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A Review of Echocardiography Training for Internal Medicine Residents: Proposed Goals, Methods, and Metrics. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9468-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pérez de Isla L, Díaz Sánchez S, Pagola J, García de Casasola Sánchez G, López Fernández T, Sánchez Barrancos IM, Martínez-Sánchez P, Zapatero Gaviria A, Anguita M, Ruiz Serrano AL, Torres Macho J. Documento de consenso de SEMI, semFYC, SEN y SEC sobre ecocardioscopia en España. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2018.05.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Kovell LC, Ali MT, Hays AG, Metkus TS, Madrazo JA, Corretti MC, Mayer SA, Abraham TP, Shapiro EP, Mukherjee M. Defining the Role of Point-of-Care Ultrasound in Cardiovascular Disease. Am J Cardiol 2018; 122:1443-1450. [PMID: 30115421 DOI: 10.1016/j.amjcard.2018.06.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 06/21/2018] [Accepted: 06/28/2018] [Indexed: 12/15/2022]
Abstract
Echocardiography is the foundation for diagnostic cardiac testing, allowing for direct identification and management of various conditions. Point-of-care ultrasound (POCUS) has emerged as an invaluable tool for bedside diagnosis and management. The objective of this review is to address the current use and clinical applicability of POCUS to identify, triage, and manage a wide spectrum of cardiac conditions. POCUS can change diagnosis and management decisions of various cardiovascular conditions in a range of settings. In the outpatient setting, it is used to risk stratify and diagnose a variety of medical conditions. In the emergency department (ED) and critical care settings, it is used to guide triage and critical care interventions. Furthermore, the skills needed to perform POCUS can be taught to noncardiologists in a way that is retained and allows identification of normal and grossly abnormal cardiac findings. Various curricula have been developed that teach residents and advanced learners how to appropriately employ point-of-care ultrasound. In conclusion, POCUS can be a useful adjunct to the physical exam, particularly in critical care applications.
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Pérez de Isla L, Díaz Sánchez S, Pagola J, García de Casasola Sánchez G, López Fernández T, Sánchez Barrancos IM, Martínez-Sánchez P, Zapatero Gaviria A, Anguita M, Ruiz Serrano AL, Torres Macho J. Consensus Document of the SEMI, semFYC, SEN, and SEC on Focused Cardiac Ultrasound in Spain. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2018; 71:935-940. [PMID: 30119954 DOI: 10.1016/j.rec.2018.05.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/18/2018] [Indexed: 11/29/2022]
Abstract
This document summarizes the concept of focused cardiac ultrasound, the basic technical aspects related to this technique, and its diagnostic objectives. It also defines training requisites in focused cardiac ultrasound. This consensus document has been endorsed by the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of Neurology (SEN), and the Spanish Society of Cardiology (SEC).
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Affiliation(s)
| | | | - Jorge Pagola
- Servicio de Neurología, Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | | | | | | | - Manuel Anguita
- Servicio de Cardiología, Hospital Reina Sofía, Córdoba, Spain
| | | | - Juan Torres Macho
- Servicio de Medicina Interna-Urgencias, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain
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Mladenovic J, O’Brien MC, Hoppman R. Shaping the Future of Point-of-Care-Ultrasound in Medical Education. South Med J 2018; 111:449-451. [DOI: 10.14423/smj.0000000000000832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Junior medical student performed focused cardiac ultrasound after brief training to detect significant valvular heart disease. IJC HEART & VASCULATURE 2018; 19:41-45. [PMID: 29946563 PMCID: PMC6016074 DOI: 10.1016/j.ijcha.2018.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/25/2018] [Indexed: 01/28/2023]
Abstract
Background Focused cardiac ultrasound (FOCUS) examination using a portable device is increasingly used for bedside diagnosis of cardiovascular diseases. This is a 4-week pilot project aiming to teach medical students to perform FOCUS to detect valvular heart lesions. Methods Patients undergoing routine transthoracic echocardiography (TTE) were recruited by third year medical students who performed physical examination (PE) and FOCUS after 6-hour training to detect significant (moderate-to-severe) valvular lesions. Performance of FOCUS and PE was compared to TTE as reference using kappa statistics. Results 10 medical students performed 212 PE and FOCUS on 107 patients with mean age 63.7 ± 14.9 years. TTE detected 126 significant valvular lesions of which FOCUS correctly identified 54 lesions (κ = 0.45) compared to 32 lesions by PE (κ = 0.28, p < 0.01). FOCUS was better than PE in identifying mitral stenosis (κ = 0.51 vs. 0.17), aortic stenosis (κ = 0.45 vs. 0.16) and tricuspid regurgitation (κ = 0.39 vs. 0.09, all p < 0.01). Students became more proficient in performing FOCUS examination with time. Conclusions Teaching junior medical students to perform and interpret FOCUS was feasible after brief training and better than PE in detecting significant valvular lesions. Further studies are warranted to determine the utility of incorporating this new technology into mainstream medical training. Teaching junior medical students to perform and interpret limited pocket-sized ultrasound was feasible after brief training. Accuracy of student performed limited pocket-sized ultrasound was higher than physical examination in detecting significant valvular lesions.
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Abstract
Technology has the potential to both distract and reconnect providers with their patients. The widespread adoption of electronic medical records in recent years pulls physicians away from time at the bedside. However, when used in conjunction with patients, technology has the potential to bring patients and physicians together. The increasing use of point-of-care ultrasound by physicians is changing the bedside encounter by allowing for real-time diagnosis with the treating physician. It is a powerful example of the way technology can be a force for refocusing on the bedside encounter.
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Affiliation(s)
- Andre Kumar
- Department of Medicine, Division of Hospital Medicine, Stanford University, mail code 5209, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Gigi Liu
- Department of Medicine, Johns Hopkins University, 600 North Wolfe Street, Meyer Building 8th Floor, Room 147, Baltimore, MD 21204, USA
| | - Jeff Chi
- Department of Medicine, Division of Hospital Medicine, Stanford University, mail code 5209, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - John Kugler
- Department of Medicine, Division of Hospital Medicine, Stanford University, mail code 5209, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Mullangi S, Sozio SM, Segal P, Menez S, Martire C, Shafi T. Point-of-care ultrasound education to improve care of dialysis patients. Semin Dial 2018; 31:154-162. [PMID: 29314256 PMCID: PMC5839962 DOI: 10.1111/sdi.12664] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Point-of-care ultrasound (POCUS) is rapidly emerging as a bedside diagnostic tool that can enhance physical diagnosis and facilitate clinical decision making. Although ultrasound is widely used by nephrologists for vascular access and kidney imaging, diagnostic POCUS skills in other anatomic areas are not part of routine nephrology training. In this narrative review, we will provide an overview of selected POCUS techniques, highlight potential uses of POCUS in routine nephrology practice, and describe a new curriculum implemented at Johns Hopkins University School of Medicine to teach diagnostic POCUS skills to nephrology fellows.
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Affiliation(s)
- Surekha Mullangi
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Stephen M. Sozio
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Paul Segal
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Steven Menez
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Carol Martire
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Tariq Shafi
- Division of Nephrology, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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McCormick TJ, Miller EC, Chen R, Naik VN. Acquiring and maintaining point-of-care ultrasound (POCUS) competence for anesthesiologists. Can J Anaesth 2018; 65:427-436. [DOI: 10.1007/s12630-018-1049-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 12/03/2017] [Accepted: 12/04/2017] [Indexed: 01/16/2023] Open
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Affiliation(s)
- Mohammed A. Chamsi-Pasha
- Cardiovascular Imaging Institute, Department of Cardiology, the Methodist DeBakey Heart and Vascular Center, Houston, TX (M.A.C.-P., W.A.Z.)
| | - Partho P. Sengupta
- Section of Cardiology, West Virginia University Heart and Vascular Institute, J.W. Ruby Memorial Hospital, Morgantown (P.P.S.)
| | - William A. Zoghbi
- Cardiovascular Imaging Institute, Department of Cardiology, the Methodist DeBakey Heart and Vascular Center, Houston, TX (M.A.C.-P., W.A.Z.)
