Diagnostic point-of-care ultrasound for hospitalists

Perception, Knowledge, Indications, and Future Prospects of Point-of-Care Ultrasound Among Medical Students in Saudi Arabia

Introduction Point-of-care ultrasound (POCUS) has become integral across medical specialties globally, addressing clinical queries, guiding procedures, and bridging the gap between physical examination and advanced imaging. Early ultrasound training for medical students enhances clinical decision-making and reduces diagnostic errors. Aims To evaluate the knowledge and attitude of senior medical students towards POCUS and to assess knowledge gaps and difficulties encountered by senior medical students to assist in the development of future curricula. Methodology This is an observational, cross-sectional approach to evaluate knowledge, attitude, and practice of POCUS among senior medical students in the Kingdom of Saudi Arabia. The study was conducted from January to September 2023. An electronic questionnaire was distributed through online platforms utilizing medical school databases across various regions. The survey encompassed sociodemographics, training methods, diagnostic indications, and participants' self-reported proficiency and attitudes toward POCUS. The data was chiefly collected using the Likert scale. Descriptive statistics were used to describe the quantitative and categorical variables. Bivariate and multivariate analyses were used to examine correlations. Results A total of 359 senior medical students completed the survey. Most responders were females (57.9%) with the predominating age group being ≤ 24 years (83.6%). The students predominantly were from the Central region of Saudi Arabia (75.5%). Ultrasound training varied among responders; 31.5% received formal courses (median duration: two hours) and 23.4% informal courses (median duration: four hours). Around 17.3% practiced POCUS self-teaching (median duration: four hours). A total of 3.6% had formal POCUS accreditation. A gargantuan 82.2% never used POCUS in their attached hospital for a variety of reasons. Multivariable logistic binary regression analysis showed a positive correlation between students' self-teaching of POCUS and their perceived difficulty performing an ultrasound examination for patients in daily practice. Discussion A comparable study was done at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) in 2022 surveying 229 senior medical students by Rajendram et al. In their study, 21.4% completed formal courses and 12.7% took informal courses. While many students in our study were not exposed to POCUS (82.2%), KSAU-HS reported a higher percentage reaching 94.8%. A study by Russel et al. demonstrated more than half of 154 surveyed medical schools in the United States have implemented POCUS into their students' curriculum. Conclusion POCUS stands as a valuable skill that can enhance the educational journey of undergraduate medical students. Considering that a significant number of participants haven't yet taken formal medical school courses suggests a lack of awareness about its significance in the medical field. Offering additional courses with practical components could enhance the proficiency, confidence, and outlook of medical students toward POCUS.

Home Ultrasound: A Contemporary and Valuable Tool for Palliative Medicine

This narrative review explores the application of point-of-care ultrasound (POCUS) in palliative care and its feasibility in home care settings. POCUS has the potential to streamline diagnostic strategies without patient transfer to the hospital, expedite timely symptomatic relief, and reduce complications from specific palliative interventions. The advent of handheld ultrasound devices has made it an attractive diagnostic and interventional adjunct in acute palliative care. POCUS has gained widespread acceptance as part of routine care in emergency medicine and intensive care, guiding certain procedures and increasing their safety. The modernization and miniaturization of ultrasound equipment have made ultra-portable devices available, allowing for better-quality images at affordable prices. Handheld devices have the potential to revolutionize everyday clinical practice in home-based palliative care, contributing to important bedside clinical decisions. Palliative care patients often require diagnostic examinations in the last months of their lives, with CT being the most frequently performed imaging procedure. However, CT imaging is associated with high costs and burdens, leading to increased suffering and impaired quality of life. Clinical ultrasound, a dialogic imaging modality, offers a safer and more efficient approach to palliative care. POCUS applications, which are cost-effective, non-invasive, and well-tolerated, can be used to improve patient satisfaction and diagnostic understanding. POCUS is a valuable tool in palliative care, improving diagnostic accuracy and reducing the time to diagnosis for various pathologies. It is a standard of care for many procedures and improves patient safety. However, there are limitations to POCUS in palliative care, such as operator-dependent examination variability and limited availability of trained professionals. To overcome these limitations, palliative care physicians should receive mandatory training in POCUS, which can be incorporated into the core curriculum. Additionally, ultrasound teleconsulting can assist less experienced examiners in real-time examinations. The literature on POCUS in palliative care is limited, but research on patient-oriented outcomes is crucial. POCUS should be considered a supplement to good clinical reasoning and regulated radiological evaluations.

Point of care obstetric ultrasound training for midwives and nurses: implementation and experiences of trainees at a rural based hospital in Sub-saharan Africa: a qualitative study

BACKGROUND

Point of care ultrasound training has been successfully implemented in some settings. This has been done due to a shortage of radiology human resource gap especially in the rural areas of low-resource settings. The purpose of the study was to implement a point of care obstetric ultrasound training program for midwives and nurses and explore their experiences following the training at a rural based hospital in Uganda.

