EDUS:Credentialing,

Accreditation and QA

Emergency US CourseJustin Bowra

SUMMARY

Credentialing vs. accreditation vs. QA QA: Why, Who & How? The ACEM process The ASUM process JB’s golden rules of part-time US

CREDENTIALLING

What you do to get trained Course & MCQ Logbook of supervised cases and results Exit exam

ACCREDITATION

Bestowed upon you by an authority! Your hospital A college eg ACEM ASUM

QUALITY ASSURANCE

Ongoing process of ensuring that care or treatment is optimal and meeting recognised standards

Saving images Maintenance of logbook results System of audit

Questions to mull over

Should you make a note in the patient record while still in training?

Can you act on your scans before you’re ‘accredited’?

How will you save & back up your images?

WHY BOTHER?

False negative and false positive results have a direct link to: Morbidity Mortality

Ultrasound is user dependent Image acquisition: training Image interpretation: experience Clinical context is crucial

WHO?

All clinicians who sometimes utilize ultrasound in patient care

Especially important for those using it intermittently / infrequently

We are fulltime clinicians who do a bit of US -not fulltime sonographers!

Who am I?

If you’re an ED physician: a hero

If you’re a radiologist: a cowboy

Now for the boring details

The ACEM & ASUM processes

www.acem.org.auwww.asum.com.au

ACEM & ASUM

ACEM (free)Guidelines onlyUp to individual hospitalVascular accessEFASTAAABELS

ASUM ($990)Piece of paperCCPU easier than DDUAlso includes:LungRapid cardiac assessmentDVTRenalBiliaryEarly pregnancy…

The requirements

Online physics module (only for CCPU) Complete an approved workshop A machine & supervisor

(DDU/CCPU/equivalent) Enough proctored EFAST/AAA/ BELS exams An exit exam Ongoing maintenance of credentials A friendly hospital (clinical privileges)

ACEM-approved US workshop

Basic principles of physics Operation of modern ultrasound machines EFAST, AAA, BELS, basic procedural guidance Skills instruction and practice on human models Recognise significant abnormalities as presented on

hard copies or videotapes of scans Exit exam

Proctored studies

Proctored studies are ultrasound examinations that are directly supervised by an emergency medicine sonologist. Alternatively the ultrasound examinations are recorded or printed and the images then reviewed by the above mentioned qualified practitioners.

How many?

Cannulas: minimum 5 successful cannulations (I think)

EFAST: minimum 25 accurate scans, >50% indicated, >5 with FF, > 3 with PTX

AAA : minimum 15 accurate scans of the aorta, >50% indicated, >5 with AAA

BELS: min 25 of your own cardiac scans, plus another 25 image library to review

Exit exam A qualified person will observe the candidate: Preparing the patient Piloting & troubleshooting the machine Acquiring adequate images Interpreting them correctly Synthesising findings w.r.t. clinical context Explaining the results to the patient Demonstrate an understanding of the indications and

limitations of ultrasound

Ongoing maintenance of credentials

3 hours of ultrasound training per year 25 BELS examinations per year 25 EFAST examinations per year 15 AAA scans per year 5 cannulas per year … I think

But it all comes down to your hospital.

You need to convince them it’s appropriate. They need to give you ‘clinical privileges’. They need to cough up the dosh for a machine!

Finally:

JB’s Golden Rules of Part-time Ultrasound

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JB’s golden rules of part-time ultrasound

1. Clinical context is paramount. Make a differential diagnosis list before you switch on the machine. All data must be considered (eg the CAPD patient hit by a car).

2. Only ask questions that you can answer. Leave the fancy stuff (eg valve disease) to others.

3. Repeat scans are crucial during resuscitation & each time clinical picture changes.

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4. 90% = 100%: Every test has its limitations. In a shocked trauma patient, no study will be 100% accurate. If this bothers you, don't practise critical care.

Q: Would you really send a critically ill patient with suspected AAA to theatre on the basis of bedside US?

A: We spent years doing just that without the benefit of US. Anything that improves our accuracy has to be an improvement!

5. When in doubt, be a doctor. You were a clinician before you were a sonographer. If the clinical picture & scan findings don’t agree, believe the clinical picture.

‘What would I diagnose if I didn’t have an US machine?’

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JB’s golden rules

1. Clinical context is paramount.

2. Only ask questions that you can answer.

3. Repeat scans are crucial.

4. 90% = 100%

5. When in doubt, be a doctor.

6. A fool with a stethoscope will be a fool with an ultrasound.

SUMMARY

Intro course Machine Supervisor Logbook of proctored examinations Exit exam Ongoing maintenance of credentials Friendly hospital