Harbor: ED Bedside Ultrasound Policy and Procedure Guidelines

Emergency Department Bedside Ultrasound (EBUS) Policy and Procedure Guidelines (Policy 4.7: CLINICAL POLICIES-MISCELLANEOUS)

This reference is intended only for quick reference and these listed DEM policies and protocols MAY NOT BE COMPLETE OR UP TO DATE.

Definitions

Emergency Department Bedside Ultrasound is a clinician performed and interpreted, point-of-care, bedside sonographic exam done on selected patients which is focused on the presence or absence of specific findings and used with other clinical and laboratory information and consultation to answer a specific clinical question. It is not a comprehensive examination of all possible findings performed outside the emergency department by ultrasound technologists and later read by an attending radiologist. EBUS training is mandated by the ACGME/RRC for Emergency Medicine, the American Board of Emergency Medicine, the American Board of Osteopathic Emergency Medicine, and the Advanced Trauma Life Support Committee of the American College of Surgeons. Utilization of EBUS is done in accordance with the policy and position statements of the American College of Emergency Physicians, Society for Academic Emergency Medicine, and American Medical Association (AMA H-385.934 and H-230.960).
Immediate, life-threatening conditions for which transport out of the emergency department may not be possible or safe include:
- Cardiac arrest and pulseless electrical activity
- Cardiac tamponade
- Abdominal aortic aneurysm
- Major trauma
- Assessment of fetal life in trauma or maternal instability
- Ectopic pregnancy
- Undifferentiated hypotension
Invasive procedures which are safer with ultrasound-guidance include:
- Vascular access
- Thoracentesis
- Paracentesis
- Foreign body localization/removal
- Culdocentesis
- Bladder catheterization or aspiration
- Abscess localization
Conditions for which care can be expedited in stable patients include:
- Obstructive uropathy
- Biliary disease
- Deep venous thromboses
- Retinal detachments
DEM Director of Emergency Ultrasound is the DEM faculty designee with specific training in EBUS responsible for primary oversight of EBUS under the auspices of the chair.

1. Credentialing

DEM faculty and attendings who meet the following didactic, hands-on training, and accuracy requirements will be credentialed by indication to perform EBUS in the emergency department according to the following protocols. Senior residents (PGY-2 and above) who meet the same requirements will be considered competent to perform EBUS in the DEM according to following protocols with review by an attending credentialed to perform EBUS.
- (A) Didactic Requirements: Participation in the “Introduction to Emergency Ultrasound” course provided by the DEM Director of Emergency Ultrasound during PGY-2 orientation or certificate of completion of 16 hours of CME in emergency ultrasound.

Hands On Training Requirements

- (B) Hands-on Training Requirements: In accordance with American College of Emergency Physicians guidelines and current RRC guidelines, demonstrated competency will be required before consideration of credentialing for each indication. All EBUS studies used for credentialing are subject to review by the Director of Emergency Ultrasound or his/her designee for image quality and accuracy. The minimum number of these exams as stated below must be done in conjunction with a credentialed DEM attending or in patients undergoing further imaging by the Department of Radiology.
- (C) Accuracy and Quality Requirements: Emergency physician candidates who meet the above didactic and hands-on training requirements must have an accuracy of at least 90% for each EBUS indication being credentialed. The accuracy and quality (see Continuous Quality Improvement below) of the studies will be assessed by the DEM Director of Emergency Ultrasound or his/her designee.
- (D) Privileges: Once a physician has completed the credentialing process, full privileges for specific EBUS indications will be granted as follows:
  - 1. Physicians trained and credentialed in EBUS at Harbor-UCLA will have further proctoring waived due to being proctored during the credentialing period. All physician privileges, however, will be subject to ongoing continuous quality improvement review.
  - 2. Physicians who meet the credentialing requirements due to training outside of Harbor-UCLA must undergo direct proctoring of 5 exams per indication by a physician with full privileges for EBUS at Harbor-UCLA. Following this period of proctoring, full privileges for EBUS will be granted, subject to ongoing continuous quality improvement review.
All EBUS exams are subject to review by the DEM Director of Emergency Ultrasound or his/her designee for continuous quality improvement.
All EBUS done for training and prior to credentialing must be conducted with patient verbal consent, may not be used for patient management, and should only be done in conjunction with a credentialed DEM attending or in patients undergoing further imaging by the Department of Radiology.

