Ultrasound Examinations by 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.

Surgeon eligibility and verification in basic ultrasonography

The surgeon should provide evidence of training by meeting the following criteria:

1. 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.
2. 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.
3. 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.

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:

1. Verification of qualifications in the basic use of ultrasound.
2. 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.]

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.

Ultrasound facility guidelines

1. 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:
   1. Maximum depth of visualization and hard copy recording with a tissue mimicking phantom.
   2. Distance accuracy.
      • Vertical distance accuracy.
      • Horizontal distance accuracy.
   3. Uniformity.
   4. Anechoic void perception.
   5. Ring down and dead space determination.
   6. Lateral resolution.
   7. Axial resolution.
   8. 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.

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*Courses must meet the criteria for Approval of Courses in New Skills, American College of Surgeons, 1998.




Reprinted from Bulletin of the American College of Surgeons
Vol.83, No. 06, June 1998