1. Emergency Ultrasound Proposal

2. Emergency Ultrasound In common use since early 1990’s In common use since early 1990’s First curriculum was published in 1994 First curriculum was published in 1994 Supported by professional societies Supported by professional societies American Board of Emergency Medicine American Board of Emergency Medicine American College of Emergency Physicians American College of Emergency Physicians Society of Academic Emergency Medicine Society of Academic Emergency Medicine Accreditation Council for Graduate Medical Education Accreditation Council for Graduate Medical Education American Medical Association American Medical Association Emergency Ultrasound Guidelines updated 2008 Emergency Ultrasound Guidelines updated 2008

3. AMA Resolution 802 (1999) “ultrasound imaging is within the scope of practice of appropriately trained physician specialists” “ultrasound imaging is within the scope of practice of appropriately trained physician specialists” “each hospital medical staff should review and approve criteria for granting ultrasound privileges … in accordance with recommended training and education standards developed by each physician's respective specialty society” “each hospital medical staff should review and approve criteria for granting ultrasound privileges … in accordance with recommended training and education standards developed by each physician's respective specialty society”

4. Benefits of an EUS Program Improved patient care Improved patient care Saves time Saves time Saves money Saves money Recruiting Recruiting Life Saving Life Saving Improved Patient Satisfaction Improved Patient Satisfaction

5. Improved patient care Better door to diagnosis time Better door to diagnosis time Better door to treatment time Better door to treatment time Focused Ultrasound is performed in concurrently with management of the patient Focused Ultrasound is performed in concurrently with management of the patient Improved patient satisfaction Improved patient satisfaction

6. Saves Time Ultrasounds often completed in minutes Ultrasounds often completed in minutes Not hours Not hours Decreased “throughput” time for ED patients Decreased “throughput” time for ED patients Better door to diagnosis time Better door to diagnosis time Better door to treatment time Better door to treatment time Better ED bed efficiency Better ED bed efficiency

7. Saves Money Alternative to more complex, expensive studies Alternative to more complex, expensive studies Decreased use of limited resources for non- funded patients Decreased use of limited resources for non- funded patients Avoid ED crowding caused by waiting for completion of ultrasound study Avoid ED crowding caused by waiting for completion of ultrasound study

8. Recruiting ACGME ACGME In 2003 required all EM residencies to provide Emergency Ultrasound training In 2003 required all EM residencies to provide Emergency Ultrasound training Emergency Ultrasound is defined as a “skill integral to the practice of Emergency Medicine” as defined in the “2007 Model of Clinical Practice of Emergency Medicine “ Emergency Ultrasound is defined as a “skill integral to the practice of Emergency Medicine” as defined in the “2007 Model of Clinical Practice of Emergency Medicine “ This has become a litmus test for whether an EM group is current This has become a litmus test for whether an EM group is current Continued board certification Continued board certification Core Content of Emergency Medicine Core Content of Emergency Medicine EM LLSA exam EM LLSA exam EM board certification exam EM board certification exam

9. Emergency Ultrasound Is a Limited, goal directed focused ultrasound exam that answers brief and important clinical questions in an organ system, or for a clinical symptom or sign involving multiple organ systems Is a Limited, goal directed focused ultrasound exam that answers brief and important clinical questions in an organ system, or for a clinical symptom or sign involving multiple organ systems Contrasted with “formal” ultrasound which is intended as a full survey of the organ / system in question. Contrasted with “formal” ultrasound which is intended as a full survey of the organ / system in question.

10. Indications Is there blood in the abdomen? Is there blood in the abdomen? Is there a pericardial effusion? Is there a pericardial effusion? Is there an abdominal aortic aneurysm? Is there an abdominal aortic aneurysm? Is there evidence of an IUP? Is there evidence of an IUP? Is there EMD? Is there EMD? Is there evidence of Cholecystitis? Is there evidence of Cholecystitis? Is there evidence of obstructive uropathy? Is there evidence of obstructive uropathy?

11. Is there blood in the abdomen? Normal Abnormal

12. Is there a pericardial effusion? Normal Abnormal

13. Components of an ED Ultrasound Program Equipment Equipment Training / Credentialing Training / Credentialing Quality assurance Quality assurance Emergency ultrasound program coordinator Emergency ultrasound program coordinator

14. Equipment

15. Requirements for ED Machine Best Machine For ED Use Image Quality Ease of Use Service Upgradeability Warranty Portability Durability Image& Report Management Cost Special Features

16. Purchase Goals Best Image Quality for Lowest Price Best Image Quality for Lowest Price Ease of Use for all users Ease of Use for all users Image and Report Management/Wireless Image and Report Management/Wireless Initial Cost Initial Cost Portability Portability Durability Durability Warranty and On Going Cost Warranty and On Going Cost Service and Reliability Service and Reliability Presentation of Images to Patient Presentation of Images to Patient

