Published in the October 2012 issue of Today’s Hospitalist
WHEN HOSPITALIST JEFFREY H. BARSUK, MD, wants to use a portable ultrasound machine to help him insert a central line or look for fluid around a patient’s heart, he has to put on his running shoes.
That’s because of the high expense associated with having readily available ultrasound at the bedside. “If it were there,” says Dr. Barsuk, associate professor of medicine at Chicago’s Northwestern University Feinberg School of Medicine, “I would use it all the time.”
Instead, he typically borrows a machine from the ICU or another service. Or, as happened recently, he might ask to delay moving a patient from the emergency room until he can use one of the ED’s machines to do an ultrasound-guided thoracentesis.
It’s a situation he doesn’t see changing any time soon. And because the hospitalist service lacks a dedicated ultrasound machine, Dr. Barsuk explains, very few of his hospitalist colleagues have jumped on the bedside-ultrasound bandwagon with him.
“We need to get the people in the hospital up to speed so that their medical students aren’t showing them up.”
When it comes to using ultrasound at the bedside, hospitalists face a range of challenges. At the University of California, Irvine, for example, there’s no lack of equipment. The medical center spent half a million dollars this year purchasing nine new portable machines, installing one on each medical floor and in each ICU.
Instead, the problem is a lack of training and a dearth of mentors. And then there’s what Liz Turner, MD, who was formerly a critical care physician and ultrasound advocate at UC Irvine, calls “the intimidation factor.” “We need to overcome the first barrier that most people have, which is thinking that ultrasound is hard to do,” she says.
Across the country at Carilion Clinic in Roanoke, Va., hospitalists have both the machines and opportunities to learn in free four-day training courses. Even so, ultrasound is not particularly high on the agendas of most hospitalists.
According to Christian H. Butcher, MD, an intensivist at Carilion, the biggest barriers to hospitalists there adopting bedside ultrasound are familiar: too much work and too few staff.
“There is such a high turnover in the hospitalist service and the service is so busy,” Dr. Butcher explains. “Those things together are conspiring against the widespread adoption of bedside ultrasound here.”
If you ask hospitalists if they would like to do bedside ultrasound to identify problems, “they are almost all going to say yes,” says Dr. Butcher. “But if you ask if it is feasible to take an additional 15 or 20 minutes to go find a machine, bring it up to the room and take a look at a patient, they will say, ‘No way. I am way too busy.’ ”
For hospitalists, many challenges remain to adopting what some insist is an incredibly valuable diagnostic tool. There are worries about equipment costs and return on investment and about political pushback from radiologists and cardiologists.
But probably the biggest single barrier to the adoption of bedside ultrasound is a lack of indisputable evidence that hospitalists using portable ultrasound for diagnostic purposes boosts quality of care and reduces costs.
In a handful of hospitals, however, hospitalists are leading the way in adopting handheld ultrasound. They are finding ways to address those challenges and move forward with more comprehensive use.
The push for evidence
Consider the University of Texas Health Science Center (UTHSC) at San Antonio, where hospitalist Nilam J. Soni, MD, moved this spring from the University of Chicago. He made the move in large part to work with colleagues who are developing bedside ultrasound training programs and conduct research into the impact of ultrasound-guided inpatient management. Dr. Soni is director of the procedure service and patient safety rotation for UTHSC’s medical residents, where the program now teaches portable ultrasound to trainees.
While Dr. Soni admits that the lack of training for hospitalists is a high hurdle, the lack of outcomes research is just as big of a barrier. “We need research showing that when bedside ultrasound is added to patient evaluation, they are able to get better care,” he says.
That’s just a hunch, but one that he hopes to prove with outcomes research. Dr. Soni believes that evidence will show that bedside ultrasound has the potential to become the standard of care for a great many calls that hospitalists have to make.
Those include determining if a patient’s lung crackles relate to edema or atelectasis, if shortness of breath is due to COPD or CHF, if leg swelling is caused by cellulitis or a DVT, if dullness at the base of the lungs comes from pneumonia or a pleural effusion, or if low urine output is due to an inoperative Foley catheter or something else altogether.
Avoiding delays and mistakes
Recently, a man ready to be discharged “got hypotensive all of a sudden,” Dr. Soni recalls. Grabbing the portable ultrasound that the hospitalist service stores at the centrally located nursing station on the medical floor, “we were able to look at his IVC (inferior vena cava) and see it was big and distended. He had too much fluid on board, and his heart function was worse.” That quick exam led to an urgent transfer to the ICU, where the patient got vasopressors to bring his blood pressure up, saving his life and buying him time for a formal echocardiogram to figure out what was really going on with his heart.
“The potential mistake we make all the time” with such a patient “is to give him more fluids,” says Dr. Soni. Instead of guessing wrong and wasting time correcting a mistake, “in a minute or two, I had a lot of useful information.” Every other way to manage such a patient “would either be invasive or at a minimum take a few hours.”
But while research has shown that noncardiologists can be trained to do ultrasound scanning, Dr. Soni says that more studies are needed to establish the effectiveness of adding the technology to hospitalists’ armamentarium.
