Impact of Different Training Methods on Daily Use of Point-of-Care Ultrasound: Survey on 515 Physicians

ABSTRACT

Point-of-care ultrasound (POCUS) curriculum varies among countries. However, the length of training required for physicians is still under debate. We investigated the impact of different training methods: short hands-on courses (STS), long academic training sessions (LTS), or both (mixed training [MTS]), for POCUS daily use and self-reported confidence overall and specific to specific clinical situations. This was a descriptive study conducted over a 3-month period through a Web-based survey designed to assess the influence of different methods of POCUS training among physicians and residents on their daily practice. The survey was sent to 1212 emergency physicians with prior POCUS training; 515 answers (42%) could be analyzed. Participants in the STS group performed POCUS less frequently than physicians in the LTS or MTS group. Daily use in the STS group was 51% versus 82% in the LTS group and 83% in the MTS group ( P < 0.01). The overall self-reported confidence in POCUS was lower in the STS group ( P < 0.01) in all studied clinical situations. There was no significant difference between LTS and MTS groups ( P > 0.05). Method of POCUS training significantly influenced POCUS daily use. Physicians who underwent long training sessions used POCUS more frequently in their routine practice and were significantly more confident in their ability to perform and interpret a POCUS examination.

Impact of an enhanced focused cardiac ultrasound on treatment changes in a population of internal medicine patients

BACKGROUND

Hospitalized patients with acute shortness of breath (SOB) could benefit from an enhanced focused cardiac ultrasound (eFoCUS) with Doppler measurements to reassess treatment and diagnosis.

METHODS

This was a retrospective observational study performed in a medical ward. Included patients were those hospitalized for acute SOB. The objectives were to assess therapeutic and diagnosis changes associated with eFoCUS. The primary endpoint of the analysis was a composite of introduction or discontinuation of diuretics, antibiotics or anticoagulation following eFoCUS.

RESULTS

Between January 2018 and July 2021, 119 patients were included, 67 women and 52 men, mean age 84 ± 11 years old. The eFoCUS was performed within a median time of 55 h (1st-3rd IQ: 21-107) following hospital admission. Overall, eFoCUS was associated with a change in diagnostic in 40 patients (34% [CI 95%: 25%-43%], p < 10-4 ) and a change in treatment in 53 patients (45% [CI 95%: 35%-54%], p < 10-4 ). Diuretics were prescribed in 94 patients before eFoCUS and in 56 after (p = 10-4 ), antibiotics in 34 before and 27 after and anticoagulation in 30 before and 40 after.

CONCLUSION

eFoCUS was associated with both therapeutic and diagnostic changes in patients with SOB. Such results should be confirmed in multicentric prospective studies.

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) SHORT VERSION

OBJECTIVE

 To evaluate the evidence and produce a summary and recommendations for the most common heart and lung point-of-care ultrasound (PoCUS).

METHODS

 We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendations were produced, including assigning levels of evidence (LoE) and grading of recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement of the summary and recommendation for each question (using a 5-point Likert scale), which was approved in the case of a level of agreement of greater than 75 %. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses.

FINDINGS AND RECOMMENDATIONS

 One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1), the remaining 9 questions achieved broad agreement with an assigned LoE of 4 and a weak GRADE recommendation (question 2), three achieved an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8) and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10).

CONCLUSION

 These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) LONG VERSION

AIMS

 To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS).

METHODS

 We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses.

FINDINGS AND RECOMMENDATIONS

 One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10).

CONCLUSION

 These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.

Justification des demandes de tomodensitométrie aux urgences

Introduction : La justification des demandes de tomodensitométrie (TDM) faites aux urgences est mal connue. Notre objectif était d’évaluer la justification des demandes de TDM dans un service d’urgences adultes.

Méthodes : La justification des demandes de scanner a été mesurée prospectivement de deux façons complémentaires. L’adéquation aux recommandations a été évaluée pour l’ensemble des demandes de TDM par confrontation à une liste préétablie de syndromes et d’hypothèses diagnostiques. La pertinence des demandes a été évaluée par un comité d’experts sur la base du dossier médical des urgences pour 100 de ces dossiers.

