Ultrasonography use in the emergency department: Six-month prospective analysis

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Study objectives: Although emergency department (ED) ultrasonography is embraced officially by the American College of Emergency Physicians and is used at virtually all emergency medicine training sites in the United States, the extent to which it has been incorporated into emergency medicine practice has not been well characterized or quantified. Our objective is to record, quantify, and characterize the use of ultrasonography at an emergency medicine training site where it has been fully implemented. Specifically, we assess the volume and frequency of studies, breadth of applications, experience level of sonographers, and impact on clinical management. Methods: This prospective observational study was conducted during a 6-month period in the high-acuity section of an urban county ED with an emergency medicine residency, an emergency medicine ultrasonography fellowship, and 3 available ultrasonography machines. Basic information about all ED ultrasonographic examinations was handwritten in logbooks located on the ultrasonographic machines. These data were imported into a computerized database for analysis. Results: From October 10, 2003, to March 10, 2004, there were a total of 19,896 patients treated in the high-acuity ED, of whom 1,855 underwent an ultrasonographic examination (9% of patients, or 1 in 11 patients), with a total of 2,467 logged ultrasonographic studies. Thirty-two distinct applications were performed. The top 5 ultrasonographic applications, their percentage of total scans, and the percentage that were positive for pathologic findings were as follows: right upper quadrant 640 (26%; 31%), focused abdominal sonography for trauma 333 (13.5%, 22%), aorta 203 (8%, 8%), renal 198 (8%, 21%), and abscess 182 (7%, 63%). Thirteen percent of studies involved were for procedural assistance (abscess, intravenous line placement, ascites, pleural fluid). Some nonstandard indications included the following: abscess (182), deep venous thrombosis (147), nonpregnant pelvic (45), ascites (42), cardiac resuscitation (42), sinus (33), eye (30), bladder (23), pleural fluid (21), testicular (19), pneumothorax (17), joint (8), late pregnancy (8), fracture (7), arterial blood gas (5), tendon (4), foreign body (4), nerve block (3), thyroid (3), and lumbar puncture (2). ED ultrasonography had an impact on patient management in 73% of cases, the remainder being performed strictly for training purposes. Forty-five percent of all studies were supervised by 1 of 4 "core ultrasonographic" faculty or the ultrasonographic fellow, whereas 29% were followed by a formal study. The ultrasonographic fellow was present for 10% of studies, and 19.5% were performed by a resident or medical student during a dedicated ED ultrasonographic rotation. Conclusion: In this ED, ultrasonography is used extensively and affects clinical management in as much as 6.6% of cases. ED ultrasonographic training appears to drive a significant proportion of examinations.