November 8, 2010
AIUM Ultrasound Practice Forum
Page 4
/ AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINEULTRASOUND PRACTICE FORUM
OB/GYN POINT-OF-CARE PROCEDURES
Moderator: Alfred Abuhamad, MD
NOVEMBER 8, 2010
Topic / Discussion/ConclusionIntroductions / Individuals representing each society present gave an introduction including use of ultrasound, use of guidelines, and professional concerns.
Societies present included:
· American College of Nurse-Midwives
· American College of Obstetricians and Gynecologists
· American College of Osteopathic Obstetricians & Gynecologists (ACOOG)
· American College of Radiology (ACR)
· Society of Radiologists in Ultrasound (SRU)
· American Institute of Ultrasound in Medicine (AIUM)
· American Registry for Diagnostic Medical Sonography (ARDMS)
· American Society for Reproductive Medicine (ASRM)
· Association of Physician Assistants in Obstetrics & Gynecology
· Society for Reproductive Endocrinology and Infertility (SREI)
· Association for Women’s Health, Obstetric & Neonatal Nursing (AWHONN)
· Society for Maternal-Fetal Medicine (SMFM)
· Society of Diagnostic Medical Sonography (SDMS)
· World Federation for Ultrasound in Medicine & Biology (WFUMB)
Explanation of flash drive contents / Dr Abuhamad gave overview of flash drive contents, explaining survey results.
a. Group was surveyed prior to the Forum to determine:
1. Frequency of OB point-of-care procedures
o Limited obstetric examination
o Fetal presentation in labor or office
o Ovarian follicle measurement
o Fetal station in labor
o Fetal cardiac activity
o Cervical length
2. The existence of practice guidelines for OB point-of-care procedures
3. The existence of qualification guidelines for OB point-of-care procedures
Purpose of meeting explained by Dr. Abuhamad / Purpose of meeting is to develop a definition of limited obstetric ultrasound and then develop the corresponding education and training requirements.
Development of definition of Limited Obstetric Ultrasound / Discussion:
a. Which applications should be defined under Limited Ultrasound Examination?
1. Limited ultrasound means answer to one question, one scan can not be responsible for everything.
2. Definition could be reworked to include several components every time.
3. Cardiac activity should always be examined.
4. AIUM used to have a statement that said if clinically feasible, a complete exam should be given.
5. If providers add components, the limited ultrasound becomes a full exam.
6. Even if scan is to determine one answer, should those performing the scan be trained in several indications?
7. Circumstances of patient and facility must be taken into consideration.
b. View AIUM Definition of Limited Ultrasound (Approved November 14, 2009)
1. Group was comfortable with definition.
2. Group to take AIUM definition one step further by listing components of Limited Ultrasound.
c. Group not unanimous in acceptance of term “Limited Ultrasound”.
1. Other words considered (Finite, Focused)
2. Action item: Dr Abuhamad to discuss term with AIUM leadership.
Outcome:
1. Definition developed.
Limited Ultrasound in Ob/Gyn: The structure or organ that is assessed by ultrasound is based upon the indication of the ultrasound examination. Definition of the components of the ultrasound examination should be indication specific and include one or more of the following:
· Fetal presentation or position
· Placental localization
· Cardiac activity
· Cervical length
· Amniotic fluid assessment
· Fetal number
· Estimate of gestational age using at least a single measurement
· Follicular measurement
· Post-void assessment of bladder volume
· Presence or absence of pelvic fluid
· Confirmation of intrauterine pregnancy
b. Components considered but rejected by group:
· IUD localization
· Procedure guidance
· Retained products
· Biosphysical profile
· Estimated fetal weight
Limited Ultrasound Qualifications / a. Group agreed that “Education, training, and competency and Credentialing should be commensurate with the focused application of the examination being performed.”
Education and Training / Discussion:
a. Association for Women’s Health Obstetric and Neonatal Nursing (AWHONN) guidelines viewed by group, many felt guidelines were too general
b. Can competency be determined by # of examinations? Group divided.
c. There is data to show the # of examinations necessary before reaching competency
d. ACEP published article; range is 25 – 50 examinations
e. Should local institutions determine competency?
f. Need to set national minimum standard in order to be sure patient care is not compromised.
g. Competency should be determined by quality and quantity of examinations
h. There could be a matrix of competencies
i. Could use different phases – ie, didactic phase, experiential phase, Credentialing phase
j. Is there a role for AIUM to create an exam for competency?
Outcome:
1. Education and Training Requirements defined:
· Educational component should include the focused application and limitations, clinical documentation of the examination, as well as the ALARA principles and basics of physics and instrumentation.
Discussion:
a. Physics considered by some to be a bit cumbersome, ultimately decided necessary by group
· Education and training must include proctored ultrasound examinations in a clinical setting by a healthcare provider who is experienced and qualified in ultrasound.
· Competency of trainees must be documented upon completion of training. Ongoing competency evaluation is recommended and its method may be determined by local institutions.
Group worked to develop mock practice guidelines / Practice Guidelines for the Performance of the Placental Localization Ultrasound Examination (Draft mock guidelines attached).
1. Introduction (not discussed).
2. Indications
Discussion:
a. Should be more about technique
b. Insurance companies will be looking for indications
c. What are criteria for reimbursement?
Outcome: Indications determined.
1. Vaginal bleeding in second or third trimester
2. History of abnormal placentation in current pregnancy
3. Placental localization prior to uterine incision
3. Qualifications & responsibility of personnel (not discussed during exercise).
4. Specifications of the examination
1. Patient in supine position
2. Bladder empty
3. Longitudinal and transverse planes in the lower segments of the uterus
4. Extend/relationship of placental edge to lower uterine segment
5. Document fetal presentation and cardiac activity
5. Documentation
Discussion: Should every image be documented?
a. Documentation should be addressed by manufacturers
b. Difficult to document the volume of images, not practical
c. Images become unreadable when scanned
d. Have to move into 21st century
e. Everyone should follow same protocol radiologists do.
f. Accreditation will require pictures.
g. Store clips of fluid assessment
h. Taking clips is great
Outcome: Documentation requirements determined.
1. Note in medical records documenting the indication for the examination and findings to include placental localization, cardiac activity and fetal presentation.
2. Image documentation should also be obtained and made part of medical records
6. Equipment specifications
a. Group unanimous.
1. Good shape
2. Prove yearly maintenance to ensure ongoing quality
3. Ability to print/store images
4. Appropriate transducers
7. Quality control & improvement
a. Group unanimous.
1. Obtain verbal informed consent
2. Inform the patient of the limitations.
Thanks / Thanks to all participating groups