Emergency clinician performed ultrasound: Availability,uses and credentialing in Australian emergency departments

Objective: To determine the current availability, uses and credentialing processes of emergency clinician performed ultrasound (EDUS) in Australian ED. Methods: Cross‐sectional survey of Australian ED that are accredited for advanced training. Results: Ninety‐four per cent of respondents (67/71, 95% confidence interval [CI] 86–98%) reported availability of EDUS. Availability was similar in both major referral and non‐major referral ED. The most common uses for EDUS were focused abdominal sonography for trauma in 93% (62/67, 95% CI 83–97%), vascular access procedures in 90% (60/67, 95% CI 80–95%) and abdominal aortic aneurysm assessment in 88% of respondents (59/67, 95% CI 78–94%). Of the 67 departments with EDUS availability, 60% (40/67, 95% CI 48–71%) had a credentialing process. Of the major referral group 80% (20/25, 95% CI 61–91%) had a credentialing process compared with 52% (20/42, 95% CI 33–62%) in the non‐major referral group. Conclusion: Emergency department ultrasound is widely available in Australia. Only 60% of surveyed ED had a credentialing process in place for EDUS. This may be of concern given the current Australasian College for Emergency Medicine policy regarding EDUS.     

Focused assessment with sonography for trauma patients by clinicians: Initial experience and results

Objectives: To describe the establishment of a service to provide bedside focused assessment sonography in trauma and to evaluate the service to date. Setting: Emergency department of an urban trauma centre. Methods: A prospective study of trauma patients who received a focused assessment sonography in trauma examination performed by a clinician managing the trauma in the emergency department. Accuracy was determined by comparing the scan interpretation with abdomino‐pelvic computerized tomography, laparotomy or postmortem examination. Results: The study period ran from 1 January 2000 to 11 September 2001 inclusive (20 months). One hundred and forty patients were included, with a final diagnosis established by computerized tomography (n = 124) and/or laparotomy (n = 18). There were 26 true‐positives, 101 true‐negatives, two false‐positives and 11 false‐negatives. Ten of the false‐negative studies were performed by clinicians who had not reached accreditation. The sensitivity of focused assessment sonography in trauma was 70%, specificity 98% and diagnostic accuracy 91%. Conclusions: We have described the implementation of a clinician‐based focused assessment sonography in trauma service within the emergency department with the support of radiology/ultrasound and trauma service. Processes for credentialling, quality assurance and training need to be in place. Significant issues exist with the length of time it takes clinicians to reach accreditation, in order that a critical mass of clinicians exists to provide a consistent service. The credentialling process should mandate a minimum number of supervised examinations.     

Variation in the management of hypothetical cases of acute agitation in Australasian emergency departments

Objective: To describe the prescribing practice of emergency medicine clinicians in the management of highly agitated patients and to identify perceived barriers to management and the gaps in training. Method: We undertook an anonymous cross‐sectional mail survey of the Australasian College for Emergency Medicine (ACEM) members (fellows and advanced trainees) between June and September 2009. A questionnaire including a case vignette of a hypothetical patient and three clinical scenarios was employed to ascertain prescribing practice and assess perceived barriers to management, confidence and the perceived usefulness of existing and future Clinical Practice Guidelines (CPGs). Results: All 2052 ACEM members were surveyed. However, seven had incorrect postal addresses and could not be reached. Of the remaining 2045, 786/2052 (38.3%, 95% CI 36.2–40.5) responses were received. Of the 786 respondents, 783 were practicing clinicians. If monotherapy was chosen, 622/783 (79.4%, 95% CI 76.4–82.2) of respondents preferred midazolam to manage the common scenario where no history was available, followed by haloperidol 45/783 (5.8%, 95% CI 4.3–7.7) and olanzapine 38/783 (4.9%, 95% CI 3.5–6.7). Most respondents 500/783 (63.9%, 95% CI 60.4–67.2) would also administer another sedative (combination therapy). Important perceived barriers to agitation management included lack of both training (352/783 [45.0%, 95% CI 41.4–48.5]) and a national CPG (313/783 [40.0%, 95% CI 36.5–43.5]). Respondents were generally confident in all aspects of management, although relatively fewer trainees were confident in determining dosing. Institutional CPGs were considered most useful for 415/783 (53.0%, 95% CI 49.4–56.5) respondents. If an ACEM‐endorsed CPG were to be developed in the future, 634/783 (81.0%, 95% CI 78.0–83.6) respondents would consider this useful. Conclusion: There is considerable variation in the management of hypothetical cases of acute agitation in Australasian EDs. Benzodiazepines and antipsychotics, either alone or in combination, are commonly used. An ACEM‐endorsed, Australasian CPG was perceived as useful.     

