Other Settings or Populations

Other Settings or Populations

Competency and Curriculum Recommendations

Competency in EUS requires the progressive development and application of increasingly sophisticated knowledge and psychomotor skills for an expanding number of EUS applications. This development parallels the performance of any EUS exam.

The ACEP definition of US competency includes the following components. First, the clinician needs to recognize the indications and contraindications for the EUS exam. Next, the clinician must be able to acquire adequate images. This begins with an understanding of basic US physics, translated into the skills needed to operate the US system correctly (knobology), while performing exam protocols on patients presenting with different conditions and body habitus. Simultaneous with image acquisition, the clinician needs to interpret the imaging by distinguishing between normal anatomy, common variants, as well as a range of pathology from obvious to subtle. Finally, the clinician must be able to integrate EUS exam findings into individual patient care plans and management. Ultimately, effective integration includes knowledge of each particular exam accuracy, as well as proper documentation, quality assurance, and EUS reimbursement. See ACEP linked resources at http://www.acep.org/sonoguide .

An EUS curriculum requires considerable faculty expertise, dedicated faculty time and resources, and departmental support. These updated guidelines continue to provide the learning objectives (See Appendix 2 ), educational methods, and assessment measures for any EUS residency or practice-based curriculum. As part of today’s effort to reinvent medical education, all educators are now faced with the challenge of creating curricula that provide for individualized learning yet result in the standardized outcomes such as those outlined in current residency milestones.

Innovative Educational Methods and Assessment Measures

As a supplement to traditional EUS education already described in previous guidelines, recent online and technological innovation is providing additional individualized educational methods and standardized assessment measures to meet this challenge. Free open access medical (FOAM) education podcasts and narrated lectures provide the opportunity to create the flipped EUS classroom. For the trainee, asynchronous learning provides the opportunity to repeatedly review required knowledge on demand and at their own pace. For educators, less time may be spent providing recurring EUS didactics, and more time dedicated to higher level tasks such as teaching psychomotor skills and integration of exam findings into patient and ED management. Both EUS faculty and trainees together may identify potential FOAM resources. However, EUS faculty must now take the new role of FOAM curator. New online resources must be carefully reviewed to ensure that each effectively teaches the objectives in these guidelines before being introduced into an EUS curriculum.

Similar to knowledge learning, there are new educational methods to teach the required psychomotor skills of EUS. The primary educational method continues to be small group hands-on training in the ED with EUS faculty, followed by supervised examination performance with timely quality assurance review. Simulation is currently playing an increasingly important role as both an EUS educational method and assessment measure. Numerous investigators have demonstrated that simulation results in equivalent image acquisition, interpretation, and operator confidence in comparison to traditional hands-on training. US simulators provide the opportunity for deliberate practice of a new skill in a safe environment prior to actual clinical performance. The use of simulation for deliberate practice improves the success rate of invasive procedures and reduces patient complications. Additionally, simulation has the potential to expose trainees to a wider spectrum of pathology and common variants than typically encountered during an EUS rotation. Blended learning created by the flipped classroom, live instructor training, and simulation provide the opportunity for self-directed learning, deliberate practice and mastery learning.

Simulation also provides a valid assessment measure of each component of EUS competency. Appropriately designed cases assess a trainee’s ability to recognize indications, demonstrate image acquisition and interpretation, as well as apply EUS findings to patient and ED management. These proven benefits and the reduction in direct faculty time justify the cost of a high fidelity US simulator. Furthermore, costs may be shared across departments.

Documenting Experience and Demonstrating Proficiency

Traditional number benchmarks for procedural training in medical education provide a convenient method for documenting the performance of a reasonable number of exams needed for a trainee to develop competency. However, learning curves vary by trainee and application. Individuals learn required knowledge and psychomotor skills at their own pace. Supervision, opportunities to practice different applications and encounter pathology also differ across departments.

Therefore, in addition to set number benchmarks individualized assessment methods need to be utilized. Recommended methods include the following: real time supervision during clinical EUS, weekly QA teaching sessions and image review, ongoing QA exam feedback, standardized knowledge assessments, small group Observed Structured Clinical Examinations (OSCEs), one-on-one standardized direct observation tools (SDOTs), simulation assessments and other focused educational tools. Ideally these assessment measures are completed both at the beginning and the end of a training period. Initial assessment measures identify each trainee’s unique needs, providing the opportunity to modify a local curriculum as needed to create more individualized learning plans. Final assessment measures demonstrate current trainee competency and future learning needs, as well as identify opportunities for improvement in local EUS education.

