- Email: [email protected]
355
Research Forum Abstracts there was no change in operative or medical treatment rates for these ectopic patients [Operative therapy: 8/30 (27%) modified vs 16/44 (36)% original; Medical therapy: 19/30 (63%) modified vs 25/44 (57%) original, p⫽0.66]. Conclusion: A modified CMC pregnancy ultrasound protocol with selective Gyn consultation can be used safely with no increase in rates of delayed operative ectopic pregnancies derived from initial indeterminate sonographic classification.
354
The Use of Emergency Department Bedside Ultrasound to Determine the Correlation Between Increased Intracranial Pressure and the Optic Nerve Sheath Diameter
Larson J, Fox JC, Lulloff L, Arcila M, Neches E/University of California, Irvine Medical Center, Orange, CA
Study Objective: The objective of this research study is to determine if emergency department (ED) physicians can use bedside ultrasound (BUS) to accurately diagnose elevated intracranial pressure (ICP). Bedside ultrasound does not expose patients to the radiation that a Computed Tomography (CT) scan does, and is a quicker and less expensive alternative for the diagnosis of elevated ICP. There have been previous studies conducted that show a correlation between elevated ICP and an increase in the size of the optic nerve sheath diameter (ONSD); however, only a limited amount of research has been performed in which BUS is used to determine the ONSD. Methods: In this study BUS was used to measure the diameter of the optic nerve sheath. The BUS results were then compared to the head CT scan results to determine whether a correlation was evident between the BUS scan and any elevated ICP findings from the head CT scan. ED physicians were unaware of the head CT scan results, and radiology physicians were unaware of the BUS scan results in order to eliminate any biases that may result. Results: Both BUS and head CT scans suggest that a patient with an ONSD greater than 5.1mm may have elevated ICP. 100 patients met the study’s inclusion criteria. The study results determined that the mean ONSD of the left and right eyes were 4.7869mm (Standard Deviation [SD] 1.1779) and 4.7364mm (SD 1.2381) respectively. Five of the study’s patients were found to have elevated ICP, and the mean ONSD of their left and right eyes were 5.08mm (SD 1.3554) and 5.12mm (SD 0.8349) respectively. Conclusion: The results from this research study are ongoing, as not enough patients have been enrolled to positively conclude whether or not the measurement of the ONSD by use of BUS can be an effective modality in the diagnosis of elevated ICP.
355
Revenue Capture in an Emergency Medicine Ultrasound Program: A Pilot Study
Nelson BP, Baumlin K/Mount Sinai School of Medicine, New York, NY
Study Objectives: Although national precedent for EM bedside ultrasound (US) billing was established prior to publication of ACEP’s US Guidelines in 2001, political and financial challenges continue to plague EM US programs. Many programs face similar financial obstacles at startup, yet there is no common method of analysis employed to assess the financial viability of a new program. This pilot study was designed to test a revenue model for an EM US program. Parameters included testing an electronic procedure template system, assessment of charge capture, and return on investment (ROI). Methods: Prior to the program inception, ROI analysis was performed. The analysis was based on average charges per scan, a 70% charge capture rate, a 30% payer reimbursement rate, and $60,000 capital investment. After review of the ROI, a prospective, consecutive, convenience sample study was undertaken in an urban academic ED (annual census 75,000). US documentation was tracked using the ED electronic charting system (IBEX; Picis, Inc. Wakefield, MA). IBEX incorporates documentation templates with embedded facility charge-capture functionality for diagnostic US. An US-credentialed physician independently logged all cardiac, abdominal, and obstetric ultrasounds (DxUS) performed, as well as ultrasounds used to guide vascular access and needle placement for nonvascular procedures (PrUS). These logs were compared to gross charge data generated by our ED faculty practice (FPA) coding company (charge capture via chart review), and charges generated by the facility (charge capture via automated electronic templates). Results: ROI analysis assumed each credentialed attending could generate 180 scans per year. Combining FPA and facility revenue, the initial capital
S106 Annals of Emergency Medicine
investment could be recouped in 13 months with only two credentialed faculty. Post-piloting our US program (during the six month study period), a single credentialed physician documented performance of 65 (41 DxUS and 24 PrUS) scans. Facility billing data revealed that 35 (85.4%) of the templated DxUS and zero (0%) of the non-templated PrUS were billed. The FPA data revealed that chart review methodology generated 23 (56.1%) DxUS and eight (19.5%) PrUS. These numbers improved to 30 (73.1%) for DxUS and 17 (70.1%) for PrUS after the credentialed physician submitted the independently recorded patient list to the practice coders. The six month total charges generated for the FPA totaled $5752; facility charges totaled $17,780. Our current collection rate is 21%; thus our total annualized net revenue for a single provider would be $9883. Conclusion: ROI analysis is valuable in assessing the economic feasibility of ultrasound program startup. Our data suggest that four credentialed US providers can generate enough revenue to cover an 18 month ROI. Electronic templates with charge-capture functionality appear to enhance charge generation.
356
The Utility of Handheld Ultrasound Evaluation in an Austere Medical Setting After a Natural Disaster
Dean AJ, Zeserson EM, Ku BS/Hospital of the University of Pennsylvania, Philadelphia, PA
Study Objectives: This is a report of the utility, applications, and sonographic findings of all patients who presented for care to a local emergency department and hospital over a 2-week period after a major natural disaster with complaints warranting ultrasound (US) evaluation. The utility of US after natural disasters and in austere medical settings is not well known. Methods: A medical relief team consisting of 3 emergency physicians went to Santiago Atitlan in the western highlands of Guatemala 3 weeks after mudslides caused by Hurricane Stan in October 2005 destroyed an entire village. They recorded the uses of a handheld ultrasound device in the evaluation and diagnosis of victims of the disaster. A Sonosite Micromaxx US machine with 4 probes [curved array 25MHz, linear array 5-10MHz, phased array 1-5MHz, endocavitary 5-8MHz] was used. Patients in the hospital ED, ambulatory clinic and inpatient beds received US from experienced emergency physician ultrasonographers. The type of ultrasound scan performed, the acuity of presenting symptoms and urgency of treatment mandated by ultrasound findings were recorded. Results: In 9 days 99 patients received 139 US of various bodily regions: 58 pelvic (58 transabdominal, 6 transvaginal), 34 right upper quadrant, 23 renal, 6 other abdominal, 7 cardiac and aorta, 3 pleura and lung, 3 soft tissue, 1 FAST. Acuity of symptoms were as follows: 23% ⬍ 24 hours, 15% 1-14days, 44%⬎ 14d. 18% were performed in prenatal clinic. Results of US ruled in 6% of cases with an emergent problem, and ruled out disease in 42%. In 14% US diagnosed a problem needing f/u in ⬍ 2 weeks, 38% with a problem requiring long term observation. The frequency of probe utilization was as follows during the study period: general curved array: 83, linear 10, endocavitary 8, phased array: 4. Conclusion: Handheld US provided a wide variety of information in a short period of time in an austere setting in Guatemala after a natural disaster.
