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24. Rudolph SS, et al. Effect of prehospital ultrasound on clinical outcomes of non-trauma
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25. Jorgensen H, Jensen CH, Dirks J.Does prehospital ultrasound improve treatment of the trauma
patient? A systematic review. Eur JEmerg Med. 2010;17(5):249–53.
26. O’Dochartaigh D, Douma M.Prehospital ultrasound of the abdomen and thorax changes
trauma patient management: a systematic review. Injury. 2015;46(11):2093–102.
27. European Resuscitation Council Guidelines for Resuscitation. 2015. https://cprguidelines.eu/.
Accessed 14 Oct 2016.
28. Gaspari R, etal. Emergency department point-of-care ultrasound in out-of-hospital and in-ED
cardiac arrest. Resuscitation. 2016;109:33–9.
29. Adhikari S, etal. Transfer of real-time ultrasound video of FAST examinations from a simu-
lated disaster scene via a mobile phone. Prehosp Disaster Med. 2014;29(03):290–3.
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H. Cochrane and H.H. Kimberly
Chapter 26
Community Ultrasound
RajeshN.Geria and RobertJ.Tillotson
Objectives
• Explain the history and current state of POC US in the community hospital
• Discuss what challenges are unique to the community hospital
• Discuss strategies to solicit department leadership support for ultrasound in the
group and community setting
• Discuss tips for training and credentialing the community physician
• Discuss the importance of image archival and overall workow to program
success
• Discuss the role of certication and accreditation in community practice
• Discuss solutions/resources for implementation and management of ultrasound
in the community hospital
R.N. Geria, MD, FACEP (*)
Department of Emergency Medicine, Robert Wood Johnson Medical School, New
Brunswick, NJ, USA
e-mail: rgeria@mac.com
R.J. Tillotson, DO, FACEP
Northwest Wisconsin Emergency Medicine, Mayo Clinic Health System, Eau Claire, WI,
USA
e-mail: tillotson.robert@mayo.edu
V. S. Tayal et al. (eds.), Ultrasound Program Management,
https://doi.org/10.1007/978-3-319-63143-1_26
409© Springer International Publishing AG 2018
410
R.N. Geria and R.J. Tillotson
Introduction
Nationwide there is a total of 5627 hospitals. Of these hospitals, there are 1007
designated teaching hospitals and only 400 academic medical centers. Consequently,
the vast majority of medicine is practiced in community hospitals. It is in these community hospitals that point of care ultrasound can have its greatest impact on patient
care. The greatest potential for growth of point of care ultrasound is also found in
community hospitals.
The focus of academic centers is typically threefold: education, research, and
patient care. But the real impact of these centers’ research and new innovations is
dependent upon the implementation of these advancements into the medical community at large. Successful implementation and management of a point of care
ultrasound program in community hospitals ensures that patients receive the benets that ultrasound provides at the bedside.
Physicians practicing in the community setting face unique challenges in developing and maintaining point of care ultrasound programs. Community physicians
have clinical demands without the advantages of physicians in training, mandated
training requirements, and protected nonclinical time. Training in ultrasound is
challenging as shown in a community ultrasound survey by Moore etal. in 2006,
which found lack of training as the biggest reason for not integrating point of care
ultrasound into community practice [1].
Community physicians face evolving standard of care issues as ultrasound is
adopted for diagnosis and procedural guidance and feeling behind can add to the
pressure of adopting ultrasound. Community physicians may not be getting the full
benet of postgraduate ultrasound fellowships according to Society of Clinical
Ultrasound Fellowships (SCUF) database. Most fellows graduating from ultrasound
fellowships are joining academic groups further contributing to the expertise void in
the community setting. Community physicians may have more justication for ultrasound adoption due to lack of availability of consultative ultrasound from traditional
providers and increased pressures for efciency and risk management. Community
physicians also have a more collegial relationship with their colleagues and face less
political battles. Physicians practicing in this setting can build successful ultrasound
programs by following national guidelines and strategies outlined in this chapter.
History ofPOC US inCommunity Setting
Emergency Medicine was early in implementing point of care ultrasound (POC US),
but the challenges Emergency Medicine encountered in the community setting mirror the challenges other specialties face. In Emergency Medicine residencies, the
initial training of residents in the use of point of care ultrasound varied by institution.
