Point-of-Care Ultrasound Use, Accuracy, and Impact on Clinical Decision Making in Rwanda Hospitals

Failure to receive prescribed imaging is associated with increased early mortality after injury in Cameroon

Despite having the highest rates of injury-related mortality in the world, trauma system capacity in sub-Saharan Africa remains underdeveloped. One barrier to prompt diagnosis of injury is limited access to diagnostic imaging. As part of a larger quality improvement initiative and to assist priority setting for policy makers, we evaluated trauma outcomes among patients who did and did not receive indicated imaging in the Emergency Department (ED). We hypothesize that receiving imaging is associated with increased early injury survival. We evaluated patterns of imaging performance in a prospective multi-site trauma registry cohort in Cameroon. All trauma patients enrolled in the Cameroon Trauma Registry (CTR) between 2017 and 2019 were included, regardless of injury severity. Patients prescribed diagnostic imaging were grouped into cohorts who did and did not receive their prescribed study. Patient demographics, clinical course, and outcomes were compared using chi-squared and Kruskal-Wallis tests. Multivariate logistic regression was used to explore associations between radiologic testing and survival after injury. Of 9,635 injured patients, 47.5% (4,574) were prescribed at least one imaging study. Of these, 77.8% (3,556) completed the study (COMPLETED) and 22.2% (1,018) did not receive the prescribed study (NC). Compared to COMPLETED patients, NC patients were younger (p = 0.02), male (p<0.01), and had markers of lower socioeconomic status (SES) (p<0.01). Multivariate regression adjusted for age, sex, SES, and injury severity demonstrated that receiving a prescribed study was strongly associated with ED survival (OR 5.00, 95% CI 3.32-7.55). Completing prescribed imaging was associated with increased early survival in injured Cameroonian patients. In a resource-limited setting, subsidizing access to diagnostic imaging may be a feasible target for improving trauma outcomes.

Utility of hand-held ultrasound for image acquisition and interpretation by trained Kenyan providers

BACKGROUND

Point-of-care ultrasound (POCUS) plays a prominent role in the timely recognition and management of multiple medical, surgical, and obstetric conditions. A POCUS training program for primary healthcare providers in rural Kenya was developed in 2013. A significant challenge to this program is the acquisition of reasonably priced ultrasound machines with adequate image quality and the ability to transmit images for remote review. The goal of this study is to compare the utility of a smartphone-connected, hand-held ultrasound with a traditional ultrasound device for image acquisition and interpretation by trained healthcare providers in Kenya.

METHODS

This study took place during a routine re-training and testing session for healthcare providers who had already received POCUS training. The testing session involved a locally validated Observed Structured Clinical Exam (OSCE) that assessed trainees' skills in performing the Extended Focused Assessment with Sonography for Trauma (E-FAST) and focused obstetric exams. Each trainee performed the OSCE twice, once using a smartphone-connected hand-held ultrasound and once using their notebook ultrasound model.

RESULTS

Five trainees obtained a total of 120 images and were scored on image quality and interpretation. Overall E-FAST imaging quality scores were significantly higher for the notebook ultrasound compared to the hand-held ultrasound but there was no significant difference in image interpretation. Overall focused obstetric image quality and image interpretation scores were the same for both ultrasound systems. When separated into individual E-FAST and focused obstetric views, there were no statistically significant differences in the image quality or image interpretation scores between the two ultrasound systems. Images obtained using the hand-held ultrasound were uploaded to the associated cloud storage using a local 3G-cell phone network. Upload times were 2-3 min.

CONCLUSION

Among POCUS trainees in rural Kenya, the hand-held ultrasound was found to be non-inferior to the traditional notebook ultrasound for focused obstetric image quality, focused obstetric image interpretation, and E-FAST image interpretation. However, hand-held ultrasound use was found to be inferior for E-FAST image quality. These differences were not observed when evaluating each E-FAST and focused obstetric views separately. The hand-held ultrasound allowed for rapid image transmission for remote review.

A survey of barriers and facilitators to ultrasound use in low- and middle-income countries

Point-of-care ultrasound has the potential to help inform assessment, diagnosis, and management of illness in low- and middle-income countries (LMIC). To better understand current ultrasound use, barriers and facilitators to use, and perceptions and practices in LMIC, we conducted an anonymous online global survey targeting healthcare providers training and using ultrasound in LMIC. A total of 241 respondents representing 62 countries participated and most were physicians working in publicly-funded urban tertiary hospitals in LMIC. Most had received ultrasound training (78%), reported expertise (65%) and confidence (90%) in ultrasound use, and had access to ultrasound (88%), utilizing ultrasound most commonly for procedures and for evaluations of lungs, heart, and trauma. Access to an ultrasound machine was reported as both the top barrier (17%) and top facilitator (53%); other common barriers included access to education and training, cost, and competition for use and other common facilitators included access to a probe, gel, and electricity, and acceptance by healthcare providers, administrators, and patients. Most (80%) noted ultrasound access was important and 96% agreed that ultrasound improves quality of care and patient outcomes. Improving access to low-cost ultrasound equipment is critical to increasing ultrasound use among those who are trained.

Point-of-care ultrasound needs assessment in a paediatric acute care setting in Malawi

OBJECTIVE

To describe the use of point-of-care ultrasound (POCUS) in an acute-care paediatric setting in Malawi, including clinical indications, types of examinations and frequency of positive findings.

