With ED Ultrasound, Credentialing Is at Issue

Dangerous practice could result

One of the major issues currently facing emergency ultrasound is credentialing, according to Leonard Bunting, MD, FACEP, assistant professor of emergency ultrasound at Wayne State University and emergency ultrasound director at St. John Hospital & Medical Center, both located in Detroit, MI.

Although bedside ultrasound has been required content for years in emergency medicine residencies, many of the graduating residents end up practicing in hospitals without privileges in place for emergency ultrasound.

"So they have the education, the skill, and the machine, but are unable to incorporate ultrasound into their practice," says Bunting.

This could lead to the dangerous practice of physicians performing studies, allowing it to affect their decision making, but failing to properly document their findings. "From a legal standpoint, this is a nightmare," says Bunting. "More programs need to pursue privileging in emergency ultrasound to lend validity and rigor to the practice."

Michael Blaivas, MD, RDMS, vice president of Bear, DE-based Emergency Ultrasound Consultants and director of emergency ultrasound at Northside Hospital in Atlanta, GA, points to a notable case from the Midwest. An emergency physician with no ultrasound credentialing from the hospital and incomplete training decided to rule out an ectopic pregnancy.

The ED physician mistook the ectopic pregnancy sitting just behind the uterus on the scan as being in the uterus. The patient was sent home and her ectopic ruptured at home.

"She sued, but interestingly enough, the emergency physician was not named due to an oversight by the plaintiff attorney," says Blaivas. "The emergency physician should have easily realized this was an ectopic if [he] had performed a standard point of care evaluation of the uterus."

To avoid situations like these, a strong quality assurance and improvement process is necessary. "Our use of ultrasound requires both the technical skill to obtain the images and the knowledge base to appropriately interpret them," says Bunting. "Monitoring your department's performance ensures no one is falling behind."

Verify Training, Skill

Blaivas says "there has been a tendency to simply let people fly by the seat of their pants with ultrasound in the ED."

One example is ultrasound-guided central line placement. "Many programs have made the assumption that if an emergency physician can put in a line blindly, they can definitely do it with ultrasound and need almost no training and credentialing," says Blaivas. "Unfortunately, this is not true."

In fact, there are some complications that can occur specifically with ultrasound guidance if someone does not adhere to, or never learned, proper technique, says Blaivas.

"If you have a complication and bad outcome using ultrasound, which is supposed to make the procedure nearly foolproof, how do you explain it other than malpractice?" says Blaivas. "At least this is what will be said to the jury by the plaintiff. Fortunately, it is not hard to avoid."

Blaivas says that until EDs can be confident that all graduating residents are well-trained in ultrasound use, it is important for a department to have a credentialing process and verify training and skill.

"This is especially the case for practicing physicians that did not get ultrasound training in residency. This is not a block to ultrasound use, but a safety measure," says Blaivas.

To ensure safety, he recommends the following:

• Implementing a structured credentialing process and good quality assurance process.

• Requiring re-credentialing every several years.

• Requiring CME training in ultrasound on a regular basis.

• Working with others in the hospital. Discuss how ultrasound will decrease your institution's liability, increase safety and improve patient care and satisfaction. The idea is to be sure the ED ultrasound program is not operating in a vacuum. "While your radiologists may not be happy you are using ultrasound, other colleagues may love it and even send you patients," says Blaivas.

• Making sure that ED physicians are performing well thought-out applications, with finite end points and focused questions. "We cannot and should not duplicate the services provided by a full-time radiology ultrasound suite," says Blaivas. "We simply have no use for most of their examinations."

• Having a policy when incidental findings arise.

You are looking at a gallbladder and think you see something in the kidney. You realize it might be a mass and scan it, but still aren't sure. What do you do?

"Be upfront with the patient that your examination was focused and it is not part of your practice to find renal tumors, but you simply cannot ignore the finding," says Blaivas. "Then, decide if this needs immediate follow-up testing or outpatient follow-up."


For more information, contact:

• Robert D. Kreisman, JD, Kreisman Law Offices, Chicago, IL. Phone: (312) 346-0045. Fax: (312) 346-2380. E-mail: bob@robertkreisman.com. Web: www.robertkreisman.com