Point-of-care ultrasound associated with shorter length of stay than computed tomography for renal colic

BACKGROUND

Despite similar diagnostic effectiveness for renal colic, computed tomography (CT) is more resource intensive than point-of-care ultrasound (PoCUS). We sought to compare Emergency Department (ED) length of stay (LOS) among patients with renal colic according to imaging modality utilized. We secondarily compared rates of infection, return ED visits, missed significant pathology, and urologic intervention.

METHODS

This was a 12-month (1/1/22-12/31/22) multi-site retrospective cohort study of all patients diagnosed with renal colic who presented to the ED on days when at least one patient had a billable renal PoCUS examination performed. Patients with a history of genitourinary malignancy, pregnancy, renal transplant, hemodialysis, single kidney, prior visit for renal colic in the previous 30 days, or an incomplete workup were excluded. Median ED LOS was compared using a Wilcoxon rank sum test, and the 95% confidence limits for the difference between medians was calculated. Secondary outcomes were compared using a Fisher's Exact test.

RESULTS

Of 415 patients screened, 325 were included for analysis: 150 had CT alone, 80 had PoCUS alone, 54 had PoCUS plus CT, and 41 had neither. Median LOS for PoCUS alone was 75.0 (95% CI 39.3-110.7) minutes shorter than CT alone (231.5 vs. 307.0 min, p < 0.0001). Similar rates of infection, return visits, and missed pathology occurred across all groups (p > 0.10). Urologic interventions were higher in the PoCUS plus CT (25.9%) group compared to CT alone (7.3%), PoCUS alone (2.5%), and neither (7.3%), p < 0.0001.

CONCLUSION

Among patients with renal colic, PoCUS was associated with shorter ED LOS compared to CT, without differences in infection rates, return visits, or missed pathology. Patients with PoCUS plus CT had a higher rate of urologic interventions, suggesting PoCUS may have a role in identifying patients who would most benefit from CT.

Radiology Imaging Adds Time and Diagnostic Uncertainty when Point of Care Ultrasound Demonstrates Cholecystitis

BACKGROUND

Point of care ultrasound (POCUS) is specific for acute cholecystitis (AC), but surgeons request radiology imaging (RI) prior to admitting patients with POCUS-diagnosed AC.

OBJECTIVES

We sought to determine the test characteristics of POCUS for AC when performed and billed by credentialed emergency physicians (EPs), the accuracy rate of RI when performed after POCUS, and the time added when RI is requested after POCUS demonstrates AC.

METHODS

We performed a dual-site retrospective cohort study of admitted adult ED patients who had received biliary POCUS from November 1, 2020 to April 30, 2022. Patients with previously diagnosed AC, liver failure, ascites, hepatobiliary cancer, or cholecystectomy were excluded. Descriptive statistics and 95% confidence intervals for point estimates were calculated. Medians were compared using a Wilcoxon signed-rank test. Test characteristics of POCUS for AC were calculated using inpatient intervention for AC as the reference standard.

RESULTS

Of 473 screened patients, 143 were included for analysis: 80 (56%) had AC according to our reference standard. POCUS was positive for AC in 46 patients: 44 true positives and two false positives, yielding a positive likelihood ratio of 17.3 (95%CI 4.4-69.0) for AC. The accuracy rate of RI after positive POCUS for AC was 39.0%. Median time from ED arrival to POCUS and ED arrival to RI were 115 (IQR 64, 207) and 313.5 (IQR 224, 541) minutes, respectively; p < 0.01.

CONCLUSION

RI after positive POCUS performed by credentialed EPs takes additional time and may increase diagnostic uncertainty.

Thoracic Aortic Aneurysm Presenting as a Subacute Cough

The suprasternal aortic notch cardiac point of care ultrasound (POCUS) window is a useful view for evaluating thoracic aortic pathologies. However, it is not routinely included in the standard cardiac POCUS exam despite its ability to capture emergent pathologies such as aortic dissection and thoracic aortic aneurysm (TAA). Ruptured aortic aneurysms can present with sudden, severe chest or back pain, as well as hemodynamic instability, resulting in a high mortality. We present an atypical case of a patient with hemoptysis who was found to have a contained aortic rupture. In this case, POCUS, specifically the suprasternal aortic notch view, was used to expedite definitive care.

Utility of Smartphone Telemedical Consultations for Peritonsillar Abscess Diagnosis and Triage

Importance

Telemedicine is rapidly gaining traction as a way to reduce costs and connect patients with medical experts outside their local communities. Peritonsillar abscess (PTA) is a logical pathologic condition to evaluate for effectiveness of remote diagnosis given its prevalence and the paucity of on-site otolaryngologists at many institutions.

Objective

To explore the potential of otolaryngology telemedical consultation in triaging and diagnosing patients with suspected PTA.

Design, Setting, and Participants

A comparative effectiveness research study was conducted from January 1 to June 30, 2018, at 3 tertiary care hospitals among 31 consecutive patients aged 18 to 85 years for whom the otolaryngology department was consulted to assess for PTA. Statistical analysis was conducted from July 1 to September 30, 2018.

Interventions

Telemedical evaluation of suspected PTA by 5 attending otolaryngologists blinded to patients' history aside from the chief report of odynophagia. Otolaryngologists rated each patient video on whether they believed the patient had a PTA and whether the case warranted prompt evaluation by an otolaryngologist. Predictions were compared with the criterion standard of drainage or negative needle aspiration. Otolaryngologists additionally assessed video quality.

