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Emergency Medicine Australasia (2014) 26, 268–273
doi: 10.1111/1742-6723.12231
ORIGINAL RESEARCH
Ultrasound use in Australasian emergency departments: A survey of Australasian College for Emergency Medicine Fellows and Trainees Simon CRAIG,1,2 Diana EGERTON-WARBURTON1,2 and Tanya MELLETT1 1 Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia, and 2Southern Clinical School, Monash University, Melbourne, Victoria, Australia
Abstract Objective: To describe current practice of EDUS by ACEM Trainees and Fellows; to describe potential barriers to US use in the Australasian setting; to determine compliance with current college guidelines regarding US credentialing. Methods: Data were collected by a cross-sectional online survey. Respondents were Trainees and Fellows of the ACEM. Outcome measures included the percentage of respondents currently undergoing or that had completed US credentialing for Focused Assessment with Sonography for Trauma (FAST) and assessment of abdominal aortic aneurysm (AAA) scans. The perceived barriers to use of emergency US were explored. Results: There were 512 survey respondents, giving an overall response rate of 15%. Fellows were more likely to be credentialed compared with Trainees. There were 61% of respondents not credentialed for FAST and assessment of AAA scans. However, a significant proportion performed these scans regularly, and did not routinely seek independent confirmation of their findings. Barriers to credentialing included limited time and no credentialing programme at the individual’s hospital.
Conclusions: The present study showed that only a minority of ACEM Trainees and Fellows are credentialed to perform routine ED scans. Many non-credentialed ACEM Trainees and Fellows are performing scans, many without independent confirmation of their findings. Key words: abdominal aortic aneurysm, credential, emergency, Focused Assessment with Sonography for Trauma, ultrasound.
• Many ED doctors are using ultrasound without being credentialed, and without documentation of independent confirmation of their findings for diagnostic scans. • Significant barriers to ultrasound credentialing exist for Australasian emergency doctors, including lack of a credentialing programme within the hospital, limited time, and a lack of relevant patients.
Introduction Bedside US continues to gain prominence in emergency medicine practice. Worldwide, many emergency medicine training bodies have produced guidelines on education, credentialing and US use.1–5 There is considerable variation between guidelines in terms of definition of ‘core’ ultrasound applications, scope of practice and responsibility for the provision of training. In the USA, bedside ultrasonography is listed as one of the procedures and skills integral to the practice of emergency medicine.6 In 2009, consensus recommendations for resident training in emergency US were published. These recommendations list 10 core applications, including five that
Correspondence: Dr Simon Craig, Emergency Department, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168, Australia. Email: [email protected] Simon Craig, FACEM, MHPE, Emergency Physician, Director, Adjunct Senior Lecturer; Diana Egerton-Warburton, FACEM, MClinEpi, Emergency Physician, Director, Adjunct Senior Lecturer; Tanya Mellett, MBBS (Hons), Emergency Registrar. Accepted 23 February 2014
Key findings
‘all EM residency programs will aim to ensure the competency of their graduates in’: Focused Assessment with Sonography for Trauma (FAST), emergent cardiac imaging, evaluation of the abdominal aorta for abdominal aortic aneurysm (AAA), identification of early intrauterine pregnancy (using transabdominal or transvaginal sonography) and procedural guidance. Other applications include biliary, renal, thoracic, soft tissue and musculoskeletal, and evaluation of suspected deep venous thrombosis.7 The Australasian College for Emergency Medicine (ACEM) has developed a specific policy for credentialing US in the setting of trauma and suspected AAA.8 The College also states that it supports the use of ultrasound for ‘ectopic pregnancy, vascular access, therapeutic diagnostic tests and evaluation of renal and biliary tract disease’, although specific policies or guidelines in these areas are not currently available. The policy for AAA and trauma scanning require emergency doctors to
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
269
ULTRASOUND USE IN AUSTRALASIAN EDs
attend an instructional workshop, complete a specified number of proctored US scans and pass an exit examination.8 This policy has recently generated debate in the emergency medicine community.9,10 Two recent studies in Australasia have provided some insights into current use and availability of ultrasound. Nagaraj et al. surveyed ED directors, acting directors and directors of emergency medicine training regarding the availability, uses and credentialing of bedside US. They found that less than two thirds of EDs had formal credentialing processes in place, and many EDs did not comply with current ACEM guidelines regarding credentialing.11 In another study, Matera and colleagues found that 37% of Australasian emergency physicians use US to guide placement of central venous access catheters. Reasons for not using US guidance included concerns that it might take too long, and not having done an US course.12 Little information is known about the use of EDUS by individual ACEM Trainees and emergency physicians. The aim of the present study is to describe current practice and to determine potential barriers to US use in the Australasian setting.
