EMERGENCY ULTRASOUND SECTION
PA and NP Use of POCUS in the ED Melissa Myers, MD FAAEM and Joshua Guttman, MD FAAEM
P
ros: Advanced Practice Practitioner Use of US in the ED
As many as one in seven emergency department patients in the United States are seen by a PA or NP.1 Often these patients are seen in an urgent care or fast track area. Patients in this area may present with musculoskeletal complaints, concern for abscess, or retained foreign body and may benefit from the use of point-of-care ultrasound in their care. Point-of-care ultrasound has been previously shown to change the management in the diagnosis and treatment of abscess and cellulitis and is effective in the diagnosis of tendon injuries.2-3 In addition to the benefits for patient care, the use of ultrasound by PAs and NPs can decrease length of stay in the emergency department. Performing ultrasound in the ED instead of referring to radiology can decrease length of stay which can increase the overall efficiency of the department. Training programs exist where PAs and NPs can receive appropriate training in the use of ultrasound. As an example, my home hospital offers an emergency medicine fellowship for PAs which includes a one month rotation with the same ultrasound requirements as the emergency medicine interns. These PAs graduate and are able to perform POCUS and should be able to use this skill set in addition to their other training. This is not, however, to say that anyone should be using ultrasound without proper training. Any PA or NP using ultrasound in the emergency department should undergo the same rigorous training as a physician performing the same exam. Emergency departments should establish baseline standards for credentialing based on previous instruction and number of exams performed for anyone performing ultrasound. These standards should be the same as any physician performing ultrasound in the emergency department. Cons: Midlevel POCUS in the ED
Performing POCUS safely is complex and is highly operator dependent. It requires three separate sets of skills: image acquisition, image interpretation, and clinical integration. Like any complex skill, becoming proficient means spending time learning and practicing prior to safe independent use. Emergency medicine (EM) residents spend a minimum of two weeks in dedicated POCUS education during their PGY1 year, often taught by EM faculty who are fellowship-trained in POCUS. Residents then have the rest of their residency to hone their skills and learn clinical integration. They graduate with a minimum of 150 completed scans (many residencies require a minimum of 300 scans). Physician assistants (PA) do not have this kind of robust training. In 2019, a survey of PA program directors found that 23% of PA programs use POCUS in their curriculum with many using it in the basic sciences section.4 Even
POCUS IS SIMPLY NOT A ‘SEE >> ONE, DO ONE, TEACH ONE’ SKILL.
then, supervision and access to skilled faculty is variable. There are, however, over 200 medical schools that integrate ultrasound into medical school education.5 Nurse practitioners (NP) training is also variable, with no standardized curriculum and no endorsed training pathways from NP societies.6 Currently, many PAs and NPs learn POCUS “on the job,” where supervision can be minimal or non-existent. While POCUS is a powerful diagnostic and procedural tool, improper training can lead to important patient safety consequences, such as misdiagnosis and procedural error. False positive exams from misinterpretation can lead to unnecessary tests and consultations which increase patient length of stay and cost. False negatives can lead to inappropriate reassurance and discharge. PAs and NPs are skilled practitioners who are certainly capable of learning POCUS and integrating it into clinical care.7-8 However, current training is insufficient to allow independent use of POCUS. POCUS is simply not a “see one, do one, teach one” skill. EDs wanting PAs, NPs, or nurses to utilize POCUS in clinical care must develop a robust training program, including didactics and safety training, supervised bedside practice, and a quality assurance program to assure high standards of care are met. References 1. Brown, D. F., Sullivan, A. F., Espinola, J. A., & Camargo, C. A. (2012). Continued rise in the use of mid-level providers in US emergency departments, 1993–2009. International journal of emergency medicine, 5(1), 1-5. 2. Tayal, V. S., Hasan, N., Norton, H. J., & Tomaszewski, C. A. (2006). The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Academic emergency medicine, 13(4), 384-388. 3. Wu, T. S., Roque, P. J., Green, J., Drachman, D., Khor, K. N., Rosenberg, M., & Simpson, C. (2012). Bedside ultrasound evaluation of tendon injuries. The American journal of emergency medicine, 30(8), 16171621. Countinued on page 39 >>
COMMON SENSE NOVEMBER/DECEMBER 2022
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