Point-of-Care Ultrasound and Modernization of the Bedside Assessment

Advancing Digital Education Technologies by Empowering Nurses With Point-of-Care Ultrasound: Protocol for a Mixed Methods Study

BACKGROUND

Bedside ultrasonography, also known as point-of-care ultrasound (PoCUS), is a promising technological tool that enhances clinical assessment, enriching diagnostic capabilities and clinical reasoning. Its use in nursing spans various patient populations and health care settings, providing nurses with a valuable health assessment tool to improve care quality and patient safety. Despite its growing integration into clinical practice, PoCUS training has mainly focused on physicians, leaving a gap for trained nurses who demonstrate similar proficiency in conducting scans and interpreting images. Previous research highlights the value of digital tools in PoCUS training, showing their role in improving professionals' and students' knowledge, image interpretation skills, and clinical acumen.

OBJECTIVE

This study aimed to (1) establish an assessment instrument gauging nurses' competency milestones in PoCUS and evaluate its content and appearance validity, (2) develop a series of 5 educational videos focused on PoCUS and assess their content and appearance validity, and (3) construct an online learning environment tailored to nurses' PoCUS training needs and evaluate its content and appearance validity.

METHODS

We will conduct a methodological study of technological production guided by Rogers' diffusion of innovations theory. Subproject 1 will design and validate a comprehensive assessment tool for evaluating nurses' competency milestones in PoCUS use. For this purpose, a scoping review will be conducted. The review will be based on JBI Collaboration guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extended for Scoping Reviews (PRISMA-ScR) checklist. Subproject 2 involves an evaluation of content and appearance validity for a series of 5 educational videos on PoCUS, designed specifically for nurses about applying peripherally inserted central catheter lines, inserting nasogastric feeding tubes, assessing gastric residual volume, assessing pressure injuries and soft tissue conditions, and assessing muscle mass to monitor patient nutritional status. In subproject 3, a comprehensive online learning environment dedicated to PoCUS training for nurses will be developed and validated. The launch of an online learning environment represents a cornerstone of our dissemination strategy, scheduled to coincide with the inaugural Brazilian PoCUS symposium for nurses, an event organized by the project members. This platform will serve as a pivotal resource for continuous learning and professional development.

RESULTS

Subproject 1 will start in the second half of 2024 and is expected to be completed by mid-2025. Subproject 2 is currently ongoing and is expected to be completed in early 2026. Subproject 3 is set to begin in early 2025 and is planned to be completed by 2026.

CONCLUSIONS

Through these concerted efforts, the project aims to bridge the existing gap in PoCUS training for nurses, thereby fostering their proficiency and enhancing patient care outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/58030.

Comparison of 6 handheld ultrasound devices by point-of-care ultrasound experts: a cross-sectional study

BACKGROUND

Point-of-care ultrasound (POCUS) has emerged as an essential bedside tool for clinicians, but lack of access to ultrasound equipment has been a top barrier to POCUS use. Recently, several handheld ultrasound devices ("handhelds") have become available, and clinicians are seeking data to guide purchasing decisions. Few comparative studies of different handhelds have been done. We conducted a cross-sectional study comparing 6 handhelds readily available in the United States (Butterfly iQ + ™ by Butterfly Network Inc.; Clarius™ by Clarius Mobile Health; Kosmos™ by EchoNous; TE Air™ by Mindray; Vscan Air™ SL and CL by General Electric; and Lumify™ by Philips Healthcare). A multi-specialty group of physician POCUS experts (n = 35) acquired three standard ultrasound views (abdominal right upper quadrant, cardiac apical 4-chamber, and superficial neck and lung views) in random order on the same standardized patients and rated the image quality. Afterward, a final survey of the overall ease of use, image quality, and satisfaction of each handheld was completed.

