STANDARDS FOR EMERGENCY ULTRASOUND IN SASKATCHEWAN

Prepared by

Babak Allie MD, Moose Jaw SKAnthony Davies MD, Estevan SKChristo Delport MD, LaRonge, SK

Puneet Kapur MD, Regina, SK Dal Lynds NP, North Battleford SK

Alison Turnquist MD, Saskatoon, SKPaul Olszynski, MD, Saskatoon SK

Submitted by

Paul Olszynski, MDDirector of Emergency Ultrasound

For

Department of Emergency MedicineUniversity of Saskatchewan

Saskatchewan Health Authority

Adopted Sept 1, 2019

TABLE OF CONTENTS

I. PREAMBLE & FRAMEWORK ………………………………………….…..…….………3II. EXECTIVE SUMMARY……………………………………………………………………4III. SCOPE OF PRACTICE…………………………….…………………….……….…….. 6IV. TRAINING STANDARDS FOR EMERGENCY ULTRASOUND………………..……8   V. EMERGENCY ULTRASOUND PRIVILEGES…………………………………….…….9  VI. EQUIPMENT…………………………………………...………………………………….10VII. QUALITY ASSURANCE….………………………….………………………………..…13VIII. REFERENCES………………………………………………………………………….. 14APPENDIX A: List of EUS applications………………..……….. ………………………... 15APPENDIX B: Table of approximate # of training scans required per application……..18APPENDIX C: Documentation template………………………………………………….…19APPENDIX D: Option for EUS CME assessment and Transition to Practice..…….….. 20APPENDIX E: Disclosures by authors………………………………………………………21APPENDIX F: Infection control measures……..……………………………………………22APPENDIX G: Recognized Courses………….……………………………………………..24APPENDIX H: Saskatchewan Health Authority Map and Area POCUS leads………….25

I. PREAMBLE AND FRAMEWORKThe use of emergency ultrasound (EUS) as an adjunct to the delivery of

emergency care is now well established in Canada as well as internationally.[1, 2, 3]

Emergency ultrasound comprises a set of focused applications utilized to diagnose life-

threatening conditions, guide invasive procedures, and treat emergency medical

conditions [2]. EUS has been used in the delivery of emergency care in both rural and

urban centres throughout the province of Saskatchewan for the past decade. During

that time, oversight over EUS was the responsibility of regional health authorities.

In 2017, the government of Saskatchewan dissolved the previous regional health

authorities and created a single provincial health authority, known as the Saskatchewan

Health Authority (SHA). At the same time, the Department of Emergency Medicine at

the University of Saskatchewan was awarded status as a provincial academic

department. In light of these significant changes within the province, the Department of

Emergency Medicine has appointed a Director of Emergency Ultrasound to support and

oversee EUS throughout Saskatchewan. With this in mind, these standards represent

one of many initiatives to help ensure high quality training in and use of EUS, and take

into account that emergency care, and thus EUS, is within the scope of emergency

physicians, family physicians and nurse practitioners. Furthermore, this document

recognizes that other healthcare providers (nurses, aeromedical services) are also now

using point of care ultrasound (POCUS) in important ways that interface with everyday

emergency care.

The authors of these standards represent the range of clinicians using

emergency ultrasound with the Saskatchewan Health Authority. It is through their

commitment to high quality emergency care, combined with their expertise in the use of

emergency ultrasound, that these recommendations were derived. Disclosures of each

author can be found in the appendix.

II. EXECTUVIE SUMMARY

Emergency ultrasound (EUS) comprises a set of focused applications utilized to

diagnose life-threatening conditions, guide invasive procedures, and treat emergency

medical conditions. [2] The proposed standards take into account that emergency care,

and thus EUS, is within the scope of emergency physicians, family physicians and

nurse practitioners. Given the significant contextual and resource differences between

urban/tertiary centres and rural/regional sites, recommendations related to training,

privileging and quality assurance are tailored accordingly.

i) Scope includes use of ultrasound during emergency care to aid in diagnosis and

procedures. Diagnostic applications include (but are not limited to) use of ultrasound in

resuscitation (including focused cardiac and thoracic scans), in expediting diagnosis

(including biliary, renal, venous applications), and in the assessment of musculoskeletal

complaints (joints, fractures and soft tissue).

