Hospitalists look at slipping ultrasounds into their tool belts
By Stacey Butterfield
Faced with a patient who needs an invasive procedure like thoracentesis, hospitalists have traditionally had two options: plunge in with the hope that one's examination skills have led to the right spot, or call a specialist.
Now, in some hospitals, there's a third option: pull an ultrasound machine out of a pocket and use it to guide the needle insertion. Ultrasound images, formerly only available from machines weighing hundreds of pounds and costing hundreds of thousands of dollars, can now be viewed on devices significantly smaller in both size and price.
Michael Westley, ACP Member, practices using a handheld ultrasound to identify and tap fluid on a slab of pork ribs. Photo courtesy of Roger W. Bush, FACP.
The relatively new pocket ultrasounds (some of which weigh less than two pounds and cost less than $10,000) are sparking interest in potential applications to hospitalist practice. Not only thoracentesis and paracentesis, but also central line insertion and bedside diagnostics could be improved—and brought definitively back into the domain of hospitalists—by the use of the gadgets, some experts say.
“These devices empower the physician at the bedside and rejuvenate the concept of the physical examination,” said Bruce Kimura, MD, medical director of the echocardiography and vascular ultrasound lab at Scripps Mercy Hospital in San Diego.
Other physicians are less certain that hospitalist-performed ultrasounds will add much value. “Before the use of the technology can be endorsed and grow, I'd think we'd want to see some evidence that it's both safe and effective,” said Mitchell Feldman, MD, professor of medicine at University of California, San Francisco and scientific consultant for the California Technology Assessment Forum of the Blue Shield of California Foundation. “I don't think we know enough yet to endorse their use.”
Even advocates of the technology agree that a number of questions need to be answered before pocket ultrasounds, also called handheld or hand-carried ultrasounds, move widely into practice: Who's going to pay for the machines? How much and what kind of training will be required? What should they be used for?
Not surprisingly, the specialists who already use ultrasounds have strong opinions on how they should be employed. “This is incredibly controversial,” said Kirk Spencer, MD, associate director of the echocardiography lab at the University of Chicago. “In my circles, there is a crowd that says anybody that isn't fully trained like us shouldn't pick these things up.”
He, on the other hand, believes the small devices will be most useful in the hands of noncardiologists, given the inferiority of their images to those available from full-size ultrasounds. “Most of the patients that I'm seeing very clearly have a cardiac complaint and need a full echo,” he said.
But among hospitalists' usual patient population, the need for cardiology testing and care is less definitive—an uncertainty that handheld ultrasounds could potentially reduce. “Where I want [hospitalists] using them is as part of the extended physical exam to detect things that would have gone undetected,” said Dr. Spencer. “Is the heart big? Is it strong? Is there fluid collection around the heart? I think those are the questions the hospitalist should be asking.”
The answers to these questions could determine the need for further testing. Dr. Spencer also sees a place for the devices in the care of patients who will definitely need other cardiac tests. “To make rapid bedside decisions: This guy needs a full echo tomorrow, but right now it's nine o’clock at night and I want to know which way to go. Should I give him fluid or not give him fluid?”
In such a case, patients would actually undergo more testing overall, acknowledged Dr. Spencer. That concerns Dr. Feldman. “Quite often, these patients end up getting two procedures instead of one,” he said. “At a time when we're worried about cost and cost containment and appropriate use of technology, I think it's important…that we make sure [new technologies] are going to improve clinical outcomes for patients.”
There is potential for handheld ultrasounds to improve clinical care, he acknowledged. “The possibility is that diagnosis can be made more quickly and easily,” Dr. Feldman said.
Pocket ultrasounds could also improve the patient experience of diagnosis or procedures, noted Roger W. Bush, FACP, who taught a pre-course on using the devices for thoracentesis and paracentesis at Internal Medicine 2011. “When you send patients away to do it, it takes them out of their room, away from their nurse, away from their family. It makes them wait in the halls, it makes them wait in radiology suites that aren't set up to take care of really sick patients,” said Dr. Bush, associate director of internal medicine residency at Virginia Mason Medical Center in Seattle.
Diagnostic use of pocket ultrasounds could also help improve the accuracy of therapy. “If we can avoid giving a therapy that might be contraindicated because we didn't know if the heart was strong or the heart was weak, then that will expedite therapy,” said Dr. Spencer.