Emergency ultrasound in the prehospital setting: the impact of environment on examination outcomes

This study aimed to compare ultrasound examinations performed within a land ambulance (stationary and moving) with those completed in a simulated emergency department (ED) to determine the feasibility of undertaking ultrasound examinations within the UK prehospital care environment. The findings suggest that abdominal aortic aneurysm and extended focused assessment with sonography in trauma emergency ultrasound examinations can be performed in the stationary or moving land ambulance environment to a standard consistent with those performed in the hospital ED.     

Status of emergency department ultrasound

Objective : To determine present attitudes to and usage of ultrasound in Australasian emergency medicine. Methods : A questionnaire was devised, field tested and sent, with Australasian College for Emergency Medicine permission, for anonymous completion by the director of emergency medicine training of each emergency department in Australia and New Zealand accredited for advanced training. Results : The overall response rate was 84% (66/79). The data were tabulated and cross‐tabulated comparing major trauma centres, base hospitals, urban hospitals and teaching hospitals. In hours, X‐ray department ultrasound was readily available, but bedside ultrasound was much less available both in and out of hours. There were marked variations in opinion as to whether bedside ultrasound was essential in clinical conditions such as trauma, abdominal or kidney pain. Computed tomography was always preferred to ultrasound. While there was little teaching of either the theoretical or practical aspects of ultrasound to emergency medicine trainees, 75% of respondents believed that ultrasound should not be undertaken only by full‐time ultrasonographers. Conclusions : The survey clearly demonstrated that while bedside or urgent ultrasound is not generally readily available, especially out of hours, the modality is considered to be important by the majority of respondents, and does not require full‐time radiographers. It is clear that formal teaching of ultrasound to trainees is infrequent.     

Are emergency department nurse practitioners homeless?

The professional body for nurses working in emergency medicine is the College of Emergency Nursing Australasia. The professional body for doctors working in emergency medicine is the Australasian College for Emergency Medicine (ACEM). There is no professional body for nurse practitioners working in emergency medicine. The clinical role of nurse practitioners in emergency medicine more closely resembles that of doctors rather than nurses. Associate membership in ACEM would recognise their role in treating patients and would enhance their access to relevant continued professional development as has been endorsed by ACEM. It would also facilitate their further integration into the body of those who autonomously treat patients in the ED.     

Ultrasound in emergency medicine

Ultrasound is a safe, non-invasive portable imaging modality, applicable to many areas of emergency medicine. Its use in emergencies such as suspected ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy, haemoperitoneum secondary to blunt abdominal trauma and cardiac tamponade is well established. Its efficacy in such diverse conditions as acute appendicitis, gallstones, renal stones and urinary obstruction, obstetric and gynaecological conditions, deep venous thrombosis, scrotal pain and soft tissue foreign body localisation has also been demonstrated. Echocardiography is particularly useful in the investigation of aortic dissection, ischaemic heart disease, suspected pericardial effusion and cardiothoracic trauma. Emergency physicians have been successfully trained in the technique in other countries. The time is right for Australasian emergency physicians to become trained in ultrasonography, use the technique in daily practice and share this knowledge with other emergency physicians and trainees.     

Development of a productive research culture in emergency medicine: Report of the outcomes of a research forum

In recent years, the Australasian College for Emergency Medicine (ACEM) has increasingly focused on the need for high‐quality research in emergency medicine (EM). One important initiative was the establishment of the ACEM Foundation, which among other responsibilities, is required to support clinical research through the provision of research funding and other measures. In February 2015, the Foundation held a Research Forum that was attended by the leading EM researchers from Australasia. The Forum aimed to determine how a productive research culture could be developed within the ACEM. Nine key objectives were determined including that research should be a core business of the ACEM and a core activity of the EM workforce, and that EM research should be sustainable and adequately supported. This report describes the background and conduct of the Forum, its recommendations and the way in which they could be implemented.     

Point‐of‐care Focused Cardiac Ultrasound for the Assessment of Thoracic Aortic Dimensions,Dilation, and Aneurysmal Disease

Objectives: Thoracic aortic aneurysm and thoracic aortic dissection are related and potentially deadly diseases that present with nonspecific symptoms. Transthoracic echocardiography (TTE) may detect thoracic aortic pathology and is being increasingly performed by the emergency physician at the bedside; however, the accuracy of point‐of‐care (POC) focused cardiac ultrasound (FOCUS) for thoracic aortic aneurysm and thoracic aortic dissection has not been studied. The objective of this pilot study was to explore the agreement, sensitivity, and specificity of FOCUS for thoracic aortic dimensions, dilation, and aneurysm compared with CT angiography (CTA) as the reference standard. Methods: This study was a retrospective pilot analysis of image and chart data on consecutive patients presenting to an urban, academic emergency department (ED) between January 2008 and June 2010, who had both a FOCUS and a CTA for suspicion of thoracic aorta pathology. Thoracic aorta dimensions were measured from recordings by three ultrasound‐trained emergency physicians blinded to any initial FOCUS and CTA results. CTA measurements were obtained by a radiologist blinded to the FOCUS results. Using cutoffs of 40 and 45 mm, we calculated the sensitivity and specificity of FOCUS for aortic dilation and aneurysm with the largest measurement on CT as the reference standard. Bland‐Altman plots with 95% limits of agreement were used to demonstrate agreement for aortic measurements, kappa statistics to assess the degree of agreement between tests for aortic dilation, and intraclass correlation for interobserver and intraobserver variability. Results: Ninety‐two patients underwent both FOCUS and CTA during the study period. Ten FOCUS studies had inadequate visualization for all measurements areas. Eighty‐two patients were included in the final analysis. Mean (±SD) age was 58.1 (±16.6) years and 58.5% were male. Sensitivity, specificity, and the observed kappa value (95% confidence interval [CI]) between FOCUS and CTA for the presence of aortic dilation at the 40‐mm cutoff were 0.77 (95% CI = 0.58 to 0.98), 0.95 (95% CI = 0.84 to 0.99), and 0.74 (95% CI = 0.58 to 0.90), respectively. The mean difference (95% limits of agreement) for the Bland‐Altman plots was 0.6 mm (?5.3 to 6.5) for the sinuses of Valsalva, 4 mm (?2.7 to 10.7) for the sinotubular junction, 1.5 mm (?5.8 to 8.8) for the ascending aorta, and 2.2 mm (?5.9 to 10.3) for the descending aorta. Conclusions: In this retrospective pilot study, FOCUS demonstrated good agreement with CTA measurements of maximal thoracic aortic diameter. FOCUS appears to be specific for aortic dilation and aneurysm when compared to CTA, but requires further prospective study. ACADEMIC EMERGENCY MEDICINE 2012; 19 :1–4 © 2012 by the Society for Academic Emergency Medicine     

Continuing the ultrasound credentialing conversation

While the Australasian College for Emergency Medicine (ACEM) encourages all emergency physicians to be competent in at least the five core areas of emergency ultrasound (US), departmental training in most hospitals does woefully little to prepare most ACEM members to attain these competencies. While full day courses are a common method of mandatory and discretionary in‐service training, that method has not been adopted for US training. We propose the development of full day courses for each of the five core competencies, taught by accredited US instructors and with emphasis on hands‐on training. These courses alone will not produce fully competent US users but will provide a solid foundation for further training.     

ACEM involvement in a successful African emergency medicine programme

In the past 5 years Botswana graduated its first home-grown doctors and emergency medicine specialists for the country. The postgraduate emergency medicine specialist training arrangement between Botswana and South Africa was challenging in development, implementation and maintenance. Numerous varied supports from ACEM and its International Emergency Medicine Network were integral to these successes. This article encourages further investment of ACEM grants and scholarships in Africa by describing how ACEM supported significant advances in Botswana emergency medicine.     

Organ and tissue donation‐related attitudes,education and practices of emergency department clinicians in Australia

Objective: The ED is emerging as a priority for efforts to improve rates of organ and tissue donation (OTD) in Australia, but little is known of ED clinicians' attitudes, education or practices in the area. We aimed to determine the attitudes and OTD‐related educational background and practices of Australian ED clinicians. Methods: This was a national cross‐sectional survey of members of the Australasian College for Emergency Medicine (ACEM) and the College of Emergency Nursing Australasia (CENA); online questionnaire of 133 items, graded responses using Likert and ordinal multi‐category scales, plus open‐ended qualitative questions. Results: Of 2969 ACEM members, 599 (20.2%) responded; of 1026 CENA members, 212 (20.7%) responded. Respondents were broadly representative of the membership, with male trainee specialists underrepresented. Most ED staff supported OTD, although many were not certain that facilitating OTD was their role, or that the ED was the right place to identify donors. Around a quarter of medical and nursing staff had received no education regarding OTD. Having received education was related to professional status, cultural background, place of work and years of experience, and was significantly associated with attitude towards OTD and whether staff participated in OTD‐related tasks. Conclusions: More education on OTD is needed and requested by ED clinicians in Australia, particularly on OTD after cardiac death, management of a donor, brain death and obtaining consent. Postgraduate curricula should reflect this need for more OTD‐related education in emergency medicine and nursing.     

