CLINICAL PRIVILEGE WHITE PAPER

Procedure 240
A supplement to Briefings on Credentialing 781/639-1872 01/07
Background
Emergency ultrasound (EUS) is a technique that uses medical imaging to give physi-
cians critical information by rapidly and noninvasively defining anatomic structures
and function. EUS is usually performed at the bedside simultaneously with the clinic-
al examination and has been described as an extension of the palpating hand and as
a visual stethoscope used during examinations.
EUS protocols are limited compared to comprehensive ultrasound protocols. For example,
a comprehensive cardiac ultrasound evaluates the heart for a large number of possible
defects, whereas an EUS during cardiac arrest can determine whether the heart is beating.
The primary applications for EUS can answer questions such as the following:
Is there blood in the trauma patients peritoneal cavity?
Does the pregnant patient with abdominal pain or vaginal bleeding have an
ectopic pregnancy?
For the patient with pulseless electrical activity, is there cardiac activity that
may benefit from aggressive resuscitation?
Does the elderly patient with abdominal or back pain have an abdominal
aortic aneurysm (AAA)?
Does the biliary colic patient have acute acalculous cholecystitis?
Does the renal colic patient have kidney stones?
Other established uses for EUS include procedural aid for central venous access, abscess
drainage, or foreign body detection. In patients with poor landmarks and a large body
habitus, EUS with Doppler can help locate central veins that are then marked prior to
venipuncture. This can increase the success rate, decrease the complication rate, and
save time. EUS is also used in some centers to detect lower-extremity deep venous
thrombosis.
Several uses of EUS are in the experimental phase, including the use of ultrasound for
detection of testicular torsion, fractures, and joint effusions. Another practical use of
EUS is for confirmation of pacemaker wire placement in patients undergoing transve-
nous pacing.
EUS is ideal for use in emergency medicine. It is readily available 24 hours per day at
the bedside and does not require a second technician or physician. The examination
time is rapid, and its use results in a decreased length of stay in the emergency depart-
ment (ED). It can be used to diagnose life-threatening problems, enabling rapid treat-
ment. Serial exams can easily be performed to reassess patients as their clinical status
Emergency ultrasound

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Emergency ultrasound Procedure 240
changes. It is safe (even in pregnancy) and noninvasive, and it has minimal operating
costs. The exams are easily performed with only a small percentage of indeterminate
results. Further, emergency physicians can learn to accurately perform the technique
with minimal training and experience.
Emergency medicine residency programs now include EUS. The residency curriculum in
EUS should include an initial course on the principles of ultrasound and knobology, as
well as an introduction to its primary applications and procedural uses. Didactic teaching
and skills labs should be used for EUS training throughout residency to expand on the
initial orientation course. The most important part of the learning process should occur
at the bedside under careful attending supervision.
Emergency medicine physicians, general surgeons, and family
practitioners
The American College of Emergency Physicians (ACEP) pub-
lishes the policy statement Emergency Ultrasound Guidelines. In
the statement, the ACEP says ultrasound is a unique diagnostic
modality for the emergency physician because it requires profi-
ciency in both a cognitive (i.e., indication and interpretation)
and psychomotor (i.e., hands-on) skill.
Training in acquiring and interpreting images must be provid-
ed through a curriculum that includes didactic lectures, demon-
strations, and technical skill laboratories. Both the cognitive and
psychomotor skill components have minimum content require-
ments that are necessary for meeting the educational objective
for training in emergency ultrasound.
Training pathways
Following are training pathways for physicians who wish to
attain competence in EUS:
A residency-based pathway should be the primary mode
for EUS training, which takes place during the 36- to 48-
month Accreditation Council for Graduate Medical Educa-
tion (ACGME)approved program in emergency medicine.
The faculty should have or obtain EUS experience in order
to supervise emergency medicine residents. An ultrasound
machine should be available for emergency medicine resi-
dents and faculty to use during emergency medicine rota-
tions. Rotations in other specialties that use ultrasound may
be useful if cooperative, hands-on experience is allowed.
A practice-based pathway for physicians who have complet-
Involved specialties
Positions of societies
and academies
ACEP
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Emergency ultrasound Procedure 240
ed their residency training without EUS training should
include initial training in a 16-hour (or longer) course cover-
ing the primary applications. There also may be a series of
one-day, single-application format courses. This experience,
as with residency training, requires the presence of an appro-
priate ultrasound machine. Each department or individual
should develop a plan during this experiential training phase
to have each emergency ultrasound reviewed by trained
peers or by a quality assurance review process.
