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Korves C, Peixoto AJ, Lucas BP, Davies L, Weinberger DM, Rentsch C, Vashi A, Young-Xu Y, King J, Asch SM, Justice AC. Hypertension Control During the Coronavirus Disease 2019 Pandemic: A Cohort Study Among US Veterans. Med Care 2024; 62:196-204. [PMID: 38284412 PMCID: PMC10922611 DOI: 10.1097/mlr.0000000000001971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
DESIGN Retrospective cohort study. OBJECTIVE We sought to examine whether disruptions in follow-up intervals contributed to hypertension control. BACKGROUND Disruptions in health care were widespread during the coronavirus disease 2019 pandemic. PATIENTS AND METHODS We identified a cohort of individuals with hypertension in both prepandemic (March 2019-February 2020) and pandemic periods (March 2020-February 2022) in the Veterans Health Administration. First, we calculated follow-up intervals between the last prepandemic and first pandemic blood pressure measurement during a primary care clinic visit, and between measurements in the prepandemic period. Next, we estimated the association between the maintenance of (or achieving) hypertension control and the period using generalized estimating equations. We assessed associations between follow-up interval and control separately for periods. Finally, we evaluated the interaction between period and follow-up length. RESULTS A total of 1,648,424 individuals met the study inclusion criteria. Among individuals with controlled hypertension, the likelihood of maintaining control was lower during the pandemic versus the prepandemic (relative risk: 0.93; 95% CI: 0.93, 0.93). Longer follow-up intervals were associated with a decreasing likelihood of maintaining controlled hypertension in both periods. Accounting for follow-up intervals, the likelihood of maintaining control was 2% lower during the pandemic versus the prepandemic. For uncontrolled hypertension, the likelihood of gaining control was modestly higher during the pandemic versus the prepandemic (relative risk: 1.01; 95% CI: 1.01, 1.01). The likelihood of gaining control decreased with follow-up length during the prepandemic but not pandemic. CONCLUSIONS During the pandemic, longer follow-up between measurements contributed to the lower likelihood of maintaining control. Those with uncontrolled hypertension were modestly more likely to gain control in the pandemic.
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Affiliation(s)
- Caroline Korves
- Department of Veterans Affairs Medical Center, White River Junction, VT
| | | | - Brian P. Lucas
- Department of Veterans Affairs Medical Center, White River Junction, VT
- Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Louise Davies
- Department of Veterans Affairs Medical Center, White River Junction, VT
- Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Daniel M. Weinberger
- Yale School of Public Health, New Haven, CT
- Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Christopher Rentsch
- Yale School of Medicine, New Haven, CT
- Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT
- London School of Hygiene & Tropical Medicine, London, England
| | - Anita Vashi
- Department of Veterans Affairs Medical Center, Palo Alto, CA
- Stanford School of Medicine, Palo Alto, CA
- Department of Emergency Medicine, University of California, San Francisco
| | - Yinong Young-Xu
- Department of Veterans Affairs Medical Center, White River Junction, VT
| | - Joseph King
- Yale School of Medicine, New Haven, CT
- Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Steven M. Asch
- Department of Veterans Affairs Medical Center, Palo Alto, CA
- Stanford School of Medicine, Palo Alto, CA
| | - Amy C. Justice
- Yale School of Medicine, New Haven, CT
- Yale School of Public Health, New Haven, CT
- Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT
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Kwon J, Lucas BP, Evans AT. How much magnesium sulfate is needed to "keep total serum magnesium above 2.0 mg/dL"? J Hosp Med 2024; 19:112-115. [PMID: 38112279 DOI: 10.1002/jhm.13251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/06/2023] [Accepted: 11/23/2023] [Indexed: 12/21/2023]
Abstract
For patients at increased risk of life-threating ventricular arrythmias, hospitalists often administer intravenous magnesium sulfate to maintain total serum magnesium concentration (TsMg) above 2 mg/dL. How long each dose keeps TsMg above this threshold is not well known, however. We collected TsMg values from 12,618 veterans who were given 24,363 doses of intravenous magnesium sulfate during 14,901 hospitalizations for acute heart failure. Across dose amounts, the average TsMg dropped below 2.0 mg/dL within 24 h of administration. When we limited our analysis to 2 g doses (the most common dose) and adjusted for baseline TsMg, estimated glomerular filtration rate, oral magnesium supplementation, and loop diuretic dosing, we found that less than half of the adjusted TsMg values remained above 2.0 mg/dL just 12 h after dose administration. Hospitalists should expect, on average, to administer 2 g intravenous magnesium sulfate at least twice daily to maintain total serum magnesium above 2 mg/dL.
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Affiliation(s)
- JooEun Kwon
- Department of Internal Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- The Dartmouth Institute of Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Arthur T Evans
- Weill Cornell Medicine, Medical College, New York, New York, USA
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Salame G, Holden M, Lucas BP, Portillo A. Change in economy of ultrasound probe motion among general medicine trainees. Ultrasound J 2024; 16:5. [PMID: 38289444 PMCID: PMC10828286 DOI: 10.1186/s13089-023-00345-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 11/07/2023] [Indexed: 02/02/2024] Open
Abstract
OBJECTIVES To observe change in economy of 9 ultrasound probe movement metrics among internal medicine trainees during a 5-day training course in cardiac point of care ultrasound (POCUS). METHODS We used a novel probe tracking device to record nine features of ultrasound probe movement, while trainees and experts optimized ultrasound clips on the same volunteer patients. These features included translational movements, gyroscopic movements (titling, rocking, and rotation), smoothness, total path length, and scanning time. We determined the adjusted difference between each trainee's movements and the mean value of the experts' movements for each patient. We then used a mixed effects model to trend average the adjusted differences between trainees and experts throughout the 5 days of the course. RESULTS Fifteen trainees were enrolled. Three echocardiographer technicians and the course director served as experts. Across 16 unique patients, 294 ultrasound clips were acquired. For all 9 movements, the adjusted difference between trainees and experts narrowed day-to-day (p value < 0.05), suggesting ongoing improvement during training. By the last day of the course, there were no statistically significant differences between trainees and experts in translational movement, gyroscopic movement, smoothness, or total path length; yet on average trainees took 28 s (95% CI [14.7-40.3] seconds) more to acquire a clip. CONCLUSIONS We detected improved ultrasound probe motion economy among internal medicine trainees during a 5-day training course in cardiac POCUS using an inexpensive probe tracking device. Objectively quantifying probe motion economy may help assess a trainee's level of proficiency in this skill and individualize their POCUS training.
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Affiliation(s)
- Gerard Salame
- Department of Medicine, Saint Joseph Hospital/SCL Health, 1375 E 19th Ave, Denver, CO, 80218, USA.
| | - Matthew Holden
- School of Computer Science, Carleton University, Ottawa, ON, Canada
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- The Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
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Weinberger DM, Bhaskaran K, Korves C, Lucas BP, Columbo JA, Vashi A, Davies L, Justice AC, Rentsch CT. Excess mortality in US Veterans during the COVID-19 pandemic: an individual-level cohort study. Int J Epidemiol 2023; 52:1725-1734. [PMID: 37802889 PMCID: PMC10749763 DOI: 10.1093/ije/dyad136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/20/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Most analyses of excess mortality during the COVID-19 pandemic have employed aggregate data. Individual-level data from the largest integrated healthcare system in the US may enhance understanding of excess mortality. METHODS We performed an observational cohort study following patients receiving care from the Department of Veterans Affairs (VA) between 1 March 2018 and 28 February 2022. We estimated excess mortality on an absolute scale (i.e. excess mortality rates, number of excess deaths) and a relative scale by measuring the hazard ratio (HR) for mortality comparing pandemic and pre-pandemic periods, overall and within demographic and clinical subgroups. Comorbidity burden and frailty were measured using the Charlson Comorbidity Index and Veterans Aging Cohort Study Index, respectively. RESULTS Of 5 905 747 patients, the median age was 65.8 years and 91% were men. Overall, the excess mortality rate was 10.0 deaths/1000 person-years (PY), with a total of 103 164 excess deaths and pandemic HR of 1.25 (95% CI 1.25-1.26). Excess mortality rates were highest among the most frail patients (52.0/1000 PY) and those with the highest comorbidity burden (16.3/1000 PY). However, the largest relative mortality increases were observed among the least frail (HR 1.31, 95% CI 1.30-1.32) and those with the lowest comorbidity burden (HR 1.44, 95% CI 1.43-1.46). CONCLUSIONS Individual-level data offered crucial clinical and operational insights into US excess mortality patterns during the COVID-19 pandemic. Notable differences emerged among clinical risk groups, emphasizing the need for reporting excess mortality in both absolute and relative terms to inform resource allocation in future outbreaks.
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Affiliation(s)
- Daniel M Weinberger
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Caroline Korves
- Department of Veterans Affairs Medical Center, Clinical Epidemiology Program, White River Junction, VT, USA
| | - Brian P Lucas
- Department of Veterans Affairs Medical Center, VA Outcomes Group, White River Junction, VT, USA
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Jesse A Columbo
- Department of Veterans Affairs Medical Center, VA Outcomes Group, White River Junction, VT, USA
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Anita Vashi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Louise Davies
- Department of Veterans Affairs Medical Center, VA Outcomes Group, White River Junction, VT, USA
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Surgery—Otolaryngology Head & Neck Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Amy C Justice
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Veterans Affairs, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Veterans Affairs, VA Connecticut Healthcare System, West Haven, CT, USA
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Gogtay M, Choudhury RS, Williams JP, Mader MJ, Murray KJ, Haro EK, Drum B, O'Brien E, Khosla R, Boyd JS, Bales B, Wetherbee E, Sauthoff H, Schott CK, Basrai Z, Resop D, Lucas BP, Sanchez-Reilly S, Espinosa S, Soni NJ, Nathanson R. Point-of-care ultrasound in geriatrics: a national survey of VA medical centers. BMC Geriatr 2023; 23:605. [PMID: 37759172 PMCID: PMC10537073 DOI: 10.1186/s12877-023-04313-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) can aid geriatricians in caring for complex, older patients. Currently, there is limited literature on POCUS use by geriatricians. We conducted a national survey to assess current POCUS use, training desired, and barriers among Geriatrics and Extended Care ("geriatric") clinics at Veterans Affairs Medical Centers (VAMCs). METHODS We conducted a prospective observational study of all VAMCs between August 2019 and March 2020 using a web-based survey sent to all VAMC Chiefs of Staff and Chiefs of geriatric clinics. RESULTS All Chiefs of Staff (n=130) completed the survey (100% response rate). Chiefs of geriatric clinics ("chiefs") at 76 VAMCs were surveyed and 52 completed the survey (68% response rate). Geriatric clinics were located throughout the United States, mostly at high-complexity, urban VAMCs. Only 15% of chiefs responded that there was some POCUS usage in their geriatric clinic, but more than 60% of chiefs would support the implementation of POCUS use. The most common POCUS applications used in geriatric clinics were the evaluation of the bladder and urinary obstruction. Barriers to POCUS use included a lack of trained providers (56%), ultrasound equipment (50%), and funding for training (35%). Additionally, chiefs reported time utilization, clinical indications, and low patient census as barriers. CONCLUSIONS POCUS has several potential applications for clinicians caring for geriatric patients. Though only 15% of geriatric clinics at VAMCs currently use POCUS, most geriatric chiefs would support implementing POCUS use as a diagnostic tool. The greatest barriers to POCUS implementation in geriatric clinics were a lack of training and ultrasound equipment. Addressing these barriers systematically can facilitate implementation of POCUS use into practice and permit assessment of the impact of POCUS on geriatric care in the future.
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Affiliation(s)
- Maya Gogtay
- South Texas Veterans Health Care System, Department of Geriatrics, Gerontology and Palliative Medicine, San Antonio, TX, USA.
| | - Ryan S Choudhury
- South Texas Veterans Health Care System, Department of Geriatrics, Gerontology and Palliative Medicine, San Antonio, TX, USA
| | - Jason P Williams
- Division of Hospital Medicine, Emory School of Medicine, Atlanta, GA, USA
- Medicine Service, Atlanta VA Medical Center, Atlanta, GA, USA
| | - Michael J Mader
- South Texas Veterans Health Care System, Research Service, San Antonio, TX, USA
| | - Kevin J Murray
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Elizabeth K Haro
- Medicine Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Brandy Drum
- Health Analysis and Information Group, Department of Veterans Affairs, Milwaukee, WI, USA
| | - Edward O'Brien
- Health Analysis and Information Group, Department of Veterans Affairs, Milwaukee, WI, USA
| | - Rahul Khosla
- Pulmonary and Critical Care Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Pulmonary, Critical Care and Sleep Medicine, The George Washington University, Washington, DC, USA
| | - Jeremy S Boyd
- Department of Emergency Medicine, VA Tennessee Valley Healthcare System-Nashville, Nashville, TN, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brain Bales
- Department of Emergency Medicine, VA Tennessee Valley Healthcare System-Nashville, Nashville, TN, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erin Wetherbee
- Pulmonary Section, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Harald Sauthoff
- Medicine Service, VA NY Harbor Healthcare System, New York, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, NY, USA
| | - Christopher K Schott
- Critical Care Service, VA Pittsburgh Health Care Systems, Pittsburgh, PA, USA
- Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Zahir Basrai
- Emergency Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dana Resop
- Department of Emergency Medicine, University of Wisconsin, Madison, WI, USA
- Emergency Department, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, VT, USA
- Department of Medicine, Dartmouth Geisel School of Medicine, Hanover, NH, USA
| | - Sandra Sanchez-Reilly
- South Texas Veterans Health Care System, Department of Geriatrics, Gerontology and Palliative Medicine, San Antonio, TX, USA
| | - Sara Espinosa
- South Texas Veterans Health Care System, Department of Geriatrics, Gerontology and Palliative Medicine, San Antonio, TX, USA
| | - Nilam J Soni
- Medicine Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
- Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Robert Nathanson
- Medicine Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
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Lucas BP, Misra S, Donnelly WT, Daubenspeck JA, Leiter J. Relative Blood Volume Profiles Hours After Loop Diuretic Administration: A Systematic Review and Meta-analysis. CJC Open 2023; 5:641-649. [PMID: 37720179 PMCID: PMC10502431 DOI: 10.1016/j.cjco.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/11/2023] [Indexed: 09/19/2023] Open
Abstract
Background Plasma refill rates can be estimated by combining measurements of urine output with relative blood volume profiles. Change in plasma refill rates could guide decongestive loop diuretic therapy in acute heart failure. The objective of the study was to assess average relative blood volume profiles generated from 2 or 3 follow-up measurements obtained hours after loop diuretic administration in subjects with vs without baseline congestion. Methods A systematic review was conducted of articles written in English, French, Spanish, and German, using MEDLINE (1964 to 2019), Cochrane Reviews (1996 to 2019), and Embase (1974 to 2019). Search terms included the following: diuretics, hemoconcentration, plasma volume, and blood volume. We included studies of adults given a loop diuretic with at least one baseline and one follow-up measurement. A single author extracted subject- or group-level blood volume measurements, aggregated them when needed, and converted them to relative changes. Results Across all 16 studies that met the prespecified inclusion criteria, relative blood volume maximally decreased 9.2% (6.6% to 12.0%) and returned to baseline after 3 or more hours. Compared to subjects without congestion, those with congestion experienced smaller decreases in relative blood volume across all follow-up periods (P = 0.001) and returned to baseline within the final follow-up period. Conclusions Single doses of loop diuretics produce measurable changes in relative blood volume that follow distinct profiles for subjects with vs without congestion. Measured alongside urine output, these profiles may be used to estimate plasma refill rates-potential patient-specific targets for decongestive therapy across serial diuretic doses.
