Current and future role of ultrasound in the emergency department

Bedside Ultrasonography at Emergency Department - “New Kids on the Block” and “Echoes of Future”

Bedside ultrasonography is increasingly being performed by emergency physician in Hong Kong. Nearly every Accident and Emergency department in Hong Kong is equipped with an ultrasound machine. Ultrasonographic examination is a powerful clinical tool as it is non-invasive, safe, reliable and inexpensive. It has a high diagnostic accuracy in an experience hand. The practice of performing ultrasonography by local emergency physician is just at the early stage. This article aims to review the characteristic, scope and limitation of bedside ultrasonography at emergency department setting. The issue of training and certification, cost effectiveness and medico-legal implication of this tool is also discussed. The goal of bedside ultrasonography program in Hong Kong is to provide round the clock ultrasound examination and interpretation by well-trained and qualified emergency physician. Establishment of the scope of emergency ultrasound examination and implementation of quality improvement audit on the services is necessary. Training and research in the area of ultrasound imaging should be encouraged. With the maturation of our specialty and the effort of our local emergency physicians, bedside emergency ultrasonography will soon emerge as the “Echoes of the future”.

Operator confidence correlates with more accurate abdominal ultrasounds by emergency medicine residents

The purpose of this study was to assess whether greater operator confidence correlates with more accurate focused abdominal ultrasounds (FAUS) by residents. This was a prospective study of novice residents performing FAUS in patients with abdominal pain. FAUS included focused assessment with sonography for trauma, gall bladder, renal, and aortic examinations. Residents answered the question, "How confident are you of your findings?" using a visual scale from 1 (doubtful) to 5 (certain). The results of the resident-performed FAUS were compared to subsequent criterion evaluations. Thirty-eight residents with an average experience of 27 (95% confidence interval [CI] 18-36) prior US examinations evaluated 504 patients. Greater operator confidence correlated with improved accuracy of FAUS (R(2) = 0.858, p = 0.0369). Sensitivity and specificity were 14% (95% CI 4-37 %) and 71% (95% CI 48-88 %) with a confidence level of 2/5 but 85% (95% CI 73-93 %) and 100% (95% CI 97-100 %) with a confidence level of 5/5. Greater operator confidence correlates with improved accuracy in FAUS. This should be considered in the development of training guidelines.

Survey of attitudes of senior emergency physicians towards the introduction of emergency department ultrasound

INTRODUCTION

Emergency department ultrasound (EDU) is widely practised in the USA, Australia, parts of Europe, and Asia. EDU has been used in the UK since the late 1990s but as yet, few areas have established a practice.

OBJECTIVES

To assess the current climate of opinion with respect to the practice, constraints, and establishment of EDU among emergency department (ED) consultants on the island of Ireland.

METHODS

A postal questionnaire was formulated, piloted, and assessed for ambiguity by a sample of ED consultants and an independent non-ED consultant, prior to being mailed to all ED consultants in Ireland.

RESULTS

Of the 58 consultants canvassed 46 (79%) responded. Of the respondents, 40 (87%) strongly agreed/agreed that EDU is appropriate and should be performed in the ED. Of these, 3 (7%) are currently performing EDU; 37 (80%) have not had formal training in EDU, however 42 (91%) support the establishment of national guidelines for training in focused ultrasound in the ED. Problems instituting EDU were often multifactorial. Commonly highlighted difficulties included financial issues (24 respondents, 52%) and radiology department support (16 respondents, 34%). Other cited problems include varying interdepartmental practices (15 respondents, 33%) and (for some EDs) low numbers of patients requiring EDU, with projected difficulties in skills maintenance.

CONCLUSION

Despite the vast majority of ED consultants being in favour of EDU, very few actually perform it on a regular basis or have had any formal training. Highlighted difficulties in EDU implementation included financial constraints, lack of support from radiology departments, and lack of formal training.

Management of acute renal colic in the UK: a questionnaire survey

Background

There is great variation in the Accident and Emergency workload and location of Urology services in UK hospitals. This study investigated the relationship of the initial management of acute renal colic with the department workload plus local facilities including location of X-ray and urology services in UK Accident and Emergency (A&E) departments.

