Emergency Emergency Ultrasound Ultrasound ProposalProposal

Emergency UltrasoundEmergency Ultrasound In common use since early 1990’sIn common use since early 1990’s First curriculum was published in 1994First curriculum was published in 1994 Supported by professional societiesSupported by professional societies

American Board of Emergency Medicine American Board of Emergency Medicine American College of Emergency Physicians American College of Emergency Physicians Society of Academic Emergency Medicine Society of Academic Emergency Medicine Accreditation Council for Graduate Medical Accreditation Council for Graduate Medical

Education Education American Medical Association American Medical Association

Emergency Ultrasound Guidelines Emergency Ultrasound Guidelines updated 2008updated 2008

AMA Resolution 802 AMA Resolution 802 (1999)(1999)

““ultrasound imaging is within the scope of ultrasound imaging is within the scope of practice of appropriately trained physician practice of appropriately trained physician specialists”specialists”

““each hospital medical staff should review and each hospital medical staff should review and approve criteria for granting ultrasound approve criteria for granting ultrasound privileges … in accordance with recommended privileges … in accordance with recommended training and education standards developed by training and education standards developed by each physician's respective specialty society” each physician's respective specialty society”

Benefits of an EUS Benefits of an EUS ProgramProgram

Improved patient careImproved patient care Saves timeSaves time Saves moneySaves money Recruiting Recruiting Life SavingLife Saving Improved Patient SatisfactionImproved Patient Satisfaction

Improved patient careImproved patient care

Better door to diagnosis timeBetter door to diagnosis time Better door to treatment timeBetter door to treatment time Focused Ultrasound is performed in Focused Ultrasound is performed in

concurrently with management of concurrently with management of the patientthe patient

Improved patient satisfactionImproved patient satisfaction

Saves TimeSaves Time

Ultrasounds often completed in Ultrasounds often completed in minutesminutes Not hoursNot hours

Decreased “throughput” time for ED Decreased “throughput” time for ED patientspatients Better door to diagnosis timeBetter door to diagnosis time Better door to treatment timeBetter door to treatment time

Better ED bed efficiencyBetter ED bed efficiency

Saves MoneySaves Money

Alternative to more complex, Alternative to more complex, expensive studiesexpensive studies

Decreased use of limited resources Decreased use of limited resources for non-funded patientsfor non-funded patients

Avoid ED crowding caused by Avoid ED crowding caused by waiting for completion of ultrasound waiting for completion of ultrasound studystudy

RecruitingRecruiting ACGMEACGME

In 2003 In 2003 requiredrequired all EM residencies to all EM residencies to provide Emergency Ultrasound trainingprovide Emergency Ultrasound training

Emergency Ultrasound is defined as a “skill Emergency Ultrasound is defined as a “skill integral to the practice of Emergency integral to the practice of Emergency Medicine” as defined in the “Medicine” as defined in the “2007 Model of 2007 Model of Clinical Practice of Emergency Medicine “Clinical Practice of Emergency Medicine “

This has become a litmus test for whether an EM This has become a litmus test for whether an EM group is currentgroup is current

Continued board certificationContinued board certification Core Content of Emergency MedicineCore Content of Emergency Medicine EM LLSA examEM LLSA exam EM board certification examEM board certification exam

Emergency UltrasoundEmergency Ultrasound

Is a Limited, goal directed focused Is a Limited, goal directed focused ultrasound exam that answers brief ultrasound exam that answers brief and important clinical questions in and important clinical questions in an organ system, or for a clinical an organ system, or for a clinical symptom or sign involving multiple symptom or sign involving multiple organ systemsorgan systems Contrasted with “formal” ultrasound Contrasted with “formal” ultrasound

which is intended as a full survey of the which is intended as a full survey of the organ / system in question.organ / system in question.

IndicationsIndications

Is there blood in the abdomen?Is there blood in the abdomen? Is there a pericardial effusion?Is there a pericardial effusion? Is there an abdominal aortic aneurysm?Is there an abdominal aortic aneurysm? Is there evidence of an IUP?Is there evidence of an IUP? Is there EMD?Is there EMD? Is there evidence of Cholecystitis?Is there evidence of Cholecystitis? Is there evidence of obstructive uropathy?Is there evidence of obstructive uropathy?

Is there blood in the abdomen?Is there blood in the abdomen?

Normal Abnormal

Is there a pericardial effusion?Is there a pericardial effusion?

Normal Abnormal

Components of an ED Components of an ED Ultrasound ProgramUltrasound Program

EquipmentEquipment Training / CredentialingTraining / Credentialing Quality assuranceQuality assurance Emergency ultrasound program Emergency ultrasound program

coordinatorcoordinator

EquipmentEquipment

Requirements for ED Requirements for ED MachineMachine

Best MachineFor ED Use

ImageQuality

Ease of Use

ServiceUpgradeability

Warranty

Portability Durability

Image& Report Management

CostSpecial Features

Purchase GoalsPurchase Goals Best Image Quality for Lowest PriceBest Image Quality for Lowest Price Ease of Use for all usersEase of Use for all users Image and Report Image and Report

Management/WirelessManagement/Wireless Initial CostInitial Cost PortabilityPortability DurabilityDurability Warranty and On Going CostWarranty and On Going Cost Service and ReliabilityService and Reliability Presentation of Images to PatientPresentation of Images to Patient