Methods A cross-sectional survey was developed using SurveyMonkey (http:// www.surveymonkey.com), after a focus group discussion of local ED staff and reviews of published surveys. A pilot survey was circulated to emergency physicians and ACEM Trainees in Southern Health and revised after feedback. The survey collected data on demographics, US training, local departmental credentialing and use of US in the ED. Respondents were also asked to identify potential barriers to completing an introductory US course, and factors that limit the use of US in their EDs. Specific questions were also asked regarding respondents’ views on US credentialing, and whether US training should become a compulsory part of ACEM registrar training, and at which level of training it should be introduced if it was to become mandatory.
The present study was approved by the Southern Health Ethics Committee and the ACEM Scientific Committee. All ACEM Trainees and Fellows on the ACEM database were emailed a request to participate in the study by administrative staff at the ACEM. No exclusion criteria were applied. The email included an explanatory letter and a web link to the survey website. A single reminder email was sent 1 month later. Survey responses were downloaded onto a password-protected Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA). Data were analysed using the Stata version 8.0 statistical package (Stata Corporation, College Station, TX, USA). Data were grouped by progression through US credentialing (credentialed and undergoing credentialing, or not credentialed), and Likert scales were grouped by ‘disagree’ and ‘agree or neutral’ for each of the statements analysed. Categorical descriptive data are
TABLE 1.
presented as number and percentage. Comparisons between groups were performed using Fisher’s exact tests, and relative risk was calculated as appropriate.
Results The overall survey response rate was 15%, with 232/2018 (11%) of Trainees and 292/1396 (21%) of Fellows completing the survey. Demographic details are provided in Table 1. Respondents were reflective of the total populations and proportions of FACEMs/ACEM Trainees by region (V. Josifovska, pers. comm., 2011), with the majority from Victoria, New South Wales and Queensland. Most Trainees were in advanced training (76%), with another 18% in provisional training. Most Trainees (83%) indicated that they were the most senior doctors in the department overnight. The majority of Fellows had attained their specialist qualification
Demographic data and credentialing status of survey respondents Trainee number (%)
Location New Zealand Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia Other Type of hospital Major referral Urban district Rural/regional Other Patient population Paediatrics only Adult only Mixed Not specified Credentialing status Credentialed Undergoing credentialing Not credentialed
FACEM number (%)
Total number (%)
26 4 57 6 30 15 14 55 24 1
(11) (2) (25) (3) (13) (6) (6) (24) (10) (0)
28 3 62 8 53 12 6 83 35 3
(10) (1) (21) (3) (18) (4) (2) (28) (12) (1)
54 7 119 14 83 27 20 138 59 4
(10) (1) (23) (3) (16) (5) (4) (26) (11) (1)
124 61 39 7
(54) (26) (17) (3)
140 86 62 6
(48) (29) (21) (2)
264 147 101 13
(50) (28) (19) (2)
7 (3) 57 (25) 168 (72) –
8 62 223 1
(3) (21) (76) (0)
15 119 391 1
(3) (23) (74) (0)
16 (7) 44 (19) 172 (74)
77 (26) 63 (22) 153 (52)
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
93 (18) 107 (20) 325 (62)
270
Number (percentage). †Missing data for some respondents – these have been excluded from analysis. ‡Calculated using Fisher’s exact test (Disagree vs Neutral & Agree) for credentialed or undergoing credentialing versus not credentialed.
