1
|
Kumar A, Weng I, Graglia S, Lew T, Gandhi K, Lalani F, Chia D, Duanmu Y, Jensen T, Lobo V, Nahn J, Iverson N, Rosenthal M, Gordon AJ, Kugler J. Point-of-Care Ultrasound Predicts Clinical Outcomes in Patients With COVID-19. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1367-1375. [PMID: 34468039 PMCID: PMC8661628 DOI: 10.1002/jum.15818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/04/2021] [Accepted: 08/16/2021] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Point-of-care ultrasound (POCUS) detects the pulmonary manifestations of COVID-19 and may predict patient outcomes. METHODS We conducted a prospective cohort study at four hospitals from March 2020 to January 2021 to evaluate lung POCUS and clinical outcomes of COVID-19. Inclusion criteria included adult patients hospitalized for COVID-19 who received lung POCUS with a 12-zone protocol. Each image was interpreted by two reviewers blinded to clinical outcomes. Our primary outcome was the need for intensive care unit (ICU) admission versus no ICU admission. Secondary outcomes included intubation and supplemental oxygen usage. RESULTS N = 160 patients were included. Among critically ill patients, B-lines (94 vs 76%; P < .01) and consolidations (70 vs 46%; P < .01) were more common. For scans collected within 24 hours of admission (N = 101 patients), early B-lines (odds ratio [OR] 4.41 [95% confidence interval, CI: 1.71-14.30]; P < .01) or consolidations (OR 2.49 [95% CI: 1.35-4.86]; P < .01) were predictive of ICU admission. Early consolidations were associated with oxygen usage after discharge (OR 2.16 [95% CI: 1.01-4.70]; P = .047). Patients with a normal scan within 24 hours of admission were less likely to require ICU admission (OR 0.28 [95% CI: 0.09-0.75]; P < .01) or supplemental oxygen (OR 0.26 [95% CI: 0.11-0.61]; P < .01). Ultrasound findings did not dynamically change over a 28-day scanning window after symptom onset. CONCLUSIONS Lung POCUS findings detected within 24 hours of admission may provide expedient risk stratification for important COVID-19 clinical outcomes, including future ICU admission or need for supplemental oxygen. Conversely, a normal scan within 24 hours of admission appears protective. POCUS findings appeared stable over a 28-day scanning window, suggesting that these findings, regardless of their timing, may have clinical implications.
Collapse
Affiliation(s)
- Andre Kumar
- Department of MedicineStanford University School of MedicineStanfordCAUSA
| | - Isabel Weng
- Quantitative Sciences UnitStanford UniversityStanfordCAUSA
| | - Sally Graglia
- Department of Emergency MedicineUniversity of California San Francisco and Zuckerberg San Francisco General HospitalSan FranciscoCAUSA
| | - Thomas Lew
- Department of MedicineStanford University School of MedicineStanfordCAUSA
| | - Kavita Gandhi
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Farhan Lalani
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - David Chia
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Youyou Duanmu
- Department of Emergency MedicineStanford University School of MedicineStanfordCAUSA
| | - Trevor Jensen
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Viveta Lobo
- Department of Emergency MedicineStanford University School of MedicineStanfordCAUSA
| | - Jeffrey Nahn
- Department of Emergency MedicineUniversity of California San Francisco and Zuckerberg San Francisco General HospitalSan FranciscoCAUSA
| | - Nicholas Iverson
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Molly Rosenthal
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | | | - John Kugler
- Department of MedicineStanford University School of MedicineStanfordCAUSA
| |
Collapse
|
2
|
Kumar A, Weng Y, Duanmu Y, Graglia S, Lalani F, Gandhi K, Lobo V, Jensen T, Chung S, Nahn J, Kugler J. Lung Ultrasound Findings in Patients Hospitalized With COVID-19. