[ST-31] Ultrasound Examinations by Surgeons
[by the American College of Surgeons]
The following statement was developed by the College's
Committee on Emerging Surgical Technology and Education (CESTE)
and was approved by the Board of Regents at its February 1998
meeting.
Introduction
Ultrasonography is a technology applicable in a wide variety
of surgical practices and surgical specialties, and has become
a routine tool for noninvasive evaluation of many organ systems
and targeting areas for intervention. Examples include ultrasonic
evaluation of the eye, the neck, reproductive organs, and the
vascular, nervous, and musculoskeletal systems. Clinical applications
of ultrasound require unique knowledge and skill.
To ensure that surgeons who use ultrasound are qualified and
that the ultrasound facilities and equipment they use are appropriate
for the medical application and meet and maintain quality standards,
a voluntary verification process has been made available to Fellows.
There are several components to this process: first, the surgeon
must meet the requirements for education and/or experience; second,
the facilities and equipment should meet recommended standards;
third, the surgeon should maintain qualifications through continued
experience and formal continuing medical education in the technique
and its applications; and fourth, surgeons' outcomes using ultrasound
should be assessed through a program of continuous quality improvement.
American College of Surgeons' Voluntary Verification Program
for Surgeons in the Use of Ultrasound
Surgeons performing ultrasound examinations and ultrasound-guided
procedures must be familiar with the principles of ultrasound
physics, and the indications, advantages, limitations, performance,
and interpretation of the ultrasound examinations. The facilities
used by the surgeon should be adequate and the equipment should
be appropriate to the application. Technologists working under
the supervision of the surgeon must be appropriately trained
and certified and their performance regularly evaluated within
the framework of the quality improvement process.
1. Surgeon eligibility and verification in basic ultrasonography
The surgeon should provide evidence of training by meeting
the following criteria:
a. Satisfactory completion of an accredited residency program
in a surgical specialty, for example, through documentation of
current certification by an ABMS Board or its equivalent.
b. When residency and/or fellowship did include documented
training in the principles of ultrasound physics, the indications,
advantages, and limitations of ultrasound, and personal experience
with performance and interpretation of the ultrasound examination
and ultrasound-guided interventional procedures, including knowledge
of the indication for these procedures, complications that might
be incurred, and techniques for successful completion of these
procedures, the surgeon will be eligible for verification of
qualifications in the basic use of Ultrasound on review of their
documentation.
c. When residency or fellowship training did not include education
and personal experience in the use of ultrasound, completion
(Level 2) of a basic approved educational program* in ultrasound
physics and instrumentation, including didactic and practical
components, is required for verification of qualifications in
the basic use of ultrasound.
The basic level of ultrasound expertise includes the ability
to acquire and interpret images of normal ultrasound anatomy.
2. Verification of surgeons who independently perform specific
ultrasound examinations and procedures
Examples of specific ultrasound applications are: FAST examination
in trauma; breast examination and biopsy; evaluation of the thyroid
and parathyroid; transrectal examination of the prostate and
rectal tumors; endoscopic examination of the upper gastrointestinal
(GI) tract and hepatobiliary system; intraoperative and laparoscopic
examination of intra-abdominal and thoracic organ systems; vascular,
obstetric, gynecologic, ophthalmologic, and transcranial examinations.
The surgeon using specific applications of ultrasound in an independent
mode must have basic and specific expertise.
Specific applications require:
a. Verification of qualifications in the basic use of ultrasound.
b. Fundamental knowledge of and current competence in the
management of the relevant clinical condition together with additional
clinical expertise and training in diagnostic ultrasound. The
ability to distinguish abnormal findings, and to perform ultrasound-guided
procedures in the relevant clinical condition is also necessary.
These qualifications can be demonstrated by:
Completion (Level 2) of an approved educational program in
the specific application of ultrasound pertaining to the specific
clinical area of interest (trauma, and so forth). OR
Documented experience and satisfactory outcomes in the use
of specific application of ultrasound in the specific clinical
area of interest and meeting the specified learning objectives
of the specific module (for example, successful completion of
the written examination).
[Criteria (a) and (b) may be fulfilled in a residency or fellowship
that specifically includes sufficient education and experience
under the supervision of a qualified physician.]
3. Recommendations for maintenance of qualifications
To maintain proficiency in ultrasound applications, surgeons
are encouraged to perform and interpret ultrasound examinations
and have regular ultrasound-related Category 1 CME. These surgeons
must document that a continuous quality improvement process is
established and that proper records are maintained.
4. Ultrasound facility guidelines1. Medical staff/medical
director.
A licensed physician is specified and responsible for determination
and documentation of the quality and appropriateness of testing.
This individual should oversee the development of a written policy
for the granting of privileges for the medical staff. Such a
policy should specify the scope of the privileges, specialty
background, and education and experience in ultrasonography.
2. Scope of practice.
The scope of practice (listing of all types of examinations
and procedures) should be explicitly stated and documented.
3. Electrical safety.
Testing of electrical safety of the ultrasound equipment must
be performed on a regular basis and the results documented.
4. Equipment.
For the proposed examinations and/or procedures the equipment
and transducer selection should be the most appropriate to obtain
optimal images of high resolution.
5. Quality control.
The ultrasound equipment should be calibrated at installation
and at least annually thereafter. The following tests are recommended
for inclusion in the quality control program on, at least, an
annual basis:
a. Maximum depth of visualization and hard copy recording
with a tissue mimicking phantom.
b. Distance accuracy.1. Vertical distance accuracy. 2. Horizontal
distance accuracy.
c. Uniformity.
d. Anechoic void perception.
e. Ring down and dead space determination.
f. Lateral resolution.
g. Axial resolution.
h. Data logs on system performance and examples of results.
The process for testing and the standards for performance
should be referenced. Technologists should be evaluated on a
quarterly basis, and the results of that evaluation documented.
Minimum performance evaluation should include:
1. Assure adherence to universal infection control precautions.
2. Distance calibration--quarterly.
3. Gray-scale photography--quarterly.
6. Clinical images.
Photographic images or films of normal and abnormal examinations
should be available for review. In those facilities performing
procedures, pre-and post-procedure films or photographs should
be clearly labeled.
7. Equipment quality control.
Each facility should have documented policies and procedures
for monitoring and evaluating the effective management and proper
performance of imaging equipment. Quality control programs should
be designed to maximize the quality of the diagnostic information.
Equipment performance should be monitored regularly in conformity
with standards for ultrasound imaging and phantom testing for
resolution. Such monitoring may be accomplished as part of a
routine preventive maintenance program.
8. Quality improvement.
Quality improvement procedures should be systematically monitored
for appropriateness of examination, for technical accuracy, and
for the accuracy of interpretation. The total number of examinations
and procedures should be documented on a quarterly basis. Incidences
of complications and adverse events incurred during ultrasound-guided
interventional procedures should be recorded and regularly reviewed
to identify opportunities to improve patient care.
*Courses must meet the criteria for Approval of Courses in
New Skills, American College of Surgeons, 1998.
Statements
__________
Reprinted from Bulletin of the American College
of Surgeons
Vol.83, No. 06, June 1998
