Credentialing of Hospitalists in Ultrasound-Guided Bedside Procedures: A Position Statement of the Society of Hospital Medicine
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.
© 2018 Society of Hospital Medicine
Assessors should be expert providers who regularly perform the ultrasound-guided procedure in a similar practice environment.9,89-94 For example, providers who are not hospitalists but who are experts in an ultrasound-guided procedure and commonly perform it on the hospital wards would be acceptable assessors. However, a radiologist who only performs that procedure in a fully-staffed interventional radiology suite with fluoroscopy or computed tomography guidance would not be an acceptable assessor. More than 1 assessor may balance idiosyncratic assessments;95 but when assessments are well structured, additional assessors are generally not needed.18
If Intramural Assessors Are Not Available, Extramural Assessors May Be Considered
Intramural assessors are generally preferred because of familiarity with the local practice environment, including the available procedure kits and typical patient characteristics. Nevertheless, extramural assessors27,77,85,96 may theoretically provide even more valid assessments than intramural ones because extramural assessors are neither influenced by relationships with local hospitalists nor biased by local hospitalists’ skills.
DISCUSSION
There are no high-quality randomized trials in support of a single credentialing pathway over any other.94,102 The credentialing pathways at the center of this position statement are based on expert opinion. Our methods can be criticized straightaway, therefore, for reliance on the experience and expertise of our working group and task force. Any position statement written without high-quality supportive evidence would be appropriately subject to the same criticism. Without evidence in support of an overall pathway, we codified specific aspects of the pathways into 16 individual recommendations.
Patient-level outcomes do not back these recommendations. Consider, for example, our recommendation that certification assessments be made from structured instruments and not simply from an assessor’s gestalt. Here, the basis is not improved patient-level outcomes from a trial (such as reduced complications or increased procedural success) but improved psychometric performance from reliability studies. The body of evidence for our recommendations is similarly indirect, mostly because the outcomes studied are more proximate and, thus, less meaningful than patient-level outcomes, which are the outcomes of greatest interest but are woefully understudied for clinical competence.17,97,103
The need for high-quality evidence is most pronounced in distinguishing how recommendations should be modified for various settings. Wide variations in resources and patient-mix will make some recommendations impracticable, meaning that they could not be carried out with available resources. For example, our recommendation that credentialing decisions should ultimately rely on certifications made by assessors during patient-based assessments may not be practicable at small, rural hospitals. Such hospitals may not have access to local assessors, and they may not admit enough patients who need the types of ultrasound-guided procedures for which hospitalists seek certification (especially given the need to coordinate the schedules of patients, procedure-performing hospitalists, and assessors).
Regardless of whether some or all hospitalists at a particular hospital are expected to perform bedside procedures, technology may help to improve the practicability of our recommendations. For example, simulators may evolve to replace actual patient-level experience in achieving minimum thresholds. Certification assessments of manual skills may even someday occur entirely on simulators. Real-time high-definition video streaming enhanced with multiple cameras may allow for remote assessments. Until such advances mature, high-quality patient-level data should be sought through additional research to refine our current recommendations.
We hope that these recommendations will improve how basic competence in ultrasound-guided bedside procedures is assessed. Our ultimate goal is to improve how hospitalists perform these procedures. Patient safety is, therefore, considered paramount to cost. Nevertheless, the hospital administrative leaders and privileging committee members on our Task Force concluded that many hospitals have been seeking guidance on credentialing for bedside procedures, and the likely difficulties of implementing our recommendations (including cost) would not be prohibitive at most hospitals, especially given recognition that these recommendations can be tailored to each setting.
