Ultrasonography in the emergency department

Cost-Effective Training Models in Point-of-Care Ultrasound for Medical Students in Emergency Medicine: An Evaluation of Current Resources

Background

Ultrasound is becoming more widely utilized in clinical practice; however, its effectiveness is limited by the operator’s skills. Simulation models are attractive options for developing skills because they allow inexperienced users to practice without the risk of endangering patients.

Objective

The purpose of this study was to identify commercially available and homemade ultrasound models to describe them in terms of materials, cost, and whether they are high- or low-fidelity for medical student education.

Methods

This is an investigational study on cost-effective ultrasound training methods for medical students. Our study was performed using search engines in Google, Google Scholar, and PubMed to search for models for the following five modalities: foreign body identification, intravenous (IV) injection training, abdominal ultrasound, ocular ultrasound, and ultrasound-guided lumbar puncture training.

Results

Most homemade models for foreign body identification, IV injection training, and ocular ultrasound could be created for less than $20. IV injection training models were the cheapest commercially available models. There are multiple commercially available options for abdominal ultrasound models, but no options were found for homemade construction. The construction cost for lumbar puncture models was larger due to the need to purchase an anatomically accurate set of lumbar vertebrae.

Conclusions

This study provides initial guidance and suggestions for ultrasound training models that are currently available. Ultrasound models that can be cheaply made or purchased increase accessibility for medical students to gain early exposure in a cost-effective and safe manner.

Characterizing the biomechanical differences between novice and expert point-of-care ultrasound practitioners using a low-cost gyroscope and accelerometer integrated sensor: A pilot study

Introduction

Point-of-care ultrasound (POCUS) has become an important diagnostic tool in acute care medicine; however, little is known about the biomechanical differences between novice and expert practitioners.

Methods

A low-cost ($50 CAD) gyroscope and accelerometer integrated sensor was assembled and affixed to an ultrasound probe. Seventeen participants, nine novices and eight experts, were recruited to perform three abdominal and four cardiac scans on a standardized patient. Participant demographics, time per scan, average acceleration, average angular velocity, decay in acceleration and angular velocity over time, and frequency of probe movements were analyzed. Video capture with blinded video review was scored.

Results

On video review, experts had higher image optimization and acquisition scores for both abdominal and cardiac scans. Experts had shorter scan times for abdominal (7 s vs. 26 s, p = 0.003) and cardiac (11 s vs. 26 s, p < 0.001) scans. There was no difference in average acceleration (g) between novices and experts performing abdominal (1.02 vs. 1.01, p = 0.50) and cardiac (1.01 vs. 1.01, p = 0.45) scans. Experts had lower angular velocity (°/s) for abdominal scans (10.00 vs. 18.73, p < 0.001) and cardiac scans (15.61 vs. 20.33, p = 0.02) There was a greater decay in acceleration over time for experts performing cardiac scans compared to novices (-0.194 vs. -0.050, p = 0.03) but not for abdominal scans or when measuring angular velocity. The frequency of movements (Hz) was higher for novices compared to experts for abdominal (16.68 vs. 13.79, p < 0.001) and cardiac (17.60 vs. 13.63, p = 0.002) scans.

Discussion

This study supports the feasibility of a low-cost gyroscope and accelerometer integrated sensor to quantify the biomechanics of POCUS. It may also support the concept of "window shopping" as a method by which experts obtain abdominal and cardiac views, where sliding is used to find an acoustic window, then smaller rocking and tilting probe movements are used to refine the image.

Effectiveness of the implementation of pediatric intussusception clinical pathway: A pre- and postintervention trial

Intussusception is common among children at the pediatric emergency department (ED) with acute abdomen. Diagnosis and treatment delay remain a challenge. This study aimed to evaluate the impact of intussusception clinical pathways (CPs) implementation, including bedside point-of-care ultrasonography, on patient management in a pediatric ED.In January 2017, an intussusception management protocol was implemented for children with symptoms of intussusception. We retrospectively examined the charts of patients diagnosed with intussusception during the preprotocol (January 2015 to December 2016) and postprotocol (January 2017 to January 2019) periods and compared their outcomes.A total of 106 and 108 patients were included in the preprotocol and postprotocol groups, respectively. After CP implementation, the median door-to-ultrasonography time decreased from 66.5 (range: 13, 761) to 54 (20, 191) minutes; meanwhile, door-to-reduction time decreased from 121.5 (37, 1077) to 80.5 (40, 285) minutes; the median ED length of stay decreased from 440 to 303.5  minutes; and finally, admission rate increased from 18.9% to 40.7% (P < .01). There was no between-group difference in the rates of complications, readmission, emergency surgery, or reduction failure.The implementation of an intussusception CP decreased time-to-diagnosis, time-to-treatment, and ED length of stay estimates among children screened using point-of-care ultrasonography. The present findings suggest that the implementation of an intussusception CP may improve the efficiency of time and resource use.

Point-of-Care Ultrasound in United States Pediatric Emergency Medicine Fellowship Programs: The Current State of Practice and Training

OBJECTIVES

In 2015, the American Academy of Pediatrics (AAP) released a policy statement regarding point-of-care ultrasonography (POCUS) by pediatric emergency physicians, which included recommendations on education and training. In the 3 years since the AAP policy statement and its accompanying technical report were published, it is unclear which aspects of the recommendations set forth by this policy have been instituted by POCUS programs throughout the country. The objective of this study was to conduct a survey of pediatric emergency medicine (PEM) fellowship directors throughout the United States regarding the current state of education and training of POCUS in their department.

METHODS

We conducted an online survey of all PEM fellowship program directors in the United States between April 1, 2018, and July 31, 2018.

RESULTS

Of the 78 PEM fellowship program directors contacted, 62 (79.5%) responded. The majority reported having an ultrasound curriculum in place to educate their fellows (77%). Fellows are being taught using a variety of educational strategies. The most commonly reported barriers were lack of qualified faculty available for training (62.9%), lack of confidence or comfort in using the existing ultrasound machine(s) in their department (54.8%), and physician resistance to using new technology (50%). The majority of programs reported having processes in place for credentialing (56%) and quality assurance (72.6%). Whereas 77.4% have a system for archiving POCUS studies after they are performed, only half of the programs report utilization of middleware for their archival system. Compliance with documentation varied significantly between programs.

CONCLUSIONS

Our survey results demonstrate that, although there is still room for improvement, POCUS programs have succeeded in many of the goals set forth by the 2015 AAP policy statement, such as establishing and growing an ultrasound curriculum and using various strategies to educate PEM fellows.

