- Email: [email protected]
Comparison of Two Transducer Types for Teaching Ultrasound-Guided Vascular Access to Novice Users on a Standard Vascular Access Model in Linear Axis
Research Forum Abstracts with an expected agreement of 48.7%. Kappa statistic was calculated to be 0.3 (95% CI 0.1 to 0.5). Conclusion: Thoracic ultrasound in the detection of pleural edema as compared to CXR did not perform as well as previously suggested with only a fair agreement between US and CXR.
66
Effect of Performing but Not Billing for Emergency Ultrasound on Emergency Department Reimbursement
Gaspari RJ, Dickman E, University of Massachusetts Medical School, Worcester, MA
Study Objectives: To determine the effect of emergency ultrasound on reimbursement when not billed as a separate procedure. Methods: Prospective, single blinded trial at a single emergency department (ED) with an annual census of 75,000 patients. Patients were eligible for the study if they had a bedside ultrasound performed during their visit to the ED. Patients were enrolled in sequential fashion during randomly selected time blocks. Ultrasound results were recorded in the patients chart. Charts were coded in a sequential blinded fashion by ED coding staff with and without ultrasound results according to standard hospital coding practices. A comparison of the coding revenue for each pair of charts (with and without ultrasound results) was performed using a one sample t test (http://www.statistics.com). Results: A total of 74 patients were enrolled generating 148 charts for coding and billing. There were 12 different ultrasounds protocols performed including focused assessment sonography of trauma (FAST), gallbladder, aorta, ocular, vascular, cardiac, and others. The most common ultrasound that increased the E&M level was the FAST exam (12 of 23, 52%). 37.8% of the patient charts showed an increase in at least 1 E&M level, with an average increase of $163.75 (95% CI ÿ113.24 to 214.26) per effected chart. Conclusion: Using bedside ultrasound increases overall coding and billing revenue independent of billing for the procedure.
68
Jansen N, Mencl F, OLVG, Amsterdam, Netherlands
Study Objectives: Previous reports have suggested that ultrasound is useful in detection of soft tissue foreign bodies, but most are case reports and few report on the teaching or learning of the technique. Our objective was to determine if a brief introductory talk is adequate to teach emergency medicine residents how to use ultrasound to locate foreign bodies using a chicken-leg model. Methods: We enrolled 21 emergency medicine residents during a one-day introductory ultrasound course, which focused on FAST, vascular access and AAA scanning. A 10 minute talk, with images, was given describing the use of ultrasound for foreign body localization. We made two 5 mm long incisions to a depth of 1 cm in each of two chicken legs, for a total of 4 cuts, and randomly placed one of 3 foreign bodies: toothpick, plastic bead (2 mm x 1cm) or paperclip (1 mm x 1 cm) into 3 incisions. The 4th incision was left empty. Six pairs of chicken legs were prepared, allowing simultaneous scanning. Each study subject had 15 minutes to scan one pair of chicken legs (4 incisions) with a small, linear, high frequency transducer using either a Sonosite Elite or Phillips HD11 scanner. Results: Residents correctly identified the presence, or absence, of a foreign body in 61/84 (72.6%) cases. 20/63 (32%) incisions were wrongly identified as empty and 3/21 (14%) as containing a foreign body. Wooden foreign bodies were most easily found (18/21). Metal was found in 16/21 and plastic was the most difficult to find (9/21). Those (11/21) with some prior experience using ultrasound, were more likely to correctly identify the absence or presence of a foreign body (35/44, 80%). The residents with no experience were correct in only 26/40 (65%) cases. In addition, the 13 residents who scanned in the afternoon were more likely to identify the presence or absence of a foreign body (40/52, 77%) than those (8) scanning earlier in the day (21/32, 66%). Conclusion: emergency medicine residents need more training than one introductory talk to correctly identify the presence or absence of foreign bodies in the soft tissues. Those with some prior experience as well as those that tested later in the day, after spending more time being exposed to other ultrasound applications, did better.