METHODS

It was an exploratory qualitative study with some elements of implementation research design involving midwives and nurses that had undergone obstetric ultrasound training at Kiwoko hospital, a rural-based hospital in Uganda. Purposive sampling was used to select twenty-five midwives and nurses. These participants underwent a 6-weeks training in point of care obstetric ultrasound. Following the training, in-depth interviews were conducted to obtain the experiences of the participants.

RESULTS

The training was conducted by qualified radiologists and sonographers and it involved both didactic sessions and rigorous practical and clinical demonstrations and eventually real-time scanning of the women. Three key themes emerged from the interviews: (1) Gaining important obstetric ultrasound skills, (2) Improving management of pregnant women and (3) Positive for task-shifting.

CONCLUSION

The point of care obstetric ultrasound training program was successfully implemented at Kiwoko Hospital. The trainees reported positive experiences from the training and while only conducted at one rural health facility, the overwhelmingly positive experience from trainees underscores the importance of point of care obstetric ultrasound in delivering imaging services.

Point-of-Care Ultrasonography in Internal Medicine: Limitations and Pitfalls for Novice Users

Point-of-care ultrasound (POCUS) is increasingly being adopted in the field of internal medicine, leading to the development of POCUS curricula in undergraduate and postgraduate medical education programs. Prominent internal medicine societies and organizations worldwide recognize the expanding utilization of POCUS by internal medicine physicians, emphasizing the need for practitioners to be aware of both its benefits and limitations. Despite the growing enthusiasm for POCUS, clinicians, particularly those with limited clinical experience, must be cautious regarding its inherent limitations and the potential impact on their clinical practice. This review aims to outline the limitations and potential drawbacks of POCUS for medical students, residents, and internists who wish to stay abreast of the escalating use of POCUS in internal medicine and have a desire, or have already commenced, to incorporate POCUS into their practice. Additionally, it provides recommendations for enhancing POCUS proficiency to mitigate these limitations.

Main applications of point-of care ultrasound in palliative care

Combined with a physical examination, clinical ultrasound offers a valuable complement that can help guide clinical decision-making. In various medical and surgical specialties, it is increasingly used for diagnostic and therapeutic purposes. Due to recent technological advances, smaller and more affordable ultrasound machines are now being developed for use in home hospice care. The purpose of this paper is to describe how clinical ultrasound may be applied in Palliative Care, where it can be a valuable tool to assist the clinician in making better clinical decisions and to assist in accurately guiding palliative procedures. Furthermore, it can be used to identify unnecessary hospitalizations and prevent them from occurring. Training programs with specific objectives are necessary to implement clinical ultrasound in Palliative Care, as well as defining learning curves and promoting alliances with scientific societies that recognize the teaching, care and research trajectory for accreditation of competencies.

Current Use and Barriers to Point-of-Care Ultrasound in Primary Care: A National Survey of VA Medical Centers

BACKGROUND

More primary care providers (PCPs) have begun to embrace the use of point-of-care ultrasound (POCUS), but little is known about how PCPs are currently using POCUS and what barriers exist. In this prospective study, the largest systematic survey of POCUS use among PCPs, we assessed the current use, barriers to use, program management, and training needs for POCUS in primary care.

METHODS

We conducted a prospective observational study of all VA Medical Centers (VAMCs) between June 2019 and March 2020 using a web-based survey sent to all VAMC Chiefs of Staff and Chiefs of primary care clinics (PCCs).

RESULTS

Chiefs of PCCs at 105 VAMCs completed the survey (82% response rate). Only 13% of PCCs currently use POCUS, and the most common applications used were bladder and musculoskeletal ultrasound. Desire for POCUS training exceeded current use, but lack of trained providers (78%), ultrasound equipment (66%), and funding for training (41%) were common barriers. Program infrastructure to support POCUS use was uncommon, and only 9% of VAMCs had local policies related to POCUS. Most PCC chiefs (64%) would support POCUS training.

CONCLUSIONS

Current use of POCUS in primary care is low despite the recent growth of POCUS training in Internal Medicine residency programs. Investment in POCUS training and program infrastructure is needed to expand POCUS use in primary care and ensure adequate supervision of trainees.

Trends in utilisation of ultrasound by older Australians (2010-2019)

BACKGROUND

Older people have increasingly complex healthcare needs, often requiring appropriate access to diagnostic imaging, an essential component of their health and disease management planning. Ultrasound is a safe imaging tool used to diagnose several conditions commonly experienced by older people such as deep vein thrombosis.

PURPOSE

To evaluate the utilisation of major ultrasound services by Australians ≥ 65 years old between 2009- and 2019.

METHODS

This population-based and yearly cross-sectional study of ultrasound utilisation per 1,000 Australians ≥ 65 years old was conducted using publicly available data sources. Overall, examination site and age- and sex-specific incidence rate (IR) of ultrasound per 1,000 people, adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated using negative binomial regression models.