Methods

A&E departments in each of the 11 UK Deanery regions were stratified based on departmental workload, namely <30,000 (small); 30,000 to 50,000 (medium); 50,000 to 80,000 (large) and >80,000 (very large) patients per year. One third of departments were selected in each group leading to a sample size of 106. A questionnaire was administered. Associations between categorical variables were investigated using the chi-squared test and when not valid, Fisher's Exact test was employed. Differences between groups in ordinal variables were investigated using the Mann-Whitney test.

Results

All questionnaires were returned. Twenty-nine units (27.4%) did not perform any radiological investigation on renal colic patients. The number of radiological investigations that were available to departments was associated with workload (P = 0.003); with 57.1% of the small departments performing none and at least 82.8% of units in the other categories performing at least one. Of those departments with X-ray facilities in or adjacent to the department, 63% performed an intravenous urography (IVU) compared to 25% of those departments without (P = 0.026). Of those departments with on-site urology services, 86% performed at least one radiological investigation compared to 52% of units without such services (P = 0.001). Department workload was associated with the first choice analgesia (NSAIDs or parenteral opiates) (P = 0.011). Of the small departments, 64.3% used NSAIDs, 21.4% used parenteral opiates and 14.3% used neither. In comparison, NSAIDS were used by at least 87%, and opiates by at most 12.5% of units in each of the other three categories of department workload.

Conclusions

Over a quarter of UK A&E departments did not perform any radiological investigations and some departments do not even offer renal colic patients any analgesia. Patient management was associated with departmental workload, location of X-ray and Urology services. National guidelines are needed to ensure optimum care for all patients.

Minimum training for right upper quadrant ultrasonography

The objective of this study was to assess if 10 right upper quadrant (RUQ) ultrasound (US) examinations could be used as a minimum standard for training. This was a retrospective review of patients with suspected gallbladder pathology who underwent resident-performed RUQ US before operative or department of radiology evaluation. Two hundred twenty-four patients were examined using resident-performed RUQ US followed by gold standard evaluations. One hundred seventy-eight patients were evaluated by 13 residents who met the "minimum training" standard of 10 prior examinations. The results of resident-performed RUQ US for gallstones and/or cholecystitis are shown subsequently. Previous suggestions that 10 examinations could be used as a minimum standard for training in focused abdominal sonography for trauma examinations cannot be used for RUQ US. The ACEP 2001 guidelines for 25 examinations are more consistent with the learning curve suggested by our data.

Performance, training, quality assurance, and reimbursement of emergency physician-performed ultrasonography at academic medical centers

OBJECTIVE

To determine the current state of bedside emergency physician-performed ultrasonography in terms of prevalence, training, quality assurance, and reimbursement at emergency medicine residency programs.

METHODS

The link to a 10-question Web-based survey was e-mailed to ultrasound/residency directors at 122 emergency medicine residency programs in the United States.

RESULTS

The overall response rate was 84%. Ninety-two percent of programs reported 24-hour emergency physician-performed ultrasonography availability. Fifty-one percent of programs reported that a credentialing/privileging plan was in place at their hospital, and 71% of programs had a quality assurance/image review procedure in place. Emergency medicine specialty-specific guidelines of 150 ultrasonographic examinations and 40 hours of didactic instruction were met by 39% and 22% of residencies, respectively, although only 13.7% of programs were completing the 300 examinations recommended by the American Institute of Ultrasound in Medicine. Sixteen programs (16%) reported that they were currently billing for emergency physician-performed ultrasonography; of those not billing, 10 (12%) planned to bill within 1 year, and 32 (37%) planned to bill at some point in the future.

CONCLUSIONS

Performance and training in emergency physician-performed ultrasonography at academic medical centers continues to increase. The number of emergency medicine residency programs meeting specialty-specific guidelines has more than doubled in the last 4 years, but only a small number are meeting American Institute of Ultrasound in Medicine guidelines. Although only 16% of programs reported that they were currently billing for emergency physician-performed ultrasonography, most had plans to bill in the future.