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Kline J, Golinski M, Selai B, Horsch J, Hornbaker K. The effectiveness of a blended POCUS curriculum on achieving basic focused bedside transthoracic echocardiography (TTE) proficiency. A formalized pilot study. Cardiovasc Ultrasound 2021; 19:39. [PMID: 34886847 PMCID: PMC8662909 DOI: 10.1186/s12947-021-00268-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/04/2021] [Indexed: 11/28/2022] Open
Abstract
Objective The study objective is to evaluate the effeteness of an existing educational platform blending didactic presentation and hands-on simulation for university doctoral SRNAs in the area of basic, 4 view identification and performance of transthoracic echocardiography (TTE). Methods Following IRB approval, SRNAs were exposed to a pre test to evaluate existing skills, then they were exposed to a graphic rich, live presentation of basic 4 view TTE. The presentation was then followed by hands on simulation and performance of the 4 basic TTE views on live models. Results Pretest scores averaged 58% and post tests scores rose to 95%. See Table 1. Conclusion Our results support the concept that the existing blended platform is effective to train university SRNAs in basic 4 view, bedside transthoracic echocardiography.
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Affiliation(s)
| | - Mary Golinski
- Oakland University Nurse Anesthesia Program, Rochester Hills, MI, USA
| | - Brian Selai
- Twin Oaks Anesthesia, Wesley Chapel, Florida, USA
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Gibson LE, White-Dzuro GA, Lindsay PJ, Berg SM, Bittner EA, Chang MG. Ensuring competency in focused cardiac ultrasound: a systematic review of training programs. J Intensive Care 2020; 8:93. [PMID: 33308314 PMCID: PMC7730755 DOI: 10.1186/s40560-020-00503-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/27/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Focused cardiac ultrasound (FoCUS) is a valuable skill for rapid assessment of cardiac function and volume status. Despite recent widespread adoption among physicians, there is limited data on the optimal training methods for teaching FoCUS and metrics for determining competency. We conducted a systematic review to gain insight on the optimal training strategies, including type and duration, that would allow physicians to achieve basic competency in FoCUS. METHODS Embase, PubMed, and Cochrane Library databases were searched from inception to June 2020. Included studies described standardized training programs for at least 5 medical students or physicians on adult FoCUS, followed by an assessment of competency relative to an expert. Data were extracted, and bias was assessed for each study. RESULTS Data were extracted from 23 studies on 292 learners. Existing FoCUS training programs remain varied in duration and type of training. Learners achieved near perfect agreement (κ > 0.8) with expert echocardiographers on detecting left ventricular systolic dysfunction and pericardial effusion with 6 h each of didactics and hands-on training. Substantial agreement (κ > 0.6) on could be achieved in half this time. CONCLUSION A short training program will allow most learners to achieve competency in detecting left ventricular systolic dysfunction and pericardial effusion by FoCUS. Additional training is necessary to ensure skill retention, improve efficiency in image acquisition, and detect other pathologies.
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Affiliation(s)
- Lauren E Gibson
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA.
| | - Gabrielle A White-Dzuro
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA
| | - Patrick J Lindsay
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA
| | - Sheri M Berg
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA
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Abstract
Background: Focused cardiac ultrasound (FCU) is widely used by healthcare providers to answer specific questions about cardiac structure and function at the bedside. Currently, no widely accepted FCU image acquisition checklist exists to assess learners with varying skill levels from different specialties. Objective: The primary objective of this project was to develop a consensus-based FCU image acquisition checklist using a multispecialty group of point-of-care ultrasound (POCUS) experts. Methods: The essential components of an FCU examination were identified on the basis of published recommendations from echocardiography and international ultrasound societies. A checklist of the essential components of an FCU examination was drafted. A panel of POCUS experts from different medical specialties in the United States and Canada was convened to vote on each checklist item by answering two questions: 1) Is this item important to include in a checklist of essential FCU skills applicable to any medical specialty? and 2) Should the learner be required to successfully complete this item to be considered competent? A modified Delphi approach was used to assess the level of agreement for each checklist item during four rounds of voting. Checklist items that achieved an agreement of 80% or greater were included in the final checklist. Results: Thirty-one POCUS experts from seven different medical specialties voted on sixty-five items to be included in the FCU image acquisition assessment tool. The majority of POCUS experts (61%) completed all four rounds of voting. During the first round of voting, 59 items reached consensus, and after revision and revoting, an additional 3 items achieved 80% or greater consensus. A total of 62 items were included in the final checklist, and 57 items reached consensus as a requirement for demonstration of competency. Conclusion: We have developed a multispecialty, consensus-based FCU image acquisition checklist that may be used to assess the skills of learners from different specialties. Future steps include studies to develop additional validity evidence for the use of the FCU assessment tool and to evaluate its utility for the translation of skills into clinical practice.
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Kimura BJ, Lou MM, Dahms EB, Han PJ, Waalen J. Prognostic Implications of a Point-of-Care Ultrasound Examination on Hospital Ward Admission. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:289-297. [PMID: 31378976 DOI: 10.1002/jum.15102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/02/2019] [Accepted: 07/12/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Bruce J Kimura
- Departments of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, California, USA
| | - May M Lou
- Departments of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, California, USA
| | - Eric B Dahms
- Departments of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, California, USA
| | - Paul J Han
- Departments of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, California, USA
| | - Jill Waalen
- Scripps Research Translational Institute, San Diego, California, USA
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Hopkins A, Doniger SJ. Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice. Hosp Pediatr 2019; 9:707-718. [PMID: 31405888 DOI: 10.1542/hpeds.2018-0118] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.
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Affiliation(s)
- Akshata Hopkins
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida; and
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Neskovic AN, Skinner H, Price S, Via G, De Hert S, Stankovic I, Galderisi M, Donal E, Muraru D, Sloth E, Gargani L, Cardim N, Stefanidis A, Cameli M, Habib G, Cosyns B, Lancellotti P, Edvardsen T, Popescu BA. Focus cardiac ultrasound core curriculum and core syllabus of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2019. [PMID: 29529170 DOI: 10.1093/ehjci/jey006] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
There is a growing trend of using ultrasound examination of the heart as a first-line diagnostic tool for initial patient evaluation in acute settings. Focus cardiac ultrasound (FoCUS) is a standardized but restricted cardiac ultrasound examination that may be undertaken by a range of medical professionals with diverse backgrounds. The intention of this core curriculum and syllabus is to define a unifying framework for educational and training processes/programmes that should result in competence in FoCUS for various medical professionals dealing with diagnostics and treatment of cardiovascular emergencies. The European Association of Cardiovascular Imaging prepared this document in close cooperation with representatives of the European Society of Anaesthesiology, the European Association of Cardiothoracic Anaesthesiology, the Acute Cardiovascular Care Association of the European Society of Cardiology and the World Interactive Network Focused On Critical Ultrasound. It aims to provide the key principles and represents a guide for teaching and training of FoCUS. We offer this document to the emergency and critical care community as a reference outline for teaching materials and courses related to FoCUS, for promoting teamwork and encouraging the development of the field.
