Introduction to CED Focused Ultrasound
Role of ultrasound in emergency medicine
The role of ultrasound in the field of emergency medicine is continually evolving. It is no longer a specialist-only skillset, but now extends all the way through from undergraduate to incorporation with specialist training programs. The focus of ultrasound training during progression through the ACEM training program is targeted to the basic modalities utilized within the resuscitation room, as well as using ultrasound to improve the safety of ED procedures.
Definition of Focused Ultrasound
Focused ultrasounds (also called Point of Care Ultrasound, POCUS and bedside ultrasound) are limited, goal directed examinations performed to answer specific clinical questions. These examinations are not comprehensive and do not replace sonography offered by diagnostic imaging departments or those performed in dedicated echocardiography units.
Use of Focused Ultrasound in Emergency Medicine
Focused ultrasound imaging has been shown to enhance the clinician’s ability to assess and manage patients with a variety of acute illnesses and injuries. Focused ultrasound examinations performed by trained emergency physicians in order to answer specific clinical questions have been shown to improve patient outcomes.
The Australasian College for Emergency Medicine (ACEM) specifically supports the use of ultrasound imaging by emergency physicians in patient populations where there is evidence for benefit for at least but not limited to the following clinical indications:
Traumatic haemoperitoneum/ haemothorax/ pneumothorax
Abdominal aortic aneurysm
Pericardial and pleural fluid
Intra-uterine pregnancy identification
Basic echocardiography in life support
Hydronephrosis
Biliary tract disease
Soft tissue studies
Deep vein thrombosis
Lung pathology
Vascular access and other procedures
North American Paediatric Emergency Medicine (PEM) POCUS programs are well established. In Australia many large Paediatric Emergency Departments run PEM POCUS programs training staff in ultrasound guided procedures, eFAST, lung, soft tissue, focused echo in life support and bowel applications (appendicitis, intussusception, pyloric stenosis). As the popularity and evidence base for focused ultrasound in PEM grows we can expect to see more formalized guidance in the PEM POCUS area.
ACEM Recommendations
ACEM encourages all emergency physicians to be competent in at least the ‘core’ areas of emergency ultrasound, being AAA, EFAST, procedural guidance, lung and echo in life support (FELS).
Equipment
Machines
CED has access to one Sonosite LX Ultrasound machine which is readily available to assist specialists and trainees in their clinical practice and their training in focused ultrasound. This machine and the three probes (high frequency linear, curvilinear, and cardiac/neonatal) are easy to use and meet the needs of our patient cohort as well as the skills of our practitioners. It is readily available for the emergent patient when required with appropriate transducers and consumables for timely use. It has a short a start-up time to ensure it is readily available to the critically ill patient.
Other equipment
The ultrasound trolley contains ultrasound probe covers, transducer gel, cleaning wipes and equipment for procedures. Please let Kylie know if there is equipment that is out of stock, or other suggested equipment.
Hygiene
Where any probe is used for needle based clinical procedures, or where there is a risk of exposure to body fluids, a probe cover should be used.
All probes should be cleaned with clinell wipes after every use.
It is the responsibility of the clinician using the ultrasound machine to clean it appropriately after each use.
Logistics
Documentation and saving images
Appropriate documentation of the clinician’s findings should be in written form either:
For credentialed clinicians: within an electronic patient record and be accessible to subsequent review by the patient’s treating team or for clinical review and audit.
For non-credentialed clinicians with findings not reviewed by a credentialed practitioner: in the clinician’s logbook.
The results of scans performed by clinicians in training should, in general, be clearly differentiated from those performed by qualified clinicians. In CED, only credentialed scans should be uploaded via a ROER’s request onto PACS.
Where non-credentialed scans are performed these should be available either on the machine, in the L drive, or on an anonymous platform such as sonoclipshare.com to supervisors/more qualified clinicians to allow quality assurance, training and feedback. Phrases such as ‘informal scan’ are to be avoided, as they imply a lack of accountability or process that ensures a scan result will be verified. Non-credentialed clinicians should not discuss any of their results with the patient but should seek a credentialed clinician to review their images and findings as soon as practicable. Real-time review is strongly encouraged for all clinicians in training.
Documentation of the ultrasound examination in the patient’s medical record should be entitled appropriately as a focused scan. The notes should describe the views obtained, the adequacy of those views and indicate whether the findings were normal, abnormal or indeterminate. If the study was inadequate, this must be clearly stated as such studies should not be used to make clinical decisions.
Documentation should also be limited to the pertinent question being addressed by the focused ultrasound and remain within the scope of the practitioner. It is unlikely that a focused ultrasound can be considered a rule-out investigation in many ED clinical scenarios and further definitive imaging should be considered.
Practitioners are strongly encouraged to seek input from credentialed or qualified practitioners in the first instance of finding incidental and/or important unexpected findings and obtain real-time review. Radiologists and Sonographers may also be of assistance but may defer formal comments until a diagnostic imaging study is complete.
Image transfer to RCP
For clinicians who have completed credentialing (or have had their scan reviewed by a credentialed clinican), clinical images/loops are retained with a report of the conclusions made via secure wireless data transfer from the Ultrasound machine to PACS. These images and report are then available to all clinicians involved with the patients care and for teaching/training purposes. This better allows reflective review of practice, to minimise duplication of process and to minimise misinterpretation errors. Recording of images and reports can allow for the detection and correction of errors (by both the initial clinician and others) but more often will help justify decisions that were based on images but subsequently questioned. Verbal reports and ‘phantom scanning’ (i.e. scanning without any record of the clinical interaction) are to be strongly discouraged.
• Document on uploading to PACS
Image transfer to home computer
Every month, complete scans will be transferred off the ultrasound machine and stored on the L drive (L: → Groups → STARSHIP → CED Resources → Ultrasound machine image archive). Incomplete or unidentifiable scans will be deleted from the machine and not stored on the L drive.
Image transfer for own use
Please use an encrypted USB if you are taking scans with patient details off site. Scans which have had patient details removed can also be stored in a cloud based system such as sonoclipshare.com
Governance
CED has an ACEM appointed CLUS who assists with the supervision, assessment, ultrasound training and education of all trainees and specialists in CED. Where there is qualified or other interested parties, they can assist in this role. The CLUS for CED is Kylie Salt.
Other roles the CLUS is responsible for include: maintaining a high quality of clinical governance and patient safety, responsibility for image reviews, feedback and sign-off, DOPS, Policy development, audit, advocacy and liaison.