Ultrasound at the point of care: who's in charge?
June 17, 2011
This report originally appeared in the June 2011 issue of DOTmed Business News
By David Willis
One in three hospitalized patients may suffer medical errors or other adverse events, a rate ten times higher than previous estimates, according to a new study published in the April issue of Health Affairs. Another study in the same issue reported medical errors cost the US health care system $17.1 billion in 2008. Taken together, these findings offer powerful evidence that administrators and physicians need to work harder to improve the quality and safety of health care.
Ultrasound at the point of care may be part of the solution. Yet as the use of ultrasound becomes more integrated into medical specialties, it also becomes more of a flashpoint in the long-simmering turf war between radiologists and non-radiologists.
Turf wars
According to an August, 2010 special report in Emergency Medicine News, ”Radiologists and Emergency Physicians Still Debating Who Should Hold the Ultrasound Probe,” the new turf war is unlike the old. A driving force seems to be the evolving applications of the technology that have lead to misunderstandings on the part of some radiologists, leading them to perceive an encroachment on their traditional domain when there is actually an opportunity for radiologists and non-radiologists to work together in new ways to improve the quality and safety of health care. The report pointed out that better understanding of the benefits of emergency ultrasound, for example, would be “a win-win for the hospital system.”
So how do we achieve this solution? Let’s examine the facts about ultrasound at the point of care. Advances in ultrasound equipment have made it possible to use this powerful, safe technology around the world –and beyond--in settings as diverse as the International Space Station (where astronauts were trained, with expert medical guidance, to perform ultrasound examinations) to the Mount Everest base camp (where ultrasound has been used to diagnose high-altitude pulmonary edema) and battlefield medicine (where portable ultrasound devices can be employed to rapidly check wounded soldiers for internal bleeding and other potentially life-threatening conditions.)
Some radiologists have contended other physicians lack the necessary expertise to use ultrasound visualization, The May/June 2009 issue of Health Imaging & IT reported, “Some radiologists remain concerned about the efficacy of the growing use of ultrasound in the [emergency department],” due to the need for seasoned reading skills required to properly diagnose the patient and recommend a treatment plan. A similar disagreement erupted in 2010, in the online publication Medscape Radiology, with radiologists and emergency physicians debating whether non-radiologists should perform ultrasonography.
However, a February New England Journal of Medicine review offers a key insight: Non-radiologists are not encroaching on the traditional domain of radiologists. Instead, the concept of a limited, or focused, examination plays an important role in use of ultrasound at the point of care, the researchers from the Departments of Emergency Medicine and Obstetrics, Gynecology, and Reproductive Sciences at Yale reported. “Clinicians from diverse specialties can become very adept at using ultrasonography to examine a particular organ, disease or procedure that is relevant to there area of expertise, whereas imaging specialists typically perform a more comprehensive examination.”
Ultrasound accuracy
The FAST (Focused Assessment with Sonography for Trauma) examination is a perfect example of this important distinction. This use of ultrasound at the point of care enables emergency medicine physicians a safer way to assess trauma patients for potentially life-threatening problems, by checking for fluid, including hemorrhaging, with a sensitivity of 73 to 99 percent, according to the NEJM review. The overall accuracy for clinically significant intraabdominal injury in trauma patients is 90 to 98 percent. What’s more, the FAST exam has been shown to decrease the need for CT and to speed up treatment, thus resulting in shorter hospital stays, lower costs, and reduced mortality.
A study presented at American College of Emergency Physicians Research Forum last year also found that ultrasound at the point of care was 85 percent accurate for evaluating acute appendicitis in children, one of the most common abdominal surgical emergencies in children, with about 80,000 such cases in the United States each year. Ultrasound is the preferred modality for this age group, due to mounting public health concerns over the risks of radiation exposure.
Emergency physicians and the other principal physician specialties that use ultrasound in their practices are trained in residency and fellowship and have clinical experience in integrating their findings into the patient’s entire treatment plan. In addition, the American College of Emergency Medicine (ACEP) updated its evidence-based emergency ultrasound guidelines in 2009, reporting that the technology is widely used at bedside to diagnose acute, life-threatening disorders, guide invasive procedures and aid emergency medicine physicians in developing a treatment plan. Not only does the ACEP deem the ability to perform and interpret emergency ultrasound to be a fundamental skill for emergency physicians, but it also endorses having dedicated ultrasound equipment at bedsides in the ED.
Ultrasound at the point of care also improves patient safety, a crucial goal for both physicians and administrators, given the high rate of medical errors that have recently been reported. The NEJM found that, “With appropriate use, point-of-care ultrasonography can decrease medical errors, provide more efficient real-time diagnosis.”
Physicians often employ ultrasound at the point of care as a safe way to guide certain invasive procedures, such as nerve block injections, central line placement, and fluid drainage, including thoracentesis and paracentesis. Ultrasound guidance of catheterization of the internal jugular vein reduces the rate of catheter-related bloodstream infections by 35 percent, offering significant cost savings. The Centers for Disease Control and Prevention estimate that the marginal costs to the healthcare system of a single catheter-related bloodstream infection is $25,000.