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Affiliation(s)
- Aleksandar N Neskovic
- Department of Cardiology, Clinical Hospital Center Zemun, Vukova 9, 11080 Belgrade, Faculty of Medicine, University of Belgrade, Serbia
| | - Henry Skinner
- Department of Anaesthesiology, Nottingham University Hospitals, Hucknall Rd, Nottingham NG5 1PB, UK
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
| | - Gabriele Via
- Department of Anesthesia and Intensive Care, Cardiocentro Ticino, Via Tesserete 48, 6900 Lugano, Switzerland
| | - Stefan De Hert
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
| | - Ivan Stankovic
- Department of Cardiology, Clinical Hospital Center Zemun, Vukova 9, 11080 Belgrade, Faculty of Medicine, University of Belgrade, Serbia
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Via S. Pansini 5, 80131 Napoli, Italy
| | - Erwan Donal
- Department of Cardiology, University Hospital of Rennes, rue H Le Guillou - Hôpital Pontchaillou, 35000 Rennes, France
| | - Denisa Muraru
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128 Padua, Italy
| | - Erik Sloth
- Department of Anaesthesiology and Intensive Care Medicine, Operation and Intensive Care East Section, Aarhus University Hospital, Skejby, 99 Palle Juul-Jensens Boulevard, 8200 Aarhus N, Denmark
| | - Luna Gargani
- Institute of Clinical Physiology - National Research Council, Via Moruzzi 1, 56124 Pisa, Italy
| | - Nuno Cardim
- Cardiology Department, Hospital da Luz, Av. Lusíada, n° 100 - 1500-650 Lisbon, Portugal
| | | | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Viale Bracci 1, Policlinico Le Scotte, 53100 Siena, Italy
| | - Gilbert Habib
- APHM, La Timone Hospital, Cardiology Department, Boulevard Jean Moulin, 13005 Marseille, France.,Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Boulevard Jean Moulin, 13005, Marseille, France
| | - Bernard Cosyns
- Centrum voor Hart en Vaatziekten (CHVZ), Unversitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, Domaine Universitaire du Sart Tilman - B.35?-?4000 Liège, Belgium
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet and University of Oslo, Sognvannsveien 20, NO-0027 Oslo, Norway
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy 'Carol Davila' - Euroecolab, Institute of Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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A Review of Echocardiography Training for Internal Medicine Residents: Proposed Goals, Methods, and Metrics. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9468-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pérez de Isla L, Díaz Sánchez S, Pagola J, García de Casasola Sánchez G, López Fernández T, Sánchez Barrancos IM, Martínez-Sánchez P, Zapatero Gaviria A, Anguita M, Ruiz Serrano AL, Torres Macho J. Documento de consenso de SEMI, semFYC, SEN y SEC sobre ecocardioscopia en España. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2018.05.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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9
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Pérez de Isla L, Díaz Sánchez S, Pagola J, García de Casasola Sánchez G, López Fernández T, Sánchez Barrancos IM, Martínez-Sánchez P, Zapatero Gaviria A, Anguita M, Ruiz Serrano AL, Torres Macho J. Consensus Document of the SEMI, semFYC, SEN, and SEC on Focused Cardiac Ultrasound in Spain. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2018; 71:935-940. [PMID: 30119954 DOI: 10.1016/j.rec.2018.05.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/18/2018] [Indexed: 11/29/2022]
Abstract
This document summarizes the concept of focused cardiac ultrasound, the basic technical aspects related to this technique, and its diagnostic objectives. It also defines training requisites in focused cardiac ultrasound. This consensus document has been endorsed by the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of Neurology (SEN), and the Spanish Society of Cardiology (SEC).
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Affiliation(s)
| | | | - Jorge Pagola
- Servicio de Neurología, Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | | | | | | | - Manuel Anguita
- Servicio de Cardiología, Hospital Reina Sofía, Córdoba, Spain
| | | | - Juan Torres Macho
- Servicio de Medicina Interna-Urgencias, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain
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Cochard E, Fulkerson Z, Carlos WG. Implementation of a point-of-care ultrasound skills practicum for hospitalists. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2018; 27:38-44. [PMID: 30774697 DOI: 10.1177/1742271x18791317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/29/2018] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Emily Cochard
- Division of Pulmonary, Critical Care, Allergy, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Zachary Fulkerson
- Division of Pulmonary, Critical Care, Allergy, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - W Graham Carlos
- Division of Pulmonary, Critical Care, Allergy, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
Healthcare providers who use peripheral vascular and cardiac ultrasound require specialized training to develop the technical and interpretive skills necessary to perform accurate diagnostic tests. Assessment of competence is a critical component of training that documents a learner's progress and is a requirement for competency-based medical education (CBME) as well as specialty certification or credentialing. The use of simulation for CBME in diagnostic ultrasound is particularly appealing since it incorporates both the psychomotor and cognitive domains while eliminating dependency on the availability of live patients with a range of pathology. However, successful application of simulation in this setting requires realistic, full-featured simulators and appropriate standardized metrics for competency testing. The principal diagnostic parameter in peripheral vascular ultrasound is measurement of peak systolic velocity (PSV) on Doppler spectral waveforms, and simulation of Doppler flow detection presents unique challenges. The computer-based duplex ultrasound simulator developed at the University of Washington uses computational fluid dynamics modeling and presents real-time color-flow Doppler images and Doppler spectral waveforms along with the corresponding B-mode images. This simulator provides a realistic scanning experience that includes measuring PSV in various arterial segments and applying actual diagnostic criteria. Simulators for echocardiography have been available since the 1990s and are currently more advanced than those for peripheral vascular ultrasound. Echocardiography simulators are now offered for both transesophageal echo and transthoracic echo. These computer-based simulators have 3D graphic displays that provide feedback to the learner and metrics for assessment of technical skill that are based on transducer tracking data. Such metrics provide a motion-based or kinematic analysis of skill in performing cardiac ultrasound. The use of simulation in peripheral vascular and cardiac ultrasound can provide a standardized and readily available method for training and competency assessment.