357
Evaluating Competency of Emergency Physicians at Pelvic Ultrasound After Implementation of an Ultrasound Credentialing Process
Colla JS, Lindsell CJ, Moak JH/University of Cincinnati, Cincinnati, OH
Study Objectives:We set out to determine the sensitivities of emergency physicians at identifying abnormal pregnancies by pelvic ultrasound after a credentialing process which included the minimal numerical goals proposed by the 2001 ACEP position statement on emergency ultrasound. Methods: An ultrasound credentialing process for emergency physicians began at our institution in May 2005 which included a combined didactic and practical training experience. Ultrasound scans performed in the ED were routinely recorded. Unsupervised scans performed by residents or attendings who had met their numerical goals were included in this study and were correct or incorrect based upon formal scan, OBGYN consultation or evidence of subsequent delivery abstracted from the medical record. Uncorroborated scans were excluded. Results: 89 pelvic ultrasounds were performed during 65 patient encounters by emergency physicians who had met their numerical goals. 3 exams were excluded for missing documentation. There were no formal confirmation found for 7 scans, 1 patient walked out and 1 had evidence of pregnancy 4 weeks after original scan. Out
Volume , . : October
354
The Use of Emergency Department Bedside Ultrasound to Determine the Correlation Between Increased Intracranial Pressure and the Optic Nerve Sheath Diameter
Larson J, Fox JC, Lulloff L, Arcila M, Neches E/University of California, Irvine Medical Center, Orange, CA
Study Objective: The objective of this research study is to determine if emergency department (ED) physicians can use bedside ultrasound (BUS) to accurately diagnose elevated intracranial pressure (ICP). Bedside ultrasound does not expose patients to the radiation that a Computed Tomography (CT) scan does, and is a quicker and less expensive alternative for the diagnosis of elevated ICP. There have been previous studies conducted that show a correlation between elevated ICP and an increase in the size of the optic nerve sheath diameter (ONSD); however, only a limited amount of research has been performed in which BUS is used to determine the ONSD. Methods: In this study BUS was used to measure the diameter of the optic nerve sheath. The BUS results were then compared to the head CT scan results to determine whether a correlation was evident between the BUS scan and any elevated ICP findings from the head CT scan. ED physicians were unaware of the head CT scan results, and radiology physicians were unaware of the BUS scan results in order to eliminate any biases that may result. Results: Both BUS and head CT scans suggest that a patient with an ONSD greater than 5.1mm may have elevated ICP. 100 patients met the study’s inclusion criteria. The study results determined that the mean ONSD of the left and right eyes were 4.7869mm (Standard Deviation [SD] 1.1779) and 4.7364mm (SD 1.2381) respectively. Five of the study’s patients were found to have elevated ICP, and the mean ONSD of their left and right eyes were 5.08mm (SD 1.3554) and 5.12mm (SD 0.8349) respectively. Conclusion: The results from this research study are ongoing, as not enough patients have been enrolled to positively conclude whether or not the measurement of the ONSD by use of BUS can be an effective modality in the diagnosis of elevated ICP.
355
Revenue Capture in an Emergency Medicine Ultrasound Program: A Pilot Study
Nelson BP, Baumlin K/Mount Sinai School of Medicine, New York, NY
Study Objectives: Although national precedent for EM bedside ultrasound (US) billing was established prior to publication of ACEP’s US Guidelines in 2001, political and financial challenges continue to plague EM US programs. Many programs face similar financial obstacles at startup, yet there is no common method of analysis employed to assess the financial viability of a new program. This pilot study was designed to test a revenue model for an EM US program. Parameters included testing an electronic procedure template system, assessment of charge capture, and return on investment (ROI). Methods: Prior to the program inception, ROI analysis was performed. The analysis was based on average charges per scan, a 70% charge capture rate, a 30% payer reimbursement rate, and $60,000 capital investment. After review of the ROI, a prospective, consecutive, convenience sample study was undertaken in an urban academic ED (annual census 75,000). US documentation was tracked using the ED electronic charting system (IBEX; Picis, Inc. Wakefield, MA). IBEX incorporates documentation templates with embedded facility charge-capture functionality for diagnostic US. An US-credentialed physician independently logged all cardiac, abdominal, and obstetric ultrasounds (DxUS) performed, as well as ultrasounds used to guide vascular access and needle placement for nonvascular procedures (PrUS). These logs were compared to gross charge data generated by our ED faculty practice (FPA) coding company (charge capture via chart review), and charges generated by the facility (charge capture via automated electronic templates). Results: ROI analysis assumed each credentialed attending could generate 180 scans per year. Combining FPA and facility revenue, the initial capital
S106 Annals of Emergency Medicine
investment could be recouped in 13 months with only two credentialed faculty. Post-piloting our US program (during the six month study period), a single credentialed physician documented performance of 65 (41 DxUS and 24 PrUS) scans. Facility billing data revealed that 35 (85.4%) of the templated DxUS and zero (0%) of the non-templated PrUS were billed. The FPA data revealed that chart review methodology generated 23 (56.1%) DxUS and eight (19.5%) PrUS. These numbers improved to 30 (73.1%) for DxUS and 17 (70.1%) for PrUS after the credentialed physician submitted the independently recorded patient list to the practice coders. The six month total charges generated for the FPA totaled $5752; facility charges totaled $17,780. Our current collection rate is 21%; thus our total annualized net revenue for a single provider would be $9883. Conclusion: ROI analysis is valuable in assessing the economic feasibility of ultrasound program startup. Our data suggest that four credentialed US providers can generate enough revenue to cover an 18 month ROI. Electronic templates with charge-capture functionality appear to enhance charge generation.
