Credentialing of Hospitalists in Ultrasound-Guided Bedside Procedures: A Position Statement of the Society of Hospital Medicine

Journal of Hospital Medicine 13(2). 2018 February;:126-135. Published online first January 17, 2018 | 10.12788/jhm.2917

January 16, 2018|Journal of Hospital Medicine

Brian P. Lucas, MD, MS;David M. Tierney, MD;Trevor P. Jensen, MD, MS;Ria Dancel, MD;Joel Cho, MD;Mahmoud El-Barbary, MD, PhD, MSc;Ricardo Franco-Sadud, MD;SHM Point-of-Care-Ultrasound Task Force;Nilam Soni, MD, MS

Ultrasound guidance is used increasingly to perform the following 6 bedside procedures that are core competencies of hospitalists: abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis. Yet most hospitalists have not been certified to perform these procedures, whether using ultrasound guidance or not, by specialty boards or other institutions extramural to their own hospitals. Instead, hospital privileging committees often ask hospitalist group leaders to make ad hoc intramural certification assessments as part of credentialing. Given variation in training and experience, such assessments are not straightforward “sign offs.” We thus convened a panel of experts to conduct a systematic review to provide recommendations for credentialing hospitalist physicians in ultrasound guidance of these 6 bedside procedures. Pathways for initial and ongoing credentialing are proposed. A guiding principle of both is that certification assessments for basic competence are best made through direct observation of performance on actual patients.

The American Board of Internal Medicine (ABIM) changed its certification policy for bedside procedures over a decade ago.¹ Acquiring manual competence in abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis is no longer an expectation of residency training. ABIM diplomates should “know” these procedures but not necessarily “do” them. Hospitalists, most of whom are themselves ABIM diplomates, are still, however, expected to do them as core competencies,²perhaps because hospitalists are often available off-hours, when roughly half of bedside procedures are performed.³

Hospitalists increasingly perform bedside procedures with ultrasound guidance.⁴ Yet training in ultrasound guidance is significantly varied as well,⁵ simply because point-of-care ultrasound (POCUS) has only recently become widespread.⁶ And though some skills are transferrable from landmark-guided to ultrasound -guided procedures, many are not.^7-10 Furthermore, ultrasound guidance is often not explicitly delineated on the privileging forms used by hospitals,¹¹ even where ultrasound guidance has become standard.¹²

Given the variability in training for both ultrasound- and landmark-guided procedures, and given the lack of a universal standard for certification, local hospitals often ask their respective hospitalist group leaders to certify hospitalists’ basic competence as part of credentialing (see the Table for definitions). How hospitalist group leaders should certify competence, however, is not clear. The importance of this gap has recently increased, as hospitalists continue to perform procedures despite not having clear answers to questions about basic competence.^13-15

Therefore, the Society of Hospital Medicine (SHM) Education Committee convened a group of experts and conducted a systematic literature review in order to provide recommendations for credentialing hospitalist physicians in ultrasound-guided bedside procedures. These recommendations do not include training recommendations, aside from recommendations about remedial training for hospitalists who do not pass certification. Training is a means to competence but does not guarantee it. We believe that training recommendations ought to be considered separately.

METHODS

Working Group Formation

In January 2015, the SHM Board of Directors asked the SHM Education Committee to convene the POCUS Task Force. The purpose of the task force was to develop recommendations on ultrasound guidance for bedside procedures. The SHM Education Committee appointed 3 chairs of the task force: 1 senior member of the SHM Education Committee and 2 POCUS experts. The chairs assembled a task force of 31 members that included 5 working groups, a multispecialty peer review group, and a guideline methodologist (supplemental Appendix 1). Invitation was based on members’ past contributions to SHM POCUS-related activities, up-front commitment, and declared conflicts of interest. Working group members self-identified as “hospitalists,” whereas peer reviewers were nonhospitalists but nationally recognized POCUS physician-leaders specializing in emergency medicine, cardiology, critical care medicine, and anesthesiology. Task force membership was vetted by a chair of the SHM POCUS Task Force and the Director of Education before work began. This position statement was authored by the Credentialing Working Group together with the chairs of the other 4 working groups and a guideline methodologist.

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