Clinical Method Applied to Focused Ultrasound: The Case of Wells' Score and Echocardiography in the Emergency Department: A Systematic Review and a Meta-Analysis

Background and Objectives: bedside cardiac ultrasound is a widely adopted method in Emergency Departments (ED) for extending physical examination and refining clinical diagnosis. However, in the setting of hemodynamically-stable pulmonary embolism, the diagnostic role of echocardiography is still the subject of debate. In light of its high specificity and low sensitivity, some authors suggest that echocardiographic signs of right ventricle overload could be used to rule-in pulmonary embolism. In this study, we aimed to clarify the diagnostic role of echocardiographic signs of right ventricle overload in the setting of hemodynamically-stable pulmonary embolism in the ED. Materials and Methods: we performed a systematic review of literature in PubMed, Web of Science and Cochrane databases, considering the echocardiographic signs for the diagnosis of pulmonary embolism in the ED. Studies considering unstable or shocked patients were excluded. Papers enrolling hemodynamically stable subjects were selected. We performed a diagnostic test accuracy meta-analysis for each sign, and then performed a critical evaluation according to pretest probability, assessed with Wells' score for pulmonary embolism. Results: 10 studies were finally included. We observed a good specificity and a low sensitivity of each echocardiographic sign of right ventricle overload. However, once stratified by the Wells' score, the post-test probability only increased among high-risk patients. Conclusions: signs of echocardiographic right ventricle overload should not be used to modify the clinical behavior in low- and intermediate- risk patients according to Wells' score classification. Among high-risk patients, however, echocardiographic signs could help a physician in detecting patients with the highest probability of pulmonary embolism, necessitating a confirmation by computed tomography with pulmonary angiography. However, a focused cardiac and thoracic ultrasound investigation is useful for the differential diagnosis of dyspnea and chest pain in the ED.

The Role of Lung Ultrasound in the Management of the Critically Ill Neonate-A Narrative Review and Practical Guide

Lung ultrasound makes use of artifacts generated by the ratio of air and fluid in the lung. Recently, an enormous increase of research regarding lung ultrasound emerged, especially in intensive care units. The use of lung ultrasound on the neonatal intensive care unit enables the clinician to gain knowledge about the respiratory condition of the patients, make quick decisions, and reduces exposure to ionizing radiation. In this narrative review, the possibilities of lung ultrasound for the stabilization and resuscitation of the neonate using the ABCDE algorithm will be discussed.

Impact of an epic-integrated point-of-care ultrasound workflow on ultrasound performance, compliance, and potential revenue

OBJECTIVES

The purpose of this study was to describe the design and impact of a point-of-care ultrasound (PoCUS) workflow integrated into the electronic medical record (EMR) on PoCUS utilization, documentation compliance, and resultant revenue potential.

METHODS

This was a single-center retrospective study at an academic center. The study period spanned from December 1, 2018 to June 30, 2019 (pre-implementation) to August 1, 2019 to February 29, 2020 (post-implementation). The implementation date was July 11, 2019 at which time a PoCUS workflow was integrated into the EMR in the emergency department without the purchase of middleware. Prior to this new workflow, a non-automated workflow was in place. PoCUS scan data were extracted from the EMR and archived examinations. The mean number of PoCUS examinations performed per month per 100 ED visits before and after implementation of the new workflow were compared using an unpaired t-test, stratified by all health care professionals, and attending physicians alone. The rate of documentation compliance before and after implementation of the new workflow were compared using a chi square contingency test. Potential revenue was calculated for each period by multiplying the number of eligible examinations by the respective 2020 Medicare conversion factor Relative Value Units.

RESULTS

Utilization of PoCUS from pre-implementation to post-implementation increased 28.7% from 5.01 to 6.45 mean examinations per month per 100 ED visits by all health care professionals (p = 0.063), and 75.1% from 2.01 to 3.52 by attending physicians (p = 0.0001). Examinations in compliance with workflow requirements increased from 153 (14.7%) to 1307 (94.0%). The rate of workflow compliance improved from 14.7% to 94.0% of examinations (p < 0.0001). Potential revenue increased from $546.01 to $22,014.47.

CONCLUSIONS

The implementation of a middleware-free PoCUS workflow at our institution was associated with increased PoCUS utilization, documentation compliance, and potential revenue.

Blinding practices during acute point-of-care ultrasound research: the BLIND-US meta-research study

OBJECTIVES

Point-of-care ultrasound (POCUS) diagnostic accuracy research has significant variation in blinding practices. This study characterises the blinding practices during acute POCUS research to determine whether research methodology adequately reflects POCUS use in routine clinical practice.

DESIGN, SETTINGS AND PARTICIPANTS

A search for POCUS diagnostic accuracy studies published in Emergency Medicine, Anaesthesia and Critical Care journals from January 2016 to January 2020 was performed. Studies were included if they were primary diagnostic accuracy studies. The study year, journal impact factor, population, hospital area, body region, study design, blinding of the POCUS interpreter to clinical information, whether the person performing the POCUS scan was the same person interpreting the scan, and whether the study reported incremental diagnostic yield were extracted in duplicate by two authors. Descriptive statistics were provided and prespecified subgroup analysis was performed.

MAIN OUTCOME MEASURES

The primary outcome was the number of studies that blinded the POCUS interpreter to at least some part of the clinical information. Secondary outcomes included whether the person performing the POCUS scan was the same person interpreting it and whether the study reported incremental diagnostic yield.

RESULTS

520 abstracts were screened with 97 studies included. The POCUS interpreter was blinded to clinical information in 37 studies (38.1%), not blinded in 34 studies (35.1%) and not reported in 26 studies (26.8%). The POCUS interpreter was the same person obtaining the images in 72 studies (74.2%), different in 14 studies (14.4%) and not reported in 11 studies (11.3%). Only four studies (4.1%) reported incremental diagnostic yield for POCUS. Inter-rater reliability was moderate (k=0.64). Subgroup analysis based on impact factor, body region, hospital area, patient population and study design did not show significant differences after completing pairwise comparisons.

CONCLUSIONS

Although blinding the POCUS interpreter to clinical information may be done in a perceived attempt to limit bias, this may result in accuracy estimates that do not reflect routine clinical practice. Similarly, having a different clinician perform and interpret the POCUS scan significantly limits generalisability to practice as it does not truly reflect 'point-of-care' ultrasound at all. Reporting incremental diagnostic yield from implementing POCUS into a diagnostic pathway better reflects the value of POCUS; however, this methodology was infrequently used.

TRIAL REGISTRATION NUMBER

The study protocol was registered on Open Science Framework (https://osf.io/h5fe7/).

Utilisation of musculoskeletal ultrasonography for the evaluation of septic arthritis in a patient presenting to the emergency department with fever during the era of COVID-19

Prompt recognition and treatment of septic arthritis are crucial to prevent significant morbidity and mortality in affected patients. During the current COVID-19 pandemic, anchoring bias may make an already challenging diagnosis like septic arthritis more difficult to diagnose quickly and efficiently. Musculoskeletal (MSK) point of care ultrasonography (POCUS) is an imaging modality that can be used to quickly and efficiently obtain objective findings that may help a clinician establish the diagnosis of septic arthritis. We report a case where MSK POCUS was a key element in establishing the diagnosis of glenohumeral joint septic arthritis and subdeltoid septic bursitis for a patient that presented to the emergency department with a fever during the era of the COVID-19 pandemic.

Completeness of reporting for systematic reviews of point-of-care ultrasound: a meta-research study

OBJECTIVES

Systematic reviews are often considered among the highest quality of evidence. Completely reported systematic reviews, however, are required so readers can assess for generalisability of the research to practice and risk of bias. The objective of this study was to assess the completeness of reporting for systematic reviews assessing the diagnostic accuracy of point-of-care ultrasound (POCUS) using the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Diagnostic Test Accuracy (PRISMA-DTA) checklist that was published in 2018.