RESULTS

Over the study period, the crude utilisation of ultrasound increased by 83% in older Australians. Most ultrasound examinations were conducted on extremities (39%) and the chest (21%), with 25% of all ultrasounds investigating the vascular system. More men than women use ultrasounds of the chest (184/1,000 vs 268/1,000 people), particularly echocardiograms (177/1,000 vs 261/1,000 people), and abdomen (88/1,000 vs 92/1,000 people), especially in those ≥ 85 years old. Hip and pelvic ultrasound were used more by women than men (212/1,000 vs 182/1,000 people). There were increases in vascular abdominal (IRR:1.07, 95%CI:1.06-1.08) and extremeties (IRR:1.06, 95%CI:1.05-1.07) ultrasounds over the study period, particularly in ≥ 75 years old men.

CONCLUSIONS

Ultrasound is a common and increasingly used diagnostic tool for conditions commonly experienced by older Australians.

"Teaching old dogs new tricks" - POCUS Education for Senior Faculty

Point of Care Ultrasound (POCUS) is a growing diagnostic modality across a variety of specialties and is increasingly being taught in undergraduate medical education. Uptake within internal medicine has been slow but is becoming more commonplace. Training of extant hospital medicine faculty, including senior members, in POCUS is an unmet need in graduate medical education with significant pedagogical and patient safety implications. With this in mind, we created a training program for the core teaching faculty at our academic internal medicine residency program. The experiential, hands-on curriculum explored the reasoning behind concepts and emphasized psychological safety for senior faculty learners and was successful and well-received. In our piece, we aim to explore the existing literature around training this unique population in POCUS and report on our single-center experience. We also provide a framework for how our program succeeded, collate tips derived from the expert ultrasound teachers and list pearls learned while teaching these experienced educators. Although this worthwhile effort requires planning and support, it was appreciated even by senior faculty.

RUSHing to the Diagnosis: Aortic Abdominal Aneurysm Detected Using the Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol in the Wards

The rapid ultrasound for shock and hypotension (RUSH) protocol is a useful tool used in the emergency department (ED) when addressing the severity and etiology of shock. It was designed to be performed in under two minutes with evaluation of the pump (heart), tank (inferior vena cava, thoracic and abdominal compartments) and the pipes (large arteries and veins). However, its application or one similar should extend beyond the ED and into the hospital floor. Here we present an 80-year-old gentleman with a history of atrial fibrillation (A-Fib) on anticoagulation who arrived at the ED due to an episode of pre-syncope just prior to arrival. Initial EKG is concerning for A-Fib with rapid ventricular response (RVR) with a rate in the 130s. After fluid resuscitation patient improved and he was admitted to the telemetry floor for further cardiac workup and cardiology consultation. While waiting for a room in the ED, patient became hypotensive, diaphoretic and pale. After complaining of lower abdominal pain, the ED physician performed a RUSH which showed an abdominal aorta of 8 cm concerning for dissection. Diagnosis was confirmed with CT angiography of the abdomen and he was taken to the OR with successful repair of the abdominal aortic aneurysm (AAA). Patient made meaningful recovery and was discharged to in-patient rehab. The patient described in this vignette was delayed in the ED due to lack of beds on the floor. This allowed for quick ultrasound work-up by the ED physician which led to immediate recognition of the AAA and immediate response by the vascular surgery team. Should this patient have been on the hospital floor, it is unclear if such prompt steps would have occurred prior to patient's further hemodynamic demise.

Current use, training, and barriers in point-of-care ultrasound in hospital medicine: A national survey of VA hospitals

BACKGROUND

Point-of-care ultrasound (POCUS) can reduce procedural complications and improve the diagnostic accuracy of hospitalists. Currently, it is unknown how many practicing hospitalists use POCUS, which applications are used most often, and what barriers to POCUS use exist.

OBJECTIVE

This study aimed to characterize current POCUS use, training needs, and barriers to use among hospital medicine groups (HMGs).

DESIGN, SETTING, AND PARTICIPANTS

A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of HMGs. These data were compared to a similar survey conducted in 2015.

RESULT

Chiefs from 117 HMGs were surveyed, with a 90% response rate. There was ongoing POCUS use in 64% of HMGs. From 2015 to 2020, procedural POCUS use decreased by 19%, but diagnostic POCUS use increased for cardiac (8%), pulmonary (7%), and abdominal (8%) applications. The most common barrier to POCUS use was lack of training (89%), and only 34% of HMGs had access to POCUS training. Access to ultrasound equipment was the least common barrier (57%). The proportion of HMGs with ≥1 ultrasound machine increased from 29% to 71% from 2015 to 2020. An average of 3.6 ultrasound devices per HMG was available, and 45% were handheld devices.

CONCLUSION

From 2015 to 2020, diagnostic POCUS use increased, while procedural use decreased among hospitalists in the VA system. Lack of POCUS training is currently the most common barrier to POCUS use among hospitalists.

Development of a Point-of-Care Ultrasound Track for Internal Medicine Residents

BACKGROUND

Point-of-care ultrasound (POCUS) training has been increasing among internal medicine (IM) residency programs, but few programs can provide longitudinal training due to barriers such as lack of trained faculty.