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Affiliation(s)
- Florence H Sheehan
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA, USA
| | - R Eugene Zierler
- Department of Surgery, Division of Vascular Surgery, University of Washington, Seattle, WA, USA
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McConnaughey S, Freeman R, Kim S, Sheehan F. Integrating Scaffolding and Deliberate Practice Into Focused Cardiac Ultrasound Training: A Simulator Curriculum. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2018; 14:10671. [PMID: 30800871 PMCID: PMC6342425 DOI: 10.15766/mep_2374-8265.10671] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 12/15/2017] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Focused cardiac ultrasound (FoCUS) is widely used for the point-of-care evaluation of basic cardiac pathology, and there is a need for efficient and consistent training in this modality. We designed a simulator-based FoCUS curriculum that integrates instructional scaffolding and deliberate practice to create a directed, self-regulated learning experience for novices. The goal of this strategy was to guide the novice's learning efforts more efficiently and moderate cognitive load while retaining the benefits of independent learning. METHODS The complex task of learning cardiac ultrasound is broken into discrete steps, with focused didactic information immediately followed by targeted simulator practice for each module. The practice complexity increases through successive modules, and learners ultimately apply their skills by completing unassisted simulator cases. Immediate visual and quantitative feedback is provided by the simulator whenever an ultrasound image was captured during practice. The entire curriculum is self-guided. RESULTS Sixteen nurse practitioners and resident physicians completed this FoCUS curriculum. In comparison to a previously validated, lecture-before-practice-style curriculum, the average time to completion decreased from 8.0 ± 2.5 hours to 4.7 ± 1.9 hours (p < .0001). There was no difference in posttraining cognitive or psychomotor outcomes between the curricula as measured by a simulator posttest. DISCUSSION A curriculum integrating scaffolding and deliberate practice provides a more efficient, but equally effective, means of teaching psychomotor and cognitive skills in FoCUS. These instructional design principles may translate to other operational learning tasks and allow novices to build skills and reach basic competency more rapidly.
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Affiliation(s)
| | - Rosario Freeman
- Professor, Division of Cardiology, University of Washington Medical Center
| | - Sara Kim
- Professor, Department of Surgery, University of Washington Medical Center
| | - Florence Sheehan
- Professor, Division of Cardiology, University of Washington Medical Center
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Conlin F, Connelly NR, Eaton MP, Broderick PJ, Friderici J, Adler AC. Perioperative Use of Focused Transthoracic Cardiac Ultrasound. Anesth Analg 2017; 125:1878-1882. [DOI: 10.1213/ane.0000000000002089] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Mohammed A. Chamsi-Pasha
- Cardiovascular Imaging Institute, Department of Cardiology, the Methodist DeBakey Heart and Vascular Center, Houston, TX (M.A.C.-P., W.A.Z.)
| | - Partho P. Sengupta
- Section of Cardiology, West Virginia University Heart and Vascular Institute, J.W. Ruby Memorial Hospital, Morgantown (P.P.S.)
| | - William A. Zoghbi
- Cardiovascular Imaging Institute, Department of Cardiology, the Methodist DeBakey Heart and Vascular Center, Houston, TX (M.A.C.-P., W.A.Z.)
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Abstract
Though the use of point-of-care ultrasound (POCUS) has increased over the last decade, formal hospital credentialing for POCUS may still be a challenge for hospitalists. This document details the Hospital Medicine Department Ultrasound Credentialing Policy from Regions Hospital, which is part of the HealthPartners organization in Saint Paul, Minnesota. National organizations from internal medicine and hospital medicine (HM) have not published recommended guidelines for POCUS credentialing. Revised guidelines for POCUS have been published by the American College of Emergency Physicians, though these are not likely intended to guide hospitalists when working with credentialing committees and medical boards. This document describes the scope of ultrasound in HM and our training, credentialing, and quality assurance program. This report is intended to be used as a guide for hospitalists as they work with their own credentialing committees and will require modification for each institution. However, the overall process described here should assist in the establishment of POCUS at various institutions.
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Affiliation(s)
- Benji K Mathews
- Department of Hospital Medicine, HealthPartners, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Michael Zwank
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Regions Hospital, St. Paul, Minnesota, USA
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Rivas R. ECOCARDIOGRAFÍA PERIOPERATORIA. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Tsai BT, Dahms EB, Waalen J, Kimura BJ. Actual use of pocket-sized ultrasound devices for cardiovascular examination by trained physicians during a hospitalist rotation. J Community Hosp Intern Med Perspect 2016; 6:33358. [PMID: 27987287 PMCID: PMC5161791 DOI: 10.3402/jchimp.v6.33358] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/26/2016] [Accepted: 11/01/2016] [Indexed: 11/23/2022] Open
Abstract
Background In actual clinical practice as opposed to published studies, the application of bedside ultrasound requires a perception of need, confidence in one's skills, and convenience. Objective As the frequency of ultrasound usage is evidence to its perceived value in patient care, we observed the pattern of autonomous use of a pocket-sized device (PSD) by ultrasound-trained residents during a night hospitalist rotation. Methods Consecutive internal medicine residents (n=24), trained in a cardiac limited ultrasound examination (CLUE) as a mandatory part of their curriculum, were sampled on their PSD use after their admitting nights, regarding perceived necessity, deterring factors, detected abnormalities, and imaging difficulties. A detailed analysis was performed with one resident who used a PSD on every admission to compare the proportion of abnormal CLUEs and utility in patients with and without a perceived need. Results Residents admitted 542 patients (mean age: 55±17 years, range: 17–95 years) during 101 shifts and performed CLUE on 230 patients (42%, range: 17–85%). Residents elected not to scan 312 (58%) patients due to 1) lack of perceived necessity (231, 74%), 2) time constraints (44, 14%), and 3) patient barriers (37, 12%). In the detailed analysis (n=71), the resident felt CLUE was necessary in 32 (45%) patients versus unnecessary in 39 (55%) patients, with abnormality rates of 50% versus 20.5% (p=0.01) and utility rates of 28.1% versus 15.4% (p=0.25), respectively. Conclusion When unbiased residents acting as hospitalists are provided with a PSD to augment initial cardiac examination, usage is frequent and suggests clinical value in hospital medicine.