METHODS

Retrospective, cross-sectional study of a convenience sample of POCUS examinations performed in one tertiary referral hospital in Lilongwe, Malawi over 1 year. POCUS examinations were performed by Paediatric Emergency Medicine physician consultants as part of routine clinical practice and at the request of local clinicians. Images were saved along with the clinical indication and physician interpretation for quality review. Ultrasounds performed by the radiology department and those examinations that were technically faulty, missing clinical application or interpretation were excluded.

RESULTS

In total, 225 ultrasounds of 142 patients were analysed. The most common clinical indications for which examinations were completed were respiratory distress (23%), oedema (11.7%) and shock/arrest (6.2%). The most common examinations performed were cardiac (41.8%) and lung (15.1%), focused assessment with sonography in trauma (FAST; 12.9%) and ultrasound-guided procedural examinations (9.8%). Pathology was identified in 68% of non-procedural examinations. Cardiac examinations demonstrated significant pathology, including reduced cardiac function (12.8%), gross cardiac structural abnormality (11.8%) and pericardial effusion (10.3%).

CONCLUSIONS

POCUS was used for both clinical decision-making and procedural guidance, and a significant number of POCUS examinations yielded positive findings. Thus, we propose that cardiopulmonary, FAST and procedural examinations should be considered in future for the POCUS curriculum in this setting.

Evaluation of antenatal Point-of-Care Ultrasound (PoCUS) training: a systematic review

INTRODUCTION

There is limited access to life-saving antenatal ultrasound in rural and low-resource settings largely due to shortages in skilled staff. Studies have shown healthcare practitioners can be upskilled in PoCUS through focused training, offering a viable solution to this deficit. However, standards for training and competency assessment are unclear and regulation surrounding practice is lacking. We aimed to review published literature examining antenatal PoCUS training programs, comparing teaching approaches and study methodologies.

METHODS

A search of electronic databases EMBASE, MEDLINE and Google Scholar was conducted. Original research articles evaluating antenatal PoCUS training of healthcare professionals worldwide were identified for analysis. Articles with limited detail on the PoCUS training intervention and those describing comprehensive diagnostic training programs were excluded. Evaluations were compared against the Kirkpatrick Evaluation Framework (KEF).

RESULTS

Twenty-seven studies were included from an initial search result of 484 articles. There was considerable heterogeneity between the PoCUS training programs described. Course duration ranged from 3 hours to 2 years, with 11 of the 27 studies delivering obstetric-exclusive content. 44% trained multidisciplinary groups of health professionals. Long-term follow-up training and skills assessments were lacking in over half of the reviewed studies. Study quality and reporting detail varied, but overall beneficial outcomes were reported with 3/4s of the studies reaching upper KEF levels 3 and 4.

CONCLUSION

PoCUS performed by upskilled healthcare professionals offers an attractive solution to the problem of inequitable access to antenatal ultrasound. A review of available literature highlighted a paucity of comparable high-quality studies needed to establish a stronger evidence base for antenatal PoCUS, and a need to standardise training and competency assessment. This review may inform educators, researchers and policy-makers on existing training formats and methodologies to assist in establishing best practice antenatal PoCUS training methods for safe service delivery by remote healthcare professionals.

Effect of Point-of-Care Ultrasound on Clinical Outcomes in Low-Resource Settings: A Systematic Review

Despite the potential for improved patient care, little is known of the true effect of point-of-care ultrasound (POCUS) on patient outcomes in resource-limited settings. Electronic databases were searched using medical subject heading and free text terms related to POCUS and resource-limited settings through August 2020. Two authors independently selected studies, assessed methodological quality using the Downs and Black scale and extracted data. Twenty observational studies were included in the final review. All studies had moderate to high risk of bias. No studies exhibited an effect on the pre-specified primary outcome of mortality. Varying degrees of change in differential diagnosis and management were reported, but definitions varied widely among studies. Estimates for change in diagnosis as a result of POCUS ranged from 15% to 52%, and those for change in management, from 17% to 87%. Articles on POCUS clinical utility represent a small part (4.6%) of the scholastic literature dedicated to POCUS in low-resource settings. POCUS is a valuable intervention to consider in resource-limited settings, with the potential to change diagnosis and patient management. The exact magnitude of effect remains unknown. There is a continued need for large-scale experimental studies to investigate the effect of POCUS on patient diagnosis, management and mortality.

Resident perception on the impact of point-of-care ultrasound in clinical care at a family medicine training program in Zambia

Background

Patient access to necessary medical imaging in low- and middle-income countries (LMICs) remains a major obstacle, complicating clinician decision-making and compromising patient outcomes.

Methods

We implemented a longitudinal point-of-care ultrasound (POCUS) training program at a new Family Medicine residency in Zambia and subsequently evaluated residents’ perceptions on the impact of POCUS in patient care. Data were documented by the scanning resident via a post-scan survey, which assessed if/how the scan assisted in medical management, and if/how the scan changed that management. The primary endpoint was frequency of scans assisting and changing management. Data were summarized using descriptive statistics.

Results

Over the 1-year study period, 366 patient encounters occurred in which POCUS was utilized, resulting in a total of 542 unique POCUS scans. POCUS assisted in decision-making in 95.6% (350/366) of patient encounters, most commonly by helping to determine a diagnosis. POCUS changed management in 65.8% (235/357) of patient encounters, most commonly leading to a medication change.