69 67
Replacing a Cart-Based Ultrasound System with a Compact System Increases Emergency Bedside Ultrasound Use and User Confidence
Leech SJ, Sierzenski PR, Gukhool JA, O’Connor RE, Christiana Care Health System, Newark, DE
Study Objectives: With technology improvements, ultrasound systems are becoming more compact and user-friendly. The impact of such systems on existing ultrasound programs (UP) has not been defined. We sought to determine the change in user practices and emergency ultrasound (EUS) utilization rates (UR) when a compact ultrasound system (COMP) was substituted for a cart-based ultrasound system (CART). Users provided feedback on comparing COMP vs. CART on several key US system qualities. Methods: This was a retrospective review of the EUS logs at an inner-city hospital ED with an annual census of 50,000 visits. A UP has been in place since 7/00, with a dedicated CART. In 6/04, a COMP replaced a CART. The EUS logs were reviewed for the period of 6 and 12 months (mo) prior to the introduction of COMP, and for the 6 mo after COMP for total EUS use and monthly UR. Users rated both EUS systems on image quality (IQ), ease of use (EU), portability (PY), and their confidence in using each system (CF) on 10-cm visual analog scales. 95% CI and Student’s t-test were performed. Results: The total EUS performed during the 6 and 12 mo of CART and 6 mo of COMP were 237, 545, and 431, respectively. The UR in the 6 and 12 mo with CART was 39.5 US/mo (95% CI 32.7 to 46.2) and 45.4 US/mo (95% CI 35.8 to 52.0), and in the 6 mo after with COMP was 71.8 US/mo (95% CI 58.1 to 85.6) (p=0.003 and 0.015 respectively). System qualities were rated by 36 users. User scores: IQ-COMP 7.2 (95% CI 6.8 to 7.6) IQ-CART 7.3 (95% CI 6.8 to 7.8) p=0.94, EU-COMP 8.0 (95% CI 7.6 to 8.4) EU-CART 4.8 (95% CI 4.1 to 5.6) p\0.01, PY-COMP 8.7 (95% CI 8.4 to 9.0) PY-CART 2.9 (95% CI 2.1 to 3.7) p\0.01, CF-COMP 7.1 (95% CI 6.5 to 7.7) CF-CART 5.6 (95% CI 4.9 to 6.4) p=0.01. Conclusion: The introduction of compact ultrasound system significantly increased bedside ultrasound use when compared with the previous 6 and 12 months when a cart-based system was available. Users rated the ease of use, portability, and user confidence of the compact ultrasound system significantly better, while image quality was not rated significantly different between a compact ultrasound system and a cart-based sysytem.
Volume 46, no. 3 : September 2005
Learning Ultrasound for Detection of Soft Tissue Foreign Bodies: How Difficult?
Comparison of Two Transducer Types for Teaching Ultrasound-Guided Vascular Access to Novice Users on a Standard Vascular Access Model in Linear Axis
Goldstein JR, Jones RA, Emerman CL, Cydulka RK, MetroHealth Medical Center, Cleveland, OH; MetroHealth Hospital, Cleveland, OH
Study Objectives: The study objective was to determine if there is a difference in difficulty experienced by novice ultrasound users in obtaining vascular access using a high frequency linear and curvilinear transducer in linear axis. Difficulty was assessed by comparing the time to successful cannulation, number of skin penetrations and needle redirections, and participants’ perceived level of difficulty. Methods: The study population was a convenience sample of fourth-year medical students, emergency medicine residents, attendings, and nurses, and off-service residents rotating in the emergency department (ED) who had performed less than three ultrasound-guided vascular access procedures. The study took place in the ED educational offices. Subjects watched a twenty-minute tutorial video on ultrasoundguided vascular access. A Blue PhantomÒ model of peripheral vessels was used to simulate peripheral venous access. Subjects were instructed to find the preferred vein in short axis, rotate to long axis, and obtain access in long axis under direct ultrasoundguidance. Subjects used SonoSiteÒ L38 5-10 MHz linear and SonoSiteÒ C11 4-7 MHz curvilinear transducers. An experienced emergency physician ultrasonographer recorded time to successful cannulation and number of skin breaks and needle redirects. Subjects rated perceived difficulty level on a 10-point Likert scale. Results: Twenty-four subjects were enrolled in the study using a pseudorandomization scheme. Time to cannulation and perceived difficulty data were analyzed with ANOVA and regression analysis with p value \0.05 considered statistically significant. Skin breaks and redirects were analyzed using negative binomial regression. The difference between the number of skin breaks and redirects between the linear and curvilinear transducers was statistically significant (p=0.002, p=0.049). The difference in perceived difficulty between the linear (mean=4.3) and curvilinear (mean=3.2) transducer was statistically significant (p=0.04). The difference in time to cannulation with the linear (mean=86 seconds) and curvilinear transducers (mean=68 seconds) was not statistically significant. Transducer sequence did not statistically significantly affect time to cannulation, perceived difficulty, number of skin breaks and number of redirects. Conclusions: Novice ultrasound users found the curvilinear transducer easier to use for simulated vascular access in the long axis. Studies utilizing patients and more experienced ultrasonographers could determine whether this difference amounts to meaningfully shorter times to cannulation and more successful first attempts.
