RSS Feed Print Category View
Training or Educational Scans
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


Sorry if this is territory already covered….

I have been asked by one of our subspecialty groups to document all of our “training” scans in the PED.  They make a reasonable argument that, despite scripting of the reasons for a scan with patients/families, the family may walk away with a sense of having had a “normal” or “abnormal” ultrasound.  This complicates their follow-up care.

How does the group document (in the EHR) scans by non-credentialed providers who are simply working towards meeting the ACEP guidelines (with a corresponding confirmatory study or bedside supervision by a credentialed provider)?  Does anyone use language along the lines of “An educational ultrasound exam was performed.  The scan was not used for clinical care.”?

Are there any pitfalls to documenting a scan that is primarily of educational value (though always with a corresponding clinical indication)?

A penny for your thoughts……

Geoff



--------
Geoffrey E. Hayden, MD, FACEP, RDMS
Assistant Professor, Director of Emergency Ultrasound
Fellowship Director, Emergency Ultrasound
Departments of Medicine and Pediatrics, Division of Emergency Medicine

Division of Emergency Medicine
Medical University of South Carolina
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


This is another debated issue.
We document "Unofficial Focused ED Ultrasound was performed...", the findings, and also list the follow-up that was performed.  We also encourage those documenting to only state what they are fairly certain of and use "limited" liberally.

Chris Raio
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


You can use scripting all you want but some of the patients will still walk out of the ED and go to their PMD's office and say "I had a _______ ultrasound in the _________ ED and they said everything was fine."  The PMD will complain to your medical director or chair when they look in the cardiology or radiology PACS system and can't find the study.  For every one that complains you can be sure their are others out there who were silent.  The percentage of patients who just don't get it is too high.  


I suspect that every ED has more than enough patients with legitimate clinical indications such that every resident can be trained in bedside ultrasound without resorting to educational studies.  I may be regarded as a blasphemer but I wish the concept of educational ultrasounds would go away.  Residents can practice on each other and medical students.  

Pat Blaine Hinfrey
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


An educational study in our ED is not one that is not clinically indicated-it is a scan performed when a credentialed MD is not present to provide oversight. This is a rare occasion but does occur. These are all performed on patients who require diagnostic testing, and a follow-up is performed in the ED.  The purpose of the documentation is to provide evidence that the procedure was performed when questioning arises downstream from the patient, PMD or consulting teams as to "what the ultrasound showed"--since the follow-up may be alternative imaging. We have found that documenting these unofficial scans has saved us a lot of investigative work and time.  

Chris Raio
pererap
Posted: Sunday, March 29, 2015
Joined: 8/31/2011
Posts: 231


We allow educational exams to be performed with the consent of the patient in the adult ED. Medical students/residents are given a script when they ask patients to consent to an "educational study." They are instructed to tell patients that they are learners and are not qualified to say whether their ultrasound exam is normal or pathologic. I expect that despite what you tell patients, that a certain percentage will walk away believing that the medical student ultrasound exam that was "normal to them" is equivalent to a comprehensive radiology performed ultrasound exam. However, that also begs the question: what do they think of the exam that anyone of my credentialed attending physicians does? Do they also think that is equivalent to a more comprehensive exam performed in radiology / cardiology? Despite my jesting that my ultrasound machine is more like a Hyundai and that the Radiologists/Cardiologists have the Cadillac version. And my explanation that I am only looking for very specific things on my ultrasound exam and am not doing this as a comprehensive study, I'll bet a large portion of them walk away believing that it is a comprehensive evaluation.

Does this therefore mean that I can only practice medicine at a training institution to the level at which a patient understands what I am doing? Do I just give up on performing a focused point of care ultrasound study because I have a patient that fails to understand these nuances and may walk away with a misguided belief that I ruled out any significant pathology on the renal or focused echo exam that I did?

This is where the brilliance of the ACEP EM US guidelines comes in to play. We, as a specialty have defined how and why we are using ultrasound. There are only a few things that my medical students/resident learners might miss that would need urgent follow up. All of which would be not the cause for their visit (because that would already be in the process of work up during their ED visit).

So, what are these:
Aorta: an asymptomatic AAA
Biliary: asymptomatic gallstones
Cardiac: a pericardial effusion; unknown drop in LVEF
Ocular: an asymptomatic RD
Pregnancy: we are going to image these at all visits anyway
Renal: Asymptomatic hydronephrosis
Thoracic: Pleural effusion
MSK/soft tissue: asymptomatic effusion

Perhaps there are some that I've missed here, but I feel that we have a good safety net in place since we require that the student/resident put in the patient's MRN as part of the study and then all of the studies are QA'd (usually within a few days) of their visit. The study stays in QPath, but does not go to the patient's chart. If we notice any pathology, than the student comments that is a known condition or we check the chart to make sure this is known/expected. We will contact the patient if it is not previously known and recommend follow up.

Very rarely will we have some sort of complaint about these studies. However, the thing I point out is all the pathology that we've picked up that would have been missed if not for all of these "educational studies." For example, we've had 2 patients in the past few months with SOB that have had a prior cards and plum visits in the weeks prior to their ED visit. In the ED both patients were awaiting CTPA for PE that had "educational studies" that found severe MR and another with LA myxoma. Both patients had been seen by Cards and an echo never performed. I don't know if the team would have ordered an ECHO if the CTPA were negative. Both patients were accurately diagnosed in a more rapid manner.  We've found incidental renal cell CA as I'm sure many of you have as well. However, none of these pathologic conditions are highlighted in the ACEP US guidelines as pathologies that we are qualifying ourselves to diagnose/exclude. So, if they were missed on an educational study, are we now responsible because the patient (despite being told otherwise) walks away with a misguided belief that the medical student performed ultrasound study done for educational purposes missed something that we are not claiming to be able to diagnose in the first place??

Now, the PED is a very different place. I have found it difficult to do educational studies there anyway. So, I have the PEM fellows (if doing an EM US rotation) do studies in the adult ED and then will often accompany them for scanning shifts in the PED. Then we mainly do clinically applicable studies anyway.

My 2 cents…

Rob

Robinson M. Ferre, MD, FACEP
Director, Emergency Ultrasound Division
Program Director, Emergency Ultrasound Fellowship
Assistant Professor, Department of Emergency Medicine
Vanderbilt University
justinstowens@gmail.com
Posted: Friday, December 4, 2015
Joined: 8/10/2011
Posts: 1


 

After reading the discussion above, I've decided that at our newly minted EM residency we will allow residents to perform "teaching" scans. As we are also a fairly ultrasound-light department that is just starting to use more ultrasound, there is a great chance that my learners on rotation won't have enough scans if they are waiting for patients that "need" them. I also echo what was said about incidental findings--I've definitely found a few important ones.

So, that said, does anyone have a template for patient discharge information for those patients that received a teaching scan? I don't see one on the documents section of the forum and I'd love to see what others are using. 

Thanks!

Justin Stowens, MD

Director of Emergency Ultrasound, Crozer Hospital

justin.stowens@crozer.org


 
Feedback
Click here to
send us feedback