DESIGN AND SETTING

In this meta-research study, MEDLINE, EMBASE and Cochrane Library databases were searched, with no date restriction, on March 1st, 2020 for systematic reviews assessing the diagnostic accuracy of POCUS. Adherence to PRISMA-DTA for the main text and abstract was scored independently and in duplicate using a modified checklist. Prespecified subgroup analyses were performed.

MAIN OUTCOME MEASURES

The primary outcome was the mean PRISMA-DTA checklist adherence for the full-text and abstract.

RESULTS

A total of 71 studies published from 2008 to 2020 met the inclusion criteria. The overall adherence for the full-text was moderate: 19.8 out of 26.0 items (76%) and for the abstract was 7.0 out of 11.0 items (64%). Although many items in the PRISMA-DTA checklist were frequently reported, several were r infrequently reported (<33% of studies), including item 5 (protocol registration), item D2 (minimally acceptable test accuracy) and item 14 (variability in target condition, index test and reference standards). Subgroup analyses showed a higher PRISMA-DTA mean adherence (SD) for high impact journals (20.9 (2.52) vs 18.9 (1.95); p<0.001), studies including supplemental materials (20.6 (2.48) vs 18.9 (2.28); p=0.004), studies citing adherence to PRISMA reporting guidelines (20.4 (1.95) vs 19.0 (3.00); p=0.038) and studies published in journals endorsing PRISMA guidelines (20.2 (2.47) vs 18.6 (2.37); p=0.025). There was variable adherence based on journal of publication (p=0.006), but not for study population (adult vs paediatric vs mixed) (p=0.62), year of publication (p=0.94), body region (p=0.78) or country (p=0.40). There was no variability in abstract adherence based on whether the abstract was structured with subheadings or not (p=0.25). A Spearman's correlation found moderate correlation between higher word counts and abstractand full-text adherence (R=0.45, p<0.001 and R=0.38, p=0.001), respectively.

CONCLUSIONS

Overall, the reporting of POCUS diagnostic accuracy systematic reviews and meta-analyses was moderate. We identified deficits in several key areas including the preregistration of systematic reviews in an online repository, handling of multiple definitions of target conditions, index tests and reference standards and specifying minimally acceptable test accuracy. Prospective registration of reviews and detailed reporting as per PRISMA-DTA during the research process could improve reporting completeness. At an editorial level, word count and supplemental material limitations may impede reporting completeness, whereas endorsement of reporting guidelines on journal websites could improve reporting.

USER Protocol as a Guide to Resuscitation of the Patient with Septic Shock in the Emergency Department

Introduction

Sepsis is a disease that is still associated with high mortality, in which timely interventions are related to better results.

Objective

To determine if there is a difference in in-hospital mortality, fluid balances, norepinephrine initiation and recovery time of blood pressure, when comparing the resuscitation of the patient who is admitted to the emergency room in septic shock by applying the ultrasound protocol (USER) versus the standard of care.

Patients and Methods

This is a prospective, cohort study conducted in the emergency room of a highly complex hospital of patients with septic shock.

Results

83 patients recruited in total. The groups were comparable in demographics, mean baseline blood pressure, disease severity given by the SOFA value, and arterial lactate. A statistically significant difference was documented in the fluid balances at 4 hours, median 1325mL (IQR:451–2455mL) in Group C versus 900mL (IQR:440–1292) in Group U (p=0.048) and at 6 hours, median 1658mL (IQR:610–2925mL) versus 1107mL (IQR:600–1500mL), p=0.026, as well as in the total fluid balance of hospital stay, median 14,564mL (IQR:8660–18,705mL) versus 8660mL (IQR:5309–16,974mL), p=0.049. On the other hand, in the USER Group, the mean blood pressure ≥ 65mmHg was achieved in 97.4% of the patients 4 hours after the start of the protocol versus 50% in Group C (p=<0.001). Mortality with the use of the protocol compared with conventional therapy was (56.4% vs 61.36%, p=0.647).

Conclusion

The use of the USER protocol in patients with septic shock in the emergency room showed lower fluid balances at 4 and 6 hours, and of the total hospital stay, as well as earlier initiation of norepinephrine and statistically significant faster improvement in blood pressure. Although a statistically significant difference was not found in the days of ICU stay, hospitalization and in-hospital mortality, a trend was observed in the reduction of these parameters.

Comprehensive residency-based point-of-care ultrasound training program increases ultrasound utilization in the emergency department

Point-of-care ultrasonography (POCUS) is a prompt and simple tool for the urgent diagnosis and treatment of patients in the emergency department (ED). We developed a comprehensive residency-based POCUS training program for ED residents and determined its effect on ultrasound utilization in the ED.We conducted a retrospective cohort study in the ED of a university-affiliated medical center, to evaluate a centralized residency-based POCUS training course for ED residents, which included 12 core ultrasound applications, from July 2017 to June 2018. Each application comprised a combined lecture and hands-on practice session that lasted for 2 hours. Pre-tests and post-tests, including still image and video interpretation, were performed. The use of POCUS (number of ultrasound studies performed divided by the number of patients each resident saw in 1 year) among ED residents, before and after the POCUS training course (July 2016-June 2017 and July 2018-June 2019), was calculated and analyzed using the Wilcoxon signed-rank test.Sixteen residents participated and completed the entire training course. The post-test score was significantly better than the pre-test score, by a median of 12 points (P = .04). Utilization of POCUS among the ED residents increased significantly, from 0.15 ultrasound studies per patient per year to 0.41 ultrasound studies per patient per year (P < .01), after completion of the entire training course. Increased POCUS scanning percentages over the cardiac tissue, soft tissue, abdominal region, vascular system, procedural guidance, and ocular regions were also noted after providing the curriculum.Conducting a comprehensive POCUS education program may enhance POCUS utilization among residents in the ED.

Novice emergency physician ultrasonography of optic nerve sheath diameter compared to ophthalmologist fundoscopic evaluation for papilledema

OBJECTIVES

The purpose of this study is to determine the sensitivity and specificity of novice emergency physician-performed point-of-care ultrasound diagnosis of papilledema using optic nerve sheath diameter (ONSD) against ophthalmologist-performed dilated fundoscopy. This observational study retrospectively analyzed results of ultrasound-measured ONSD of emergency department (ED) patients with suspected intracranial hypertension from a period spanning June 2014 to October 2017.

METHODS

This study concerns a population of ED patients at a large, tertiary-care urban academic medical center from June 2014 to October 2017 over the age of 18 years with primary vision complaints evaluated for papilledema both by an emergency physician-performed ultrasound and an ophthalmologist-performed fundoscopic examination during their ED stay. Sensitivity and specificity of emergency physician-performed ultrasound measurement of optic nerve sheath diameter in the diagnosis of papilledema were primary outcomes for this study.