For these reasons, many physicians practicing in community hospitals have limited
experience in point of care ultrasound, nor do they have anyone to train, mentor, or
administrate the implementation of ultrasound into these community hospitals.
26 Community Ultrasound
411
In the 2000s, it became evident from the academic centers that ultrasound was
going to be a new standard of care for many clinicians. Following this trend, there
was a resulting spike in sales of ultrasound machines to community hospitals. Soon,
most community emergency departments were equipped with an ultrasound
machine for point of care evaluation. Many community-based emergency physicians
took introductory ultrasound courses under the assumption that the course would
adequately prepare them to effectively implement point of care ultrasound into their
practice. Now possessing an ultrasound machine, emergency physicians assumed
that learning to utilize the machine and incorporating it into their practice would be
simple, similar to incorporating the Gluidescope or Ez-IO.
Unfortunately, many physicians failed to understand that, in addition to the foundational training obtained in introductory courses, full implementation of point of
care ultrasound also required having a number of proctored or over-read studies
until the clinician mastered acquisition and recognition of both normal and abnormal images. Most community emergency departments did not provide, or have
access to, the additional oversight and mentorship necessary to ensure physician
competency in point of care ultrasound. Incomplete image acquisition and inconsistent image quality resulted in ineffective integration of bedside ultrasound. This
effect was magnied in low volume community Emergency Departments because
of the lack of available patients and pathology. Consequently, the benet of clinical
ultrasound as a diagnostic modality was not realized in most community hospitals,
and ultrasound machines were banished to the corner to collect dust. In fact, the
challenges faced by emergency medicine in this respect offer great lessons for other
specialties.
Although some community hospitals were able to successfully implement emergency ultrasound into the emergency department, most of these hospitals had no
consistent workow to follow. Archived images for education, credentialing, and
patient records were printed pictures and videos; few had electronic storage solutions. There was no established workow or QA process, so most borrowed from
academic centers or created their own. Inconsistency in interpretation and documentation of results was common, undermining credibility of EUS with the medical
staff. This resulted in ineffective integration into patient care workow. Therefore,
use of ultrasound was sporadic and inconsistent. Unfortunately, many community
hospitals attempting to implement EUS into the practice of emergency medicine did
not reach their full potential.
There have been additional obstacles to the implementation of EUS in community hospitals from both within and outside the emergency department. Medical
staff challenges arose both as turf battles and a lack of condence in the results
obtained by emergency physicians. Many community hospital emergency departments are not uniformly staffed, which creates challenges in EUS implementation
and consistency within emergency department groups. Navigating the political
structure of the group to obtain participation and support was difcult, especially
since most of these physicians had practiced successfully for years using radiology consultants for ultrasound and did not appreciate the benet of doing ultrasounds themselves. After all, it was easier to check a box than to try and do an
ultrasound oneself.
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R.N. Geria and R.J. Tillotson
Finally, community hospitals do not have the benet of an academic program to
support and perpetuate complex advances in medicine, such as point of care ultrasound. There is a paucity of dedicated funds for training, ultrasound directors, and
equipment expenditures. Early on many champions encountered uphill battles with
administration to justify allocating funds for developing an ultrasound program.
Administrators, often viewed EUS as a duplication of services and did not understand the need to dedicate physician resources to manage an ultrasound program in
their emergency departments. However, much of this has or is now changing.
Creating aSuccessful Ultrasound Program intheCommunity
Setting
The core of a successful ultrasound program in the community hospital is making
ultrasound an effective tool in the hands of the practicing physicians in those hospitals. This quintessential statement is the key to having ultrasound integrated successfully. This book gives detailed instructions on how to implement a successful
ultrasound program. The principles detailed apply to both academic and community
hospitals. This chapter will focus on the obstacles that are unique to the community
setting and their possible solutions (Table26.1).