Additionally, the gadgets could be used to decide when some patients, those with heart failure for example, are ready for discharge. “There are some conditions where we decide when to send patients home by a physical examination of them and it's very clear that this is a better way to examine people, so I think we'll be able to discharge patients more intelligently,” Dr. Spencer said.
If these pre-discharge ultrasounds—or any of the other potential applications of the technology—led to shorter lengths of stay, that could be a justification for hospitals or hospitalist programs to purchase the devices. Currently, the cost-effectiveness of pocket ultrasounds, both for society and hospitalists, is uncertain. If one is used to guide a procedure that would otherwise be referred to a specialist, the hospitalist would acquire the reimbursement for the procedure.
The finances of diagnostic uses are trickier. “If you had a technique that improved patient care and saved downstream costs, it would be worth arming your front-line people with these devices,” said Dr. Kimura. “How much would you pay for that? Will that payment incentive become the mechanism by which general physicians decide to go buy a hand-carried ultrasound?”
Not according to Dr. Spencer. “If hospitalists are interested in getting this and learning [diagnostic uses] so they can have a billable procedure in their pockets, that's not where this is going. There's no chance insurance companies are going to start paying for another huge group of physicians to do cardiac ultrasounds,” he said.
There's some potential that hospitals will be interested in buying the devices, if it turns out that downstream savings aid them in their efforts to become accountable care organizations, said David B. Hellman, MACP, chairman of the department of medicine at Johns Hopkins Bayview Medical Center in Baltimore.
“My theory is that this will improve patient satisfaction and decrease costs. I am aware that other people have hypothesized the reverse—that it could increase errors and increase costs—and I think the only way to answer these questions is to do the studies well,” he said.
The shortage of well-done studies led Dr. Feldman to write a cautionary article about handheld ultrasounds in the March 2010 Journal of Hospital Medicine. “There really wasn't sufficient evidence to support the use of this technology in the emergency department setting, and even less evidence to support its use by hospitalists,” he said.
Dr. Hellman and other researchers are working to provide that evidence. “Our own studies show that with about 40 hours of training and about 40 patients, hospitalists got much better at making assessments of the heart using ultrasound than they did by physical exam,” he reported. But, he added, “They still weren't as good as an echo technician and there still remain legitimate questions about whether they were good enough.”
Other issues to resolve include the proper protocol and timing of the assessments. “Upon initial evaluation and then perhaps, depending on how convenient it is, on daily rounding,” Dr. Kimura proposed. “What we're going to have to agree on is a basic ultrasound examination that we can apply as a method to augment general admission physical examination,” he said. “The alternative is that every center comes up with its own imaging protocol.”
To some extent, the alternative process may already be occurring. “There are a number of medical schools now where students are being exposed to ultrasound training. If this is the case, it is only a matter of time before students carry their desire to use ultrasound with them into their residencies,” said Jeanette Mladenovic, MACP, professor of medicine at the University of Miami.
Ultrasound training also appears to be edging into education for practicing hospitalists, in the form of new courses about it at both ACP and the Society of Hospital Medicine's annual meetings this year.
Such short courses are probably not going to be sufficient if pocket ultrasounds move into routine, widespread practice, the experts cautioned. “I think we need to develop an educational and credentialing process for hospitalists [using ultrasounds],” Dr. Hellman said. “In emergency rooms, hospitals have come up with training programs for the use of ultrasounds. The same as far as I know has not been done for hospitalists and I think that needs to be done.”
Dr. Mladenovic agreed. “Other specialties [emergency medicine and critical care] are ahead of internal medicine and we are just starting,” she said.
The good news is that the catch-up process should be pleasant, if hospitalists choose to undertake it. Dr. Hellman has conducted trials teaching hospitalists to use ultrasounds. “We asked them at the end what their interest was and how much they enjoyed it. The vast majority said they were delighted to learn this, very interested in ultrasound, and they wished it was part of their everyday job,” he reported.
Despite the open questions about handheld ultrasounds' cost, training and outcomes, Dr. Hellman predicts that those hospitalists will get their wish before long. “My guess is that in the next five years, you will see most hospitalists trained in some aspects of ultrasound,” he said.
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