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:89-96. [PMID: 33665872 PMCID: PMC8014702 DOI: 10.1002/jum.15683] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/01/2021] [Accepted: 02/16/2021] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Lung ultrasound (LUS) can accurately diagnose several pulmonary diseases, including pneumothorax, effusion, and pneumonia. LUS may be useful in the diagnosis and management of COVID-19. METHODS This study was conducted at two United States hospitals from 3/21/2020 to 6/01/2020. Our inclusion criteria included hospitalized adults with COVID-19 (based on symptomatology and a confirmatory RT-PCR for SARS-CoV-2) who received a LUS. Providers used a 12-zone LUS scanning protocol. The images were interpreted by the researchers based on a pre-developed consensus document. Patients were stratified by clinical deterioration (defined as either ICU admission, invasive mechanical ventilation, or death within 28 days from the initial symptom onset) and time from symptom onset to their scan. RESULTS N = 22 patients (N = 36 scans) were included. Eleven (50%) patients experienced clinical deterioration. Among N = 36 scans, only 3 (8%) were classified as normal. The remaining scans demonstrated B-lines (89%), consolidations (56%), pleural thickening (47%), and pleural effusion (11%). Scans from patients with clinical deterioration demonstrated higher percentages of bilateral consolidations (50 versus 15%; P = .033), anterior consolidations (47 versus 11%; P = .047), lateral consolidations (71 versus 29%; P = .030), pleural thickening (69 versus 30%; P = .045), but not B-lines (100 versus 80%; P = .11). Abnormal findings had similar prevalences between scans collected 0-6 days and 14-28 days from symptom onset. DISCUSSION Certain LUS findings may be common in hospitalized COVID-19 patients, especially for those that experience clinical deterioration. These findings may occur anytime throughout the first 28 days of illness. Future efforts should investigate the predictive utility of these findings on clinical outcomes.
Collapse
Affiliation(s)
- Andre Kumar
- Department of MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Yingjie Weng
- Quantitative Sciences UnitStanford UniversityStanfordCaliforniaUSA
| | - Youyou Duanmu
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Sally Graglia
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Farhan Lalani
- Department of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Kavita Gandhi
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Viveta Lobo
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Trevor Jensen
- Department of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Sukyung Chung
- Quantitative Sciences UnitStanford UniversityStanfordCaliforniaUSA
| | - Jeffrey Nahn
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - John Kugler
- Department of MedicineStanford University School of MedicineStanfordCaliforniaUSA
| |
Collapse
|
3
|
Kumar A, Weng Y, Graglia S, Chung S, Duanmu Y, Lalani F, Gandhi K, Lobo V, Jensen T, Nahn J, Kugler J. Interobserver Agreement of Lung Ultrasound Findings of COVID-19. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2369-2376. [PMID: 33426734 PMCID: PMC8013417 DOI: 10.1002/jum.15620] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/24/2020] [Accepted: 12/21/2020] [Indexed: 05/10/2023]
Abstract
BACKGROUND Lung ultrasound (LUS) has received considerable interest in the clinical evaluation of patients with COVID-19. Previously described LUS manifestations for COVID-19 include B-lines, consolidations, and pleural thickening. The interrater reliability (IRR) of these findings for COVID-19 is unknown. METHODS This study was conducted between March and June 2020. Nine physicians (hospitalists: n = 4; emergency medicine: n = 5) from 3 medical centers independently evaluated n = 20 LUS scans (n = 180 independent observations) collected from patients with COVID-19, diagnosed via RT-PCR. These studies were randomly selected from an image database consisting of COVID-19 patients evaluated in the emergency department with portable ultrasound devices. Physicians were blinded to any patient information or previous LUS interpretation. Kappa values (κ) were used to calculate IRR. RESULTS There was substantial IRR on the following items: normal LUS scan (κ = 0.79 [95% CI: 0.72-0.87]), presence of B-lines (κ = 0.79 [95% CI: 0.72-0.87]), ≥3 B-lines observed (κ = 0.72 [95% CI: 0.64-0.79]). Moderate IRR was observed for the presence of any consolidation (κ = 0.57 [95% CI: 0.50-0.64]), subpleural consolidation (κ = 0.49 [95% CI: 0.42-0.56]), and presence of effusion (κ = 0.49 [95% CI: 0.41-0.56]). Fair IRR was observed for pleural thickening (κ = 0.23 [95% CI: 0.15-0.30]). DISCUSSION Many LUS manifestations for COVID-19 appear to have moderate to substantial IRR across providers from multiple specialties utilizing differing portable devices. The most reliable LUS findings with COVID-19 may include the presence/count of B-lines or determining if a scan is normal. Clinical protocols for LUS with COVID-19 may require additional observers for the confirmation of less reliable findings such as consolidations.
Collapse
Affiliation(s)
- Andre Kumar
- Department of MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Yingjie Weng
- Quantitative Sciences UnitStanford UniversityStanfordCaliforniaUSA
| | - Sally Graglia
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Sukyung Chung
- Quantitative Sciences UnitStanford UniversityStanfordCaliforniaUSA
| | - Youyou Duanmu
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Farhan Lalani
- Department of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Kavita Gandhi
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Viveta Lobo
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Trevor Jensen
- Department of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Jeffrey Nahn
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - John Kugler
- Department of MedicineStanford University School of MedicineStanfordCaliforniaUSA
| |
Collapse
|
4
|
Garibaldi BT, Russell SW. Strategies to Improve Bedside Clinical Skills Teaching. Chest 2021; 160:2187-2195. [PMID: 34242633 DOI: 10.1016/j.chest.2021.06.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 11/18/2022] Open
Abstract
The bedside encounter between a patient and physician remains the cornerstone of the practice of medicine. However, physicians and trainees spend less time in direct contact with patients and families in the modern healthcare system. The current pandemic has further threatened time spent with patients. This lack of time has led to a decline in clinical skills, and a decrease in the number of faculty who are confident in teaching at the bedside. In this review we offer several strategies to get physicians and trainees back to the bedside to engage in clinical skills teaching and assessment. We recommend that providers pause before bedside encounters to be present with patients and learners and develop clear goals for a bedside teaching session. We suggest that clinical teachers practice an evidence-based approach, including a hypothesis-driven physical examination. We encourage the use of point-of-care technology to assist in diagnosis and allow learners to calibrate traditional physical exam skills with real-time visualization of pathology. Tools like point-of-care ultrasound can be powerful levers to get learners excited about bedside teaching, and to engage patients in their clinical care. We value telemedicine visits as unique opportunities to engage with patients in their home environment and to participate in patient-directed physical exam maneuvers. Finally, we recommend that educators provide feedback to learners on specific clinical exam skills, whether in the clinic, the wards, or during dedicated clinical skills assessments.
Collapse
Affiliation(s)
- Brian T Garibaldi
- Department of Medicine, Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Stephen W Russell
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
| |
Collapse
|
5
|
Jacobsen AP, Khiew YC, Murphy SP, Lane CM, Garibaldi BT. The Modern Physical Exam - A Transatlantic Perspective from the Resident Level. TEACHING AND LEARNING IN MEDICINE 2020; 32:442-448. [PMID: 32090631 DOI: 10.1080/10401334.2020.1724792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Issue: The physical examination has been in decline for many years and poorer skills contribute to medical errors and adverse events. Diagnostic error is also increasing with the complexity of medicine. Comparing the physical examination in Ireland and the United States with a focus on education, assessment, culture, and health systems may provide insight into the decline of the physical exam in the United States, uncover possible strategies to improve clinical skills, and limit diagnostic error. Evidence: The physical exam is a core component of both undergraduate and postgraduate medical education in Ireland. This is reflected by the time and effort invested by medical schools and medical societies in Ireland in teaching and assessing skills. This high standard of skills results in the physical exam being a key component of the diagnostic process and a gatekeeper to expensive investigations essential in a resource-limited health system such as Ireland. Use of the physical exam in the United States is hindered by the high-tech transformation of healthcare and a more litigious society. Known strategies to highlight the role of the physical exam in clinical practice include creating an evidence base to show that better physical exam skills improve outcomes, identifying accurate physical exam maneuvers, stressing the therapeutic alliance the physical exam brings to the patient encounter, and the incorporation of technology into the bedside exam. Implications: Contrasting the education and clinical use of the physical examination in the United States with Ireland allowed us to identify a number of strategies which could be used to promote the physical exam among learners in both countries. Highlighting simple and pragmatic physical exam maneuvers combined with evidence-based physical exam diagnostic data may renew confidence in the physical exam as a core diagnostic tool. Use of the hypothesis-driven approach may streamline a clinician's physical exam during a patient encounter, focusing on the key examination components and avoiding unnecessary and low yield maneuvers. The absence of assessment of physical exam skills using real patients in United States licensing exams communicates to learners that these skills are not important. However, steps to introduce a culture of assessment to drive learning are being introduced. One area Ireland could learn from the United States is incorporating more technology into the bedside exam. Enhanced physical examination skills in both countries could reduce reliance on expensive investigations and improve diagnostic accuracy.