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Affiliation(s)
- Benjamin T Tsai
- Department of Graduate Medical Education, Scripps Mercy Hospital, San Diego, CA, USA
| | - Eric B Dahms
- Department of Graduate Medical Education, Scripps Mercy Hospital, San Diego, CA, USA
| | - Jill Waalen
- Scripps Translational Science Institute, San Diego, CA, USA
| | - Bruce J Kimura
- Department of Graduate Medical Education, Scripps Mercy Hospital, San Diego, CA, USA;
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18
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Image-based resuscitation of the hypotensive patient with cardiac ultrasound: An evidence-based review. J Trauma Acute Care Surg 2016; 80:511-8. [PMID: 26670112 DOI: 10.1097/ta.0000000000000941] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article is a detailed review of the literature regarding the use of cardiac ultrasound for the resuscitation of hypotensive patients. In addition, figures regarding windows and description of how to perform the test are included.
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Abstract
Pleural effusions are common and account for high morbidity and mortality in a range of patients. Thoracentesis can provide significant symptom relief and improvement in physiologic parameters including dyspnea, exercise, and sleep. Recent advances, including the use of ultrasound and dedicated procedural teams, have improved the safety of thoracentesis. This has allowed thoracentesis to be performed on higher-risk individuals including those with elevated bleeding risk and bilateral pleural effusions. This review will summarize recent advances in thoracentesis procedural safety, symptom relief following thoracentesis, and understanding of the physiologic basis for such improvements.
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Affiliation(s)
- Erin M. DeBiasi
- Department of Pulmonary and Critical Care Medicine, Yale University, New Haven, CT, USA
| | - Jonathan Puchalski
- Department of Pulmonary and Critical Care Medicine, Yale University, New Haven, CT, USA
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20
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Beshay A, Liu M, Fox L, Shinkai K. Inpatient dermatology consultative programs: A continued need, tools for needs assessment for curriculum development, and a call for new methods of teaching. J Am Acad Dermatol 2016; 74:769-71. [DOI: 10.1016/j.jaad.2015.11.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/08/2015] [Accepted: 11/15/2015] [Indexed: 10/22/2022]
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Cowie B. The Preoperative Patient With a Systolic Murmur. Anesth Pain Med 2015; 5:e32105. [PMID: 26705529 PMCID: PMC4688819 DOI: 10.5812/aapm.32105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 09/04/2015] [Indexed: 01/16/2023] Open
Abstract
Context: Patients with undifferentiated systolic murmurs present commonly during the perioperative period. Traditional bedside assessment and auscultation has not changed significantly in almost 200 years and relies on interpreting indirect acoustic events as a means of evaluating underlying cardiac pathology. This is notoriously inaccurate, even in expert cardiology hands, since many different valvular and cardiac diseases present with a similar auditory signal. Evidence Acquisition: The data on systolic murmurs, physical examination, perioperative valvular disease in the setting of non-cardiac surgery is reviewed. Results: Significant valvular heart disease increases perioperative risk in major non-cardiac surgery and increases long term patient morbidity and mortality. We propose a more modern approach to physical examination that incorporates the use of focused echocardiography to allow direct visualization of cardiac structure and function. This improves the diagnostic accuracy of clinical assessment, allows rational planning of surgery and anaesthesia technique, risk stratification, postoperative monitoring and appropriate referral to physicians and cardiologists. Conclusions: With a thorough preoperative assessment incorporating focused echocardiography, anaesthetists are in the unique position to enhance their role as perioperative physicians and influence short and long term outcomes of their patients.
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Affiliation(s)
- Brian Cowie
- Department of Anaesthesia, St. Vincent’s Hospital, Melbourne, Australia
- Corresponding author: Brian Cowie, Department of Anaesthesia, St. Vincent’s Hospital, 41 Victoria Parade, Fitzroy 3065, Melbourne, Australia. Tel: +61-39288 2211, E-mail:
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Adler AC, Greeley WJ, Conlin F, Feldman JM. Perioperative Anesthesiology UltraSonographic Evaluation (PAUSE): A Guided Approach to Perioperative Bedside Ultrasound. J Cardiothorac Vasc Anesth 2015; 30:521-9. [PMID: 27013122 DOI: 10.1053/j.jvca.2015.11.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Indexed: 01/29/2023]
Affiliation(s)
- Adam C Adler
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiothoracic Anesthesiology; The Children's Hospital of Philadelphia, Philadelphia, PA.
| | - William J Greeley
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiothoracic Anesthesiology; The Children's Hospital of Philadelphia, Philadelphia, PA; The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Frederick Conlin
- Department of Anesthesiology, Baystate Medical Center, Springfield, MA; Tufts University School of Medicine, Boston, MA
| | - Jeffrey M Feldman
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiothoracic Anesthesiology; The Children's Hospital of Philadelphia, Philadelphia, PA; The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Abstract
Focused cardiac ultrasound (FCU) is a bedside examination of the heart performed with a small, portable ultrasound platform by a physician as an adjunct to their physical examination. The goal is to recognize a narrow list of abnormalities that are both detectable by physicians with limited ultrasound training and have high clinical assessment value. Results from the FCU examination are integrated with traditional bedside assessment (physical examination and history) to provide early management plans and patient triage in settings when echocardiography cannot be obtained or is not immediately available.
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Affiliation(s)
- Kirk T Spencer
- University of Chicago, 5841 S Maryland MC 5084, Chicago, IL, 60637, USA,
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24
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Xie JX, Shaw LJ. Creating Opportunities to Guide Efficient and Cost-Effective Echocardiography in the Era of Value-Based Cardiac Imaging. J Am Soc Echocardiogr 2015; 28:1060-1. [DOI: 10.1016/j.echo.2015.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Affiliation(s)
| | - Y Chandrashekhar
- University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York.
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26
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Blehar DJ, Barton B, Gaspari RJ. Learning curves in emergency ultrasound education. Acad Emerg Med 2015; 22:574-82. [PMID: 25903780 DOI: 10.1111/acem.12653] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 11/07/2014] [Accepted: 11/10/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Proficiency in the use of bedside ultrasound (US) has become standard in emergency medicine residency training. While milestones have been established for this training, supporting data for minimum standard experience are lacking. The objective of this study was to characterize US learning curves to identify performance plateaus for both image acquisition and interpretation, as well as compare performance characteristics of learners to those of expert sonographers. METHODS A retrospective review of an US database was conducted at a single academic institution. Each examination was scored for agreement between the learner and expert reviewer interpretation and given a score for image quality. A locally weighted scatterplot smoothing method was used to generate a model of predicted performance for each individual examination type. Performance characteristics for expert sonographers at the site were also tracked and used in addition to performance plateaus as benchmarks for learning curve analysis. RESULTS There were 52,408 US examinations performed between May 2007 and January 2013 and included for analysis. Performance plateaus occurred at different points for different US protocols, from 18 examinations for soft tissue image quality to 90 examinations for right upper quadrant image interpretation. For the majority of examination types, a range of 50 to 75 examinations resulted in both excellent interpretation (sensitivity > 84% and specificity > 90%) and good image quality (90% the image quality benchmark of expert sonographers). CONCLUSIONS Educational performance benchmarks occur at variable points for image interpretation and image quality for different examination types. These data should be considered when developing training standards for US education as well as experience requirements for US credentialing.