Training Pathways

There are two recommended pathways for clinicians to become proficient in EUS. See Figure 3 . The majority of emergency physicians today receive EUS training as part of an ACGME-approved EM residency. A second practice-based pathway is provided for practicing EM physicians and other EM clinicians who did not receive EUS training through completion of an EM residency program.

Pathways for emergency ultrasound training, credentialing, and incorporation of new applications.

These updated EUS guidelines continue to provide the learning objectives, educational methods and assessment measures for either pathway. Learning objectives for each application are described in Appendix 2 .

Residency-Based Pathway

EUS has been considered a fundamental component of emergency medicine training for over two decades. The ACGME mandates procedural competency in EUS for all EM residents as it is a “skill integral to the practice of Emergency Medicine” as defined by the 2013 Model of the Clinical Practice of EM. The ACGME and the American Board of Emergency Medicine (ABEM) recently defined twenty-three sub competency milestones for emergency medicine residency training. Patient Care Milestone twelve (12) describes the sequential learning process for EUS and should be considered a guideline in addition to other assessment methods mentioned in this guideline. Appendix 3 provides recommendations for EM residency EUS education.

Upon completion of residency training, emergency medicine residents should be provided with a standardized EM Resident EUS credentialing letter. For the EUS faculty, ED Director or Chairperson at the graduate’s new institution, this letter provides a detailed description of the EUS training curriculum completed, including the number of quality reviewed training exams completed by application and overall, and performance on SDOTs and simulation assessments.

Practice Based Pathway

For practicing emergency medicine (EM) attendings who completed residency without specific EUS training, a comprehensive course, series of short courses, or preceptorship is recommended. Shorter courses covering single or a combination of applications may provide initial or supplementary training. As part of pre-course preparation, EUS faculty must consider the unique learning needs of the participating trainees. The course curriculum should include trainee-appropriate learning objectives, educational methods and assessment measures as outlined by these guidelines. If not completed previously, then introductory training on US physics and knobology is required prior to training in individual applications. Pre-course and post-course online learning may be utilized to reduce the course time spent on traditional didactics and facilitate later review. Small group hands-on instruction with EUS faculty on models, simulators, and task trainers provides experience in image acquisition, interpretation, and integration of EUS exam findings into patient care. See Appendix 4 .

Preceptorships typically lasting 1-2 weeks at an institution with an active EUS education program have also been utilized successfully to train practicing physicians. Each preceptorship needs to begin with a discussion of the trainees’ unique educational needs, hospital credentialing goals as well as financial support for faculty teaching time. Then the practicing physician participates in an appropriately tailored curriculum typically in parallel with ongoing student, resident, fellow and other educational programming.

Similar to an EM Resident EUS credentialing letter, course and preceptorship certificates should include a description of the specific topics and applications reviewed, total number of training exams completed with expert supervision, performance on other course assessment measures such as SDOTs or simulation cases, as well as the number of CME hours earned. These certificates are then given to local EUS faculty or ED Director/Chairperson to document training.

Advanced Practice Providers, Nursing, Paramedics, and other EM clinicians

In many practice environments, EUS faculty often provide clinical US training to other to non-physician staff including Advanced Practice Professionals, Nurses, Paramedics, Military Medics and Disaster Response Team members. The recommendations in these guidelines should be utilized by EUS faculty when providing such training programs. Pre-course preparation needs to include discussions with staff leadership to define role-specific learning needs and applications to be utilized. Introductory US physics, knobology, and relevant anatomy and pathophysiology are required prior to training in targeted applications.

For Advanced Practice Providers and other clinicians practicing in rural and austere environments where direct EUS trained EM physician oversight is not available, EUS training needs to adhere to the recommendations in these guidelines. Specifically, comprehensive didactics and skills training, as well as minimum benchmarks need to be completed prior to independent EUS utilization. Beyond this initial training, EUS faculty are needed to provide ongoing quality assurance review. Telemedicine may provide the opportunity for real time patient assessment, assistance with image acquisition, and immediate review of patient images.