Commitment
In order for point of care ultrasound to become an effective tool in the community
hospital setting, an ultrasound program committed to following established guidelines must be implemented. There is no academic drive, competition, or curriculum
to fuel implementation of an ultrasound program in a community hospital. Therefore,
someone has to be the impetus to make this happen. To make matters worse, there
will be many obstacles to building this program. Commitment is the key to
Table 26.1 Community management obstacles and solutions
Community management
obstacles Solutions
Department chair
commitment
Ultrasound director
training
Funding Demonstrate reimbursement potential, decrease cost of procedural
Physician training Imported courses, curated online medical education, scanning
Credentialing Follow ACEP guidelines [5]
Quality improvement Workow middleware
Demonstrate safety, quality, value, standard of care additional
benets: Recruiting, innovation
Take management course, recruit fellowship trained physician,
attend preceptorship (mini-fellowship)
complications, approach donors
shifts, functional quality assurance program
26 Community Ultrasound
overcoming these obstacles. This commitment starts with an ultrasound champion.
That champion could be the medical director, department chair, nurse director, an
emergency physician who took an ultrasound course, a new physician out of residency that was trained in ultrasound, or an Ultrasound Director. The champion’s
rst objective is to foster support from their physician group. If the group does not
show commitment to implementing ultrasound, it will be an uphill battle. Typically,
the group will support the idea if it is framed in a way that shows physicians how
ultrasound will improve their clinical practice.
This champion will also need to obtain commitment from hospital administration. Keep in mind that many hospital administrators invested money in an ultrasound machine in the early 2000s that ultimately sat in the corner; they will need to
be convinced that commitment is sincere. After all, an ultrasound machine with a
workow solution, ongoing expenses for supplies and maintenance, and compensation for an ultrasound director, will be one of the biggest single item expenditures
brought to the hospital as a capital request.
413
Soliciting Department Chair/Director Support
Support from the chair or director is critical to the success of any ultrasound program.
Most chairs recognize the positive impact bedside ultrasound has had on patient care.
This section is designed to assist the practitioners who may nd themselves up
against stiff chairmen resistance to developing an ultrasound program. Academic
chairs often implement what is right for the residency program and as mentioned in
the introduction, involves an aggressive ultrasound curriculum in order fulll RRC
mandates. Chairmen of community ED’s and contract groups do not have this incentive so it falls on the ultrasound director to develop a creative approach to attain support to move forward. Community chairs may not need to adhere to residency
guidelines but they do need to ensure patients are getting high quality care. In the
current healthcare climate, all chairs face pressures from the hospital to comply with
the Affordable Care Act to deliver high quality, cost- effective, and safe care. It is
important for ultrasound directors to leverage these goals and build the following
equation into any conversation with a Chair when trying to attain program support:
Quality=Safety/Cost
Value=Quality
Safety
This is the lowest hanging fruit with the biggest impact. Multiple studies have demonstrated that ultrasound guidance improves the success rates and safety of invasive
procedures including central lines, paracentesis, and thoracentesis. Using ultrasound guidance to insert central venous catheters is not a novel concept anymore. In
414
R.N. Geria and R.J. Tillotson
fact, it is essentially standard of care and any community ED not using this is practicing suboptimal care that could result in grave consequences for the patient.
Complications resulting from blind attempts at central venous access have been
well documented inclusive of pneumothorax, arterial hemorrhage, CVA, pericardial
tamponade, hemothorax, and central line associated blood stream infections
(CLABSI). In 2011, the CDC released guidelines to reduce CLABSI and number 7
is the use of ultrasound guidance to place central venous catheters to reduce the
number of cannulation attempts and mechanical complications. In 2013, CMS
released its nalized payment reduction program for Hospital Acquired Conditions
(HAC), which essentially states that 1% of Medicare payments to hospitals performing in the bottom 25th percentile will be at risk. The Agency for Healthcare
Research and Quality (AHRQ) lists ultrasound guidance for central venous catheters as a top 10 recommendations for clinicians to make healthcare safer for patients.
The Joint Commission (JC) lists using ultrasound for central line insertion in Chap.
3 of the Central Line Associated Blood Stream Infections CLABSI toolkit. Any
reluctant chair could be reminded that from a pure safety perspective in 2016 ultrasound use will be mandated for central line guidance by the National Quality Forum
(NQF). Another useful strategy illustrating the importance of safety that may be
even more effective than external evidence and supporting literature is leveraging
complications that occurred at the home institution such as the dreaded sentinel
event. Keep track of cases where ultrasound guidance was not used that resulted in
poor outcomes and show administrators. Medical directors interested in improving
safety for patients can easily accomplish this by supporting the purchase of smaller
scale machines with one transducer. The linear transducer is capable of doing a
large percentage of basic procedural ultrasound applications and is the recommended entry point into the world of point of care ultrasound for any community
ED practice because it is clearly the path of least resistance.
