Point-of-care ultrasound is an accurate, time-saving, and cost-effective modality for post-operative imaging after pyeloplasty

Current Utilization and Perceptions of Formal Education of Point-of-care Ultrasound in Urology

OBJECTIVE

To assess the extent of formal point-of-care ultrasound (POCUS) training, current utilization of POCUS, and contemporary perceptions of POCUS amongst urologists.

METHODS

A survey including questions regarding demographics, prior ultrasound education, current ultrasound utilization in practice/training, perceived optimal POCUS utilization, and the perception of formal ultrasound training was developed. The survey was disseminated to residency program directors (PDs) via the SAU and members of AUA subsection organizations. Data were collected via Redcap.

RESULTS

A total of 40 PDs and 159 other respondents completed the survey with approximately half (51%) in an academic practice and two-thirds (68%) with more than 10years in practice. PD response rate was 28%, and general response rate was 2%. Among all respondents, 95% (186/196) and 82% (160/194) agreed/strongly agreed formal POCUS training would be worthwhile during and after residency. Among urology residency PDs, 93% (37/40) agreed/strongly agreed that formal POCUS training is worthwhile in residency. The majority of respondents used some form of ultrasound in practice (77%, 154/199). However, only 37% (72/199) of all respondents had prior formal POCUS training, and 19% (5/26) of PDs reported formal training in their programs. Of respondents without formal training, 63% (80/127) reported interest in pursuing formal training.

CONCLUSION

POCUS is widely utilized in many practices. Yet, most urologists have not participated in formal POCUS training and most programs do not have curricula. Urologists have favorable opinions of the utility, safety, and efficacy of POCUS and desire training.

Ultrasonographic stabilization of hydronephrosis after pyeloplasty: Key determinant of postoperative follow-up?

INTRODUCTION

Although more than 1500 pediatric pyeloplasties are performed in the United States per year, there is a lack of consensus on the adequate imaging modality and timing of follow-up after surgery.

OBJECTIVE

The aim of this study is to evaluate if ultrasonographic stabilization in the grade of hydronephrosis after pyeloplasty is an adequate parameter to define the optimal length of follow-up after surgery and to detect failed procedures. Secondarily, we want to analyze clinical variables that could impact ultrasonographic stabilization.

STUDY DESIGN

This is a retrospective chart review of patients who underwent pyeloplasty between 2012 and 2020. Patients were included if they were ≤21 years-old at the time of surgery, had pre and postoperative renal-ultrasounds, had ≥3 months of postoperative follow-up, and had met the criteria for ultrasonographic stabilization after surgery. Ultrasonographic stabilization was defined as 2 consecutive ultrasounds after pyeloplasty, a minimum of 1-month apart, with the same degree of hydronephrosis according to the Society for Fetal Urology (SFU) grading system. Data concerning clinical, surgical, and postoperative variables were collected.

RESULTS

A total of 143 pyeloplasties met the inclusion criteria. Median age at surgery was 10.5 months with a median post-operative follow-up time of 29 months. Ultrasonographic stabilization was achieved in a mean time of 14.5 months post-operatively. Compared to the preoperative US SFU grade, at ultrasonographic stabilization 127 (88.9%) patients had an improvement of ≥1 grades of hydronephrosis. There were 9 pyeloplasty failures that were diagnosed and surgically corrected in a median of 7.5 months after the initial surgery. No clinical or surgical variables were associated with time to achieve ultrasonographic stabilization.

DISCUSSION

There is great variability in the length of follow-up after pyeloplasty, ranging from 3-months to 7-years. In our cohort, the bast majority of patients had achieved ultrasonographic stabilization and displayed improvement in their initial grade of hydronephrosis by 14.5 months after surgery. Timeframe in which surgical failures were diagnosed and corrected. There were not clinical or surgical variables associated to time to achieve stabilization. Similar results have been reported in the literature; however, most of them have evaluated as their main outcome resolution and not stabilization of hydronephrosis.

CONCLUSION

Ultrasonographic stabilization is a suitable and non-invasive parameter for determining the length of follow-up after unilateral pyeloplasty, as it is an adequate timeframe for identifying failed pyeloplasties, observing improvement or stabilization of hydronephrosis, and performing any additional procedure required after the primary repair.