Retrospective analysis of eFAST ultrasounds performed on trauma activations at an academic level-1 trauma center

BACKGROUND:Point-of-care ultrasound(POCUS)has become increasingly integrated into the practice of emergency medicine.A common application is the extended focused assessment with sonography in trauma(eFAST)exam.The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation.The objective of this study was to conduct a review of performed,documented and billed eFAST ultrasounds on trauma activation patients.METHODS:This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center.A list comparing all trauma activations was crossreferenced with a list of all billed eFAST scans.Medical records were reviewed to determine whether an eFAST was indicated,performed,and appropriately documented.RESULTS:We found that 1,507 of 1,597 trauma patients had indications for eFAST,but 396(27%)of these patients did not have a billed eFAST.Of these 396 patients,87(22%)had documentation in the provider note that an eFAST was performed but there was no separate procedure note.The remaining 309(78%)did not have any documentation of the eFAST in the patient’s chart although an eFAST was recorded and reviewed during ultrasound quality assurance.CONCLUSION:A significant proportion of trauma patients had eFAST exams performed but were not documented or billed.Lack of documentation was multifactorial.Emergency ultrasound programs require appropriate reimbursement to support training,credentialing,equipment,quality assurance,and device maintenance.Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.     

Ultrasound Training for Emergency Physicians— A Prospective Study

OBJECTIVES: Bedside ultrasound examination by emergency physicians (EPs) is being integrated into clinical emergency practice, yet minimum training requirements have not been well defined or evaluated. This study evaluated the accuracy of EP ultrasonography following a 16-hour introductory ultrasound course. METHODS: In phase I of the study, a condensed 16-hour emergency ultrasound curriculum based on Society for Academic Emergency Medicine guidelines was administered to emergency medicine houseofficers, attending staff, medical students, and physician assistants over two days. Lectures with syllabus material were used to cover the following ultrasound topics in eight hours: basic physics, pelvis, right upper quadrant, renal, aorta, trauma, and echo-cardiography. In addition, each student received eight hours of hands-on ultrasound instruction over the two-day period. All participants in this curriculum received a standardized pretest and posttest that included 24 emergency ultrasound images for interpretation. These images included positive, negative, and nondiagnostic scans in each of the above clinical categories. In phase II of the study, ultrasound examinations performed by postgraduate-year-2 (PGY2) houseofficers over a ten-month period were examined and the standardized test was readministered. RESULTS: In phase I, a total of 80 health professionals underwent standardized training and testing. The mean +/- SD pretest score was 15.6 +/- 4.2, 95% CI = 14. 7 to 16.5 (65% of a maximum score of 24), and the mean +/- SD posttest score was 20.2 +/- 1.6, 95% CI = 19.8 to 20.6 (84%) (p < 0. 05). In phase II, a total of 1,138 examinations were performed by 18 PGY2 houseofficers. Sensitivity was 92.4% (95% CI = 89% to 95%), specificity was 96.1% (95% CI = 94% to 98%), and overall accuracy was 94.6% (95% CI = 93% to 96%). The follow-up ultrasound written test showed continued good performance (20.7 +/- 1.2, 95% CI = 20.0 to 21.4). CONCLUSIONS: Emergency physicians can be taught focused ultrasonography with a high degree of accuracy, and a 16-hour course serves as a good introductory foundation.     

Rapid Assessment of the Neonate With Sonography (RANS) Scan

The use of point‐of‐care sonography in clinical settings such as emergency medicine and intensive care units has increased, but adoption in neonatology has been slow. Unlike the focused assessment with sonography for trauma scan used in adults, a quick bedside scan to rapidly evaluate an acutely deteriorating neonate does not exist. The objective of our article is to introduce a focused bedside ultrasound scan that is easy to learn, rapidly performed, and relatively inexpensive.© 2018 by the American Institute of Ultrasound in Medicine     