Cost
Cost-effective care is the new focus for today’s administrators and healthcare leaders. The fee for service model is being phased out and replaced with fee for quality.
Point of care ultrasound is helping reduce hospital and patient expenses by reducing the cost to the health system and the time required for diagnosis and treatment.
The increasing utilization of CT is an area of concern in this country as it continues
to burden the healthcare system with high cost while also leading to radiation
induced cancer. There is a national movement led by AIUM to promote an
“Ultrasound Approach” for common conditions like trauma, renal colic and undifferentiated abdominal pain in order to cut down the number of CT scans being
ordered. Another way to look at cost in the eyes of the community or large group
director is LOS and impact on practitioner RVU. Some critics of bedside ultrasound in this setting argue that it will slow them down and directly impact their
compensation. If ultrasound slows them down fewer patients will be seen resulting
26 Community Ultrasound
415
in increased LOS. One study evaluated this theory by looking at a community
group where compensation was entirely RVU based. The investigators found that
the practitioners categorized as the highest performers of bedside ultrasound actually had the highest RVU’s in the group [2]. Plain and simple, ultrasound allows
rapid narrowing of the differential diagnosis and often cuts down the workup
required to safely treat and disposition the patient. Community directors will have
to be convinced that bedside ultrasound can actually increase physician productivity while leading to safer higher quality care.
There is a general perception that ordering more CT scans may prevent frivolous
malpractice lawsuits. In addition, using bedside ultrasound may expose clinicians to
medicolegal risk. It is important for ultrasound directors to discuss the rise in cases
in the malpractice legal literature where guilty verdicts are being given for failure to
use ultrasound in the ED when it was available specically with relation to vascular
access.
Training andCredentialing theCommunity Physician
The lack of these resources and inherent motivation of community physicians to
come in on “days off” to scan in order to meet credentialing guidelines set forth by
ACEP create a challenging problem for the chair unique to this setting. The rst
consideration must be what training does the “ultrasound director” have? Is this
individual a recent graduate of a residency program or a seasoned community physician that may have grandfathered into this role with minimal ultrasound experience?
The chair should consider investing resources to develop the “ultrasound director”
if he/she falls into the latter category. Ultrasound preceptorships or mini-fellowship
programs are available and excellent ways to gain experience of running an ultrasound program while fullling the ACEP requirements to become credentialed in
the process. A listing of these programs can be found on the ACEP Ultrasound
Section website and range from anywhere between 4 and 7K/month (Table26.2).
Table 26.2 Ultrasound preceptorship sites
(CA) University of California (NC) Carolinas Medical Center
(DE) Christiana Care Health System (NJ) Morristown Memorial Hospital
(GA) Medical College of Georgia (NY) Albany Medical Center
(IL) John H.Stoger Hospital
of Cook County
(MA) Massachusetts General Hospital (NY) NY Hospital-Queens/Weill Cornell Med Coll
(MA) Tufts Medical Center (NY) NewYork Methodist Hospital
(MA) University of Massachusetts (NY) North Shore University Hospital
(MD) Johns Hopkins Hospital (NY) St. Luke’s—Roosevelt Hospital Center
(OH) Mid-Ohio Emergency Services
Adapted from ACEP.org
(NY) Mount Sinai School of Medicine
416
R.N. Geria and R.J. Tillotson
The initial didactic component of training can easily be accomplished by an
internal or external course but ongoing hands on scanning and pattern recognition
are crucial to developing real skill (See Chap. 5 – Introductory Education and Chap.