0.002 1.26 (1.09–1.46) 50 (18) 78 (28) 152 (54) 35 (18) 132 (68)
26 (13)
Emergency Medicine Australasia (2014) 26, 268–273
doi: 10.1111/1742-6723.12231
ORIGINAL RESEARCH
Ultrasound use in Australasian emergency departments: A survey of Australasian College for Emergency Medicine Fellows and Trainees Simon CRAIG,1,2 Diana EGERTON-WARBURTON1,2 and Tanya MELLETT1 1 Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia, and 2Southern Clinical School, Monash University, Melbourne, Victoria, Australia
Abstract Objective: To describe current practice of EDUS by ACEM Trainees and Fellows; to describe potential barriers to US use in the Australasian setting; to determine compliance with current college guidelines regarding US credentialing. Methods: Data were collected by a cross-sectional online survey. Respondents were Trainees and Fellows of the ACEM. Outcome measures included the percentage of respondents currently undergoing or that had completed US credentialing for Focused Assessment with Sonography for Trauma (FAST) and assessment of abdominal aortic aneurysm (AAA) scans. The perceived barriers to use of emergency US were explored. Results: There were 512 survey respondents, giving an overall response rate of 15%. Fellows were more likely to be credentialed compared with Trainees. There were 61% of respondents not credentialed for FAST and assessment of AAA scans. However, a significant proportion performed these scans regularly, and did not routinely seek independent confirmation of their findings. Barriers to credentialing included limited time and no credentialing programme at the individual’s hospital.
Conclusions: The present study showed that only a minority of ACEM Trainees and Fellows are credentialed to perform routine ED scans. Many non-credentialed ACEM Trainees and Fellows are performing scans, many without independent confirmation of their findings. Key words: abdominal aortic aneurysm, credential, emergency, Focused Assessment with Sonography for Trauma, ultrasound.
• Many ED doctors are using ultrasound without being credentialed, and without documentation of independent confirmation of their findings for diagnostic scans. • Significant barriers to ultrasound credentialing exist for Australasian emergency doctors, including lack of a credentialing programme within the hospital, limited time, and a lack of relevant patients.
Introduction Bedside US continues to gain prominence in emergency medicine practice. Worldwide, many emergency medicine training bodies have produced guidelines on education, credentialing and US use.1–5 There is considerable variation between guidelines in terms of definition of ‘core’ ultrasound applications, scope of practice and responsibility for the provision of training. In the USA, bedside ultrasonography is listed as one of the procedures and skills integral to the practice of emergency medicine.6 In 2009, consensus recommendations for resident training in emergency US were published. These recommendations list 10 core applications, including five that
Correspondence: Dr Simon Craig, Emergency Department, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168, Australia. Email: [email protected] Simon Craig, FACEM, MHPE, Emergency Physician, Director, Adjunct Senior Lecturer; Diana Egerton-Warburton, FACEM, MClinEpi, Emergency Physician, Director, Adjunct Senior Lecturer; Tanya Mellett, MBBS (Hons), Emergency Registrar. Accepted 23 February 2014
Key findings
‘all EM residency programs will aim to ensure the competency of their graduates in’: Focused Assessment with Sonography for Trauma (FAST), emergent cardiac imaging, evaluation of the abdominal aorta for abdominal aortic aneurysm (AAA), identification of early intrauterine pregnancy (using transabdominal or transvaginal sonography) and procedural guidance. Other applications include biliary, renal, thoracic, soft tissue and musculoskeletal, and evaluation of suspected deep venous thrombosis.7 The Australasian College for Emergency Medicine (ACEM) has developed a specific policy for credentialing US in the setting of trauma and suspected AAA.8 The College also states that it supports the use of ultrasound for ‘ectopic pregnancy, vascular access, therapeutic diagnostic tests and evaluation of renal and biliary tract disease’, although specific policies or guidelines in these areas are not currently available. The policy for AAA and trauma scanning require emergency doctors to
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
269
ULTRASOUND USE IN AUSTRALASIAN EDs
attend an instructional workshop, complete a specified number of proctored US scans and pass an exit examination.8 This policy has recently generated debate in the emergency medicine community.9,10 Two recent studies in Australasia have provided some insights into current use and availability of ultrasound. Nagaraj et al. surveyed ED directors, acting directors and directors of emergency medicine training regarding the availability, uses and credentialing of bedside US. They found that less than two thirds of EDs had formal credentialing processes in place, and many EDs did not comply with current ACEM guidelines regarding credentialing.11 In another study, Matera and colleagues found that 37% of Australasian emergency physicians use US to guide placement of central venous access catheters. Reasons for not using US guidance included concerns that it might take too long, and not having done an US course.12 Little information is known about the use of EDUS by individual ACEM Trainees and emergency physicians. The aim of the present study is to describe current practice and to determine potential barriers to US use in the Australasian setting.