356
The Utility of Handheld Ultrasound Evaluation in an Austere Medical Setting After a Natural Disaster
Dean AJ, Zeserson EM, Ku BS/Hospital of the University of Pennsylvania, Philadelphia, PA
Study Objectives: This is a report of the utility, applications, and sonographic findings of all patients who presented for care to a local emergency department and hospital over a 2-week period after a major natural disaster with complaints warranting ultrasound (US) evaluation. The utility of US after natural disasters and in austere medical settings is not well known. Methods: A medical relief team consisting of 3 emergency physicians went to Santiago Atitlan in the western highlands of Guatemala 3 weeks after mudslides caused by Hurricane Stan in October 2005 destroyed an entire village. They recorded the uses of a handheld ultrasound device in the evaluation and diagnosis of victims of the disaster. A Sonosite Micromaxx US machine with 4 probes [curved array 25MHz, linear array 5-10MHz, phased array 1-5MHz, endocavitary 5-8MHz] was used. Patients in the hospital ED, ambulatory clinic and inpatient beds received US from experienced emergency physician ultrasonographers. The type of ultrasound scan performed, the acuity of presenting symptoms and urgency of treatment mandated by ultrasound findings were recorded. Results: In 9 days 99 patients received 139 US of various bodily regions: 58 pelvic (58 transabdominal, 6 transvaginal), 34 right upper quadrant, 23 renal, 6 other abdominal, 7 cardiac and aorta, 3 pleura and lung, 3 soft tissue, 1 FAST. Acuity of symptoms were as follows: 23% ⬍ 24 hours, 15% 1-14days, 44%⬎ 14d. 18% were performed in prenatal clinic. Results of US ruled in 6% of cases with an emergent problem, and ruled out disease in 42%. In 14% US diagnosed a problem needing f/u in ⬍ 2 weeks, 38% with a problem requiring long term observation. The frequency of probe utilization was as follows during the study period: general curved array: 83, linear 10, endocavitary 8, phased array: 4. Conclusion: Handheld US provided a wide variety of information in a short period of time in an austere setting in Guatemala after a natural disaster.
357
Evaluating Competency of Emergency Physicians at Pelvic Ultrasound After Implementation of an Ultrasound Credentialing Process
Colla JS, Lindsell CJ, Moak JH/University of Cincinnati, Cincinnati, OH
Study Objectives:We set out to determine the sensitivities of emergency physicians at identifying abnormal pregnancies by pelvic ultrasound after a credentialing process which included the minimal numerical goals proposed by the 2001 ACEP position statement on emergency ultrasound. Methods: An ultrasound credentialing process for emergency physicians began at our institution in May 2005 which included a combined didactic and practical training experience. Ultrasound scans performed in the ED were routinely recorded. Unsupervised scans performed by residents or attendings who had met their numerical goals were included in this study and were correct or incorrect based upon formal scan, OBGYN consultation or evidence of subsequent delivery abstracted from the medical record. Uncorroborated scans were excluded. Results: 89 pelvic ultrasounds were performed during 65 patient encounters by emergency physicians who had met their numerical goals. 3 exams were excluded for missing documentation. There were no formal confirmation found for 7 scans, 1 patient walked out and 1 had evidence of pregnancy 4 weeks after original scan. Out
Volume , . : October