AIM

Describe the development of a longitudinal POCUS track for IM residents using local and external resources, including a national POCUS certificate program.

SETTING

University-based IM residency program affiliated with a public and veterans affairs hospital.

PARTICIPANTS

Twelve IM residents from 2018 to 2021.

PROGRAM DESCRIPTION

Residents complete a national POCUS certificate program by attending live courses and completing online modules, an image portfolio, and final knowledge/skills assessments. Locally, residents participate in 1-month procedure and diagnostic POCUS rotations and provide peer-to-peer POCUS teaching of residents and medical students.

PROGRAM EVALUATION

The POCUS track increased residents' use and comfort with diagnostic and procedural applications. All residents rated being satisfied or very satisfied with the track and would recommend it to prospective applicants (100%). The most commonly reported barriers to utilizing POCUS per residents were time constraints (83%), lack of available ultrasound equipment (83%), and lack of trained faculty (58%).

DISCUSSION

IM residency programs with limited faculty expertise in POCUS can leverage external resources to provide longitudinal POCUS training to its residents.

Accuracy of Point-of-Care Ultrasound in Follow Up Abdominal Aortic Aneurysm Imaging

BACKGROUND

Point-of-care ultrasound (POCUS) has been reported as a valuable tool for bedside diagnoses of abdominal Aortic Aneurysms (AAA). However, no data exist regarding POCUS in measuring follow-up AAA diameter studies in patients with existing AAAs. The purpose of this study was to determine the variability of aortic measurements performed by a non-physician using POCUS vs standard of care (SOC) measurements by a registered vascular technologist or an abdominal/pelvic CT scan.

METHODS

A prospective observational ultrasound study was performed from 1/1/2019 to 3/31/2021 on patients with a diagnosis of an AAA (≥3.0 cm). A research coordinator (non-physician) underwent a 3-hour training session in ultrasound operation and basic human anatomy to measure AAA diameter. The maximum aortic diameter was documented and compared to measurements obtained by SOC ultrasonography or CT scan. The POCUS and SOC ultrasounds were separated by no more than 90 days. Clinical risk factors including age, race, body mass index, coronary artery disease, hypertension, peripheral vascular disease, cerebrovascular disease, diabetes, and current smoking were also collected.

RESULTS

Eighty-one patients (mean age: 73.6 ± 5.8 years, body mass index: 29.5 ± 6.2 kg/m2) were being followed in a vascular clinic and underwent both a POCUS and SOC ultrasounds. One indeterminant study was reported in identifying an AAA diagnosis, due to an overlying colostomy. The average follow-up time from initial screening aortic diameter to POCUS was 4.4 ± 3.7 years. Overall average aortic diameter measurements obtained were 4.1 ± .9 cm for POCUS and 4.0 ± .9 cm for SOC (P = NS). Average difference in aortic measurement for POCUS and SOC was -.1 ± .3 cm.

CONCLUSIONS

POCUS is an accurate method to follow AAA diameter in patients. POCUS could improve patient follow up with AAA diameter measurements, streamline care and reduce overall burden for both patients and Radiology Departments in assessing follow up AAA diameters.

Ultrasound in Medical Education: Can Students Teach Themselves?

INTRODUCTION

A new technology in medical education is ultrasound simulation, which has been shown to help students learn while reducing load on clinical instructors. The goal of this study is to compare the efficacy of teaching using ultrasound simulators versus more traditional instructor-led sessions with ultrasound machines.

METHODS

Ultrasound was used to teach cardiac anatomy and physiology to medical students. Volunteers in one group were instructed using an ultrasound simulator (SonoSim) with built-in lessons; the other group received a traditional instructor-led session with an ultrasound machine. Efficacy of each type of teaching was assessed by measuring improvement from a pre-session test to a post-session test, using a one-sample paired t-test to compare averages between groups. Participants were given a survey to solicit opinions of the lessons.

RESULTS

Twenty-one medical students participated, with 12 in the instructor-led group and 9 in the simulator group. Both groups increased their test scores from pre-session to post-session; the average increase was 5% in the instructor-led and 10% in the simulator group (p = 0.437). There was no statistically significant difference between groups in how effective or enjoyable the lesson felt. Participants from either group who tried both methods were likely to prefer the traditional ultrasound teaching.

CONCLUSION

Self-guided learning with simulators and traditional instructor-led lectures are both effective for teaching basic cardiac anatomy and physiology via ultrasound. However, most students prefer learning with instructors if given the opportunity. Self-guided ultrasound simulators may serve as an effective standalone learning method or an adjunct to instructor-led sessions.

Interprofessional Point-of-Care Ultrasound Training of Resident Physicians by Sonography Student-Coaches

INTRODUCTION

Point-of-care ultrasound (POCUS) education is growing throughout medical education, but many institutions lack POCUS-trained faculty. Interprofessional education offers a strategy for expanding the pool of available teachers while providing an opportunity for collaboration between health professional students.