Conclusions

Zambian resident physicians perceived POCUS to be very helpful in their clinical decision-making. These data support the need to advance POCUS education at the residency level throughout LMICs, which may be an ideal strategy to promote widespread utilization of POCUS in low-resource settings globally.

Focused Cardiac Ultrasound Findings in Children Presenting With Shock to a Tertiary Care Hospital in Rwanda

OBJECTIVES

Shock remains a leading proximate cause of death in children. Children in sub-Saharan African (SSA) countries present with shock from a wide range of pathologies. Routine physiologic parameters may not reflect underlying physiology. No previous work has systematically described ultrasound findings in children with shock in an SSA country. We set out to perform focused cardiac ultrasound (FOCUS) on children with shock in Rwanda and describe the findings in this pilot study.

METHODS

In a prospective descriptive study, we trained pediatric residents to perform FOCUS on children presenting with shock to an urban tertiary care pediatric emergency department in Kigali, Rwanda. Images were transmitted via cellphone network and reviewed by experts. Primary outcome was expert's description of the FOCUS findings. Secondary outcomes included mortality at 48-hour, change in assessment and treatment after FOCUS, and agreement of FOCUS findings between residents and experts.

RESULTS

Between January 2020 and April 2020, 25 subjects were enrolled by 8 residents. Eleven of 25 (44%) were newly diagnosed with acquired or congenital heart disease. The 48-hour mortality rate was higher in this group compared with those without heart disease (8 of 11 vs 1 of 14). The resident reported changing assessment and treatment based on FOCUS findings in 60% of patients (15 of 25). There was good to excellent agreements between residents and FOCUS experts on left ventricle function, pericardial effusion, and intravascular volume.

CONCLUSIONS

In children presenting with signs and symptoms of shock in SSA, one could perform a screening FOCUS to distinguish between hypovolemic and cardiogenic shock.

Task shifting for point of care ultrasound in primary healthcare in low- and middle-income countries-a systematic review

Low-and middle-income countries (LMIC) are faced with healthcare challenges including lack of specialized healthcare workforce and limited diagnostic infrastructure. Task shifting for point-of-care ultrasound (POCUS) can overcome both shortcomings. This review aimed at identifying benefits and challenges of task shifting for POCUS in primary healthcare settings in LMIC. Medline and Embase were searched up to November 22nd, 2021. Publications reporting original data on POCUS performed by local ultrasound naïve healthcare providers in any medical field at primary healthcare were included. Data were analyzed descriptively. PROSPERO registration number CRD42021223302. Overall, 36 publications were included, most (n = 35) were prospective observational studies. Medical fields of POCUS application included obstetrics, gynecology, emergency medicine, infectious diseases, and cardiac, abdominal, and pulmonary conditions. POCUS was performed by midwives, nurses, clinical officers, physicians, technicians, and community health workers following varying periods of short-term training and using different ultrasound devices. Benefits of POCUS were yields of diagnostic images with adequate interpretation impacting patient management and outcome. High cost of face-to-face training, poor internet connectivity hindering telemedicine components, and unstable electrici'ty were among reported drawbacks for successful implementation of task shifting POCUS. At the primary care level in resource-limited settings task shifting for POCUS has the potential to expand diagnostic imaging capacity and impact patient management leading to meaningful health outcomes.

Cardiovascular examination using hand-held cardiac ultrasound

Echocardiography is the first-line imaging modality for assessing cardiac function and morphology. The miniaturisation of ultrasound technology has led to the development of hand-held cardiac ultrasound (HCU) devices. The increasing sophistication of available HCU devices enables clinicians to more comprehensively examine patients at the bedside. HCU can augment clinical exam findings by offering a rapid screening assessment of cardiac dysfunction in both the Emergency Department and in cardiology clinics. Possible implications of implementing HCU into clinical practice are discussed in this review paper.

The Power of Mobile Health: The Girl With the Gadgets in Uganda

Medical-grade ultrasound devices are now pocket sized and can be easily transported to underserved parts of the world, allowing health care providers to have the tools to optimize diagnoses, inform management plans, and improve patient outcomes in remote locations. Other great advances in technology have recently occurred, such as artificial intelligence applied to mobile health devices and cloud computing, as augmented reality instructions make these devices more user friendly and readily applicable across health care encounters. However, broader awareness of the impact of these mobile health technologies is needed among health care providers, along with training on how to use them in valid and reproducible environments, for accurate diagnosis and treatment. This article provides a summary of a Mayo International Health Program journey to Bwindi, Uganda, with a portable mobile health unit. This article shows how point-of-care ultrasonography and other technologies can benefit remote clinical diagnosis and management in underserved areas around the world.

Innovations with tele-ultrasound in education sonography: the use of tele-ultrasound to train novice scanners

Objectives

Point-of-care ultrasound (POCUS) has become increasingly integrated into medical education given the growing role of evaluative and procedural techniques in practice today. Tele-ultrasound is a new and promising venture that aims to expand medical knowledge and education to previously unreached or underserved areas. This study aimed to determine the non-inferiority of teaching ultrasound remotely using tele-ultrasound via the Philips Lumify (Philips Medical Systems, Bothell, WA) system, which utilizes video conferencing technology and real-time imaging that can be viewed by the operator and educator simultaneously.

