Abstract
Previous research has evaluated the sensitivity and specificity of emergency medicine ultrasound (EMU); however, the literature on clinical governance issues such as the quality of training, competence of the operator, development of clinical guidelines or standard setting within individual trusts is very limited. Although national guidelines have been issued regarding governance of non-radiology performed ultrasound, it is unclear whether the expectations provided within the guidance are being implemented in clinical practice.
The aim of this study was to explore the clinical governance and service provision of emergency medicine practitioners who had attended a two-day formal training course on EMU. The method used was a prospective non-randomized study using an electronic questionnaire to 160 clinicians who had attended a two-day EMU course. The questions investigated the clinicians’ EMU clinical practice in their departments including profession, grade, number of scans, types of examinations, equipment used and clinical governance arrangements such as scope of practice, audit, guidelines, support, archiving of reports and images. Responses were obtained from 59 of 160 (37%) delegates. The mean time they had been involved in emergency medicine was 8.31 years. Most (73%) were performing EMU in their current roles. Nearly all (86%) felt that the two-day course had given them adequate training and over half were performing extra examinations to those taught on the course. Only 23 (39%) respondents had supervision in their workplace after the course. Less than half (46%) were aware of national EMU guidelines, and only 22% of respondents indicated there were local clinical guidelines in place. A significant proportion of departments (37%) do not undertake audit. In conclusion, most of the respondents were not aware of the national guidelines around EMU and there was a lack of evidence that clinical governance issues were being enforced by all trusts. Many departments showed a limited use of clinical guidelines, audit regimes or competency assessment.
The benefits and accuracy of emergency medicine ultrasound (EMU) have been comprehensively researched over the last three decades. 1 Studies have shown that ultrasound performed early in a patient's assessment can increase the efficiency and safety of their management, reducing the time taken to detect potentially life-threatening pathology or expediting the evaluation of the patient where diagnosis is uncertain.2,3
Radiology departments have vehemently tried to maintain control of such developments with radiologists initially performing the focused assessment with sonography in trauma. 4 However, with increased demands on radiology resources and limited access to ultrasound out of hours, emergency physicians have taken the opportunity to extend their scope into this field.5,6 To underpin this development short courses have been developed to support the skills development required to perform and interpret these examinations, 7 most of which are accredited by the College of Emergency Medicine (CEM). 8
Although there has been much research which has assessed the sensitivity and specificity of EMU,8,9 there is limited literature evaluating clinical governance issues such as the quality of training, competence of the operator, development of clinical guidelines or standard-setting within individual emergency departments. National guidelines have been issued regarding governance of non-radiology performed ultrasound by a subgroup of the National Imaging Board, 10 yet it is unclear whether the expectations provided within the guidance are being implemented in clinical practice.
The aim of this study was to explore the clinical governance and service provision of emergency medicine practitioners who had attended a two-day formal training course on EMU.
Method
This was a prospective non-randomized study. A questionnaire (see Appendix A) was sent electronically (attached to an email) to a convenience sample of 160 emergency medicine practitioners who had attended a CEM accredited two-day EMU course between June 2004 and February 2007. This was conducted as a follow-up to the course; therefore there were no ethical issues related to use of delegate data. This course faculty included emergency medicine consultants and experienced sonographers and comprised didactic lectures covering ultrasound physics, equipment ‘knobology’, basic ultrasound technique and applications. Practical hands-on supervised scanning was performed on patients and healthy volunteers, and learning outcomes were assessed by an informal exam at the end of day 2. There were a total of eight courses in this period, each with a cohort of 20 delegates.
The questionnaire included a mixture of closed and openended questions investigating the clinicians’ EMU clinical practice in their departments. Data collection included profession, grade, number of scans, types of examinations, equipment used and clinical governance arrangements such as scope of practice, audit, guidelines, support, archiving of reports and images. Data analysis was via descriptive statistics.
Results
Participant demographics
Responses were obtained from 59 of the 160 (37%) delegates in the sample. A further 22 (14%) were returned as not delivered; therefore, the true response rate was 43% (n = 59/138). The numbers of respondents related to the year of course attendance are demonstrated in Figure 1.