RESULTS

Thirty-five POCUS experts specializing in internal medicine/hospital medicine, critical care, emergency medicine, and nephrology acquired and rated right upper quadrant, apical 4-chamber, and superficial neck and lung views with 6 different handhelds. For image quality, the highest-rated handhelds were Vscan Air™ for the right upper quadrant view, Mindray TE Air™ for the cardiac apical 4-chamber view, and Lumify™ for superficial views of the neck and lung. Overall satisfaction with image quality was highest with Vscan Air™, Lumify™, and Mindray, while overall satisfaction with ease of use was highest with Vscan Air™. The 5 most desirable characteristics of handhelds were image quality, ease of use, portability, probe size, and battery life. Ultimately, all 6 handhelds had notable advantages and disadvantages, with no single device having all desired qualities or features.

CONCLUSIONS

The overall satisfaction with image quality was rated highest with Vscan Air™, Lumify™, and Mindray TE Air™when acquiring right upper quadrant, apical 4-chamber, and superficial neck and lung views. No single handheld was perceived to be superior in image quality for all views. Vscan Air™ was rated highest for overall ease of use and was the most preferred handheld for purchase by POCUS experts.

Is it worth trying? A cross-sectional study on the implementation of point-of-care ultrasound in Hungarian primary care

BACKGROUND

Although the number of point-of-care ultrasound devices available in Hungarian primary care practices are increasing due to government funding, their use in day-to-day patient care is limited and unregulated. Our study aimed to evaluate the attitudes and needs of general practitioners (GPs) and patients in Hungary regarding the introduction of bedside ultrasonography in primary care practices.

METHODS

As a part of a cross-sectional study, an anonymous, self-administered questionnaire was distributed to GPs and patients on a social media platform. Data collection was carried out from August 2023 to October 2023. Chi-square test was used to determine the associations between categorical variables.

RESULTS

The survey was completed by 415 GPs (mean age 53.8 ± 11.1 years, 54.9% female, mean 19.5 ± 11.9 years of practice) and 693 patients (mean age 45.5 ± 12.3 years, 95.2% female). There was a statistically significant increase in interest in PoCUS among young and middle-aged GPs (age 28-59; p = 0.02). In addition, this population of GPs was also more likely to undertake training in PoCUS than their older colleagues (p < 0.0001). An inverse relationship was found between the duration of practice and training willingness (p = 0.0011). Even with the government's financial support, only 8.2% of GPs currently use PoCUS in a daily basis, and 59.5% of GPs are unfamiliar with the indications and the ways of using it. Patients would even pay to have the examination done in a primary care setting, even though only 45.9% of patients would pay a GP who is not certified in PoCUS, but the willingness to pay increased to 99.4% for those with formal training (p = 0.024).

CONCLUSION

Our findings indicate a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary.

Barriers to learning and performing point-of-care ultrasound (POCUS): An integrative review

BACKGROUND

Point-of-care ultrasound (POCUS) is a valuable adjunct to traditional imaging and physical exam. Adult-Gerontology Acute Care Nurse Practitioners (AGACNPs) serve as primary providers for acutely ill patients across the country, yet there is limited literature to describe the AGACNP experience with POCUS training and clinical application.

PURPOSE

This integrative review was to describe barriers to learning and performing POCUS that AGACNP's experience, identify necessary components of a successful POCUS curriculum, and synthesize evidence to propose solutions.

METHOD

CINAHL, PubMed, and Ovid databases were systematically searched for publications. Two reviewers completed the quality appraisal of the 12 articles identified during the literature search.

RESULTS

Common barriers include: formal training; access to ultrasound machines; quality assurance; time to perform exams; inability to use findings in documentation/decision making. Low confidence may be an underrepresented barrier. Successful training programs include an introductory class with mixed didactic and hands-on training, training with live models, direct supervision and image review by experts, and longitudinal training.

CONCLUSION

Adult-Gerontology Acute Care Nurse Practitioners are capable of learning and incorporating POCUS use into clinical practice. Broad solutions can be instituted to remove barriers, but more research is needed to describe necessary components of a successful POCUS training program.

Technical assessment of resolution of handheld ultrasound devices and clinical implications

PURPOSE

Since handheld ultrasound devices are becoming increasingly ubiquitous, objective criteria to determine image quality are needed. We therefore conducted a comparison of objective quality measures and clinical performance.

MATERIAL AND METHODS

A comparison of handheld devices (Butterfly IQ+, Clarius HD, Clarius HD3, Philips Lumify, GE VScan Air) and workstations (GE Logiq E10, Toshiba Aplio 500) was performed using a phantom. As a comparison, clinical investigations were performed by two experienced ultrasonographers by measuring the resolution of anatomical structures in the liver, pancreas, and intestine in ten subjects.

RESULTS

Axial full width at half maximum resolution (FWHM) of 100µm phantom pins at depths between one and twelve cm ranged from 0.6-1.9mm without correlation to pin depth. Lateral FWHM resolution ranged from 1.3-8.7mm and was positively correlated with depth (r=0.6). Axial and lateral resolution differed between devices (p<0.001) with the lowest median lateral resolution observed in the E10 (5.4mm) and the lowest axial resolution (1.6mm) for the IQ+ device. Although devices showed no significant differences in most clinical applications, ultrasonographers were able to differentiate a median of two additional layers in the wall of the sigmoid colon and one additional structure in segmental portal fields (p<0.05) using cartwheel devices.

CONCLUSION

While handheld devices showed superior or similar performance in the phantom and routine measurements, workstations still provided superior clinical imaging and resolution of anatomical substructures, indicating a lack of objective measurements to evaluate clinical ultrasound devices.

Point-of-Care Ultrasound to Assess Diaphragmatic Paralysis in Resource-Limited Setting: A Case Series

Diaphragmatic dysfunction can arise from various factors, and Guillain-Barre syndrome, characterized by acute inflammatory polyradiculoneuropathy, is one such cause that may result in respiratory failure due to diaphragmatic paralysis. Prompt recognition and timely intervention, including airway protection and addressing the underlying pathology, are crucial for achieving optimal patient outcomes. Point-of-care ultrasound, specifically utilizing the M-mode function, can be employed for individuals displaying symptoms of diaphragmatic paralysis. This diagnostic approach is uncomplicated an effective tool for serial follow-up. In this context, we present a case series involving three patients with diaphragmatic paralysis in a limited-resource setting.

Self-administered at-home lung ultrasound with remote guidance in patients without clinical training

BACKGROUND

Access to timely and accurate diagnostic imaging is essential for high-quality healthcare. Point-of-care ultrasound has been shown to be accessible and effective in many aspects of healthcare, including assessing changes in lung pathology. However, few studies have examined self-administered at-home lung ultrasound (SAAH-LUS), in particular performed by non-clinical patients (NCPs).

RESEARCH QUESTION

Are NCPs able to perform SAAH-LUS using remote teleguidance and produce interpretable images?

STUDY DESIGN

Patients were enrolled to the study in a mix of in-person and virtual recruitment, and shipped a smartphone as well as a point of care ultrasound device. Tele-guidance was provided by a remote physician using software integrated with the point of care ultrasound device, allowing real-time remote visualization and guidance of a patient scanning their own chest. A post-intervention survey was conducted to assess patient satisfaction, feasibility, and acceptability of SAAH-LUS. Two POCUS expert reviewers reviewed the scans for interpretability, and inter-rater agreement between the two reviewers was also computed.

RESULTS

Eighteen patients successfully underwent 7-14 days of daily telemedicine in parallel to daily SAAH-LUS. Across 1339 scans obtained from ten different lung zones, the average proportion of interpretability was 96% with a chance-corrected agreement, or Cohen's kappa, reported as κ = 0.67 (significant agreement). 100% of NCPs surveyed found SAAH-LUS to be a positive experience, particularly for its ease of operation and ability to increase access to healthcare services.

