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

Basic Manual Competence Must Be Certified Through Patient-Based Assessments

Multiple interacting factors, including environment, patients, baseline skills, training, experience, and skills decay, affect manual competence. Certifications that are based solely on reaching minimum thresholds of experience, even when accurate, are not valid reflections of manual competence,^15,40-43 and neither are those based on self-perception.⁴⁴ Patient-based assessments are, thus, necessary to ensure manual competence.^45-48

Certification Assessments of Manual Competence Should Combine 2 Types of Structured Instruments: Checklists and Overall Scores

Assessments based on direct observation are more reliable when formally structured.^49,50 Though checklists used in observed structured clinical examinations capture many important manual skills,^51-56 they do not completely reflect a hospitalist’s manual competence;⁵⁷ situations may occur in which a hospitalist meets all the individual items on a checklist but cannot perform an entire procedure with basic competence. Therefore, checklists should be paired with overall scores.^58-61 Both checklists and overall scores ought to be obtained from reliable and valid instruments.

Certification Assessments Should Include Feedback

Assessments without feedback are missed learning opportunities.⁶² Both simulation-⁶³ and patient-based assessments should provide feedback in real time to reinforce effective behaviors and remedy faulty ones.

If Remedial Training is Needed, Simulator-Based Training Can Supplement but Not Replace Patient-Based Training

Supervised simulator-based training allows hospitalists to master basic components of a procedure⁶⁴ (including orientation to equipment, sequence of operations, dexterity, ultrasound anatomy, and real-time guidance technique) while improving both cognitive and manual skills.^42,43,65-71 In addition to their role in basic training (which is outside the scope of this position statement), simulators can be useful for remedial training. To be sufficient for hospitalists who do not pass their patient-based assessments, however, remedial training that begins with simulation must also include patient-based training and assessment.^72-75

Initial Credentialing Process

A Minimum Threshold of Experience Should Be Reached before Patient-Based Assessments are Conducted (Figure 1)

Initial Certification Assessments Should Ideally Begin on Simulators

Simulators allow the assurance of safe manual skills, including proper needle insertion techniques and disposal of sharp objects.^3,79 If simulators are not available, however, then patient-based training and assessments can still be performed under direct observation. Safe performance of ultrasound-guided procedures during patient-based assessments (without preceding simulator-based assessments) is sufficient to certify manual competence.

Ongoing Credentialing

Certification to Perform Ultrasound-Guided Procedures Should Be Routinely Re-Evaluated During Ongoing Credentialing (Figure 2)

Observed Patient-Based Assessments Should Occur When a Periprocedural Safety Event Occurs that is Potentially Caused by “Provider Error”

Safety events include both near misses and adverse events. Information about both is ideally “flagged” and “pushed” to hospitalist group leaders by active surveillance and reporting systems. Once reviewed, if a safety event is considered to potentially have been caused by provider error (including knowledge- and skill-based errors),⁸³ then the provider who performed the procedure should undergo an observed patient-based assessment.

Simulation-Based Practice Can Supplement Patient-Based Experience for Ongoing Credentialing

When hospitalists do not achieve a minimum threshold of patient-based experience since the antecedent certification, simulation-based training can supplement their patient-based experience.⁸⁴ In these cases, however, an observed patient-based assessment must occur. Another consideration is whether or not the privilege should be relinquished because of an infrequent need.

Credentialing Infrastructure

Hospitalists Themselves Should Not Bear the Financial Costs of Developing and Maintaining Training and Certification Programs for Ultrasound-Guided Procedures

Equipment and personnel costs^85,86 commonly impede ultrasound-guided procedure programs.^4,87,88 Hospitalists whose job descriptions include the performance of ultrasound-guided procedures should not be expected to bear the costs of ultrasound machines, image archival software, equipment maintenance, and initial and ongoing training and certification.

Assessors Should Be Unbiased Expert Providers Who Have Demonstrated Mastery in Performance of the Procedure Being Assessed and Regularly Perform It in a Similar Practice Environment