METHODS

Six students enrolled in the diagnostic medical sonography (DMS) program participated in a case-based, train-the-trainer session to practice a standardized approach for POCUS instruction. They then served as coaches to 25 first-year internal medicine residents learning to perform ultrasound exams of the kidneys, bladder, and aorta. Course assessment included an objective structured exam (OSCE), coaching evaluations, and course evaluations.

RESULTS

Residents scored an average of 81% (71.3 out of 88 points, SD = 7.5) on the OSCE. Residents rated the DMS student-coaches positively on all teacher evaluation questions. Both the residents and DMS student-coaches gave positive course evaluations scores.

DISCUSSION

An interprofessional workshop with DMS students coaching internal medicine residents was an effective strategy for teaching POCUS skills. This approach may offer a solution for programs wanting to implement POCUS training with limited faculty expertise or time.

Design and evaluation of the I-SCAN faculty POCUS program

BACKGROUND

Point-of-care ultrasound (POCUS) is becoming widely adopted with increasing accessibility of courses. Little is known about the optimal design of the introductory course or longitudinal training programs targeting hospitalists that are critical to success.

METHODS

Hospitalists at four academic sites participated in a two-day introductory course and a longitudinal phase comprising clinical POCUS practice, clip uploading with online feedback, hands-on teaching, and monthly ultrasound conferences. Assessments were performed immediately before and after the two-day course and after 1 year.

RESULTS

Knowledge increased from baseline to post two-day course (median score 58 and 85%, respectively, p < 0.001) and decreased slightly at 1 year (median score 81%, p = 0.012). After the two-day introductory course, the median score for hands-on image acquisition skills, the principal metric of participant success, was 75%. After 1 year, scores were similar (median score 74%). Confidence increased from baseline to post two-day course (1.5 to 3.1 on a 4 point Likert scale from Not at all confident (1) to Very confident (4), p < 0.001), and remained unchanged after 1 year (2.73). Course elements correlating with a passing score on the final hands-on test included number of clip uploads (r = 0.85, p,0.001), attendance at hands-on sessions (r = 0.7, p = 0.001), and attendance at monthly conferences (r = 0.50, p = 0.03).

CONCLUSIONS

The I-ScaN POCUS training program increased hospitalist knowledge, skill and confidence with maintained skill and confidence after 1 year. Uploading clips and attending hands-on teaching sessions were most correlative with participant success.

A Mixed-Methods Evaluation of Medical Residents' Attitudes Towards Interprofessional Learning and Stereotypes Following Sonography Student-Led Point-of-Care Ultrasound Training

BACKGROUND

Point-of-care ultrasound (POCUS) training is growing across internal medicine graduate medical education, but lack of trained faculty is a barrier to many programs. Interprofessional education (IPE) may offer a solution but must overcome potential biases of trainees.

AIM

To evaluate the impact of an interprofessional POCUS training on residents' attitudes towards interprofessional learning and stereotypes.

SETTING

Midwestern health sciences university.

PARTICIPANTS

Diagnostic medical sonography (DMS) students (n = 13) served as teachers for first-year internal medicine residents (IMR) (n = 49).

PROGRAM DESCRIPTION

DMS students participated in a train-the-trainer session to learn teaching strategies via case-based simulation, then coached IMR to acquire images of the kidneys, bladder, and aorta on live models.

PROGRAM EVALUATION

Mixed-methods evaluation, including pre-/post-surveys and focus group interviews. The survey response rate was 100% (49/49 IMR). Composite survey scores evaluating residents' attitudes towards IPE and stereotyping of sonographers improved significantly following the intervention. Qualitative analysis of focus group interviews yielded four themes: enhanced respect for other disciplines, implications for future practice, increased confidence of DMS students, and interest in future IPE opportunities.

DISCUSSION

Interprofessional POCUS education can improve residents' perceptions towards IPE, increase their level of respect for sonographers, and motivate interest in future interprofessional collaboration.

Prognostic Implications of a Point-of-Care Ultrasound Examination on Hospital Ward Admission

OBJECTIVES

Few data exist regarding the use of ultrasound (US) to risk stratify ward admissions. Therefore, we evaluated associations between a cardiopulmonary limited ultrasound examination (CLUE) on admission and subsequent hospital outcomes.

METHODS

Over a 22-month period in a 300-bed hospital, CLUE data reviewed from a series of nonelective ward admissions were correlated with the composite outcome of a hospital stay of longer than 2 days, disposition to hospice, or death. The CLUE included 5 quick-look signs of left ventricular dysfunction, left atrial enlargement, lung B-lines, pleural effusions, and inferior vena cava plethora and had been performed as warranted by 1 of 31 US-trained admitting residents and then repeated by a cardiologist as the reference standard. The admitting condition, medical history, results of routine admission testing, and CLUE were assessed for an association with the outcome in univariate and multivariable models.