RESULTS

A total of 206 individual patients (male 49%, female 51%; median age 45 years) were included in the study with a total of 212 patient encounters. Calculated sensitivity for the ocular ultrasound examination performed by emergency physicians to diagnose papilledema was 46.9% (95% confidence interval [CI], 32.5% to 61.7%), and specificity was 87.0% (95% CI, 82.8% to 90.5%). Positive predictive value and negative predictive value were calculated to be 35.4% (95% CI, 23.9% to 48.2%) and 91.5% (95% CI, 87.8% to 94.4%), respectively.

CONCLUSIONS

Sonographic measurement of ONSD by emergency physicians has low sensitivity but high specificity for detection of papilledema compared to ophthalmologist-conducted fundoscopy.

Use of point-of-care ultrasound to diagnose an alternate cause of flank pain in a patient with presumed renal colic

This is a case of a 34-year-old male patient who presented to the emergency department (ED) with severe left flank pain. Due to the patient's cardiac history, elevated troponin, lactic acidosis, and lack of renal calculi on a noncontrast CT, focused cardiac ultrasound was performed, which showed left ventricle thrombus. The patient was later found to have bi-interventricular thrombi causing both pulmonary embolism and renal infarction. This is an uncommon diagnosis in the ED, where point-of-care ultrasound helped in diagnosing and guiding the management and disposition of this case.

Handheld Ultrasound Device Usage and Image Acquisition Ability Among Internal Medicine Trainees: A Randomized Trial

BACKGROUND

There is insufficient knowledge about how personal access to handheld ultrasound devices (HUDs) improves trainee learning with point-of-care ultrasound (POCUS).

OBJECTIVE

To assess whether HUDs, alongside a yearlong lecture series, improved trainee POCUS usage and ability to acquire images.

METHODS

Internal medicine intern physicians (n = 47) at a single institution from 2017 to 2018 were randomized 1:1 to receive personal HUDs (n = 24) for patient care/self-directed learning vs no-HUDs (n = 23). All interns received a repeated lecture series on cardiac, thoracic, and abdominal POCUS. Main outcome measures included self-reported HUD usage rates and post-intervention assessment scores using the Rapid Assessment of Competency in Echocardiography (RACE) scale between HUD and no-HUD groups.

RESULTS

HUD interns reported performing POCUS assessments on patients a mean 6.8 (SD 2.2) times per week vs 6.4 (SD 2.9) times per week in non-HUD arm (P = .66). There was no relationship between the number of self-reported examinations per week and a trainee's post-intervention RACE score (rho = 0.022, P = .95). HUD interns did not have significantly higher post-intervention RACE scores (median HUD score 17.0 vs no-HUD score 17.8; P = .72). Trainee confidence with cardiac POCUS did not correlate with RACE scores.

CONCLUSIONS

Personal HUDs without direct supervision did not increase the amount of POCUS usage or improve interns' acquisition abilities. Interns who reported performing more examinations per week did not have higher RACE scores. Improved HUD access and lectures without additional feedback may not improve POCUS mastery.

Diagnostic accuracy of ultrasound for small bowel obstruction: A systematic review and meta-analysis

PURPOSE

Accurate diagnosis of small bowel obstruction (SBO) remains challenging. The evidence of the diagnostic accuracy of ultrasound varies among studies, with reporting sensitivity ranging from 82 % to 100 % and specificity ranging from 54 % to 100 %. The aim of our study is to perform a systematic review and meta-analysis to investigate the accuracy of ultrasound for diagnosing SBO.

METHOD

The PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were searched from database inception to March 2020. Randomized controlled trials, quasi randomized studies, and prospective or retrospective cohort studies that evaluated the diagnostic performance of ultrasound for the diagnosis of bowel obstruction in adult patients (age ≥ 16 years) were eligible. The QUADAS-2 tool was used to assess the quality of the included studies. The pooled sensitivities, specificities were analyzed using a bivariate random-effects model. (PROSPERO ID: CRD42020170010).

RESULTS

Fifteen studies, with most rating as a moderate risk of bias, met the inclusion criteria. The pooled sensitivity and specificity were 92 % (95 % CI: 89%-95%) and 93 % (95 % CI: 85%-97%), respectively. Subgroup analysis revealed no significant differences in sensitivity when ultrasound was performed on different continents, in different settings, and under different reference standards. However, the specificity was significantly lower when ultrasound was performed in the North America, in the emergency department, and when computed tomography was used as the only reference standard.

CONCLUSIONS

Overall, ultrasound is a highly sensitive and specific tool for the diagnosis of SBO. Using ultrasound to rule in patients with SBO should be used with caution, as variations in the specificity were observed in different study setting, operators from different continents and reference standards used.

Barriers to reporting guideline adherence in point-of-care ultrasound research: a cross-sectional survey of authors and journal editors

OBJECTIVE

Although the literature supporting the use of point-of-care ultrasound (POCUS) continues to grow, incomplete reporting of primary diagnostic accuracy studies has previously been identified as a barrier to translating research into practice and to performing unbiased systematic reviews. This study assesses POCUS investigator and journal editor attitudes towards barriers to adhering to the Standards for Reporting of Diagnostic Accuracy Studies (STARD) 2015 guidelines.

DESIGN, SETTING, PARTICIPANTS

Two separate surveys using a 5-point Likert scale were sent to POCUS study investigators and journal editors to assess for knowledge, attitude and behavioural barriers to the complete reporting of POCUS research. Respondents were identified based on a previous study assessing STARD 2015 adherence for POCUS studies published in emergency medicine, anaesthesia and critical care journals. Responses were anonymously linked to STARD 2015 adherence data from the previous study. Written responses were thematically grouped into the following categories: knowledge, attitude and behavioural barriers to quality reporting, or other. Likert response items are reported as median with IQRs.

MAIN OUTCOME MEASURES

The primary outcome was the median Likert score for the investigator and editor surveys assessing knowledge, attitude and behavioural beliefs about barriers to adhering to the STARD 2015 guidelines.

RESULTS

The investigator survey response rate was 18/69 (26%) and the editor response rate was 5/21 (24%). Most investigator respondents were emergency medicine practitioners (13/21, 62%). Two-thirds of investigators were aware of the STARD 2015 guidelines (12/18, 67%) and overall agreed that incomplete reporting limits generalisability and the ability to detect risk of bias (median 4 (4, 5)). Investigators felt that the STARD 2015 guidelines were useful, easy to find and easy to use (median 4 (4, 4.25); median 4 (4, 4.25) and median 4 (3, 4), respectively). There was a shared opinion held by investigators and editors that the peer review process be primarily responsible for ensuring complete research reporting (median 4 (3, 4) and median 4 (3.75, 4), respectively). Three of 18 authors (17%) felt that the English publication language of STARD 2015 was a barrier to adherence.

CONCLUSIONS

Although investigators and editors recognise the importance of completely reported research, reporting quality is still a core issue for POCUS research. The shared opinion held by investigators and editors that the peer review process be primarily responsible for reporting quality is potentially problematic; we view completely reported research as an integral part of the research process that investigators are responsible for, with the peer review process serving as another additional layer of quality control. Endorsement of reporting guidelines by journals, auditing reporting guideline adherence during the peer review process and translation of STARD 2015 guidelines into additional languages may improve reporting completeness for the acute POCUS literature.