INTERPRETATION

This study demonstrates that NCPs can obtain interpretable LUS images at home, highlighting the potential for SAAH-LUS to increase diagnostic capacity, particularly for rural and remote regions where complex imaging and healthcare providers are difficult to obtain. Trial registration The clinical trials has been registered (clinicaltrials.gov).

REGISTRATION NUMBER

NCT04967729.

Developing an Educational Program for Ultrasound Hip Screening during Newborn and Infant Home Visits: A Protocol Paper

Ultrasound hip screening is suitable for the early identification of developmental dysplasia of the hip (DDH). Newborn and infant home visits are good opportunities for hip screening in the community, but studies focusing on nurse-led screenings are lacking. Based on a pre-post design, this study aims to develop and evaluate an ultrasound training program to improve nurses' assessment skills in detecting DDH cases during newborn and infant home visits. Said educational program will include e-learning, hands-on seminars, and clinical training. The primary outcome will be the success rate of imaging standard planes (standardized images for hip assessment) in clinical training. The secondary outcomes will include knowledge test results, objective structured clinical examination scores, time required for imaging, and inter-rater reliability between nurses and physicians. The educational program will address the issue of missed and late detection of DDH cases in resource-limited communities. This study will demonstrate the feasibility of procedures and the effectiveness of the educational program in 2024. The protocol was registered in the University Hospital Medical Information Network Clinical Trial Registry before starting the study (no. UMIN000051929, 16 August 2023).

Point-of-Care Ultrasound for the Diagnosis of Frequent Cardiovascular Diseases: A Review

Point-of-care ultrasound (POCUS) has emerged as an indispensable diagnostic tool in cardiology, particularly within the emergency department. This narrative synthesis provides a comprehensive exploration of POCUS applications in cardiovascular diseases, elucidating its multifaceted roles and addressing challenges. The review delves into the technical attributes of POCUS, emphasizing its non-invasive nature, radiation-free qualities, and suitability for non-radiologists. It navigates through educational strategies, stressing the importance of structured programs for the seamless integration of POCUS into clinical practice. Highlighting its efficacy, the synthesis discusses POCUS applications in various scenarios such as dyspnea, chest pain, cardiac arrest, aortic dissection, pericardial effusion, and pulmonary embolism. Beyond acute care, the review explores the role of POCUS in outpatient and inpatient settings, focusing on chronic and acute heart failure, valvular heart diseases, and more. Acknowledging operator-dependent challenges and the need for continuous education, the review underscores the transformative potential of POCUS across diverse healthcare settings. This narrative synthesis accentuates POCUS as a valuable and versatile diagnostic tool in cardiology, offering efficiency, safety, and cost-effectiveness. Despite challenges, POCUS stands out as a transformative addition to clinical practices, poised to enhance patient outcomes and reshape the landscape of cardiovascular diagnostics.

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

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

Diagnostic test accuracy of ultrasound for orbital cellulitis: A systematic review

BACKGROUND

Periorbital and orbital cellulitis are inflammatory conditions of the eye that can be difficult to distinguish using clinical examination alone. Computer tomography (CT) scans are often used to differentiate these two infections and to evaluate for complications. Orbital ultrasound (US) could be used as a diagnostic tool to supplement or replace CT scans as the main diagnostic modality. No prior systematic review has evaluated the diagnostic test accuracy (DTA) of ultrasound compared to cross-sectional imaging.

OBJECTIVE

To conduct a systematic review of studies evaluating the DTA of orbital ultrasound compared with cross-sectional imaging, to diagnose orbital cellulitis.

METHODS

MEDLINE, EMBASE, CENTRAL, and Web of Science were searched from inception to August 10, 2022. All study types were included that enrolled patients of any age with suspected or diagnosed orbital cellulitis who underwent ultrasound and a diagnostic reference standard (i.e., CT or magnetic resonance imaging [MRI]). Two authors screened titles/abstracts for inclusion, extracted data, and assessed the risk of bias.