Ongoing Education

As with all aspects of emergency medicine, ongoing education is required regardless of training pathway. The amount of education needed depends on the number of applications being performed, frequency of utilization, the local practice of the individual clinician and other developments in EUS and EM. Individual EUS credentialed physicians should continue their education with a focus on US activities as part of their overall educational activities. Educational sessions that integrate US into the practice of EM are encouraged, and do not have to be didactic in nature, but may be participatory or online. Recommended EUS educational activities include conference attendance, online educational activities, preceptorships, teaching, research, hands-on training, program administration, quality assurance, image review, in-service examinations, textbook and journal readings, as well as morbidity and mortality conferences inclusive of US cases. US quality improvement is an example of an activity that may be used for completion of the required ABEM Assessment of Practice Performance activities.

Fellowship Training

Fellowships provide the advanced training needed to create future leaders in evolving areas of medicine such as clinical US. This advanced training produces experts in clinical US and is not required for the routine utilization of EUS.

An EUS fellowship provides a unique, focused, and mentored opportunity to develop and apply a deeper comprehension of advanced principles, techniques, applications, and interpretative findings. Knowledge and skills are continually reinforced as the fellow learns to effectively educate new trainees in EUS, as well as clinicians in other specialties, and practice environments. A methodical review of landmark and current literature, as well as participation in ongoing research, creates the ability to critically appraise and ultimately generate the evidence needed for continued improvements in patient care through clinical US. Furthermore, fellowship provides practical experience in EUS program management including quality assurance review, medical legal documentation, image archiving, reimbursement, equipment maintenance, and other administrative duties of an EUS program director.

Recommendations for fellowship content, site qualifications, criteria for fellowship directors, and minimum graduation criteria for fellows have been published by national EUS leadership and ACEP Emergency Ultrasound Fellowship Guidelines. Each fellowship program’s structure and curriculum will vary slightly based on local institution and department resources. At all fellowship programs, mentorship and networking are fundamental to a fellow’s and program’s ultimate success. Both require significant EUS faculty time for regular individual instruction as well as participation in the clinical US community locally and nationally. Hence, institution and department leadership support is essential to ensuring an appropriate number of EUS faculty, each provided with adequate non-clinical time.

For the department, a fellowship speeds the development of an EUS program. Fellowships improve EM resident training resulting in increased performance of EUS examinations. Furthermore, a fellowship training program may have a significant positive impact on overall EUS utilization, timely quality assurance review, faculty credentialing, billing revenue, and compliance with documentation. For an institution, an EUS fellowship provides a valuable resource for other specialties just beginning clinical US programs. Collaborating with EUS faculty and fellows, clinicians from other departments are often able to more rapidly educate staff and create effective clinical US programs.

US in Undergraduate Medical Education

Emergency Medicine has again taken a lead role in efforts to improve Undergraduate Medical Education (UME) through the early integration of clinical US. During the preclinical years, US has been demonstrated to be an effective educational method to reinforce student understanding of anatomy, physical examination skills, pathology and bedside diagnostic skills. During the clinical years, students are then better able to utilize US for clinical diagnosis and on specific rotations. US exposure in UME can provide a solid knowledge base for individuals to build upon and later utilize as US is integrated into their clinical training.

Integrating US into UME

Integration of US into pre-clinical UME often begins with medical student and faculty interest. By working closely with a medical school’s curriculum committee, US may then be incorporated as a novel educational method to enhance learning within existing preclinical courses. Although dedicated US specific curriculum time is not often available in UME, considerable clinical US faculty time and expertise is still required for effective integration of US into existing medical school courses. Widespread clinical US utilization by different specialties within a medical school’s teaching hospitals, and education within Graduate Medical Education programs, provides initial faculty expertise, teaching space, and US equipment. Ongoing education then requires local departmental and medical school leadership support, as well as continued organized collaboration between faculty from participating specialties.

Innovative educational methods again provide the opportunity for clinical US faculty to focus on small group hands-on instruction as described in the innovative education section.