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Affiliation(s)
- Brian P. Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- The Dartmouth Institute of Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Shantum Misra
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - William T. Donnelly
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | | | - J.C. Leiter
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
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Weinberger DM, Bhaskaran K, Korves C, Lucas BP, Columbo JA, Vashi A, Davies L, Justice AC, Rentsch CT. Absolute and relative excess mortality across demographic and clinical subgroups during the COVID-19 pandemic: an individual-level cohort study from a nationwide healthcare system of US Veterans. medRxiv 2023:2023.05.12.23289900. [PMID: 37293086 PMCID: PMC10246058 DOI: 10.1101/2023.05.12.23289900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Most analyses of excess mortality during the COVID-19 pandemic have employed aggregate data. Individual-level data from the largest integrated healthcare system in the US may enhance understanding of excess mortality. Methods We performed an observational cohort study following patients receiving care from the Department of Veterans Affairs (VA) between 1 March 2018 and 28 February 2022. We estimated excess mortality on an absolute scale (i.e., excess mortality rates, number of excess deaths), and a relative scale by measuring the hazard ratio (HR) for mortality comparing pandemic and pre-pandemic periods, overall, and within demographic and clinical subgroups. Comorbidity burden and frailty were measured using the Charlson Comorbidity Index and Veterans Aging Cohort Study Index, respectively. Results Of 5,905,747 patients, median age was 65.8 years and 91% were men. Overall, the excess mortality rate was 10.0 deaths/1000 person-years (PY), with a total of 103,164 excess deaths and pandemic HR of 1.25 (95% CI 1.25-1.26). Excess mortality rates were highest among the most frail patients (52.0/1000 PY) and those with the highest comorbidity burden (16.3/1000 PY). However, the largest relative mortality increases were observed among the least frail (HR 1.31, 95% CI 1.30-1.32) and those with the lowest comorbidity burden (HR 1.44, 95% CI 1.43-1.46). Conclusions Individual-level data offered crucial clinical and operational insights into US excess mortality patterns during the COVID-19 pandemic. Notable differences emerged among clinical risk groups, emphasising the need for reporting excess mortality in both absolute and relative terms to inform resource allocation in future outbreaks.
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Affiliation(s)
- Daniel M. Weinberger
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, US
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, US
| | - Krishnan Bhaskaran
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Caroline Korves
- Clinical Epidemiology Program, Department of Veterans Affairs Medical Center, White River Junction, VT
| | - Brian P. Lucas
- VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT, US
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, US
| | - Jesse A. Columbo
- VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT, US
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, US
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, US
| | - Anita Vashi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, US
- Department of Emergency Medicine, University of California, San Francisco, CA, US
| | - Louise Davies
- VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT, US
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, US
- Department of Surgery - Otolaryngology Head & Neck Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH, US
| | - Amy C. Justice
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, US
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US
- VA Connecticut Healthcare System, Department of Veterans Affairs, West Haven, CT, US
| | - Christopher T. Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US
- VA Connecticut Healthcare System, Department of Veterans Affairs, West Haven, CT, US
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Weinberger DM, Rose L, Rentsch C, Asch SM, Columbo JA, King J, Korves C, Lucas BP, Taub C, Young-Xu Y, Vashi A, Davies L, Justice AC. Excess Mortality Among Patients in the Veterans Affairs Health System Compared With the Overall US Population During the First Year of the COVID-19 Pandemic. JAMA Netw Open 2023; 6:e2312140. [PMID: 37155169 PMCID: PMC10167568 DOI: 10.1001/jamanetworkopen.2023.12140] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/24/2023] [Indexed: 05/10/2023] Open
Abstract
Importance During the first year of the COVID-19 pandemic, there was a substantial increase in the rate of death in the United States. It is unclear whether those who had access to comprehensive medical care through the Department of Veterans Affairs (VA) health care system had different death rates compared with the overall US population. Objective To quantify and compare the increase in death rates during the first year of the COVID-19 pandemic between individuals who received comprehensive medical care through the VA health care system and those in the general US population. Design, Setting, and Participants This cohort study compared 10.9 million enrollees in the VA, including 6.8 million active users of VA health care (those with a visit in the last 2 years), with the general population of the US, with deaths occurring from January 1, 2014, to December 31, 2020. Statistical analysis was conducted from May 17, 2021, to March 15, 2023. Main Outcomes and Measures Changes in rates of death from any cause during the COVID-19 pandemic in 2020 compared with previous years. Changes in all-cause death rates by quarter were stratified by age, sex, race and ethnicity, and region, based on individual-level data. Multilevel regression models were fit in a bayesian setting. Standardized rates were used for comparison between populations. Results There were 10.9 million enrollees in the VA health care system and 6.8 million active users. The demographic characteristics of the VA populations were predominantly male (>85% in the VA health care system vs 49% in the general US population), older (mean [SD], 61.0 [18.2] years in the VA health care system vs 39.0 [23.1] years in the US population), and had a larger proportion of patients who were White (73% in the VA health care system vs 61% in the US population) or Black (17% in the VA health care system vs 13% in the US population). Increases in death rates were apparent across all of the adult age groups (≥25 years) in both the VA populations and the general US population. Across all of 2020, the relative increase in death rates compared with expected values was similar for VA enrollees (risk ratio [RR], 1.20 [95% CI, 1.14-1.29]), VA active users (RR, 1.19 [95% CI, 1.14-1.26]), and the general US population (RR, 1.20 [95% CI, 1.17-1.22]). Because the prepandemic standardized mortality rates were higher in the VA populations prior to the pandemic, the absolute rates of excess mortality were higher in the VA populations. Conclusions and Relevance In this cohort study, a comparison of excess deaths between populations suggests that active users of the VA health system had similar relative increases in mortality compared with the general US population during the first 10 months of the COVID-19 pandemic.
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Affiliation(s)
- Daniel M. Weinberger
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
- Department of Veterans Affairs Connecticut Healthcare System, West Haven
| | - Liam Rose
- Department of Veterans Affairs Medical Center, Palo Alto, California
- Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Palo Alto, California
| | - Christopher Rentsch
- Department of Veterans Affairs Connecticut Healthcare System, West Haven
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Steven M. Asch
- Department of Veterans Affairs Medical Center, Palo Alto, California
- Division of Primary Care and Population Health, Stanford School of Medicine, Palo Alto, California
- Department of Health Research and Policy, Stanford School of Medicine, Palo Alto, California
| | - Jesse A. Columbo
- Department of Veterans Affairs Medical Center, White River Junction, Vermont
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Joseph King
- Department of Veterans Affairs Connecticut Healthcare System, West Haven
- Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Caroline Korves
- Department of Veterans Affairs Medical Center, White River Junction, Vermont
| | - Brian P. Lucas
- Department of Veterans Affairs Medical Center, White River Junction, Vermont
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Cynthia Taub
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Yinong Young-Xu
- Department of Veterans Affairs Medical Center, White River Junction, Vermont
| | - Anita Vashi
- Department of Veterans Affairs Medical Center, Palo Alto, California
- Department of Health Research and Policy, Stanford School of Medicine, Palo Alto, California
- Department of Emergency Medicine, University of California, San Francisco
| | - Louise Davies
- Department of Veterans Affairs Medical Center, White River Junction, Vermont
- Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Amy C. Justice
- Department of Veterans Affairs Connecticut Healthcare System, West Haven
- Department of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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9
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Nathanson R, Williams JP, Gupta N, Rezigh A, Mader MJ, Haro EK, Drum B, O'Brien E, Khosla R, Boyd JS, Bales B, Wetherbee E, Sauthoff H, Schott CK, Basrai Z, Resop D, Lucas BP, Soni NJ. Current Use and Barriers to Point-of-Care Ultrasound in Primary Care: A National Survey of VA Medical Centers. Am J Med 2023; 136:592-595.e2. [PMID: 36828205 DOI: 10.1016/j.amjmed.2023.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND More primary care providers (PCPs) have begun to embrace the use of point-of-care ultrasound (POCUS), but little is known about how PCPs are currently using POCUS and what barriers exist. In this prospective study, the largest systematic survey of POCUS use among PCPs, we assessed the current use, barriers to use, program management, and training needs for POCUS in primary care. METHODS We conducted a prospective observational study of all VA Medical Centers (VAMCs) between June 2019 and March 2020 using a web-based survey sent to all VAMC Chiefs of Staff and Chiefs of primary care clinics (PCCs). RESULTS Chiefs of PCCs at 105 VAMCs completed the survey (82% response rate). Only 13% of PCCs currently use POCUS, and the most common applications used were bladder and musculoskeletal ultrasound. Desire for POCUS training exceeded current use, but lack of trained providers (78%), ultrasound equipment (66%), and funding for training (41%) were common barriers. Program infrastructure to support POCUS use was uncommon, and only 9% of VAMCs had local policies related to POCUS. Most PCC chiefs (64%) would support POCUS training. CONCLUSIONS Current use of POCUS in primary care is low despite the recent growth of POCUS training in Internal Medicine residency programs. Investment in POCUS training and program infrastructure is needed to expand POCUS use in primary care and ensure adequate supervision of trainees.