The experiential component for both pathways integrates the
psychomotor and cognitive components of EUS and significant-
ly improves with practice and overlap in the learning curves of
the various primary applications. Thus, experience in one ab-
dominal application leads to better technique and interpretation
of other similar applications.
After didactic content, emergency physicians should obtain
experience using the ultrasound before presenting cases for for-
mal recognition. This period can be viewed as a training, proc-
toring, or provisional privileging period. Ultrasounds performed
during this period should be reviewed for technique, image ac-
quisition, and outcome.
If an institution lacks an emergency medicine colleague who
possesses ultrasound training or credentials, it may request as-
sistance from peers at related institutions that use emergency
ultrasound. Alternatively, the institution may pursue assistance
from related imaging professionals within the institution. Wheth-
er by experience, proctoring, or quality review, the emergency
physician should be able to incorporate emergency ultrasound
into emergency care while gradually improving his or her skills
during this training period.
Training experience
The recommended training experience suggested for emergency
credentialing is consistent with ranges of proficiency between
25 to 50 documented and reviewed ultrasound examinations
per primary application. Emergency physicians desiring general
emergency ultrasound privileges (i.e., not application-specific)
should perform a minimum of 150 examinations.
There are several qualifiers to the aforementioned recommen-
dations. First, proficiency may not always be defined by numer-
ical goals, and certain physicians may gain competency at lower
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Emergency ultrasound Procedure 240
or higher thresholds. Second, these examinations should be
performed during patient encounters in the ED, approved train-
ing experiences with other imaging specialties, or other contin-
uing medical education (CME) training in ultrasound.
Third, all cases should not be normal, and some pathologic
findings should be present in a portion of cases submitted (e.g.,
hemoperitoneum for trauma ultrasounds, gallstones for biliary
ultrasound, aortic aneurysm in AAA scanning, etc.).
More sophisticated sonographic techniques may require dif-
ferent credentialing requirements or modes of confirmation
beyond the primary emergency indications.
Continuing proficiency
After the initial phase of training, continuous use of the ultra-
sound technology is advised to maintain skills. The frequency
of experience with emergency ultrasound should continue at a
steady if not increasing rate in the years after the initial training.
This frequency would maintain comfort with imaging skills yet
account for individual practice settings, which may vary.
The Society for Academic Emergency Medicine (SAEM) publishes
the document Ultrasound Position Statement. In the statement,
the SAEM says that because the use of diagnostic ultrasound has
proven to be of value in the diagnosis and management of a
variety of emergency conditions, and because the mission of
SAEM is to enhance education and research in emergency care,
SAEM endorses the following principles:
Research should be encouraged to delineate the appropriate
uses of diagnostic ultrasound in the ED
Educational research should be encouraged to determine
the optimal amount and types of training required to per-
form ED ultrasound evaluations
Specific training in the performance and interpretation
of EUS should be available to emergency physicians dur-
ing residency training
A curriculum of the study for optimum training in EUS
should be established, which ensures adequate training
for emergency physicians
The American Board of Emergency Medicine (ABEM) grants
certification in emergency medicine. Physicians seeking ABEM
certification must fulfill the following requirements:
SAEM
Positions of societies
and academies
ABEM
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Emergency ultrasound Procedure 240
Graduate from a medical school approved by the Liaison
Committee on Medical Education. Graduates of approved
schools of osteopathic medicine in the United States are
considered when they have satisfactorily met credential
requirements.
Successfully complete a minimum of 36 months of postmed-
ical-school training under the control of an emergency medi-
cine residency program accredited by the ACGME or the Royal
College of Physicians and Surgeons of Canada (RCPSC).
Hold a medical license that is current, active, valid, unre-
stricted, and unqualified in at least one jurisdiction in the
United States, its territories, or Canada, and in each jurisdic-
tion in which they practice.
If an applicant applies for certification one year or more after
the date of graduating from an emergency medicine residen-
cy, submit for ABEMreview documentation of 50 hours per
year of CME in emergency medicine.
Pass the written qualifying examination and the oral certifi-
cation examination.
The ABEM also recognizes the following specific combined
training programs that have been approved in advance by the
respective sponsoring boards:
Emergency/internal medicine, which is a five-year training
program approved by the ABEM and the American Board of
Internal Medicine (ABIM). When completed, the program
provides physicians with the option of certification in emer-
gency and internal medicine.
