Creating a POCUS presence where there isn't one already

Occasionally clinicians spend resources, time and effort to learn and perfect their ultrasound skills, only to find that they are having difficulty obtaining privileging through their organization’s credentialing committee. Occasionally, this is because the credentialing committee has no prior experience privileging for POCUS, there is no precedence for the POCUS program or there is opposition from another department who views the utilization of POCUS as a threat.

The following represents some challenges to privileging, along with some possible solutions and literature to support the position.

We want to hear your story. Please give SPOCUS feedback on the barriers you face locally so we can help you to blaze a trail that others may follow.

Lack of Support from Within Your Group

If you wish to employ bedside ultrasound and your group or the facility seems to lack supportive then point to some of the benefits of bedside ultrasound.

Patient Safety

There are multiple studies demonstrating the safety benefits to utilizing bedside ultrasound to perform procedures. In 2001, the Agency for Healthcare Research and Quality Guidelines recommended the use of ultrasound guidance for the placement of CVCs as one of the top 11 evidence-based practices that health care providers can use to improve patient care and patient safety. As a result of this practice, many hospitals have been able to drastically reduce the incidence of iatrogenic pneumothoraces.

Patient Satisfaction

Bedside US has the potential not only to expedite care and diagnosis, but also to maximize satisfaction scores and improve the patient-physician relationship, which has increasing relevance to health care organizations and hospitals that rely on satisfaction surveys.

Howard et al found that patients who had a bedside US had statistically significant higher satisfaction scores with respect to overall ED care, diagnostic testing, and with their perception of the skill and the ability of the clinician.

Increased Throughput

Utilization of POCUS to evaluate certain medical conditions has been shown to decrease the length of stay in the ED. For example, Zanobetti et al. found that patients who were evaluated for dyspnea with POCUS had an average length of stay of 24 minutes, compared to the usual care group that took an average of 186 minutes to evaluate the cause of dyspnea.

Wilson et al found that for patients being evaluated with a pelvic ultrasound had a length of stay which was 66 minutes shorter if the study was done at the point of care, compared to a consultative study.

Cost savings

A POCUS program can also result in savings to our healthcare system. As we move to a value based reimbursement, the financial health of many of our institutions may rely on the judicious utilization of our resources. For example Mitchell et al found Savings of $20,000 for patients treated for sepsis utilizing ultrasound.

In addition to the clinical efficacy of ultrasound for renal colic, it is significantly less expensive than CT. A report by KNG Health Consulting, LLC, found that if ultrasound was used first in a diagnostic algorithm, our nation’s healthcare system and your patients could realize significant cost savings. KNG’s examination of 2009 Medicare data showed that if ultrasound was substituted for CT in 30 percent of renal colic diagnoses, the savings to Medicare would have been $21.6 million. Had it been substituted 70 percent of the time, the savings would have jumped to more than $50 million. In summary, ultrasound not only provides a safe and effective first line approach for many patients with renal colic, it is significantly more cost-effective for the patient and the health system.

Increased Revenue

A healthy POCUS program not only conserves resources and is a less expensive way of answering many clinical questions, the POCUS program can also generate revenue. Regardless of the practice setting POCUS studies are billed utilizing CPT codes, just like any other procedure. In fact Adhikari et al. a studied an emergency room with 70,000 visits and found that an active billing practice can generate $350,000 a year.

Medical Liability is an is always a concern in our medical environment. However, when trying to assess data which demonstrated harm to patients from groups of professions performing POCUS, there exists a paucity of data. In fact, as of this writing, a Pubmed search does not return any case studies to demonstrate harm to patients with the implementation of POCUS. In fact, since there is no data on this subject, there are at least 3 studies (POCUS lawsuits Blaivas, POCUS Lawsuits 5, Analysis of lawsuits related to point-of-care ultrasonography in neonatology and pediatric subspecialties) which looked at the number of law suits filed in state and federal court related to POCUS. Over the 20 year period, these authors found law suits related to POCUS in the 20 years studied. in each of these cases, the breach of duty was alleged to be “a failure to perform the bedside sonogram,” thereby violating the standard of care.

American Medical Association Policy

AMA affirms that ultrasound imaging is within the scope of practice of appropriately trained physicians;
AMA policy on ultrasound acknowledges that broad and diverse use and application of ultrasound imaging technologies exist in medical practice;
AMA policy on ultrasound imaging affirms that privileging of the physician to perform ultrasound imaging procedures in a hospital setting should be a function of hospital medical staffs and should be specifically delineated on the Department’s Delineation of Privileges form; and
AMA policy on ultrasound imaging states that each hospital medical staff should review and approve criteria for granting ultrasound privileges based upon background and training for the use of ultrasound technology and strongly recommends that these criteria are in accordance with recommended training and education standards developed by each physician’s respective specialty.(Res. 802, I-99; Reaffirmed: Sub. Res. 108, A-00; Reaffirmed: CMS Rep. 6, A-10)

Translated

Ultrasound is not the intellectual property of any medical specialty. Every medical specialty should decide for itself, through the use of guidelines, how ultrasound should be implemented.
Specialties do not need to request permission from another specialty for the use of ultrasound. Specialties must determine their OWN SCOPE OF PRACTICE and delineate how POCUS best complements their respective specialty.
JHACO standards require the credentialing process to be fair and unbiased. Privileging is awarded or denied based upon state law, documented training, experience, and current demonstrated competence in clinical practice.¹ Any attempt to control the privileging and the credentialing processes, particularly if that influence is motivated by the desire to protect “exclusive imaging contracts” runs afoul of AMA ethical standards where “financial interest above the welfare of their patients,” (American Medical Association Opinion 8.03) an
Credentialing based on any other factor is contrary to written standards.¹

Summary

Those of you facing these barriers have a unique opportunity to lead change within your local medical culture/practice. You are uniquely poised to contribute to the advancement of POCUS to ultimately better the care your patients are receiving in your practice. Academic Life in Emergency Medicine provides some excellent pearls and pitfalls to be considered when looking to implement a change such as the establishment of a POCUS program. If you want your organization to change and advance in the ways you wish, lead that change and let SPOCUS assist you in your endeavors.

Reference

Medical Staff CredentialingMedical Staff Credentialing … (n.d.). Retrieved November 14, 2016, from http://www.nmlegis.gov/lcs/handouts/LHHS 081312 Medical Staff Credentialing and Peer Review.pdf JCAHO medical staff standards, MS.06.01.03 – Credentialing, MS.06.01.07 – Analysis and Use of Information