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Affiliation(s)
- David J. Blehar
- Department of Emergency Medicine; University of Massachusetts Medical School; Worcester MA
| | - Bruce Barton
- Department of Quantitative Health Sciences; University of Massachusetts Medical School; Worcester MA
| | - Romolo J. Gaspari
- Department of Emergency Medicine; University of Massachusetts Medical School; Worcester MA
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27
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Abstract
BACKGROUND Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
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28
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Soni NJ, Lucas BP. Diagnostic point-of-care ultrasound for hospitalists. J Hosp Med 2015; 10:120-4. [PMID: 25408226 DOI: 10.1002/jhm.2285] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 10/21/2014] [Accepted: 10/28/2014] [Indexed: 11/11/2022]
Abstract
We review the literature on diagnostic point-of-care ultrasound applications most relevant to hospital medicine and highlight gaps in the evidence base. Diagnostic point-of-care applications most relevant to hospitalists include cardiac ultrasound for left ventricular systolic function, pericardial effusion, and severe mitral regurgitation; lung ultrasound for pneumonia, pleural effusion, pneumothorax, and pulmonary edema; abdominal ultrasound for ascites, aortic aneurysm, and hydronephrosis; and venous ultrasound for central venous volume assessment and lower extremity deep venous thrombosis. Hospitalists and other frontline providers, as well as physician trainees at various levels of training, have moderate to excellent diagnostic accuracy after brief training programs for most of these applications. Despite the evidence supporting the diagnostic accuracy of point-of-care ultrasound, experimental evidence supporting its clinical use by hospitalists is limited to cardiac ultrasound.
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Affiliation(s)
- Nilam J Soni
- Department of Medicine, University of Texas Health Science Center, San Antonio, Texas
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Neskovic AN, Edvardsen T, Galderisi M, Garbi M, Gullace G, Jurcut R, Dalen H, Hagendorff A, Lancellotti P, Popescu BA, Sicari R, Stefanidis A. Focus cardiac ultrasound: the European Association of Cardiovascular Imaging viewpoint. Eur Heart J Cardiovasc Imaging 2014; 15:956-60. [PMID: 24866902 DOI: 10.1093/ehjci/jeu081] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The concept of point-of-care, problem-oriented focus cardiac ultrasound examination (FoCUS) is increasingly applied in the settings of medical emergencies, including cardiac diseases. The European Association of Cardiovascular Imaging (EACVI) recognizes that cardiologists are not the only medical professionals dealing with cardiovascular emergencies. In reality, emergency cardiac diagnostics and treatment are also carried out by a wide range of specialists. For the benefit of the patients, the EACVI encourages any medical professional, sufficiently trained to obtain valuable information from FoCUS, to use it in emergency settings. These medical professionals need to have the necessary knowledge to understand the obtained information entirely, and to use it correctly, thoughtfully and with care. In this document, the EACVI underlines major differences between echocardiography and FoCUS, and underscores the need for specific education and training in order to fully utilize advantages and minimize drawbacks of this type of cardiac ultrasound examination in the critically ill patients.
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Affiliation(s)
- Aleksandar N Neskovic
- Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Maurizio Galderisi
- Department of Translational Medical Sciences, Federico II University Hospital, Naples, Italy
| | - Madalina Garbi
- King's Health Partners, King's College Hospital NHS Foundation Trust, London, UK
| | - Giuseppe Gullace
- Cardiovascular Department of Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | - Ruxandra Jurcut
- Department of Cardiology, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute of Cardiovascular Diseases, Bucharest, Romania
| | - Havard Dalen
- MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway Department of Internal Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
| | - Andreas Hagendorff
- Department of Cardiology-Angiology, University of Leipzig, Leipzig, Germany
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium
| | | | - Bogdan A Popescu
- Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway Department of Translational Medical Sciences, Federico II University Hospital, Naples, Italy King's Health Partners, King's College Hospital NHS Foundation Trust, London, UK Cardiovascular Department of Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy Department of Cardiology, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute of Cardiovascular Diseases, Bucharest, Romania MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway Department of Internal Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway Department of Cardiology-Angiology, University of Leipzig, Leipzig, Germany Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium
| | - Rosa Sicari
- Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway Department of Translational Medical Sciences, Federico II University Hospital, Naples, Italy King's Health Partners, King's College Hospital NHS Foundation Trust, London, UK Cardiovascular Department of Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy Department of Cardiology, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute of Cardiovascular Diseases, Bucharest, Romania MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway Department of Internal Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway Department of Cardiology-Angiology, University of Leipzig, Leipzig, Germany Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium
| | - Alexander Stefanidis
- Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway Department of Translational Medical Sciences, Federico II University Hospital, Naples, Italy King's Health Partners, King's College Hospital NHS Foundation Trust, London, UK Cardiovascular Department of Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy Department of Cardiology, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute of Cardiovascular Diseases, Bucharest, Romania MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway Department of Internal Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway Department of Cardiology-Angiology, University of Leipzig, Leipzig, Germany Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium
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Martin LD, Ziegelstein RC, Howell EE, Martire C, Hellmann DB, Hirsch GA. Hospitalists' ability to use hand-carried ultrasound for central venous pressure estimation after a brief training intervention: a pilot study. J Hosp Med 2013; 8:711-4. [PMID: 24243560 DOI: 10.1002/jhm.2103] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 09/26/2013] [Accepted: 09/30/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Access to hand-carried ultrasound technology for noncardiologists has increased significantly, yet development and evaluation of training programs are limited. OBJECTIVE We studied a focused program to teach hospitalists image acquisition of inferior vena cava (IVC) diameter and IVC collapsibility index with interpretation of estimated central venous pressure (CVP). METHODS Ten hospitalists completed an online educational module prior to attending a 1-day in-person training session that included directly supervised IVC imaging on volunteer subjects. In addition to making quantitative assessments, hospitalists were also asked to visually assess whether the IVC collapsed more than 50% during rapid inspiration or a sniff maneuver. Skills in image acquisition and interpretation were assessed immediately after training on volunteer patients and prerecorded images, and again on volunteer patients at least 6 weeks later. RESULTS Eight of 10 hospitalists acquired adequate IVC images and interpreted them correctly on 5 of the 5 volunteer subjects and interpreted all 10 prerecorded images correctly at the end of the 1-day training session. At 7.4 ± 0.7 weeks (range, 6.9-8.6 weeks) follow-up, 9 of 10 hospitalists accurately acquired and interpreted all IVC images in 5 of 5 volunteers. Hospitalists were also able to accurately determine whether the IVC collapsibility index was more than 50% by visual assessment in 180 of 198 attempts (91% of the time). CONCLUSIONS After a brief training program, hospitalists acquired adequate skills to perform and interpret hand-carried ultrasound IVC images and retained these skills in the near term. Though calculation of the IVC collapsibility index is more accurate, coupling a qualitative assessment with the IVC maximum diameter measurement may be acceptable in aiding bedside estimation of CVP.