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Abstract
Though the use of point-of-care ultrasound (POCUS) has increased over the last decade, formal hospital credentialing for POCUS may still be a challenge for hospitalists. This document details the Hospital Medicine Department Ultrasound Credentialing Policy from Regions Hospital, which is part of the HealthPartners organization in Saint Paul, Minnesota. National organizations from internal medicine and hospital medicine (HM) have not published recommended guidelines for POCUS credentialing. Revised guidelines for POCUS have been published by the American College of Emergency Physicians, though these are not likely intended to guide hospitalists when working with credentialing committees and medical boards. This document describes the scope of ultrasound in HM and our training, credentialing, and quality assurance program. This report is intended to be used as a guide for hospitalists as they work with their own credentialing committees and will require modification for each institution. However, the overall process described here should assist in the establishment of POCUS at various institutions.
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Affiliation(s)
- Benji K Mathews
- Department of Hospital Medicine, HealthPartners, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Michael Zwank
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Regions Hospital, St. Paul, Minnesota, USA
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Ruddox V, Norum IB, Stokke TM, Edvardsen T, Otterstad JE. Focused cardiac ultrasound by unselected residents-the challenges. BMC Med Imaging 2017; 17:22. [PMID: 28259149 PMCID: PMC5336635 DOI: 10.1186/s12880-017-0191-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/21/2017] [Indexed: 11/22/2022] Open
Abstract
Background Focus Cardiac Ultrasound (FoCUS) performed by internal medicine residents on call with 2 h of training can provide a means for ruling out cardiac disease, but with poor sensitivity. The purpose of the present study was to evaluate diagnostic usefulness as well as diagnostic accuracy of FoCUS following 4 h of training. Methods All residents on call were given a 4-h training course with an additional one-hour training course after 6 months. They were asked to provide a pre- and post-FoCUS diagnosis, with the final diagnosis at discharge as reference. Results During a 7 month period 113 FoCUS examinations were reported; after 53 were excluded this left 60 for evaluation with a standard echocardiogram performed on average 11.5 h after FoCUS. Examinations were performed on the basis of chest pain and dyspnoea/edema. The best sensitivity was found in terms of the detection of reduced left ventricular (LV) ejection fraction (EF) (92%), LV dilatation (85%) and pericardial effusion (100%). High values were noted for negative predictive values, although false positives were seen. A kappa > 0.6 was observed for reduced LVEF, right ventricular area fraction and dilatation of LV and left atrium. In 48% of patients pre- and post-FoCUS diagnoses were identical and concordant with the final diagnosis. Importantly, in 30% examinations FoCUS correctly changed the pre-FoCUS diagnosis. Conclusions A FoCUS protocol with a 4-h training program gained clinical usefulness in one third of examinations. False positive findings represented the major challenge.
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Affiliation(s)
- Vidar Ruddox
- Department of cardiology, Vestfold Hospital Trust, Po. Box 2168, N3103, Tønsberg, Norway. .,Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
| | - Ingvild Billehaug Norum
- Department of cardiology, Vestfold Hospital Trust, Po. Box 2168, N3103, Tønsberg, Norway.,Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Thomas Muri Stokke
- Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Thor Edvardsen
- Department of cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway.,Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Jan Erik Otterstad
- Department of cardiology, Vestfold Hospital Trust, Po. Box 2168, N3103, Tønsberg, Norway
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Kimura BJ. Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside. Heart 2017; 103:987-994. [PMID: 28259843 DOI: 10.1136/heartjnl-2016-309915] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/02/2017] [Indexed: 12/19/2022] Open
Abstract
The development of hand-carried, battery-powered ultrasound devices has created a new practice in ultrasound diagnostic imaging, called 'point-of-care' ultrasound (POCUS). Capitalising on device portability, POCUS is marked by brief and limited ultrasound imaging performed by the physician at the bedside to increase diagnostic accuracy and expediency. The natural evolution of POCUS techniques in general medicine, particularly with pocket-sized devices, may be in the development of a basic ultrasound examination similar to the use of the binaural stethoscope. This paper will specifically review how POCUS improves the limited sensitivity of the current practice of traditional cardiac physical examination by both cardiologists and non-cardiologists. Signs of left ventricular systolic dysfunction, left atrial enlargement, lung congestion and elevated central venous pressures are often missed by physical techniques but can be easily detected by POCUS and have prognostic and treatment implications. Creating a general set of repetitive imaging skills for these entities for application on all patients during routine examination will standardise and reduce heterogeneity in cardiac bedside ultrasound applications, simplify teaching curricula, enhance learning and recollection, and unify competency thresholds and practice. The addition of POCUS to standard physical examination techniques in cardiovascular medicine will result in an ultrasound-augmented cardiac physical examination that reaffirms the value of bedside diagnosis.
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Affiliation(s)
- Bruce J Kimura
- Department of Cardiology, Scripps Mercy Hospital, San Diego, California, USA.,Department of Graduate Medical Education, Scripps Mercy Hospital, San Diego, California, USA
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Fiorelli EM, Casella F, Torzillo D, Cogliati C. Bedside focused cardiac ultrasound in the evaluation of systolic dysfunction. Intern Emerg Med 2017; 12:241-245. [PMID: 28063115 DOI: 10.1007/s11739-016-1598-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 12/27/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Elisa Maria Fiorelli
- Department of Internal Medicine, L. Sacco Hospital, University of Milan, via GB Grassi 74, Milan, Italy.
| | - Francesco Casella
- Department of Internal Medicine, L. Sacco Hospital, University of Milan, via GB Grassi 74, Milan, Italy
| | - Daniela Torzillo
- Department of Internal Medicine, L. Sacco Hospital, University of Milan, via GB Grassi 74, Milan, Italy
| | - Chiara Cogliati
- Department of Internal Medicine, L. Sacco Hospital, University of Milan, via GB Grassi 74, Milan, Italy
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Singh Y. Echocardiographic Evaluation of Hemodynamics in Neonates and Children. Front Pediatr 2017; 5:201. [PMID: 28966921 PMCID: PMC5605552 DOI: 10.3389/fped.2017.00201] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/31/2017] [Indexed: 11/13/2022] Open
Abstract
Hemodynamic instability and inadequate cardiac performance are common in critically ill children. The clinical assessment of hemodynamic status is reliant upon physical examination supported by the clinical signs such as heart rate, blood pressure, capillary refill time, and measurement of the urine output and serum lactate. Unfortunately, all of these parameters are surrogate markers of cardiovascular well-being and they provide limited direct information regarding the adequacy of blood flow and tissue perfusion. A bedside point-of-care echocardiography can provide real-time hemodynamic information by assessing cardiac function, loading conditions (preload and afterload) and cardiac output. The echocardiography has the ability to provide longitudinal functional assessment in real time, which makes it an ideal tool for monitoring hemodynamic assessment in neonates and children. It is indispensable in the management of patients with shock, pulmonary hypertension, and patent ductus arteriosus. The echocardiography is the gold standard diagnostic tool to assess hemodynamic stability in patients with pericardial effusion, cardiac tamponade, and cardiac abnormalities such as congenital heart defects or valvar disorders. The information from echocardiography can be used to provide targeted treatment in intensive care settings such as need of fluid resuscitation versus inotropic support, choosing appropriate inotrope or vasopressor, and in providing specific interventions such as selective pulmonary vasodilators in pulmonary hypertension. The physiological information gathered from echocardiography may help in making timely, accurate, and appropriate diagnosis and providing specific treatment in sick patients. There is no surprise that use of bedside point-of-care echocardiography is rapidly gaining interest among neonatologists and intensivists, and it is now being used in clinical decision making for patients with hemodynamic instability. Like any other investigation, it has certain limitations and the most important limitation is its intermittent nature. Sometimes acquiring high quality images for precise functional assessment in a ventilated child can be challenging. Therefore, it should be used in conjunction with the existing tools (physical examination and clinical parameters) for hemodynamic assessment while making clinical decisions.