RESULTS

Of 547 patients, the mean age ± SD was 62.9 ± 15.5 years; 59% were male; and the mean stay was 5.6 ± 8.1 days, with 355 (65%) lasting longer than 2 days and 21 (4%) having hospice disposition or death. An abnormal CLUE exam was found in 368 (67%) of patients, was related to the outcome (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.23-2.68; P = .001) when obtained by a resident or cardiologist, and was included in a best-fit multivariable model with renal failure (OR, 2.44; 95% CI, 1.44-4.14; P < .001), infection/sepsis (OR, 2.25; 95% CI, 1.17-4.32; P = .02), and chest pain (OR, 0.36; 95% CI, 0.21-0.61; P < .001).

CONCLUSIONS

An abnormal admission point of care ultrasound exam was related to complex hospitalization, specifically a longer length of stay.

Diagnostic Yield of Ultrasound-guided Trucut Biopsy in Diagnosis of Peripheral Lung Malignancies

Introduction While computed tomography (CT) guided lung biopsy has been standard in histological diagnosis of pulmonary lesions, its use is limited to the interventional radiologists only. Ultrasound (US) guided biopsy of pulmonary lesions, which can be performed in-clinic by the pulmonologists only, is becoming a more popular technique. It also has the edge of real-time techniques, multi-planar imaging, and no radiation exposure to the patients. Methods This is a retrospective review of all the patients presenting with pleural-based lung lesions who underwent US-guided biopsy for diagnosis in the Department of Pulmonology, Liaquat University of Medical and Health Sciences Hospital, Hyderabad, Pakistan from 1^st January 2013 till 31^st December 2017. The diagnostic yield, sensitivity, specificity, and accuracy of US-guided biopsies were evaluated for diagnoses of peripheral lung malignancies. Results Ultrasound-guided biopsies for lung lesions has a diagnostic yield of 88.3%, sensitivity of 95.80%, and specificity of 90% with an accuracy of 95.35%. Pneumothorax as an immediate complication was seen only in 1.5% cases. Conclusion US-guided biopsies are a much safer diagnostic alternative to CT-guided biopsy for lung lesions and have high diagnostic yield. It doesn't require special radiological interventionists, can be performed at patients' bedsides, and the equipment is not as expensive.

A Primary Care Ultrasound Fellowship: Training for Clinical Practice and Future Educators

As ultrasound devices become smaller, more portable, and more user friendly, there is now widespread use of this technology by physicians of all specialties, yet there are currently few structured opportunities for ultrasound education outside of emergency and critical care medicine. Anticipating the rising educational demand in the primary care specialties, the University of South Carolina School of Medicine created a primary care ultrasound fellowship in 2011, the first yearlong training program in point-of-care ultrasonography for graduates of internal medicine, medicine-pediatrics, pediatrics, and family medicine residencies. This paper reviews the history of point-of-care ultrasonography fellowships and then provides an overview of the primary care ultrasound fellowship.

Ultrasound-guided Bedside Core Needle Biopsy: A Hospitalist Procedure Team's Experience

Tissue pathology is integral for the diagnosis of various conditions, especially malignancy. Traditionally, biopsy procedures, including core needle biopsy (CNB), are performed by surgeons or radiologists. With the increasing utilization of point of care ultrasound (POCUS) skills and competence in bedside procedures by general internists, CNB can be safely moved to the patient's bedside with maintained accuracy and increased cost savings compared to traditional procedural methods. We aim to review the experience of our hospitalist-run medical procedure service in performing these ultrasound-guided procedures at the bedside.

Point-of-Care Ultrasound for Hospitalists: A Position Statement of the Society of Hospital Medicine

Many hospitalists incorporate point-of-care ultrasound (POCUS) into their daily practice to answer specific diagnostic questions or to guide performance of invasive bedside procedures. However, standards for hospitalists in POCUS training and assessment are not yet established. Most internal medicine residency training programs, the major pipeline for incoming hospitalists, have only recently begun to incorporate POCUS in their curricula. The purpose of this document is to inform a broad audience on what POCUS is and how hospitalists are using it. This document is intended to provide guidance for the hospitalists who use POCUS and administrators who oversee its use. We discuss POCUS 1) applications, 2) training, 3) assessments, and 4) program management. Practicing hospitalists must continue to collaborate with their local credentialing bodies to outline requirements for POCUS use. Hospitalists should be integrally involved in decision-making processes surrounding POCUS program management.

