November 8, 2010

AIUM Ultrasound Practice Forum

Page 4

/ AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE
ULTRASOUND PRACTICE FORUM
ULTRASOUND-GUIDED PROCEDURES
Moderator: Jay Smith, MD

NOVEMBER 8, 2010

Topic / Discussion/Conclusion
Workshop 1: Performance & Training/Qualifications Guidelines Development / Today’s task: Practice guidelines – the “what, when, how?”
Future – training guidelines – the “who?”
Both needed for accreditation
AIUM accredits practices but does not certify individuals
Work towards commonalities in developing guidelines.
For example, regardless of the procedure, the task involved getting a needle near or into something or taking something out (biopsy). This requires planning and a set of skills to execute successfully.
Start with general categories of US guided procedures:
·  Preliminary scanning
·  Patient preparation
·  Needle tracking
·  Artifacts
After that:
·  Identify specific procedures (e.g. joint injections, perineural injections)
·  Develop action plan
Difference between credentialing (certification) and accreditation
Review of template for prior AIUM Practice Guidelines
Preamble – standard language
Introduction - context
Indications/contraindications
Qualifications – may refer to respective organizations. Can be addressed in subsequently developed AIUM Training Guidelines for US Guided Procedures
Written Request
Specifications (General and specific)
Documentation
Equipment (specifications, care)
What procedures are we talking about:
Joint injections/aspirations
Peritendinous injections
Biopsy of masses (lymph; thyroid, mass, visceral parenchyma, etc). This will overlap with Track 3.
Muscle biopsy/injection
Aspiration of abscesses and other fluid collections
Inject Alcohol into cysts; inoperable tumors (ablation) in thyroid, parathyroid, lymph;
Calcifications (breaking up; disruption)
Advanced MSK US procedures (e.g. percutaneous tenotomy, hydrodissection)
Needle guidance for advanced electrodiagnostic procedures
Nerve block (peripheral and axial)
Needles everywhere
Reviewing the “Guidelines Template”
Preamble - What the document will not cover
Contraindications /Limitations
-Consider discussion of role of US versus other imaging modalities for guidance purposes (strengths and weaknesses)
Penetration
-Depth of penetration
-Limited penetration in certain tissues (e.g US cannot penetrate bone) Limited aco
-Limited acoustic window (e.g. poor visualization in the retroesophageal region)
Historic Perspective – where does this fit in?
Qualifications
-Board certification in respective specialty
Responsibility of examiner to identify US as the appropriate modality
-Expertise – US can be used when appropriate (note limitations of the practitioner)
-Understanding of US physics as pertains to interventional procedures
-Knowledge and skills in needle tracking under ultrasound using “In plane” (whole needle and shaft in the transducer) and “out of plane” (cross section of needle) techniques
-Knowledge and recognition of sonographic appearance of common target tissues and “at risk” tissues (e.g. nerve vs. tendon vs. artery vs. vein).
-Skills to acquire and optimize sonographic picture of target as well as surrounding tissues
-Awareness of pathophysiology of disorders for which US guided interventions are relevant, including recognition of the role of the procedure in the context of the disorder
-Knowledge and recognition of common artifacts (e.g. enhancement; shadowing; reverberation)
-Knowledge and skills necessary to practice safe US (e.g. ALARA)(may draw upon other AIUM documents)
Obtain ASRA guidelines for competencies
Obtain relevant ACR guidelines for competencies
Written Request
-Diagnostic scans need written requests for reimbursement
-Appropriate documentation of the indication for a procedure is needed
-Deviation from indication/procedure requires appropriate documentation
Specifications
-There should be an informed consent process based upon your individual practices
-Discussion regarding the role of the preliminary scan
> Obtain and optimize image
> Identify efficient, risk-free route to target
>Does patient need a prior diagnostic scan?
>Do you just obtain a picture of the target or do you do a limited examination of the target?
-A complete exam should be performed based on the organ being imaged.
-Consider the following language “Preliminary scan should be performed to optimize image; to identify landmarks; determine best approach for procedure; identifying contraindications (anomalies that might alter the procedure) and communicating them back to the originating physician.”
-Ultrasound was performed for the purpose of ___(thyroid biopsy, nerve block, etc.) Identify regional anatomy
-Standard of care for thyroid biopsies is that you need to fully scan the thyroid, and document
-For nerve blocks, you do a “quick scan of region”, but this is not necessary “diagnostic” from a documentation and billing standpoint
-Incidental pathology vs. contraindication of the procedure. If an unexpected finding is seen, then it needs to be reported back to the requesting physician.
Documentation
-Need picture of the target
-CPT code requires documentation of target, but not a picture of needle en route to target
-Use of US guidance without billing may diminish the perceived value of US as a reimbursable image guidance modality
-When is documentation/billing important vs. not important? This is likely to be determined by specific practice patterns.
-When documenting:
Need picture of the target.
In written report, the method by which you reached the target (describe the procedure).
Procedural specifications / Documentation
Ergonomics
-Ergonomoic considerations for optimal procedural success
-May include general considerations
-Consider referral to AIUM or ARDMS documents
-May include procedural-specific ergonomic considerations (work groups)
Infection control
-Sterile technique vs. Aseptic technique vs. others
Sterile technique as required by the procedure.
>Obtain surface probe sterility parameters
Needle guidance
-In plane (provide synonyms such as Transverse, Long axis, etc)
-Out of plane
-Free hand vs. needle guides
-Shortest distance to target
Equipment – reprocessing
-Transducer selection – standardized by AIUM
-Maintenance– standardized by AIUM
-Cleaning (surface probes)- sprays and wipes adequate
-AIUM Recommendations for Cleaning Transabdominal Transducers
ApprovedJune 22, 2005
After each examination, transducers used on the skin surface should be cleaned according to guidelines already established for endocavitary transducers. Probes should be cleaned with soap and water or quaternary ammonium sprays or wipes as directed by the manufacturer (see operating manual). Additional cleansing may be necessary in cases of blood or other contamination.
-See also: Guidelines for Cleaning and Preparing Endocavitary Ultrasound Transducers Between Patients ApprovedJune 4, 2003
Specific procedures (refer to REI guidelines)
-Joint Aspirations/Injections
-Fluid Aspirations (bursa, cyst, ganglion, hematoma, abscess)
-Tendon sheath injection/aspiration
-Nerve blocks (axial vs peripheral)
-Biopsies (masses, lymph nodes, organ, etc.)
-Advanced MSK procedures (e.g. percutaneous tenotomy)
Training Guidelines / Preliminary discussion of training guidelines
Reminder that primary focus at this time is Practice Guidelines, not Training Guidelines
Example – Must perform at least 10 procedures/month (AACE)
How to put ultrasound training into medical schools? Goal for AIUM.
How to show competency when there is no program for ultrasound available for medical schools?
What about for those pioneering ultrasound?
Hard to get around having some number in the document.
Need to come up with some minimum skill set.
Next Steps / Collate results from today’s forum
Generate a list of procedures (see above) and have forum members sign up to develop procedure specific practice guidelines, including:
-Specific procedure (e.g. biopsy)
-Indications/contraindications
-Specific qualifications (as relevant)
-Specific procedural considerations (as relevant)
-Specific documentation considerations (as relevant)
Form working groups around these procedures and have working groups generate information to be incorporated into master document
Estimated time frame – first or second quarter 2011
Thanks / Thanks to all participating groups