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Viewpoint: Ultrasound Use Still Lags — to EM's Detriment

Noble, Vicki E. MD; Stone, Michael MD; Camargo, Carlos A. Jr., MD, DrPH

doi: 10.1097/01.EEM.0000398967.70268.1b


Over the past 15 years, emergency ultrasound has rapidly matured from the FAST exam to point-of-care ultrasound. Today, in many U.S. emergency departments, emergency physicians use ultrasound to assess volume status, confirm intrauterine pregnancy, diagnose pneumothorax, evaluate for aortic aneurysms, and more. Emergency ultrasound research has provided evidence that emergency physicians are accurate in answering focused diagnostic questions using ultrasound, and that there is a decreased time to diagnosis if point-of-care ultrasound is used. (Ann Emerg Med 1992;21[6]:709; Acad Emerg Med 2000;7[9]:988.)

Because of this evidence supporting more efficient ED treatment and throughput and because of advocacy by ultrasound groups in the professional emergency medicine societies, ultrasound training is now recognized as a core competency for emergency medicine. In 2009, the Council of Emergency Medicine Residency Directors endorsed a plan for training residents that sets a national standard, and has led to an overall increase in the quality of ultrasound education for emergency medicine residents. (Acad Emerg Med 2009;16[Suppl 2]:S32.)

Nevertheless, there still is less than universal access and utilization of emergency ultrasound nationwide. While results of the recent ACEP Ultrasound Section survey are pending, surveys of 2003 to 2005 emergency medicine training program graduates have shown that only 73 percent had access to point-of-care ultrasound performed by emergency physicians, with higher access in academic programs (97%) than non-academic centers (62%). (J Emerg Med 2010;38[2]:214.) A 2009 survey of all ED directors in Colorado, Georgia, Massachusetts, and Oregon showed an even greater discrepancy between urban, high-volume EDs (71% immediate access) and rural, low-volume EDs (39% immediate access) when asked about physician-performed point-of-care ultrasound. (“Access to immediate bedside ultrasound in the emergency department.” West J Emerg Med 2011; in press.) Why is this, and why do we think it is so important to address this issue?

The gap has several explanations, but we suspect that the most important is a lack of time and resources to get ultrasound programs started in practices that are already stretched to meet the demand of ever increasing visit volumes. Anyone who has started an ultrasound program knows about the substantial time and effort needed to train physicians, set up appropriate quality assurance processes, establish a work flow for reporting, and ensure appropriate archiving and billing practices so throughput is not slowed down. Consequently, the argument for shifting resources to the ultrasound effort is not always straightforward. Technology solutions and the increasing attention of industry to point-of-care ultrasound are starting to address the needs and workflow realities of emergency physicians who use point-of-care ultrasound. The new focus on health care reform and improved efficiency, however, makes the “why ultrasound” question just as important to answer as the “how ultrasound” question.

To convince practices that these efforts are important, ultrasound research is increasingly focused on why ultrasound is important to emergency care. Point-of-care ultrasound in the hands of an experienced emergency physician provides the opportunity to evaluate for the presence of specific disease processes rapidly and non-invasively, streamlining diagnostic testing. Indeed, two large federally funded studies are looking at role of point-of-care ultrasound in renal colic (a multicenter randomized trial at the University of California, San Francisco [R01 HS019312; Smith-Bindman, PI] and an observational study at Yale University [R01 HS018322; Moore, PI]). Both studies address the potential of ultrasound to limit computed tomography imaging in renal colic appropriately.

“A more global understanding and evidence of ‘value’ is really what we as emergency physicians want to emphasize,” said Paul Sierzenski, MD, the ultrasound director at Christiana Care Health System in Delaware, in a recent online discussion on the challenges facing point-of-care ultrasound. “As discussed, cost, resource utilization, radiation reduction, risk modulation, physician satisfaction, recruitment, retention, patient satisfaction, and access to care are all facets of the ‘value’ concept. This may be easier to demonstrate as we move into an era of accountable care organizations rather than episode of care model for payment.”

Emergency ultrasound is not just important because it can potentially decrease the number of computed tomography scans ordered in the ED. It has the potential to improve many of the factors we've listed, making broad-based research concepts that look beyond a “just numbers” approach necessary. The Emergency Medicine Foundation recognizes this research gap, and has begun to offer a $20,000 grant underwritten by Siemens to look at outcomes research in point-of-care ultrasound.

What if physicians who perform point-of-care ultrasound have higher job satisfaction and retention rates because of their sense of professionalism and self-reliance, for example? What if patients have a better experience in the ED when a physician spends time at the bedside teaching and demonstrating anatomy with the ultrasound that is relevant to their chief complaint? What if access to care is improved because streamlined diagnostic imaging strategies, including the use of point-of-care ultrasound, result in decreases in ED length of stay?

Many of these questions will have undoubtedly have complex answers, but in the effort to broaden point-of-care ultrasound utilization, it's essential to look at all of the potential benefits (and costs) of this technology.

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Dr. Nobleis the chair of the American College of Emergency Physicians' Emergency Ultrasound Section, an assistant professor of emergency medicine at Harvard Medical School, and an attending physician at Massachusetts General Hospital in Boston.Dr. Stoneis an attending physician in emergency medicine at Alameda County Medical Center-Highland General Hospital, a clinical assistant professor at the University of California, San Francisco (UCSF) School of Medicine, the chair-elect of ACEP's Emergency Ultrasound section, and a co-founder and course instructor for Ultrasound Learning Seminars ( Dr. Camargois an associate professor of medicine at Harvard Medical School, an associate professor of epidemiology at the Harvard School of Public Health, and the director of the EMNet Coordinating Center at Massachusetts General Hospital in Boston.

© 2011 Lippincott Williams & Wilkins, Inc.