RESULTS

Of the 3548 studies identified, 20 were included: 3 cohort studies and 17 case reports/series. None of the cohort studies directly compared the diagnostic accuracy of ultrasound with CT or MRI, and all had high risk of bias. Among the 46 participants, diagnostic findings were interpretable in 18 (39%) cases which reported 100% accuracy. We were unable to calculate sensitivity and specificity due to limited data. In the descriptive analysis of the case reports, ultrasound was able to diagnose orbital cellulitis in most (n = 21/23) cases.

CONCLUSION

Few studies have evaluated the diagnostic accuracy of orbital ultrasound for orbital cellulitis. The limited evidence based on low quality studies suggests that ultrasound may provide helpful diagnostic information to differentiate orbital inflammation. Future research should focus studies to determine the accuracy of orbital US and potentially reduce unnecessary exposure to radiation.

Accuracy of ultrasonographic fatty liver index using point-of-care ultrasound in stratifying non-alcoholic fatty liver disease patients

BACKGROUND

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing in the USA. Some of these patients develop non-alcoholic steatohepatitis (NASH), which can progress to cirrhosis. Ultrasound imaging is one of the most used modalities for diagnosing hepatic steatosis. Primary care providers are increasingly using point-of-care ultrasound (POCUS), which could increase the number of subjects diagnosed with NAFLD. This study evaluates the accuracy of POCUS in identifying patients with NASH.

METHODS

Patients with hepatic steatosis without excess alcohol intake or other liver diseases undergoing liver biopsy were included in this study. These patients underwent POCUS and vibration-controlled transient elastography (VCTE) evaluations within 3 months of a liver biopsy. A comparison of POCUS data with liver histology and VCTE were made to assess the validity of POCUS evaluation in diagnosing NAFLD and NASH.

RESULTS

The steatosis score from the liver histology had a low correlation with the controlled attenuation parameter score from VCTE ( r  = 0.27) and a moderate correlation with the grade of steatosis detected by the POCUS exam ( r  = 0.57). The NAFLD activity score on histology was found to correlate with the ultrasonographic fatty liver index (USFLI) from the POCUS exam ( r  = 0.59). A USFLI ≥ 6 diagnosed NASH with a sensitivity of 81%, and a value of ≤3 ruled out the diagnosis of NASH with a sensitivity of 100%.

CONCLUSION

The provider can use the POCUS exam in clinical practice to diagnose NAFLD and reliably stratify patients who have NASH.

Using Iterative RE-AIM to enhance hospitalist adoption of lung ultrasound in the management of patients with COVID-19: an implementation pilot study

BACKGROUND

Lung ultrasound (LUS) is a clinician-performed evidence-based imaging modality that has multiple advantages in the evaluation of dyspnea caused by multiple disease processes, including COVID-19. Despite these advantages, few hospitalists have been trained to perform LUS. The aim of this study was to increase adoption and implementation of LUS during the 2020 COVID-19 pandemic by using recurrent assessments of RE-AIM outcomes to iteratively revise our implementation strategies.

METHODS

In an academic hospital, we implemented guidelines for the use of LUS in patients with COVID-19 in July 2020. Using a novel "RE-AIM dashboard," we used an iterative process of evaluating the high-priority outcomes of Reach, Adoption, and Implementation at twice monthly intervals to inform revisions of our implementation strategies for LUS delivery (i.e., Iterative RE-AIM process). Using a convergent mixed methods design, we integrated quantitative RE-AIM outcomes with qualitative hospitalist interview data to understand the dynamic determinants of LUS Reach, Adoption, and Implementation.