ii) Training (and proof thereof) should include a clear induction to the ultrasound

application(s) in question, followed by a supervised apprenticeship, and an objective

assessment of knowledge and skill. This standard, when applied to core/basic

applications, is attainable throughout all sites in the province. However, with many of the

extended applications where clinicians in rural/regional sites may have little local

expertise to rely on, exceptions are warranted. In these cases, rural clinicians who

already have credentials in basic EUS are advised to develop clear plans (in

consultation with their site/area EUS lead) for ongoing practice and self-audit. Residents

who have received robust emergency ultrasound training are encouraged to submit

supporting documents that outline the details of their performance within their

residency-based ultrasound training program.

iii) Privileges should be determined with the above training recommendations in mind, in

recognition that not all credentials are created equal.

iv) Documentation of emergency ultrasound should include a note in the patient’s chart

that is trackable for review. Major teaching centers are encouraged to make use of

image capture technologies.

v) Quality assurance and improvement are now routine aspects of clinical practice. In

urban/tertiary centres, this means continuous audits of group practice with feedback

being provided to both individuals and the department from the site lead. In rural and

regional centres where clinicians must balance a wide range of competing demands on

time, emergency ultrasound should be included within broader quality improvement

programs.

vi) Leadership will include emergency ultrasound leads (site and/or area) and the

Director of Emergency Ultrasound, in collaboration with all members of the Department

of Emergency Medicine. These leaders will work collaboratively to support excellence in

emergency ultrasound training, clinical care and research.

These standards represent one of many initiatives developed to help ensure high

quality training in, and use of, EUS in the province of Saskatchewan.

III. SCOPE OF PRACTICE Emergency Ultrasound (EUS) is the medical use of US technology for the

bedside evaluation of acute or critical medical conditions. [1] It is utilized for diagnosis of

many emergency conditions, resuscitation of the acutely ill, critically ill or injured,

guidance of procedures, monitoring of certain pathologic states and as an adjunct to

therapy. [1, 2] EUS examinations are typically performed, interpreted, and integrated

into care by emergency physicians, family physicians and nurse practitioners whose

scope of practice includes emergency care, or those under the supervision of

emergency physicians in the setting of the emergency department. It may be performed

as a single examination, repeated due to clinical need or deterioration, or used for

monitoring of physiologic or pathologic changes.

    As per the recent CAEP EM POCUS guidelines [4], EUS is best classified

according to the clinical context in which it is being applied and includes two main

categories: diagnostic and procedural. Diagnostic applications of EUS can be further

divided into the following 3 categories: resuscitative, advanced diagnostic, and

therapeutic.

Resuscitative EUS is directly related to resuscitation and critical care. This

includes the use of ultrasound to determine the etiology of shock or hypotension, as well

as to assist with identifying the cause of respiratory distress and to guide cardiac arrest

management. Generally, resuscitative EUS includes, but is not limited to, assessment of

left ventricular (LV) systolic function, right ventricular (RV) size, assessment for

pericardial effusion and tamponade, IVC size and respiratory variability, thoracic EUS

for the identification of pneumothorax, hemothorax, pleural effusion and interstitial lung

syndrome, and abdominal EUS for the identification of a AAA or free fluid

Advanced diagnostic EUS is an emergent diagnostic imaging capacity.

These applications have a positive impact by expediting patient care and improving

departmental flow. As an example, EUS can rapidly detect ureteric obstruction in a

patient presenting with renal colic, or the presence of gallstones and signs of

cholecystitis in a patient presenting with right upper quadrant pain. Diagnostic EUS

includes, but is not limited to, focused assessment of the hepatobiliary system, genito-

urinary tract, abdominal aorta, deep venous system of the lower limbs, the large and

small bowel, the eyes, joints, soft tissues, and musculoskeletal system for fractures,

effusions, dislocations and identification of cutaneous foreign bodies.

Therapeutic and Monitoring EUS is used in therapeutics or in physiologic

monitoring. This is especially relevant with the growing body of literature highlighting the

potential risks of “over-resuscitation” with crystalloids. Cardiac output monitoring, fluid

tolerance, fluid responsiveness (velocity time integral (VTI), IVC collapsibility, carotid

flow), and response to treatment of interstitial lung syndrome (resolution of B-lines) all

represent potential monitoring modalities by means of POCUS.