Methods

Three commonly used ultrasound exams were taught and evaluated in 56 ultrasound-naive medical participants: Focused Assessment with Sonography in Trauma (FAST), Lower Extremity Deep Venous Thrombosis (LEDVT) screening, and ultrasound-guided vascular access. The participants were randomized into either in-person traditional learning or tele-ultrasound learning with the Philips Lumify (Philips Medical Systems, Bothell, WA) units. The primary outcome of interest was the ability to perform certain tasks for each exam

Results

Competency on each exam was tested across all exams and no inferiority was found between in-person and remote learning (p < 0.05).

Conclusions

Our findings support the use of tele-ultrasound in beginner ultrasound education.

Pragmatic Recommendations for the Use of Diagnostic Testing and Prognostic Models in Hospitalized Patients with Severe COVID-19 in Low- and Middle-Income Countries

Management of patients with severe or critical COVID-19 is mainly modeled after care of patients with severe pneumonia or acute respiratory distress syndrome from other causes. These models are based on evidence that primarily originates from investigations in high-income countries, but it may be impractical to apply these recommendations to resource-restricted settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for microbiology and laboratory testing, imaging, and the use of diagnostic and prognostic models in patients with severe COVID-19 in LMICs. For diagnostic testing, where reverse transcription-PCR (RT-PCR) testing is available and affordable, we recommend using RT-PCR of the upper or lower respiratory specimens and suggest using lower respiratory samples for patients suspected of having COVID-19 but have negative RT-PCR results for upper respiratory tract samples. We recommend that a positive RT-PCR from any anatomical source be considered confirmatory for SARS-CoV-2 infection, but, because false-negative testing can occur, recommend that a negative RT-PCR does not definitively rule out active infection if the patient has high suspicion for COVID-19. We suggest against using serologic assays for the detection of active or past SARS-CoV-2 infection, until there is better evidence for its usefulness. Where available, we recommend the use of point-of-care antigen-detecting rapid diagnostic testing for SARS-CoV-2 infection as an alternative to RT-PCR, only if strict quality control measures are guaranteed. For laboratory testing, we recommend a baseline white blood cell differential platelet count and hemoglobin, creatinine, and liver function tests and suggest a baseline C-reactive protein, lactate dehydrogenase, troponin, prothrombin time (or other coagulation test), and D-dimer, where such testing capabilities are available. For imaging, where availability of standard thoracic imaging is limited, we suggest using lung ultrasound to identify patients with possible COVID-19, but recommend against its use to exclude COVID-19. We suggest using lung ultrasound in combination with clinical parameters to monitor progress of the disease and responses to therapy in COVID-19 patients. We currently suggest against using diagnostic and prognostic models as these models require extensive laboratory testing and imaging, which often are limited in LMICs.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Reliability of ultrasound findings acquired with handheld apparatuses to inform urgent obstetric diagnosis in a high-volume resource-limited setting

OBJECTIVE

To evaluate the reliability of obstetric handheld smartphone-based point-of-care ultrasound (POCUS) in a resource-limited high-volume setting.

METHODS

A single-center prospective observational study among women requiring urgent diagnosis and admitted to a maternity referral hospital in Sierra Leone from March to April 2019. Pre-specified ultrasound findings were obtained with a handheld POCUS device; a comprehensive ultrasound examination was then performed by an experienced operator using conventional full-feature apparatus. Agreement was assessed by diagnostic accuracy and Cohen κ-statistics.

RESULTS

Overall, there were 307 participants. The mean aggregated diagnostic accuracy was 95.5% (κ-statistic, 0.90; 95% confidence interval [CI], 0.89-0.93; P < 0.001). Highest accuracy was reported for detecting free fluid collection in the abdominal cavity (100%; κ-statistic, 1.00; 95% CI, 1.00-1.00; P < 0.001). Ultrasound findings obtained with the handheld device for intrauterine pregnancy, fetal heartbeat, cephalic presentation, multifetal pregnancy, and assessment of gestational age based on bi-parietal diameter were highly reliable (agreement, >90%; κ-statistic, >0.80). Detection of low-lying placenta or placenta previa was the least reliable (κ-statistic, 0.53; 95% CI, 0.13-0.93; P < 0.001).

CONCLUSION

Handheld POCUS findings were found to be reliable for detecting pre-specified urgent obstetric findings in a high-volume resource-limited referral hospital.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

A Novel Multimodal Approach to Point-of-Care Ultrasound Education in Low-Resource Settings

Point-of-care ultrasound (POCUS) enables physicians to make critical diagnosis and treatment decisions at the bedside. However, access to and expertise with this technology remain limited in Peru. Establishing longitudinal POCUS educational curriculums in remote, low-resource settings can be challenging due to geographical distances, encumbering the ability to provide ongoing hands-on support. Previously described educational interventions have focused on training individual users on clinical applications of POCUS, rather than training physicians how to teach POCUS, thereby limiting scalability and sustainable impact. We therefore describe our experiences establishing the first ultrasound fellowship curriculum in Peru, which incorporates tele-ultrasonography to circumvent traditional geographical barriers.

Obstetrics and Gynecology Residents Can Accurately Classify Benign Ovarian Tumors Using the International Ovarian Tumor Analysis Rules

OBJECTIVES

Recognition of benign versus malignant tumors is essential in gynecologic ultrasound (US). The International Ovarian Tumor Analysis (IOTA) rules have been proposed as part of resident US training. The objective of this study was to examine whether they could be accurately used by obstetrics and gynecology residents in Rwanda.