2. Patient Management Using EBUS

EBUS must always be used for patient management in concert with clinical and/or laboratory evaluation, and appropriate specialty consultation. In some circumstances, i.e., acute life-threatening conditions and invasive procedures, formal imaging outside the emergency department and delayed interpretation by a Department of Radiology attending physician is impossible because of inherent excess risks. However, in other circumstances, particularly among stable patients, if EBUS studies are read as indeterminate, technically limited, or suggestive of unexpected pathology, then optimal patient management should be ensured by subsequent imaging and interpretation by the Department of Radiology and appropriate clinical follow-up as dictated by the responsible DEM attending physician or consultation with appropriate specialists. In addition, all patients should be informed of the nature of their EBUS evaluation and this information should be provided to them for management by their continuing care physicians.
- (A) Patient Management Algorithms: In order to ensure optimal patient management and follow-up, patient care algorithms for various clinical scenarios have been developed.
- (B) Patient Education and Communication of Care to Subsequent Providers: In order to ensure that patients are adequately informed of the nature of their EBUS evaluation and that their continuing care provider has a clear understanding of the EBUS result, a report of the EBUS used for clinical management will be electronically filed in the patient’s medical record.

3. Continuous Quality Improvement

To ensure ongoing education, training, and quality, a strict process for quality assurance will be followed:
- (A) An ultrasound procedure note will be completed on all exams done for medical care (not studies performed solely for the purpose of education) in the hospital electronic health record. Appropriate images that accompany the procedure note will be stores in the hospital PACS system.
- (B) EBUS studies will be reviewed by the DEM Director of Emergency Ultrasound or his/her designee for quality assurance. Images will be reviewed for:
  - 1. Use of proper settings and probe orientation
  - 2. Proper identification of anatomical structures and key findings
  - 3. Use of proper depth, focal zones, and gain
  - 4. Optimal visualization of near and far fields
  - 5. Optimal visualization of leading and receding edges
  - 6. Adequacy for clear interpretation
  - 7. Proper interpretation
- (C) Once reviewed, selected studies will be sent to the emergency physician for feedback. If appropriate, the physician will then sign the studies, acknowledging that he/she has reviewed the quality assurance comments and understands them. Once these studies are returned to the DEM Director of Emergency Ultrasound or his/her designee, they will then be officially logged in the emergency physician’s file.
- (D) If repeated deficiencies are found in an emergency physician’s studies (e.g., accuracy rate consistently less than 90%), his/her privileges for ultrasound will be temporarily suspended until remediation with the DEM Director of Emergency Ultrasound can be completed.

4. Equipment maintenance and care

(A) Before using any of the ultrasound machines, physicians must:
- 1. Check the cords. Power/electrical cords should be gently unplugged before moving the ultrasound machine. The probe cords should be hanging from appropriate holders and hooks on the machine without any cords lying under the machine or wheels. In addition, physicians should ensure that the cords are not wrapped around any objects before moving the machine to avoid severing or otherwise damaging the cords.
- 2. Visually inspect the machine and wipe off any dirt or gross contaminants with a towel. If there is any evidence of blood products or body fluids on the machine, wash the area with a towel and warm soap water, followed by wiping the area with a dry towel. Then, use T-spray or a decontaminating wipe appropriate for the respective machine and surface.
- 3. Visually inspect the probe, including the probe head and cord. Probes with dirt or gross contaminants should be removed with a dry towel. If there is any evidence of blood products or body fluids on the probe head, wash the area with a towel and warm soap water, followed by wiping the area with a dry towel. Then, use T-spray to decontaminate the probe head. Once the probe head is dry, it can be used for clinical care. If there is any evidence of blood products or body fluids on the probe cord, you may use T-spray or a disinfectant wipe to clean the cord. Endocavitary probes will be sent to central supplies for cleaning. Probes with visible cracks in the probe head or cord should not be used and should be reported to the Director of Emergency Ultrasound or his/her designee for repair.
(B) Following use of the ultrasound machine, physicians must:
- 1. Visually inspect the machine and wipe off any dirt or gross contaminants with a towel. If there is any evidence of blood products or body fluids on the machine, wash the area with a towel and warm soap water, followed by wiping the area with a dry towel. Then, use T-spray or a decontaminating wipe appropriate for the respective machine and surface.
- 2. Visually inspect the probe, including the probe head and cord. Any dirt or gross contaminants should be removed with a dry towel. If there is any evidence of blood products or body fluids on the probe head, wash the area with a towel and warm soap water, followed by wiping the area with a dry towel. Then, use T-spray to decontaminate the probe head. If there is any evidence of blood products or body fluids on the probe cord, you may use T-spray or a disinfectant wipe to clean the cord. If an endocavitary probe, was used, return to central supplies for cleaning.
- 3. Return the ultrasound machine to its appropriate place in the DEM.