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Affiliation(s)
- Robert Nathanson
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Division of Hospital Medicine, University of Texas Health San Antonio.
| | - Jason P Williams
- Atlanta VA Medical Center, Medicine Service, Ga; Division of Hospital Medicine, Emory School of Medicine, Atlanta, Ga
| | - Neil Gupta
- Joe R. & Teresa Lozano Long School of Medicine
| | - Austin Rezigh
- Division of General Internal Medicine, University of Texas Health San Antonio
| | - Michael J Mader
- Research Service, South Texas Veterans Health Care System, San Antonio
| | - Elizabeth K Haro
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio
| | - Brandy Drum
- Health Analysis and Information Group, Department of Veterans Affairs, Milwaukee, Wis
| | - Edward O'Brien
- Health Analysis and Information Group, Department of Veterans Affairs, Milwaukee, Wis
| | - Rahul Khosla
- Department of Pulmonary, Critical Care and Sleep Medicine, The George Washington University, Washington, DC; Pulmonary and Critical Care Medicine, Veterans Affairs Medical Center, Washington, DC
| | - Jeremy S Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Emergency Medicine, VA Tennessee Valley Healthcare System-Nashville
| | - Brian Bales
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Emergency Medicine, VA Tennessee Valley Healthcare System-Nashville
| | - Erin Wetherbee
- Pulmonary Section, Minneapolis Veterans Affairs Health Care System, Minn; Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - Harald Sauthoff
- Medicine Service, VA NY Harbor Healthcare System, New York, NY; Division of Pulmonary, Critical Care, and Sleep Medicine, New York University Grossman School of Medicine, New York, NY
| | - Christopher K Schott
- Critical Care Service, VA Pittsburgh Health Care Systems, Pa; Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh, Pa
| | - Zahir Basrai
- Emergency Medicine, VA Greater Los Angeles Healthcare System, Calif; Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Dana Resop
- Department of Emergency Medicine, University of Wisconsin, Madison; Emergency Department, William S. Middleton Memorial Veterans Hospital, Madison, Wis
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, Vt; Department of Medicine, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Nilam J Soni
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Division of Hospital Medicine, University of Texas Health San Antonio; Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio
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10
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Williams JP, Nathanson R, LoPresti CM, Mader MJ, Haro EK, Drum B, O'Brien E, Khosla R, Boyd JS, Bales B, Wetherbee E, Sauthoff H, Schott CK, Basrai Z, Resop D, Lucas BP, Soni NJ. Current use, training, and barriers in point-of-care ultrasound in hospital medicine: A national survey of VA hospitals. J Hosp Med 2022; 17:601-608. [PMID: 35844080 DOI: 10.1002/jhm.12911] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/18/2022] [Accepted: 05/29/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) can reduce procedural complications and improve the diagnostic accuracy of hospitalists. Currently, it is unknown how many practicing hospitalists use POCUS, which applications are used most often, and what barriers to POCUS use exist. OBJECTIVE This study aimed to characterize current POCUS use, training needs, and barriers to use among hospital medicine groups (HMGs). DESIGN, SETTING, AND PARTICIPANTS A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of HMGs. These data were compared to a similar survey conducted in 2015. RESULT Chiefs from 117 HMGs were surveyed, with a 90% response rate. There was ongoing POCUS use in 64% of HMGs. From 2015 to 2020, procedural POCUS use decreased by 19%, but diagnostic POCUS use increased for cardiac (8%), pulmonary (7%), and abdominal (8%) applications. The most common barrier to POCUS use was lack of training (89%), and only 34% of HMGs had access to POCUS training. Access to ultrasound equipment was the least common barrier (57%). The proportion of HMGs with ≥1 ultrasound machine increased from 29% to 71% from 2015 to 2020. An average of 3.6 ultrasound devices per HMG was available, and 45% were handheld devices. CONCLUSION From 2015 to 2020, diagnostic POCUS use increased, while procedural use decreased among hospitalists in the VA system. Lack of POCUS training is currently the most common barrier to POCUS use among hospitalists.
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Affiliation(s)
- Jason P Williams
- Medical Education, Atlanta VA Medical Center, Medicine Service, Atlanta, Georgia, USA
- Division of Hospital Medicine, Emory School of Medicine, Atlanta, Georgia, USA
| | - Robert Nathanson
- Department of Medicine, South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas, USA
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Charles M LoPresti
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael J Mader
- Department of Medicine, South Texas Veterans Health Care System, Research Service, San Antonio, Texas, USA
| | - Elizabeth K Haro
- Department of Medicine, South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas, USA
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Brandy Drum
- Department of Veterans Affairs, Healthcare Analysis and Information Group, Milwaukee, Wisconsin, USA
| | - Edward O'Brien
- Department of Veterans Affairs, Healthcare Analysis and Information Group, Milwaukee, Wisconsin, USA
| | - Rahul Khosla
- Department of Pulmonary, Critical Care and Sleep Medicine, George Washington University Medical Faculty Associates, Washington, District of Columbia, USA
- Pulmonary and Critical Care Medicine, Washington Veterans Affairs Medical Center, Washington, District of Columbia, USA
| | - Jeremy S Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, VA Tennessee Valley Healthcare System-Nashville, Nashville, Tennessee, USA
| | - Brian Bales
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, VA Tennessee Valley Healthcare System-Nashville, Nashville, Tennessee, USA
| | - Erin Wetherbee
- Pulmonary Section, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Harald Sauthoff
- Medicine Service, VA NY Harbor Healthcare System, New York, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, New York, USA
| | - Christopher K Schott
- Critical Care Service, VA Pittsburgh Health Care Systems, Pittsburgh, Pennsylvania, USA
- Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zahir Basrai
- Emergency Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Dana Resop
- Department of Emergency Medicine, University of Wisconsin, Madison, Wisconsin, USA
- Emergency Department, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- Department of Medicine, Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Nilam J Soni
- Department of Medicine, South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas, USA
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
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11
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Chang PW, Schroeder AR, Lucas BP, McDaniel CE. Impact of Diagnostic Criteria on UTI Prevalence in Young Infants With Jaundice: A Meta-analysis. Hosp Pediatr 2022; 12:425-440. [PMID: 35322269 DOI: 10.1542/hpeds.2021-006382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Previously reported prevalence of urinary tract infections (UTIs) in infants with jaundice range from <1% to 25%. However, UTI criteria are variable and, as demonstrated in a meta-analysis on UTI prevalence in bronchiolitis, disease prevalence is greatly impacted by disease definition. The objective of this study was to conduct a systemic review and meta-analysis examining the impact of including positive urinalysis (UA) results as a diagnostic criterion on the estimated UTI prevalence in young infants with jaundice. METHODS The data sources used were Medline (1946-2020) and Ovid Embase (1976-2020) through January 2020 and bibliographies of retrieved articles. We selected studies reporting UTI prevalence in young infants with jaundice. Data were extracted in accordance with meta-analysis of observational studies in epidemiology guidelines. Random-effects models produced a weighted pooled event rate with 95% confidence intervals (CI). RESULTS We screened 526 unique articles by abstract and reviewed 53 full-text articles. We included 32 studies and 16 contained UA data. The overall UTI prevalence in young infants with jaundice from all 32 studies was 6.2% (95% CI, 3.9-8.9). From the 16 studies with UA data, the overall UTI prevalence was 8.7% (95% CI, 5.1-13.2), which decreased to 3.6% (95% CI, 2.0-5.8) with positive UA results included as a diagnostic criterion. CONCLUSIONS The estimated UTI prevalence in young infants with jaundice decreases substantially when UA results are incorporated into the UTI definition. Due to the heterogeneity of study subjects' ages and definitions of jaundice, positive UA results, and UTI, there is uncertainty about the exact prevalence and about which infants with hyperbilirubinemia warrant urine testing.
