Act now to improve your ultrasound program
When a surgeon was called to the emergency department (ED) to take a patient to the operating room for cholecystitis, he complained that he didn’t trust the accuracy of the ultrasound scans.
"When I showed him the images of the inflamed gallbladder and the stones in it, and then the videotape of it, his demeanor changed completely," says Michael Blaivas, MD, RDMS, director of emergency ultrasound at North Shore University Hospital in Manhasset, NY. The surgeon smiled and agreed to take the patient for surgery after a second course of antibiotics, he reports.
The above anecdote illustrates the importance of demonstrating a quality ED ultrasound program, says Blaivas. "Complaints are often used to undermine or shut down an ED ultrasound program," he stresses. The more organized you appear, the better you can defend against any attacks, adds Blaivas. "Be prepared for complaints, and show that you have a dynamic system that fixes errors and continually improves," he says.
An effective quality assurance (QA) program can make or break the survival of your ultrasound program, according to Christopher DiOrio, DO, emergency ultrasound coordinator at Medical College of Georgia in Augusta. "No test is 100% sensitive or specific, so it is important to have a system designed to handle the minority of missed cases," he adds.
Here are ways to improve your ultrasound program:
• Videotape all ultrasound examinations. Blaivas advises you to videotape all examinations, instead of only printing a few still images. "Videotaping allows the physician to review the scan at a later time to see if any additional findings were present, or if anything was missed," he says. He acknowledges that many ED physicians are reluctant to do this, fearing mistakes will be discovered subsequently. "But you can’t practice to cover up any possible errors. You can learn from these errors," he says, adding that the tape is probably protected from discovery in the event of a lawsuit since it’s part of QA. Videotapes allow you to see where the novice ultrasonographer makes mistakes and help him or her to make corrections, he says.
• Each ultrasound performed by a noncredentialled physician must be reviewed by a credentialled staff member. It would be optimum to do this using real-time video, says DiOrio. "However, this is probably logistically impossible since this would take much too long," he explains. "In light of this, we use still images of key portions of the exam." For example, the goal may be to rule out an ectopic pregnancy, says DiOrio. "We usually can ascertain this adequately with an intravaginal two-view approach, clearly pictured on still copies for QA review," he adds.
DiOrio cautions that if a decision needs to be made immediately, and if a credentialled ultrasound faculty member is not available, then a confirmatory test needs to be obtained such as a repeat ultrasound, computerized tomography, or serial exams. He also warns against basing medical decisions on ultrasound alone if you are not certain of the images obtained. Just as additional tests may be needed to rule out a heart attack, a single ultrasound may not be enough to adequately evaluate other disease processes, says DiOrio.
• Have a dedicated individual responsible for ultrasound QA. A single individual should be responsible for managing all QA data and investigating any negative outcomes, says Blaivis. "This should not be left up to individual physicians any more than other departments would leave QA for electrocardiograms or chest X-ray readings up to individuals," he adds. Blaivas advises against assigning QA to someone who has no interest in it. "Ideally it would be a volunteer position, attracting someone who is really interested in emergency ultrasound," he says.
It’s a mistake to allow someone from radiology do QA for the ED, adds Blaivas. "They have no true understanding of emergency practice, nor will they have the welfare of any department other than their own in mind," he says. "This is just the reality of business."
Sources
For more information about emergency department ultrasound, contact:
• Michael Blaivas, MD, RDMS, Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. Telephone: (516) 562-2927. Fax: (516) 562-2828. E-mail: [email protected].
• Christopher DiOrio, DO, Department of Emergency Medicine, AF2037, Medical College of Georgia, 1120 15th St., Augusta, GA 30912-2800. Telephone: (706) 721-4412. Fax: (706) 721-7718. E-mail: [email protected].
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