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Affiliation(s)
- Yogen Singh
- Department of Neonatology and Pediatric Cardiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,University of Cambridge Clinical School of Medicine, Cambridge, United Kingdom
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67
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Krishnan DK, Pawlaczyk B, McCullough PA, Enright S, Kunadi A, Vanhecke TE. Point-of-Care, Ultraportable Echocardiography Predicts Diuretic Response in Patients Admitted with Acute Decompensated Heart Failure. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:201-208. [PMID: 28008296 PMCID: PMC5170880 DOI: 10.4137/cmc.s38896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 08/11/2016] [Accepted: 08/11/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Routine management of patients with acute decompensated heart failure (ADHF) requires careful attentiveness to fluid status and diuretic treatment efficacy. New advances in ultrasound have made ultraportable echocardiography (UE) available to physicians for point-of-care use. The purpose of this study is to explore physiologic measures of intravascular fluid volume derived from UE and explore predictors of diuretic response in ADHF. METHODS Various echocardiography imaging measurements, particularly diameter and collapse of inferior vena cava (IVC), were collected from 77 patients admitted with a primary diagnosis of ADHF. Patients were divided into two groups based on whether or not they achieved a net negative fluid output of 3 L within 48 hours. The demographic information, serum laboratory markers, and physical characteristics of the subjects were obtained to correlate with daily ultrasound measurements. Univariate and multivariate analyses were used to compare diuretic “responders” to “nonresponders.” RESULTS A negative change in the IVC diameter at 48 hours was robust in prediction of diuretic response. For every 1 mm decrease in the IVC diameter at 48 hours, there was an odds ratio of 1.62 (95% CI: 1.20–2.19) for responding to diuretic therapy independent of other variables including baseline renal filtration function and blood B-type natriuretic peptide. CONCLUSION Assessment of central venous pressure as a proxy for passive renal congestion independently predicts initial diuretic response in ADHF. Future research is needed to further understand the individual variation in response to loop diuresis and to identify optimal treatment approaches that utilize anatomic and physiologic measures such as venous ultrasound.
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Affiliation(s)
- Dena K Krishnan
- Department of Internal Medicine, Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA.; Department of Cardiovascular Medicine, Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Barbara Pawlaczyk
- Department of Internal Medicine, Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Peter A McCullough
- Department of Internal Medicine and Cardiovascular Medicine, St. John Providence Health System, Providence Park Heart Institute, Novi, MI, USA
| | - Susan Enright
- Department of Internal Medicine, Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Arvind Kunadi
- Department of Nephrology, Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
| | - Thomas E Vanhecke
- Department of Cardiovascular Medicine, Genesys Regional Medical Center/Ascension Health, Grand Blanc, MI, USA
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Bhagra A, Tierney DM, Sekiguchi H, Soni NJ. Point-of-Care Ultrasonography for Primary Care Physicians and General Internists. Mayo Clin Proc 2016; 91:1811-1827. [PMID: 27825617 DOI: 10.1016/j.mayocp.2016.08.023] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/02/2016] [Accepted: 08/17/2016] [Indexed: 12/12/2022]
Abstract
Point-of-care ultrasonography (POCUS) is a safe and rapidly evolving diagnostic modality that is now utilized by health care professionals from nearly all specialties. Technological advances have improved the portability of equipment, enabling ultrasound imaging to be executed at the bedside and thereby allowing internists to make timely diagnoses and perform ultrasound-guided procedures. We reviewed the literature on the POCUS applications most relevant to the practice of internal medicine. The use of POCUS can immediately narrow differential diagnoses by building on the clinical information revealed by the traditional physical examination and refining clinical decision making for further management. We describe 2 common patient scenarios (heart failure and sepsis) to highlight the impact of POCUS performed by internists on efficiency, diagnostic accuracy, resource utilization, and radiation exposure. Using POCUS to guide procedures has been found to reduce procedure-related complications, along with costs and lengths of stay associated with these complications. Despite several undisputed advantages of POCUS, barriers to implementation must be considered. Most importantly, the utility of POCUS depends on the experience and skills of the operator, which are affected by the availability of training and the cost of ultrasound devices. Additional system barriers include availability of templates for documentation, electronic storage for image archiving, and policies and procedures for quality assurance and billing. Integration of POCUS into the practice of internal medicine is an inevitable change that will empower internists to improve the care of their patients at the bedside.
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Affiliation(s)
- Anjali Bhagra
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - David M Tierney
- Abbott Northwestern Hospital, Medical Education Department, Minneapolis, MN
| | - Hiroshi Sekiguchi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nilam J Soni
- Section of Hospital Medicine, South Texas Veterans Health Care System and Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center, San Antonio, TX
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Kobal SL, Liel-Cohen N, Shimony S, Neuman Y, Konstantino Y, Dray EM, Horowitz I, Siegel RJ. Impact of Point-of-Care Ultrasound Examination on Triage of Patients With Suspected Cardiac Disease. Am J Cardiol 2016; 118:1583-1587. [PMID: 27634025 DOI: 10.1016/j.amjcard.2016.08.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/02/2016] [Accepted: 08/02/2016] [Indexed: 11/19/2022]
Abstract
Complementing the physical examination with a point-of-care ultrasound study (POCUS) can improve patient triage. We aimed to study the impact of POCUS on the diagnosis and management of outpatients and hospitalized patients with suspected cardiac disease. In this multicenter study, a pocket-sized device was used to perform POCUS when the diagnosis or patient management was unclear based on anamnesis, physical examination, and basic diagnostic testing. Eighteen physicians (cardiac fellows 49%, cardiologists 30%, and echocardiographers 21%) performed physical examinations extended by POCUS on 207 patients (inpatients 83% and outpatients 17%). POCUS findings resulted in a change in the primary diagnosis in 14% of patients. In patients whose diagnosis remained unchanged, POCUS results reinforced the initial diagnosis in 48% of the cases. In 39% of the patients, the diagnostic plan was altered, including referral (16%) or deferral (23%) to other diagnostic techniques. Alteration in medical treatment (drug discontinuation or initiation) occurred in 11% of the patients, and in 7% POCUS results influenced the decision whether to perform a therapeutic procedure. Hospitalization or discharge was determined after POCUS in 11% of the patients. In conclusion, during patient triage, extension of the physical examination by POCUS can cause physicians to alter their initial diagnosis, resulting in an immediate change of diagnostic and therapeutic procedures. Based on POCUS results, physicians altered the diagnostic plan either by avoiding or referring patients to other diagnostic procedures in almost half of the studied population.
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Affiliation(s)
- Sergio L Kobal
- Division of Cardiology, Soroka University Medical Center and Joyce and Irving Goldman Medical School, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Noah Liel-Cohen
- Division of Cardiology, Soroka University Medical Center and Joyce and Irving Goldman Medical School, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Sarah Shimony
- Heart Institute, Kaplan Medical Center, Rehovot and Hadassah Medical School, The Hebrew University, Jerusalem, Israel
| | - Yoram Neuman
- Division of Cardiology, Meir Medical Center, Kfar-Saba and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yuval Konstantino
- Division of Cardiology, Soroka University Medical Center and Joyce and Irving Goldman Medical School, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Efrat Mazor Dray
- Division of Cardiology, Soroka University Medical Center and Joyce and Irving Goldman Medical School, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Itai Horowitz
- Division of Cardiology, Soroka University Medical Center and Joyce and Irving Goldman Medical School, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Robert J Siegel
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center and UCLA, Los Angeles, California.
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Arques S, Roux E. [Usefulness of natriuretic peptide testing and Doppler echocardiography at bedside in the diagnosis of acute heart failure]. Ann Cardiol Angeiol (Paris) 2016; 65:334-339. [PMID: 27693163 DOI: 10.1016/j.ancard.2016.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/02/2016] [Indexed: 06/06/2023]
Abstract
Acute heart failure is a common condition that leads to hospital admission, with important mortality and readmission rates. A prompt and accurate diagnosis of this condition by hospitalists is essential for an early and tailored medical management. The use of natriuretic peptide testing (BNP and NT-proBNP) through a two cut-point strategy is currently recommended as the first-line diagnostic complement to the initial clinical evaluation in the acute care setting. Transthoracic Doppler echocardiography is an other noninvasive method that can be used at bedside, especially in patients with intermediate, inconclusive natriuretic peptides levels. In this regard, left ventricular ejection fraction and several simple Doppler indexes (restrictive mitral filling pattern, spectral tissue Doppler E/e' ratio), have been validated in the emergency diagnosis of acute heart failure. The aim of the present review is to overview the respective contribution of natriuretic peptides and Doppler echocardiography at bedside to the diagnosis of acute heart failure in the acute care setting.