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Affiliation(s)
- Pearl W Chang
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Brian P Lucas
- Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Corrie E McDaniel
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
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12
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Soni NJ, Boyd JS, Mints G, Proud KC, Jensen TP, Liu G, Mathews BK, Schott CK, Kurian L, LoPresti CM, Andrus P, Nathanson R, Smith N, Haro EK, Mader MJ, Pugh J, Restrepo MI, Lucas BP. Comparison of in-person versus tele-ultrasound point-of-care ultrasound training during the COVID-19 pandemic. Ultrasound J 2021; 13:39. [PMID: 34487262 PMCID: PMC8419826 DOI: 10.1186/s13089-021-00242-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/24/2021] [Indexed: 11/18/2022] Open
Abstract
Background Lack of training is currently the most common barrier to implementation of point-of-care ultrasound (POCUS) use in clinical practice, and in-person POCUS continuing medical education (CME) courses have been paramount in improving this training gap. Due to travel restrictions and physical distancing requirements during the COVID-19 pandemic, most in-person POCUS training courses were cancelled. Though tele-ultrasound technology has existed for several years, use of tele-ultrasound technology to deliver hands-on training during a POCUS CME course has not been previously described. Methods We conducted a retrospective observational study comparing educational outcomes, course evaluations, and learner and faculty feedback from in-person versus tele-ultrasound POCUS courses. The same POCUS educational curriculum was delivered to learners by the two course formats. Data from the most recent pre-pandemic in-person course were compared to tele-ultrasound courses during the COVID-19 pandemic. Results Pre- and post-course knowledge test scores of learners from the in-person (n = 88) and tele-ultrasound course (n = 52) were compared. Though mean pre-course knowledge test scores were higher among learners of the tele-ultrasound versus in-person course (78% vs. 71%; p = 0.001), there was no significant difference in the post-course test scores between learners of the two course formats (89% vs. 87%; p = 0.069). Both learners and faculty rated the tele-ultrasound course highly (4.6–5.0 on a 5-point scale) for effectiveness of virtual lectures, tele-ultrasound hands-on scanning sessions, and course administration. Faculty generally expressed less satisfaction with their ability to engage with learners, troubleshoot image acquisition, and provide feedback during the tele-ultrasound course but felt learners completed the tele-ultrasound course with a better basic POCUS skillset. Conclusions Compared to a traditional in-person course, tele-ultrasound POCUS CME courses appeared to be as effective for improving POCUS knowledge post-course and fulfilling learning objectives. Our findings can serve as a roadmap for educators seeking guidance on development of a tele-ultrasound POCUS training course whose demand will likely persist beyond the COVID-19 pandemic. Supplementary Information The online version contains supplementary material available at 10.1186/s13089-021-00242-6.
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Affiliation(s)
- Nilam J Soni
- South Texas Veterans Health Care System, San Antonio, TX, USA. .,Department of Medicine, UT Health San Antonio, San Antonio, TX, USA. .,University of Texas Health San Antonio, South Texas Veterans Health Care System, 7703 Floyd Curl Drive, MC 7982, San Antonio, TX, 78229, USA.
| | - Jeremy S Boyd
- Department of Emergency Medicine, Veterans Affairs - Tennessee Valley Healthcare System, Nashville, TN, USA.,Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory Mints
- Division of Hospital Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Kevin C Proud
- South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Trevor P Jensen
- Division of Hospital Medicine, University of California San Francisco Medical Center at Parnassus, San Francisco, CA, USA
| | - Gigi Liu
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Benji K Mathews
- Department of Hospital Medicine, Regions Hospital, HealthPartners, St. Paul, MN, USA
| | - Christopher K Schott
- Department of Critical Care Medicine, Veterans Affairs of Pittsburgh Health Care System, Pittsburgh, PA, USA.,Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Linda Kurian
- Division of Hospital Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Charles M LoPresti
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Phil Andrus
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Robert Nathanson
- South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Natalie Smith
- South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Elizabeth K Haro
- South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Michael J Mader
- South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Jacqueline Pugh
- Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Marcos I Restrepo
- South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Brian P Lucas
- White River Junction VA Medical Center, White River Junction, VT, USA.,Department of Medicine, Dartmouth Geisel School of Medicine, Hanover, NH, USA
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13
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Schott CK, LoPresti CM, Boyd JS, Core M, Haro EK, Mader MJ, Pascual S, Finley EP, Lucas BP, Colon-Molero A, Restrepo MI, Pugh J, Soni NJ. Retention of Point-of-Care Ultrasound Skills Among Practicing Physicians: Findings of the VA National POCUS Training Program. Am J Med 2021; 134:391-399.e8. [PMID: 32931765 DOI: 10.1016/j.amjmed.2020.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/07/2020] [Accepted: 08/22/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) use continues to increase in many specialties, but lack of POCUS training is a known barrier among practicing physicians. Many physicians are obtaining POCUS training through postgraduate courses, but the impact of these courses on skill retention and frequency of POCUS use post-course is unknown. The purpose of this study was to assess the change in POCUS knowledge, skills, and frequency of use after 6-9 months of participating in a brief training course. METHODS Course participants' POCUS knowledge and hands-on technical skills were tested pre-course using an online, 30-question knowledge test and a directly observed skills test, respectively. The same knowledge and skills tests were repeated immediately post-course and after 6-9 months using remote tele-ultrasound software. Course participants completed a survey on their POCUS use pre-course and after 6-9 months post-course. RESULTS There were 127 providers who completed the POCUS training course from October 2016 to November 2017. Knowledge test scores increased from a median of 60% to 90% immediately post-course followed by a slight decrease to 87% after 8 months post-course. Median skills test scores for 4 common POCUS applications (heart, lung, abdomen, vascular access) increased 36-74 points from pre-course to immediately post-course with a 2-7-point decrease after 8 months. Providers reported more frequent POCUS use post-course, which suggests application of their POCUS knowledge and skills in clinical practice. More frequent use of cardiac POCUS applications was associated with significantly greater retention of cardiac skills at 8 months. CONCLUSIONS Practicing physicians can retain POCUS knowledge and hands-on skills 8 months after participating in a 2.5-day POCUS training course, regardless of frequency of POCUS use post-course.