Résultats : Les 273 TDM incluses concernaient le crâne (52%), l’abdomen (17%), le thorax (11%) ou une autre localisation (20%). Elles étaient en adéquation avec les recommandations dans 215 cas (79%). Pour 100 dossiers analysés par le comité d’experts, la pertinence a été adjugée à l’unanimité pour 95 cas ; 67 TDM (71%) ont été jugées pertinentes. La concordance entre l’adéquation aux recommandations et la pertinence évaluée par le comité d’expert était faible (kappa, 0,27, intervalle de confiance à 95%, de 0,06 à 0,47). Le seul facteur associé significativement à la pertinence était l’opinion du clinicien en charge du patient que la TDM ne pouvait pas être reportée (OR=6,7 avec IC95% [1,6-28,1], p=0,01).

Conclusion : La proportion des demandes de TDM qui ne sont pas en adéquation avec les recommandations et la proportion de demandes non pertinentes sont élevées. Elles suggèrent que le nombre de TDM demandées par les services d’urgences pourrait être diminué.

Evaluation of short training session for venous limited compression ultrasonography: prospective multicenter study

Background

Venous limited compression ultrasonography (VLCU) is recommended in case of suspicion of deep venous thrombosis (DVT). Current training pathways are rather long and include experiential phase. This aim of this study was to investigate the efficacy of a short training session for VLCU without experiential phase. The training session was applied in residents without previous ultrasound skills. Program included operation of ultrasound device and interpretation of venous images. Included patients were older than 18 years and had a suspicion of DVT. After realization of VLCU using usual technique, residents reported the dynamic compressibility of the femoral and popliteal veins, the presence or not of a visible thrombus, self-reported difficulty and duration. Patients then underwent a whole leg ultrasonography (WLCU) in the local laboratory which was blinded to VLCU results. The main criterion was the negative-predictive value (NPV) of VLCU for the absence of proximal DVT diagnosed with WLCU. Secondary criteria were VLCU diagnostic performances, rate of inability to conclude, difficulty and duration. For a NPV of 95 ± 6%, the needed number of patients was 96. This study was approved by the ethical committee.

Results

102 patients were analyzed. 46 residents were trained. A DVT was diagnosed by WLCU in 18 patients (prevalence of 17.6% [95% CI 11–26%]). VLCU detected 15 DVT (NPV of 96% [95% CI 89–99%]). The positive likelihood ratio was 9.9, the negative likelihood ratio 0.19 and Cohen’s Kappa 0.62 [95% CI 0.52–0.71]. The sensitivity was 83% [CI 95% 60–94%] and specificity 88% [CI 95% 79–93%]. The mean number of VLCU by residents was 2.3 ± 2.1, median 2 (minimum 1, maximum 8). Mean duration was 3.4 min, difficulty was 3.7 ± 2.

Conclusion

The principal objective, NPV 96% [95% CI 89–99%], was achieved. However, this short training session was inadequate to allow ruling-out a DVT with sufficient security. Thus, the experiential phase seems to be essential.

Assessment of rewarming methods in unplanned out-of-hospital births from a prospective cohort

Background

Mobile intensive care units frequently manage unplanned out-of-hospital births (UOHB). Rewarming methods during pre-hospital management of UOHB have not yet been compared. The aim was to compare rewarming methods used during pre-hospital management in a large prospective cohort of UOHB in France.

Methods

We analysed UOHB from the prospective AIE cohort from 25 prehospital emergency medical services in France. The primary outcome was the change in body temperature from arrival at scene to arrival at hospital.

Results

From 2011 to 2018, 1854 UOHB were recorded, of whom 520 were analysed. We found that using incubator care was the most effective rewarming method (+ 0.8 °C during transport), followed by the combination of plastic bag, skin-to-skin and cap (+ 0.2 °C). The associations plastic bag + cap and skin-to-skin + cap did not allow the newborn to be warmed up but rather to maintain initial temperature (+ 0.0 °C). The results of the multivariate model were consistent with these observations, with better rewarming with the use of an incubator. We also identified circumstances of increased risk of hypothermia according to classification and regression tree, like premature birth (< 37 weeks of gestation) and/or low outside temperature (< 8.4 °C).

Conclusions

Using an incubator was the most effective rewarming method during pre-hospital management of UOHB in our French prospective cohort. Based on our model, in cases of term less than 37 weeks of gestation or between 37 and 40 weeks with a low outside temperature or initial hypothermia, using such a method would be preferred.