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Affiliation(s)
- S Arques
- Service de cardiologie, centre hospitalier Édmond-Garcin, avenue des Sœurs-Gastine, 13400 Aubagne, France.
| | - E Roux
- Service de cardiologie, centre hospitalier Édmond-Garcin, avenue des Sœurs-Gastine, 13400 Aubagne, France
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71
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Sabath BF, Singh G. Point-of-care ultrasonography as a training milestone for internal medicine residents: the time is now. J Community Hosp Intern Med Perspect 2016; 6:33094. [PMID: 27802866 PMCID: PMC5089158 DOI: 10.3402/jchimp.v6.33094] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/16/2016] [Accepted: 09/20/2016] [Indexed: 12/13/2022] Open
Abstract
Point-of-care (POC) ultrasonography is considered fundamental in emergency medicine training and recently has become a milestone in critical care fellowship programs as well. Currently, there is no such standard requirement for internal medicine residency programs in the United States. We present a new case and briefly review another case at our institution – a community hospital – in which internal medicine house staff trained in ultrasonography were able to uncover unexpected and critical diagnoses that significantly changed patient care and outcomes. We also review the growing evidence of the application of ultrasound in the diagnosis of a myriad of conditions encountered in general internal medicine as well as the mounting data on the ability of internal medicine residents to apply this technology accurately at the bedside. We advocate that the literature has sufficiently established the role of POC ultrasonography in general internal medicine that there should no longer be any delay in giving this an official place in the development of internal medicine trainees. This may be particularly useful in the community hospital setting where 24-h echocardiography or other sonography may not be readily available.
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Affiliation(s)
- Bruce F Sabath
- Department of Medicine, Greater Baltimore Medical Center, Baltimore, MD, USA; @gbmc.org
| | - Gurkeerat Singh
- Department of Medicine, Greater Baltimore Medical Center, Baltimore, MD, USA
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72
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Town JA, Bergl PA, Narang A, McConville JF. Internal Medicine Residents' Retention of Knowledge and Skills in Bedside Ultrasound. J Grad Med Educ 2016; 8:553-557. [PMID: 27777666 PMCID: PMC5058588 DOI: 10.4300/jgme-d-15-00383.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The long-term retention of knowledge and skills in bedside ultrasound by internal medicine residents after ultrasound training is not well understood. OBJECTIVE We sought to determine whether knowledge and skills acquired from focused training in bedside ultrasound are retained over time, and whether retention is related to independent practice. METHODS We conducted a prospective observational trial of 101 internal medicine residents at an academic medical center who participated in a bedside ultrasound workshop followed by 12 months of independent practice. Performance was measured on image-based knowledge and skills assessment using direct observation, both before the workshop and 12 months later. Individual usage data were obtained along with a survey on attitudes toward bedside ultrasound. RESULTS Participants' mean knowledge assessment score increased from a baseline of 63.7% to 84.5% immediately after training (P < .001). At 12 months, mean knowledge score fell to 73.0%, significantly different from both prior assessments (P < .001). Despite knowledge decline, the mean skills assessment score improved from a baseline of 30.5% to 50.4% at 12 months (P < .001). Residents reporting more ultrasound use (> 25 examinations) had higher scores in baseline knowledge and skills assessments than those with lower usage (< 25 examinations). Change in knowledge and image acquisition skills between assessments was equal in both subgroups. CONCLUSIONS Residents' knowledge of ultrasound improved after brief training but decayed over time, whereas skills showed marginal improvement over the study, with minimal support. Growth and retention of ultrasound abilities were not impacted by usage rates.
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Affiliation(s)
- James A. Town
- Corresponding author: James A. Town, MD, University of Washington, Medicine, 1959 NE Pacific Street, Box 356522, Seattle, WA 98195, 206.616.8378,
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Wilkinson JS, Barake W, Smith C, Thakrar A, Johri AM. Limitations of Condensed Teaching Strategies to Develop Hand-Held Cardiac Ultrasonography Skills in Internal Medicine Residents. Can J Cardiol 2016; 32:1034-7. [DOI: 10.1016/j.cjca.2015.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/08/2015] [Accepted: 10/08/2015] [Indexed: 11/16/2022] Open
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Image-based resuscitation of the hypotensive patient with cardiac ultrasound: An evidence-based review. J Trauma Acute Care Surg 2016; 80:511-8. [PMID: 26670112 DOI: 10.1097/ta.0000000000000941] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article is a detailed review of the literature regarding the use of cardiac ultrasound for the resuscitation of hypotensive patients. In addition, figures regarding windows and description of how to perform the test are included.
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75
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Levine AR, Buchner JA, Verceles AC, Zubrow MT, Mallemat HA, Papali A, McCurdy MT. Ultrasound images transmitted via FaceTime are non-inferior to images on the ultrasound machine. J Crit Care 2016; 33:51-5. [PMID: 27006267 DOI: 10.1016/j.jcrc.2016.02.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/20/2016] [Accepted: 02/22/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Remote telementored ultrasound (RTMUS) systems can deliver ultrasound (US) expertise to regions lacking highly trained bedside ultrasonographers and US interpreters. To date, no studies have evaluated the quality and clinical utility of US images transmitted using commercially available RTMUS systems. METHODS This prospective pilot evaluated the quality of US images (right internal jugular vein, lung apices and bases, cardiac subxiphoid view, bladder) obtained using a commercially available iPad operating FaceTime software. A bedside non-physician obtained images and a tele-intensivist interpreted them. All US screen images were simultaneously saved on the US machine and captured via a FaceTime screen shot. The tele-intensivist and an independent US expert rated image quality and utility in guiding clinical decisions. RESULTS The tele-intensivist rated FaceTime images as high quality (90% [69/77]) and could comfortably make clinical decisions using these images (96% [74/77]). Image quality did not differ between FaceTime and US images (97% (75/77). Strong inter-rater reliability existed between tele-intensivist and US expert evaluations (Spearman's rho 0.43; P<.001). CONCLUSION An RTMUS system using commercially available two-way audiovisual technology can transmit US images without quality degradation. For most anatomic sites assessed, US images acquired using FaceTime are not inferior to those obtained directly with the US machine.
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Affiliation(s)
- Andrea R Levine
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, 3459 Fifth Avenue, 628 NW, Pittsburgh, PA, 15213, United States.
| | - Jessica A Buchner
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 S. Paca St., 2nd Floor, Baltimore, MD, 21201, United States.
| | - Avelino C Verceles
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 S. Paca St., 2nd Floor, Baltimore, MD, 21201, United States.
| | - Marc T Zubrow
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 S. Paca St., 2nd Floor, Baltimore, MD, 21201, United States; Program in Trauma, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, United States; University of Maryland eCare, University of Maryland Medical System, 110 S. Paca St., Suite 5-N-162, Baltimore, MD, 21201, United States.
| | - Haney A Mallemat
- University of Maryland School of Medicine, Department of Emergency Medicine, 110 S. Paca St., 6th Floor, Baltimore, MD, 21201, United States.
| | - Alfred Papali
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 S. Paca St., 2nd Floor, Baltimore, MD, 21201, United States.
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 S. Paca St., 2nd Floor, Baltimore, MD, 21201, United States; University of Maryland School of Medicine, Department of Emergency Medicine, 110 S. Paca St., 6th Floor, Baltimore, MD, 21201, United States.
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Johnson BK, Tierney DM, Rosborough TK, Harris KM, Newell MC. Internal medicine point-of-care ultrasound assessment of left ventricular function correlates with formal echocardiography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2016; 44:92-9. [PMID: 26179460 DOI: 10.1002/jcu.22272] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/01/2015] [Indexed: 05/24/2023]
Abstract
PURPOSE Although focused cardiac ultrasonographic (FoCUS) examination has been evaluated in emergency departments and intensive care units with good correlation to formal echocardiography, accuracy for the assessment of left ventricular systolic function (LVSF) when performed by internal medicine physicians still needs independent evaluation. METHODS This prospective observational study in a 640-bed, academic, quaternary care center, included 178 inpatients examined by 10 internal medicine physicians who had completed our internal medicine bedside ultrasound training program. The ability to estimate LVSF with FoCUS as "normal," "mild to moderately decreased," or "severely decreased" was compared with left ventricular ejection fraction (>50%, 31-49%, and <31%, respectively) from formal echocardiography interpreted by a cardiologist. RESULTS Sensitivity and specificity of FoCUS for any degree of LVSF impairment were 0.91 (95% confidence interval [CI] 0.80, 0.97) and 0.88 (95% CI 0.81, 0.93), respectively. The interrater agreement between internal medicine physician-performed FoCUS and formal echocardiography for any LVSF impairment was "good/substantial" with κ = 0.77 (p < 0.001), 95% CI (0.67, 0.87). Formal echocardiography was classified as "technically limited due to patient factors" in 20% of patients; however, echogenicity was sufficient in 100% of FoCUS exams to classify LVSF. CONCLUSIONS Internal medicine physicians using FoCUS identify normal versus decreased LVSF with high sensitivity, specificity, and "good/substantial" interrater agreement when compared with formal echocardiography. These results support the role of cardiac FoCUS by properly trained internal medicine physicians for discriminating normal from reduced LVSF.
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Affiliation(s)
- Benjamin K Johnson
- Abbott Northwestern Hospital, Department of Medical Education, 800 East 28th Street, Minneapolis, MN, 55407
| | - David M Tierney
- Abbott Northwestern Hospital, Department of Medical Education, 800 East 28th Street, Minneapolis, MN, 55407
| | - Terry K Rosborough
- Abbott Northwestern Hospital, Department of Medical Education, 800 East 28th Street, Minneapolis, MN, 55407
| | - Kevin M Harris
- Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, 920 East 28th Street, Suite 300, Minneapolis, MN, 55407
| | - Marc C Newell
- Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, 920 East 28th Street, Suite 300, Minneapolis, MN, 55407
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The Role of Focused Echocardiography in Pediatric Intensive Care: A Critical Appraisal. BIOMED RESEARCH INTERNATIONAL 2015; 2015:596451. [PMID: 26605333 PMCID: PMC4641179 DOI: 10.1155/2015/596451] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/15/2015] [Accepted: 10/18/2015] [Indexed: 01/22/2023]
Abstract
Echocardiography is a key tool for hemodynamic assessment in Intensive Care Units (ICU). Focused echocardiography performed by nonspecialist physicians has a limited scope, and the most relevant parameters assessed by focused echocardiography in Pediatric ICU are left ventricular systolic function, fluid responsiveness, cardiac tamponade and pulmonary hypertension. Proper ability building of pediatric emergency care physicians and intensivists to perform focused echocardiography is feasible and provides improved care of severely ill children and thus should be encouraged.
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78
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Saha NM, Barbat JJ, Fedson S, Anderson A, Rich JD, Spencer KT. Outpatient Use of Focused Cardiac Ultrasound to Assess the Inferior Vena Cava in Patients With Heart Failure. Am J Cardiol 2015; 116:1224-8. [PMID: 26279108 DOI: 10.1016/j.amjcard.2015.07.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/12/2015] [Accepted: 07/12/2015] [Indexed: 10/23/2022]
Abstract
Accurate assessment of volume status is critical in the management of patients with heart failure (HF). We studied the utility of a pocket-sized ultrasound device in an outpatient cardiology clinic as a tool to guide volume assessment. Inferior vena cava (IVC) size and collapsibility were assessed in 95 patients by residents briefly trained in focused cardiac ultrasound (FCU). Cardiologist assessment of volume status and changes in diuretic medication were also recorded. Patients were followed for occurrence of 30-day events. There was a 94% success rate of obtaining IVC size and collapsibility, and agreement between visual and calculated IVC parameters was excellent. Most patients were euvolemic by both FCU IVC and clinical bedside assessment (51%) and had no change in diuretic dose. Thirty-two percent had discrepant FCU IVC and clinical volume assessments. In clinically hypervolemic patients, the FCU evaluation of the IVC suggested that the wrong diuretic management plan might have been made 46% of the time. At 30 days, 14 events occurred. The incidence of events increased significantly with FCU IVC imaging categorization, from 11% to 23% to 36% in patients with normal, intermediate, and plethoric IVCs. By comparison, when grouped in a binary manner, there was no significant difference in event rates for patients who were deemed to be clinically volume overloaded. Assessment of volume status in an outpatient cardiology clinic using FCU imaging of the IVC is feasible in a high percentage of patients. A group of patients were identified with volume status discordant between FCU IVC and routine clinic assessment, suggesting that IVC parameters may provide a valuable supplement to the in-office physical examination.
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Abstract
Focused cardiac ultrasound (FCU) is a bedside examination of the heart performed with a small, portable ultrasound platform by a physician as an adjunct to their physical examination. The goal is to recognize a narrow list of abnormalities that are both detectable by physicians with limited ultrasound training and have high clinical assessment value. Results from the FCU examination are integrated with traditional bedside assessment (physical examination and history) to provide early management plans and patient triage in settings when echocardiography cannot be obtained or is not immediately available.
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Affiliation(s)
- Kirk T Spencer
- University of Chicago, 5841 S Maryland MC 5084, Chicago, IL, 60637, USA,
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80
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Kini V, Mehta N, Mazurek JA, Ferrari VA, Epstein AJ, Groeneveld PW, Kirkpatrick JN. Focused Cardiac Ultrasound in Place of Repeat Echocardiography: Reliability and Cost Implications. J Am Soc Echocardiogr 2015; 28:1053-9. [PMID: 26165448 PMCID: PMC4777333 DOI: 10.1016/j.echo.2015.06.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Health care systems are increasingly moving toward models that emphasize the delivery of high-quality health care at lower costs. Rates of repeat echocardiography (two or more transthoracic echocardiographic studies performed within a short interval) are high and can contribute substantially to the cost of providing cardiovascular care. Certain findings from handheld ultrasound scans performed by echocardiographers have been shown to correlate well with findings on transthoracic echocardiography (TTE). It therefore may be feasible and cost effective to use expert focused cardiac ultrasound (eFCU) in place of repeat TTE for highly selected indications in certain settings. The aim of this study was to determine the reliability and cost implications of using eFCU in place of repeat TTE in selected inpatients. METHODS Inpatients who underwent repeat TTE (prior TTE within 30 days) ordered for the assessment of ventricular function, pericardial effusion, or inferior vena cava collapse were prospectively enrolled. Subjects underwent eFCU in addition to TTE, and results were compared for correlation using the weighted κ statistic. The potential cost savings of using eFCU in place of TTE were modeled from the provider perspective (i.e., physicians and hospitals). RESULTS Over 45 days, 105 patients were enrolled. The majority of scans were performed for assessment of left ventricular function and pericardial effusions. eFCU showed excellent correlation with TTE for most parameters, including left ventricular systolic function (κ = 0.80) and the presence and size of pericardial effusions (κ = 0.81) (P < .001 for both). Adoption of this eFCU protocol could save between $41 and $64 per study, or between $34,512 and $53,871 annually at the authors' institution. CONCLUSIONS Findings from eFCU correlate well with those from TTE when used in the setting of repeat testing for assessment of ventricular function, pericardial effusion, and inferior vena cava collapse. The judicious use of eFCU in place of repeat inpatient TTE has the potential to deliver quality cardiac imaging at reduced cost.
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Affiliation(s)
- Vinay Kini
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nidhi Mehta
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victor A Ferrari
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew J Epstein
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter W Groeneveld
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James N Kirkpatrick
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Mizubuti GB, Allard RV, Tanzola RC, Ho AM. Pro: Focused Cardiac Ultrasound Should be an Integral Component of Anesthesiology Residency Training. J Cardiothorac Vasc Anesth 2015; 29:1081-5. [DOI: 10.1053/j.jvca.2015.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Indexed: 01/06/2023]
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82
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Levine AR, McCurdy MT, Zubrow MT, Papali A, Mallemat HA, Verceles AC. Tele-intensivists can instruct non-physicians to acquire high-quality ultrasound images. J Crit Care 2015; 30:871-5. [PMID: 26122274 DOI: 10.1016/j.jcrc.2015.05.030] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 04/25/2015] [Accepted: 05/30/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Intensive care unit telemedicine (tele-ICU) uses audiovisual systems to remotely monitor and manage patients. Intensive care unit ultrasound can augment an otherwise limited bedside evaluation. To date, no studies have utilized tele-ICU technology to assess the quality and clinical use of real-time ultrasound images. We assessed whether tele-intensivists can instruct nonphysicians to obtain high-quality, clinically useful ultrasound images. METHODS This prospective pilot evaluated the effectiveness of a brief educational session of nonphysician "ultrasonographers" on their ability to obtain ultrasound images (right internal jugular vein, bilateral lung apices and bases, cardiac subxiphoid view, bladder) with real-time tele-intensivist guidance. All ultrasound screen images were simultaneously photographed with a 2-way camera and saved on the ultrasound machine. The tele-intensivist assessed image quality, and an independent ultrasound expert rated their use in guiding clinical decisions. RESULTS The intensivist rated the tele-ICU camera images as high quality (70/77, 91%) and suitable for guiding clinical decisions (74/77, 96%). Only bilateral lung apices demonstrated differences in quality and clinical use. All other images were rated noninferior and clinically useful. CONCLUSION Tele-intensivists can guide minimally trained nonphysicians to obtain high-quality, clinically useful ultrasound images. For most anatomic sites, tele-ICU images are of similar quality to those acquired directly by ultrasound.