CORD‐AEUS: Consensus Document for the Emergency Ultrasound Milestone Project

In 2012, the Accreditation Council for Graduate Medical Education (ACGME) designated ultrasound (US) as one of 23 milestone competencies for emergency medicine (EM) residency graduates. With increasing scrutiny of medical educational programs and their effect on patient safety and health care delivery, it is imperative to ensure that US training and competency assessment is standardized. In 2011, a multiorganizational committee composed of representatives from the Council of Emergency Medicine Residency Directors (CORD), the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine (SAEM), the Ultrasound Section of the American College of Emergency Physicians (ACEM), and the Emergency Medicine Residents' Association was formed to suggest standards for resident emergency ultrasound (EUS) competency assessment and to write a document that addresses the ACGME milestones. This article contains a historical perspective on resident training in EUS and a table of core skills deemed to be a minimum standard for the graduating EM resident. A survey summary of focused EUS education in EM residencies is described, as well as a suggestion for structuring education in residency. Finally, adjuncts to a quantitative measurement of resident competency for EUS are offered.     

Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum

Objectives: To evaluate non-radiologist performed emergency ultrasound for the detection of haemoperitoneum after abdominal trauma in a British accident and emergency department.

Methods: Focused assessment with sonography for trauma (FAST) was performed during the primary survey on adult patients triaged to the resuscitation room with suspected abdominal injury over a 12 month period. All investigations were performed by one of three non-radiologists trained in FAST. The ultrasound findings were compared against the investigation of choice of the attending surgeon/accident and emergency physician. The patients were followed up for clinically significant events until hospital discharge or death.

Results: One hundred patients who had sustained blunt abdominal trauma, were evaluated by FAST. Nine true positive scans were detected and confirmed by computed tomography, diagnostic peritoneal lavage, or laparotomy. There was one false positive in this group, giving a sensitivity of 100%, specificity 99%, and positive predictive value of 90%. Ten patients with penetrating injuries were evaluated with a sensitivity and specificity for FAST of 33% and 86% respectively.

Conclusions: Emergency torso ultrasound for the detection of haemoperitoneum can be successfully performed by trained non-radiologists within a British accident and emergency system. It is an accurate and rapid investigation for blunt trauma, but the results should be interpreted with caution in penetrating injury.

     

False positive abdominal aortic aneurysm on bedside emergency ultrasound

Bedside ultrasound is the diagnostic method of choice for unstable patients with suspected abdominal aortic aneurysm. Its ability to provide rapid and accurate diagnosis is critical in an emergency setting. Previous studies have documented the ability of Emergency Physicians to accurately diagnose abdominal aortic aneurysms, thus potentially saving lives. A search of the medical literature did not reveal any reports of false positive abdominal aortic aneurysm diagnosis with ultrasound use. We report a case of a false positive abdominal aortic aneurysm diagnosed in a patient with a previously unknown large malignant para-aortic lymph node.     

Outcome of conservative medical treatment of patients with infrarenal abdominal aortic aneurysms

OBJECTIVE: Since non-invasive diagnostic methods have become available and screening programs have become popular, abdominal aortic aneurysms are more frequently being detected at an early stage of the disease. We analyzed the course of conservatively treated patients with infrarenal abdominal aortic aneurysms (AAA), and determined independent risk factors for aneurysm expansion. METHODS: The study was designed as a retrospective-cohort study including 110 consecutive patients with AAA. Cardiovascular risk factors, comorbidities, current medication, and the findings of color coded duplex sonography and computed tomography were recorded. Ninety-two conservatively treated patients were re-investigated every 6 or 12 months (depending on an initial aneurysm size of > 45 mm or < 45 mm respectively) after initial detection by color coded duplex sonography. We performed a multivariate Cox regression analysis to determine independent predictors of diameter progression (diameter increase > or = 5 mm). RESULTS: We found AAA expansion in 46 conservatively treated patients (50%) during the median follow up period of 23 months (IQR 13 to 33), but no rupture occurred. Baseline diameter > 45 mm (HR 2.3, 95% CI 1.0 to 5.3, P = .04) and signs of aortic dissection in duplex ultrasound (HR 2.2, 1.0 to 4.6, P = .04) were independently associated with aneurysm expansion. The presence of an intraluminal thrombus showed a trend towards higher rates of disease progression (HR 2.6, 95% CI 0.9 to 7.6, P = .08). CONCLUSION: Patients with an aneurysm diameter > 45 mm or ultrasound signs of aortic dissection have an increased risk for AAA progression and need careful evaluation, optimization of risk factors and close (six-month) follow-up intervals. For patients with an aneurysm diameter below 45 mm and without additional risk factors, follow-up intervals of 12 months seem to be safe.