Delegate numbers
In relation to the respondents’ grade (Figure 2), 28 (48%) were presently employed as consultants in emergency medicine, 20 (40%) were specialist registrars, five (8%) were senior house officers (SHO) and three (5%) comprised a staff grade, an associate specialist and a consultant radiographer. A further three (5%) respondents did not state their grade.
Participant demographics
The 59 respondents had been involved in emergency medicine for mean 8.31 years (range 1–20 years) and the majority (n = 43; 73%) of respondents were performing ultrasound in their current role. Of the 16 (27%) who did not indicate current ultrasound practice, a variety of reasons were given including difficulty accessing equipment (n = 10; 37%), followed by no clinical need (n = 4; 25%). Other reasons stated were a perceived lack of confidence or need for additional training (n = 3; 19%), no radiology support for service (n = 1; 6%), or a career move away from emergency medicine (n = 1; 6%). In relation to the grade of non-scanning respondents, five (31%) were consultants, six (38%) were specialist registrars and one (6%) an associate specialist. A further four (25%) did not specify their grade.
In relation to the ultrasound equipment used, seven (12%) respondents admitted they did not know the type of equipment they used and two (3%) respondents indicated that it depended what equipment was available in the radiology department at the time.
Scope of practice
Of the 59 replies, 51 (86%) indicated that they thought that the course had provided adequate training. Only 46 of the respondents (78%) indicated the scope of ultrasound examinations being performed; however of these, over half (n = 26; 59%) were performing additional scan techniques to those taught and assessed on the two-day course. Further, a number expressed interest in extending their scope to scanning for foreign bodies, pregnancy, deep vein thrombosis, gallbladder, echocardiology and musculoskeletal indications. Others included hip effusions in children, renal and chest ultrasound, and ultrasound-guided venous access as their service requirements.
In relation to clinical support after the initial course, of the 59 respondents only 23 (39%) had direct supervision in the workplace. Of these, 11 (48%) had been supervised by emergency medicine consultants, five (22%) by radiologists, three (13%) by sonographers, one by a senior radiographer (4%) and one by a staff grade doctor (4%). In addition, 27 (46%) of the respondents indicated they had access to ongoing support in practice, nine specified radiologists, a further nine sonographers; five had support from both radiologists and sonographers; four from EM consultants; additionally one indicated support from both an EM consultant and a sonographer.
Clinical governance
Of the respondents, almost half (n = 27; 46%) were aware of the national guidance related to EMU. However in relation to local practice guidelines, eight did not respond to the specific question; of those who did, 13 (25%) indicated there were local clinical guidelines in place, 29 (57%) had no guidelines and nine (18%) did not know.
In relation to reviewing scans, 11 respondents failed to answer the question. Of the remaining 48, only 31% of departments (n = 15) carried out audit of EM ultrasound, 46% (n = 22) did not undertake audit and a further 30% of respondents (n = 11) did not know about their department audit regime.
Discussion
To our knowledge this is the first study evaluating current EMU practice in the UK from a governance perspective. The poor response rate of 43% was disappointing and a limiting factor in the generalizability of these data. This may have been due to the geographic mobility of this group and length of time since course attendance. Most of the replies came from ED consultants who anecdotally are most likely to still remain in the same posts they held when they were delegates. Unsurprisingly, the majority of attendees were from an EM background, although one radiographer attended as part of a novel development related to blurring of clinical boundaries at a consultant level. That said, EMU is incorporated into at least one UK undergraduate radiography curriculum. 11
The wide range of experience in EM demonstrates there is no obvious time frame for attending this type of course and it was unclear whether the driver was personal continuing professional development or clinical department need. 12 However, it is interesting that 10% of respondents were SHO grade, perhaps an indication of their aspirations to develop in this field. The literature shows an increasing awareness of the use of EMU over the last two decades and this may be influencing and encouraging interest. It is however recognized that since the courses described within this study, there has been an integration of EMU into specialty training which will probably have driven down the grade of attendees within more recent years.
