Getting started

Figure 2.1 Baby steps. When starting to perform point-of-care ultrasonography, it is best to use a stepwise approach.

The initial implementation of an ultrasound program is often fraught with administrative, political, and technical obstacles. Overcoming these hindrances can be facilitated by following a well-thought-out, comprehensive plan. While there is no single formula for success, addressing the issues outlined in this chapter early in the process will lead to greater benefit and allow for smoother transition incorporating ultrasound into everyday practice. Although the recommendations set forth here are based on the experience in an emergency department, the points outlined may be applied across multiple different specialties.

Step 1: identifying a point person

Before starting any ultrasound program, an ultrasound program director must be identified. Ideally, this person should be within the department or division starting the program and should already be well trained in point-of-care ultrasound, or be prepared to undertake additional ultrasound training. Their ultrasound skills must be sufficient such that they will be able to teach machine basics, ultrasound physics, and instrumentation, acquire images, and recognize clinical indications for ultrasound use. Once the faculty begins to incorporate ultrasound into clinical practice, the director will review all training images and provide feedback with respect to image acquisition and interpretation. The director will also assume roles involving quality assurance and interdepartmental communication. Without an ultrasound director, staff and trainees will become frustrated without the necessary guidance and assistance in troubleshooting.

The ultrasound director should have acquired additional ultrasound skill and knowledge during the course of his/her training. This can be accomplished by various means: having a focus on ultrasound during residency or fellowship, extra training as a faculty member, or completing a dedicated point-of-care ultrasound fellowship. Completing a fellowship is not an absolute requirement, but often provides a useful comprehensive background in establishing and running an ultrasound division. Regardless of his/her training, the director needs to have an adequate understanding of ultrasound principles such that that knowledge can be imparted to the rest of the faculty, fellows, and residents. If not, sufficient time will need to be devoted to training the ultrasound director. This can be accomplished in a variety of ways, but should include a point-of-care ultrasound course, in addition to a considerable amount of time performing hands-on training with an experienced sonographer.

There is some debate with regard to the requisite credentials of the ultrasound director. Currently, there exist no strict qualifications for ultrasound directors, and it is up to division leadership to decide on the necessary experience. Many directors have chosen to pursue the Registered Diagnostic Medical Sonographer (RDMS) certification, which is generally what ultrasound technologists have obtained. While this certification may be of some value both educationally and to hospital leadership, it is by no means necessary as it encompasses a much broader range of ultrasound imaging knowledge than should be necessary for point-of-care ultrasound applications. In the future, more specific point-of-care ultrasound certification may be available.

Step 2: program planning

Choose the indications

The first step in program planning is to consider what type of ultrasound scans will be performed. Several factors should be considered when making this decision. First, determine which indications will have the greatest impact on patient care. Choosing a core set of applications that may identify life-threatening conditions or improve the safety of a commonly performed procedure will be an easier sell to not only the departmental faculty, but also hospital leadership. Those conditions in which significant morbidity or mortality may result from a delay in diagnosis (e.g. hemopericardium from a stab wound to the chest) should be strongly considered. Second, consider the patient population. For centers that see a high volume of trauma, incorporating the FAST (focused assessment with sonography for trauma) examination would seem prudent. For centers that see a high rate of pregnancy-related complications, pelvic ultrasound would be appropriate. Third, consider what services are already available. While few hospitals have ultrasound technologists 24 hours per day, many do have overnight radiology residents and fellows. It can be a more difficult task convincing departmental and hospital leadership of the need for an ultrasound program based on non-urgent conditions when sonography is available at all hours.

Determining the type of examinations to be performed will set the foundation for the training and credentialing process, as well as direct the purchasing of the ultrasound system. The ultrasound director should attempt to identify all potential ultrasound indications in the initial development of the program. For each type of ultrasound examination chosen, trainees will need to be exposed to didactic sessions, participate in hands-on practice sessions, and be required to obtain a minimum number of images reviewed by the ultrasound director or other appropriately trained staff member.

Set the training requirements

Once an ultrasound director has been identified and an ultrasound system has been purchased, a well-thought-out training plan must be in place before education may begin. Each ultrasound practitioner in the department must learn when to use ultrasound appropriately, how to obtain and interpret these images for each indication, and be able to apply their findings to individual clinical scenarios.

Certain subspecialties have published minimal standards and requirement for ultrasound training within their respective fields. Other subspecialties in which ultrasound may be a new tool have left training requirements more nebulous. Guidelines from the American College of Radiology and the American Institute of Ultrasound in Medicine (AIUM) are geared towards comprehensive, diagnostic examinations and may be too extensive for point-of-care ultrasound. Therefore, the American College of Emergency Physicians (ACEP) published consensus training guidelines, based upon expert opinion and previous published data, which have now become the current standard in emergency medicine. A collaborative group consisting of the American Academy of Pediatrics (AAP), Society for Academic Emergency Medicine (SAEM), and AIUM is in the process of creating pediatric-specific guidelines. Generally speaking, programs should establish a minimum number of didactic hours, a minimum number of overall ultrasound examinations, and a minimum number of specific studies to look for a particular finding. Whenever possible, specialty-specific guidelines pertaining to essential requirements should be followed.

Credentialing and privileging

Credentialing or privileging (terms often used interchangeably) defines a physician’s scope of practice. It is the process by which hospitals allow physicians to join the medical staff, and the pathway by which the hospital approves an individual department’s delineation of privileges for physicians within that department. For example, any physician who performs procedural sedation must have sedation privileges and be credentialed by the hospital for such. The pathway to achieve this credentialing may be varied, specialty-specific, and based on either prior experience obtained in training or internal departmental training. Similarly, point-of-care ultrasound credentialing will be hospital specific and based on specialty-specific guidelines. In support of point-of-care ultrasound, the American Medical Association (AMA) passed resolution HR 802.99.2001 (Privileging for ultrasound imaging), which states that “privileging of the physician to perform ultrasound imaging procedures in a hospital setting should be a function of the hospital medical staff and should be specifically delineated on the Department’s Delineation of Privileges form . . . and that each hospital medical staff should review and approve criteria for granting ultrasound privileges based upon background . . . and training standards developed by each physician’s respective specialty.” In this manner, point-of-care ultrasound falls under the purview of each specialty, and no one specialty has jurisdiction over all of ultrasound imaging. Accordingly, departmental leadership should request general point-of-care ultrasound privileging for its faculty, with specific requirements and maintenance to be monitored internally.

Credentialing goes hand-in-hand with training, and should be based upon meeting the minimum requirements set forth in the training plan. The departmental leadership and the ultrasound director should agree upon the credentialing plan. Expert recommendations exist, but in general credentialing requirements should entail the following:

1. A one- to two-day ultrasound course that teaches point-of-care ultrasound fundamentals and physics, and the various relevant ultrasound applications (Figure 2.2). For each application, there should be some didactic time devoted to the fundamentals of image acquisition and interpretation of positive and negative results. Additionally, there should be some hands-on time where the participant may apply what they have just learned (Figure 2.3). Clinicians should not be considered proficient and credentialed after a one- to two-day course. This instruction merely serves as a foundation for further learning in ultrasonography.

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