Welch, Shari J. MD
While emergency department bedside ultrasound is uniformly taught to emergency medicine residents, only 19 percent of nonteaching community hospitals have 24-hour-a-day ED bedside ultrasound, according to a 2006 Yale University survey. (Ann Emerg Med 2006;47:147.)
There is a preoccupation in training programs with teaching residents to perform ultrasound, store images, and meet comprehensive documentation requirements, but the current practice world doesn't make use of these skills. What are we to make of this wholesale disconnect between training and practice? Are community hospital practitioners, as William Mallon, MD, has suggested, a bunch of old dogs incapable of learning new tricks? (EM-Blog.com; Sept. 7, 2009; http://bit.ly/EM-blogmallon.) Or have we veered onto the wrong path, one that may not be sustainable for our specialty?
It appears we have been seduced by ultrasound at academic centers, and convinced to use a technology that may not be sustainable in the world of community hospital emergency medicine. In this pursuit of ultrasound technology at warp speed, we seem to have lost sight of the game plan. In early models of bedside ultrasound utilization, physicians (especially night warriors) envisioned the possibility of getting imaging answers at 2 a.m. when there was no opportunity to do so through the radiology department. The little SonoSite (one of the earliest bedside ultrasound machines) would tell us stories in the wee hours that were important: the pregnancy in the uterus, the aorta not dissecting, the gallbladder with stones, no free fluid in Morrison's pouch. The questions we asked of ultrasound at 2 a.m. were one sentence long, and the answers were monosyllabic.
We thought of the SonoSite as another tool to aid us in physical diagnosis, much like the stethoscope. In most instances, we planned for a definitive formal ultrasound study later; we had no fantasy that billing for bedside ultrasound would make us rich women and men. Early ED bedside ultrasound coexisted peacefully alongside the ultrasound department and the radiologists.
Fast forward a decade, and it is difficult to recognize where we are. ACEP's Emergency Ultrasound Section has developed exhaustive guidelines for performing and documenting ED ultrasounds. These reports should include the indications for the ultrasound, the positioning of the patient, the views used, measurements like the common bile duct diameter, and a “qualitative assessment of the wall and pericholecystic regions.” The documentation for these bedside exams is now often as long as the documentation for the ED visit itself, and we find ourselves also responsible for storing images. To add to the complexities, now that we are in the medical recordkeeping business, we have to ask, are we HIPAA compliant?
Many groups continue to invest more money and time in the equipment and software to do this. They also need equipment maintenance, which is more involved with the complicated new-generation machines, and ongoing quality control and improvements, which require more documentation still. Of the less than 20 percent of EDs performing bedside ultrasound, a mere 16 percent report that they are “requesting reimbursement.” To date, the majority of EDs do not bill for ED ultrasound and relations with radiologists are less than friendly over the issue. Where is the return on this investment? For those committed and enthusiastic about bedside ultrasound, we ask three salient questions.
First, is the emergency physician ever as good at this as the ultrasonographer and the radiologist doing it all day? Radiologists do a four-year residency and often a one- to two-year ultrasound fellowship. Are we really suggesting that with some CME and 25 bedside exams in each category, we can earn a certificate to be ultrasound experts? As with fiberoptic laryngoscopy, are we doing enough of these various and infrequently performed studies to be clever and completely competent? Is it really in the best interest of the patient to substitute the bedside ultrasound for a formal study?
Second, what are the liability implications for us if we perform the ultrasound, document the findings, store the images, and bill for the study? If emergency physicians perform first-trimester ultrasounds, are they in it for the game with these pregnant patients? What if the emergency physician misses an abnormality of the pancreas or liver that is consequential? Where does the liability of the emergency physician begin and end for bedside ultrasound? Though litigation in this area is not prevalent, has the specialty spent enough time considering this risk?
The third question is the most critical: In terms of patient flow and workflow, is bedside ultrasound in its current iteration the right thing to do? Are there data to demonstrate that an emergency practitioner is in fact better off performing, documenting, storing, and billing for an ultrasound as opposed to seeing the next patient? Does the bedside ultrasound process in its current iteration improve efficiency and flow, or impede them? Emergency medicine is a zero-sum game. A physician engrossed in ultrasound processes is not seeing and evaluating a new patient, reviewing patient data, writing prescriptions, or talking to consultants and families. He is not performing the myriad other tasks that require his attention and for which he is uniquely qualified. If an emergency physician is storing ultrasound images, he is not evaluating the next patient with abdominal pain. A technology that was supposed to expedite care has evolved into a drain on the department and its most precious resource: physician time.
Indeed, emergency medicine may have gone down a wrong path. We envisioned that smart little SonoSite eventually living in our pockets. We would carry it with us, and use it for procedures to answer those one-sentence questions with monosyllabic answers at 2 a.m. We thought it would be like “x-ray-vision-in-a-pocket,” and make us all better clinicians. This is not a call to do away with bedside ultrasound, but rather to look at the current iteration of bedside ultrasound incorporated into the practice of emergency medicine.
Does it really make sense for our specialty to use the technology this way? If we stripped away having to store the images, document results, and billing, wouldn't bedside ultrasound enhance workflow? If we continued to teach screening bedside ultrasound and stopped trying to make ourselves ultrasonographers, wouldn't the model be a better fit for our fast-moving specialty? Do we really want to store images? Do we really want to take on more liability in this risk-ridden specialty of ours? Do we really want to measure the common bile duct? Do we really want to be ultrasound techs?
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