METHODS

Patients undergoing explorative laparotomy for adnexal masses at the University Teaching Hospital of Kigali were included. Before the study, a didactic lecture on the IOTA rules for classifying adnexal masses was performed. Preoperative transabdominal US examinations were performed by residents at different levels of training, who were blinded to the results of prior US examinations. The IOTA classification was compared to the final pathologic diagnosis.

RESULTS

There were 72 patients who underwent 116 US examinations. Only 15.5% of US examinations were considered inconclusive. First-year residents (12) correctly diagnosed 18 of 20 masses (90%) as benign and 4 of 4 as malignant. Second-year residents (9) classified 29 of 29 masses correctly. Third-year residents (10) accurately identified 21 of 22 (95.5%) as benign and 5 of 5 as malignant. Fourth-year residents (13) accurately identified 11 of 12 (91.7%) as benign and 6 of 6 as malignant. Therefore, 74 of 78 tumors (94.9%) considered benign by IOTA rules were confirmed by histologic results. Similarly, all 20 tumors classified as malignant were confirmed. Overall, the sensitivities to diagnose benign and malignant tumors by the IOTA rules were 83.3% and 100%, respectively. The positive and negative predictive values were 100% and 94.9%. There were no significant differences noted between residency years.

CONCLUSIONS

All levels of Rwandan obstetrics and gynecology residents were able to use the IOTA rules to accurately distinguish benign from malignant tumors.

Point-of-Care Ultrasound in the Diagnosis of Melioidosis in Laos

Melioidosis is endemic in many rural areas in Southeast Asia where facilities for culture and identification of Burkholderia pseudomallei are often limited. We performed a prospective observational study in patients presenting with fever to Mahosot Hospital, the primary referral hospital in Laos, to establish whether the detection of abscesses on ultrasound could support a presumptive diagnosis of melioidosis. All patients underwent ultrasound examination to detect abscesses in the liver, spleen, prostate, or, if indicated, subcutaneous tissue. We enrolled 153 patients, including 18 patients with melioidosis. Of these, 11 (61%) had an abscess at one or more sites, including five (28%) with splenic and/or liver abscesses. Absence of abscesses cannot rule out melioidosis, but the positive predictive value of abscesses for melioidosis was high at 93% (88–96%). Therefore, in endemic areas, the presence of abscesses in febrile patients should prompt empiric antibiotic therapy for melioidosis even in the absence of culture confirmation.

Observational descriptive study of ultrasound use and its impact on clinical decisions in the accident and emergency department at Georgetown public hospital corporation

Introduction

Point-of-care ultrasound (POCUS) is physician-performed at the bedside, and it is a powerful diagnostic tool, especially in resource-limited emergency medicine healthcare settings. This study aims to quantify both the use of ultrasound and its impact on patient care at the Accident and Emergency Department at the Georgetown Public Hospital Corporation (GPHC).

Methods

This is a cross-sectional observational descriptive analysis of data collected for quality assessment in the GPHC Accident and Emergency Department. Over the course of two months, physicians were asked to record each ultrasound exam performed and record whether the ultrasound results changed patient disposition or the medication used in management.

Results

During the study period, there were 173 ultrasound data sheets collected representing 426 ultrasound studies. 196 studies were positive with pathologic findings (46.0%). The use of ultrasound in patient care either changed the patient’s final disposition or medication 78.6% of the time.

Conclusion

Ultrasound is used frequently at the Georgetown Public Hospital Corporation for a wide variety of applications. When utilized, POCUS frequently influenced patient care.

Impact of bedside lung ultrasound on physician clinical decision-making in an emergency department in Nepal

Background

Lung ultrasound is an effective tool for the evaluation of undifferentiated dyspnea in the emergency department. Impact of lung ultrasound on clinical decisions for the evaluation of patients with dyspnea in resource-limited settings is not well-known. The objective of this study was to evaluate the impact of lung ultrasound on clinical decision-making for patients presenting with dyspnea to an emergency department in the resource-limited setting of Nepal.

Methods

A prospective, cross-sectional study of clinicians working in the Patan Hospital Emergency Department was performed. Clinicians performed lung ultrasounds on patients presenting with dyspnea and submitted ultrasounds with their pre-test diagnosis, lung ultrasound interpretation, post-test diagnosis, and any change in management.

Results

Twenty-two clinicians participated in the study, completing 280 lung ultrasounds. Diagnosis changed in 124 (44.3%) of patients with dyspnea. Clinicians reported a change in management based on the lung ultrasound in 150 cases (53.6%). Of the changes in management, the majority involved treatment (83.3%) followed by disposition (13.3%) and new consults (2.7%).

Conclusions

In an emergency department in Nepal, bedside lung ultrasound had a significant impact on physician clinical decision-making, especially on patient diagnosis and treatment.

Diagnostic Utility and Impact on Clinical Decision Making of Focused Assessment With Sonography for HIV-Associated Tuberculosis in Malawi: A Prospective Cohort Study

BACKGROUND

The focused assessment with sonography for HIV-associated tuberculosis (TB) (FASH) ultrasound protocol has been increasingly used to help clinicians diagnose TB. We sought to quantify the diagnostic utility of FASH for TB among individuals with HIV in Malawi.