Procedural applications are those procedures that are done with ultrasound

guidance and range from nerve blocks, to intravenous access, to fracture reduction.

Generally, procedural guidance includes, but is not limited to, vascular access,

paracentesis, thoracentesis, pericardiocentesis, suprapubic catheterisation, regional

anesthesia, joint aspiration and injection, lumbar puncture, cutaneous and peritonsillar

abscess drainage, endotracheal intubation, foreign body removal, and reduction of

fractures and dislocations.

For a comprehensive list of applications, please see Appendix A.

IV. TRAINING STANDARDS FOR EMERGENCY ULTRASOUND    In light of the expanding number of EUS applications, we continue to see both

residents as well as clinicians already in practice pursuing EUS training. As such, there

is a range of options for developing emergency ultrasound skills, as well as a range of

accompanying credentials, not all of which confer proficiency in emergency ultrasound

(for example, a certificate of attendance to a course does not confer proficiency,

whereas certificates that attest to a supervised training regime that included an

objective assessment of knowledge and skill does provide reasonable evidence of

proficiency). Guidance in terms of the approximate number of training scans usually

required to achieve proficiency can be found in Appendix B.

The training standards herein have been developed in recognition that EUS is a

skill both specific to emergency clinicians (physicians and acute-care-trained nurse

practitioners) as well as a skill within the full scope of rural family practice and as such

comprise distinct recommendations for training for these groups.

Standards for Clinicians Already in Practice (CME pathway)

The recommended training process requires the candidate to attend an

instructional workshop or course, perform and record a requisite number of supervised

scans, and pass an exit examination (testing both knowledge and image generation

skills). Examples of the above recommended training processes include the Canadian

Point of Care Ultrasound Society's (CPoCUS) Independent Practitioner (IP) program

which awards certificates for completion of their traineeships in various applications.

Other traineeships such as those with the Ultrasound Leadership Academy (ULA) or

those completed at specific institutions such as SickKids PEM POCUS program are

also highly regarded and should be considered as adequate providing that they include

the three key criteria of training as outlined above. Where, in instances of deficiency,

clinicians should be provided with an approach to complete their training (this may

include examinations offered by the local site/area or within through the broader

provincial department of Emergency Medicine).

Rural and regional practice is very different from that at a tertiary centre, with

significant difference in frequency of patient encounters. Simultaneously, it is at these

remote centres that patients and their clinicians stand to gain the most from use of EUS

in emergency care. Rural and regional clinicians also face geographic and resource

challenges that may make the above training criteria challenging to meet. Once a rural

or regional clinician has demonstrated proficiency in the common (aka core) EUS

applications (using the above criteria) and has been awarded privileges to use them, it

may be appropriate that they develop and apply additional skills through a greater

degree of self-study as compared to clinicians at tertiary centres. Such an approach

would benefit from the development of a portfolio that demonstrates self-monitoring and

quality assurance. Rural and regional clinicians interested in this type of further

development should connect with their local EUS site or area lead in order to maximize

access to potential resources and supports.

Standards for Residency-Based Training in Emergency Ultrasound

Clinicians and residents who have extensive residency-based training in EUS will

be asked to submit an EUS CV that provides proof that their program met the above set

of 3 training criteria. Physicians who have completed fellowship programs will be

strongly encouraged to take on EUS leadership roles within their respective

departments.

Supervision of Trainees

Clinicians who have met the above criteria for training are qualified to teach and

supervise trainees across the medical education spectrum. Such supervision includes

overall supervision in a training plan, as well as direct supervision of trainee scans when

as part of patient care. Once a trainee’s competency committee (or program director

where competency committees do not exist) has deemed a trainee adequately

knowledgeable and proficient in a given application based on on-shift assessments,

exam marks, etc.., they may be deemed competent to perform and interpret their scans

without direct supervision.

V. EUS PRIVILEGESPrivileging bodies (i.e.: hospital sites, area and department leads) are

encouraged to review the clinician's EUS credentials with awareness that not all

credentials imply the same level of competence. It is strongly recommended that

credentials be scrutinized for evidence of the 3 training criteria (introduction, supervised

apprenticeship, examination) while simultaneously keeping in mind practice type

(tertiary centre vs. rural/regional practice).