For placing central lines, the Agency for Healthcare Research and Quality (AHRQ) identifies ultrasound guidance as one of 11 patient safety practices warranting widespread adoption. AHRQ found that “real-time ultrasound guidance for CVC insertion…improves catheter insertion success rates, reduces the number of venipuncture attempts prior to successful placement and reduces the number of complications associated with catheter placement.” Complications, including pneumothorax, are reduced substantially, with a relative risk reduction of 78 percent.
A NICE guideline
In the United Kingdom, the National Institute of Clinical Excellence (NICE) has issued national guidelines recommending ultrasound guidance as the preferred method to lower the risk of such serious complications as collapsed lung, arterial puncture, nerve injury, and arteriovenous fistula. It’s now become the standard of care. In the U.S., many top medical centers have adopted an institution-wide policy requiring ultrasound guidance for all central line placements. The 2011 CDC Guidelines for the Prevention of Intravascular Infections list the use of ultrasound for central venous catheter placement to reduce the number of cannulation attempts and mechanical complications.
The rationale is simple: It’s safer to place a central line when physicians can see the jugular vein under ultrasound, instead of working blindly. Since patients’ anatomy can vary, landmark methods are also more likely to result in multiple insertion attempts, with initial failure rates of up to 35 percent reported in medical literature.
Adverse events resulting from blind insertions of central lines also pose another financial hazard: expensive litigation. An analysis by the American Society of Anesthesiology found that the median malpractice payment for central venous catheter-related claims was $105,500, with multi-million dollar payments reported for certain catheter injuries, such as cardiac tamponade, hemothorax, and blood vessel injury.
Over the past five years, use of ultrasound guidance has expanded significantly in anesthesiology, where even for experienced anesthesiologists, injecting regional anesthesia blindly is challenging, creating a risk of injuries to adjacent structures. While nerve stimulation offers a reliable method of locating the correct nerve, it can be a time-consuming process of trial and error, as various nerves are tested. Ultrasound offers a safe, cost-efficient and speedier solution.
Here is a case where seeing truly is believing—in the power of ultrasound at the point of care to save time and money, while powerfully enhancing patient safety, no matter which practitioner is holding the ultrasound probe.
David Willis is Vice President, Innovation and Competitive Strategy at SonoSite, Inc. in Bothell, Washington. He was also a sonographer at the Health Sciences Center in Winnipeg, Canada and is a registered medical sonographer (RDMS, RDCS). He completed the Executive Education Program at the Wharton School of Business.
By David Willis
One in three hospitalized patients may suffer medical errors or other adverse events, a rate ten times higher than previous estimates, according to a new study published in the April issue of Health Affairs. Another study in the same issue reported medical errors cost the US health care system $17.1 billion in 2008. Taken together, these findings offer powerful evidence that administrators and physicians need to work harder to improve the quality and safety of health care.
Ultrasound at the point of care may be part of the solution. Yet as the use of ultrasound becomes more integrated into medical specialties, it also becomes more of a flashpoint in the long-simmering turf war between radiologists and non-radiologists.
Turf wars
According to an August, 2010 special report in Emergency Medicine News, ”Radiologists and Emergency Physicians Still Debating Who Should Hold the Ultrasound Probe,” the new turf war is unlike the old. A driving force seems to be the evolving applications of the technology that have lead to misunderstandings on the part of some radiologists, leading them to perceive an encroachment on their traditional domain when there is actually an opportunity for radiologists and non-radiologists to work together in new ways to improve the quality and safety of health care. The report pointed out that better understanding of the benefits of emergency ultrasound, for example, would be “a win-win for the hospital system.”
So how do we achieve this solution? Let’s examine the facts about ultrasound at the point of care. Advances in ultrasound equipment have made it possible to use this powerful, safe technology around the world –and beyond--in settings as diverse as the International Space Station (where astronauts were trained, with expert medical guidance, to perform ultrasound examinations) to the Mount Everest base camp (where ultrasound has been used to diagnose high-altitude pulmonary edema) and battlefield medicine (where portable ultrasound devices can be employed to rapidly check wounded soldiers for internal bleeding and other potentially life-threatening conditions.)
Some radiologists have contended other physicians lack the necessary expertise to use ultrasound visualization, The May/June 2009 issue of Health Imaging & IT reported, “Some radiologists remain concerned about the efficacy of the growing use of ultrasound in the [emergency department],” due to the need for seasoned reading skills required to properly diagnose the patient and recommend a treatment plan. A similar disagreement erupted in 2010, in the online publication Medscape Radiology, with radiologists and emergency physicians debating whether non-radiologists should perform ultrasonography.
However, a February New England Journal of Medicine review offers a key insight: Non-radiologists are not encroaching on the traditional domain of radiologists. Instead, the concept of a limited, or focused, examination plays an important role in use of ultrasound at the point of care, the researchers from the Departments of Emergency Medicine and Obstetrics, Gynecology, and Reproductive Sciences at Yale reported. “Clinicians from diverse specialties can become very adept at using ultrasonography to examine a particular organ, disease or procedure that is relevant to there area of expertise, whereas imaging specialists typically perform a more comprehensive examination.”