Handheld Point-of-Care Ultrasound: Safety Considerations for Creating Guidelines

BACKGROUND

Compared to traditional ultrasound machines, emerging handheld point-of-care-ultrasound (HPOCUS) systems exhibit superior portability and affordability. Thus, they have been increasingly embraced in the intensive care setting. However, there is scarce data on patient safety and current regulatory body guidelines are lacking. Here, we critically appraise the literature with a focus on the merits, concerns, and framework of existing POCUS guidelines. Subsequently, we provide recommendations for future regulatory guidelines.

METHODS

A comprehensive literature review was conducted using the PubMed database employing the key words "point-of-care/handheld/portable ultrasound" and "guidelines" alone, in combination, and using thesaurus terms. Eligible articles were scrutinized for description of potential benefits and concerns of HPOCUS, especially from a patient safety perspective, as well as currently existing POCUS practice guidelines. Data was extracted, reported thematically using a narrative synthesis approach, then subsequently used to guide our proposed guidelines.

RESULTS

The most widely reported benefits of HPOCUS include superior portability, affordability, imaging, facilitation of expedited diagnosis and management, and integration with medical workplace flow. However, major barriers to adoption include device security/patient confidentiality and patient safety. Furthermore, except for a policy published by the American College of Emergency Physicians (ACEP) in 2018, there are few other national regulatory guidelines pertaining to handheld POCUS. In light of this, we propose a framework for HPOCUS guideline development to address these and other concerns. Such guidelines include training and credentialing, bioengineering approval, and strategic integration with electronic medical record systems.

CONCLUSION

HPOCUS can be a powerful tool for expedited diagnosis and management guidance. However, there is limited data regarding patient safety and current regulatory body guidelines are lacking. Our assessment illuminates that there remain many unsolved problems about HPOCUS, and in turn, we propose guidelines to address safe regulation and implementation.

Point-of-Care Ultrasound Reduces Visit Time and Cost of Care for Infants with Developmental Dysplasia of the Hip

BACKGROUND

Healthcare institutions and policymakers are searching for system-wide approaches to reduce costs while maintaining quality and improving patient outcomes. In most healthcare systems infants referred for the detecting or treating developmental dysplasia of the hip (DDH) are sent to a radiology department for sonographic evaluation. The total duration of visit and cost of visit are essential variables in any healthcare setting and affect both efficiency and "the bottom line". By having the treating clinician perform point-of-care ultrasound (POCUS) for the detection and follow-up of patients with DDH, we hypothesize that there would be a significant reduction in the time spent on the visit and the cost incurred without compromising quality or patient satisfaction. To our knowledge, no prior study has examined the effect of incorporating POCUS on the duration and cost of the visit in patients with DDH.

PURPOSE

To determine if there was a difference in the duration of the visit for patients with DDH when POCUS was performed compared to when traditional "formal" sonography was performed. To determine if there was a difference in the cost of the visit for patients with DDH when POCUS was performed compared to when traditional "formal" sonography was performed.

METHODS

Data for visits to a specialized outpatient office were collected over two years at a single-specialty orthopedic hospital, comparing the duration and cost of the visit between patient encounters for infants who had "formal" sonograms performed in the radiology suite to infants who underwent POCUS of the hip. In all, we included 532 patient encounters, 326 patients had POCUS performed, and 206 had a "formal" ultrasonographic evaluation performed. Of these, 140 were new evaluations and 392 were follow-up evaluations for treatment. Of the 140 new patients, 80 were in the POCUS group, and 60 were in the "formal" US group. Of the 392 follow-ups, 246 were in the POCUS group, and 146 were in the "formal" US group.

RESULTS

The mean duration of the encounter for the POCUS group was 42 min (range 16-75 min), and for the "formal" US group, it was 92 min (range 36-163 min). This difference was statistically significant (p = 0.002). The mean cost of the encounter for the POCUS group was $121.13, and for the "formal" US group, it was $339.38. This difference was statistically significant (p = 0.002).

CONCLUSION

Ultimately, our study demonstrated a statistically significant reduction in the duration and cost of a patient encounter for infants with DDH when they undergo POCUS rather than "formal" sonographic evaluation.