Annals of Emergency Medicine S21
66
Effect of Performing but Not Billing for Emergency Ultrasound on Emergency Department Reimbursement
Gaspari RJ, Dickman E, University of Massachusetts Medical School, Worcester, MA
Study Objectives: To determine the effect of emergency ultrasound on reimbursement when not billed as a separate procedure. Methods: Prospective, single blinded trial at a single emergency department (ED) with an annual census of 75,000 patients. Patients were eligible for the study if they had a bedside ultrasound performed during their visit to the ED. Patients were enrolled in sequential fashion during randomly selected time blocks. Ultrasound results were recorded in the patients chart. Charts were coded in a sequential blinded fashion by ED coding staff with and without ultrasound results according to standard hospital coding practices. A comparison of the coding revenue for each pair of charts (with and without ultrasound results) was performed using a one sample t test (http://www.statistics.com). Results: A total of 74 patients were enrolled generating 148 charts for coding and billing. There were 12 different ultrasounds protocols performed including focused assessment sonography of trauma (FAST), gallbladder, aorta, ocular, vascular, cardiac, and others. The most common ultrasound that increased the E&M level was the FAST exam (12 of 23, 52%). 37.8% of the patient charts showed an increase in at least 1 E&M level, with an average increase of $163.75 (95% CI ÿ113.24 to 214.26) per effected chart. Conclusion: Using bedside ultrasound increases overall coding and billing revenue independent of billing for the procedure.
68
Jansen N, Mencl F, OLVG, Amsterdam, Netherlands
Study Objectives: Previous reports have suggested that ultrasound is useful in detection of soft tissue foreign bodies, but most are case reports and few report on the teaching or learning of the technique. Our objective was to determine if a brief introductory talk is adequate to teach emergency medicine residents how to use ultrasound to locate foreign bodies using a chicken-leg model. Methods: We enrolled 21 emergency medicine residents during a one-day introductory ultrasound course, which focused on FAST, vascular access and AAA scanning. A 10 minute talk, with images, was given describing the use of ultrasound for foreign body localization. We made two 5 mm long incisions to a depth of 1 cm in each of two chicken legs, for a total of 4 cuts, and randomly placed one of 3 foreign bodies: toothpick, plastic bead (2 mm x 1cm) or paperclip (1 mm x 1 cm) into 3 incisions. The 4th incision was left empty. Six pairs of chicken legs were prepared, allowing simultaneous scanning. Each study subject had 15 minutes to scan one pair of chicken legs (4 incisions) with a small, linear, high frequency transducer using either a Sonosite Elite or Phillips HD11 scanner. Results: Residents correctly identified the presence, or absence, of a foreign body in 61/84 (72.6%) cases. 20/63 (32%) incisions were wrongly identified as empty and 3/21 (14%) as containing a foreign body. Wooden foreign bodies were most easily found (18/21). Metal was found in 16/21 and plastic was the most difficult to find (9/21). Those (11/21) with some prior experience using ultrasound, were more likely to correctly identify the absence or presence of a foreign body (35/44, 80%). The residents with no experience were correct in only 26/40 (65%) cases. In addition, the 13 residents who scanned in the afternoon were more likely to identify the presence or absence of a foreign body (40/52, 77%) than those (8) scanning earlier in the day (21/32, 66%). Conclusion: emergency medicine residents need more training than one introductory talk to correctly identify the presence or absence of foreign bodies in the soft tissues. Those with some prior experience as well as those that tested later in the day, after spending more time being exposed to other ultrasound applications, did better.
