COUNTERPOINT: Should the Use of Diagnostic Point-of-Care Ultrasound in Patient Care Require Hospital Privileging/Credentialing? No

Point-of-Care Ultrasound in Post-acute and Long-Term Care: A Scoping Review

OBJECTIVES

Point-of-care ultrasound (POCUS) is an emerging application of ultrasonography that is being integrated into patient care in many medical specialties. The post-acute and long-term care (PALTC) setting has opportunities to adopt POCUS as a diagnostic aid to improve patient outcomes. We aim (1) to describe the current use of POCUS in PALTC and (2) to examine how the use of POCUS can advance in PALTC settings.

DESIGN

Scoping review.

SETTING AND PARTICIPANTS

PALTC facilities and residents.

METHODS

The MEDLINE, Embase, CINAHL Complete, and Web of Science databases were searched by a medical librarian for studies on the use of POCUS in PALTC. All studies underwent dual, independent review during 2 phases of screening. We included all study designs where POCUS was obtained and interpreted by a provider at the bedside.

RESULTS

Six studies met inclusion criteria. Most studies were conducted in the setting of COVID19 outbreaks in nursing homes and communities. The organ systems examined using POCUS were lung and vasculature. Lung ultrasound was shown to have variable diagnostic and prognostic utility in assessing lung injury secondary to COVID19. Ultrasound measurements of the vasculature were not useful for predicting hydration status.

CONCLUSION AND IMPLICATIONS

Implementation of POCUS in PALTC is feasible, but current literature is limited to use in only 2 organ systems. These results suggest potential for expanding POCUS in PALTC. Further work is required to ascertain if POCUS use can improve patient outcomes in this health care setting.

Characterizing Point-of-Care Ultrasound Credentialing in Pediatric Emergency Departments

OBJECTIVE

It is unclear which pediatric emergency departments (PEDs) have a point-of-care ultrasound (POCUS) credentialing process or if this process is consistent per expert guidelines. Our objective was to describe formalized POCUS credentialing processes across PEDs that are active in the pediatric emergency medicine POCUS (P2) Network.

METHODS

A survey was developed from nationally recommended credentialing guidelines. This anonymous survey was sent out to the P2 Network comprising more than 230 members involved in pediatric POCUS. The survey was analyzed using descriptive analysis with counts and percentages.

RESULTS

A total of 36 PEDs responded to the survey. All departments had a faculty member in charge of maintaining the credentialing process, and all faculty members had POCUS education available; 88.6% of education was scheduled didactics or bedside teaching. There were 80.6% of PEDs that had a process for internally credentialing faculty. Some PEDs offered protected education for POCUS, however, 44.8% had <50% of their faculty credentialed. There were 4 PEDs that offered incentives for completion of POCUS credentialing including salary bonuses; only 1 offered shift buy down as incentive. That PED had 100% of its faculty credentialed. All PEDs performed quality assurance on POCUS scans done in the ED, most done weekly. Billing for scans occurred in 26 PEDs. Skin/soft tissue and focused assessment with sonography for trauma were the 2 most common applications credentialed.

CONCLUSIONS

Among PEDs surveyed, there was a lack of standardization of POCUS resources and components of credentialing. Incentives may be beneficial in improving credentialing faculty and standardizing the credentialing process.

Egyptian Consensus on the Role of Lung Ultrasonography During the Coronavirus Disease 2019 Pandemic

Background & Aims

Coronavirus disease 2019 (COVID-19) is a global health problem, presenting with symptoms ranging from mild nonspecific symptoms to serious pneumonia. Early screening techniques are essential in the diagnosis and assessment of disease progression. This consensus was designed to clarify the role of lung ultrasonography versus other imaging modalities in the COVID-19 pandemic.

Methods

A multidisciplinary team consisting of experts from different specialties (ie, pulmonary diseases, infectious diseases, intensive care unit and emergency medicine, radiology, and public health) who deal with patients with COVID-19 from different geographical areas was classified into task groups to review the literatures from different databases and generate 10 statements. The final consensus statements were based on expert physically panelists’ discussion held in Cairo July 2021 followed by electric voting for each statement.