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Affiliation(s)
- Christopher K Schott
- Department of Critical Care Medicine, Veterans Affairs of Pittsburgh Health Care System, Pittsburgh, Pa; Department of Critical Care Medicine and Emergency Medicine, University of Pittsburgh and University of Pittsburgh Medical Center (UPMC), Pa.
| | - Charles M LoPresti
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Ohio; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jeremy S Boyd
- Department of Emergency Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville; Department of Emergency Medicine, Vanderbilt University, Nashville, Tenn
| | - Megan Core
- Department of Emergency Medicine Service, Orlando Veterans Affairs Medical Center, Fla; Department of Medicine, University of Central Florida College of Medicine, Orlando
| | - Elizabeth K Haro
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, Texas
| | - Michael J Mader
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, Texas
| | | | - Erin P Finley
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, Texas
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vt; Department of Medicine, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Angel Colon-Molero
- VHA Specialty Care Service, Veterans Affairs Central Office (VACO), Washington, DC
| | - Marcos I Restrepo
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, Texas
| | - Jacqueline Pugh
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, Texas
| | - Nilam J Soni
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, Texas
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14
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Lonhart JA, Edwards AR, Agarwal S, Lucas BP, Schroeder AR. Consent Rates Reported in Published Pediatric Randomized Controlled Trials. J Pediatr 2020; 227:281-287. [PMID: 32599033 DOI: 10.1016/j.jpeds.2020.06.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/19/2020] [Accepted: 06/19/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the average reported consent rate for published pediatric randomized controlled trials (RCTs) and whether this rate varies by trial characteristics. STUDY DESIGN A review of pediatric RCTs published in Medline in 2009, 2010, or 2015 was performed. Secondary analyses of prior trials, trials including adults, trials not requiring consent, or trials with missing or unclear consent data were excluded. Consent rate was defined as the number of patients enrolled divided by number of eligible patients where families were approached. Random effects meta-regression was conducted to determine the weighted average consent rate. RESULTS Of 2347 trials identified, 1651 were excluded. An additional 418 of 696 (60%) were excluded because the consent rate was missing or unclear. The average consent rate for 278 included RCTs was 82.6% (95% CI, 80.3%-84.8%) and was higher for vaccination compared with behavioral trials and for industry-funded compared with National Institutes of Health-funded or other government-funded trials. The average consent rate was <70% for 26% of included trials. Of these trials, US trials (28/77 [36.4%]) had a higher probability of a consent rate of <70% than non-US studies (35/64 [21.3%]) and multinational (9/37 [24.3%]) studies. There was slight variation by funding category. CONCLUSIONS Although the average consent rate for published trials was reasonably high, approximately one-quarter of trials had consent rates of <70%. Consent rates reporting has improved over time, but remains suboptimal. Our findings should assist with the planning of future pediatric RCTs, although consent data from unpublished trials are also needed.
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Affiliation(s)
| | | | - Swati Agarwal
- Department of Pediatrics, Inova Children's Hospital, Falls Church, VA
| | - Brian P Lucas
- The Dartmouth Institute of Health Policy & Clinical Practice, Hanover, NH
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15
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Abstract
This cross-sectional study examines the association between article citations, Altmetric attention scores, and cumulative page views of pediatric research articles from 4 high-impact medical journals.
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Affiliation(s)
- Andrew J. Giustini
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, California
| | - David M. Axelrod
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Brian P. Lucas
- Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- White River Junction Veterans Affairs Hospital, White River Junction, Virginia
| | - Alan R. Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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16
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Maw AM, Lucas BP, Sirovich BE, Soni NJ. Discharge-ready volume status in acute decompensated heart failure: a survey of hospitalists. J Community Hosp Intern Med Perspect 2020; 10:199-203. [PMID: 32850065 PMCID: PMC7426988 DOI: 10.1080/20009666.2020.1759867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Acute decompensated heart failure is the leading cause of hospitalization in older adults. Clinical practice guidelines recommend patients should be euvolemic at hospital discharge – yet accurate assessment of volume status is recognized to be exceptionally challenging. This conundrum led us to investigate how hospitalists are assessing volume status and discharge- readiness of patients hospitalized with heart failure. We collected audience response data during a didactic heart failure presentation at the 2019 Society of Hospital Medicine annual meeting. Respondents (n = 216), 76% of whom were practicing physician hospitalists caring for more than 20 acute heart failure patients per year, were presented six questions. Eighteen percent of respondents reported not being able to determine the completeness of decongestion on discharge and 32% reported that complete decongestion was not a treatment target. These findings suggest important differences between guideline recommendations and how hospitalists treat heart failure in current clinical practice.
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Affiliation(s)
- Anna M Maw
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Brian P Lucas
- Department of Medicine, White River Junction VA Medical Center, White River Junction, VT, USA.,Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Brenda E Sirovich
- Department of Medicine, White River Junction VA Medical Center, White River Junction, VT, USA.,Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Nilam J Soni
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA.,Division of Pulmonary and Critical Care Medicine and Division of General and Hospital Medicine, The University of Texas School of Medicine at San Antonio, San Antonio, TX, USA
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17
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Bradley JM, Lucas BP. MISSION Possible, but Incomplete: Pairing Better Access with Better Transitions in Veteran Care. J Hosp Med 2020; 15:188-189. [PMID: 32155408 PMCID: PMC7064301 DOI: 10.12788/jhm.3361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/17/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Joel M Bradley
- White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Children’s Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire
- Corresponding Author: Joel Bradley, MD; E-mail: ; Telephone: 802-295-9363 extension 5990; Twitter: @bradleyhashtag
| | - Brian P Lucas
- White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire
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18
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Anstey J, Lucas BP. Worry Loves Company, but Unnecessary Consultations May Harm the Patients We Comanage. J Hosp Med 2020; 15:60-61. [PMID: 31869302 PMCID: PMC6932593 DOI: 10.12788/jhm.3304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/09/2019] [Accepted: 08/09/2019] [Indexed: 11/20/2022]
Affiliation(s)
- James Anstey
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire
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Affiliation(s)
- Benjamin Mba
- Department of Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois
| | - Brian P Lucas
- Department of Medicine, White River Junction Veterans Affairs Medical Center, White River Junction, Vermont
| | - Nathan Houchens
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Udit Joshi
- Department of Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois
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20
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Trooboff SW, Wanken ZJ, Gladders B, Lucas BP, Moore KO, Barnes JA, Sedrakyan A, Columbo JA, Suckow BD, Stone DH, Goodney PP. Characterizing Reimbursements for Medicare Patients Receiving Endovascular Abdominal Aortic Aneurysm Repair at Vascular Quality Initiative Centers. Ann Vasc Surg 2019; 62:148-158. [PMID: 31610277 DOI: 10.1016/j.avsg.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 09/09/2019] [Accepted: 09/21/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVR) has a major financial impact on health care systems. We characterized reimbursement for index EVR hospitalizations among Medicare beneficiaries having surgery at Vascular Quality Initiative (VQI) centers. METHODS We linked Medicare claims to VQI clinical registry data for patients undergoing EVR from 2003 to 2015. Analysis was limited to patients fully covered by fee-for-service Medicare parts A and B in the year of their operation and assigned a corresponding diagnosis-related group for EVR. The primary outcome was Medicare's reimbursement for inpatient hospital and professional services, adjusted to 2015 dollars. We performed descriptive analysis of reimbursement over time and univariate analysis to evaluate patient demographics, clinical characteristics, procedural variables, and postoperative events associated with reimbursement. This informed a multilevel regression model used to identify factors independently associated with EVR reimbursement and quantify VQI center-level variation in reimbursement. RESULTS We studied 9,403 Medicare patients who underwent EVR at VQI centers during the study period. Reimbursements declined from $37,450 ± $9,350 (mean ± standard deviation) in 2003 to $27,723 ± $10,613 in 2015 (test for trend, P < 0.001). For patients experiencing a complication (n = 773; 8.2%), mean reimbursement for EVR was $44,858 ± $23,825 versus $28,857 ± $9,258 for those without complications (P < 0.001). Intestinal ischemia, new dialysis requirement, and respiratory compromise each doubled Medicare's average reimbursement for EVR. After adjusting for diagnosis-related group, several patient-level factors were independently associated with higher Medicare reimbursement; these included ruptured abdominal aortic aneurysm (+$2,372), additional day in length of stay (+$1,275), and being unfit for open repair (+$501). Controlling for patient-level factors, 4-fold variation in average reimbursement was seen across VQI centers. CONCLUSIONS Reimbursement for EVR declined between 2003 and 2015. We identified preoperative clinical factors independently associated with reimbursement and quantified the impact of different postoperative complications on reimbursement. More work is needed to better understand the substantial variation observed in reimbursement at the center level.