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Affiliation(s)
- Andrea R Levine
- Department of Medicine, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD, 21201, United States.
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 S. Paca St., 2nd Floor, Baltimore, MD, 21201, United States; Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca St., 6th Floor, Baltimore, MD, 21201, United States.
| | - Marc T Zubrow
- Program in Trauma, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, United States; University of Maryland eCare, University of Maryland Medical System, 110 S. Paca St., Suite 5-N-162, Baltimore, MD, 21201, United States.
| | - Alfred Papali
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 S. Paca St., 2nd Floor, Baltimore, MD, 21201, United States.
| | - Haney A Mallemat
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca St., 6th Floor, Baltimore, MD, 21201, United States.
| | - Avelino C Verceles
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 110 S. Paca St., 2nd Floor, Baltimore, MD, 21201, United States.
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84
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Nelson BP, Sanghvi A. Point-of-Care Cardiac Ultrasound: Feasibility of Performance by Noncardiologists. Glob Heart 2015; 8:293-7. [PMID: 25690629 DOI: 10.1016/j.gheart.2013.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Cardiac ultrasound has been used for decades to assess a wide variety of structural and functional pathology, as well as to monitor response to therapy. It offers the advantages of noninvasive, real-time dynamic functional assessment without the risk of radiation. Cardiologists have traditionally employed this modality and have established robust guidelines on the use of echocardiography. However, other specialties such as emergency medicine and critical care have realized the benefit of cardiac ultrasound and have established specialty guidelines in its use. There is growing evidence for the benefit of cardiac ultrasound at the point of care on hospital wards, clinics, and even pre-hospital environments as well. The pervasive use of focused ultrasound is perhaps most evident in the advent of ultrasound training in undergraduate medical curricula. This paper reviews some of the key literature on the use of focused, point-of-care ultrasound by noncardiologists. Feasibility, clinical utility, and emerging trends are reviewed.
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Affiliation(s)
- Bret P Nelson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Amy Sanghvi
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Mirabel M, Celermajer D, Beraud AS, Jouven X, Marijon E, Hagège AA. Pocket-sized focused cardiac ultrasound: strengths and limitations. Arch Cardiovasc Dis 2015; 108:197-205. [PMID: 25747662 DOI: 10.1016/j.acvd.2015.01.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 01/09/2015] [Accepted: 01/13/2015] [Indexed: 10/23/2022]
Abstract
Focused cardiac ultrasound (FCU) has emerged in recent years and has created new possibilities in the clinical assessment of patients both in and out of hospital. The increasing portability of echocardiographic devices, with some now only the size of a smartphone, has widened the spectrum of potential indications and users, from the senior cardiologist to the medical student. However, many issues still need to be addressed, especially the acknowledgment of the advantages and limitations of using such devices for FCU, and the extent of training required in this rapidly evolving field. In recent years, an increasing number of studies involving FCU have been published with variable results. This review outlines the evidence for the use of FCU with pocket-echo to address specific questions in daily clinical practice.
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Affiliation(s)
- Mariana Mirabel
- Assistance publique-Hôpitaux de Paris, hôpital Européen-Georges-Pompidou, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 75006 Paris, France; Inserm U970, Paris Cardiovascular Research Centre-PARCC, 75737 Paris Cedex 15, France.
| | | | - Anne-Sophie Beraud
- Stanford University Hospital, Stanford, CA, USA; Clinique Pasteur, 31300 Toulouse, France
| | - Xavier Jouven
- Assistance publique-Hôpitaux de Paris, hôpital Européen-Georges-Pompidou, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 75006 Paris, France; Inserm U970, Paris Cardiovascular Research Centre-PARCC, 75737 Paris Cedex 15, France
| | - Eloi Marijon
- Assistance publique-Hôpitaux de Paris, hôpital Européen-Georges-Pompidou, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 75006 Paris, France; Inserm U970, Paris Cardiovascular Research Centre-PARCC, 75737 Paris Cedex 15, France
| | - Albert A Hagège
- Assistance publique-Hôpitaux de Paris, hôpital Européen-Georges-Pompidou, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 75006 Paris, France; Inserm U970, Paris Cardiovascular Research Centre-PARCC, 75737 Paris Cedex 15, France
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Abstract
BACKGROUND Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
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Lei J, Dhamoon AS, Wang J, Iannuzzi M, Liu K. Walking the tightrope: Using quantitative Doppler echocardiography to optimize ventricular filling pressures in patients hospitalized for acute heart failure. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 5:130-40. [PMID: 25694508 DOI: 10.1177/2048872615573517] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 01/28/2015] [Indexed: 01/03/2023]
Affiliation(s)
- Juan Lei
- Department of Cardiology, Sun Yat-Sen Memorial Hospital, China
| | - Amit S Dhamoon
- Department of Medicine, State University of New York, USA
| | - Jingfeng Wang
- Department of Cardiology, Sun Yat-Sen Memorial Hospital, China
| | | | - Kan Liu
- Department of Medicine, State University of New York, USA
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88
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Mozzini C, Garbin U, Fratta Pasini AM, Cominacini L. Short training in focused cardiac ultrasound in an Internal Medicine department: what realistic skill targets could be achieved? Intern Emerg Med 2015; 10:73-80. [PMID: 25492052 DOI: 10.1007/s11739-014-1167-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 11/27/2014] [Indexed: 12/21/2022]
Abstract
The importance of focused cardiac ultrasound (FCU) in Internal Medicine care has been recognized by the American Society of Echocardiography. The aim of this study was to test what realistic skill targets could be achieved in FCU, with a relatively short training (theoretical and practical) of 9 h offered to Internal Medicine certification board attending students, and if the addition of further 9 h of training could significantly improve the level of competence. Kappa statistic was used to calculate the inter-observer agreement (trainees/tutor). The agreement between the trainees (who completed the entire training) and the tutor was, respectively, "substantial" (k = 0.71) for the identification of pericardial effusion, "moderate" (k = 0.56-0.54) for the identification of marked right ventricular and left ventricular enlargement, "substantial" (k = 0.77) for the assessment of global cardiac systolic function by visual inspection and "fair" (k = 0.35) for the assessment of size and respiratory change in the diameter of the inferior cave vein (IVC). 18 h training in FCU provided proficiency in obtaining adequate images from the parasternal window without providing the ability to correctly master the apical and subcostal windows. As concerns the interpretative skills, only pericardial effusion and visual estimation of global systolic function could be correctly identified, while ventricular enlargement and IVC prove to be more difficult to evaluate. This study supports incorporating FCU into Internal Medicine fellowship training programs, and should facilitate the design of other similar training courses.