Emergency/internal/critical-care medicine, which is a six-
year training program approved by the ABEM and ABIM.
When completed, the program provides physicians the op-
tion of certification in emergency medicine, internal medi-
cine, and critical-care medicine.
Emergency medicine/pediatrics, which is a five-year train-
ing program approved by the ABEM and American Board
of Pediatrics. When completed, the program provides physi-
cians with the option of certification in emergency medicine
and pediatrics.
The AOA grants certification in emergency medicine through
the American Osteopathic Board of Emergency Medicine.
Candidates must meet the following eligibility requirements:
Graduate from an AOA-accredited college of osteopathic
medicine
Possess a valid or unrestricted license to practice in the state
AOA
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Emergency ultrasound Procedure 240
or territory where their practice is conducted
Be able to document evidence of conformity to the standards
set forth in the AOA Code of Ethics
Be a member in good standing of the AOA or the Canadian
Osteopathic Association for two years immediately preceding
the date of certification
Satisfactorily complete an AOA-approved internship
Satisfactorily complete a period of two years of AOA-approv-
ed training in emergency medicine following the required
year of internship provided the residency training was initi-
ated prior to July 1, 1989
Satisfactorily complete three years of approved AOA train-
ing in emergency medicine following the required year of
internship if the residency training was initiated on or after
July 1, 1989
Continue the practice of emergency medicine while complet-
ing the certification examination process
Show evidence of one year of practice in emergency medi-
cine or one year of subspecialty training that directly relates
to the practice of emergency medicine
Pass a written, an oral, and a clinical examination
Applicants who have successfully completed an AOA-approv-
ed dual residency program in emergency medicine and other
specialties are eligible to enter and complete the certification
process after showing evidence of one year of practice in emer-
gency medicine.
According to Rob Reardon, MD, director of ultrasound edu-
cation at Hennepin County Medical Center Department of
Emergency Medicine in Minneapolis, there are several ways
in which physicians who want to perform EUS can receive
training in the technique. The preferred method is as part of
an emergency medicine residency program, which is becom-
ing more common as the benefits of EUS are recognized.
Physicians who did not receive EUS training in their residency
program can complete a two-day course, says Reardon. These
courses consist of 75% lecture and 25% hands-on training and are
taught by experienced ultrasound practitioners. The trainees are
supervised in 25 ultrasound examinations per primary application.
Reardon says 25 cases could be considered overkill for an appli-
cation such as AAA screening, as it is an easy skill to learn. But
because the ACEP recommends that 10% of a physicians cases
Hennepin County
Medical Center,
Minneapolis
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Emergency ultrasound Procedure 240
should be abnormal and that some pathologic findings should
be present, the number becomes more reasonable. Youre
probably going to find two or three aneurysms out of 25 cases,
particularly since its estimated that 10% of the male popula-
tion over 65 whove ever smoked have them, he says.
There are also one-year fellowship programs in EUS. A lot of
the bigger [EDs] want someone with recognized expertise to be
in charge of their ultrasound program, explains Reardon. With
fellowship training, emergency physicians are then qualified to
teach other physicians the technique.
Reardon says there are cardiologists and radiologists in small-
er hospitals who still object to ultrasound machines in the ED
because they say the emergency physicians arent experienced
enough.
He argues that these emergency physicians can be readily
trained to perform vital applications such as screening for AAA or
for cardiac activity. It has become a standard of care to have
ultrasound in the emergency department, he says.
The following draft criteria are intended to serve solely as a
starting point for the development of an institutions policy
regarding this procedure.
Basic education: MD or DO
Minimum formal training: Successful completion of an
ACGME-/AOA-accredited postgraduate training program
in emergency medicine. If the program did not include EUS
training, applicants must demonstrate successful completion
of one of the following:
EUS fellowship training
A formal course in EUS covering primary applications
A series of single-application courses
Training by an experienced EUS physician
All EUS training programs should include proctored cases
Required previous experience: Applicants must be able to
demonstrate that they have successfully performed at least 25
ultrasounds for each primary application for which privileges
are requested or 150 ultrasounds for general EUS applications
in the past 12 months.
Minimum threshold criteria
for requesting core privileges
in EUS
CRC draft criteria
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Emergency ultrasound Procedure 240
A letter of reference must come from the director of the appli-
cants EUS training program. Alternatively, a letter of reference
regarding competence should come from the chief of emer-
gency medicine at the institution where the applicant most
recently practiced.
