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Ask the Expert - Emergency Ultrasound Section Newsletter - January 2011

Question: Ultrasound guidance (USG) for central line placement has become standard of care at many institutions. What criteria should be used for physician credentialing and why? 

Paul R. Sierzenski, MD, RDMS, FACEP
Member, CMS MedCAC
Member, ACEP QPC & FGA Committees
Director, EM, Trauma & Critical Care Ultrasound
Director, Emergency Ultrasound Fellowship
Christiana Care Health System, Delaware
Past-Chair, ACEP & SAEM US Sections 
 

Edited by John T. Powell, MD, Emergency Ultrasound Fellow, Christiana Care Heath System

My first response is, “Wow...way to set me up guys. There is no fixed consensus on this topic, and I am sure this will foster some discussion and debate!” The prime reason for potential controversy is the concept that ultrasound is an adjunct to an established skill set such as central venous cannulation (CVC), so why would distinct credentialing in ultrasound guidance be required. First allow me to provide some key background and build the case for some proposed USG-Procedure/CVC credentialing criteria and education.

It is important to note that though physician credentialing and privileging has been around for decades, the metrics and rules have changed. The concept of see-one, do-one, teach-one is no longer valid or accepted by governing bodies or the public. Also gone, is the sense of no harm-no foul.1 Evidence of performance competency with continuous evaluation is the expectation and mandate by The Joint Commission (TJC) and has been adopted by the Accreditation Council for Graduate Medical Education (ACGME).

In 2007, T JC, previously the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), revamped its recommendations and standards for physician credentialing and privileging (great reading for those with insomnia). This document highlights the importance of carefully monitoring volume and performance of each procedure in which a particular practitioner is privileged. Doing so in an ongoing fashion is essential.

Per TJC; “before the/any core/bundle (credential) is granted, the organization must evaluate each applicant's education, training and current competence to perform each activity listed in the core/bundle, and any that are assigned outside the core/bundle.”2 

According to TJC 2007 Standards on Credentialing and Privileging,3 organizations must:

  • Conduct an ongoing professional practice evaluation for each practitioner and collect data on good performance, not just outlier or trending data
  • Use the data to trigger a focused professional practice evaluation when issues affecting care are identified
  • Use the ongoing review and focused review data to determine the status of each practitioner’s privileges

This process is fairly straight-forward for a residency graduate that has faculty and leadership who perform these evaluations and validate competency. This is not generally the case in the community ED setting, especially as new skills are learned and new credentials are requested.

The argument that USG is an adjunct to an already credentialed skill set in central venous cannulation (CVC) is factually true. However, there is a strong argument that sufficient differences in USG-CVC warrant either core/bundled credentialing for USG procedures or even USG-CVC. Some differences to note are: 

  • USG-CVC site location selection varies from traditional approaches
  • Sonographic approaches may vary (eg, a posterior approach to the internal jugular vein is often more common with USG-CVC, and this can place the carotid posterior to the internal jugular vein)
  • Threshold for performing USG-CVC on high risk patients is lower (we have all placed an USG internal jugular line in a coagulopathic patient)
  • USG affords the user sonographic findings/differences in critical steps when performing the USG-CVC versus landmark techniques, for example:
    • Confirmation of target vessel and critical structures to avoid
    • Visual confirmation of vein patency (absence of deep venous thrombosis)
    • Visual confirmation of vein diameter and path
    • Confirmation of needle tip location
    • Identification of spontaneous hematoma development
    • Confirmation of wire location and direction prior to dilatation
    • Multiple USG approaches are possible including in-plane, out-of-plane, short axis, long axis, etc.
     

A potential financial reason may exist as well. Just as some (eg, American College of Radiology) have argued that emergency ultrasound (EUS) is “an extension of the physical exam (PE)...and thus should not be reimbursed,” defining USG as simply an adjunct to CVC may paint us into a corner respective to performing USG-CVC as an unfunded mandate. The rationalization that EUS is an exam extender may aid in defusing controversy when gaining the technology or reducing clinician “hoop-jumping” for credentialing, but it has a potential downside: denial of reimbursement or bundling of charges. Credentialing reaffirms that USG-Procedures/CVC is a unique and separate privilege from non-USG CVC, and as such, should be billed and reimbursed separately.

Changes in residency training driven by ACGME and the Residency Review Committee-Emergency Medicine and expanded mandates for competency assessment are driving credentialing metrics to the right. Many residencies have a competency-based progression for USG-CVC. A standard structure includes initial didactic education, practical training, simulation with competency thresholds prior to live patient performance, then proctored live performance with outcomes tracking. This process will likely compel community physician credentialing to be more rigorous.