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Affiliation(s)
- Chiara Mozzini
- Section of Internal Medicine, Department of Medicine, University of Verona, 10, Piazzale L.A. Scuro, 37134, Verona, Italy,
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89
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Ojeda JC, Colbert JA, Lin X, McMahon GT, Doubilet PM, Benson CB, Wu J, Katz JT, Yialamas MA. Pocket-sized ultrasound as an aid to physical diagnosis for internal medicine residents: a randomized trial. J Gen Intern Med 2015; 30:199-206. [PMID: 25387438 PMCID: PMC4314490 DOI: 10.1007/s11606-014-3086-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 06/17/2014] [Accepted: 10/21/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Proficiency and self-confidence in the physical examination is poor among internal medicine residents and interest in ultrasound technology has expanded. OBJECTIVE We aimed to determine whether a pocket-sized ultrasound improves the diagnostic accuracy and confidence of residents after a 3-h training session and 1 month of independent practice. DESIGN This was a randomized parallel group controlled trial. PARTICIPANTS Forty internal medicine residents in a single program at an academic medical center participated in the study. INTERVENTION Three hours of training on use of pocket-sized ultrasound was followed by 1 month of independent practice. MAIN MEASURES The primary outcome was a comparison of the diagnostic accuracy of a physical exam alone versus a physical examination augmented with a pocket-sized ultrasound. Other outcomes included confidence in exam findings and a survey of attitudes towards the physical exam and the role of ultrasound. KEY RESULTS Residents in the intervention group using a pocket-sized ultrasound correctly identified an average of 7.6 of the 17 abnormal findings (accuracy rate of 44.9 %). Those in the control group correctly identified an average of 6.4 abnormal findings (accuracy rate of 37.6 %, p = 0.11). Residents in the intervention group identified on average 15.9 findings as abnormal when no abnormality existed (false positive rate of 16.8 %). Those in the control group incorrectly identified an average of 15.5 positive findings (false positive rate of 16.3 %). There was no difference between groups regarding self-assessed confidence in physical examination. Residents in the intervention group identified 6.1 of 13 abnormal cardiac findings versus the control group's 4.5 of 13, an accuracy rate of 47.0 % versus 34.6 % (p = 0.023). CONCLUSIONS The diagnostic ability of internal medicine residents did not significantly improve with use of a pocket-sized ultrasound device after a 3-h training session and 1 month of independent practice. TRIAL REGISTRATION clinicaltrials.gov: number NCT01948076; URL http://clinicaltrials.gov/ct2/show/study/NCT01948076?term=ultrasound+physical+exam&rank=2.
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Affiliation(s)
- Jason C Ojeda
- Department of Medicine, Jefferson University, Philadelphia, PA, USA
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90
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Siqueira VN, Mancuso FJN, Campos O, De Paola AA, Carvalho AC, Moises VA. Training Program for Cardiology Residents to Perform Focused Cardiac Ultrasound Examination with Portable Device. Echocardiography 2015; 32:1455-62. [DOI: 10.1111/echo.12887] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Vicente N. Siqueira
- Cardiology Department; Paulista School of Medicine; Federal University of São Paulo; Brazil
| | | | - Orlando Campos
- Cardiology Department; Paulista School of Medicine; Federal University of São Paulo; Brazil
| | - Angelo A. De Paola
- Cardiology Department; Paulista School of Medicine; Federal University of São Paulo; Brazil
| | - Antonio C. Carvalho
- Cardiology Department; Paulista School of Medicine; Federal University of São Paulo; Brazil
| | - Valdir A. Moises
- Cardiology Department; Paulista School of Medicine; Federal University of São Paulo; Brazil
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91
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Walley PE, Walley KR, Goodgame B, Punjabi V, Sirounis D. A practical approach to goal-directed echocardiography in the critical care setting. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:681. [PMID: 25672460 PMCID: PMC4331439 DOI: 10.1186/s13054-014-0681-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Urgent cardiac ultrasound examination in the critical care setting is clinically useful. Application of goal-directed echocardiography in this setting is quite distinct from typical exploratory diagnostic comprehensive echocardiography, because the urgent critical care setting mandates a goal-directed approach. Goal-directed echocardiography most frequently aims to rapidly identify and differentiate the cause(s) of hemodynamic instability and/or the cause(s) of acute respiratory failure. Accordingly, this paper highlights 1) indications, 2) an easily memorized differential diagnostic framework for goal-directed echocardiography, 3) clinical questions that must be asked and answered, 4) practical issues to allow optimal image capture, 5) primary echocardiographic views, 6) key issues addressed in each view, and 7) interpretation of findings within the differential diagnostic framework. The most frequent indications for goal-directed echocardiography include 1) the spectrum of hemodynamic instability, shock, and pulseless electrical activity arrest and 2) acute respiratory failure. The differential diagnostic categories for hemodynamic instability can be remembered using the mnemonic ‘SHOCK’ (for Septic, Hypovolemic, Obstructive, Cardiogenic, and (K) combinations/other kinds of shock). RESP-F (for exacerbation of chronic Respiratory disease, pulmonary Embolism, ST changes associated with cardiac or pericardial disease, Pneumonia, and heart Failure) can be used for acute respiratory failure. The goals of goal-directed echocardiography in the unstable patient are: assessing global ventricular systolic function, identifying marked right ventricular and left ventricular enlargement, assessing intravascular volume, and the presence of a pericardial effusion. In an urgent or emergent setting, it is recommended to go directly to the best view, which is frequently the subcostal or apical view. The five views are the subcostal four-chamber view, subcostal inferior vena cava view, parasternal long axis view, parasternal short axis view, and the apical four chamber view. Always interpret goal-directed echocardiographic findings in the context of clinically available hemodynamic information. When goal-directed echocardiography is insufficient or when additional abnormalities are appreciated, order a comprehensive echocardiogram. Goal-directed echocardiography and comprehensive echocardiography are not to be used in conflict with each other.
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92
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Model Point-of-Care Ultrasound Curriculum in an Intensive Care Unit Fellowship Program and Its Impact on Patient Management. Crit Care Res Pract 2014; 2014:934796. [PMID: 25478217 PMCID: PMC4248397 DOI: 10.1155/2014/934796] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 10/02/2014] [Accepted: 10/30/2014] [Indexed: 12/21/2022] Open
Abstract
Objectives. This study was designed to assess the clinical applicability of a Point-of-Care (POC) ultrasound curriculum into an intensive care unit (ICU) fellowship program and its impact on patient care. Methods. A POC ultrasound curriculum for the surgical ICU (SICU) fellowship was designed and implemented in an urban, academic tertiary care center. It included 30 hours of didactics and hands-on training on models. Minimum requirement for each ICU fellow was to perform 25–50 exams on respective systems or organs for a total not less than 125 studies on ICU. The ICU fellows implemented the POC ultrasound curriculum into their daily practice in managing ICU patients, under supervision from ICU staff physicians, who were instructors in POC ultrasound. Impact on patient care including finding a new diagnosis or change in patient management was reviewed over a period of one academic year. Results. 873 POC ultrasound studies in 203 patients admitted to the surgical ICU were reviewed for analysis. All studies included were done through the POC ultrasound curriculum training. The most common exams performed were 379 lung/pleural exams, 239 focused echocardiography and hemodynamic exams, and 237 abdominal exams. New diagnosis was found in 65.52% of cases (95% CI 0.590, 0.720). Changes in patient management were found in 36.95% of cases (95% CI 0.303, 0.435). Conclusions. Implementation of POC ultrasound in the ICU with a structured fellowship curriculum was associated with an increase in new diagnosis in about 2/3 and change in management in over 1/3 of ICU patients studied.
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93
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Brief Group Training of Medical Students in Focused Cardiac Ultrasound May Improve Diagnostic Accuracy of Physical Examination. J Am Soc Echocardiogr 2014; 27:1238-46. [DOI: 10.1016/j.echo.2014.08.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Indexed: 11/23/2022]
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Arienti V, Di Giulio R, Cogliati C, Accogli E, Aluigi L, Corazza GR. Bedside ultrasonography (US), Echoscopy and US point of care as a new kind of stethoscope for Internal Medicine Departments: the training program of the Italian Internal Medicine Society (SIMI). Intern Emerg Med 2014; 9:805-14. [PMID: 25145290 DOI: 10.1007/s11739-014-1113-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023]
Abstract
In recent years, thanks to the development of miniaturized ultrasound devices, comparable to personal computers, tablets and even to smart phones, we have seen an increasing use of bedside ultrasound in internal medicine departments as a novel kind of ultrasound stethoscope. The clinical ultrasound-assisted approach has proved to be particularly useful in assessing patients with nodules of the neck, dyspnoea, abdominal pain, and with limb edema. In several cases, it has allowed a simple, rapid and precise diagnosis. Since 2005, the Italian Society of Internal Medicine and its Ultrasound Study Group has been holding a Summer School and training courses in ultrasound for residents in internal medicine. A national network of schools in bedside ultrasound was then organized for internal medicine specialists who want to learn this technique. Because bedside ultrasound is a user-dependent diagnostic method, it is important to define the limits and advantages of different new ultrasound devices, to classify them (i.e. Echoscopy and Point of Care Ultrasound), to establish appropriate different levels of competence and to ensure their specific training. In this review, we describe the point of view of the Italian Internal Medicine Society on these topics.