TRIAL REGISTRATION NUMBER

Open Science Framework Registry (https://osf.io/5pzxs/).

Necrotizing Soft-Tissue Infections: Clinical Features and Diagnostic Aspects

The term necrotizing soft-tissue infection (NSTI) encompasses a heterogenous group of patients with necrotizing infections, involving any body part. NSTI is diagnosed by surgical exploration, where necrosis of the subcutaneous tissue and/or muscle tissue, undermining of the skin, thrombosis of the superficial veins, and deliquescent tissue can be seen. Patients can present with vague symptoms, and approximately half of patients experience severe pain. The clinical presentation and microbiological etiology vary according to affected body site, with NSTI located to the extremities being dominated by monomicrobial group A streptococcal infections, and NSTI located to the anogenital area dominated by polymicrobial infections. No set of diagnostic criteria exists, and suspicion of the diagnosis should come from careful clinical examination and signs of local or systemic severity. Laboratory blood values show no distinct pattern but resemble those of sepsis. Imaging can aid the diagnostic process but must not delay surgical intervention.

Usefulness of point-of-care ultrasound for the evaluation of non-traumatic eye emergencies

The role of clinical ultrasound or Point-of-Care Ultrasound (POCUS) in patients with urgent pathology has expanded exponentially in recent years. With clinical ultrasound, physicians can make a quick assessment and decide how to act in time critical situations. Ocular ultrasound is one of the most recently developed applications. In patients with severe non-traumatic ocular pathology it has numerous clinically relevant uses: retinal detachment, occlusion of the central retinal artery or optic nerve pathologies, among others. The technique is widely available, easy to perform, and can provide information even when fundoscopy is impossible. In this review, we describe the bases of clinical ocular ultrasound, focusing on the management of the main non-traumatic urgent ophthalmological pathologies that the physician may face in their clinical practice.

Abdominal mycotic aortic aneurysm presenting as chronic constipation

A mycotic aneurysm is a life-threatening disease that usually presents with nonspecific symptoms. A prompt diagnosis is essential because of the risk of aneurysm rupture and high mortality rate. We describe a case of an abdominal mycotic aortic aneurysm presenting as chronic constipation for 3 weeks, without fever or abdominal pain. Point-of-care ultrasound has the ability to detect silent abdominal aortic aneurysms and serves as a follow-up tool for patients under medical treatment.

Intraoperative Focused Cardiac Ultrasound for Assessment of Hypotension: A Systematic Review

Focused cardiac ultrasound (FoCUS) has become a valuable tool to assess unexplained hypotension in critically ill patients. Due to increasing availability of transthoracic echocardiography (TTE) equipment in the operating room, there is a widespread interest in its usefulness for intraoperative diagnosis of hypotension as an alternative to transesophageal echocardiography (TEE). The objective of this systematic review is to evaluate the utility of intraoperative FoCUS to assess patients experiencing unexplained hypotension while undergoing noncardiac surgery. We performed a systematic literature search of multiple publication databases for studies that evaluated the utility of intraoperative FoCUS for assessment and management of unexplained hypotension in patients undergoing noncardiac surgery, including retro- and prospective clinical studies. A summary of the study findings, study quality, and assessment of level of evidence is presented. We identified 2227 unique articles from the literature search, of which 27 were potentially relevant, and 9 were included in this review. The number of patients pooled from these studies was 255, of whom 228 had intraoperative diagnoses with the aid of intraoperative FoCUS. The level of evidence of all studies included was very low according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. This systematic review has demonstrated that FoCUS may be a useful, noninvasive method to differentiate causes of intraoperative hypotension and guide correcting interventions, although the quality of evidence is very low. Further prospective high-quality studies are needed to investigate whether intraoperative FoCUS has a diagnostic utility that is associated with improved outcomes.

A comparison of handheld ultrasound versus traditional ultrasound for acquisition of RUSH views in healthy volunteers

Few studies evaluate the use of handheld ultrasound devices for point-of-care ultrasonography in the emergency department. We hypothesized that image acquisition time and image quality are similar between a handheld device and a traditional device. We compared these 2 types of devices in healthy, non-pregnant adults with using a crossover non-inferiority design while acquiring Rapid Ultrasound for Shock and Hypotension (RUSH) view. We excluded those with a history of surgical intervention or known abnormality to the lungs, abdomen, or pelvis. Images were compiled into a de-identified video clip reviewed for image quality by 2 blinded reviewers. Cohen's Kappa was used to determine interrater agreement. Disagreements were adjudicated by an independent physician. Imaging time was compared using a paired Student's t test. Of 59 screened participants, 9 were excluded. Most subjects (N = 30, 60%) were female with a mean age of 39 (Range: 19-67) years. The median time to complete the RUSH exam did not differ (handheld 249.4, interquartile range 33.5 seconds); traditional 251.4, interquartile range 66.3 seconds); [P = 0.81]). Agreement between ultrasound reviewers was good (agreement 83%; k = 0.69; 95% CI, 0.49-0.88). Images were determined to be of adequate quality for interpretation in 41/50 (82%) and 43/50 (86%) in the handheld and traditional devices, respectively (P = 0.786). Neither time to image acquisition nor image quality differed between the handheld and traditional devices. The handheld device may be an alternative for use in RUSH exams.

Physiological Changes and Cardiovascular Investigations in Pregnancy

Profound physiological changes in the maternal cardiovascular system occur shortly after conception. These changes may impact upon the investigation of healthy and complicated pregnancies. Additionally, concerns regarding fetal exposure to ionising radiation are important considerations in maternal testing. This manuscript reviews the important physiological changes pertinent to the investigation of maternal cardiovascular disease in pregnancy.

Review of simulation model for education of point-of-care ultrasound using easy-to-make tools

Point-of-care ultrasound (POCUS) is a powerful diagnostic tool and provides treatment guidelines in acute critical settings. However, the limitation of using POCUS is operator dependent. Appropriate and validated training for acquiring and using skills in practice must be conducted before using POCUS in clinical settings in order to keep patients safe. Simulation education models have been introduced as a way to solve and overcome these concerns. However, the commercial simulator with sufficiently secured fidelity is expensive and not always available. This review focused on the inexpensive and easily made simulators for education on POCUS in critical specific situations related to the airway, breathing, circulation, and disability. We introduced the simulators that used non-infectious materials, with easily transportable features, and that had a sonographic appearance reproducibility similar to human tissue. We also introduced the recipe of each simulator in two parts: Materials surrounding disease simulators (surrounding materials) and specific disease simulators themselves (target simulators). This review article covered the following: endotracheal or oesophageal intubation, lung (A-lines, B-lines, lung sliding, and pleural effusions such as hemothorax), central vein access, pericardial fluid (cardiac tamponade), the structure related to the eyes, soft tissue abscess, nerve (regional nerve block), and skull fracture simulators.