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Affiliation(s)
- L David Martin
- Division of Chemical Dependence, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused Cardiac Ultrasound: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2013; 26:567-81. [DOI: 10.1016/j.echo.2013.04.001] [Citation(s) in RCA: 415] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Sekiguchi H, Bhagra A, Gajic O, Kashani KB. A general Critical Care Ultrasonography workshop: results of a novel Web-based learning program combined with simulation-based hands-on training. J Crit Care 2013; 28:217.e7-12. [DOI: 10.1016/j.jcrc.2012.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 03/20/2012] [Accepted: 04/01/2012] [Indexed: 10/28/2022]
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Martin LD, Mathews S, Ziegelstein RC, Martire C, Howell EE, Hellmann DB, Hirsch GA. Prevalence of asymptomatic left ventricular systolic dysfunction in at-risk medical inpatients. Am J Med 2013. [PMID: 23177548 DOI: 10.1016/j.amjmed.2012.06.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asymptomatic left ventricular systolic dysfunction is an important risk factor for heart failure and death. Given the availability of patients, trained personnel, and equipment, the hospital is an ideal setting to identify and initiate treatment for left ventricular systolic dysfunction. The purpose of this study was to determine the prevalence of asymptomatic left ventricular systolic dysfunction in patients 45 years of age or older with at least one clinical heart failure risk factor admitted to a general medical service. METHODS Bedside, hand-carried echocardiography provided quantitative assessment of left ventricular systolic function in 217 medical inpatients 45 years of age or older who had at least one heart failure risk factor. Patients with known or suspected heart failure or with an assessment of left ventricular function in the past 5 years were excluded. We measured the prevalence of asymptomatic left ventricular systolic dysfunction, defined by left ventricular ejection fraction of 50% or lower, and its association with heart failure risk factors. RESULTS Of 207 patients with interpretable images, 11 (5.3%) had a left ventricular ejection fraction of 50% or lower. Patients with left ventricular systolic dysfunction had more heart failure risk factors than those without left ventricular systolic dysfunction (3.09±0.8 vs 2.5±1.0, P=.04). The total number of heart failure risk factors trended towards an association with a greater prevalence of asymptomatic left ventricular systolic dysfunction, but this did not reach significance (odds ratio 1.74; 95% confidence interval, 0.97-3.12, P=.06). CONCLUSIONS Asymptomatic left ventricular systolic dysfunction is present in about 1 of every 20 general medical inpatients with at least one risk factor for heart failure. Because treatment of asymptomatic left ventricular systolic dysfunction may reduce morbidity, further studies examining the costs and benefits of using hand-carried ultrasound to identify this important condition in general medical inpatients are warranted.
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Affiliation(s)
- L David Martin
- Division of Chemical Dependence, Department of Medicine, Johns Hopkins Bayview Medical Center, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
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Frederiksen CA, Juhl-Olsen P, Nielsen DG, Eika B, Sloth E. Limited intervention improves technical skill in focus assessed transthoracic echocardiography among novice examiners. BMC MEDICAL EDUCATION 2012; 12:65. [PMID: 22863138 PMCID: PMC3477018 DOI: 10.1186/1472-6920-12-65] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 07/30/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Previous studies addressing teaching and learning in point-of-care ultrasound have primarily focussed on image interpretation and not on the technical quality of the images. We hypothesized that a limited intervention of 10 supervised examinations would improve the technical skills in Focus Assessed Transthoracic Echocardiography (FATE) and that physicians with no experience in FATE would quickly adopt technical skills allowing for image quality suitable for interpretation. METHODS Twenty-one physicians with no previous training in FATE or echocardiography (Novices) participated in the study and a reference group of three examiners with more than 10 years of experience in echocardiography (Experts) was included. Novices received an initial theoretical and practical introduction (2 hours), after which baseline examinations were performed on two healthy volunteers. Subsequently all physicians were scheduled to a separate intervention day comprising ten supervised FATE examinations. For effect measurement a second examination (evaluation) of the same two healthy volunteers from the baseline examination was performed. RESULTS At baseline 86% of images obtained by novices were suitable for interpretation, on evaluation this was 93% (p = 0.005). 100% of images obtained by experts were suitable for interpretation. Mean global image rating on baseline examinations was 70.2 (CI 68.0-72.4) and mean global image rating after intervention was 75.0 (CI 72.9-77.0), p = 0.0002. In comparison, mean global image rating in the expert group was 89.8 (CI 88.8-90.9). CONCLUSIONS Improvement of technical skills in FATE can be achieved with a limited intervention and upon completion of intervention 93% of images achieved are suitable for clinical interpretation.
