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Bridging the Grayscale Gap: Guiding Emergency Physicians through Ultrasound Credentialing

Sara Damewood, MD; Resa Lewiss, MD; Azita Hamedani, MD, MBA, MPH

Clinical ultrasound has been shown to improve patient satisfaction and patient safety. It is currently best practice and standard of care to guide central line placement and other high-risk procedures. Specifically, ultrasound guidance for central lines has been shown to reduce the number of attempts and decrease complications, such as bloodstream infections, arterial punctures and pneumothoraces (1-3).

Since ultrasound is an operator dependent skill, standardized training and continued use are necessary to ensure competency. In 2008, The American College of Emergency Physicians (ACEP) published guidelines for credentialing physicians in clinical ultrasound. These guidelines suggest completing 16 hours of didactic content, and performing 25-50 ultrasound examinations each in eleven applications (4). The experiential training should be under the supervision of confirmatory radiological studies or of someone experienced in clinical ultrasound. In 2003, the Accreditation Council on Graduate Medical Education (ACGME) deemed ultrasound a required part of emergency medicine (EM) training. As a result, most EM residency programs have dedicated ultrasound rotations.

Unfortunately, emergency physicians who completed their training prior to the 2003 mandate, have few options for gaining competency. There are regional and national ultrasound courses available to learn the didactic and some of the practical content; however, sustainable ultrasound use requires continual oversight and feedback to ensure quality standards.

Experienced emergency physicians who have developed their clinical practice without the use of ultrasound may have difficulty in appreciating its value to patient care. If physician compensation models rely on productivity metrics, some emergency physicians may feel that learning and inefficiently using ultrasound during the course of patient care would detract from their income. In fact, in some emergency departments, it may be more convenient and efficient to obtain department of radiology ultrasound examinations. These are a few of the challenges motivating certain learners.

How can department chairpersons motivate emergency physicians to become credentialed in clinical ultrasound? Our group of academic EM faculty recently completed a credentialing process. We followed ACEP US guidelines and a protocol negotiated with hospital administration and the Department of Radiology. Those emergency physicians without significant ultrasound training underwent 16 hours of didactic ultrasound content by enrolling in a course. They then acquired 25 technically adequate (as reviewed by the ultrasound director) ultrasound examinations for four applications of their choosing. Those emergency physicians with attestations of competence in clinical ultrasound from their residency programs followed a different process. For this latter group, twenty technically adequate examinations were required in total. At the end of the process, the emergency physicians completed a survey on their attitudes and perspectives of the credentialing process.

According to survey results, our group of academic emergency physicians identified three primary motivators for pursing clinical ultrasound credentialing: financial, the ability to use ultrasound in clinical practice, and the ability to teach ultrasound to residents. It should be noted that financial incentive strongly motivated participants to complete the credentialing process. If faculty did not complete the ultrasound credentialing process, additional merit based compensation was withheld. The ability to use ultrasound in clinical practice moderately influenced participants. Teaching residents ultrasound was the least motivating of the three identified factors.

Most of the time and effort to complete the credentialing process included further developing ultrasound scanning skills to meet the criteria for technically adequate ultrasound examinations. Specifically, many emergency physicians submitted scans early in the process that included technically inadequate images or incomplete examinations. As such, many faculty seeking ultrasound credentialing pursued individual scanning sessions with ultrasound fellowship trained faculty. These individual scanning sessions were identified as the most helpful in improving scanning skills and the quality of scans obtained. Overall, participants felt that their ultrasound skills had significantly improved after the credentialing process. Most were interested in pursuing more ultrasound education after they completed the credentialing process. In aggregate, we went from six faculty credentialed in ultrasound to seventeen faculty – which includes all but two faculty who are still in the process. By improving the skill set of our faculty, improvements in both patient care and resident education has undoubtedly followed. Given our single academic department experience, department chairpersons may opt to tie a form of compensation to an ultrasound credentialing process. To best develop or polish ultrasound skills, scanning with fellow emergency physicians with ultrasound training is likely to be the most helpful. Thus, chairpersons could also ensure appropriate protected time for ultrasound faculty to provide peer-to-peer scanning sessions.

With a relatively small financial incentive (e.g. withholding year end bonus) and investment (e.g. protecting ultrasound faculty time to provide teaching), these departmental efforts could result in a larger cohort of emergency physicians with the ultrasound skills required for best practice and standard of care, as well as training of future generations of physicians.


  1. Howard ZD et al. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014 Jan;46(1):46-53
  2. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2012 Mar;116(3):539-73.
  3. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996;24:2053-2058
  4. Emergency ultrasound guidelines. Ann Emerg Med 2009. Apr; 53(4):550-70



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