Collapse
Affiliation(s)
- Alan P Jacobsen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yii Chun Khiew
- Department of Medicine, Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - Sean P Murphy
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Conor M Lane
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian T Garibaldi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
6
|
Kumar A, Weng Y, Wang L, Bentley J, Almli M, Hom J, Witteles R, Ahuja N, Kugler J. Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial. J Hosp Med 2020; 15:e1-e6. [PMID: 32118565 DOI: 10.12788/jhm.3351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 11/03/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage. OBJECTIVE This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS. METHODS Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures. RESULTS Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores. CONCLUSIONS Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.
Collapse
Affiliation(s)
- Andre Kumar
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Yingjie Weng
- Quantitative Science Unit, Stanford University School of Medicine, Stanford, California
| | - Libo Wang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jason Bentley
- Quantitative Science Unit, Stanford University School of Medicine, Stanford, California
| | - Marta Almli
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jason Hom
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ronald Witteles
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Neera Ahuja
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - John Kugler
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
7
|
Goyal A, Garibaldi B, Liu G, Desai S, Manesh R. Morning report innovation: Case Oriented Report and Exam Skills. ACTA ACUST UNITED AC 2019; 6:79-83. [PMID: 30901311 DOI: 10.1515/dx-2018-0086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 02/18/2019] [Indexed: 11/15/2022]
Abstract
Morning report is a valuable educational conference but is often a stand-alone classroom-based discussion which misses the opportunity for bedside education. In this report, we describe an innovative morning report structure - the Case Oriented Report and Exam Skills (CORES) - that addresses this pitfall of the traditional case conference format and brings learners to the bedside. The key components of CORES include highlighting concepts of clinical reasoning, emphasizing evidence-based and hypothesis-driven physical exam (HDPE), and integrating emerging bedside technologies such as point-of-care ultrasound (POCUS).
Collapse
Affiliation(s)
- Amit Goyal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian Garibaldi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gigi Liu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sanjay Desai
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Reza Manesh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
8
|
Kumar A, Kugler J, Jensen T. Evaluation of Trainee Competency with Point-of-Care Ultrasonography (POCUS): a Conceptual Framework and Review of Existing Assessments. J Gen Intern Med 2019; 34:1025-1031. [PMID: 30924088 PMCID: PMC6544692 DOI: 10.1007/s11606-019-04945-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Point-of-care ultrasonography (POCUS) has the potential to transform healthcare delivery through its diagnostic expediency. Trainee competency with POCUS is now mandated for emergency medicine through the Accreditation Council for Graduate Medical Education (ACGME), and its use is expanding into other medical specialties, including internal medicine. However, a key question remains: how does one define "competency" with this emerging technology? As our trainees become more acquainted with POCUS, it is vital to develop validated methodology for defining and measuring competency amongst inexperienced users. As a framework, the assessment of competency should include evaluations that assess the acquisition and application of POCUS-related knowledge, demonstration of technical skill (e.g., proper probe selection, positioning, and image optimization), and effective integration into routine clinical practice. These assessments can be performed across a variety of settings, including web-based applications, simulators, standardized patients, and real clinical encounters. Several validated assessments regarding POCUS competency have recently been developed, including the Rapid Assessment of Competency in Echocardiography (RACE) or the Assessment of Competency in Thoracic Sonography (ACTS). However, these assessments focus mainly on technical skill and do not expand upon other areas of this framework, which represents a growing need. In this review, we explore the different methodologies for evaluating competency with POCUS as well as discuss current progress in the field of measuring trainee knowledge and technical skill.
Collapse
Affiliation(s)
- Andre Kumar
- Department of Medicine, Stanford University School of Medicine, Pasteur Drive, Stanford, CA, USA.
| | - John Kugler
- Department of Medicine, Stanford University School of Medicine, Pasteur Drive, Stanford, CA, USA
| | - Trevor Jensen
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|