Credentialing

In 2021, ACEP issued a policy statement specific to USGNBs, affirming that USGNBs performed by emergency physicians are not only within the scope of practice but a “core component” of pain control for ED patients, pointing to their rising role as the new standard of care for acutely ill or injured patients (acep.org/patient-care/policy-statements/ultrasound-guided-nerve-blocks/). Landmark-based nerve blocks have long been a part of the American College of Graduate Medical Education’s EM residency education requirement. Ultrasound-guidance improves the safety profile of nerve blocks. According to ACEP guidelines the physician with emergency ultrasound privileges needs no outside certification to perform USGNBs (acep.org/patient-care/policy-statements/emergency-ultrasound-certification-by-external-entities/). While this may seem surprising to some, note that no other clinical procedure requires special external certification, e.g., central venous access or intubation, which follow a similar historical path of being brought into EM after initially exclusively being performed by anesthesia or critical care specialists. As with EM, anesthesia physicians also require no additional certification to perform nerve blocks.⁸

Initiating and updating emergency physicians’ USGNB privileges can be safely done via intradepartmental credentialing approval process. ACEP guidelines require individuals obtaining initial credentialing complete the training and proof of competency determined by their own emergency department.⁹ In departments with established emergency ultrasound programs (i.e., an ultrasound division or an ultrasound fellowship) newly branching into USGNBs, the ultrasound director should partner with the USGNB champion to create an appropriate process for credentialing of individuals.¹⁰ In EDs without a distinct ultrasound division, the USGNB champion should partner with the EM chairperson to determine what training and proof of competency would be appropriate.

At this time, the exact number of supervised nerve blocks an ED provider needs to perform to be independently capable is unclear. ACEP guidelines suggest an approximate threshold of 10 when new ultrasound procedures which build upon existing procedural skills, e.g., 10 transvaginal ultrasounds for those who already perform POCUS, rather than the usual threshold of 25 when learning a new application of ultrasound. The principles of needle visualization required to safely perform ultrasound-guided vascular access, along with identification of neurovascular bundles and their relationship to surrounding muscle and other structure, are similar skills needed for USGNBs. This suggests that 10 total USGNBs may be an appropriate minimum threshold. However, given the broader range of USGNBs than typical vascular access sites, some departments may select a higher minimum for credentialing each provider. For reference, anesthesiology residency requires 40 nerve blocks across three years, recognizing that the spectrum of blocks performed by anesthesiology providers is likely much broader than those carried out in the emergency department. The American Institute of Ultrasound in Medicine recommends anesthesiologists perform 20 USGNB per year to maintain competence. As modeled in ACEP’s ultrasound guidelines, we feel it is best to leave it to each ED to determine their own credentialing threshold (aium.org/officialStatements/60).⁹