Monday, March 15, 2004

Implementing Emergency Ultrasound at the Bedside

The only constant in life is change. Change in ourselves and our practices is a reality and it’s ostensibly why those who regulate us prescribe minimum continuing medical education, periodic specialty recertification and other requirements. We ourselves mostly strive for more than those minimums for our own self-satisfaction and our patients’ well-being. Yet, try as we might, maintaining the clinical edge can be wearing.

My inspiration for this column comes from every clinician’s struggle for clinical currency, particularly as I observe colleagues over the past year or more adding emergency bedside ultrasonography to their practice armamentarium. At weekly case discussions, opportunities for bedside ultrasound are scrutinized for the effect on the patient’s outcome. Unspoken, but obviously considered by some of my junior colleagues is why wasn’t a particular patient studied with bedside emergency ultrasound in a particular instance? Did it have anything to do with the experience and training of the emergency physician?

Introducing emergency ultrasound (EUS) at my hospital has been more than a year-long project, fraught with difficulty and expense. I’m glad we proceeded and today have staff utilizing EUS regularly. Obviously, we needed to have a trained faculty if we were to teach our residents the skill, now required for an approved EM residency. Though we have a process for privileging our staff for EUS, the rate of acquisition of those privileges remains painstakingly slow. Am I supporting our physicians appropriately? How should I speed up the rate of acquisition of EUS skills among our nearly 30 physician staff?

First, since I know from conversations with colleagues that EUS isn’t universally deployed and so some of you may be interested in how we proceeded. Your hospital may require some variation, but in general, if you’re adding a new procedure to your list of privileges—and EUS was clearly a new procedure for us—the JCAHO requires that your medical staff process oversees the addition of EUS to your privileging list.

Since it’s likely that most of your staff, even if residency trained, completed training prior to the routine deployment of EUS, you’ll have to address the training and experience deficiency as part of the implementation. Therein lies much of the difficulty and expense—depending on the size of your staff, even more expense than the capital acquisition of and ultrasound machine itself.

We were fortunate because one of our staff had some relevant ultrasound experience from her obstetrical training, undertaken for several years before entering and completing an emergency medicine residency. She, as assistant residency director had been with us for several years and was a well respected by colleague, even by more senior staff. It would have been difficult if our only potential leader for our EUS program came from the ranks of newest graduates on our staff.

My somewhat experienced colleague had urged the purchase of an ultrasound machine for some time, so we went ahead and purchased one after a seeing several machines from different vendors. We tried several out for a week or so each in the ED before making the decision to buy. We had few users, but the availability of the device meant that some consultants could also use the machine and surgeons, cardiologists and obstetricians all did make use of it.

My colleague, though she was eager to proceed, felt that she needed to complete more formal training, both because of the limited focus of her previous experience and the period that had elapsed since her obstetrical experience. So we supported her for a month upstate where at another ED with an established EUS program she completed a self-study, didactic and practical program that gave her the skills and experience recommended by ACEP for an emergency physician performing EUS. Of course we paid her salary during this time and we paid her tuition, travel and living expenses at the other facility as well.

There she learned the techniques for the five core indications:

1. fluid, i.e., blood, in the abdominal cavity secondary to trauma or other causes including ruptured ectopic pregnancy;

2. echocardiography for cardiac activity and pericardial effusion/tamponade;

3. abdominal aortic aneurysm;

4. biliary ultrasound for cholelithiasis and cholecystitis;

5. renal ultrasound for obstruction.

She performed each of these studies in scores of patients so that she could gain experience both with normal and abnormal studies. All of her studies were reviewed by an experienced emergency physician and ultrasonographer—some in real-time, but many through static images and chart alone.

After returning home we then took our draft credentialing process to the chairman of radiology—merely as a courtesy—and to the chairman of the medical staff credentials committee. I also met with several of the medical staff officers and with several surgeons who were performing intra-operative ultrasound of the liver during intra-abdominal cancer surgeries. I brought not only our documents, but the documents from ACEP and SAEM on EUS and adopted AMA resolutions relevant to overlap of credentials among specialties and the entitlement of departments to credential their own staff.

I won’t tell you that all was smooth sailing thereafter. It was not. I was disappointed when the chairman of radiology rather than confronting me directly, instead wrote to the chair of the credentials committee. The same radiologist later relented and stood aside. He recognized that his department wasn’t providing the service around the clock and that our residency was dependent upon our developing facility with these focused studies which aid in answering specific clinical questions.

We ultimately gained executive committee support and implemented the ACEP guidelines as our process. A weekend of formal training for half the staff and the ardent support and engagement of a number of junior faculty who were trained in their residency means that we are doing more examinations all of the time. Yet, still some lag in acquiring the skill. How shall I address it?

Though our staff expect testing on ultrasound in the ABEM recertification program going forward, the pace of adoption remains slower than I like. I’ve continued my persuasion, arguing the value to patients of early decisions, consultation and disposition of bedside EUS. How have you brought this skill to the entirety of your staff or are you struggling also? Offering the training alone hasn’t been sufficient; what am I missing? Please write and share your thoughts.