Results

The statements were electronically voted to be either “agree,” “not agree,” or “neutral.” For a statement to be accepted to the consensus, it should have 80% agreement.

Conclusion

Lung ultrasonography is a rapid and useful tool, which can be performed at bedside and overcomes computed tomography limitations, for screening and monitoring patients with COVID-19 with an accepted accuracy rate.

A Call to Action for the Pediatric Critical Care Community

Healthcare regulatory bodies have escalated concerns regarding the use of point-of-care ultrasound by nonradiology and noncardiology physicians. A recently published PCCMPerspective identified that data do not support many of these concerns and addressed common misconceptions associated with point-of-care ultrasound use in the critical care setting. Indeed, the global point-of-care ultrasound community and specifically the pediatric critical care community have the opportunity to be leaders in demonstrating how to translate new skills and technologies to the bedside in a safe and effective manner. We seek to extend the conversation and propose next steps in supporting integration of point-of-care ultrasound in pediatric critical care practice.

Multi-Level Stakeholder Perspectives on Determinants of Point of Care Ultrasound Implementation in a US Academic Medical Center

There is growing interest from multiple specialties, including internal medicine, to incorporate diagnostic point of care ultrasound (POCUS) into standard clinical care. However, few internists currently use POCUS. The objective of this study was to understand the current determinants of POCUS adoption at both the health system and clinician level at a U.S. academic medical center from the perspective of multi-level stakeholders. We performed semi-structured interviews of multi-level stakeholders including hospitalists, subspecialists, and hospital leaders at an academic medical center in the U.S. Questions regarding the determinants of POCUS adoption were asked of study participants. Using the framework method, team-based analysis of interview transcripts were guided by the contextual domains of the Practical Robust Implementation and Sustainability Model (PRISM). Thirty-one stakeholders with diverse roles in POCUS adoption were interviewed. Analysis of interviews revealed three overarching themes that stakeholders considered important to adoption by clinicians and health systems: clinical impact, efficiency and cost. Subthemes included two that were deemed essential to high-fidelity implementation: the development of credentialing policies and robust quality assurance processes. These findings identify potential determinants of system and clinician level adoption that may be leveraged to achieve high-fidelity implementation of POCUS applications that result in improved patient outcomes.

Utility of Lung Ultrasound in Decision making to prioritize hospital admission for COVID-19 patients: A Developing Country Perspective

BACKGROUND & AIMS

In healthcare settings with limited resources, it is crucial to make a plan to prioritize hospital admission for patients affected by COVID-19. So, we tried to develop a novel approach for triaging COVID-19 patients and deciding the priority for hospital admission using Lung Ultrasound. In this study, we aimed to evaluate the efficacy of lung ultrasound in triaging suspected COVID-19 patients and assessment of the severity of COVID-19 pneumonia and its comparison with CT chest as the gold standard.

METHOD

This was a multicenter cross-sectional study enrolled on 243 COVID-19 confirmed patients presented to the emergency department in three major University hospitals in Egypt. Lung ultrasound was done by an experienced emergency physician or chest physician according to the local protocol of each hospital. Demographic, clinical, and laboratory data were collected from each patient. Each patient was subjected to CT chest and lung ultrasound.

RESULTS

A total of 243 confirmed COVID-19 patients were enrolled in this study, with a mean age of 46.7+10.4 years. Ground glass opacity (GGO), subpleural consolidation, trans-lobar consolidation, and crazy paving were reported in chest CT scans of 54.3%, 15.2%, 11.1%, and 8.6% of patients, respectively. B-line artifacts were found in 81.1% of COVID-19 patients, which was of confluent pattern in 18.9% of patients. The lung ultrasound findings of 197 patients (81.1%) were completely coincident with those of CT with a Kappa agreement value of 0.77, and this offered a diagnostic sensitivity of 74 %, a diagnostic specificity of 97.9 %, positive predictive value (PPV) of 90.2% and negative predictive value (NPV) of 93.6 % for lung ultrasound in triaging COVID-19 patients. Adding O2 saturation to the findings of lung imaging, the accuracy of evaluation of lung ultrasound to differentiate between severe and non-severe lung diseases showed that ultrasound had 100% sensitivity and specificity.