A novel measure for characterizing ultrasound device use and wear

Point-of-care ultrasound (POCUS) equipment management is critical in optimizing daily clinical operations in emergency departments (EDs). Traditional consultative ultrasound laboratories are well practiced at operations management, but this is not the case for POCUS programs, because machine upgrade and replacement metrics have not been developed or tested. We present a data-driven method for assessment of POCUS equipment maintenance and replacement named the ULTrA (a data-driven approach to point-of-care ultrasound upgrade) score. This novel model of assessing each ultrasound machine by quantitative scoring in each of four mostly objective categories: use (U), likeability (L), trustworthiness (Tr), and age (A). We propose the ULTrA model as a method to identify underperforming devices which could be upgraded or eliminated, and to compare relative performance amongst a group of departmental ultrasound machines. This composite score may be a useful objective tool that could replace individual proxies for clinical effectiveness, such as age, use, or individual provider preference. Additional research in multiple centers would be needed to refine and validate the ULTrA score. Once fully developed, the ULTrA score could be deployed in EDs and other clinical settings where POCUS is used to help streamline resources to maintain a functional and state-of-the-art fleet of ultrasound machines over time.

Increased body mass index does not impact the imaging quality of focused assessment with sonography in trauma

BACKGROUND

Many clinicians believe that a patient's body mass index (BMI) affects the likelihood of obtaining high quality ultrasound images.

OBJECTIVES

To assess the hypothesis that increased BMI is associated with worsening focused assessment with sonography in trauma (FAST) image quality.

METHODS

We conducted a retrospective single-center study of FAST examinations performed in a large academic emergency department (ED) with fellowship-trained emergency ultrasonography faculty performing quality assurance review.

RESULTS

Mean (SD) BMI was 28.0 (6.6) among the 302 included studies. The overall quality rating tended to decrease as BMI increased but did not achieve statistical significance in a univariable setting (P = .06) or after adjustment for age and sex (P = .06). Operators perception of image adequacy was largely unaffected by BMI, with the exception of the pericardial view.

CONCLUSION

This study did not identify a statistically significant difference in FAST quality with increased BMI. This result may help assuage clinician concerns about ultrasonography for patients in the ED.

Application of Point-of-Care Ultrasound for Family Medicine Physicians for Abdominopelvic and Soft Tissue Assessment

Point-of-care ultrasound (POCUS) improves both the sensitivity and specificity with which clinicians can make a variety of diagnoses at the bedside from abdominal aortic aneurysm to kidney stones. In outpatient clinics, urgent care centers, and emergency departments, where ultrasound imaging may be delayed by hours or even days, the use of POCUS can be very helpful. We believe that POCUS facilitates both the triage of patients and provides diagnostic information quickly. We hope to advance the use of POCUS in the primary care setting and have reviewed six sonographic topics where we believe ultrasound can be of immense assistance to the physician in the outpatient setting.

Quality Health Care in Acute Shoulder Pain: What Is the Contribution of Musculoskeletal Ultrasound?

For the purpose of assessing the impact of ultrasound in patients with acute shoulder pain, we conducted an analysis of quality health care indicators: need for reevaluation of the pain, rate of referral to specialized medicine and length of time in the emergency department. We reviewed the 1,433 records of patients attended to between 2015 and 2016. Thirty days after the first examination, 90 patients (10.1%) had returned to the control group (56 through the emergency department and 34 because of the), whereas, in the ultrasound (US) group, 14 (2.5%) had returned at least once (12 through the emergency department and 2 because of the PCC) (P<.001). The rate of referral to specialized medicine in the control group was 36.5%, whereas in the US group it was 6.21% (P<.0001). The average length of stay was 94.5 (standard deviation [SD] 34.3) minutes in the control group and 105.4 (SD 40.1) minutes in the US group (P<.0001). Our results suggest that the practice of shoulder ultrasound improves health care quality in these patients, at the cost of a slight increase in health care time.

Clinical ultrasonography in patients who inject drugs (the CUPID protocol): an illustrated case series

In 2017, there were ≈47,600 opioid overdose-related deaths in the United States. US emergency department (ED) visits for suspected opioid overdose increased by 30% between July 2016 and September 2017.2 The current US opioid epidemic makes it critical for emergency physicians to be aware of common and uncommon infectious and non-infectious complications of injection drug use. Point-of-care ultrasound has become a widely available, non-invasive diagnostic tool in EDs across the United States and worldwide. The increasing population of injection drug use patients is at risk for serious morbidity and mortality from an array of disease states amenable to ultrasound-based diagnosis. We propose a protocol for clinical ultrasonography in patients who inject drugs (the CUPID protocol), a focused, 3-system point-of-care ultrasound approach emphasizing cardiovascular, thoracic, and musculoskeletal imaging. The protocol is a screening tool, designed to detect high risk infectious and noninfectious complications of injection drug use.

Adherence to the Standards for Reporting of Diagnostic Accuracy (STARD) 2015 Guidelines in Acute Point-of-Care Ultrasound Research

IMPORTANCE

Incomplete reporting of diagnostic accuracy research impairs assessment of risk of bias and limits generalizability. Point-of-care ultrasound has become an important diagnostic tool for acute care physicians, but studies assessing its use are of varying methodological quality.

OBJECTIVE

To assess adherence to the Standards for Reporting of Diagnostic Accuracy (STARD) 2015 guidelines in the literature on acute care point-of-care ultrasound.

EVIDENCE REVIEW

MEDLINE was searched to identify diagnostic accuracy studies assessing point-of-care ultrasound published in critical care, emergency medicine, or anesthesia journals from 2016 to 2019. Studies were evaluated for adherence to the STARD 2015 guidelines, with the following variables analyzed: journal, country, STARD citation, STARD-adopting journal, impact factor, patient population, use of supplemental material, and body region. Data analysis was performed in November 2019.

FINDINGS

Seventy-four studies were included in this systematic review for assessment. Overall adherence to STARD was moderate, with 66% (mean [SD], 19.7 [2.9] of 30 items) of STARD items reported. Items pertaining to imaging specifications, patient population, and readers of the index test were frequently reported (>66% of studies). Items pertaining to blinding of readers to clinical data and to the index or reference standard, analysis of heterogeneity, indeterminate and missing data, and time intervals between index and reference test were either moderately (33%-66%) or infrequently (<33%) reported. Studies in STARD-adopting journals (mean [SD], 20.5 [2.9] items in adopting journals vs 18.6 [2.3] items in nonadopting journals; P = .002) and studies citing STARD (mean [SD], 21.3 [0.9] items in citing studies vs 19.5 [2.9] items in nonciting studies; P = .01) reported more items. Variation by country and journal of publication were identified. No differences in STARD adherence were identified by body region imaged (mean [SD], abdominal, 20.0 [2.5] items; head and neck, 17.8 [1.6] items; musculoskeletal, 19.2 [3.1] items; thoracic, 20.2 [2.8] items; and other or procedural, 19.8 [2.7] items; P = .29), study design (mean [SD], prospective, 19.7 [2.9] items; retrospective, 19.7 [1.8] items; P > .99), patient population (mean [SD], pediatric, 20.0 [3.1] items; adult, 20.2 [2.7] items; mixed, 17.9 [1.9] items; P = .09), use of supplementary materials (mean [SD], yes, 19.2 [3.0] items; no, 19.7 [2.8] items; P = .91), or journal impact factor (mean [SD], higher impact factor, 20.3 [3.1] items; lower impact factor, 19.1 [2.4] items; P = .08).

