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Do you encounter resistance from colleagues regarding ultrasound use in the ED? If so, new guidelines from the Dallas-based American College of Emergency Physicians (ACEP) may be a valuable tool. "The guidelines demonstrate support of ACEP for ED ultrasound, which is a big step," says Robert Jones, DO, RDMS, FACEP, emergency ultrasound coordinator at Doctor’s Hospital in Columbus, OH. "We now have specialty-specific criteria to go by."
The guidelines provide recommendations for training, scope of practice, quality assurance, and certification of ED staff in ultrasound, says Michael Blaivas, MD, RDMS, director of emergency ultrasound at North Shore University Hospital in Manhasset, NY. "Many community EDs are being spurred on by these guidelines to pursue ultrasound implementation," he reports. (See excerpt of guidelines in this issue.)
Here are things to consider regarding ultrasound use in the ED, according to the ACEP guidelines:
• ED physicians must complete a certain number of ultrasound examinations. The ACEP guidelines recommend a total of 150 ultrasound examinations be completed before an ED physician is credentialed, including 25 trauma, 25 pregnancy evaluations, 25 cardiac, 25 aorta, 25 biliary, and 25 renal. (See Emergency Medicine Ultrasound Course Curriculum, and forms for Ob/Gyn Ultrasonography and Gallbladder Ultrasonography, below.)
However, Jones cautions that these numbers are not absolute. "The guidelines give us ballpark numbers to work with. But if someone reached that number of exams, yet their images were subquality or they were not coming up with the correct diagnosis, they won’t be granted credentials," he says. (See "Credentialing Criteria for Independent Privileges in Emergency Ultrasonography" in this issue.) The goal of the training period is to ascertain proficiency, but further exams may be needed before credentialing is granted, Jones explains. "We review all the studies done during the training exam period, and we continue to do that afterward so things don’t fall through the cracks," he says.
• You need to have an effective system to ensure quality. ED physicians should keep a log of all scans and perform their own quality assurance to improve accuracy and catch errors, Blaivas recommends. "This will also require some CME to further improve skill and knowledge," he says.
At Medical College of Georgia in Augusta, quality assurance is performed through a system of saving still images and reviewing them with a credentialed physician, says Christopher DiOrio, DO, the hospital’s emergency ultrasound coordinator. "Also, each exam is stored with interpretation and findings as noted by the performing physician," he adds. "Each physician using the ultrasound machine is critiqued, each exam performed is reviewed, and each picture is verified for validity."
After completing the criteria, not everyone will be at the same level, says Jones. "There is no guarantee that when you hit that number of 150 exams that you have expertise. There will be variability," he explains. "So you will need to have ongoing monitoring." At Doctor’s Hospital’s ED, all studies are reviewed during the credentialing period and compared to the findings of "gold standard" studies, such as computed tomography scans or operative reports.
• Consider important issues in advance. You’ll need to work out all the details before you approach administrators about implementing an ED ultrasound program, advises Blaivas. "This will be especially helpful when communicating with other departments, some of whom may see the introduction of ultrasound in the ED as a threat," he adds. (See Letter to Radiology Department, below.)
Blaivas recommends "picking your allies" to support your efforts to introduce ED ultrasound. "The most important thing is not to be short on answers when pressed by the medical board or other departments," he says. "It also helps to have things outlined in writing." (For more information about implementing an ED ultrasound program, see "Ultrasound in the ED can mean dramatic improvement in care, research shows" in ED Management, March 2001.)
• One individual should head the program. Jones advises having one physician act as a liaison and director for the ED ultrasound program. "That individual should be someone who is passionate about this, whose training is above and beyond other clinicians, and who can offer education," he says.
• Be clear about your limitations. You’ll need to convey the specific indications for ultrasound in the ED to avoid confusion, warns Jones. (See "Scope of Practice" in this issue.) "If a surgeon hears you saying in the middle of night that a gallbladder ultrasound was negative, they may mistakenly think it was done by radiology," he says. Jones explains that this could result in a dangerous misunderstanding because the ED physician may be looking for stones, but no other pathology.
Jones suggests saying the following to avoid confusion: "Dr. Smith, we saw your patient with right upper quadrant pain in the ED. Because it was during off hours, I did an ultrasound exam myself, following our agreed-upon protocol. I did a limited gallbladder ultrasound and saw no stones, no tenderness over the gallbladder, and the gallbladder had normal dimensions. So I will let her go home and follow up with you, and you can arrange for further testing." Always clarify your limitations, says Jones. "You don’t want to pawn yourself off to be a radiologist. They are looking for any sonographically detectable pathology they can find, whereas we are goal-oriented,’ he says.
For more information about the American College of Emergency Physicians’ ultrasound guidelines, contact:
• Michael Blaivas, MD, RDMS, Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. Phone: (516) 562-2927. Fax: (516) 562-2828. E-mail: email@example.com.
• Christopher DiOrio, DO, Department of Emergency Medicine, AF2037, Medical College of Georgia, 1120 15th St., Augusta, GA 30912-2800. Telephone: (706) 721-4412. Fax: (706) 721-7718. E-mail: firstname.lastname@example.org.
• Robert Jones, DO, RDMS, FACEP, Department of Emergency Medicine, Doctor’s Hospital, 1087 Dennison Ave., Columbus, OH 43201. E-mail: Jones8673@aol.com.