METHODS

Between March 2016 and August 2017, 210 adults with HIV who had 2 or more signs and symptoms that were concerning for TB (fever, cough, night sweats, weight loss) were enrolled from a public HIV clinic in Lilongwe, Malawi. The treating clinicians conducted a history, physical exam, FASH protocol, and additional TB evaluation (laboratory diagnostics and chest radiography) on all participants. The clinician made a final treatment decision based on all available information. At the 6-month follow-up visit, we categorized participants based on clinical outcomes and diagnostic tests as having probable/confirmed TB or unlikely TB; association of FASH with probable/confirmed TB was calculated using Fisher's exact tests. The impact of FASH on empiric TB treatment was determined by asking the clinicians prospectively about whether they would start treatment at 2 time points in the baseline visit: (1) after the initial history and physical exam; and (2) after history, physical exam, and FASH protocol.

RESULTS

A total of 181 participants underwent final analysis, of whom 56 were categorized as probable/confirmed TB and 125 were categorized as unlikely TB. The FASH protocol was positive in 71% (40/56) of participants with probable/confirmed TB compared to 24% (30/125) of participants with unlikely TB (odds ratio=7.9, 95% confidence interval=3.9,16.1; P<.001). Among those classified as confirmed/probable TB, FASH increased the likelihood of empiric TB treatment before obtaining any other diagnostic studies from 9% (5/56) to 46% (26/56) at the point-of-care. For those classified as unlikely TB, FASH increased the likelihood of empiric treatment from 2% to 4%.

CONCLUSION

In the setting of HIV coinfection in Malawi, FASH can be a helpful tool that augments the clinician's ability to make a timely diagnosis of TB.

Point-of-care ultrasound in resource-limited settings: the PURLS fellowship

Background

The role of point-of-care ultrasonography (POCUS) is rapidly expanding in both resource-rich and resource-limited settings (RLS). One limitation to this rapid expansion has been the lack of educators adequately trained to teach this user-dependent skill. This is particularly true in RLS, where disease presentations, infrastructure limitations, and approach to medical education present unique challenges to the direct application of resource-rich emergency department POCUS curricula.

Objectives

We describe the point-of-care ultrasound in resource-limited settings (PURLS) fellowship, a novel curriculum designed to provide advanced training and expertise in clinical care and POCUS application and education in RLS.

Conclusion

Our curriculum design is one approach to create context-specific POCUS education for use in RLS, thereby improving patient care.

Diagnostic Capacity of Pocket-Sized Ultrasound Devices at Point of Care by a Non-radiologist Resident in Patients with Suspected Abdominal Pathology

Studies have reported the usefulness and tolerability in practice of abdominal ultrasound performed by non-radiologists in various clinical situations. This prospective observational single-center study included 184 patients hospitalized in an internal medicine department who underwent conventional abdominal ultrasound. A medical resident with basic training performed point-of-care clinical ultrasound using a pocket-sized device. The concordance obtained between the researcher and the radiologist was good (k >0.6) for the gallbladder, splenomegaly, longitudinal diameter of the kidney, presence of renal cysts and hydronephrosis. The specificity was >90% for all parameters assessed except normal renal size. A negative predictive value >90% was obtained for all variables studied except the presence of hepatic space-occupying lesions and gallbladder pathology, the negative predictive values for which were >80%. A positive predictive value >80% was obtained for all of these variables, except the presence of adenopathies, hepatomegaly, space-occupying lesions, echogenicity and/or enlargement of the biliary tract, left renal atrophy and right renal masses. We conclude there was a high concordance between a conventional abdominal study and that performed with a pocket-sized ultrasound device after a brief learning curve.

Cardiac ultrasound in resource-limited settings (CURLS): towards a wider use of basic echo applications in Africa

Background

Point-of-care ultrasound is increasingly being used as a diagnostic tool in resource-limited settings. The majority of existing ultrasound protocols have been developed and implemented in high-resource settings. In sub-Saharan Africa (SSA), patients with heart failure of various etiologies commonly present late in the disease process, with a similar syndrome of dyspnea, edema and cardiomegaly on chest X-ray. The causes of heart failure in SSA differ from those in high-resource settings. Point-of-care ultrasound has the potential to identify the underlying etiology of heart failure, and lead to targeted therapy. Based on a literature review and weighted score of disease prevalence, diagnostic impact and difficulty in performing the ultrasound, we propose a context-specific cardiac ultrasound protocol to help differentiate patients presenting with heart failure in SSA.

Results

Pericardial effusion, dilated cardiomyopathy, cor pulmonale, mitral valve disease, and left ventricular hypertrophy were identified as target conditions for a focused ultrasound protocol in patients with cardiac failure and cardiomegaly in SSA. By utilizing a simplified 5-question approach with all images obtained from the subxiphoid view, the protocol is suitable for use by health care professionals with limited ultrasound experience.

Conclusions

The “Cardiac ultrasound for resource-limited settings (CURLS)” protocol is a context-specific algorithm designed to aid the clinician in diagnosing the five most clinically relevant etiologies of heart failure and cardiomegaly in SSA. The protocol has the potential to influence treatment decisions in patients who present with clinical signs of heart failure in resource-limited settings outside of the traditional referral institutions.

Proximal deep vein thrombosis among hospitalised medical and obstetric patients in Rwandan university teaching hospitals: prevalence and associated risk factors: a cross-sectional study

OBJECTIVES

To determine the prevalence of proximal deep vein thrombosis (DVT) by ultrasound scanning, as well as associated clinical features and known risk factors, among medical and obstetrics-gynaecology inpatients in two Rwandan tertiary hospitals.

DESIGN

Cross-sectional study.

SETTINGS

Rwanda teaching hospitals: Kigali and Butare University Teaching Hospitals.