Methods A cross-sectional survey was developed using SurveyMonkey (http:// www.surveymonkey.com), after a focus group discussion of local ED staff and reviews of published surveys. A pilot survey was circulated to emergency physicians and ACEM Trainees in Southern Health and revised after feedback. The survey collected data on demographics, US training, local departmental credentialing and use of US in the ED. Respondents were also asked to identify potential barriers to completing an introductory US course, and factors that limit the use of US in their EDs. Specific questions were also asked regarding respondents’ views on US credentialing, and whether US training should become a compulsory part of ACEM registrar training, and at which level of training it should be introduced if it was to become mandatory.
The present study was approved by the Southern Health Ethics Committee and the ACEM Scientific Committee. All ACEM Trainees and Fellows on the ACEM database were emailed a request to participate in the study by administrative staff at the ACEM. No exclusion criteria were applied. The email included an explanatory letter and a web link to the survey website. A single reminder email was sent 1 month later. Survey responses were downloaded onto a password-protected Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA). Data were analysed using the Stata version 8.0 statistical package (Stata Corporation, College Station, TX, USA). Data were grouped by progression through US credentialing (credentialed and undergoing credentialing, or not credentialed), and Likert scales were grouped by ‘disagree’ and ‘agree or neutral’ for each of the statements analysed. Categorical descriptive data are
TABLE 1.
presented as number and percentage. Comparisons between groups were performed using Fisher’s exact tests, and relative risk was calculated as appropriate.
Results The overall survey response rate was 15%, with 232/2018 (11%) of Trainees and 292/1396 (21%) of Fellows completing the survey. Demographic details are provided in Table 1. Respondents were reflective of the total populations and proportions of FACEMs/ACEM Trainees by region (V. Josifovska, pers. comm., 2011), with the majority from Victoria, New South Wales and Queensland. Most Trainees were in advanced training (76%), with another 18% in provisional training. Most Trainees (83%) indicated that they were the most senior doctors in the department overnight. The majority of Fellows had attained their specialist qualification
Demographic data and credentialing status of survey respondents Trainee number (%)
Location New Zealand Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia Other Type of hospital Major referral Urban district Rural/regional Other Patient population Paediatrics only Adult only Mixed Not specified Credentialing status Credentialed Undergoing credentialing Not credentialed
FACEM number (%)
Total number (%)
26 4 57 6 30 15 14 55 24 1
(11) (2) (25) (3) (13) (6) (6) (24) (10) (0)
28 3 62 8 53 12 6 83 35 3
(10) (1) (21) (3) (18) (4) (2) (28) (12) (1)
54 7 119 14 83 27 20 138 59 4
(10) (1) (23) (3) (16) (5) (4) (26) (11) (1)
124 61 39 7
(54) (26) (17) (3)
140 86 62 6
(48) (29) (21) (2)
264 147 101 13
(50) (28) (19) (2)
7 (3) 57 (25) 168 (72) –
8 62 223 1
(3) (21) (76) (0)
15 119 391 1
(3) (23) (74) (0)
16 (7) 44 (19) 172 (74)
77 (26) 63 (22) 153 (52)
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
93 (18) 107 (20) 325 (62)
270
Number (percentage). †Missing data for some respondents – these have been excluded from analysis. ‡Calculated using Fisher’s exact test (Disagree vs Neutral & Agree) for credentialed or undergoing credentialing versus not credentialed.
0.002 1.26 (1.09–1.46) 50 (18) 78 (28) 152 (54) 35 (18) 132 (68)
26 (13)