For urban/tertiary care clinicians, privileges should be awarded for those EUS

applications that the clinician has demonstrably met the 3 training criteria. Clinicians do

not need to be in good standing with any one society or association in order to have

EUS privileges in Saskatchewan.

As identified in the training section, rural and regional clinicians (and their

patients) stand to gain a great deal from use of EUS, while simultaneously facing

additional challenges in terms of access to training resources and supervision. In light of

this reality, where and when the above criteria are not met, EUS privileges should be

carefully considered on a case by case basis. Those clinicians who have demonstrated

core EUS skills and have shown a clear commitment to self-study and quality assurance

should be recognized as capable of practicing and performing these additional

applications safely. Whenever possible, these clinicians should be offered opportunities

to challenge examinations in order to receive formal recognition of the time and effort

they have invested (including CME credits and official privileges).

Clinicians who have taken ultrasound courses and are in the process of obtaining

the requisite number of supervised scans need to inform their patients of the

educational nature of the scan. These scans should be documented in the chart but

clearly denoted as having been performed during apprenticeship and considered

indeterminate. If there is an appropriately privileged clinician nearby able to supervise

the scan, then that scan can be considered determinate.

VI. EQUIPMENTUltrasound machines should be able to tolerate the rigors of multiple users

employing them in multiple locations in the emergency department. The machines

ideally should also have at least 2 or 3 probes (as determined by local practice). All

ultrasound equipment must meet contemporary standards and be properly maintained

and calibrated. Use of handheld units (i.e.: GE VSCAN) is acceptable for screening

purposes but should be used in a complementary fashion to the larger, portable units.

  If any defect or problem is identified [which affects image generation], the

equipment must be marked “out of service” and removed from the emergency

department. There should be regular checks to ensure that the probes are functioning

properly.

Infection Control Issues Associated with Point of Care Ultrasound Equipment

As per the CAEP EM POCUS Position Statement Update for 2019: Programs

should have a clear policy for infection control, that includes machine hygiene (including

keyboard, controls, screen and cart) and the transducers. It should be noted that every

user should be responsible for performing appropriate cleaning and disinfection of the

ultrasound machine and probes before and after every patient encounter. Sterile

ultrasound gel must be used for all invasive procedures that pass a device through

tissue (e.g., needle joint aspiration, nerve blocks and vascular access) and for all

procedures involving sterile environment or non-intact skin, and on neonates. Sterile

gels should be used for procedures performed on intact mucous membranes (e.g.,

oesophageal, vaginal, etc). Aseptic technique should be followed when using sterile

gels. The Department of Emergency Medicine supports the use of endocavitary probes

providing that rigorous infection prevention policies are followed that outline the

handling, cleaning and high-level sterilization of the probes. These policies must be in

accordance with local and national infection control policies. When used, these probes

must be covered with a disposable sheath. Patients must be asked for a history of Latex

allergy prior to the scan. Do not use Tegaderm products as sheath covers as they may

damage the transducer.

A full description of the infection control recommendations can be found in Appendix 3

of the CAEP 2019 EM POCUS Document.

VII. QUALITY ASSURANCE    Emergency physicians performing EUS must have an active medical license,

current privileges and be in good standing. Leadership will include (whenever possible)

site leads, area leads, and the director of Emergency Ultrasound who reports to the

Provincial Department Head. At minimum, each urban centre (Saskatoon, Regina and

Prince Albert) should have an EUS site lead who will assist with quality improvement,

machine maintenance, coordinate and provide training of clinicians and trainees. These

responsibilities should be determined after discussion with the area leads and provincial

department head. Whenever possible, fair compensation or remuneration that is

representative of the time commitment and effort required should be secured.

Rural and Regional Centres are encouraged to identify site EUS leads to

integrate EUS quality into current Quality Assurance and Improvement processes.

Given the broad scope of rural practice, image capture and routine EUS chart audits are

not feasible. However, at minimum, the EUS site and/or area lead should be appointed

as the primary contact should concerns about equipment or training arise. These site

and area leads will be supported by the provincial director of emergency ultrasound.

The Director of Emergency Ultrasound should serve as a resource to all

Saskatchewan clinicians who use emergency ultrasound as well as to emergency

medicine residency programs. This person will be actively involved in teaching across

the entire spectrum of medical education, will visit other sites to offer support and

training, will carry out quality improvement locally and regionally, and will engage in

EUS research. This person will also represent the department of Emergency Medicine

within the province-wide, multidisciplinary POCUS program.