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Affiliation(s)
- Christian Alcaraz Frederiksen
- Department of Anesthesiology and Intensive care, Aarhus University Hospital, Brendstrupgaardsvej 100, 8200 Aarhus, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Peter Juhl-Olsen
- Department of Anesthesiology and Intensive care, Aarhus University Hospital, Brendstrupgaardsvej 100, 8200 Aarhus, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Dorte Guldbrand Nielsen
- Unit for Medical Education, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Berit Eika
- Unit for Medical Education, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Erik Sloth
- Department of Anesthesiology and Intensive care, Aarhus University Hospital, Brendstrupgaardsvej 100, 8200 Aarhus, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
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Ecocardiografía clínica en Medicina Interna. Med Clin (Barc) 2012; 138:567-9. [DOI: 10.1016/j.medcli.2011.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 12/15/2011] [Indexed: 02/06/2023]
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Geriatricians’ Interest to Learn Bedside Portable Ultrasound (GEBUS) for Application in the Clinical Practice and in Education. J Am Med Dir Assoc 2012; 13:308.e7-10. [DOI: 10.1016/j.jamda.2011.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 06/01/2011] [Indexed: 11/21/2022]
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37
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Ecocardiografía clínica básica en Medicina Interna. Rev Clin Esp 2012; 212:141-6. [DOI: 10.1016/j.rce.2011.09.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 09/15/2011] [Accepted: 09/18/2011] [Indexed: 11/20/2022]
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Bedside Hand-Carried Ultrasound by Internal Medicine Residents Versus Traditional Clinical Assessment for the Identification of Systolic Dysfunction in Patients Admitted with Decompensated Heart Failure. J Am Soc Echocardiogr 2011; 24:1319-24. [DOI: 10.1016/j.echo.2011.07.013] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Indexed: 11/24/2022]
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Abstract
Heart failure is a major source of cardiovascular morbidity, including acute decompensations requiring hospitalization. Because most therapeutic interventions in acute heart failure target optimization of cardiac output and volume status, accurate assessment of these parameters at the point of care is critical to guide management. However, physician bedside assessments of left ventricular (LV) function and volume status have limited accuracy. Traditional echocardiographic platforms, while useful for assessing ventricular and valvular function and volume status, have limitations for bedside use or frequent serial evaluation. Handcarried cardiac ultrasound devices, with their substantially lower costs, portability, and ease of use, circumvent many of the limitations of traditional echocardiographic platforms. The diagnostic capabilities of handcarried devices provide the opportunity for ultrasound assessment of LV function and serial bedside evaluation of volume status in patients with acutely decompensated heart failure.
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Culp BC, Mock JD, Chiles CD, Culp WC. The pocket echocardiograph: validation and feasibility. Echocardiography 2011; 27:759-64. [PMID: 20412264 DOI: 10.1111/j.1540-8175.2009.01125.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND A new, miniaturized ultrasound device, the pocket echocardiograph (PE), is highly portable and can be carried inside a lab-coat pocket. Studies of this device are limited and have not examined the use by novice echocardiographers. We hypothesize that a novice echocardiographer can use PE to produce interpretable cardiac images, and that both novice and expert echocardiographers can use PE to accurately quantify ejection fraction. METHODS Unselected subjects (n = 40) in an echocardiography laboratory underwent blinded formal transthoracic echocardiography (TTE) and PE (Acuson P10, Siemens, Mountain View, CA, USA). A cardiology fellow with 2 months of echocardiography training acquired PE images. The fellow and an experienced echocardiographer interpreted the PE studies offline in a blinded fashion. To assess adequacy, studies were graded as technically adequate, limited, or inadequate. A visual estimation of ejection fraction was made. Comparisons were made to the formal reported TTE. RESULTS Subjects were heterogeneous, 43% male; age 64 ± 17 years, and ejection fraction 52.4%± 12.3%. All PE studies were interpretable, and the vast majority of PE and TTE images were considered technically adequate (77.5% and 85% respectively; P = 0.32). Ejection fraction showed a good correlation, bias, and limits of agreement for the fellow's interpretation (r = 0.78, -5.9%, ±16.6%) with stronger association for the experienced echocardiographer (r = 0.88, -0.8%, ±11.4%). CONCLUSION Novice echocardiographers using the PE can produce adequate quality images. Both expert and novice echocardiographers can use PE to quantify ejection fraction over a broad range of patients. The device's low cost and portability may greatly expand the availability of bedside echocardiography for routine or urgent cardiovascular assessment.
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Affiliation(s)
- Benjamin C Culp
- Department of Internal Medicine, The TexasA&M University System Health Science Center College of Medicine/Scott and White Hospital, Temple, TX, USA.
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Maru DSR, Schwarz R, Jason A, Basu S, Sharma A, Moore C. Turning a blind eye: the mobilization of radiology services in resource-poor regions. Global Health 2010; 6:18. [PMID: 20946643 PMCID: PMC2964530 DOI: 10.1186/1744-8603-6-18] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2010] [Accepted: 10/14/2010] [Indexed: 11/17/2022] Open
Abstract
While primary care, obstetrical, and surgical services have started to expand in the world's poorest regions, there is only sparse literature on the essential support systems that are required to make these operations function. Diagnostic imaging is critical to effective rural healthcare delivery, yet it has been severely neglected by the academic, public, and private sectors. Currently, a large portion of the world's population lacks access to any form of diagnostic imaging. In this paper we argue that two primary imaging modalities--diagnostic ultrasound and X-Ray--are ideal for rural healthcare services and should be scaled-up in a rapid and standardized manner. Such machines, if designed for resource-poor settings, should a) be robust in harsh environmental conditions, b) function reliably in environments with unstable electricity, c) minimize radiation dangers to staff and patients, d) be operable by non-specialist providers, and e) produce high-quality images required for accurate diagnosis. Few manufacturers are producing ultrasound and X-Ray machines that meet the specifications needed for rural healthcare delivery in resource-poor regions. A coordinated effort is required to create demand sufficient for manufacturers to produce the desired machines and to ensure that the programs operating them are safe, effective, and financially feasible.
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Abstract
Caring for critically ill patients requires rapid and accurate diagnosis followed by prompt interventions. The physical examination remains an important part of the assessment of such patients, but it has been shown to have a low sensitivity and specificity in judging left ventricular function and intravascular volume. Invasive hemodynamic monitoring has similarly been shown to have significant limitations and has failed to demonstrate a mortality benefit in several recent studies. In some studies, it has been shown to be harmful. Focused transthoracic echocardiography (TTE) has emerged as a noninvasive and portable imaging technique that is capable of providing rapid and accurate information about the heart at the bedside. It can be used to complement the physical examination and result in marked improvement in diagnostic accuracy. Focused TTE can be used as a screening and monitoring tool. Studies have shown that clinicians can be trained to determine left ventricular function, detect pericardial effusions, predict intravenous fluid responsiveness, and identify important valvular defects in a relatively short period. This article describes the indications for focused TTE, provides evidence that clinicians can be rapidly taught the technique, reviews how the focused studies affect management, and discusses the advantages and limitations of this tool.
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Affiliation(s)
- Faisal A Khasawneh
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA.