Ultrasound accuracy
The FAST (Focused Assessment with Sonography for Trauma) examination is a perfect example of this important distinction. This use of ultrasound at the point of care enables emergency medicine physicians a safer way to assess trauma patients for potentially life-threatening problems, by checking for fluid, including hemorrhaging, with a sensitivity of 73 to 99 percent, according to the NEJM review. The overall accuracy for clinically significant intraabdominal injury in trauma patients is 90 to 98 percent. What’s more, the FAST exam has been shown to decrease the need for CT and to speed up treatment, thus resulting in shorter hospital stays, lower costs, and reduced mortality.
A study presented at American College of Emergency Physicians Research Forum last year also found that ultrasound at the point of care was 85 percent accurate for evaluating acute appendicitis in children, one of the most common abdominal surgical emergencies in children, with about 80,000 such cases in the United States each year. Ultrasound is the preferred modality for this age group, due to mounting public health concerns over the risks of radiation exposure.
Emergency physicians and the other principal physician specialties that use ultrasound in their practices are trained in residency and fellowship and have clinical experience in integrating their findings into the patient’s entire treatment plan. In addition, the American College of Emergency Medicine (ACEP) updated its evidence-based emergency ultrasound guidelines in 2009, reporting that the technology is widely used at bedside to diagnose acute, life-threatening disorders, guide invasive procedures and aid emergency medicine physicians in developing a treatment plan. Not only does the ACEP deem the ability to perform and interpret emergency ultrasound to be a fundamental skill for emergency physicians, but it also endorses having dedicated ultrasound equipment at bedsides in the ED.
Ultrasound at the point of care also improves patient safety, a crucial goal for both physicians and administrators, given the high rate of medical errors that have recently been reported. The NEJM found that, “With appropriate use, point-of-care ultrasonography can decrease medical errors, provide more efficient real-time diagnosis.”
Physicians often employ ultrasound at the point of care as a safe way to guide certain invasive procedures, such as nerve block injections, central line placement, and fluid drainage, including thoracentesis and paracentesis. Ultrasound guidance of catheterization of the internal jugular vein reduces the rate of catheter-related bloodstream infections by 35 percent, offering significant cost savings. The Centers for Disease Control and Prevention estimate that the marginal costs to the healthcare system of a single catheter-related bloodstream infection is $25,000.
For placing central lines, the Agency for Healthcare Research and Quality (AHRQ) identifies ultrasound guidance as one of 11 patient safety practices warranting widespread adoption. AHRQ found that “real-time ultrasound guidance for CVC insertion…improves catheter insertion success rates, reduces the number of venipuncture attempts prior to successful placement and reduces the number of complications associated with catheter placement.” Complications, including pneumothorax, are reduced substantially, with a relative risk reduction of 78 percent.
A NICE guideline
In the United Kingdom, the National Institute of Clinical Excellence (NICE) has issued national guidelines recommending ultrasound guidance as the preferred method to lower the risk of such serious complications as collapsed lung, arterial puncture, nerve injury, and arteriovenous fistula. It’s now become the standard of care. In the U.S., many top medical centers have adopted an institution-wide policy requiring ultrasound guidance for all central line placements. The 2011 CDC Guidelines for the Prevention of Intravascular Infections list the use of ultrasound for central venous catheter placement to reduce the number of cannulation attempts and mechanical complications.
The rationale is simple: It’s safer to place a central line when physicians can see the jugular vein under ultrasound, instead of working blindly. Since patients’ anatomy can vary, landmark methods are also more likely to result in multiple insertion attempts, with initial failure rates of up to 35 percent reported in medical literature.
Adverse events resulting from blind insertions of central lines also pose another financial hazard: expensive litigation. An analysis by the American Society of Anesthesiology found that the median malpractice payment for central venous catheter-related claims was $105,500, with multi-million dollar payments reported for certain catheter injuries, such as cardiac tamponade, hemothorax, and blood vessel injury.
Over the past five years, use of ultrasound guidance has expanded significantly in anesthesiology, where even for experienced anesthesiologists, injecting regional anesthesia blindly is challenging, creating a risk of injuries to adjacent structures. While nerve stimulation offers a reliable method of locating the correct nerve, it can be a time-consuming process of trial and error, as various nerves are tested. Ultrasound offers a safe, cost-efficient and speedier solution.
Here is a case where seeing truly is believing—in the power of ultrasound at the point of care to save time and money, while powerfully enhancing patient safety, no matter which practitioner is holding the ultrasound probe.
David Willis is Vice President, Innovation and Competitive Strategy at SonoSite, Inc. in Bothell, Washington. He was also a sonographer at the Health Sciences Center in Winnipeg, Canada and is a registered medical sonographer (RDMS, RDCS). He completed the Executive Education Program at the Wharton School of Business.