RSS Feed Print Category View
Quality Assurance in Emergency Ultrasound
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


For those of you doing QA, what percentage of images of your already credentialed physicians do you review each month?
 
Guidelines say "sample", I've heard 25-80% of images. . .  how do others interpret this?
 
Thanks,
Nicole
 
Nicole Seleno MD
Director of Emergency Ultrasound
Saint Joseph Mercy
Ann Arbor, MI
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


10%
Vivek Tayal, MD
Carolinas Medical Center
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


I review all of them. Less intensely as they gain experience. Still misses 300+ scans into training. Great learning for QA physician(s) but takes time.

-Matt Flannigan
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


100%

We review every image acquired by our residents, fellows and attendings every week and use this as a teaching tool. Approximately 200-300 scans. It takes about 4-6 hours.

Lawrence E. Haines MD, MPH, RDMS, FACEP
Emergency Ultrasound Fellowship Director
Maimonides Medical Center
Brooklyn, NY
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


Depends on the level of training: attendings, about 10-20%. Residents about 50% overall. Med students 100%.
We see about 87k pts/year.

Janet Young, MD
Virginia Tech- Carilion
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


Minimum 10%.
But in reality many more for teaching/feedback.
-Otto Liebmann
(Brown Univ.)
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


100%
We also review all the scans performed by the residents, fellows and attending every week. The rotating residents, students and fellows have the opportunity to participate at the QA and receive feedbacks on their scans.

Hamid

Hamid Shokoohi, MD, MPH, RDMS, RDCS
Associate Professor of Emergency Medicine
Director, Emergency Ultrasound Fellowship
Department of Emergency Medicine
George Washington University
2120 L street, NW Suite 450
Washington DC 20037
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


We also do 100% review at MedStar.  This is approximately 150-200 scans per and takes about a 1/2 day session.

Thanks,
Kerri

Kerri Layman, MD RDMS FACEP
Assistant Professor Emergency Medicine
Director Emergency Ultrasound Fellowship
Emergency Ultrasound Site Director
Medstar Georgetown University Hospital
Medstar Washington Hospital Center
Department of Emergency Medicine
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


This is an interesting discussion.  By the postings it looks like some of you are able to QA approximately 50 scans per hour (1.2 minutes per QA'd study).  Is that correct?  

We might do 15-20 scans per hour and this includes:

1) briefly reading through the ED visit note to have an idea why the study was performed
2) reading the US report note in the EMR
3) reviewing the images for gain/depth and appropriate interpretation
4) completing the QA form in Ultralinq
5) pointing things out to learners in the room and discussion
6) sometimes messaging the provider as to any issues that were uncovered.  


This goes faster with more than one person and more than one computer/screen.  Of course, the sonographer's skill or lack thereof affects the QA process.  It would be great to know what everybody means when they say QA and how many people, computers, screens, projectors, etc... that are required.  To answer the initial question, we QA about 20-25% of scans here.  

Thanks

Pat Blaine Hinfrey
Newark Beth Israel
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


When I read these numbers, I wondered whether Dr Haines was referring to a single image / clip when he referred to  a “scan”?
 
Typically our trainees record 4-10 ten-sec clips [plus some still images] per application (e.g. “FAST” or “kidney/bladder scan”), and with the software we use (Q-path) it would take more than this amount of time just to upload the typical number of clips without reviewing them, or communicating feedback.  Reviewing clinical data, and addressing clinical issues if there are significant new findings obviously makes the process even slower.    
 
While those of us with fellowship programs get significant educational mileage from this process, we tend to “pay the hours back” during post-QA review.  We should not underestimate the time QA takes.  To do so would be to undervalue our own labor and also make it harder for ultrasound directors in non-fellowship settings who are trying to obtain the infrastructure and resources  for a robust ultrasound program from hospital administrators who are delighted by the possibility of an untapped reimbursement /revenue stream, but not by the need to pay for it.
 
Aj
 
 
Anthony J. Dean, MD, FAAEM, FACEP
Associate Professor of Emergency Medicine and Associate Professor of Emergency Medicine in Radiology
Director, Division of Emergency Ultrasonography
Department of Emergency Medicine
University of Pennsylvania Medical Center
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


Hi Pat,

Your frustration and concern is evident.  There can always be confusion but some possible solutions:
(1) place a note in the chart clearly defining the ultrasound as for education only
(2) place a dedicated discharge instruction for educational ultrasound
(3) send letters to most utilized primary care providers etc describing what is happening

Lots more solutions too, if the goal is to not get yelled at or not cause confusion there are many solutions.

Sincerely,
Venk

Venkatesh Bellamkonda, M.D. | Consultant Physician | Director of Emergency Ultrasound | Department of Emergency Medicine | Gold Quality Fellow | Mayo Clinic Quality Academy | Assistant Professor of Emergency Medicine | College of Medicine
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


Agree with Anthony and would caution against calling it “quality assurance” unless it is thoroughly reviewed. Whatever QA process you design is likely to remain under the radar until there is a case that is missed. If something has gone through “quality assurance” and was missed here as well it will call the program into question.

We have our review separated into three levels:
1. documentation - simply ensuring that things are filled out without regard to correctness of findings
2. review of images to see that images captured match findings documented
3. review of patient course, including any additional imaging/ testing/ surgical path, follow-up etc.

We attempt to do daily level 1 on 100%, which is typically about 40-50 studies/ day divided among three fellows and three faculty each of which have a day. We encourage level 2 QA on studies by non-credentialed attendings and residents. We encourage level 3 QA on any questionable findings on images and/or positive studies. While we try to do a portion of level 2 QA on credentialed attendings this is only a subset (i.e. not all negative FAST exams by a credentialed attending will be reviewed). We are careful not to say that we are “overreading” any studies - the findings documented by a credentialed attending are their findings and will remain, though we may occasionally find something that we try to follow up. We flag interesting/ positive/ questionable/ good examples of negatives for review by the group once a week.

While it depends on volume it is very difficult to do 100% true “quality" assurance, and would not call it QA unless you are ready to stand behind the process fully.

Not sure how many of you are attending the SCUF conference in April but might be a good topic to discuss.

Chris


Christopher L. Moore MD
Associate Professor, Department of Emergency Medicine
Yale University School of Medicine
 
Feedback
Click here to
send us feedback