoring of various diseases.
Applications for CEUS include cardiovascular disease, liver disorders, kidney conditions, cancer and other medical conditions in which assessment of vascularity or tissue perfusion can provide clinically relevant information.
Unlike imaging modalities that use X-rays or other forms of ionizing radiation, ultrasound does not expose patients to ionizing radiation. CEUS therefore represents an imaging option that can provide contrast-enhanced information while retaining the non-ionizing characteristics of conventional ultrasound.
ICUS also noted that CEUS can sometimes be performed at a lower cost than alternative imaging examinations, potentially supporting its use in settings where accessibility and resource utilization are important considerations.
For CEUS to be delivered efficiently, however, the imaging team needs access to the appropriate clinical resources, including personnel capable of establishing IV access and administering the contrast agent when required.
Implications for Healthcare Organizations
Dr. Richard Barr, an ICUS board member, professor of radiology at Northeast Ohio Medical University and editor-in-chief of the Journal of Ultrasound in Medicine, said the findings could be relevant to healthcare organizations seeking to expand access to CEUS.
The review may encourage hospitals, outpatient imaging centers and physician practices to examine how their internal policies relate to state statutes, professional standards and credentialing requirements.
Rather than assuming that state law prohibits a procedure because there is no explicit state statute addressing it, organizations may need to evaluate the complete regulatory and professional framework governing their clinicians and imaging personnel.
Dr. Michael Main, an ICUS board member, professor of medicine at the University of Missouri-Kansas City, President of Saint Luke’s Physician Group and Chief Clinical Officer for BJC Health System (West Region), emphasized the importance of reviewing institutional policies.
He said healthcare organizations should ensure that their policies reflect current professional standards and consider the interests of patients while maintaining appropriate safety and competency requirements.
Radiologic Technology Regulations May Differ
The ICUS report also points to an important distinction between sonography and other imaging professions.
Although most states do not regulate diagnostic medical sonography through dedicated statutes, many states have detailed regulations governing radiologic technologists and radiologist assistants.
Those regulatory frameworks can address issues associated with exposure to ionizing radiation, which is relevant to radiography and other X-ray-based imaging technologies but does not apply in the same way to ultrasound.
ICUS said regulations governing radiologic professionals should therefore not automatically be interpreted as applying to sonographers or ultrasound contrast administration.
This distinction may be particularly important when healthcare organizations develop policies covering multiple imaging departments and professional groups.
Interdisciplinary Review Included Legal and Medical Experts
The ICUS report was prepared by an interdisciplinary team involving legal and medical professionals. Contributors included Linda Feinstein and Eugene Giudice of Dentons US, Norah Guenthner of New York University, and Strom.
The involvement of legal and clinical professionals was intended to provide a broader examination of the regulatory landscape and its relationship to clinical practice.
The review does not establish a universal authorization for sonographers to administer ultrasound contrast agents. Instead, its findings are intended to clarify what state statutes and regulations reviewed by the investigators do and do not expressly require.
ICUS emphasized that laws, regulations and professional standards can change. Healthcare organizations and individual providers therefore need to evaluate the requirements applicable in their specific jurisdictions and clinical environments.
Potential Impact on CEUS Access
The report’s findings could prompt healthcare organizations to reassess policies that limit sonographer involvement in IV placement or ultrasound contrast administration when those policies are based on an assumption that state law prohibits the practice.
For patients, the issue can have practical consequences. If a CEUS examination requires an IV and trained sonographers are not permitted to establish access because of an institutional policy, the examination may have to wait for another qualified healthcare professional. Where staffing is limited, this could potentially contribute to scheduling delays.
ICUS argues that reviewing these policies against actual state statutes, professional standards and institutional credentialing requirements could help organizations determine whether existing restrictions remain necessary.
At the same time, the organization recognizes that patient safety, appropriate training and competency remain central considerations. Any expansion of sonographer responsibilities would need to occur within applicable legal, professional and institutional frameworks.
Overall, the ICUS review presents a detailed examination of the legal landscape surrounding sonographers and ultrasound contrast administration in the United States. Its central finding is that the investigators did not identify a state statute expressly prohibiting trained and credentialed sonographers from placing IV lines or administering ultrasound contrast agents. The review also identified four states—Ohio, New Hampshire, New Mexico and North Dakota—with provisions affirmatively supporting the practice in specified ways.
For hospitals, imaging centers and physician practices, the findings highlight the importance of distinguishing explicit legal requirements from internal policies and professional standards. As CEUS continues to support diagnostic evaluation across cardiovascular, liver, kidney and cancer care, ICUS said greater clarity around sonographer scope of practice could help healthcare organizations evaluate policies that may affect timely access to this imaging technology.
About ICUS
The International Contrast Ultrasound Society (ICUS) is a nonprofit medical society dedicated to advancing the safe and medically appropriate use of contrast-enhanced ultrasound (CEUS) worldwide. Through education, research and advocacy, ICUS works to improve patient access to CEUS and promote best practices in the use of ultrasound contrast agents.