17. Training and Credentialing Prerequisites Prerequisites A. Education- MD or DO; AND A. Education- MD or DO; AND B. Training- Board Certified or eligible in Emergency Medicine ; OR completion of residency in Emergency Medicine ; AND B. Training- Board Certified or eligible in Emergency Medicine ; OR completion of residency in Emergency Medicine ; AND Credentialing process Credentialing process Residency training in Emergency Ultrasound with acceptable verification Residency training in Emergency Ultrasound with acceptable verification Practice Based Pathway Practice Based Pathway Provisional Provisional Active Active

18. Training Practice Based Pathway Overview Overview Initial Training in a 16 - 24 hour Introductory Course Initial Training in a 16 - 24 hour Introductory Course Experiential and Competency Phase Experiential and Competency Phase Credentialed in Emergency Ultrasound Credentialed in Emergency Ultrasound Continuing Medical Education Continuing Medical Education

19. Training Practice Based Pathway Initial Training in a 16 - 24 hour Introductory Course Initial Training in a 16 - 24 hour Introductory Course Covers Core Applications Covers Core Applications Practical hands-on Sessions Course Practical hands-on Sessions Course Models are in the Emergency Ultrasound Guidelines and the ACEP Web Site Models are in the Emergency Ultrasound Guidelines and the ACEP Web Site Shorter 4 - 8 hour course Shorter 4 - 8 hour course Focus on Core application or Skill Focus on Core application or Skill Didactic and Hands on Didactic and Hands on

20. Training Two options Two options Each physician attend a formal course Each physician attend a formal course Expensive $800 - $2000 x # in group = _______ Expensive $800 - $2000 x # in group = _______ “Import” a course here “Import” a course here Use our own US machines Use our own US machines Less expensive Less expensive OK’d by Medical Education OK’d by Medical Education Commitment by national EUS instructor Commitment by national EUS instructor

21. Training Practice Based Pathway Experiential and Competency Phase Experiential and Competency Phase Develops the Psychomotor and cognitive Components Develops the Psychomotor and cognitive Components For General Emergency Competency For General Emergency Competency 150 - 250 Cases in a case controlled manner 150 - 250 Cases in a case controlled manner 25 - 50 in each of the Core Application 25 - 50 in each of the Core Application Procedural Procedural 10 Cases in a case controlled manner 10 Cases in a case controlled manner Completion of a Module with a high Quality Training Phantom Completion of a Module with a high Quality Training Phantom

22. Credentialing Active (Full) Active (Full) A. MD or DO; AND B. Board Certified or eligible in Emergency Medicine AND C. Residency training in EUS with acceptable verification; OR D. General A. Performance of 150 -250 total exams with competence documented Case controlled review E. Procedural A. Performance of 10 total exams with competence documented by case controlled review. F. Letter of reference by the Emergency Ultrasound Director.

23. Quality Assurance Performed by EUS director or other credentialed EMP’s Performed by EUS director or other credentialed EMP’s Purpose Purpose as a tool for education and feedback for physicians completing the credentialing process as a tool for education and feedback for physicians completing the credentialing process to monitor ongoing performance of physicians that have completed the credentialing process to monitor ongoing performance of physicians that have completed the credentialing process

24. Quality Assurance The ultrasounds will be reviewed on three criteria: The ultrasounds will be reviewed on three criteria: Was the study indicated by the patient’s presentation? Was the study indicated by the patient’s presentation? Was the study technically adequate? Was the study technically adequate? Was the interpretation correct? Was the interpretation correct? The findings of the review process will drive the ongoing medical education in the form of: The findings of the review process will drive the ongoing medical education in the form of: Journal Club Journal Club Formal didactics Formal didactics Practice sessions. Practice sessions.

25. Financial Estimated Initial Expenditure Ultrasound equipment (2)$80,000 (range 65k to 120k) Initial Training Course $5,000 (range up to 21k: 26 EP’s x $800) Quality Assurance$19,500 (range up to 40k if outside QA) Ongoing Expenditure Paper, cleaner, etc.$1000/year Insurance/maintenance$1000/year Estimated Total Expenditure$104,500 plus $1000-2000 annual

26. Financial Estimated Income Trauma APC # 0266 and 0697 $179.26 Estimated patients/year 480 Total $86,044 Approx 30% collection $25,813 Pregnancy/IUPAPC # 0266 $92.74 Estimated patients/year 1095 $101550 Approx 30% collection $30,465 Estimated Income, Trauma and IUP only$56,278/year

27. Summary Significant benefit of emergency US program Significant benefit of emergency US program Minimal financial risk Minimal financial risk Supported by: Supported by: National societies National societies Trauma Trauma Critical Care Committee Critical Care Committee Emergency Physicians Emergency Physicians