Physicians, radiologists clash over the use of ultrasound in the ED

Proponents say using ultrasound in the ED to diagnose potentially life-threatening disease states improves outcomes and is more cost-effective. Opponents question whether emergency clinicians are held to the proper standards.

Why are certain technologies slow in gaining acceptance in ED? In the case of ultrasound, a growing cadre of emergency physicians has advocated the wider use of ultrasound studies in evaluating patients with suspected ectopic pregnancies or symptomatic aortic aneurysms.

Proponents say using the technology saves time-to-surgery, decreases morbidity, and potentially raises the rate of positive outcomes substantially through early intervention. Furthermore, the equipment is portable, easy to use, and inexpensive in light of its value in offsetting risk-management concerns surrounding faulty diagnoses.

Cost-savings are questioned

Those are important concerns in these cost-conscious days of managed care, advocates contend. Evidence suggests that using ultrasound in the ED can shorten hospital stays, lessen dependence on consulting physicians and radiologists, and it has the potential to increase patient satisfaction measures. But few studies conclusively support these claims.

Last year, the use of ultrasound in the ED was amply explored in the clinical literature. The Annals of Emergency Medicine ran a series of articles that advocated directed ultrasound studies in detecting ectopics and gall bladder disease.

But most hospitals have been slow to embrace the technology for the ED particularly in evaluating blunt abdominal and penetrating cardiac wounds.

Why? "It's a political hot potato," says Stephen R. Hoffenberg, MD, a proponent of ED ultrasound usage. "The radiology lobby says it's concerned about quality and physician credentialing. But it's really all about money and turf," contends Hoffenberg, president of Denver-based CarePoint PC, a 100-member emergency group practice.

Hospitals shouldn't take risks

Ultrasound specialists beg to differ while airing their own concerns. Radiologist Lennard Greenbaum, MD, cautions that hospitals shouldn't take lightly the importance of tough physician credentialing and the extensive administrative requirements of maintaining a quality ultrasound program in any department.

"If emergency physicians want to meet the established criteria for ultrasound, God bless them. But hospitals should not keep one set of credentialing standards for radiology and another for emergency," says Greenbaum, co-director of The Hughes Center for Fetal Diagnostics at Arnold Palmer Hospital for Children and Women in Orlando, FL.

Greenbaum also serves as secretary of the American Institute of Ultrasound in Medicine (AIUM), a professional group in Laurel, MD, which maintains ostensibly tough credentialing criteria that govern ultrasound professionals. (For a copy of AIUM's credentialing criteria, see the editor's note at the end of this article.)

Most hospitals that allow ultrasound studies to be done by emergency physicians tend to establish their own standards, Hoffenberg states. And that's how it should be, argues Lt. Cmdr. Thomas K. Tandy, MD, an emergency physician at the U.S. Naval Medical Center in Portsmouth, VA and an ultrasound advocate.

The credentialing criteria for emergency physicians shouldn't be confused with "the criteria required for the performance of a complete abdominal or pelvic ultrasound examination by a radiologist," he writes with Hoffenberg in a 1996 article.1

"In the ED, we're asking very specific questions and using ultrasound to look for very specific answers," Tandy told The Managed Care Emergency Department. Tandy further writes: "Emergency physicians have safely and accurately performed limited ultrasound examinations in the ED using less stringent training and credentialing criteria than those required by other specialists."1

Physicians push for credentialing

Aware of the necessity for achieving credibility, emergency physicians are nevertheless pushing for stronger credentialing and quality improvement programs. By establishing such standards, they hope to gain greater hospital approvals, says Tandy.

But unimpeachable, universal standards for ED ultrasound have been slow in coming, despite efforts by such notable bodies as the Society for Academic Emergency Medicine in Lansing, MI and the American College of Emergency Physicians in Irving, TX.

The lack of conclusive data to support patient-care and cost-savings claims hasn't helped either. It's another reason that hospitals haven't rushed in to rubber-stamp approvals. Managed care organizations (MCOs) haven't paid much heed either, although some, like Kaiser Permanente Medical Foundation in Oakland, CA, are exploring the idea.

But these issues shouldn't hinder a hospital from moving toward establishing a quality program, Hoffenberg states. The goal of an ED ultrasound program should be five-fold:

    · to provide the service to patients on an immediate basis in the presence of high mortality or morbidity-24 hours a day, seven days a week; (This is the strongest reason for maintaining an ultrasound program in the ED, proponents say.)

    · to establish the scope of ED ultrasound studies and provide the proper documentation for their indication and results;

    · to ensure that physicians providing the ultrasound service be properly trained, experienced, and credentialed in emergency ultrasonography; (For suggested training and education criteria from Tandy and Hoffenberg, see the chart on page 7.)

    · to create a monitoring and quality improvement program that can track the service's effectiveness in determining diagnosis and outcomes;

    · to obtain equipment that can effectively achieve the previous four goals.

Radiology standards are tougher

Radiologist Greenbaum of AIUM maintains that in actuality, emergency physicians fall short of meeting acceptable training and experience standards. This concerns him.

He questions whether EDs are staffed or equipped to meet the rigorous coding and documentation guidelines to avoid fraud-and-abuse issues or the filing systems that are designed to efficiently track patients for follow-ups or complications.

"Is a hospital willing to take the medical and legal risk of allowing physicians in two separate departments operate under different standards? That's the question," Greenbaum asks.

Editor's note: To obtain a copy of the American Institute of Ultrasound in Medicine (AIUM) credentialing criteria, contact: Stephanie Reisberg, public affairs, AIUM, 14750 Sweitzer Lane, Suite 400, Laurel, MD. Telephone: (301) 498-4100. Fax: (301) 498-4450. E-mail: http://www.aium.org

Reference

    1. Tandy TK, Hoffenberg S. Emergency department ultrasound services by emergency physicians: model for gaining hospital approval. Ann Emerg Med 1997;29:367-373.