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 ([email protected])Northwest: Dal Lynds ([email protected])Southeast: Southwest: Michael Kapusta ([email protected])Regina: Ankit Kapur ([email protected])Saskatoon: Paul Olszynski ([email protected])
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