All clinicians should participate in ongoing medical education and competency

review. Examples include [but are not limited to] formal CME, other CME that includes

ultrasound, online learning, teaching, reading, department in-services. Increasingly,

emergency physicians in Saskatoon are saving sample images/clips for QA review. The

Department of Emergency Medicine in Saskatoon has secured wireless image archiving

system in order to further improve opportunities for image review (valuable for both

training purposes as well as opportunities for quality assurance). See Appendix C for a

list of real-time skill assessment options.

Should concerns arise regarding a clinician’s EUS skills, a meeting with the local

EUS lead/Director and that clinician will be arranged. If it is determined that remediation

should be undertaken, EUS privileges will be suspended until such a time that

remediation has been completed and the EUS lead and the clinician in question have

agreed to proceed with re-instatement of privileges.  The area POCUS lead will be kept

aware of any remediation activities of members of the emergency medicine department.

Documentation Standard

Emergency department paper charts should be marked for easy retrieval while

electronic records should have a clear EUS tracking capability. Documentation should

include the type(s) of scan performed, the findings, and then how it was integrated into

patient care (see Appendix D). Indeterminate scans (where the view was inadequate) or

those scans performed by clinicians in training, should be documented as such.

Suspected “positive” training scans should be followed by either supervision by a

qualified colleague or further evaluated by additional imaging.

Incidental findings (such as simple renal cysts) should be discussed with the

patient. Appropriate imaging follow up (if indicated) and communication to the primary

care provider should be arranged.

VII. REFERENCES

1. American College of Emergency Physicians Policy Statement: Emergency   Ultrasound Guidelines. Ann Emerg Med. 2009;53: 500-570.

2. American Institute of Ultrasound in Medicine (AIUM) (2018) ‘Training Guidelines and Practice Parameters’. Available at: https://aium.org/resources/viewStatement.aspx?id=59 (Accessed: 19 November 2018).

3. Atkinson, P., Ross, P., & Henneberry, R. (2013). Coming of age: emergency point of care ultrasonography in Canada. Canadian Journal of Emergency Medicine,     online first, 1-4.

4. Canadian Association of Emergency Physicians.Position Statement on Use of POCUS in Emergency Medicine. Lewis et al. CJEM – in press (but will be available at http://www.caep.ca)

5. Canadian Association of Emergency Physicians Policy Statement: Emergency Department Targeted Ultrasound. Can J Emerg Med. 2006; 8(3):170-171 Available at: http://www.caep.ca

6. Henneberry, J., Hanson, A., Healey, A., Hebert, G., Ip, U., Mensour, M. et al. (2012). Use of point of care sonography by emergency physicians. CJEM., 14(2), 106- 112.

7. The Royal College of Physicians and Surgeons of Canada. (2011). Objectives of training in emergency medicine. Retrieved from The Royal College of Physicians and Surgeons of Canada http://www.medicine.mcgill.ca/postgrad/accreditation_2013/PSQs/1_Emergency_ Medicine/05_OTR_Emergency_Medicine_2008.pdf

APPENDIX A List of EUS Applications

The following list includes the most commonly used applications in emergency medicine(EM). This list is not to be viewed as a curriculum, nor is it expected that every emergencyphysician should be expected to be competent in all of these applications.

1. RESUSCITATIVE AND DIAGNOSTIC APPLICATIONSa. Cardiovascular

i. Transthoracic views and Transesophageal echo (TEE)ii. Cardiac - pericardium, cardiac form, cardiac function, valvesiii. IVC - filling/volume assessmentiv. Abdominal aorta - aneurysmv. Deep vein thrombosis (DVT) - upper and lower limb

b. Respiratoryi. Thoracic - pleural fluid, hemothorax, pneumothoraxii. Lung - pneumonia, pulmonary edema

c. Gastrointestinali. Bowel - bowel obstruction, appendicitisii. Hepatobiliary - gallstones, cholecystitis, biliary dilatationiii. Peritoneum - hemoperitoneum, ascites, pneumoperitoneum

d. Genitourinaryi. Renal - hydronephrosis, renal calculiii. Bladder - bladder volume and emptyingiii. Female pelvis - ovarian cysts, pelvic fluidiv. Testicular - torsion, epididymo-orchitis, hydrocele

e. Pregnancyi. Transabdominal and transvaginal assessmentii. First trimester pregnancy complication - PV bleeding, ectopicpregnancy

f. Musculoskeletali. Joint effusionii. Fracturesiii. Dislocationsiv. Soft tissue (muscle/tendon) injury, infection and inflammation

g. Cutaneousi. Cellulitisii. Cutaneous and subcutaneous abscessiii. Cutaneous and subcutaneous foreign body identification

h. Head and Necki. Ocular - retina, chambers, optic nerve sheath

i. Multisystemi. Traumaii. Shock

iii. Dyspneaiv. Cardiac arrestv. Chest painvi. Abdominal pain

2. PROCEDURAL GUIDANCEa. Cutaneous abscess drainageb. Cutaneous foreign body removalc. Cricothyrotomyd. Endotracheal intubatione. Guided therapeutic injectionsf. Joint aspirationg. Lumbar punctureh. Paracentesisi. Pericardiocentesisj. Peritonsillar abscess drainagek. Reduction of fractures and dislocationsl. Regional and peripheral anesthesiam. Suprapubic cathetern. Thoracentesiso. Vascular access

APPENDIX B)

Approximate scan numbers for proficiency in image generation

Approximate number of scans required to reach proficiency in image generation in a particular application. Please note, proficiency in image generation is not proof of mastery of image interpretation and clinical integration. Thus, a summative assessment of all domains of the application (indication, image generation and interpretation, and clinical integration) is required.

EUS Application Training Scans (approximate)

Positive cases (approximate)

Focused Cardiac Ultrasound (PSL, PSS, A4C, SC, IVC)

50 15

Thoracic (Lung and pleural bases) 20 10

Biliary (cholelithiasis, cholecystitis, prox. CBD)

50 10

Renal (Hydronephrosis) 20 10

Bladder (volume) 10 5

Lower extremity Venous (DVT) 40 10

MSK (fracture) 20 5

MSK (Effusion) 20 5

Soft Tissue (Cellulitis, FB) 30 10

FAST (extended)/ FAFF 50 10

Obstetric (IUP via TA) 50 15

AAA 50 10

APPENDIX C

REAL TIME SKILLS ASSESSMENT (an option for CME)

Real time assessments of technique as well as image generation can take place in one of the following ways:   i. Course Lecturers/ Bedside Instructors. Assisting with courses/teaching allows for a thorough review of theory and technique. These are led by lead instructors who meet with bedside instructors prior, during and following courses to further discuss techniques and feedback.   ii. Attendance at a nationally recognized Emergency Ultrasound Course will satisfy 1 year’s worth of skill maintenance   iii. Proctoring trainees. This includes either 2 half-day sessions with a trainee/year or a total of 30 scans proctored with various trainees over the year (on shift, small sessions, etc…) with documentation.   iv. Submission of 12 digitally recorded scans (3/area) to the QA lead for review on an annual basis. Scans need to be dynamic clip recordings downloaded from the department’s machines.   v. Group review. A minimum of 3 clinicians can get together and review scanning technique amongst each other or on patient volunteers. 4 hrs spent this way per year will satisfy 1 year of requirements for skill maintenance. TRANSITION TO PRACTICE

Additionally, for clinicians who have recently completed an apprenticeship and passed their exams, local EUS leads may offer to assist with indirect supervision of scans via uploading of anonymized cases for review. This may be of particular interest when clinicians are integrating some of the more challenging applications (biliary, resuscitative echo).

APPENDIX D

EMERGENCY ULTRASOUND Documentation (paper or electronic)

EUS FINDINGS:

Heart Pericardial fluid No pericardial fluid Indeterminate

Contractility present Contractility absent Indeterminate

Abd. Aorta Aneurismal (> 3 cm) Normal (< 3 cm) Indeterminate

Abdomen Free fluid No free fluid Indeterminate

Obstetrical IUP LIUP

NDIUP Indeterminate

Advanced EDUS:____________________________________________________________________________________________________________________________________________________________________________________________________________________________ Consultative Imaging Report (if obtained):_______________________________________________________________________________________________________________________________________________________________

X ______________________________________________               Clinician        (Signature)

APPENDIX E: Disclosures

Babak Allie is a family physician in Moose Jaw, SK. He does not hold any commercial interests in any course or company that produces ultrasound or ultrasound-related products.

