Professor Bob Jarman, a consultant in emergency medicine, discusses how to develop a culture where ultrasound becomes the de factostandard in emergency care – providing an insight into the benefits and the barriers that need to be overcome.
Point-of-care (POC) ultrasound is now commonly used in emergency departments throughout the UK. These instruments provide valuable insight for the assessment of both trauma and non-trauma patients, as well as helping to guide procedures such as venous access, insertion of chest drains and aspiration of fluids from thoracic and abdominal cavities. But for many departments, the use of POC ultrasound is limited by a lack of training and poor instrument availability. The Great North Trauma and Emergency Centre – situated in the Newcastle upon Tyne Hospitals NHS Foundation Trust’s Royal Victoria Infirmary – has begun a long-term initiative to integrate ultrasound into its routine clinical practices, implementing a multi-system approach and broad training programme to maximise uptake of this technology.
The four key ultrasound skills that a junior doctor training in emergency medicine in the UK is required to learn are FAST scanning, aortic aneurysm screening, basic echocardiography and venous access. These are the day-in, day-out procedures performed up and down the country, but the list of potential applications for POC ultrasound in an emergency setting is virtually endless. As interest in this technology continues to grow, doctors are using ultrasound for an increasingly broad range of applications, from more advanced echocardiography and thoracic scanning to bladder volume scanning and looking for ocular problems. In some Trusts, ultrasound is becoming a routine part of assessing patients coming into the department.
There is a growing body of evidence showing that POC ultrasound is more specific and often more sensitive than traditional approaches for many emergency medicine applications, both for the assessment of patients and for the guidance of interventions. The key to increasing its use is creating a culture where ultrasound scanning is considered to be part of ‘normal’ patient assessment and management, rather than being an ad hoc diagnostic tool.
Historically there has been a misconception that clinicians using POC ultrasound were somehow trying to replace the radiologist. Fortunately, a lot of work has been done over the past few years to help people understand that ultrasound is an adjunct to clinical assessment and procedures, which often complements contemporary radiology practice. Doctors and allied healthcare professionals are far more focused in their use than sonographers; it is a tool, rather than a standalone investigation.
Breaking down barriers
Once this mindset is established within a Trust, the next task is to overcome the other major obstacles to ultrasound use – insufficient access to both training and equipment. The Great North Trauma and Emergency Centre (GNTEC) – the largest major trauma centre in the north of England – has recently embarked on a long-term programme to demonstrate the benefits of ultrasound to emergency medicine and acute care, pioneering a multisystem approach and a rolling training scheme designed to address these issues.
With the support of a major ultrasound instrument provider (Fujifilm SonoSite), the GNTEC currently has eight POC ultrasound systems in the department; two cartmounted, high-end instruments (X-Porte) for advanced scanning, two additional cartbased systems (S-FAST) for vascular access, and four pendant-mounted units (S-FAST) in the resus room. Careful consideration of how the systems would be used, as well as where to locate them to maximise access, was key at the outset of the project.
Each of the cart-mounted systems has a designated location when not in use to ensure staff do not waste precious time roaming the department looking for them, which might discourage use in a busy and stressful environment. The remaining systems were ‘fixed’ in the resus room, as this not only ensured that they were readily available to turn on and use, it also avoided having to bring a trolley into an already busy space.
Confidence is key
To develop a culture where ultrasound use becomes the de facto standard of care, it is vital to ensure that staff are not just sufficiently trained to be competent in ultrasound use, but are comfortable and familiar enough with the systems to use them routinely. As part of a major teaching hospital, the GNTEC already had many of the necessary training structures in place for junior doctors, but the availability of systems and experienced trainers has allowed ultrasound to be introduced at a much earlier stage of the clinical curriculum.
Increasing system availability has also been key to opening up ultrasound use to allied healthcare professionals, including nurses and paramedics. For example, many nurses at the GNTEC are now trained in basic practices, such as bladder volume scanning and vascular access. Although straightforward, many such basic ultrasound procedures are performed in huge numbers in a busy department, and the greater speed and efficiency offered by this technology can make a real difference to productivity.
Difficult venous access, for example, might previously have taken up to 45 minutes, occupying a lot of clinician time and requiring multiple attempts. This could be upsetting for patients, and extremely frustrating for already busy doctors. With POC ultrasound systems readily available, as soon as doctors anticipate that there might be a problem, they can use ultrasound guidance, ensuring the patient can be cannulated in five to 10 minutes in even the most complex cases. Patients are happier, because it improves the thoroughness of their care and avoids multiple needle-sticks, and staff love it because it makes their lives easier and helps to make the department more efficient.
Leading by example
One of the GNTEC’s main aims for the programme is to demonstrate – not just within the Trust, but nationally and internationally – the advantages of a multisystem approach to POC ultrasound. Gathering data on when and how the systems are being used is therefore essential, and a pro forma reporting tool has been created to allow every ultrasound scan to be documented. Making this process as quick and easy as possible is vital, both to ensure proper record keeping in a busy department and to avoid the risk of a laborious reporting process that might discourage ultrasound use. Gathering as much data as possible will enable the GNTEC to perform more comprehensive qualitative and quantitative research into the benefits of POC ultrasound, as well as allowing the department to participate in large-scale studies without taking up valuable clinician time.
The GNTEC is also taking advantage of the greater availability of equipment to provide additional education and training opportunities. By partnering with the Faculty of Medical Sciences at Newcastle University, the department has been able to set up a number of POC ultrasound-focused research projects, as well as developing an interest group within the faculty. This is not only leading to earlier exposure of undergraduate and post-graduate students to ultrasound techniques, it is also helping to attract research funding and collaborations. At a more senior level, the GNTEC is also developing an international fellowship scheme, providing the opportunity for clinicians from around the world to develop their ultrasound skills and see first-hand how a multisystem POC ultrasound strategy can benefit emergency care.
Laying the foundations
Developing an interest in ultrasound among junior doctors – even though they don’t usually learn ultrasound skills until later in their careers – is vital. These are the people who will shape medical practice for the next 20 years, so the possibilities of ultrasound need to be demonstrated at the earliest opportunity, and for most it is a real eye-opener. It is a work in progress, but getting the junior doctors and even medical students on board is what will drive POC ultrasound use forward.
Ultrasound is really revolutionising the patient experience and the time it takes to deliver appropriate care, and it is only by having rapid, widespread access to systems that Trusts can provide this level of service. Medicine isn’t black and white, so using ultrasound to see what is really going on should be encouraged, not just in emergency medicine, but across almost every specialty.
Professor Bob Jarman is a consultant in emergency medicine at the Great North Trauma and Emergency Centre, Royal Victoria Infirmary, Newcastle upon Tyne.
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