PARTICIPANTS

901 adult patients admitted to the Departments of Internal Medicine and Obstetrics-Gynecology (O&G) who were at least 21 years of age and willing to provide a consent.

OUTCOMES

Prevalence of proximal DVT, clinical features and known risk factors associated with DVT.

METHODS

Between August 2015 and August 2016, participants were screened for DVT by compressive ultrasound of femoral and popliteal veins, conducted as a monthly cross-sectional survey of all consenting eligible inpatients. Patients completed a self-report survey on DVT risk factors. Prevalence of proximal DVT by compression ultrasonography was the primary endpoint, with univariate and multivariate regression analyses performed to assess associated clinical features and risk factors.

RESULTS

Proximal DVT was found in 5.5% of the study population, with similar rates in medical and O&G inpatients. The mean age was 41±16 SD (range, 21-91), 70% were female and 7% were pregnant. Univariate analysis showed active malignancy, immobilisation, prolonged recent travel and history of DVT to be significant risk factors for proximal DVT (all p values <0.05); while only active malignancy was an independent risk factor on multivariate regression (OR 5.2; 95% CI 2.0 to 13). Leg pain or tenderness, increased calf circumference, unilateral limb swelling or pitting oedema were predictive clinical features of DVT on both univariate analysis and multivariate regression (all p values <0.05).

CONCLUSION

Proximal DVT prevalence is high among hospitalised medical and O&G patients in two tertiary hospitals in Rwanda. For reducing morbidity and mortality, research to develop Africa-specific clinical prediction tools for DVT and interventions to increase thromboprophylaxis use in the region are urgently needed.

Impact of ultrasound on management for dyspnea presentations in a Rwandan emergency department

BACKGROUND

The complexity of diagnosis for critically ill dyspnea presentations in the emergency department remains a challenge. Accurate and rapid recognition of associated life-threatening conditions is paramount for timely treatment. Point-of-care ultrasound (POCUS) has been shown to impact the diagnosis of dyspnea presentations in resource-rich settings, and may be of greater diagnostic benefit in resource-limited settings.

METHODS

We prospectively enrolled a convenience sample of 100 patients presenting with dyspnea in the Emergency Department at University Teaching Hospital of Kigali (UTH-K) in Rwanda. After a traditional history and physical exam, the primary treating team listed their 3 main diagnoses and ranked their confidence accuracy in the leading diagnosis on a Likert scale (1-5). Multi-organ ultrasound scans performed by a separate physician sonographer assessed the heart, lungs, inferior vena cava, and evaluated for lower extremity deep vein thrombosis or features of disseminated tuberculosis. The sonographer reviewed the findings with the treating team, who then listed 3 diagnoses post-ultrasound and ranked their confidence accuracy in the leading diagnosis on a Likert scale (1-5). The hospital diagnosis at discharge was used as the standard in determining the accuracy of the pre- and post-ultrasound diagnoses.

RESULTS

Of the 99 patients included in analysis, 57.6% (n = 57) were male, with a mean age of 45 years. Most of them had high-level acuity (54.5%), the dyspnea was of acute onset (45.5%) and they came from district hospitals (50.5%). The most frequent discharge diagnoses were acute decompensated heart failure (ADHF) (26.3%) and pneumonia (21.2%). Ultrasound changed the leading diagnosis in 66% of cases. The diagnostic accuracy for ADHF increased from 53.8 to 100% (p = 0.0004), from 38 to 85.7% for pneumonia (p = 0.0015), from 14.2 to 85.7% for extrapulmonary tuberculosis (p = 0.0075), respectively, pre and post-ultrasound. The overall physician diagnostic accuracy increased from 34.7 to 88.8% pre and post- ultrasound. The clinician confidence in the leading diagnosis changed from a mean of 3.5 to a mean of 4.7 (Likert scale 0-5) (p < 0.001).

CONCLUSIONS

In dyspneic patients presenting to this Emergency Department, ultrasound frequently changed the leading diagnosis, significantly increased clinicians' confidence in the leading diagnoses, and improved diagnostic accuracy.

Use of ultrasound and mHealth to improve perinatal outcomes in low and middle income countries

The explosion of mobile health and portable obstetric ultrasound interventions in low- and middle-income countries (LMIC) reflects the optimism that technology can help reduce persistently high rates of maternal and neonatal mortality and morbidity in these settings. While these technology-driven interventions have had success in improving aspects of antenatal and perinatal care, they have not clearly demonstrated reductions in mortality. The expanding synergy between mobile health (mHealth) and ultrasound technology shows promise to enhance care, but it will likely take combining these technological advances with system-wide approaches that also address referral patterns and infrastructure barriers to improve outcomes.

Enhanced Point-of-Care Ultrasound Applications by Integrating Automated Feature-Learning Systems Using Deep Learning

Recent applications of artificial intelligence (AI) and deep learning (DL) in health care include enhanced diagnostic imaging modalities to support clinical decisions and improve patients' outcomes. Focused on using automated DL-based systems to improve point-of-care ultrasound (POCUS), we look at DL-based automation as a key field in expanding and improving POCUS applications in various clinical settings. A promising additional value would be the ability to automate training model selections for teaching POCUS to medical trainees and novice sonologists. The diversity of POCUS applications and ultrasound equipment, each requiring specialized AI models and domain expertise, limits the use of DL as a generic solution. In this article, we highlight the most advanced potential applications of AI in POCUS tailored to high-yield models in automated image interpretations, with the premise of improving the accuracy and efficacy of POCUS scans.