Anthony Davies is a family physician/GP anesthetist in Estevan, SK. He is an instructor with the EDE course and the EGLS course. He receives financial compensation for time spent organizing and teaching at courses. He does not hold any commercial interests in any course or company that produces ultrasound or ultrasound-related products.

Christo Delport is a family physician in LaRonge, SK. He does not hold any commercial interests in any course or company that produces ultrasound or ultrasound-related products.

Puneet Kapur is an emergency physician in Regina and Saskatoon. He is an instructor with the EDE course, the EDE 2 course, and the EGLS course. He receives financial compensation for time spent organizing and teaching at courses. He does not hold any commercial interests in any course or company that produces ultrasound or ultrasound-related products.

Dal Lynds is an acute care trained nurse practitioner working in North Battleford Hospital. He is a regional emergency ultrasound lead with the Sasksonic program. He is a course instructor and regional lead with The EDE course. He is also an active member of the Canadian Point of Care Ultrasound Society (CPOCUS) and their Rural Independent Practitioner Program (RIPP). He receives financial compensation for time spent organizing and teaching at courses as well as for time supervising trainee scanning and administering their exams.

Paul Olszynski is the Director of Emergency Ultrasound (0.25 FTE) and Director of the Clinical Ultrasonography program for the College of Medicine (0.15 FTE) at the University of Saskatchewan (Sasksonic). He has also been the UGME Ultrasound Lead (~0.15 FTE) for the past 5 years (term ending July 1st, 2019). Duties include the administration and delivery of educational programing related to POCUS across the medical education spectrum (curricular development, teaching, program evaluation and medical education scholarship). He is also a regional lead for several POCUS courses: The EDE Course, The EGLS Course, The EDE2 Course, and the EDTU course. He receives financial compensation for time spent organizing and teaching at courses. He does not hold any commercial interests in any course or company that produces ultrasound devices or ultrasound-related products.

Alison Turnquist is an emergency physician in Saskatoon. She is an instructor with the EDE course and the EGLS course. She receives financial compensation for time spent organizing and teaching at courses. She does not hold any commercial interests in any course or company that produces ultrasound or ultrasound-related products.

APPENDIX F - INFECTION CONTROL ISSUES ASSOCIATED WITH POINT OF CARE ULTRASOUND EQUIPMENT

1. Ultrasound Machines and Transducers

a. Cleaning - A mechanical process that removes visible soil (organic and inorganic) from objects and surfaces. Cleaning is an essential first step to any disinfection process since physical debris may interfere with effectiveness of chemical or physical agents. For ultrasound transducers, this means wiping off visible gel and debris with a towel or dry wipe prior to any other process.

b. Low level Disinfection - A chemical process that eliminates live bacteria, some fungi and enveloped viruses. Examples include solutions or wipes impregnated with 3% hydrogen, 0.5% enhanced action formulation hydrogen peroxide, some quaternary ammonium compounds (QUATS), phenolics and diluted sodium hypochlorite (e.g., bleach) solutions. The contact time required for disinfection depends on the manufacturer’s instructions.

c. High Level Disinfection- A chemical process that eliminates bacteria, mycobacteria, fungi, and enveloped and non- enveloped viruses, but not necessarily bacterial spores.  Examples include 6% hydrogen peroxide, 0.55% ortho-phthalaldehyde and 2% enhanced hydrogen peroxide. This is necessary for endocavitary probes or probes used on open skin, even though a probe sheath may be used.

d. Sterilisation - A physical or chemical process that eliminates or destroys all forms of microbial life, including spores. This is not done for ultrasound transducers because of their delicate electronics. (60–65)

2. Assessing Transmission Risk

The Spaulding Classification is used to classify medical equipment according to the potential infectious risk posed to the patient (66). The classification is as follows:

a. Critical Items - Equipment that is used in normally sterile body cavities and so carries a significant risk of infection if contaminated. Examples include surgical instruments, biopsy instruments and implants. These items must be cleaned and then sterilized, usually with heat.

b. Semicritical Items - Equipment that contacts mucous membranes and non-intact skin and confers a moderate risk of infectious complications. Examples are endocavitary ultrasound transducers, laryngoscope blades

and endoscopes. These items must be cleaned and then undergo high level disinfection after every use.

c. Noncritical Items - Equipment that comes into contact with intact skin, thus carrying only a small infectious risk to patients. Examples include ultrasound transducers (non-endocavitary), ultrasound machines, bedpans, oximeters and stethoscopes. These should undergo cleaning followed by low level disinfection after every use.