Many academic departments that currently offer clinical rotations within Emergency Medicine already include an introduction to EUS as a workshop, or a set number of EUS shifts. Dedicated EUS elective rotations provide an additional opportunity for medical students interested in Emergency Medicine and other specialties utilizing clinical US to participate in an EUS rotation adapted to their level of training and unique career interests. See Appendix 5 for recommendations for EUS and Clinical US medical school rotations.

US in UME continuing into Clinical US in GME

UME US experience should prepare new physicians to more rapidly utilize clinical US to improve patient care during graduate medical education (GME) training. Medical students today therefore should graduate with a basic understanding of US physics, machine operation, and common exam protocols such as US guided vascular access. Medical students matriculating from a school with an integrated US curriculum, as well as those completing an elective clinical US rotation, should be provided with a supporting letter similar in regards to didactics, hands-on training, and performed examinations. Although all trainees need to complete the EUS residency milestones, trainees with basic proficiency in clinical US from UME training may progress more rapidly and ultimately achieve higher levels of EUS expertise during GME. Additionally, these residents may provide considerable EUS program support as peer-to-peer instructors, residency college leaders, investigators and potentially future fellows.

Emergency US Director

The emergency US director is a board-eligible or certified emergency physician who has been given administrative oversight over the emergency US program from the EM Chairperson, director or group. This may be a single or group of physicians, depending on size, locations, and coverage of the group.

Specific responsibilities of an US director and associates may include:

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  Developing and ensuring compliance to overall program goals: educational, clinical, financial, and academic.

  
  
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  Selecting appropriate US machines for clinical care setting and developing and monitoring maintenance care plan to ensure quality and cleanliness

  
  
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  Designing and managing an appropriate credentialing and privileging program for physicians, residents, or advanced practice providers (APP) or other type of providers within the group and/or academic facility.

  
  
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  Designing and implementing in-house and/or out-sourced educational programs for all providers involved in the credentialing program.

  
  
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  Monitoring and documenting individual physician privileges, educational experiences, and US scans,

  
  
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  Developing, maintaining, and improving an adequate QA process in which physician scans are reviewed for quality in a timely manner and from which feedback is generated.

The emergency US director must be credentialed as an emergency physician and maintain privileges for emergency US applications. If less than two years in the position of US director, it is recommended that the director have either: 1) graduated from an emergency US fellowship, 2) participated in an emergency US management course, or 3) completed an emergency US preceptorship or mini-fellowship. If part of a multihospital group, there must be consideration of local US directors with support from overall system US director. Institutional and departmental support should be provided for the administrative components listed above.

Supervision of US Training and Examinations

Ultrasound programs in clinical specialties have a continuing and exponential educational component encompassing traditionally graduate and post-graduate medical training, but now undergraduate, APP, prehospital, remote, and other trainees are seeking training. Policies regarding the supervision and responsibility of these US examinations should be clear. (See Sections 2, 3 , and 4 )

US Documentation

Emergency US is different from consultative US in other specialties as the emergency physician not only performs but also interprets the US examination. In a typical hospital ED practice, US findings are immediately interpreted, and should be communicated to other physicians and services by written reports in the ED medical record. Emergency US documentation reflects the nature of the exam, which is focused, goal-directed, and performed at the bedside contemporaneously with clinical care. This documentation may be preliminary and brief in a manner reflecting the presence or absence of the relevant findings. Documentation as dictated by regulatory and payor entities may require more extensive reporting including indication, technique, findings, and impression. Although EMRs are quickly becoming the norm, documentation may be handwritten, transcribed, templated, or computerized. Regardless of the documentation system, US reports should be available to providers to ensure timely availability of interpretations for consultant and health care team review. Ideally, EMR systems should utilize effective documentation tools to make reporting efficient and accurate.

During out-of-hospital, remote, disaster, and other scenarios, US findings may be communicated by other methods within the setting constraints. Incidental findings should be communicated to the patient or follow-up provider. Discharge instructions should reflect any specific issues regarding US findings in the context of the ED diagnosis. Hard copy (paper, film, video) or digital US images are typically saved within the ED or hospital archival systems. Digital archival with corresponding documentation is optimal and recommended. Finally, documentation of emergency US procedures should result in appropriate reimbursement for services provided. (See Section 6 – Value and Reimbursement )

Quality Improvement Process

Quality improvement (QI) systems are an essential part of any US program. The objective of the QI process is to evaluate the images for technical competence, the interpretations for clinical accuracy, and to provide feedback to improve physician performance.