CONCLUSIONS AND RELEVANCE

Overall, the literature on acute care point-of-care ultrasound showed moderate adherence to the STARD 2015 guidelines, with more complete reporting found in studies citing STARD and those published in STARD-adopting journals. This study has established a current baseline for reporting; however, future studies are required to understand barriers to complete reporting and to develop strategies to mitigate them.

Evaluation of Interdisciplinary Emergency Ultrasound Workshop for Primary Care Physicians in Nepal

PURPOSE

Point-of-care ultrasound (POCUS) is a quick bedside tool that has the potential to improve emergency care in resource-limited settings due to its relatively low cost and accessibility. Effort to disseminate the knowledge and skills about POCUS is inadequate in low and middle income countries like Nepal. We conducted a two-day interdisciplinary advanced emergency ultrasound workshop that targeted physicians working in emergency department and primary care, especially in rural Nepal. We explored the effectiveness of this training based on validated Kirkpatrick's 4 steps of evaluating training outcomes.

MATERIALS AND METHODS

We conducted a prospective quasi-experimental study with mixed research design. Multidisciplinary physicians working in emergency departments participated in the two-day workshop. We assessed and compared the pre- and post-workshop knowledge. We collected on-site and a follow-up feedback to explore pre- and post-workshop confidence level, perceived usefulness and clinical use of ultrasound using a 5-point Likert scale. The barriers to use POCUS were explored.

RESULTS

A total of 50 physicians from different parts of Nepal participated in the workshop. The academic level of the participants, duration of their clinical experience and the previous use of POCUS did not have a significant difference in their pre- and posttest knowledge scores. The difference between the median (IQR) pre- and posttest scores [14 (12.75-17.75) and 24.5 (22.25-25.5), respectively] was statistically significant (p<0.001). Perceived confidence level and usefulness of the POCUS increased significantly in all of its domains (p<0.001). Self-reported increase in its clinical use was significant (p<0.001) for all fields.

CONCLUSION

The participation in this emergency ultrasound workshop increased the knowledge of participants in POCUS. Their confidence, perceived usefulness and clinical use of POCUS improved significantly. Objective longitudinal follow-up of participants' skill and demonstration of increased clinical use of POCUS in emergency department influencing the clinical outcome would be the focus of future research.

[Sonography in intensive care and emergency medicine : A new training concept]

Structured sonography training in internal medicine intensive care and emergency medicine (SIN) comprises two levels and was proposed by three national societies in Germany (DGIIN, DGK and DEGUM). The curriculum consists of a basic level (SIN-I) and an expert level (SIN-II) which are consecutive levels teaching both theoretical and hands-on skills using a symptom-based approach. Competency is assessed using written, oral and practical structured assessments at the end of each level. The goal is to implement national and international recommendations regarding the use of point-of-care ultrasound into clinical practice.

The management of emergency hospital visits for inflammatory bowel diseases: A French national expert consensus report

BACKGROUND

Management of inflammatory bowel diseases (IBD) in the emergency department is often suboptimal.

AIMS

To develop a national consensus checklist of indicators to facilitate decision-making in emergency departments concerning hospitalisation and referral for abdominopelvic computed tomography (CT).

METHODS

A Delphi survey was used to obtain consensus on a checklist of clinical and biological variables. 119 healthcare professionals experienced in treating IBD were invited to participate. Panellists were provided with a literature survey and invited to agree or disagree with items on a prototype checklist. Two successive rounds of voting were organised.

RESULTS

The prototype checklist included fifteen clinical or laboratory indicators for hospitalisation or CT. Four indicators were not retained in the Delphi process and four additional indicators added. The final indicators retained were: abdominal signs/symptoms of disease exacerbation, intravenous morphine titration, fever, vomiting, dehydration, recent intestinal surgery, ano-perineal abscess, bowel obstruction, haemodynamic instability, anaemia, acute kidney failure and elevated C-reactive protein. Consensus for the retained indicators was >88%.

CONCLUSIONS

Use of this consensus checklist for the management of IBD in the emergency department may help improve standards of care and thus reduce the burden of these diseases.

Point-of-care ultrasound in resource-limited settings: the PURLS fellowship

Background

The role of point-of-care ultrasonography (POCUS) is rapidly expanding in both resource-rich and resource-limited settings (RLS). One limitation to this rapid expansion has been the lack of educators adequately trained to teach this user-dependent skill. This is particularly true in RLS, where disease presentations, infrastructure limitations, and approach to medical education present unique challenges to the direct application of resource-rich emergency department POCUS curricula.

Objectives

We describe the point-of-care ultrasound in resource-limited settings (PURLS) fellowship, a novel curriculum designed to provide advanced training and expertise in clinical care and POCUS application and education in RLS.

Conclusion

Our curriculum design is one approach to create context-specific POCUS education for use in RLS, thereby improving patient care.

The Use of Point-of-Care Ultrasound to Evaluate Pulsus Paradoxus in Children With Asthma

Pulsus paradoxus (PP) is defined as a fall of systolic blood pressure of greater than 10 mm Hg during the inspiratory phase of respiration. Measurement of PP is recommended by national and international asthma guidelines as an objective measure of asthma severity but is rarely used in clinical practice. Cardiac point-of-care ultrasound with pulsed wave Doppler imaging measuring respiratory-phasic changes of mitral valve inflow velocities is well described in cardiac tamponade as "sonographic" PP. We present 10 cases of acute asthma presenting to an emergency department showing the finding of sonographic determined PP in the apical 4-chamber view of the heart on pulsed wave Doppler imaging.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial

BACKGROUND

Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage.

OBJECTIVE

This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS.

METHODS

Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures.

RESULTS

Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores.

CONCLUSIONS

Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.

Point-of-care ultrasound for the acute abdomen in the primary health care

Point-of-care ultrasound (POCUS) is a focused examination, which is performed and interpreted at the bedside by the treating physician answering a specific clinical question. It is currently utilized as an essential adjunct to physical examination in many medical specialties. Recent advances in technology have made POCUS machines portable, affordable, and could be used with minimal training even by nonradiologists. This review aims to cover the fundamental physics of POCUS and its applications for diagnosing the acute abdomen in the primary health care including the most common causes encountered by family physicians. These are acute appendicitis, acute cholecystitis, renal colic, ectopic pregnancy, acute diverticulitis, bowel obstruction, and abdominal aortic aneurysm. We hope to encourage primary care physicians to incorporate POCUS in their routine clinical practice. We also highlight challenges encountered when using POCUS in the primary health care including limited availability and the need for proper training. Furthermore, we review the POCUS results when performed by primary health-care physicians. Integrating POCUS in primary health care empowers primary health-care physicians to provide high-quality, safe, and cost-effective care to the patients.

Impact of point-of-care ultrasound on the hospital length of stay for internal medicine inpatients with cardiopulmonary diagnosis at admission: study protocol of a randomized controlled trial-the IMFCU-1 (Internal Medicine Focused Clinical Ultrasound) study

Background

Point-of-care ultrasound (POCUS) is emerging as a reliable and valid clinical tool that impacts diagnosis and clinical decision-making as well as timely intervention for optimal patient management. This makes its utility in patients admitted to internal medicine wards attractive. However, there is still an evidence gap in all the medical setting of how its use affects clinical variables such as length of stay, morbidity, and mortality.