RESULTS

Over the 1-year study period, 453 LUSs were performed in 298 of 12,567 eligible inpatients with COVID-19 (Reach = 2%). These 453 LUS were ordered by 43 out of 86 eligible hospitalists (LUS order adoption = 50%). However, the LUSs were performed/supervised by only 8 of these 86 hospitalists, 4 of whom were required to complete LUS credentialing as members of the hospitalist procedure service (proceduralist adoption 75% vs 1.2% non-procedural hospitalists adoption). Qualitative and quantitative data obtained to evaluate this Iterative RE-AIM process led to the deployment of six sequential implementation strategies and 3 key findings including (1) there were COVID-19-specific barriers to LUS adoption, (2) hospitalists were more willing to learn to make clinical decisions using LUS images than obtain the images themselves, and (3) mandating the credentialing of a strategically selected sub-group may be a successful strategy for improving Reach.

CONCLUSIONS

Mandating use of a strategically selected subset of clinicians may be an effective strategy for improving Reach of LUS. Additionally, use of Iterative RE-AIM allowed for timely adjustments to implementation strategies, facilitating higher levels of LUS Adoption and Reach. Future studies should explore the replicability of these preliminary findings.

Point-of-care ultrasound: An emerging clinical tool to enhance physical assessment

ABSTRACT

Point-of-care ultrasound (PoCUS) is a cost-effective diagnostic technology that, with training, is accessible, portable, and a convenient diagnostic modality to complement physical assessments. PoCUS is beneficial in that it can reduce the number of imaging tests required, while also mitigating barriers to healthcare for rural and remote communities.

Residents' Perspective on Need for Point-of-Care Ultrasound Education During Pediatric Residency

OBJECTIVES

Many medical disciplines incorporate point-of-care ultrasound (POCUS) into their practice. Despite well-defined applications, POCUS has not been widely adopted in pediatrics and is not commonly taught during residency. Our objective was to profile the current state of POCUS education in pediatric residency training from the resident perspective.

METHODS

We surveyed pediatric trainees about their POCUS education, general opinions about POCUS, and perceived barriers to POCUS training in residency. We distributed the survey to a random sample of Ohio pediatric residents, stratified by program size and training level. Descriptive statistics were used to characterize responses.

RESULTS

We sampled 66.4% of the population (371 of 559) of Ohio pediatric residents and achieved a response rate of 59.3%. Only 15% of respondents received POCUS training during residency, with 85% having never performed a POCUS scan. Most (86%) desired POCUS education and 67% believed it should be required during residency. Residents felt that POCUS would be useful for procedural guidance (95%), clinical diagnosis (94%), and patient safety (74%). Most residents (61%) believed POCUS education would benefit their careers, particularly those planning on subspecialization. Barriers to POCUS education included lack of an established curriculum (75%), competing educational priorities (58%), and a shortage of qualified instructors (52%).

CONCLUSIONS

Although Ohio pediatric residents do not receive formal POCUS education in residency, they desire such training and believe it would benefit their future practice. Consensus on scope of practice, development of a standardized curriculum, and increased faculty training in POCUS may help address this educational gap.

Design and comparison of a hybrid to a traditional in-person point-of-care ultrasound course

Background

Traditional introductory point-of-care ultrasound (POCUS) courses are resource intensive, typically requiring 2–3 days at a remote site, consisting of lectures and hands-on components. Social distancing requirements resulting from the COVID-19 pandemic led us to create a novel hybrid course curriculum consisting of virtual and in-person components.

Methods

Faculty, chief residents, fellows and advanced practice providers (APPs) in the Department of Medicine were invited to participate in the hybrid curriculum. The course structure included 4 modules of recorded lectures, quizzes, online image interpretation sessions, online case discussions, and hands-on sessions at the bedside of course participant’s patients. The components of the course were delivered over approximately 8 months. Those participants who completed a minimum of 3 modules over the year were invited for final assessments. Results from the hybrid curriculum cohort were compared to the year-end data from a prior traditional in-person cohort.

Results

Participant knowledge scores were not different between traditional (n = 19) and hybrid (n = 24) groups (81% and 84%, respectively, P = 0.9). There was no change in POCUS skills as measured by the hands-on test from both groups at end-of-course (76% and 76%, respectively, P = 0.93). Confidence ratings were similar across groups from 2.73 traditional to 3.0 hybrid (out of possible 4, P = 0.46). Participants rated the course highly, with an average overall rating of 4.6 out 5.