Point-of-Care Ultrasound in Established Settings

The original and most widely accepted applications for point-of-care ultrasound (POCUS) are in the settings of trauma, shock, and bedside procedures. Trauma was the original setting for the introduction of POCUS and has been standardized under the four-plus view examination called the Focused Assessment with Sonography in Trauma (FAST). This examination was found to be especially practice changing for achieving rapid diagnoses in critically ill patients who are too unstable for the delays and transportation inherent in more advanced imaging with computed tomography. This application was broadened from the critically ill trauma patient to any critically ill patient, particularly the patient in undifferentiated shock. Although the Focused Assessment with Sonography in Trauma examination originally focused on sources of hemorrhage causing hypovolemic shock, POCUS also can quickly differentiate cardiogenic, obstructive, and distributive shock and help identify the more specific etiology such as massive pulmonary emboli, pericardial tamponade, and pneumothoraces. By expediting diagnosis, POCUS facilitates faster definitive treatment of life-threatening conditions. In pursuing treatment, US continues to serve a role in the form of visually guiding many procedures that were previously done blindly. US guidance of procedures has improved the safety of central line insertion, thoracentesis, and paracentesis, and has an emerging role in lumbar puncture. Experience in bedside US is becoming a vital tool in the clinician's bedside assessment and management, filling a void between the stethoscope and the more advanced studies and interventions available through radiology. Understanding the strengths and limitations of US enables clinicians to identify the appropriate situations in which they can apply this tool confidently.

Skills acquisition for novice learners after a point-of-care ultrasound course: does clinical rank matter?

BACKGROUND

Few studies have compared the effectiveness of brief training courses on point-of-care ultrasound (POCUS) skill acquisition of novice attending physicians vs. trainees. The purpose of this study was to evaluate the change in POCUS image interpretation skills and confidence of novice attending physicians vs. trainees after a 1-day POCUS training course.

METHODS

A 1-day POCUS training course was held in March 2017 in Japan. A standardized training curriculum was developed that included online education, live lectures, and hands-on training. The pre-course assessment tools included a written examination to evaluate baseline knowledge and image interpretation skills, and a physician survey to assess confidence in performing specific ultrasound applications. The same assessment tools were administered post-course, along with a course evaluation. All learners were novices and were categorized as trainees or attending physicians. Data were analyzed using two-way analysis of variance.

RESULTS

In total, 60 learners attended the course, and 51 learners (85%) completed all tests and surveys. The 51 novice learners included 29 trainees (4 medical students, 9 PGY 1-2 residents, 16 PGY 3-5 residents) and 22 attending physicians (6 PGY 6-10 physicians, and 16 physicians PGY 11 and higher). The mean pre- and post-course test scores of novice trainees improved from 65.5 to 83.9% while novice attending physicians improved from 66.7 to 81.5% (p < 0.001). The post-course physician confidence scores in using ultrasound significantly increased in all skill categories for both groups. Both trainees and attending physicians demonstrated similar improvement in their post-course test scores and confidence with no statistically significant differences between the groups. The course evaluation scores for overall satisfaction and satisfaction with faculty members' teaching skills were 4.5 and 4.6 on a 5-point scale, respectively.

CONCLUSIONS

Both novice trainees and attending physicians showed similar improvement in point-of-care ultrasound image interpretation skills and confidence after a brief training course. Although separate training courses have traditionally been developed for attending physicians and trainees, novice learners of point-of-care ultrasound may acquire skills at similar rates, regardless of their ranking as an attending physician or trainee. Future studies are needed to compare the effectiveness of short training courses on image acquisition skills and determine the ideal course design.

Implementation of a point-of-care ultrasound skills practicum for hospitalists

Introduction

Point-of-care ultrasound is recognized as a safe and valuable diagnostic tool for patient evaluation. Hospitalists are prime candidates for advancing the point-of-care ultrasound field given their crucial role in inpatient medicine. Despite this, there is a notable lack of evidence-based ultrasound training for hospitalists. Most research focuses on diagnostic accuracy rather than the training required to achieve it. This study aims to improve hospitalists' point-of-care ultrasound knowledge and skills through a hands-on skills practicum.

Methods

Four skill practicums were conducted with pre-course, post-course, and six-month evaluations and knowledge assessments.

Results

The mean pre- vs. post-course knowledge assessment scores significantly improved, 41.7% vs. 75.9% (SD 16.1% and 12.7%, respectively, p < 0.0001). The mean ultrasound skills confidence ratings on a 10-point Likert scale significantly increased post-course (2.60 ± 1.66 vs. 6.33 ± 1.63, p < 0.0001), but decreased at six months (6.33 ± 1.63 vs. 4.10 ± 2.22, p < 0.0001). The greatest limitations to usage pre-course and at six months were knowledge/skills and lack of machine access. While knowledge/skills decreased from pre-course (82.0%) as compared to six-months (64.3%), lack of machine access increased from pre-course (15.8%) to six-months (28.6%) (p = 0.28).

Conclusion

Hospitalists agree that point-of-care ultrasound has utility in the diagnostic and therapeutic management of patients, though the lack of training is a significant limitation. Our study demonstrated that a brief skills practicum significantly improves hospitalists' confidence and knowledge regarding ultrasound image acquisition and interpretation in the short term. Long-term confidence and usage wanes, which appears to be due to the lack of machine access.

