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Emergency Ultrasound

Pediatric Emergency Ultrasound Update

Kelly R. Bergmann, DO, FAAP
Valerie Whitcomb, MD, FAAP
Russ Horowitz, MD, RDMS


Announcement – New Pediatric Point-of-Care Ultrasound Guidelines

The past few years have seen incredible growth in pediatric point-of-care ultrasound. In addition to the development of consensus educational guidelines,1 publication of the first pediatric point-of-care ultrasound textbook,2 and foundation of the P2Network, a landmark policy statement and technical report endorsing the use of point-of-care ultrasonography by pediatric emergency medicine (PEM) providers was published.3 As a collaborative effort between the American Academy of Pediatrics (AAP), Society for Academic Emergency Medicine, American College of Emergency Physicians (ACEP), and the World Interactive Network Focused on Critical Ultrasound, this policy statement garners consensus among the PEM community and provides the framework for point-of-care ultrasound development within pediatric emergency departments (EDs). 

Why does this matter?

The AAP policy statement underscores the importance of pediatric-specific ultrasound training. Until now PEM providers have largely relied on ACEP guidelines4 for direction, which has not been ideal since these guidelines are not tailored for pediatric patients. For example, bowel ultrasound for intussusception is extremely important for PEM providers but is not included in the general ACEP guidelines. Alternatively, while abdominal aortic aneurysm identification is a core ultrasound examination in adult practice, this may not be as relevant to PEM providers. To this end, Vieira et al recently published training guidelines and proposed core content for PEM fellows.1 The AAP policy statement solidifies the need for on-going development of such criteria within the PEM community.

Perhaps most importantly, the AAP policy statement gives credence to the growing body of PEM providers already utilizing point-of-care ultrasound in their practice. Where administrators may have been previously hesitant to rely on “adult” ultrasound guidelines, the publication of AAP-endorsed guidelines now provides the support mechanism needed to bring about departmental and institutional change. In essence, the AAP policy statement provides a voice for all PEM providers and recognizes their right to utilize ultrasound as an adjunct tool in the emergent care of children and thereby improve diagnostic and procedural acumen, and ultimately patient care.

Importance for PEM providers

Many PEM programs have only recently begun to implement point-of-care ultrasound into practice. This has been largely driven by new faculty with some form of ultrasound training during their fellowship. Consequently, there has been a need to provide distinct training for those who may not have had formal ultrasound education as part of their training. Marin et al. highlight two possible pathways for gaining experience in the accompanying technical report, both of which include three key aspects of point-of-care ultrasound education: introductory instruction, experiential learning, and longitudinal experience. The first is a training-based pathway for current fellowship trainees. This is particularly important as the American Board of Pediatrics now includes point-of-care ultrasound in the core content required for PEM fellowship certification.5 A training-based model can include a dedicated ultrasound rotation or scanning shifts with hands-on instruction, in addition to image review and educational sessions. The second pathway is a practice-based approached for faculty with limited ultrasound experience. This can be accomplished through participation in an introductory point-of-care ultrasound course, with continued “educational” scans performed at the home institution and reviewed by the ultrasound director.

In order to successfully implement a point-of-care ultrasound program, safety and accuracy must be central to all decisions. Knowing how to perform ultrasound examinations is essential, however, recognizing the limitations of point-of-care ultrasound and when to utilize such studies in lieu of formal examinations is vital to patient safety. To this end, the AAP policy statement concludes with five recommendations for PEM programs:

  1. Familiarity – PEM physicians should be familiar with point-of-care ultrasound applications
  2. Competency – PEM Providers should be competent in specific examinations
  3. Education and Assessment –Processes should be in place for ongoing education, skills assessment, quality assurance (QA), and privileging
  4. Fellowship – PEM fellowships should have a structured point-of-care ultrasound curriculum
  5. Expertise – Criteria for what defines a point-of-care ultrasound expert should be developed by national organizations


Where do we go from here?


The AAP policy statement highlights several areas for future development. On a departmental level these include establishing point-of-care ultrasound leaders, implementing QA processes, and developing institutional-specific credentialing and privileging pathways. On a national level, there is a need to develop universal criteria for what defines an expert in point-of-care ultrasonography and for accreditation and safety processes. The ACEP Ultrasound Section has recently developed a program – the Clinical Ultrasound Accreditation Program – that may be a model for accreditation among PEM providers.

The development of pediatric point-of-care ultrasound programs should be a collaborative effort among various departments within each institution. The most notable stakeholders include radiology, information technology (implementation of QA), cardiology and surgery. In some cases, other specialists simply may not be aware of the body of literature in support of point-of-care evaluations. Successful implementation of an ultrasound program will only be strengthened by a multi-disciplinary approach.

Point-of-care ultrasound training for future PEM providers will continue to evolve. Many medical school and pediatric residencies are already offering ultrasound rotations. PEM programs are beginning to offer one-year fellowships specific to point-of-care ultrasound development. Simultaneously, more PEM providers are undertaking further training via the registered diagnostic medical sonography (RDMS) examination.

One thing is clear: the way forward in pediatric emergency medicine will involve point-of-care ultrasound.

References

  1. Vieira RL, Hsu D, Nagler J, et al. Pediatric emergency medicine fellow training in ultrasound: consensus educational guidelines. Acad Emerg Med. 2013;20(3):300-306.
  2. Doniger S. Pediatric Emergency and Critical Care Ultrasound: Cambridge University Press; 2013.
  3. Marin JR, Lewiss RE. American Academy of Pediatrics CoPEM, et al. Point-of-care ultrasonography by pediatric emergency medicine physicians. Pediatrics. 2015;31(7):525.
  4. American College of Emergency Physicians. Policy Statement: Emergency Ultrasound Guidelines. Dallas, TX: American College of Emergency Physicians, 2008. 
  5. American Board of Pediatrics. Pediatric Emergency Medicine: Subspecialty In-training, Certification, and Maintenance of Certification Examinations. Chapel Hill, NC: American Board of Pediatrics, 2011. 



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