6 – Continuing Education). There are several strategies that community chairs can
try to encourage physicians to partake in the experiential phase of credentialing. A
dedicated number of scan shifts with and without the ultrasound director is a good
start. This will fail unless physicians are held accountable for this process. It is critical for the chair to emphasize the importance of this to the overall mission of the
department and build language into re-appointment contracts that reect ultrasoundcredentialing expectations. An example may be Dr. X will not be re- appointed after
year 2 if not credentialed in at least 2 of the 5 core applications of bedside ultrasound. The other approach could be strictly monetary. Each ultrasound performed
as part of the credentialing process holds some monetary value in terms of annual
bonus. Physicians in the group that perform more ultrasound will effectively make
more bonus money. How much is each ultrasound worth? Do physicians really want
to come in on a “day off” to make a few extra bonus dollars? Maybe a better strategy
is to link the entire bonus to ultrasound performance? A study by Budhram etal.
showed the successful implementation of ultrasound training using monetary incentives [3]. It is often only after physicians perform high volumes of scans that they
begin to see the true value of the technology. It may take 15 FAST exams to see a
positive but that single case may be enough evidence to convince the physician to
use it in the future for a similar patient. After a time, there may not be a need to link
ultrasound performance to nancial incentives because credentialing requirements
will have been met and ultrasound will be perceived as part of good care rather than
a hindrance. In this era of Free Online Access to Medical Education (FOAM), there
are countless resources available online for community physicians to learn the
didactics of ultrasound. The motivated community chair should be aggressive to
stimulate physician training and credentialing so that the group can begin billing for
point of care ultrasound and get direct return on investment for the hospital.
Ultrasound Director Support
The role of ultrasound director is almost always undervalued regardless of academic
or community practice settings. Sometimes it is hard to nd justication to take the
ultrasound director position in the community setting. Attractive titles, book chapters, and research grants are scarce in nonacademic settings. So how then can the
community ultrasound director make the case that he/she should be supported in
terms of monetary compensation, protected time, or both. It starts with educating
and training faculty (See Chap. 2 – Ultrasound Directors).
How much time will the ultrasound director be spending up front training the
group and what is this worth? The chair should consider providing annual stipends
to cover educational time until × % of faculty are credentialed in the majority of
core complications. This maybe kept as simple as a 1 year guaranteed stipend for
procedural guidance alone since vascular access is the low hanging fruit and then
26 Community Ultrasound
417
renegotiating after that goal is met. If procedural guidance is the focus of year 1, it
may be smart to bundle nurse training into the deal as additional support may come
from the hospital as this is clearly high priority for the delivery of safe care.
Placement of more peripheral lines may reduce number of central lines leading to
an overall decrease in cost while ensuring safe patient care. The biggest challenge
most community ultrasound directors eventually have to deal with is what happens
when all the education and training of the group are completed. Can a stipend still
be justied? The answer is yes. The common denominator between academic and
community ultrasound director time requirements is quality assurance. As the credentialed physicians in the group start billing for studies there needs to be an even
higher level of quality assurance in place. The one common denominator that ultrasound directors must accomplish in both academic and community settings is quality assurance. As physicians become credentialed they will begin documenting and
billing for studies. A percentage of these exams will still need to be reviewed for
ongoing quality and of course re-credentialing. Recommendations on numbers are
given in the ACEP Ultrasound Guidelines.
Time spent performing quality assurance must be tracked and used as justication to community chairs to provide ongoing protected time even though the training period is over. In academic settings, there are new people to train every year as
a new resident class starts and therefore ongoing protected time is granted regardless of QA volume. A common question in the community setting is how much
protected time is fair to ask for. This varies depending on number of faculty in the
group, baseline experience with ultrasound, and depth of ultrasound division. Is the
ultrasound director a fresh residency grad or fellowship trained? One may be able to
negotiate a higher salary, stipend and/or protected time with fellowship experience.
If the ultrasound director is starting a new program from scratch, there is a lot more
room for negotiation. It is important the community chair understands that before
any billing can be done for ultrasound a critical mass of physicians must be trained.
Furthermore, a solid infrastructure must be built from the ground up with heavy
emphasis on front and back end workow. Purchasing a machine is just the rst
step. How will ndings be documented? How will consultants review images and
reports? Who is responsible for ongoing machine maintenance? Who will perform
daily checks that images are being transferred? Will there be a database for easy
query for teaching and tracking purposes? All of this fall on the ultrasound director
and will require signicant time commitment. A solid infrastructure and critical
mass of trained clinicians may take several years to build, so the chair must be ready
to provide multiple years of support for the ultrasound director.
Importance ofWorkow
The true power of ultrasound becomes evident when there is complete institutional
transparency. It is important to diagnose a ruptured ectopic pregnancy within minutes of arrival to ED.But if the OB can’t see the images in PACS or report in the
EMR, will there still be delay in care? It would be great if consultants just took the