Training and Training and CredentialingCredentialing

Prerequisites Prerequisites A. Education- A. Education- MD or DO;MD or DO; ANDAND B. Training- B. Training- Board Certified or eligible in Board Certified or eligible in

Emergency MedicineEmergency Medicine; ; OR OR completion of completion of

residency in Emergency Medicineresidency in Emergency Medicine; ; ANDAND

Credentialing processCredentialing process Residency training in Emergency Residency training in Emergency

Ultrasound with acceptable verificationUltrasound with acceptable verification Practice Based PathwayPractice Based Pathway

ProvisionalProvisional ActiveActive

TrainingTrainingPractice Based PathwayPractice Based Pathway

OverviewOverview Initial Training in a 16 - 24 hour Initial Training in a 16 - 24 hour

Introductory Course Introductory Course Experiential and Competency PhaseExperiential and Competency Phase Credentialed in Emergency UltrasoundCredentialed in Emergency Ultrasound Continuing Medical EducationContinuing Medical Education

TrainingTrainingPractice Based PathwayPractice Based Pathway

Initial Training in a 16 - 24 hour Initial Training in a 16 - 24 hour Introductory Course Introductory Course Covers Core ApplicationsCovers Core Applications Practical hands-on Sessions Course Practical hands-on Sessions Course Models are in the Emergency Ultrasound Models are in the Emergency Ultrasound

Guidelines and the ACEP Web SiteGuidelines and the ACEP Web Site Shorter 4 - 8 hour courseShorter 4 - 8 hour course

Focus on Core application or SkillFocus on Core application or Skill Didactic and Hands on Didactic and Hands on

TrainingTraining

Two optionsTwo options Each physician attend a formal courseEach physician attend a formal course

Expensive $800 - $2000 x Expensive $800 - $2000 x # in group # in group = = ______________

““Import” a course hereImport” a course here Use our own US machinesUse our own US machines Less expensiveLess expensive

OK’d by Medical EducationOK’d by Medical Education Commitment by national EUS instructorCommitment by national EUS instructor

TrainingTrainingPractice Based PathwayPractice Based Pathway

Experiential and Competency PhaseExperiential and Competency Phase Develops the Psychomotor and cognitive Develops the Psychomotor and cognitive

ComponentsComponents For General Emergency CompetencyFor General Emergency Competency

150 - 250 Cases in a case controlled manner150 - 250 Cases in a case controlled manner 25 - 50 in each of the Core Application25 - 50 in each of the Core Application

ProceduralProcedural 10 Cases in a case controlled manner10 Cases in a case controlled manner Completion of a Module with a high Quality Completion of a Module with a high Quality

Training PhantomTraining Phantom

CredentialingCredentialing

Active (Full)Active (Full)A.A. MD or DO; MD or DO; ANDAND

B.B. Board Certified or eligible in Emergency Board Certified or eligible in Emergency Medicine Medicine ANDAND

C.C. Residency training in EUS with acceptable Residency training in EUS with acceptable verification; verification; OROR

D.D. GeneralGeneral

A.A. Performance of 150 -250 total exams with Performance of 150 -250 total exams with competence documented Case controlled competence documented Case controlled reviewreview

E.E. ProceduralProcedural

A.A. Performance of 10 total exams with Performance of 10 total exams with competence documented by case controlled competence documented by case controlled review.review.

F.F. Letter of reference by the Emergency Letter of reference by the Emergency Ultrasound Director. Ultrasound Director.

Quality AssuranceQuality Assurance

Performed by EUS director or other Performed by EUS director or other credentialed EMP’scredentialed EMP’s

PurposePurpose as a tool for education and feedback for as a tool for education and feedback for

physicians completing the credentialing physicians completing the credentialing processprocess

to monitor ongoing performance of to monitor ongoing performance of physicians that have completed the physicians that have completed the credentialing process credentialing process

Quality AssuranceQuality Assurance The ultrasounds will be reviewed on three The ultrasounds will be reviewed on three

criteria: criteria: Was the study indicated by the patient’s presentation?Was the study indicated by the patient’s presentation? Was the study technically adequate?Was the study technically adequate? Was the interpretation correct?Was the interpretation correct?

The findings of the review process will drive the The findings of the review process will drive the ongoing medical education in the form of:ongoing medical education in the form of: Journal ClubJournal Club Formal didactics Formal didactics Practice sessions.Practice sessions.

FinancialFinancialEstimated Initial ExpenditureUltrasound equipment (2) $80,000 (range 65k to 120k)Initial Training Course $5,000 (range up to 21k: 26 EP’s x $800)Quality Assurance $19,500 (range up to 40k if outside QA)

Ongoing ExpenditurePaper, cleaner, etc. $1000/yearInsurance/maintenance $1000/year

Estimated Total Expenditure $104,500 plus $1000-2000 annual

FinancialFinancial

Estimated IncomeTrauma APC # 0266 and 0697 $179.26

Estimated patients/year 480

Total $86,044Approx 30% collection $25,813

Pregnancy/IUP APC # 0266 $92.74Estimated patients/year

1095 $101550

Approx 30% collection $30,465

Estimated Income, Trauma and IUP only$56,278/year

SummarySummary

Significant benefit of emergency US Significant benefit of emergency US programprogram

Minimal financial riskMinimal financial risk Supported by:Supported by:

National societiesNational societies TraumaTrauma Critical Care CommitteeCritical Care Committee Emergency PhysiciansEmergency Physicians