“I’m looking for volunteers, not hostages.”
— Mike Tomlin (Head Coach of the Pittsburgh Steelers Football Team)
I enjoy quotes that help keep things in perspective (even though I’m more an ice hockey fan than an American football fan), and I could have used coach’s advice after my Emergency Ultrasound Fellowship concluded in 2002. I believed, then, that every Emergency Physician would find the allure of ultrasound’s rapid, portable diagnosis irresistible and abruptly begin using it. A string of successful research and equally enthused editors would publish article after article and ease the path to acceptance of “emergency medicine ultrasound” or “point-of-care ultrasound” (POCUS).
As if data would impose ultrasound adoption.
The hard pivot did not come as quickly as I hoped. As an example, my early work examined how ultrasound improved the safety of central venous cannulation. The fields of Anesthesia and Interventional Radiology learned this years before Emergency Medicine, and it seemed natural that, once adopted, finding a vein with ultrasound anywhere would prove too irresistible for the Emergency Physician to pass up.
I soon discovered that trainees embraced ultrasound (they knew no alternative) but more experienced providers passed on it, stubbornly reverting to what they found more comfortable. They rationalized that learning something new disrupted their workflow. Besides, their cases rarely had complications.
Make no mistake, youth alone would not resolve the disrupted workflow dilemma. A few years later, motivated by the work of Peter Pronovost in intensive care units and championed by Atul Gawande’s Checklist Manifesto, my research team attempted to incorporate ultrasound-guided central line checklists in the Emergency Department to decrease central line-associated bloodstream infections. After presentations at journal club and grand rounds, we measured checklist adherence at exactly zero! I distinctly remember trainees’ wry joy in seeing my face as the paper with the printed checklist was ceremoniously discarded, the central line expertly inserted under ultrasound, and the patient stabilized. The academic journals and even the lay press had done their part disseminating the new information but implementation of a checklist…that was a new challenge unto itself.
Examining what changes behavior in healthcare feels like psychoanalysis. Lesson one is we’re not rational beings moved by published data. The AIUM promotes guidelines, education, and training, and offers a stage to persuade and model the benefits of ultrasound-assisted medicine. But is this enough?
The growing field of Implementation Science suggests there’s more to do. A salient theory pertinent to changing behavior in health care is known as the COM-B system. Capability, Opportunity, and Motivation are essential conditions that underpin Behavior. In our checklist example, we possessed the capability and opportunity but the motivation was so low it sank adoption. Behavior didn’t change. Data was not enough.
Our team, led by Dr. Enyo Ablordeppey, took a different approach to adopting new ultrasound techniques, which we presented at AIUM 2022 in San Diego. Before we imposed confirming central line placement solely by ultrasound, precluding the chest x-ray and saving radiation exposure, we worked backward from COM-B to create a framework of interventions. We gathered the group of end-users and began by listening to them. Out of these sessions, we developed seven strategies:
- Organizational buy-in
- Decision support
- Planned adaptation (ie, prizes for, and promotion of, early adopters)
- Algorithm development
Our program to De-Implement Routine Chest Radiographs after Adoption of Ultrasound Guided Insertion and Confirmation of Central Venous Catheter Protocol is called DRAUP. It’s a mouthful and a mound of work but, 6 months into it, we increased ultrasound adoption and decreased chest x-ray utilization by 50% with identical complication rates to conventional behavior. For comparison, 10 years later, we still don’t utilize the central line insertion checklists!
At the root of it, implementing innovative ultrasound requires addressing an interplay of environmental, cognitive, sensory, and emotional processes. All ultrasound users have experienced the implementation challenge when an innovation seems blithely disregarded despite impact. Procedural guidance, nerve blocks, spectral Doppler diagnostics (all topics expertly covered in San Diego at AIUM 2022) lack traction despite concluding slides with imperceptible font sizes to document volumes of references!
Why isn’t the evidence enough? Perhaps we’ve taken the wrong approach? Perhaps we need to uncover barriers from our non-ultrasound using hostages and promote facilitators from our ultrasound volunteers! What’s worked at your shop?
Dr. Daniel Theodoro, MD, MSCI, is the Division Director of Washington University’s Emergency Medicine Ultrasound Program. In 2002, he completed the first Emergency Medicine Ultrasound Fellowship at North Shore University Hospital in Manhasset, New York. His team’s current projects include how to de-implement dogmatic chest x-rays after ultrasound-driven central line placement confirmation, how well COVID lung findings prognosticate future oxygen requirements, and how TEE can inform CPR quality. Tweet him @TeddyDanielz!
Interested in learning more about POCUS? Check out the following posts from the Scan: