Point‐of‐care Ultrasonography by Pediatric Emergency Medicine Physicians

Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews. Point-of-care ultrasonography (US) is a bedside technology that enables clinicians to integrate clinical examination findings with real-time sonographic imaging. General emergency physicians and other specialists have used point-of-care US for many years, and more recently, pediatric emergency medicine (PEM) physicians have adopted point-of-care US as a diagnostic and procedural adjunct. This technical report and accompanying policy statement1 provide a framework for point-of-care US training and point-of-care US integration into pediatric care by PEM physicians. HISTORY OF EMERGENCY PHYSICIAN POINT-OF-CARE US In 1990, the American College of Emergency Physicians (ACEP) published a position statement supporting the performance of US by appropriately trained emergency physicians.2 The next year, the Society for Academic Emergency Medicine endorsed that statement and called for a training curriculum, which Mateer and colleagues published in 1994.3,4 By 1996, the published emergency medicine core content included point-of-care This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Technical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, technical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. www.pediatrics.org/cgi/doi/10.1542/peds.2015-0343 DOI: 10.1542/peds.2015-0343 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2015 by the American Academy of Pediatrics PEDIATRICS Volume 135, number 4, April 2015 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on August 16, 2018 www.aappublications.org/news Downloaded from US for residency graduates.5 With the passage of the American Medical Association Resolution 802 and policy H-230.960 in 1999, “recommending hospital [privileging] committees recognize specialty-specific guidelines for US credentialing decisions,”6 emergency physicians were given full responsibility for developing the guidelines of their field. By 2001, the Accreditation Council for Graduate Medical Education mandated that all emergency medicine residents attain competency in the use of pointof-care US,7 and the ACEP published the first emergency US guidelines.8 In 2008, the ACEP published an update to the original guidelines, thereby establishing the most comprehensive specialty-specific training and practice to date.9 Subsequently, the Society for Academic Emergency Medicine, the Council of Emergency Medicine Residency Directors, and the American Institute of Ultrasound in Medicine officially recognized that document.10,11 Currently, guidelines from the Council of Emergency Medicine Residency Directors consensus documents from 2009 and 2012 are a mainstay for residency education.10,12 In addition, competency assessment tools for the evaluation of emergency medicine residents are being considered.12 POINT-OF-CARE US IN PEDIATRIC EMERGENCY MEDICINE More recently, PEM physicians have been using point-of-care US for patient care. According to a survey from 2011, 95% of emergency departments (EDs) with a PEM fellowship program use point-of-care US in some manner, and 88% of programs provide training in pointof-care US for their fellows.13 This is a dramatic increase, because only 57% of programs reported the use of point-of-care US in 2006, and only 65% at that time incorporated training for their fellows.14 Despite the growing use of point-of-care US by pediatric emergency physicians, there have been no published guidelines specific to pediatric emergency providers. The indications set forth in existing policy statements are written for emergency physicians who predominantly care for adult patients. DIAGNOSTIC AND PROCEDURAL INDICATIONS To date, numerous diagnostic and procedural applications for point-ofcare US have been described. The literature supports the ability of general emergency physicians to use point-of-care US to improve the care of adult patients by accurately diagnosing time-sensitive and common ED conditions,15–38 decreasing patient lengths of stay,15,39–41 and reducing complications.15,42–45 Furthermore, emergency physicians are able to achieve competency in performing point-of-care US for various indications after completing adequate training.20,26,46–48 Point-of-care US in pediatric patients by PEM providers has recently been adopted into practice, and the literature is still evolving. Nonetheless, there are numerous studies demonstrating the accuracy of point-of-care US by PEM physicians49–58 and the ability of PEM physicians to become proficient in point-of-care US after adequate training.55,56,59 Although the point-ofcare US examinations performed should be specific to the needs of the department, the most common indications for which point-of-care US is being used in PEM are for focused assessment with sonography in trauma, soft tissue evaluation, and vascular access.13 Physicians should be aware that examinations in children and adolescents with disabilities and chronic medical problems may be more challenging to perform and integrate. As always, interpretations should be made carefully in the context of the clinical scenario (eg, the focused assessment with sonography in trauma examination may demonstrate free peritoneal fluid at baseline in a patient with a ventriculoperitoneal shunt). DEVELOPMENT OF A POINT-OF-CARE US PROGRAM The development of a point-of-care US program begins with a clinical need for these services. It is not necessary that all relevant applications be introduced at the same time. In fact, it is most effective to identify the applications that will be the most important in emergent scenarios or most commonly used. The program may then be extended as PEM physicians become more proficient. Point-of-care US has become more prevalent in medicine,60 and consequently more physicians are using this bedside technology. Preparing the workforce of the future for point-of-care US means embedding training strategies in the infrastructure of residency and fellowship training. Point-of-Care US Leadership A point-of-care US director or core group of leaders is established to facilitate and manage the educational and administrative tasks of coordinating a point-of-care US program within a division or department. Overall, responsibilities for developing a program include education for the clinician operators and administrative processes and procedures for credentialing and quality assurance (QA). The point-of-care US director (or several directors) has significant US experience encompassing the breadth of pediatric point-of-care US applications. As more PEM point-of-care US fellowships become available, it is likely that US directors will be fellowshiptrained. The director works with the departmental leaders to define a vision and goals for the program. These include equipment accrual, e1114 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on August 16, 2018 www.aappublications.org/news Downloaded from training guideline development, QA program development, payment strategies, workflow solution implementation for image storage, and creation of credentialing and privileging documents.