69 67
Replacing a Cart-Based Ultrasound System with a Compact System Increases Emergency Bedside Ultrasound Use and User Confidence
Leech SJ, Sierzenski PR, Gukhool JA, O’Connor RE, Christiana Care Health System, Newark, DE
Study Objectives: With technology improvements, ultrasound systems are becoming more compact and user-friendly. The impact of such systems on existing ultrasound programs (UP) has not been defined. We sought to determine the change in user practices and emergency ultrasound (EUS) utilization rates (UR) when a compact ultrasound system (COMP) was substituted for a cart-based ultrasound system (CART). Users provided feedback on comparing COMP vs. CART on several key US system qualities. Methods: This was a retrospective review of the EUS logs at an inner-city hospital ED with an annual census of 50,000 visits. A UP has been in place since 7/00, with a dedicated CART. In 6/04, a COMP replaced a CART. The EUS logs were reviewed for the period of 6 and 12 months (mo) prior to the introduction of COMP, and for the 6 mo after COMP for total EUS use and monthly UR. Users rated both EUS systems on image quality (IQ), ease of use (EU), portability (PY), and their confidence in using each system (CF) on 10-cm visual analog scales. 95% CI and Student’s t-test were performed. Results: The total EUS performed during the 6 and 12 mo of CART and 6 mo of COMP were 237, 545, and 431, respectively. The UR in the 6 and 12 mo with CART was 39.5 US/mo (95% CI 32.7 to 46.2) and 45.4 US/mo (95% CI 35.8 to 52.0), and in the 6 mo after with COMP was 71.8 US/mo (95% CI 58.1 to 85.6) (p=0.003 and 0.015 respectively). System qualities were rated by 36 users. User scores: IQ-COMP 7.2 (95% CI 6.8 to 7.6) IQ-CART 7.3 (95% CI 6.8 to 7.8) p=0.94, EU-COMP 8.0 (95% CI 7.6 to 8.4) EU-CART 4.8 (95% CI 4.1 to 5.6) p\0.01, PY-COMP 8.7 (95% CI 8.4 to 9.0) PY-CART 2.9 (95% CI 2.1 to 3.7) p\0.01, CF-COMP 7.1 (95% CI 6.5 to 7.7) CF-CART 5.6 (95% CI 4.9 to 6.4) p=0.01. Conclusion: The introduction of compact ultrasound system significantly increased bedside ultrasound use when compared with the previous 6 and 12 months when a cart-based system was available. Users rated the ease of use, portability, and user confidence of the compact ultrasound system significantly better, while image quality was not rated significantly different between a compact ultrasound system and a cart-based sysytem.
Volume 46, no. 3 : September 2005
Learning Ultrasound for Detection of Soft Tissue Foreign Bodies: How Difficult?
Comparison of Two Transducer Types for Teaching Ultrasound-Guided Vascular Access to Novice Users on a Standard Vascular Access Model in Linear Axis
Goldstein JR, Jones RA, Emerman CL, Cydulka RK, MetroHealth Medical Center, Cleveland, OH; MetroHealth Hospital, Cleveland, OH
Study Objectives: The study objective was to determine if there is a difference in difficulty experienced by novice ultrasound users in obtaining vascular access using a high frequency linear and curvilinear transducer in linear axis. Difficulty was assessed by comparing the time to successful cannulation, number of skin penetrations and needle redirections, and participants’ perceived level of difficulty. Methods: The study population was a convenience sample of fourth-year medical students, emergency medicine residents, attendings, and nurses, and off-service residents rotating in the emergency department (ED) who had performed less than three ultrasound-guided vascular access procedures. The study took place in the ED educational offices. Subjects watched a twenty-minute tutorial video on ultrasoundguided vascular access. A Blue PhantomÒ model of peripheral vessels was used to simulate peripheral venous access. Subjects were instructed to find the preferred vein in short axis, rotate to long axis, and obtain access in long axis under direct ultrasoundguidance. Subjects used SonoSiteÒ L38 5-10 MHz linear and SonoSiteÒ C11 4-7 MHz curvilinear transducers. An experienced emergency physician ultrasonographer recorded time to successful cannulation and number of skin breaks and needle redirects. Subjects rated perceived difficulty level on a 10-point Likert scale. Results: Twenty-four subjects were enrolled in the study using a pseudorandomization scheme. Time to cannulation and perceived difficulty data were analyzed with ANOVA and regression analysis with p value \0.05 considered statistically significant. Skin breaks and redirects were analyzed using negative binomial regression. The difference between the number of skin breaks and redirects between the linear and curvilinear transducers was statistically significant (p=0.002, p=0.049). The difference in perceived difficulty between the linear (mean=4.3) and curvilinear (mean=3.2) transducer was statistically significant (p=0.04). The difference in time to cannulation with the linear (mean=86 seconds) and curvilinear transducers (mean=68 seconds) was not statistically significant. Transducer sequence did not statistically significantly affect time to cannulation, perceived difficulty, number of skin breaks and number of redirects. Conclusions: Novice ultrasound users found the curvilinear transducer easier to use for simulated vascular access in the long axis. Studies utilizing patients and more experienced ultrasonographers could determine whether this difference amounts to meaningfully shorter times to cannulation and more successful first attempts.
Annals of Emergency Medicine S21