Conclusions

A hybrid virtual and in-person POCUS course was highly rated and as successful as a traditional course in improving learner knowledge, hands-on skill and confidence at 8 months after course initiation. These results support expanding virtual elements of POCUS educational curricula.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-022-00261-x.

POINT-OF-CARE ULTRASOUND IN THE EARLY DIAGNOSIS OF NECROTIZING FASCIITIS

OBJECTIVE

The aim: To detect the ultrasonographic signs of necrotizing fasciitis (NF) suitable for its early diagnosis.

PATIENTS AND METHODS

Materials and methods: Eigty two patients with soft tissue infection, including 14 with necrotizing faciitis, were examined by ultrasonography at the admission. Ultrasonografic features were compared to intraoperative findings by the same surgeon.

RESULTS

Results: The thickening of subcutaneous tissue had high sensitivity (100%), but low specificity (5.8%). The hypoechoic and hyperechoic zones had the shape of "cobblestone" with sensitivity - 78.5%, specificity - 33.8%. Higher specificity (69.1%) had sign of "cobblestone separation" on two layers. The presence of fluid above the fascia (sensitivity - 71.4%; specificity - 69.1%), thickening of the fascia (sensitivity - 85.7%; specificity - 58.8%), indistinctness of the fascia edges (sensitivity - 85.7%; specificity - 66.1%) and loss of fascial homogeneity (sensitivity - 71.4%, specificity - 66.1%) were noted in early stages of NF. Advanced cases of NF were accompanied by the dissection of thick¬ened fascia with a strip of fluid (sensitivity - 57.1%, specificity - 92.6%) and accumulation of a fluid under the fascia (sensitivity - 28.5%, specificity - 95.5%). The muscles thickening (sensitivity - 28.5%; specificity - 67.6%), skin thickening (sensitivity - 57.1%; specificity - 58.8%), and loss of the skin's lower edge clarity (sensitivity - 57.1%; specificity - 63.2%) don't have diagnostic value without other signs of NF.

CONCLUSION

Conclusions: Point-of-care ultrasonography allows visualization of soft tissue changes that may be hidden in the initial stages of necrotizing fasciitis and should be recommended for implementation as mandatory method of examination in patients with suspected surgical soft tissue infection.

Point-of-Care Ultrasound Training in Pediatric Residency: A National Needs Assessment

BACKGROUND AND OBJECTIVES

As point-of-care ultrasound (POCUS) evolves into a standard tool for the care of children, pediatric residency programs need to develop POCUS training programs. Few POCUS training resources exist for pediatric residents, and little is known about POCUS training in pediatric residencies. We aim to describe pediatric residency leadership perspectives regarding the value of POCUS and to elucidate the current state of POCUS training in pediatric residency programs.

METHODS

A group of pediatric educators and POCUS experts developed a novel survey followed by cognitive interviews to establish response-process validity. The survey was administered electronically to pediatric residency associate program directors between December 2019 and April 2020. Program characteristics, including region, setting, and size, were used to perform poststratification for analyses. We performed comparative analyses using program and respondent characteristics.

RESULTS

We achieved a 30% (58 of 196) survey response rate. Although only a minority of respondents (26%) used POCUS in clinical practice, a majority (56%) indicated that all pediatric residents should be trained in POCUS. A majority of respondents also considered 8 of 10 POCUS applications important for pediatric residents. Only 37% of programs reported any POCUS training for residents, primarily informal bedside education. Most respondents (94%) cited a lack of qualified instructors as a barrier to POCUS training.

CONCLUSIONS

Most pediatric residency programs do not provide residents with POCUS training despite its perceived value and importance. Numerous POCUS applications are considered important for pediatric residents to learn. Future curricular and faculty development efforts should address the lack of qualified POCUS instructors.

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.