The revised ACEP Emergency Ultrasound Guidelines,4 pertinent to community and academic settings, state:

  • “As a class of ultrasound procedures, each emergency ultrasound application represents a clinical bedside skill that can be of great advantage in a variety of emergency settings.”
  • “Emergency ultrasound requires emergency physicians to become knowledgeable in the indications for ultrasound applications, competent in image acquisition and interpretation, and able to integrate the findings appropriately in the clinical management of his or her patients.”
  • “These various aspects of the clinical use of emergency ultrasound all require proper education and training. The ACGME mandates procedural competency for all EM residents in emergency ultrasound as it is considered a ‘skill integral to the practice of Emergency Medicine’ as defined by the 2007 Model of Clinical Practice of Emergency Medicine.”
  • “Procedural guidance represents one of five Core Categories defined for emergency ultrasound.”
  • “If a number of examinations for USG procedure is required (for credentialing), we would recommend 10 US-guided procedures examinations or completion of a module on ultrasound guided procedures with simulation on a high quality ultrasound phantom.”
  • “The ED medical director or his/her designate (Emergency Ultrasound Director) is responsible for the periodic assessment of clinical privileges of emergency physicians.”
  • “..the American Medical Association (AMA) House of Delegates in 1999 passed a resolution (AMA HR. 802) recommending hospitals’ credentialing committees follow specialty specific guidelines for hospital credentialing decisions related to ultrasound use by clinicians.”
  • “Emergency medicine departments should either list emergency ultrasound within their core emergency medicine privileges, or as a single separate privilege for “emergency ultrasound” without further designation. - this is often not possible due to specific departmental or hospital processes or politics. 
  • Specific to procedural ultrasound: 
    • Describe the indications and limitations when using ultrasound to assist in bedside procedures.
    • Understand the 2D approaches of transverse and longitudinal approaches to procedural guidance with their advantages and disadvantages.
    • Define the relevant local anatomy for the particular application.
    • Understand the standard protocols when using ultrasound to assist in procedures. These procedures may include: central and peripheral vascular access
    • Recognize the relevant focused finding when performing ultrasound for procedural assistance.

Regardless if you plan to have a core, or bundled set of credentials in EUS, you should list “procedural ultrasound” per ACEP’s EUS Guidelines. This will address credentialing either within the “emergency department delineation of privileges,” if physicians are globally credentialed in the hospital in “Emergency Ultrasound” or specifically at the hospital credentialing level such as in “Ultrasound Guided Procedures.”

The Joint Commission’s comments regarding credentialing for new privileges also note “before the core/bundle is granted, the organization must evaluate each applicant's education, training and current competence to perform each activity listed in the core/bundle, and any that are assigned outside the core/bundle.” 

  • It cannot be assumed that every applicant can do every activity listed.
  • There needs to be a clearly defined method for the applicant to request deletion of specific activities.
  • If they don't wish for them to be granted or if organization's evaluation determines that the applicant is not competent to perform certain activities, then the organization must modify the core/bundle that is granted to the applicant
  • In accordance with the medical staff standards the applicant and all appropriate internal and/or external persons or entities (as defined by the organization and applicable law) are notified as to the granting decision, ie, whether the full core/bundle or a modified bundle has been granted.
  • If the core/bundle was modified, the notification must detail the specific modifications.

In conclusion, I promote the following specialty specific training and credentialing concepts: 

  • USG procedures or USG-CVC should be delineated either in the departmental or hospital emergency ultrasound credentialing documents. This is really based on the history and politics of the institution. Either method is appropriate, but a specialty-specific approach is key.
  • USG-Procedure/CVC education must include didactic, practical and supervised training, gained through either American Board of Emergency Medicine/American Osteopathic Board of Emergency Medicine residency training or American Medical Association Category 1 Continuing Medical Education supported education. This training should cover sonographic findings (anatomy, landmarks, needle tracking, sonographic findings of increased risk - clot, small size, hematoma, etc.).
  • Training and supervision should only be provided by practitioners who actually perform the procedure. USG-CVC training by sonographers or practitioners who do not actually perform USG-CVC does not meet training standards and does not meet the credentialing threshold in my opinion....and this may lead to medical liability concerns.  
  • Competency assessment is critical and can be performed through many mechanisms, including simulation, direct visualized supervision, image reviews, outcome assessment, etc. Many residencies have moved to a “certification” pathway for procedures with numerical thresholds such as 5 internal jugular, 5 subclavian and/or 3 femoral CVCs. Although numerical thresholds alone are not ideal, ample data supports that proficiency and competency increases with the volume of procedures; the issue is at what volume. For the practicing physician these number thresholds are not a practical reality, but concomitant direct or indirect review is sufficient.
  • Image retention, either static or dynamic, should be maintained. For most, I support an image of the “wire in the vein” as evidence that the user identified the landmarks and confirmed appropriate vessel prior to dilatation for the catheter.

 References: 

  1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. The National Academies Press, 2001.
  2. http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=42&ProgramId=1 
  3. The Joint Commission Credentialing and Privileging Conference Call, April 30, 2007. Transcript available at http://www.jointcommission.org/NR/rdonlyres/8AB389E2-412D-49F0-BAC9- 996D7EF098B1/0/audio_conference_043007.pdf 
  4. American College of Emergency Physicians. Emergency Ultrasound Guidelines [policy statement]; 2008, 2010. https://www.acep.org/WorkArea/DownloadAsset.aspx?id=32878 

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