A new skill set
“We know it’s safe, it’s basically radiation-free, patients like it and it gives you immediate information,” explains Bradley T. Rosen, MD, MBA, medical director of the nonteaching hospitalist program at Los Angeles’ Cedars-Sinai Medical Center.
He’s also the co-founder and co-director of the procedure and ultrasound precourse given every year at the Society of Hospital Medicine’s annual meeting. “The barriers are, ‘I don’t know how to do it,’ ‘I don’t have anyone to teach me how to use it,’ ‘I don’t know if I want to spend the money because I don’t know if I am going to get reimbursed,’ and ‘I don’t want to deal with the politics from radiology.’ All those issues feed on each other and result in inertia.”
For hospitalists who do their own procedures, Dr. Rosen says, “that’s a great opportunity to get ‘the camel’s nose under the tent.’ When you’re trying to get a big thing in, start with something small.” At Cedars-Sinai, the “camel’s nose for hospitalists and bedside ultrasound was the need for ultrasound-guided procedures, which have proven to be safer and to improve the quality of patient care.”
Once hospitalists acquire the machines to guide procedures, he says, “They start thinking, ‘I have this great machine, what else can I do with it and what else can I see?’ You discover the incredible potential to help you make better decisions at the bedside and focus your work-up and treatment. That saves time and helps patients.”
Interestingly, while Dr. Rosen is a staunch advocate of helping hospitalists use bedside ultrasound, he has encountered an unanticipated consequence of having expert proceduralists readily available at his institution: The hospitalists in his group don’t have to maintain procedural privileges, let alone think about learning the art of diagnostic ultrasound.
But efforts are underway, he explains, to change that. Mark Ault, MD, the founder of Cedars-Sinai’s procedure center, has recently started a series of ultrasound training sessions for internists and hospitalists. Dr. Rosen is a part of that effort. “Like any new skill set, it takes time to build a critical mass to overcome the hurdles,” he says. “If we stick with it, I have no doubt that bedside diagnostic ultrasound will be incorporated into the routine evaluation and care of patients before too long.”
Costs and training
In Virginia, Dr. Butcher takes a similar view. “If you are going to spend tens of thousands of dollars on a piece of ultrasound equipment to put in central lines, you might as well spend an extra $5,000 to get a cardiac probe to start looking at the heart,” he says. “You don’t want to have equipment sitting in the corner gathering dust. You are not recouping any of your investment.”
As long as you have a way to store your images “which Dr. Butcher says can be as simple as dumping the machine’s memory onto an external hard drive every so often, as he does currently “you can bill many payers for limited ultrasound exams or limited echocardiograms.
In addition, he says, the cost of some of the machines may drop dramatically. He mentions a general pocket-sized machine (GE’s Vscan is one example) that “will probably be great in a few years” when second-generation scanners come to market.
Just as some of cost barriers may change over time, so may the issue of training. Dr. Butcher says the three-year old Virginia Tech Carilion School of Medicine has incorporated ultrasound throughout its medical school curriculum. The medical students first handle the equipment in first-year anatomy class and continue to use it until they graduate. The next generation of doctors, Dr. Butcher says, will likely look at the equipment and its bedside use as standard procedure.
Residents at Northwestern are likewise learning bedside ultrasound. While residency programs didn’t use to include ultrasound, ACGME requirements now mandate ultrasound training for pulmonary and critical care. Emergency medicine also now trains all residents in bedside ultrasound.
Even given that requirement, resistance to change can act as a speed bump, slowing down adoption of new technology. It is estimated that fewer than half the emergency departments in the country have a diagnostic ultrasound system under their control, says Theodore J. Nielsen, director of critical care and emergency medicine for SonoSite Inc., a major manufacturer of the equipment.
He adds, however, that “this is changing fast. When emergency medicine doctors come out of residency now and take jobs, they ask, ‘Where is the ultrasound system?’ It’s an incentive for recruitment.” Critical care is the next frontier, says Mr. Nielsen, and hospital medicine will likely come onboard after that.
“When we talk about the rate of adoption,” he says, “it is likely to increase because of several factors right now: improving patient safety, reducing the potential risk for infection, and decreasing costs and radiation exposure.”
Tackling hospital politics
At the University of California, Irvine, Dr. Turner worked to create training programs, thanks to a special grant she received from the University of California Center for Health Quality and Innovation.
A former hospitalist, Dr. Turner was the director of UC Irvine’s medical ICU. (She has since been recruited to the University of California, Los Angeles, where she is director of bedside ultrasound.) That position will entail training not only the critical care doctors but the hospitalists as well as other disciplines.
Dr. Turner thinks the best way to “lose the intimidation factor” is “by putting the probe in physicians’ hands and let them see that they can do it.” She notes that she has had success overcoming several barriers by first tackling another big challenge: hospital politics.