Assessment of Point-of-Care Ultrasound Training for Clinical Educators in Malawi, Tanzania and Uganda

Integrating point-of-care ultrasound (POCUS) to enhance diagnostic availability in resource-limited regions in Africa has become a main initiative for global health services in recent years. In this article, we present lessons learned from introducing POCUS as part of the Global Health Service Partnership (GHSP), a collaboration started in 2012 between the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Peace Corps and Seed Global Health to provide health care work force education and training in resource-limited countries. A cross-sectional survey of GHSP clinical educators trained to use POCUS and provided with hand-held ultrasound during their 1-y deployment during the period 2013-2017. The survey consisted of 35 questions on the adequacy of the training program and how useful POCUS was to their overall clinical and educational mission. Clinical educators engaged in a series of ultrasound educational initiatives including pre-departure training, bedside training in the host institutions, online educational modules, educational feedback on transmitted images and training of local counterparts. In this study 63 GHSP clinical educators who participated in the POCUS trainings were identified, and 49 were included at the study (78% response rate). They were assigned to academic institutions in Tanzania (n = 24), Malawi (n = 21) and Uganda (n = 18). More than 75% reported use of POCUS in clinical diagnoses and 50% in determining treatment, and 18% reported procedural application of ultrasound in their practice. The top indications for POCUS were cardiac exams, second- and third-trimester obstetric exams, lung and pleura, liver and spleen and gynecology/first-trimester obstetrics. The largest perceived barriers were lack of ultrasound knowledge by the clinical educators, lack of time, equipment security, difficulty accessing the Internet and equipment problems. We concluded that our multiphase POCUS training program has increased the utility, acceptability and usage of POCUS in resource-limited settings.

Remote real-time supervision via tele-ultrasound in focused cardiac ultrasound: A single-blinded cluster randomized controlled trial

BACKGROUND

Supervision via tele-ultrasound presents a remedy for lacking on-site supervision in focused cardiac ultrasound, but knowledge of its impact is largely absent. We aimed to investigate tele-supervised physicians' cine-loop quality compared to that of non-supervised physicians and compared to that of experts.

METHODS

We conducted a single-blinded cluster randomized controlled trial in an emergency department in western Denmark. Physicians with basic ultrasound competence scanned admitted patients twice. The first scan was non-supervised, and the second was non-supervised (control) or tele-supervised (intervention). Finally, experts in focused cardiac ultrasound scanned the same patient. Two blinded observers graded cine-loops recorded from all scans on a 1-5 scale. The outcome was the mean summarized scan gradings compared with a linear mixed-effects model.

RESULTS

In each group, 10 physicians scanned 44 patients. From the mean summarized gradings, on a scale from 4 to 20, the second non-supervised scan grading was 10.9 (95% CI 10.2-11.7), whereas the tele-supervised grading was 12.6 (95% CI: 11.8-13.3). From the first to the second scan, tele-supervised physicians moved 9% (1.09; 95% CI: 1.00-1.19; P = 0.041) closer to the experts' quality than the non-supervised physicians.

CONCLUSION

Tele-supervised physicians performed scans of better quality than non-supervised physicians. The present study supports the use of tele-supervision for physicians with basic focused ultrasound competence in a setting where on-site supervision is unavailable.

Point-of-care ultrasound findings in unselected patients in an emergency department -results from a prospective observational trial

Background

Point-of-care ultrasound (POCUS) can improve patient management in the emergency department (ED). However, previous studies have focused only on selected groups of patients, such as trauma, shock, dyspnea, or critically ill patients, or patients with an already known diagnosis. Most patients seen in the ED do not match these criteria. We aim to present total prevalence of positive findings when basic POCUS is applied to the broad population of patients seen in an emergency department.

Methods

We conducted a single-center prospective explorative observational study of 405 unselected patients aged 18 years or over. A structured whole-body ultrasound examination was performed on all patients within 2 h of arrival to the ED. The ultrasound examination consisted of focused cardiac ultrasound, focused abdominal ultrasound, focused assessment with sonography for trauma (FAST), and focused lung ultrasound.

Results

We managed to perform 94.5% of all planned examinations. The study revealed positive findings in 39.3% of all included patients. This study presents the prevalence of positive findings among subgroups of patients. Divided among the categories of chief complaint, we found 62 positive examinations in 58 (14.3%; 95% CI, 10.9–17.7) unique patients with orthopedic complaints, 77 positive examinations among 59 (14.6%; 95% CI, 11.1–18.0) unique patients with medical complaints, and 55 positive examinations among 42 (10.4%; 95% CI, 7.4–13.3) unique patients with abdominal surgical complaints.

Conclusion

POCUS revealed positive findings in more than one third of unselected patients in the emergency department. The study presents the findings and distribution among categories of chief complaints. Future investigations are necessary to elucidate the implication of the findings.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0211-4) contains supplementary material, which is available to authorized users.

Ultrasound and Other Innovations for Fluid Management in the ICU

Ultrasound is a user-dependent tool that can help guide therapy. The use of ultrasound to guide central line placement decreases complication rates. Cardiac ultrasound can help with the diagnosis of cases of hypotension. Lung and pleura ultrasound is a useful adjunct for diagnosis causes of desaturation. Abdominal ultrasound can help in rapid visitation of fluid and intra-abdominal structures.