Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography.
STUDY OBJECTIVE: Nearly all emergency medicine residency programs provide some training in emergency physician-performed ultrasonography, but the extent of emergency physician-performed ultrasonography in community emergency departments (EDs) is not known. We seek to determine the state of ultrasonography in community EDs in terms of access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians. METHODS: A 6-page survey that addressed access to ultrasonography performed by other specialists and emergency physician-performed ultrasonography was designed and pilot tested. A list of all US ED directors was obtained from the American College of Emergency Physicians. Twelve hundred of 5264 EDs were randomly selected to receive the anonymous survey, with responses tracked by separate postcard. There were 3 mailings from Fall 2003 to Spring 2004. RESULTS: Overall response rate was 61% (684/1130). Respondents who self-reported as being academic with emergency medicine residents were excluded from further analysis (n=35). A sensitivity analysis (reported in parentheses) was performed on the key outcome question to adjust for response bias. As reported by ED directors, ultrasonography was available in the ED for use by emergency physicians at all times in 19% of EDs (12% to 28%), with an additional 15% (9% to 21%) reporting a machine available for use by emergency physicians in some capacity and 66% (51% to 80%) reporting that there was no access to a machine for emergency physician use. ED directors reported being requested or required to limit ultrasonography orders performed by radiology in 41% of EDs, with less timely access to radiology-performed ultrasonography in off hours. Of EDs with emergency physician-performed ultrasonography, the most common applications were Focused Assessment with Sonography for Trauma (FAST) examination (85%), code situation (72%), and check for pericardial effusion (67%). Of physicians performing ultrasonography, 16% stated they were currently requesting reimbursement (billing). The primary reason cited for not implementing emergency physician-performed ultrasonography was lack of emergency physician training. For the statement "emergency medicine residents now starting residency should be trained to perform and interpret focused bedside ultrasonography," 84% of ED directors agreed, 14% were neutral, and less than 2% disagreed. CONCLUSION: Community ED directors continue to report barriers to obtaining ultrasonography from consultants, especially in off hours. Nineteen percent of community ED directors report having a machine available for emergency physician use at all times; however, two thirds of EDs report no access to ultrasonography for emergency physician use. A majority of community ED directors support residency training in emergency physician-performed ultrasonography.