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You might be convinced that ultrasound use will benefit ED patients, but be prepared for opposition, warns Robert Jones, DO, FACEP, emergency ultrasound coordinator for the emergency medicine residency program at Doctor’s Hospital in Columbus, OH. "The ED use of ultrasound remains controversial," he says. "It is an extremely political issue. Most radiologists are opposed to us doing it." Here are ways to obtain buy-in from administrators and other departments:
• Produce evidence to support ED ultrasound programs. Demonstrate the acceptance of ED ultrasound use in the medical community to administrators, suggests Jones. He points to policy statements supporting this practice that have been developed by several national organizations within the last two years. "These position statements are in clear support of EDs doing this," he says. (See "Use of ultrasound imaging by emergency physicians" and "Privileging for ultrasound imaging," in this issue.)
There is also growing evidence in the literature that ED patients will benefit from ultrasound, argues Jones. Show these studies to administrators and resistant individuals in other departments, he recommends. (See reading list on ED ultrasound use, p. 31.)
• Obtain buy-in from other departments. If you want to start an ultrasound program, don’t fight this battle alone, advises Jones. "There are always going to be people who want to shoot this down," he says. "Radiologists are usually the ones that feel threatened. Their attitude is usually I did a four-year residency in this, I’m the expert.’" The ED is frequently put "under the microscope" by other departments, Jones says. "So if we take this on by ourselves, it’s very unlikely that it’s going to be successful," he says. "Your most important allies will be either surgery or obstetrics."
• Start an ultrasound program on a small scale. Jones recommends implementing ultrasound in a "baby step" fashion. "You may want to initiate a trauma ultrasound program first," he says. If your facility doesn’t see a lot of trauma cases, obstetrics is another area that has been very supportive of ultrasound, Jones suggests. "The team has been very supportive of us doing this, because it reduces their workload. At 2 a.m., if you can’t do a scan in the ED, you’ll need to get an obstetrician consult."
• Document negative outcomes as a result of inadequate ultrasound service from its typical providers. This might seem harsh, but it’s simply a quality assurance reality, says Michael Blaivas, MD, RDMS, director of emergency ultrasound at North Shore University Hospital in Manhasset, NY. "For instance, did a patient die from an abdominal aortic aneurysm because his/her diagnosis was delayed as they waited for a CT scan from radiology?" he asks. "The suspicious ED physician could have diagnosed them in one minute of the AAA being put on the differential diagnosis."
Use cases with bad outcomes as benchmark cases, Jones advises. "For example, point out that you didn’t realize a patient was bleeding internally from a car accident and that patient later crashed over in CT," he says.
• Emphasize cost savings and reimbursement. A good quality ultrasound machine can now be obtained for under $30,000, says Blaivas. "Even lower cost can be achieved with some minor cutbacks," he notes. For example, you can cut back by not buying as many probes, suggests Blaivas. "On some machines you can get a cheaper monitor or recording device," he says. "You can also obtain used equipment from a number of different companies, which can be much cheaper."
Point out to administrators how much of the cost can be recouped, advises Blaivas. "A number of emergency medicine groups are billing for the ultrasound services they provide," he says. "The billing codes are already available, and the reimbursement would, in most cases, more than pay for any investment into equipment." Factor in costs of occasional upkeep, says Blaivas. "You can either pay for it each time something needs to be fixed or adjusted, or you will have to buy a service plan," he says.
Blaivas says a service plan is best for the ED setting, where the machines occasionally can be handled roughly and damage is to be expected from time to time. "Make sure to negotiate the best price for the plan that you can," he advises.
• Explain that ultrasound will give the hospital a competitive edge. Ultrasound is an excellent marketing tool, stresses Jones. "You can tell the community that your hospital has this capability to better serve you, in the event that you experience a traumatic injury," he says. When a local hospital started an ultrasound program in the ED, it advertised with billboards depicting an ED physician and trauma surgeon standing together, with the ultrasound machine between them, notes Jones. "Once we started doing it, Ohio Health System picked up on it right away as a marketing tool," he reports. "I did a 6 o’clock news spot about our 24-hour ultrasound capability in the ED and talked about a patient with a AAA who was rapidly diagnosed."