With support from UC Irvine Medical Center’s top medical executives, she says, the hospital a year ago convened a multidisciplinary ultrasound utilization committee that included representatives from every department in the hospital that uses ultrasound, from radiology and cardiology to ob-gyn, ED and ICU. Monthly meetings helped everyone first “understand each other” and then “understand how bedside ultrasound is different from formal ultrasound.”
Initially, Dr. Turner says, the radiologists and cardiologists “just like their colleagues elsewhere “viewed portable ultrasound as an incursion into their territory.
“But then they agreed that they cannot be there to take a quick peek at a patient’s IVC after giving the patient a liter of fluid,” she notes. They eventually agreed that “we need to be able to do that.”
The end result, says Dr. Turner, was “harmony,” followed by a successful request from the entire committee for portable ultrasound machines for all the ICUs and medical floors.
“We asked for 12, and they gave us nine,” she says. “In these hard financial times, we could justify that this is for patient safety and cost savings, and that it is now becoming the standard of care for all procedures. How can you say no when it’s coming from the entire committee?”
A bridge for teaching
Dr. Turner points out that the institutional barriers are going to be different in every hospital. But once she and her team removed the political and financial obstacles, they could turn their attention to training.
Medical students at UC Irvine, like those at Virginia Tech Carilion, now learn ultrasound as part of their curriculum. “I think that what we are doing is just a bridge,” says Dr. Turner. “We need to get the people in the hospital up to speed so that their medical students aren’t showing them up “and so they can properly supervise their medical students.” The students will know how to get a picture, she adds, “but may not know how to put it into context and what to do with it.”
Despite a host of barriers, advocates for bedside ultrasound say the technology and its acceptance is advancing steadily, if slower than they might like.
“My prediction,” says Dr. Butcher, “is that 10 years down the road, you may be able to buy a very high quality machine for less money that will do everything you want it to do. The only people who are going to be using stethoscopes are the rural folks and people in third-world countries.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
The new stethoscope?
WHILE MANY ADVOCATES of point-of-care portable ultrasound describe the equipment as on its way to becoming the stethoscope of the 21st century, others say that description does the technology a disservice.
“I think it’s an unfortunate analogy,” says Liz Turner, MD, former director of the medical ICU at the University of California, Irvine, who is now director of bedside ultrasound at the University of California, Los Angeles. She notes that she never really liked a stethoscope.
“It doesn’t tell you a whole lot, and there is not much training that goes into using it. You plug it in your ears and listen “and you may or may not interpret what you hear correctly, as auscultation can be non-specific,” says Dr. Turner. “If you downgrade ultrasound to that level, then it means anybody can do it and nobody is going to be incentivized to learn it properly. You’ll miss something big that would have been obvious if you had training. You don’t want people to be cowboy about it, and I think we are pretty cavalier about our stethoscopes.”
Theodore J. Nielsen, director of critical care and emergency medicine for SonoSite Inc., a manufacturer of the equipment, says the analogy is “comparing apples to oranges. Comparing the use of ultrasound to a stethoscope ignores many of the capabilities of ultrasound imaging.” Adequate training, however, remains the key to its success. “Ultrasound in the hands of a skilled operator will contribute to the speed and safety with which physicians may effectively manage their patients toward positive outcomes.”
Others reject the comparison for financial reasons. Just as nobody reimburses doctors for using their stethoscopes, there may be no way to compensate practitioners if ultrasound becomes just a regular part of every physical exam.
“When ultrasound becomes ubiquitous, the question will be why are payers paying you more to use it?” explains Bradley T. Rosen, MD, MBA, medical director of the inpatient specialty program at Los Angeles’ Cedars-Sinai Medical Center.
Although he personally doesn’t agree with this argument, Dr. Rosen says he hears it all the time: “Right now, physicians or their institution can offset the upfront costs of purchasing an ultrasound machine by billing payers using established CPT codes each time it is used. But if everyone has an ultrasound and its use becomes the standard of care, then payers may stop reimbursing for its use.” That runs the risk, he adds, of removing one benefit of investing in ultrasound in the first place: professional reimbursement.
In his mind, bedside ultrasound already is the stethoscope of the 21st century in terms of it being an essential clinical tool. Nilam Soni, MD, assistant professor of medicine and director of the procedure service and patient safety rotation at the University of Texas Health Science Center at San Antonio, agrees. He points out that ultrasound is “better because you can see what you are trying to listen to or feel, and you get a lot more information.”
One more reason to consider ultrasound
STARTING OCT. 1, the Centers for Medicare and Medicaid Services (CMS) has added at least one more hospital-acquired complication that it won’t pay for: iatrogenic pneumothorax from venous catheterization. Studies have indicated that the increased costs associated with that complication may be more than $2,700 and that a patient’s length of stay may be prolonged an average of 1.4 days. While the CMS will continue to pay for the underlying condition that made thoracentesis necessary, it will no longer foot the bill to treat the complication.
Guidelines now recommend ultrasound-guided thoracentesis over the use of X-rays or CTs, with ultrasound guidance linked to lower pneumothorax rates. Hospitals are already publicly reporting their rates of iatrogenic pneumothorax on Hospital Compare.