Early point-of-care focused echocardiographic asystole as a predictive factor for absence of return of spontaneous circulatory in out-of-hospital cardiac arrests: a study protocol for a prospective, multicentre observational study

INTRODUCTION

Management of out-of-hospital cardiac arrests (OHCAs) in France is performed by a particular prehospital system based on medicalisation of mobile intensive care units composed of an emergency physician and a nurse with all the required devices for advanced care. It follows the European recommendations which advocate for the use of early point-of-care focused echocardiography (EPOCE) in the prehospital setting. An ability of EPOCE may be to predict the absence of return of spontaneous circulation (ROSC) in cases of absence of cardiac motion. We thus intended to investigate this predictive value with a prospective multicentre study. This paper describes the study protocol, while the first patients were recruited in December 2018.

METHODS

ACE is a prospective multicentre (n=8) prognostic study. Briefly, as soon as OHCA is diagnosed and advanced life support (ALS) is initiated, EPOCE will be performed during the automated external defibrillator' analysis period. The physician will assess detectable motion within the heart and reversible causes of OHCA. However, as the prognostic value of absence of cardiac motion is not currently validated, the results of EPOCE will not be used to withdraw ALS, and the decision to withdraw life support will be done following the European Resuscitation Council recommendations during our study.

ANALYSIS

The primary endpoint is the positive predictive value of absence of cardiac motion for the absence of final ROSC. The secondary endpoints are predictive characteristics of EPOCE asystole on morbimortality 30 days after OHCA, description of reversible cause and analysis of the EPOCE technique.

ETHICS AND DISSEMINATION

ACE was approved by an ethical committee (2018-AO1491-54). While ACE is adapted to the French prehospital system, its results will be translatable to other organisations if inter-rater variability is not found.

TRIAL REGISTRATION NUMBER

NCT03494153.

Response to letter to the editor: "comment on unplanned out-of-hospital birth and risk factors of adverse perinatal outcome: findings from a prospective cohort"

The aim of this Letter to the Editor was to respond to a comment highlighting potential statistical biases in an analysis of our recently published article. We therefore specified the method for selecting the model variables in order to limit overfitting, then we used the Firth method to control the sparse data bias, and finally for checking internal validity we used bootstrapping methods. In total, the conclusions of our model were not changed by these new analyses.

Unplanned out-of-hospital birth and risk factors of adverse perinatal outcome: findings from a prospective cohort

Background

In France, while most babies are delivered at hospital, emergency medical services (EMS) weekly manage calls for unplanned out-of-hospital births. The objective of our study was to describe neonatal morbidity and mortality, defined as death or neonatal intensive care unit hospitalization at Day 7, in a prospective multicentric cohort of unplanned out-of-hospital births.

Methods

We prospectively analyzed out-of-hospital births from 25 prehospital EMS units in France. The primary outcome was neonatal morbidity and mortality, and the secondary outcome was risk factors associated with neonatal morbidity and mortality. A univariate logistic regression was first made, followed by a multivariate logistic regression with backward selection.

Results

From October 2011 to August 2018, a total of 1670 unplanned out-of-hospital births were included. Of these, 1652 (99.2%) were singleton and 1537 (93.5%) had prenatal care. Maternal mean age of the study population was 30 ± 5.5 (range 15 to 48). The majority of women were multiparous, but 13% were nulliparous. Overall, 45.3% of these unplanned out-of-hospital births were medically-driven, either by phone during medical regulation (12.5%) or on scene by the prehospital emergency medical service units (32.9%). The prevalence of neonatal morbidity and mortality was 6.3% (n = 106) after an unplanned out-of-hospital birth (death before Day 7: n = 20; 1.2%). The multivariate logistic regression found that multiparity (adjusted Odds Ratio = 70.7 [4.7–1062]), prematurity (adjusted Odds Ratio = 6.7 [2.1–21.4]), maternal pathology (adjusted Odds Ratio = 2.8 [1.0–7.5]) and hypothermia (adjusted Odds Ratio = 2.8 [1.1–7.6]) were independent predictive factors of neonatal morbidity and mortality.

Conclusions

Our study assessed for the first time risk factors for adverse perinatal outcome in a large and multicenter cohort of unplanned out-of-hospital births. We have to improve temperature management in the out-of-hospital field and future trials are required to investigate strategies to optimize newborns management in the prehospital area.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0600-z) contains supplementary material, which is available to authorized users.

Changes in the availability of bedside ultrasound practice in emergency rooms and prehospital settings in France

OBJECTIVE

Ensuring the availability of ultrasound devices is the initial step in implementing clinical ultrasound (CUS) in emergency services. In France in 2011, 52% of emergency departments (EDs) and only 9% of mobile intensive care stations (MICS) were equipped with ultrasound devices. The main goal of this study was to determine the movement of these rates since 2011.