It is disappointing to find that, despite attending the course, over a quarter of the clinicians had not incorporated ultrasound into their practice, although the acceptance of EMU as a core component of clinical care and training in EM should, in the future, reduce issues related to the lack of support and service need. Access to equipment proved to be a difficulty, with many having to rely on the use of radiology equipment, rather than dedicated emergency department resources. Although clinical governance guidance for ultrasound 10 provides advice for the procurement and management of equipment and resultant images, this study suggests that in many hospitals such systems are not in place. The respondents also indicated that access to appropriate training/supervision were barriers to scanning, although many acknowledged the role that radiologists and sonographers, as well as other EM consultants, had played in the initial and ongoing support for their development. This has been echoed by others who recognize the need for interprofessional working to maintain skills and standards.10,13–15
Over 68% of respondents said that they thought a two-day course provided adequate training and some had gone on to undertake further training in EMU and others acknowledged the need for regular updates. Whether this was because of clinical need or personal interest was beyond the scope of this study.
There has been much debate over the type and length of training undertaken by emergency physicians to perform ultrasound and the Royal College of Radiologists (RCR) has provided guidance to non-radiologists on training provision. 15 This has been further clarified by the CEM with the development of its level 1 (basic) and level 2 (advanced) curricula.7,16 What constitutes adequate training for the performance and interpretation of ultrasound is a contentious issue.17,18 Unlike the RCR, the CEM has not specified a minimum number of examinations, but candidates should have a record of examinations they have been involved with and have their competence assessed by an appropriately experienced examiner. 19 However in this study 67% of respondents who scan in their current role were scanning unsupervised after only the two-day course (minimum of 10 examinations on normal volunteers and two patients) and had undertaken no further education. It is acknowledged that this degree of independent practice may have been influenced by a potentially limited number of individuals initially available within EM to supervise scans. The ambition of many to develop further ultrasound skills is acknowledged and the cited areas appear to match the scope of the level 2 curriculum 16 and justify the need for more advanced courses to support theoretical and practical training.
The initial CEM guidelines on EMU have been in place since 2004, and have been revised regularly. However, 37% of the respondents were not aware of their (or any other national guideline) existence. This suggests that at the time of this survey this information had not been widely distributed or reinforced in departments, although there has been significant progress over the last two years with the introduction of regional training coordinators. 8 Other governance issues raised include a perceived lack of local guidelines and a paucity of audit mechanisms. This is despite national guidance 10 calling for the establishment of local clinical ultrasound boards to support governance mechanisms between radiology and non-radiology ultrasound users.
This study provides a snapshot of the service delivery and governance issues experienced by a group of clinicians who attended a two-day course in EMU. As the questionnaires were to individuals rather than the clinical departments, it is unclear whether these issues highlighted in this study are widespread or contained within a small number of clinical departments. A wider national survey of ultrasound practices in ED is suggested to answer this question and to identify barriers and examples of good practice, which would support development of this field. In the meantime, further education, including example audit mechanisms and equipment selection, have since been included in the delivery of this course following this study, and knowledge of such topics are an expectation of level 1 practice. 19
Conclusion
Most of the respondents were not aware of the national guidelines around EMU and there was a lack of evidence that clinical governance issues were being enforced by all trusts. Many of the departments showed limited use of department clinical guidelines, audit regimes or competency assessment.
Despite having been taught the appropriate skills, a large proportion of clinicians were not scanning in their current roles and there is evidence of a lack of support from radiology departments. Many acknowledged the need for refresher courses to maintain the level of knowledge and expertise.
Declarations
The authors have no conflicts of interest to declare.
Footnotes
Emergency Medicine Ultrasound (EMU) Questionnaire
All data will be treated in the strictest confidence and will remain completely anonymous.
May we thank you in anticipation for your cooperation.
Please put a tick in the appropriate boxes
If other, please specify __________________________________________________
If no, did you scan in your previous role? _________________________.
If pregnancy, up to which gestation _________________________
If other, please specify _________________________
If yes, who by/grade? ________________________________________
If other, please specify _________________________
If yes, where are the images stored? _________________________
If other, please specify type of support _________________________
If yes, details ________________________________________________
If yes, how often? ________________________________________________
If yes, details ________________________________________________
If no, why not ________________________________________________
___________________________________________________________________