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Medd D. Bedside ultrasound: part of the physical examination. Am J Med 2010; 123:e11; author reply e13. [PMID: 20399304 DOI: 10.1016/j.amjmed.2009.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 11/04/2009] [Accepted: 11/04/2009] [Indexed: 10/19/2022]
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Abstract
Hand-carried ultrasound (HCU) is a burgeoning technology at a critical point in its development as a general diagnostic technique. Despite the known safety and accuracy of ultrasound in radiology and echocardiography, the use of HCU to augment physical diagnosis by all physicians has yet unrealized potential. In order to incorporate ultrasound into a diagnostic model of routine bedside application, simple imaging and training protocols must first be derived and validated. Simplified cardiac ultrasound exams have already been validated to detect evidence-based targets such as subclinical atherosclerosis, heart failure, and elevated central venous pressures. However, for general examination of the acutely ill patient, it is the internist-hospitalist who should derive a full-body ultrasound examination, balancing training requirements with the numerous clinical applications potentially available. As the hospital's leading diagnostician with ultrasound expertise available in-house, the hospitalist could develop HCU so as to triage and refer more appropriately and limit unnecessary testing and hospital stays. Active involvement by hospitalists now in the planning of outcome, validation, and training studies, will be invaluable in the formation of an "ultrasound-assisted" physical examination in the future and will promote competent, cost-effective applications of HCU within general medical practice.
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Affiliation(s)
- Bruce J Kimura
- Departments of Cardiology, Internal Medicine, and Graduate Medical Education, Scripps Mercy Hospital, San Diego, California, USA.
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Feldman MD, Petersen AJ, Tice JA. "On the other hand ...": the evidence does not support the use of hand-carried ultrasound by hospitalists. J Hosp Med 2010; 5:168-71. [PMID: 20235286 DOI: 10.1002/jhm.604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In the right hands, ultrasound is a safe and helpful diagnostic imaging tool. However, evidence supporting the use of hand-carried ultrasound (HCU) by hospitalist physicians has not kept pace with expanding application of these devices. In spite of its strategic point-of-care benefit, use of this technology by hospitalists may not ultimately translate into improved efficiency and better clinical outcomes. Optimal levels of training in image acquisition and interpretation remain to be established. Novelty, availability, and the results of a few small studies lacking patient-centered outcomes remain insufficient grounds to justify the expanded clinical utilization of these medical imaging devices by nonspecialists.
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Affiliation(s)
- Mitchell D Feldman
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, California 94143-0320, USA.
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Lucas BP, Candotti C, Margeta B, Evans AT, Mba B, Baru J, Asbury JK, Asmar A, Kumapley R, Patel M, Borkowsky S, Fung S, Charles-Damte M. Diagnostic accuracy of hospitalist-performed hand-carried ultrasound echocardiography after a brief training program. J Hosp Med 2009; 4:340-9. [PMID: 19670355 DOI: 10.1002/jhm.438] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The duration of training needed for hospitalists to accurately perform hand-carried ultrasound echocardiography (HCUE) is uncertain. OBJECTIVE To determine the diagnostic accuracy of HCUE performed by hospitalists after a 27-hour training program. DESIGN Prospective cohort study. SETTING Large public teaching hospital. PATIENTS A total of 322 inpatients referred for standard echocardiography (SE) between March and May 2007. INTERVENTION Blinded to SE results, attending hospitalist physicians performed HCUE within hours of SE. MEASUREMENTS Diagnostic characteristics of HCUE as a test for 6 cardiac abnormalities assessed by SE: left ventricular (LV) systolic dysfunction; severe mitral regurgitation (MR); moderate or severe left atrium (LA) enlargement; moderate or severe LV hypertrophy; medium or large pericardial effusion; and dilatation of the inferior vena cava (IVC). RESULTS A total of 314 patients underwent both SE and HCUE within a median time of 2.8 hours (25th to 75th percentiles, 1.4 to 5.1 hours). Positive and negative likelihood ratios for HCUE increased and decreased, respectively, the prior odds by 5-fold or more for LV systolic dysfunction, severe MR regurgitation, and moderate or large pericardial effusion. Likelihood ratios changed the prior odds by 2-fold or more for moderate or severe LA enlargement, moderate or severe LV hypertrophy, and IVC dilatation. Indeterminate HCUE results occurred in 2% to 6% of assessments. CONCLUSIONS The diagnostic accuracy of HCUE performed by hospitalists after a brief training program was moderate to excellent for 6 important cardiac abnormalities.
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Affiliation(s)
- Brian P Lucas
- Department of Medicine, Stroger Hospital of Cook County and Rush Medical College, Chicago, Illinois, USA.
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Alpert JS, Mladenovic J, Hellmann DB. Should a hand-carried ultrasound machine become standard equipment for every internist? Am J Med 2009; 122:1-3. [PMID: 19114160 DOI: 10.1016/j.amjmed.2008.05.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 05/20/2008] [Indexed: 11/20/2022]
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Martin LD, Howell EE, Ziegelstein RC, Martire C, Whiting-O'Keefe QE, Shapiro EP, Hellmann DB. Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination? Am J Med 2009; 122:35-41. [PMID: 19114170 DOI: 10.1016/j.amjmed.2008.07.022] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2008] [Revised: 06/05/2008] [Accepted: 07/09/2008] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The traditional physical examination of the heart is relatively inaccurate. There is little information regarding whether cardiac hand-carried ultrasound performed by noncardiologists adds to the accuracy of physical examinations. The purpose of this study was to determine whether hand-carried ultrasound can add to the accuracy of hospitalists' cardiac physical examinations. METHODS During a focused training program in hand-carried echocardiography, 10 hospitalists performed cardiac examinations of 354 general medical inpatients first by physical examination and then by hand-carried ultrasound. Eligible inpatients included those for whom a conventional hospital echocardiogram was ordered. We measured how frequently the hospitalists' cardiac examination with or without hand-carried ultrasound matched or came within 1 scale level of an expert cardiologist's interpretation of the hospital echocardiogram. RESULTS Adding hand-carried ultrasound to the physical examination improved hospitalists' assessment of left ventricular function, cardiomegaly, and pericardial effusion. For left ventricular function, using hand-carried ultrasound increased the percentage of exact matches with the expert cardiologist's assessment from 46% to 59% (P=.005) and improved the percentage of within 1-level matches from 67% to 88% (P=.0001). The addition of hand-carried ultrasound failed to improve the assessments of aortic stenosis, aortic regurgitation, and mitral regurgitation. CONCLUSION Adding hand-carried ultrasound to physical examination increases the accuracy of hospitalists' assessment of left ventricular dysfunction, cardiomegaly, and pericardial effusion, and fails to improve assessment of valvular heart disease. The clinical benefit achieved by improved immediacy of this information has not been determined. An important limitation is that the study assessed only 1 level of training in hand-carried ultrasound.
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Affiliation(s)
- L David Martin
- Department of Medicine, the Johns Hopkins University, School of Medicine and the Johns Hopkins Bayview Medical Center, Baltimore, Md, USA
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