When I arrived to my shift in the Emergency Department one Thursday, there were 5 unassessed patients on my side with more than 25 in the waiting room, some waiting for hours to be seen. Anyone who works in a busy practice knows the pressure to expeditiously evaluate these patients, and point-of-care ultrasound (POCUS) may be the last thing on your mind.
However, when used properly, POCUS is a time saver. It can lead us to the diagnosis faster, allow for next-step downstream testing, and alert our colleagues in other specialties early that we might need them soon, perhaps even occasionally saving lives.
The excuses to not do an ultrasound are many. How do I fit it into my busy practice? The question is: truly how do I not?
- Have the equipment easily accessible.
Searching for an ultrasound machine can be extremely frustrating and a disincentive to using it. No one likes to walk around and search every patient room before you even start to scan.
Because of this, every area should have their designated machine with a home base that is clearly marked and known to everybody. There are additional smart ways to ease this process. We are using a Real Time Location System with RFID technology where equipment is easily located on a tracking board. Other institutions can page an assistant through their EMR to set up the ultrasound in the patient room. Though more cost-intensive, some have chosen to have a wall-mounted machine in every room.
- Bring the machine with you.
Don’t be lazy. There are many patient complaints such as shortness of breath, flank or upper abdominal pain, first trimester bleeding, or eye problems where I am likely going to do an ultrasound study. In these cases, I will bring the machine into the room when first meeting the patient, rather than excuse myself to get it later. Through this, the traditional fragmentation of patient evaluation—ordering a test and waiting for the results—becomes streamlined and sometimes provides the definitive answer immediately.
- Rethink your work-flow.
It does not help to bring the ultrasound system with you if you first need to place an EMR order. Although institution-specific, some have found ways to break up the traditional work-flow (order > worklist > scan), allowing evaluation of patients right away. This requires a discussion with your IT department and administrator but can enable you to rapidly use ultrasound at the bedside.
Also get in the habit of doing an exam the same way every time and maybe set up your machine with predefined labels. You will be surprised how much more efficient you will be and how the quality of your scans will improve with repetition.
- Have learners leave the machine in the room.
Our more senior trainees are very versed with ultrasound and usually can get high-quality images without much hands-on direction. If you have learners at different stages, I highly recommend having them leave the ultrasound machine in the room after completing an exam. You can then review their study right in the room and obtain more views as needed. This avoids setting up the equipment again just for a few additional images.
- Keep equipment on the machine.
Having commonly-used supplies on the machine can reduce frustration of going in and out of the room. The most common ultrasound-guided procedure at our facility is IV access. For this reason, we stock the special catheters as well as sterile gel packets on the machine.
Recall the last time you weren’t lazy, rolled the ultrasound machine into the room with you and found the ileocolonic intussusception and asked the pediatric radiologist to stay late to do the air contrast enema, or the surgeon to take the patient to the OR with a ruptured abdominal aortic aneurysm (AAA)? Perhaps it was as simple as knowing it was acute cholecystitis and not ordering the contrast CT scan, sparing the young person contrast and radiation. If I can do it on a busy night, so can you.
Do you have other tips on how to fit ultrasound into your busy practice? How has ultrasound made your job easier? Comment below or let us know on Twitter: @AIUM_Ultrasound.
Tobias Kummer, MD, RDMS, FACEP, is Director of Emergency Ultrasound in the Department of Emergency Medicine at Mayo Clinic in Rochester, MN.
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All great points Tobias. I also mention to learners that, unlike their stethoscope, ultrasound keeps your ears unplugged so you can continue taking the patient’s history while scanning.
Perhaps one of the biggest issues is that it takes dedicated practice over many scans and patients to achieve speed and efficiency. Think about about how fast you were with your first few attempts at suturing or applying a cast. Now imagine that your suture and cast supplies are scattered all over the department and no one is quite sure where they are or when you need them. This is the stage many clinicians are at with ultrasound. Get experienced, get equipment supplies standardized and in designated locations, anticipate which patient will need them, and you will find ultrasound can be performed on the busiest of shifts. (And I consider it a good day in my department when we have anything less than 25 patients waiting to be seen and waits under 4 hours.)
Another tip to finding USS machine- look for rooms with light off.
Also, colour code them if you have two of the same make- Users can put in report which machine has images on HD (“stored on green machine”) and so you know when the ward has pinched one.