6 secrets of implementing ultrasound in pediatric emergency medicine

A Roadmap to Expediting Care, Improving Patient Safety and Reducing Costs

Ultrasound is an important tool for rapid assessment of trauma patients, central venous catheterization (CVC) placement, regional nerve block placement, facilitating difficult peripheral intravenous (PIV) access, and assessing cardiac function during resuscitations.Here are six strategies to help implement ultrasound at the bedside in a pediatric emergency medicine (PEM division), drawing on experience at the Ann & Robert H. Lurie Children's Hospital of Chicago.

Secret Number 1: Examine clinical and economic benefits of bedside ultrasound.

A sentinel case highlighted potential benefits of implementing ultrasound in our emergency department. A boy arrived by ambulance after being shot in the chest with a BB gun. An x-ray showed the pellet near the skin surface, suggesting a minor injury. Two hours later, a CT scan revealed a large pericardial effusion. The pellet had ricocheted off his heart, punching a hole in its lining--a potentially lethal injury.

Had ultrasound been available at the bedside, it could have detected the severity of the injury immediately, at a fraction of the cost of a CT scan, greatly accelerating the transfer to surgery. Ultrasound's ability to detect free fluid in the chest or abdomen is the basis of the FAST exam (focused assessment with sonography in trauma) widely used to rapidly evaluate trauma patients for internal injuries.2

Secret Number 2: Identify an Ultrasound Champion.

Our experience suggests that the ideal champion is a junior or midlevel faculty member. A faculty member provides enough credibility and positional power on institutional committees (such as trauma or radiology) to effectively advocate for using ultrasound to improve the safety and quality of PEM care. Another option is for PEM department leaders to collaborate with an ultrasound expert from another department, such as general emergency medicine, where ultrasound has well-established role.

Secret Number 3: Build the Right Support Team with physician leadership.

A 3-person team, comprised of the champion, a senior faculty member, and a fellow or junior faculty member, provides the critical mass to launch a culture supportive of ultrasound in PEM. To effectively guide decision-making as the program develops, the senior team member should have a leadership role within the division, such as the division or research director.

Secret Number 4: Network with Local Experts--and Launch an Ultrasound Program.

Our adult emergency medicine (EM) colleagues have long been adept at adopting ultrasound into their training curriculum and clinical use,3 making them an invaluable resource for PEM department leaders seeking a successful roadmap for building an ultrasound program. We began with 6 PEM fellows, who attended monthly workshops and received hands-on training at the bedside. Workshops were also started for all PEM attending physicians, faculty and pediatric critical care fellows.

Secret Number 5: Target High-Yield Ultrasound Applications First.

Starting with a few high-yield applications first, such as the FAST exam, provides early successes to build on. Other high-yield applications include:

Vascular access. In a recent pediatric study, 98% of CVC attempts were successful with ultrasound guidance, versus 79% without it.4 Ultrasound CVC guidance can reduce--or eliminate--such complications as pneumothorax, which can lengthen hospital stay by 4 to 7 days at an extra cost of up to $45,000.5

Evaluating skin and soft tissue infections. In pediatric studies, bedside ultrasound has a sensitivity of up to 97% for distinguishing cellulitis from abscess.6,7

Evaluating suspected appendicitis. For suspected appendicitis, American College of Radiology guidelines identify ultrasound as the "preferred" initial diagnostic test, with a sensitivity and specificity close to CT.8 In a recent meta-analysis using ultrasound first for appendicitis evaluation cost $88.30, versus $547 for CT.9

Secret Number 6: Share Success Stories to Help an Ultrasound Culture Take Root.

To accelerate adoption of bedside ultrasound, PEM department leaders and the core team should highlight the benefits of ultrasound mastery, such as error and cost reduction safer vascular access, and faster diagnoses. In the ED, being able to make an immediate diagnosis at bedside can literally mean the difference between life and death. These sentinel moments inspire PEM physicians to become ultrasound champions and deliver the safest care to the youngest, most vulnerable patients when they need it the most.

Author bio: Russ Horowitz MD, RDMS is Director, Emergency and Critical Care Ultrasound and an attending physician at Ann & Robert H. Lurie Children's Hospital of Chicago, where he received the 2014 Faculty Excellence in Education Award, Department of Pediatrics, Pediatrics Residency. He also serves as Assistant Professor in Pediatrics-Emergency at the Feinberg School of Medicine, Northwestern University.

1 Kim IK, Cross K, Horowitz R and Warkentine F. Eight Secrets to Implementing Bedside Ultrasonography in Pediatric Emergency Medicine. Clin Pediatr Emer Med 2011; 12 (1), 65-72
2 American Institute of Ultrasound in Medicine, American College of Emergency Physicians. AIUM practice guideline for the performance of the focused assessment with sonography for trauma (FAST) examination. J Ultrasound Med. 2014 Nov. 33 (11):2047-5
3 American College of Emergency Physicians. ACEP emergency ultrasound guidelines—2001. Ann Emerg Med 2001; 38:470-81.
4 Gallagher RA, Levy J, Vieira RL Ultrasound assistance for central venous catheter placement in a pediatric emergency department improves placement success rates. Acad Emerg Med. 2014 Sep;21(9):981-6.
5 Zhan C, M Smith and D Stryer. Incidences, Outcomes and Factors Associated with Iatrogenic Pneumothorax in Hospitalized Patients [abstract]. In: AcademyHealth Annual Research Meeting.; 2004; San Diego, Calif. Academy Health. 2004; 21: abstract no. 1862.
6 Marin JR, Bilker W, Lautenbach E, Alpern ER. Reliability of clinical examinations for pediatric skin and soft-tissue infections. Pediatrics. 2010;126(5): 925-930.
7 ivitz AB, Lam SH, Ramirez-Schrempp D, Valente JH, Nagdev AD. Effect of bedside ultrasound on management of pediatric soft-tissue infection. J Emerg Med. 2010;39(5):637-643.
8 Smith MP et al. ACR Appropriateness Criteria Right Lower Quadrant Pain—Suspected Appendicitis. 2013. Accessed at http://www.acr.org/~/media/7425a3e08975451eab571a316db4ca1b.pdf
9 Parker L, Nazarian LN et al. Cost and Radiation Savings of Partial Substitution of Ultrasound for CT in Appendicitis Evaluation: A National Projection. AJR Am J Roentgenol. 2014;202: 124-135.

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