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Affiliation(s)
- Vincenzo Arienti
- Department of Internal Medicine, Internal Medicine A, Maggiore Hospital, Bologna, Italy,
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95
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Khan HA, Wineinger NE, Uddin PQ, Mehta HS, Rubenson DS, Topol EJ. Can hospital rounds with pocket ultrasound by cardiologists reduce standard echocardiography? Am J Med 2014; 127:669.e1-7. [PMID: 24674919 PMCID: PMC4074438 DOI: 10.1016/j.amjmed.2014.03.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 03/14/2014] [Accepted: 03/14/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Frequently, hospitalized patients are referred for transthoracic echocardiograms. The availability of a pocket mobile echocardiography device that can be incorporated on bedside rounds by cardiologists may be a useful and frugal alternative. METHODS This was a cross-sectional study designed to compare the accuracy of pocket mobile echocardiography images with those acquired by transthoracic echocardiography in a sample of hospitalized patients. Each patient referred for echocardiography underwent pocket mobile echocardiography acquisition and interpretation by a senior cardiology fellow with level II training in echocardiography. Subsequently, transthoracic echocardiography was performed by skilled ultrasonographers and interpreted by experienced echocardiographers. Both groups were blinded to the results of the alternative imaging modality. Visualizability and accuracy for all key echocardiographic parameters (ejection fraction, wall motion abnormalities, left ventricular end-diastolic dimension, inferior vena cava size, aortic and mitral valve pathology, and pericardial effusion) were determined and compared between imaging modalities. RESULTS A total of 240 hospitalized patients underwent echocardiography with pocket mobile echocardiography and transthoracic echocardiography. The mean age was 71 ± 17 years. Pocket mobile echocardiography imaging time was 6.3 ± 1.5 minutes. Sensitivity of pocket mobile echocardiography varied by parameter and was highest for aortic stenosis (97%) and lowest for aortic insufficiency (76%). Specificity also varied by parameter and was highest for mitral regurgitation (100%) and lowest for left ventricular ejection fraction (92%). Equivalence testing revealed the pocket mobile echocardiography outcomes to be significantly equivalent to the transthoracic echocardiography outcomes with no discernible differences in image quality between pocket mobile echocardiography and transthoracic echocardiography (P = 7.22 × 10(-7)). All outcomes remain significant after correcting for multiple testing using the false discovery rate. CONCLUSIONS The results from rapid bedside pocket mobile echocardiography examinations performed by experienced cardiology fellows compared favorably with those from formal transthoracic echocardiography studies. For hospitalized patients, this finding could shift the burden of performing and interpreting the echocardiogram to the examining physician and reduce the number and cost associated with formal echocardiography studies.
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Affiliation(s)
- Hashim A Khan
- Division of Cardiovascular Diseases, Scripps Clinic, Scripps Health, La Jolla, Calif; Scripps Translational Science Institute, La Jolla, Calif
| | | | - Poulina Q Uddin
- Division of Cardiovascular Diseases, Scripps Clinic, Scripps Health, La Jolla, Calif
| | - Hirsch S Mehta
- Division of Cardiovascular Diseases, Scripps Clinic, Scripps Health, La Jolla, Calif
| | - David S Rubenson
- Division of Cardiovascular Diseases, Scripps Clinic, Scripps Health, La Jolla, Calif
| | - Eric J Topol
- Division of Cardiovascular Diseases, Scripps Clinic, Scripps Health, La Jolla, Calif; Scripps Translational Science Institute, La Jolla, Calif.
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96
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Gillon S, Zafiropoulos A, Madhivathanan P. Echocardiography training for non-cardiologists. Br J Hosp Med (Lond) 2014; 75:346-8. [DOI: 10.12968/hmed.2014.75.6.346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Stuart Gillon
- Specialty Registrar in Intensive Care Medicine, King's College Hospital, London SE5 9RS
| | - Andreas Zafiropoulos
- Specialty Registrar in Anaesthesia and Intensive Care Medicine, Barts Health, London
| | - Pradeep Madhivathanan
- Specialty Registrar in Anaesthesia and Intensive Care Medicine, St George's Hospital, London
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97
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Cullen MW, Blauwet LA, Vatury OM, Mulvagh SL, Behrenbeck TR, Scott CG, Pellikka PA. Diagnostic capability of comprehensive handheld vs transthoracic echocardiography. Mayo Clin Proc 2014; 89:790-8. [PMID: 24684783 PMCID: PMC4082693 DOI: 10.1016/j.mayocp.2013.12.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/03/2013] [Accepted: 12/05/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess the diagnostic capability of handheld echocardiography (HHE) compared with transthoracic echocardiography (TTE) performed and evaluated by experienced sonographers and expert echocardiographers. PATIENTS AND METHODS We conducted a prospective study of adult outpatients undergoing comprehensive TTE between July 9, 2012, and April 3, 2013. Experienced sonographers performed a detailed, standardized examination using a handheld ultrasound device that included 2-dimensional and color Doppler images from standard imaging windows. Images from TTE and HHE were independently interpreted by expert echocardiographers to whom the other study was masked. Agreement between the standard TTE and the HHE reports was analyzed. RESULTS The study group contained 190 patients (mean ± SD age, 62 ± 17 years; 49% male [n=93]). The κ values were 0.52 for left ventricular (LV) enlargement, 0.52 for right ventricular enlargement, 0.62 for regional wall motion abnormalities, 0.73 for aortic stenosis, and 0.61 for mitral regurgitation. Lin concordance correlation coefficients ranged from 0.89 for LV end-systolic diameter to 0.78 for LV end-diastolic diameter. In 51 patients (27%), echocardiographic findings were discordant between HHE and standard TTE. The most common discordant finding was the presence vs absence of any regional wall motion abnormalities. In discordant cases, HHE tended to underestimate, rather than overestimate, the severity of abnormal findings. CONCLUSION In experienced hands, HHE shows moderate correlation with standard TTE, but discordant findings were present in 27% of patients. Even when performed and interpreted by experienced operators, HHE should not be used as a surrogate for standard TTE. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01558518.
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Affiliation(s)
| | - Lori A Blauwet
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ori M Vatury
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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98
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Dhamoon A, Liu K. How can we improve inpatient management of heart failure? JACC. HEART FAILURE 2014; 2:199-200. [PMID: 24720930 DOI: 10.1016/j.jchf.2013.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/18/2013] [Indexed: 10/25/2022]
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99
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Cogliati C, Antivalle M, Torzillo D, Birocchi S, Norsa A, Bianco R, Costantino G, Ditto MC, Battellino M, Sarzi Puttini PC, Montano N. Standard and pocket-size lung ultrasound devices can detect interstitial lung disease in rheumatoid arthritis patients. Rheumatology (Oxford) 2014; 53:1497-503. [DOI: 10.1093/rheumatology/keu033] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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100
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Victor K, Rajani R, Bruemmer-Smith S, Kabir S, Chambers J. A training programme in screening echocardiography. CLINICAL TEACHER 2014; 10:176-80. [PMID: 23656680 DOI: 10.1111/tct.12019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although the value of echocardiography in acutely unwell patients is well established, it is often difficult to deliver conventional studies immediately. This has led to the development of training programmes in screening echocardiography. CONTEXT Echocardiography is a difficult skill to master and requires an integration of knowledge-based learning and mentored practical training. INNOVATION We developed a three-stage programme: (1) a 1-day course containing didactic lectures on normal and abnormal pathology, a 2-hour practical element with rotation through different tutors then seminars and self-assessment, with an interactive quiz; (2) a period of consolidation via apprenticeship with a recognised trainer; and (3) formal assessment. IMPLICATIONS We propose a specific training programme to teach the difficult practical skill of screening echocardiography. The use of theoretical and practical elements with structured teaching and an apprenticeship may serve as a model for teaching other practical skills in clinical medicine.
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Affiliation(s)
- Kelly Victor
- Department of Adult Echocardiography, St Thomas' Hospital, London, UK
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