Spearheading a POCUS Program

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. This may be 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 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 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 support, 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 CVC placement as one of the top 11 evidence-based practices. Many hospitals have been able to drastically reduce the incidence of iatrogenic pneumothoraces as a result.

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. 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 the perception of the clinician's skill.

Increased Throughput

Utilization of POCUS to evaluate certain conditions has been shown to decrease length of stay. Zanobetti et al. found that patients evaluated for dyspnea with POCUS had an average length of stay of 24 minutes, compared to the usual care group at 186 minutes. Wilson et al found that pelvic ultrasound at the point of care was associated with a 66-minute shorter length of stay.

Cost Savings

A POCUS program can result in savings to the healthcare system. Mitchell et al found savings of $20,000 for patients treated for sepsis utilizing ultrasound. A KNG Health Consulting report found that substituting ultrasound for CT in 30% of renal colic diagnoses would save Medicare $21.6 million annually; at 70% substitution, savings would exceed $50 million.

Increased Revenue

A healthy POCUS program can also generate revenue. POCUS studies are billed utilizing CPT codes, just like any other procedure. Adhikari et al. studied an emergency room with 70,000 visits and found that an active billing practice can generate $350,000 a year.

Medical Liability

A PubMed search does not return case studies demonstrating harm to patients from the implementation of POCUS. In fact, three studies examining POCUS-related lawsuits found that in each case, 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 (1): AMA affirms that ultrasound imaging is within the scope of practice of appropriately trained physicians.

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.

AMA (2): AMA policy acknowledges that broad and diverse use and application of ultrasound imaging technologies exist in medical practice.

Translated: 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.

AMA (3): AMA affirms that privileging should be a function of hospital medical staffs and specifically delineated on the Department's Delineation of Privileges form.

Translated: JCAHO 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.

AMA (4): AMA states that hospital medical staff should review and approve criteria for granting ultrasound privileges based upon background and training.

Translated: Credentialing based on any other factor — particularly if motivated by a desire to protect exclusive imaging contracts — is contrary to written standards and AMA ethical guidelines.

Summary

Those of you facing these barriers have a unique opportunity to lead change within your local medical culture and practice. You are uniquely poised to contribute to the advancement of POCUS to ultimately better the care your patients are receiving. 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

1. JCAHO medical staff standards, MS.06.01.03 – Credentialing, MS.06.01.07 – Analysis and Use of Information.