Scope of point-of-care ultrasound practice in rural New Zealand

ABSTRACT INTRODUCTION Point-of-care ultrasound (POCUS) is an increasingly common adjunct to the clinical assessment of patients in rural New Zealand. AIM To describe the scope of POCUS being practiced by rural generalist hospital doctors and gain insights, from their perspective, into its effect. METHODS This was a mixed-methods descriptive study. Main outcome measures were type and frequency of POCUS being undertaken. A questionnaire was given to POCUS-active rural hospital doctors to survey the effect of POCUS on clinical practice and assess issues of quality assurance. RESULTS The most commonly performed scans were: cardiac (18%) and volume scans (inferior vena cava and jugular venous pressure) (14%), followed by gallbladder (13%), kidney (11%), Focused Assessment with Sonography in Trauma (FAST) (7%), bladder (6%), leg veins (6%) and lungs (5%). There was large variation in frequency of scan types between the study hospitals that could not be accounted for by differences in training. The participating doctors considered that POCUS had a positive and significant effect on their practice, largely by adding to diagnostic certainty. Challenges identified included maintenance of POCUS skills, lack of systems for POCUS set-up and the absence of quality assurance for POCUS in rural hospitals. DISCUSSION Rural generalists consider the broad scope of POCUS they practise to be an important but challenging skill set. Clinical governance, including an agreed scope and standards, may increase the benefits and improve the safety of rural POCUS.

Reproducibility of point-of-care ultrasonography for central vein diameter measurement: Separating image acquisition from interpretation

PURPOSE

Central vein point-of-care ultrasonography must be reproducible to detect intravascular volume changes. We sought to determine which measurement step, image acquisition or interpretation, could be more compromising for reproducibility.

METHODS

Three investigators each acquired inferior vena cava (IVC) and internal jugular (IJV) vein ultrasonographic sequences (US) from a convenience sample of 21 hospitalized general medicine participants and then interpreted each US three separate times. We partitioned the random errors of acquisition and interpretation, attributing wider dispersions of each to larger reductions in reproducibility.

RESULTS

We analyzed 351 interpretations of 39 IVC and 432 interpretations of 48 IJV US. Reproducibility of the maximum (standard error of measurement 3.3 mm [95% confidence interval, CI 2.7-4.2 mm]) and minimum (4.8 mm [3.9-6.3 mm]) IVC diameter measurements were worse than that of the mediolateral (2.5 mm [2.0-3.2 mm]) and anteroposterior (2.5 mm [2.0-3.1 mm]) IJV diameters. The dispersions of random measurement errors were wider among acquisitions than interpretations.

CONCLUSIONS

Among our investigators, central vein diameter measurements obtained by point-of-care ultrasonography are not sufficiently reproducible to distinguish clinically meaningful intravascular volume changes from measurement errors. Reproducibility could be most effectively improved by reducing the random measurement errors of acquisition. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:488-496, 2017.

Ultrasound-guided versus computed tomography-scan guided biopsy of pleural-based lung lesions

Background:

Computed tomography (CT) guided biopsies have long been the standard technique to obtain tissue from the thoracic cavity and is traditionally performed by interventional radiologists. Ultrasound (US) guided biopsy of pleural-based lesions, performed by pulmonologists is gaining popularity and has the advantage of multi-planar imaging, real-time technique, and the absence of radiation exposure to patients. In this study, we aim to determine the diagnostic accuracy, the time to diagnosis after the initial consult placement, and the complications rates between the two different modalities.

Methods:

A retrospective study of electronic medical records was done of patients who underwent CT-guided biopsies and US-guided biopsies for pleural-based lesions between 2005 and 2014 and the data collected were analyzed for comparing the two groups.

Results:

A total of 158 patients underwent 162 procedures during the study period. 86 patients underwent 89 procedures in the US group, and 72 patients underwent 73 procedures in the CT group. The overall yield in the US group was 82/89 (92.1%) versus 67/73 (91.8%) in the CT group (P = 1.0). Average days to the procedure was 7.2 versus 17.5 (P = 0.00001) in the US and CT group, respectively. Complication rate was higher in CT group 17/73 (23.3%) versus 1/89 (1.1%) in the US group (P < 0.0001).

Conclusions:

For pleural-based lesions the diagnostic accuracy of US guided biopsy is similar to that of CT-guided biopsy, with a lower complication rate and a significantly reduced time to the procedure.

Faculty development in point of care ultrasound for internists

Lack of general medicine faculty expertise is a likely contributor to the slow adoption of point of care ultrasound (POCUS) by internal medicine (IM) residency training programs. We developed a 10-week faculty development program, during which 15 faculty members participated in 2 hours and 10 hours of online didactic and hands-on training, respectively. Pre-post comparisons showed that there were statistically significant improvements in faculty participants' ability to interpret images (p<0.001), perceived understanding of the capabilities and limitations of POCUS (p=0.003), comfort using POCUS to make clinical decisions (p=0.003), and perceptions regarding the extent to which POCUS can improve patient care (p=0.026). The next challenge for IM programs is to improve access to ultrasound machines and provide follow-up workshops to facilitate further development of skills and integration of POCUS into daily practice by general medicine faculty.