METHODS

We conducted a cross-sectional, descriptive, multicentre study in the form of a questionnaire. To estimate the numbers of EDs and MICS equipped with at least one ultrasound system with a confidence level of 95% and margin of error of 5%, 170 responding EDs and 145 MICS were required. Each service was solicited three times by secure online questionnaire and then by phone.

RESULTS

Three hundred and twenty-eight (84%) services responded to the questionnaire: 179 (86%) EDs and 149 (82%) MICS. At least one ultrasound machine was available in 127 (71%, 95% CI [64; 78]) EDs vs. 52% in 2011 (P<0.01). 42 (28%, 95% CI [21; 35]) MICS were equipped vs. 9% in 2011 (P<0.01). In 97 (76%) EDs and 24 (55%) MICS, less than a half of physicians were trained. CUS was used at least three times a day in 52 (41%) EDs and in 8 (19%) MICS.

CONCLUSION

Our study demonstrates improved access to ultrasound devices in French EDs and MICS. Almost three-quarters of EDs and nearly one-third of MICS are now equipped with at least one ultrasound device. However, the rate of physicians trained per service remains insufficient.

Prognostic performance of early absence of pupillary light reaction after recovery of out of hospital cardiac arrest

INTRODUCTION

Loss of pupillary light reactivity (PLR) three days after a cardiorespiratory arrest is a prognostic factor. Its predictive value upon hospital admission remains unclear. Our objective was to determine the prognostic value of the absence of PLR upon hospital admission in patients with out-of-hospital cardiac arrest.

METHODS

We prospectively included all out-of-hospital cardiac arrests occurring between July 2011 and July 2017 treated by a mobile medical team (MMT) based on data from a French cardiac arrest registry database. PLR was evaluated upon hospital admission and the outcome on day 30. The prognosis was classified as good for Cerebral Performance Category (CPC) 1 or 2, and poor for CPC 3-5 or in case of death.

RESULTS

Data from 10151 patients was analysed. The sensitivity and specificity of the absence of PLR for a poor outcome were 72.2% (71.2-73.2) and 68.8% (66.7-70.1), respectively. We identified several variables modifying the sensitivity values and the false positive fraction of a factor, ranging from 0.49 (0.35-0.69) for the Glasgow Coma Scale to 2.17 (1.09-2.48) for pupillary asymmetry. Among those living with CPC 1 or 2 on day 30 (n = 1990; 19.6%), 621 (31.2% (29.2-33.3)) had no PLR upon hospital admission. In the multivariate analysis, loss of PLR was associated with a poor outcome (OR = 3.1 (2.7-3.5)).

CONCLUSIONS

Loss of pupillary light reactivity upon hospital admission is predictive of a poor outcome after out-of-hospital cardiac arrest. However, it does not have sufficient accuracy to determine prognosis and decision making.

Acute fissuration of a giant splenic artery aneurysm detected by point-of-care ultrasound: case report

Background

Epigastric pain is frequent in Emergency Medicine and remains a challenging situation. Besides benign etiologies such as gastritis or uncomplicated cholelithiasis, it could reveal myocardial infarction or vascular disease. Point-of-care ultrasound (POCUS) could be performed in such situation.

Case presentation

A healthy 66-year-old man with no previous medical history was admitted to the Emergency Department for a rapid onset epigastric pain. He reported taking non-steroidal anti-inflammatories for 1 week prior to admission. His pain had rapidly subsided and the physical examination was inconclusive. ECG and blood samples were normal. POCUS revealed a vascular mass located between the spleen and the left kidney measuring 80 * 74 mm associated with small amounts of free peritoneal fluid. Computed tomography diagnosed a fissurated giant aneurysm of the splenic artery. The aneurysm was managed emergently by endovascular exclusion by selective splenic artery embolization. The post-intervention course was uneventful and the patient was discharged home 3 days later. The patient has remained free from any complications of the embolization 6 months after the procedure.

Conclusion

Spontaneously regressive epigastric pain with a normal physical and biology/ECG should not necessarily reassure the physician, in particular if patients have cardiovascular risk factors. A POCUS should be considered for these patients.

Electronic supplementary material

The online version of this article (10.1186/s13089-018-0086-3) contains supplementary material, which is available to authorized users.