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Affiliation(s)
- Spencer W Trooboff
- VA National Quality Scholars Program, Veterans Health Administration, White River Junction, VT; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; Department of Surgery, Section of General Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
| | - Zachary J Wanken
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Barbara Gladders
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Brian P Lucas
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; White River Junction Veterans Affairs Medical Center, White River Junction, VT
| | - Kayla O Moore
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - J Aaron Barnes
- Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Art Sedrakyan
- Department of Health Care Policy and Research, Weill Cornell Medicine, New York, NY
| | - Jesse A Columbo
- Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Bjoern D Suckow
- Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - David H Stone
- Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Department of Surgery, Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
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21
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Soni NJ, Franco-Sadud R, Kobaidze K, Schnobrich D, Salame G, Lenchus J, Kalidindi V, Mader MJ, Haro EK, Dancel R, Cho J, Grikis L, Lucas BP. Recommendations on the Use of Ultrasound Guidance for Adult Lumbar Puncture: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:591-601. [PMID: 31251163 PMCID: PMC6817310 DOI: 10.12788/jhm.3197] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
When ultrasound equipment is available, along with providers who are appropriately trained to use it, we recommend that ultrasound guidance should be used for site selection of lumbar puncture to reduce the number of needle insertion attempts and needle redirections and increase the overall procedure success rates, especially in patients who are obese or have difficult-to-palpate landmarks. We recommend that ultrasound should be used to more accurately identify the lumbar spine level than physical examination in both obese and nonobese patients. We suggest using ultrasound for selecting and marking a needle insertion site just before performing lumbar puncture in either a lateral decubitus or sitting position. The patient should remain in the same position after marking the needle insertion site. We recommend that a low-frequency transducer, preferably a curvilinear array transducer, should be used to evaluate the lumbar spine and mark a needle insertion site. A high-frequency linear array transducer may be used in nonobese patients. We recommend that ultrasound should be used to map the lumbar spine, starting at the level of the sacrum and sliding the transducer cephalad, sequentially identifying the lumbar spine interspaces. We recommend that ultrasound should be used in a transverse plane to mark the midline of the lumbar spine and in a longitudinal plane to mark the interspinous spaces. The intersection of these two lines marks the needle insertion site. We recommend that ultrasound should be used during a preprocedural evaluation to measure the distance from the skin surface to the ligamentum flavum from a longitudinal paramedian view to estimate the needle insertion depth and ensure that a spinal needle of adequate length is used. We recommend that novices should undergo simulation-based training, where available, before attempting ultrasound-guided lumbar puncture on actual patients. We recommend that training in ultrasound-guided lumbar puncture should be adapted based on prior ultrasound experience, as learning curves will vary. We recommend that novice providers should be supervised when performing ultrasound-guided lumbar puncture before performing the procedure independently on patients.
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Affiliation(s)
- Nilam J Soni
- Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
- Corresponding Author: Nilam J Soni, MD, MSc; E-mail: ; Telephone: 210-743-6030
| | - Ricardo Franco-Sadud
- Division of Hospital Medicine, Naples Community Hospital, Naples, Florida
- Department of Medicine, University of Central Florida College of Medicine, Orlando, Florida
| | - Ketino Kobaidze
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta,
Georgia
| | - Daniel Schnobrich
- Divisions of General Internal Medicine and Hospital Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Gerard Salame
- Division of Hospital Medicine, University of Colorado and Denver Health and Hospital Authority, Denver, Colorado
| | - Joshua Lenchus
- Division of Hospital Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Michael J Mader
- Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Elizabeth K Haro
- Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Ria Dancel
- Division of Hospital Medicine, University of North Carolina, Chapel Hill, North Carolina
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Joel Cho
- Department of Hospital Medicine, Kaiser Permanente Medical Center, San Francisco, California
| | - Loretta Grikis
- White River Junction VA Medical Center, White River Junction, Vermont
| | | | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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Wang ME, Biondi EA, McCulloh RJ, Garber MD, Natt BC, Lucas BP, Schroeder AR. Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis. Pediatrics 2019; 144:peds.2018-3979. [PMID: 31395621 DOI: 10.1542/peds.2018-3979] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To determine factors associated with cerebrospinal fluid (CSF) testing in febrile young infants with a positive urinalysis and assess the probability of delayed diagnosis of bacterial meningitis in infants treated for urinary tract infection (UTI) without CSF testing. METHODS We performed a retrospective cohort study using data from the Reducing Excessive Variability in Infant Sepsis Evaluation quality improvement project. A total of 20 570 well-appearing febrile infants 7 to 60 days old presenting to 124 hospitals from 2015 to 2017 were included. A mixed-effects logistic regression was conducted to determine factors associated with CSF testing. Delayed meningitis was defined as a new diagnosis of bacterial meningitis within 7 days of discharge. RESULTS Overall, 3572 infants had a positive urinalysis; 2511 (70.3%) underwent CSF testing. There was wide variation by site, with CSF testing rates ranging from 64% to 100% for infants 7 to 30 days old and 10% to 100% for infants 31 to 60 days old. Factors associated with CSF testing included: age 7 to 30 days (adjusted odds ratio [aOR]: 4.6; 95% confidence interval [CI]: 3.8-5.5), abnormal inflammatory markers (aOR: 2.2; 95% CI: 1.8-2.5), and site volume >300 febrile infants per year (aOR: 1.8; 95% CI: 1.2-2.6). Among 505 infants treated for UTI without CSF testing, there were 0 (95% CI: 0%-0.6%) cases of delayed meningitis. CONCLUSIONS There was wide variation in CSF testing in febrile infants with a positive urinalysis. Among infants treated for UTI without CSF testing (mostly 31 to 60-day-old infants), there were no cases of delayed meningitis within 7 days of discharge, suggesting that routine CSF testing of infants 31 to 60 days old with a positive urinalysis may not be necessary.
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Affiliation(s)
- Marie E Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children's Hospital Stanford and School of Medicine, Stanford University, Stanford, California;
| | - Eric A Biondi
- Division of Pediatric Hospital Medicine, Johns Hopkins Children's Center and School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Russell J McCulloh
- Division of Pediatric Hospital Medicine, University of Nebraska Medical Center and Children's Hospital and Medical Center, Omaha, Nebraska
| | - Matthew D Garber
- Division of Hospital Pediatrics, Department of Pediatrics, College of Medicine, University of Florida, Jacksonville, Florida
| | - Beth C Natt
- Department of Pediatrics, School of Medicine, University of Connecticut, Farmington, Connecticut; and
| | - Brian P Lucas
- The Dartmouth Institute for Health Policy and Clinical Practice and Department of Medicine, School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Alan R Schroeder
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children's Hospital Stanford and School of Medicine, Stanford University, Stanford, California
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Franco-Sadud R, Schnobrich D, Mathews BK, Candotti C, Abdel-Ghani S, Perez MG, Rodgers SC, Mader MJ, Haro EK, Dancel R, Cho J, Grikis L, Lucas BP, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:E1-E22. [PMID: 31561287 DOI: 10.12788/jhm.3287] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 02/02/2023]
Abstract
PREPROCEDURE 1)We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure. 2)We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures. 3)We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection. 4)We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation. TECHNIQUES General Techniques 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures. 6)We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience. 7)We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures. 8)We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation. 9)To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. Central Venous Access Techniques 10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion. 11)We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion. 12)We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates. 13)We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques. 14)We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates. Peripheral Venous Access Techniques 15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques. 16)We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access. 17)We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access. Arterial Access Techniques 18)We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques. 19)We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications. 20)We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques. POSTPROCEDURE 21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs. 22)We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise. TRAINING 23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients. 24)We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency. 25)We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important. 26)We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically. 27)We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools. 28)We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation. 29)We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.