3. Low Level Disinfection Considerations

Low level disinfectant wipes and solutions are often used hospital-wide. Not all wipes are compatible with all transducer brands, so check the machine manufacturer’s instructions to ensure compatibility. Alcohol swabs should not be used on the transducer surface since they may cause damage. All users should be taught to clean the probe after every use, and to start by cleaning it with a dry wipe or towel to remove the gel and debris. Then they should apply the wipe or solution for the designated contact time.

4. High Level Disinfection System Considerations for ED Programs

High Level Disinfection (HLD) System implementation should be undertaken in conjunction with the Infection Control Department of the hospital, and should comply with provincial guidelines. An ED considering how best to organise a HLD program should first consider where the best place for transducer processing is. Options include: central processing, a system shared with diagnostic imaging or endoscopy, or an ED-based processing system.One of the first two options may be best choice in lower volume departments, or when there is either a lack of capital for an ED based system, or a lack of personnel required for consistent system maintenance. A non-departmental HLD process should be quick, readily available in off hours, and have traceability to avoid equipment misplacement.

Choosing to locate the HLD system in the ED allows a faster turnaround time and has a lower likelihood of transducer damage or loss. However, it requires a capital equipment investment, an ongoing plan for maintenance and supplies, and dedicated personnel for maintenance and processing. All systems require a log that details machine and solution testing, and usage dates and times to ensure traceability and compliance. Physicians can process the probes themselves but require upfront training and a clear set of instructions that are readily available at the time of use.There are essentially three types of systems to choose from:

A) Soak Station- A small wall-mounted fumehood that safely contains the chemicals required for HLD, usually >6% hydrogen peroxide or 0.55% Ortho-Phthalaldehyde (OPA). Depending on the agent, disinfection is achieved after a 10-30 minutes soak. The probe must then be well rinsed and dried.  The solution replacement time intervals and disposal processes are agent-dependent. An ED contemplating implementing a soak station system needs to train and designate an individual to safely maintain it.

B) Enhanced Action Hydrogen Peroxide System- A closed systems that use energized hydrogen peroxide to disinfect probes in 10 minutes or less. Chemical byproducts are simply oxygen and water, and require no disposal or PPE to maintain.

C) UV-C Disinfection System- A closed, chemical-free system using UV light to disinfect probes in less than 2 minutes.

APPENDIX G - Recognized Courses

Resuscitative- The EDE course- Echo-Guided Life support (EGLS)- Emergency Department Targeted Ultrasound (EDTU)- Emergency Department Targeted Ultrasound X (EDTUX)- Canadian resuscitative ultrasound course (western)- Montreal Ultrasound Education (MUSE)- other courses will be reviewed for quality on case by case basis

Diagnostic- The EDE2 Course- Echo-Guided Life Support- other courses will be reviewed for quality on case by case basis

Procedures- UBC UGEMP (ultrasound guide emergency medicine procedure course)- The EDE2 course- other courses will be reviewed for quality on case by case basis

Msk / Ophthalmology / esoteric applications / tendon / advanced echo- The EDE3 Course- other courses will be reviewed for quality on case by case basis

Universal Approval- completion of the Ultrasound Leadership Academy (with proof of examination)- Recognized fellowship in emergency ultrasound - RDMS (any country)- Anesthesia ultrasound fellowship- Critical Care Ultrasound Fellowship- PEM PoCUS fellowship

APPENDIX HSaskatchewan Health Authority Map and Area POCUS Leads

Northeast: James Samson (jameysamson@gmail.com)Northwest: Dal Lynds (dlynds@ualberta.ca)Southeast: Southwest: Michael Kapusta (michaelkapusta@outlook.com)Regina: Ankit Kapur (ankit@kapur.org)Saskatoon: Paul Olszynski (p.olszynski@usask.ca)