Parameters to be evaluated might include image resolution, anatomic definition, and other image quality acquisition aspects such as gain, depth, orientation, and focus. In addition, the QI system should compare the impression from the emergency US interpretation to patient outcome measures such as consultative US, other imaging modalities, surgical procedures, or patient clinical outcome.

The QI system design should strive to provide timely feedback to physicians. Balancing quality of review with provision of timely feedback is a key part of QA process design. Any system design should have a data storage component that enables data and image recall.

A process for patient callback should be in place and may be incorporated into the ED’s process for calling patients back. Callbacks should occur when the initial image interpretation, upon QA review, may have been questionable, inappropriate and of clinical significance. In all cases, the imaging physician is informed of the callback and appropriate counseling/training is provided.

Due to the necessities of credentialing, it is prudent to expect that all images obtained prior to a provider attaining levels sufficient for credentialing should be reviewed.

Once providers are credentialed, programs should strive to sample a significant number of images from each provider that ensures continued competency. Due to the varieties of practice settings, the percentage of scans undergoing quality assurance should be determined by the US director and should strive to protect patient safety and maintain competency. While this number can vary, a goal of 10% may be reasonable, adjusted for the experience of the providers and newness of the US application in that department.

The general data flow in the QA system is as follows:

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  Images obtained by the imaging provider should be archived, ideally on a digital system. These images may be still images or video clips, and should be representative of the US findings.

  
  
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  Clinical indications and US interpretations are documented on an electronic or paper record by the imaging provider.

  
  
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  These images and data are then reviewed by the US director or his/her designee.

  
  
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  Reviewers evaluate images for accuracy and technical quality and submit the reviews back to the imaging provider.

  
  
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  Emergency US studies are archived and available for future review should they be needed.

QA systems currently in place range from thermal images and log books to complete digital solutions. Finding the system that works best for each institution will depend on multiple factors, such as machine type, administrative and financial support, and physician compliance. Current digital management systems offer significant advantages to QA workflow and are recommended.

US QA may also contribute to the ED’s local and national QI processes. US QA activities may be included in professional practice evaluation, practice performance, and other quality improvement activities. Measures such as performance of a FAST exam in high acuity trauma, detection of pregnancy location, use of US for internal jugular vein central line cannulation may be the initial logical elements to an overall quality plan. In addition, US QA databases may contribute to a registry regarding patient care and clinical outcomes.

US programs that include multiple educational levels and various types of providers should implement processes to integrate QA into the education process as well as the departmental or institutional quality framework. Technology allowing remote guidance and review may be integrated into the US QA system.

US Machines, Safety, and Maintenance

Dedicated US machines located in the ED for use at all times by emergency physicians are essential. Machines should be chosen to handle the rigors of the multi-user, multi-location practice environment of the ED. Other issues that should be addressed regarding emergency US equipment include: regular in-service of personnel using the equipment and appropriate transducer care, stocking and storage of supplies, adequate cleaning of external and internal transducers with respect to infection control, maintenance of US machines by clinical engineering or a designated maintenance team, and efficient communication of equipment issues. Ultrasound providers should follow common.

ED US safety practices including ALARA, probe decontamination, and machine maintenance.

Risk Management

US can be an excellent risk reduction tool through 1) increasing diagnostic certainty, 2) shortening time to definitive therapy, and 3) decreasing complications from procedures that carry an inherent risk for complications. An important step to managing risk is ensuring that physicians are properly trained and credentialed according to national guidelines such as those set by ACEP. Proper quality assurance and improvement programs should be in place to identify and correct substandard practice. The greatest risk in regards to emergency US is lack of its use in appropriate cases.

The standard of care for emergency US is the performance and interpretation of US by a credentialed emergency physician within the limits of the clinical scenario. Physicians performing US imaging in other specialties or in different settings have different goals, and documentation requirements, and consequently should not be compared to emergency US. As emergency US is a standard emergency medicine procedure, it is included in any definition of the practice of emergency medicine with regards to insurance and risk management.