Methods/design

A prospective randomized controlled trial assessing the effect of a surface POCUS of the heart, lungs, and femoral and popliteal veins performed by an internal medicine physician during the first 24 h of patient admission to the unit with a presumptive cardiopulmonary diagnosis. The University of Melbourne iHeartScan, iLungScan, and two-point venous compression protocols are followed to identify left and right ventricular function, significant valvular heart disease, pericardial and pleural effusion, consolidation, pulmonary edema, pneumothorax, and proximal deep venous thrombosis. Patient management is not commanded by the protocol and is at the discretion of the treating team. A total of 250 patients will be recruited at one tertiary hospital. Participants are randomized to receive POCUS or no POCUS. The primary outcome measured will be hospital length of stay. Secondary outcomes include the change in diagnosis and management, 30-day hospital readmission, and healthcare costs.

Discussion

This study will evaluate the clinical impact of multi-organ POCUS in internal medicine patients admitted with cardiopulmonary diagnosis on the hospital length of stay. Recruitment of participants commenced in September 2018 and is estimated to be completed by March 2020.

Trial registration

Australian and New Zealand Clinical Trial Registry, ACTRN12618001442291. Registered on 28 August 2018.

An Interprofessional Approach to Targeted Sonography Training Using Computer-Based Simulation in Medical Students’ Clinical Training: A Case Series

Purpose:

Document a feasibility study of an interprofessional approach to targeted sonography training (TST) for medical students, incorporating computer-based simulation (CBS).

Procedure:

Three participants received TST on the abdominal aorta from credentialed sonographers using CBS. Training included didactic instruction, skill demonstration, debrief, and feedback. An assessment template was developed to assess students’ skills and provide structured feedback. Students completed a feedback survey on the learning process that followed the training.

Results:

Students’ template scores were similar, despite varying prior exposure to CBS. The importance of deliberate practice, direct feedback when a student is struggling, and a debrief session following skill demonstration was evident in this study. Students agreed that this targeted instructional process provided a low-pressure environment where they could learn from mistakes and improve their confidence.

Conclusion:

This case series demonstrated how readily a TST session can be accomplished using computer-based simulation and the value of structured feedback.

The use of evaluation tool for ultrasound skills development and education to assess the extent of point-of-care ultrasound adoption in lebanese emergency departments

Background:

Previously acknowledged as “bedside ultrasound”, point-of-care ultrasound (PoCUS) is gaining great recognition nowadays and more physicians are using it to effectively diagnose and adequately manage patients. To measure previous, present and potential adoption of PoCUS and barriers to its use in Canada, Woo et al established the questionnaire “Evaluation Tool for Ultrasound skills Development and Education” (ETUDE) in 2007. This questionnaire sorted respondents into innovators, early adopters, majority, and nonadopters.

Objectives:

In this article, we attempt to evaluate the prevalence of PoCUS and the barriers to its adoption in Lebanese EDs, using the ETUDE.

Materials and Methods:

The same questionnaire was again utilized in Lebanon to assess the extent of PoCUS adoption. Our target population is emergency physicians (EPs). To achieve a high response rate, hospitals all over Lebanon were contacted to obtain contact details of their EPs. Questionnaires with daily reminders were sent on daily basis.

Results:

The response rate was higher in our population (78.8%) compared to Woo et al's (36.4%), as the questionnaire was sent by email to each physician with subsequent daily reminders to fill it. In fact, out of the total number of the surveyed (85 physicians), respondents were 67, of which 76.1% were males and of a median age of 43. Using ETUDE, results came as nonadopters (47.8%), majority (28.3%), early adopters (16.4%), and innovators (7.5%). Respondents advocated using PoCUS currently and in the future in five main circumstances: focused assessment with sonography in trauma (FAST) (current 22.9%/future 62.9%), first-trimester pregnancy (current 17.1%/future 68.6%), suspected abdominal aortic aneurysm (current 5.7%/future 51.4%), basic cardiac indications (current 8.6%/future 57.1%), and central venous catheterization (current 22.9%/future 85.7%).

Conclusion:

This study is the first to tackle the extent of use and the hurdles to PoCUS adoption in Lebanese emergency medicine practice, using ETUDE. The findings from this study can be used in Lebanon to strengthen PoCUS use in the future.

Advanced Imaging Interpretation by Radiologists and Nonradiologist Physicians: A Training Issue

OBJECTIVE. The purpose of this study was to examine the degree to which nonradiologist physicians provide formal interpretations for advanced imaging and to consider whether adequate training can be achieved for those physicians. This investigation assumed that hospitals are the only places where formal imaging training occurs. MATERIALS AND METHODS. The CMS Physician/Supplier Procedure Summary Master Files (PSPSMFs) of the Medicare Part B datasets for 2015 were reviewed. We selected the Current Procedural Terminology (CPT) codes for four categories of noninvasive diagnostic imaging: CT, MRI, PET, and general nuclear imaging. Medicare place-of-service codes allowed us to determine the location of each study interpretation. We narrowed our analysis to data from the three major hospital places of service: inpatient facilities, hospital outpatient departments, and emergency departments. Provider specialties were determined using Medicare's 108 specialty codes. Procedure volumes among nonradiologist physicians were compared with those among radiologists. RESULTS. Of the 17,824,297 hospital-based CT examinations performed in the Medicare fee-for-service population, radiologists interpreted 17,698,360 (99.29%) and nonradiologists interpreted 125,937 (0.71%). Of the 4,512,627 MRI examinations performed, radiologists interpreted 4,469,275 (99.04%) and nonradiologist physicians interpreted 43,352 (0.96%). Of 391,688 PET studies performed, radiologists interpreted 368,913 (94.19%) and nonradiologist physicians interpreted 22,775 (5.81%). Of the 2,070,861 general nuclear medicine studies performed, radiologists interpreted 1,307,543 (63.14%) and nonradiologist physicians interpreted 763,318 (36.86%). Cardiologists had the largest involvement of nonradiologist physicians, contributing approximately 3% of all advanced imaging interpretations. All other nonradiologist physicians interpreted a tiny fraction of advanced imaging studies. CONCLUSION. Besides radiologists and cardiologists, no other medical specialty provides sufficient education for their trainees and practitioners in advanced imaging interpretation to justify allowing them to interpret these studies in practice, except under carefully controlled circumstances.

Iatrogenic Aortic Dissection Presenting With Leg Pain Diagnosed With Point-of-care Ultrasound

Iatrogenic aortic dissection (IAD) status-post-cardiac catheterization is a rare complication often isolated to the proximal aorta. This is a case of IAD isolated to the distal aorta in a 41-year-old female who presented to the emergency department with right leg pain after undergoing three cardiac catheterizations. The diagnosis of IAD was made upon discovery of an intimal flap in the distal aorta and femoral artery while performing a point-of-care ultrasound to evaluate for deep vein thrombosis.