Reappointment should be based on unbiased, objective results
of care according to the organizations existing quality assur-
ance mechanisms.
Applicants must be able to demonstrate that they have main-
tained competence by documenting that they have successfully
performed at least 25 ultrasounds for each primary application
for which privileges are requested or 150 ultrasounds for gener-
al EUS applications annually over the reappointment cycle.
In addition, continuing education related to emergency medi-
cine and EUS should be required.
For more information regarding this procedure, contact:
American Board of Emergency Medicine
3000 Coolidge Road
East Lansing, MI 48823-6319
Telephone: 517/332-4800
Fax: 517/332-2234
Web site: www.abem.org
American College of Emergency Physicians
1125 Executive Circle
Irving, TX 75038-2522
Mailing: P.O. Box 619911
Dallas, TX 75261-9911
Telephone: 972/550-0911
Fax: 972/580-2816
Web site: www.acep.org
American Osteopathic Association
142 East Ontario Street
Chicago, IL 60611
Telephone: 312/202-8000
Fax: 312/202-8200
Web site: www.aoa-net.org
References
Reappointment
For more information
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Emergency ultrasound Procedure 240
Hennepin County Medical Center
701 Park Avenue
Minneapolis, MN 55415
Telephone: 612/873-5683
Fax: 612/904-4241
Society for Academic Emergency Medicine
901 North Washington Avenue
Lansing, MI 48906-5137
Telephone: 517/485-5484
Fax: 517/485-0801
Web site: www.saem.org
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Emergency ultrasound Procedure 240
In order to be eligible to request clinical privileges in EUS, an applicant must meet the
following minimum threshold criteria:
Basic education: MD or DO.
Minimum formal training: Successful completion of an ACGME-/AOA-accredited postgradu-
ate training program in emergency medicine. If the program did not include EUS training, ap-
plicants must demonstrate successful completion of one of the following:
Fellowship training
A formal course covering primary applications
A series of single-application courses
Training by an experienced physician
All EUS training programs should include proctored cases.
Required previous experience: Applicants must be able to demonstrate that they have suc-
cessfully performed at least 25 ultrasounds for each primary application for which privileges are
requested or 150 ultrasounds for general EUS applications in the past 12 months.
References: A letter of reference must come from the director of the applicants EUS training
program. Alternatively, a letter of reference regarding competence should come from the chief
of emergency medicine at the institution where the applicant most recently practiced.
Reappointment: Reappointment should be based on unbiased, objective results of care accord-
ing to the organizations existing quality assurance mechanisms.
Applicants must be able to demonstrate that they have maintained competence by document-
ing that they have successfully performed at least 25 ultrasounds for each primary application
for which privileges are requested or 150 ultrasounds for general EUS applications annually over
the reappointment cycle.
In addition, continuing education related to emergency medicine and EUS should be required.
I understand that by making this request I am bound by the applicable bylaws or policies
of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this
request.
Physicians signature: _____________________________________________________
Typed or printed name: ___________________________________________________
Date: ___________________________________________________________________
Privilege request form
Emergency ultrasound
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Emergency ultrasound Procedure 240
12 A supplement to Briefings on Credentialing 781/639-1872 01/07
Emergency ultrasound Procedure 240
Darrell L. Cass, MD, FACS, FAAP
Codirector, Center for Fetal Surgery
Texas Childrens Hospital
Houston, TX
Jack Cox, MD
Senior Vice President/Chief Quality Officer
Hoag Memorial Hospital Presbyterian
Newport Beach, CA
Stephen H. Hochschuler, MD
Cofounder and Chair
Texas Back Institute
Phoenix, AZ
Bruce Lindsay, MD
Professor of Medicine,
Director, Cardiac Electrophysiology
Washington University School
of Medicine
St. Louis, MO
The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own
local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted
for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource
Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained.
Reproduction in any form outside the recipients institution is forbidden without prior written permission. Copyright 2007 HCPro, Inc., Marblehead, MA 01945.
Beverly Pybus
Senior Consultant
The Greeley Company
a division of HCPro, Inc.
Marblehead, MA
Richard Sheff, MD
Chair and Executive Director
The Greeley Company,
a division of HCPro, Inc.
Marblehead, MA
Group Publisher:
Bob Croce,
bcroce@hcpro.com
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eniemeyer@comcast.net
Managing Editor:
Margot Suydam,
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