Main Outcomes and Measures

Rates of accurate diagnosis and triage of PTA based on otolaryngologists' review of oropharyngeal examinations recorded using standard smartphone cameras, as well as percentage of videos of oropharyngeal examinations using standard smartphone cameras deemed of sufficiently high quality for clinical decision-making.

Results

A total of 31 patients (16 women [51.6%]; mean age, 31.9 years [range, 18-62 years]) were recruited, and 16 patients (51.6%) had a PTA. Comparing otolaryngologists' predictions with PTA status by the criterion standard, the prediction was consistent with that of the criterion standard 81% of the time averaged across otolaryngologists (mean diagnostic accuracy, 0.81). Similarly, the mean diagnostic accuracy was 0.83 when comparing the otolaryngologist's suggestion for a prompt in-person evaluation with actual PTA status by the criterion standard. Comparing patients who were deemed to require prompt otolaryngology evaluation and those with PTA by the criterion standard, mean sensitivity was 90%. Videos were rated as of sufficiently high quality to make a diagnosis in 154 of 155 videos (99.4%).

Conclusions and Relevance

This study suggests that telemedical consultation is a viable, cost-conscious, efficient, and safe approach to PTA management. Despite having some difficulty diagnosing PTAs based on "history concerning for PTA" and oropharyngeal video alone, otolaryngologists are able to determine, with high sensitivity, which patients require prompt otolaryngology evaluation. The recording of consistently high-quality video using a standard smartphone camera is achievable without formal training.

Training for Failure: A Simulation Program for Emergency Medicine Residents to Improve Communication Skills in Service Recovery

OBJECTIVES

Service failures such as long waits, testing delays, and medical errors are daily occurrences in every emergency department (ED). Service recovery refers to the immediate response of an organization or individual to resolve these failures. Effective service recovery can improve the experience of both the patient and the physician. This study investigated a simulation-based program to improve service recovery skills in postgraduate year 1 emergency medicine (PGY-1 EM) residents.

METHODS

Eighteen PGY-1 EM residents participated in six cases that simulated common ED service failures. The patient instructors (PIs) participating in each case and two independent emergency medicine (EM) faculty observers used the modified Master Interview Rating Scale to assess the communication skills of each resident in three simulation cases before and three simulation cases after a service recovery debriefing. For each resident, the mean scores of the first three cases and those of the last three cases were termed pre- and postintervention scores, respectively. The means and standard deviations of the pre- and postintervention scores were calculated by the type of rater and compared using paired t-tests. Additionally, the mean scores of each case were summarized. In the framework of the linear mixed-effects model, the variance in scores from the PIs and faculty observers was decomposed into variance contributed by PIs/cases, the program effect on individual residents, and the unexplained variance. In reliability analyses, the intraclass correlation coefficient between rater types and the 95% confidence interval were reported before and after the intervention.

RESULTS

When rated by the PIs, the pre- and postintervention scores showed no difference (p = 0.852). In contrast, when scored by the faculty observers, the postintervention score was significantly improved compared to the preintervention score (p < 0.001). In addition, for the faculty observers, the program effect was a significant contributor to the variation in scores. Low intraclass correlation was observed between rater groups.

CONCLUSIONS

This innovative simulation-based program was effective at teaching service recovery communication skills to residents as evaluated by EM faculty, but not PIs. This study supports further exploration into programs to teach and evaluate service recovery communication skills in EM residents.

Can the degree of hydronephrosis on ultrasound predict kidney stone size?

OBJECTIVE

The aim of the study was to determine if the degree of hydronephrosis on focused emergency renal ultrasound correlates with kidney stone size on computed tomography.

METHODS

A retrospective study was performed on all adult patients in the emergency department who had a focused emergency renal ultrasound and ureterolithiasis on noncontrast computed tomography. Severity of hydronephrosis was determined by the performing physician. Ureteral stone size was grouped into 5 mm or less and larger than 5 mm based on likelihood of spontaneous passage.

RESULTS

One hundred seventy-seven ultrasound scans were performed on patients with ureteral calculi. When dichotomized using test characteristic analysis, patients with none or mild hydronephrosis (72.9%) were less likely to have ureteral calculi larger than 5 mm than those with moderate or severe hydronephrosis (12.4% vs 35.4%; P < .001) with a negative predictive value of 0.876 (95% confidence interval, 0.803-0.925).

CONCLUSION

Patients with less severe hydronephrosis were less likely to have larger ureteral calculi.

Massive hemoperitoneum resulting from spontaneous rupture of uterine leiomyoma

Uterine leiomyomas are very common tumors found in women. Rupture of a uterine leiomyoma is an unusual source of hemoperitoneum. This is a case report of such. A 28-year old woman presented to the emergency department with acute onset of abdominal pain after a bowel movement and who had a history of fibroids. The patient was stable and went for a formal ultrasound, which showed a large fibroid and free fluid in the peritoneum. She had a laparotomy, and an actively bleeding fibroid surface vein was found. The patient required transfusion of 2 U of packed red blood cells, and a myomectomy was performed, with an uneventful postoperative course. Because surgical intervention is the only definitive treatment, emergency physicians should be aware of this rare complication.