CONCLUSION

Lung Ultrasound with Oxygen saturation is a very efficient tool for decision-making to prioritize hospital admission for patients affected by COVID-19 in healthcare settings with limited resources.

Correlation between Chest Computed Tomography and Lung Ultrasonography in Patients with Coronavirus Disease 2019 (COVID-19)

There is growing evidence regarding chest X-ray and computed tomography (CT) findings for coronavirus disease 2019 (COVID-19). At present, the role of lung ultrasonography (LUS) has yet to be explored. The main purpose of this study was to evaluate the correlation between LUS findings and chest CT in patients confirmed to have (positive reverse transcription polymerase chain reaction [RT-PCR]) or clinically highly suspected of having (dyspnea, fever, myasthenia, gastrointestinal symptoms, dry cough, ageusia or anosmia) COVID-19. This prospective study was carried out in the emergency department, where patients confirmed of having or clinically highly suspected of having COVID-19 were recruited and underwent chest CT and concurrent LUS exam. An experienced emergency department physician performed the LUS exam blind to the clinical history and results of the CT scan, which were reviewed by two radiologists in consensus for signs compatible with COVID-19 (bilateral ground-glass opacities in peripheral distribution). A compatible LUS exam was considered a bilateral pattern of B-lines, irregular pleural line and subpleural consolidations. Between March and April 2020, 51 patients were consecutively enrolled. The indication for CT was a negative or indeterminate RT-PCR test (49.0%) followed by suspicion of pulmonary embolism (41.2%). Radiologic signs compatible with COVID-19 were present in 37 patients (72.5%) on CT scan and 40 patients (78.4%) on LUS exam. The presence of LUS findings was correlated with a positive CT scan suggestive of COVID-19 (odds ratio: 13.3, 95% confidence interval: 4.5-39.6, p < 0.001) with a sensitivity of 100.0%, specificity of 78.6%, positive predictive value of 92.5% and negative predictive value of 100.0%. There was no missed diagnosis of COVID-19 with LUS compared with CT in our cohort. The correlation between LUS score and CT total severity score was good (intraclass correlation coefficient: 0.803, 95% confidence interval: 0.60-0.90, p < 0.001). LUS exhibited similar accuracy compared with chest CT in the detection of lung abnormalities in COVID-19 patients.

Lung ultrasound in the monitoring of COVID-19 infection

INTRODUCTION

Coronavirus disease 2019 (COVID-19) is a highly contagious illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Pneumonia and acute respiratory distress syndrome (ARDS) are the most common severe complications. There is growing evidence regarding the imaging findings of COVID-19 in chest X-rays and computed tomography (CT); however, their availability to clinical staff in this pandemic outbreak might be compromised. At this moment, the role of lung ultrasound (LUS) has yet to be explored. The purpose of this case report is to describe the natural course of the disease in mild infection managed at home.

CASE REPORT

We report a 35-year-old man with recently diagnosed COVID-19 infection. Clinical examination was unremarkable. The diagnosis of mild disease was made clinically which was later reaffirmed by LUS after identifying a bilateral small pleural effusion and a thickened pleural line. During follow up, subpleural consolidations appeared before symptoms slightly aggravated (cough, tiredness and fever). The patient's condition improved after adjustment of therapy at home.

CONCLUSION

LUS is an excellent tool in the characterisation of COVID-19 infection and is more available than CT or X-ray. We emphasise the utility and the opportunity that LUS presents in some clinical scenarios, like this COVID-19 pandemic, and how it may serve as a monitoring and therapy guide.