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Affiliation(s)
| | - Daniel Schnobrich
- Divisions of General Internal Medicine and Hospital Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Benji K Mathews
- Department of Hospital Medicine, Regions Hospital, Health Partners, St. Paul, Minnesota
| | - Carolina Candotti
- Division of Hospital Medicine, University of California Davis, Davis, California
| | - Saaid Abdel-Ghani
- Department of Hospital Medicine, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Martin G Perez
- Department of Hospital Medicine, Memorial Hermann Northeast Hospital, Humble, Texas
| | - Sophia Chu Rodgers
- Division of Pulmonary Critical Care Medicine, Lovelace Health Systems, Albuquerque, New Mexico
| | - Michael J Mader
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Elizabeth K Haro
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Ria Dancel
- Division of Hospital Medicine, University of North Carolina, Chapel Hill, North Carolina
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Joel Cho
- Department of Hospital Medicine, Kaiser Permanente Medical Center, San Francisco, California
| | - Loretta Grikis
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | | | - Nilam J Soni
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
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24
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LoPresti CM, Boyd JS, Schott C, Core M, Lucas BP, Colon-Molero A, Kessler C, Mader MJ, Haro EK, Finley EP, Restrepo MI, Pugh J, Soni NJ. A National Needs Assessment of Point-of-Care Ultrasound Training for Hospitalists. Mayo Clin Proc 2019; 94:1910-1912. [PMID: 31486389 DOI: 10.1016/j.mayocp.2019.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Charles M LoPresti
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jeremy S Boyd
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN; Department of Emergency Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Christopher Schott
- Critical Care Service, Veterans Affairs Pittsburgh Health Care Systems, PA; Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh, PA
| | - Megan Core
- Department of Emergency Medicine Service, Orlando Veterans Affairs Medical Center, FL; Department of Medicine, University of Central Florida College of Medicine, Orlando, FL
| | - Brian P Lucas
- Medicine Service, White River Junction Veterans Affairs Medical Center, VT; Department of Medicine, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Angel Colon-Molero
- Veterans Health Administration Specialty Care Service, Veterans Affairs Central Office, Washington, DC
| | - Chad Kessler
- Department of Medicine, Duke University School of Medicine, Durham, NC; Primary Care Service, Durham Veterans Affairs Health Care System, NC
| | - Michael J Mader
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, TX
| | - Elizabeth K Haro
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, TX
| | - Erin P Finley
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, TX
| | - Marcos I Restrepo
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, TX
| | - Jacqueline Pugh
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, TX
| | - Nilam J Soni
- Medicine Service, South Texas Veterans Health Care System, San Antonio; Department of Medicine, UT Health San Antonio, TX
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25
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Lucas BP, D'Addio A, Block C, Manning H, Remillard B, Leiter JC. Limited agreement between two noninvasive measurements of blood volume during fluid removal: ultrasound of inferior vena cava and finger-clip spectrophotometry of hemoglobin concentration. Physiol Meas 2019; 40:065003. [PMID: 31091520 DOI: 10.1088/1361-6579/ab21af] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Plots of blood volume measurements over time (profiles) may identify euvolemia during fluid removal for acute heart failure. We assessed agreement between two noninvasive measurements of blood volume profiles during mechanical fluid removal, which exemplifies the interstitial fluid shifts that occur during diuretic-induced fluid removal. APPROACH During hemodialysis we compared change in maximum diameter of the inferior vena cava by ultrasound ([Formula: see text]) to change in relative blood volume derived from capillary hemoglobin concentration from finger-clip spectrophotometry (RBVSpHb). We grouped profiles of these measurements into three distinct shapes using an unbiased, data-driven modeling technique. METHODS Fifty patients who were not in acute heart failure underwent a mean of five paired measurements while an average of 1.3 liters of fluid was removed over 2 h during single hemodialysis sessions. [Formula: see text] changed -1.0 mm (95% CI -1.9 to -0.2 mm) and the RBVSpHb changed -1.1% (95% CI -2.7 to +0.5%), but these changes were not correlated (r -0.04, 95% CI -0.32 to +0.24). Nor was there agreement between categorization of profiles of change in the two measurements (kappa -0.1, 95% CI -0.3 to +0.1). SIGNIFICANCE [Formula: see text] and RBVSpHb estimates of blood volume do not agree during mechanical fluid removal, likely because regional changes in blood flow and pressure modify IVC dimensions as well as changes total blood volume.
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Affiliation(s)
- Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, VT, United States of America. Geisel School of Medicine at Dartmouth College, Hanover, NH, United States of America. Author to whom any correspondence should be addressed. White River Junction VA Medical Center, 215 N Main Street, White River Junction, VT, United States of America
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26
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Affiliation(s)
- James Anstey
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire
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27
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Boyd JS, LoPresti CM, Core M, Schott C, Mader MJ, Lucas BP, Haro EK, Finley EP, Restrepo MI, Kessler C, Colon-Molero A, Pugh J, Soni NJ. Current use and training needs of point-of-care ultrasound in emergency departments: A national survey of VA hospitals. Am J Emerg Med 2019; 37:1794-1797. [PMID: 30878406 DOI: 10.1016/j.ajem.2019.02.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/25/2019] [Accepted: 02/28/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jeremy S Boyd
- VA Tennessee Valley Healthcare System-Nashville, Department of Emergency Medicine, Nashville, TN, USA; Vanderbilt University, Department of Emergency Medicine, Nashville, TN, USA.
| | - Charles M LoPresti
- Louis Stokes Cleveland VA Medical Center, Medicine Service, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Department of Medicine, Cleveland, OH, USA.
| | - Megan Core
- Orlando VA Medical Center, Department of Emergency Medicine, Orlando, FL, USA; University of Central Florida College of Medicine, Department of Medicine, Orlando, FL, USA
| | - Christopher Schott
- VA Pittsburgh Health Care Systems, Critical Care Service, Pittsburgh, PA, USA; University of Pittsburgh, Departments of Critical Care Medicine and Emergency Medicine, Pittsburgh, PA, USA.
| | - Michael J Mader
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; UT Health San Antonio, Division of General & Hospital Medicine, San Antonio, TX, USA.
| | - Brian P Lucas
- White River Junction VA Medical Center, Medicine Service, White River, Junction, VT, USA; Dartmouth Geisel School of Medicine, Department of Medicine, Hanover, NH, USA.
| | - Elizabeth K Haro
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; UT Health San Antonio, Division of General & Hospital Medicine, San Antonio, TX, USA; (m) UT Health San Antonio, Division of Pulmonary & Critical Care Medicine, San Antonio, TX, USA.
| | - Erin P Finley
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; UT Health San Antonio, Division of General & Hospital Medicine, San Antonio, TX, USA.
| | - Marcos I Restrepo
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; (m) UT Health San Antonio, Division of Pulmonary & Critical Care Medicine, San Antonio, TX, USA.
| | - Chad Kessler
- Durham VA Health Care System, Primary Care Service, Durham, NC, USA; Duke University School of Medicine, Department of Medicine, Durham, NC, USA.
| | | | - Jacqueline Pugh
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; UT Health San Antonio, Division of General & Hospital Medicine, San Antonio, TX, USA.
| | - Nilam J Soni
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; UT Health San Antonio, Division of General & Hospital Medicine, San Antonio, TX, USA; (m) UT Health San Antonio, Division of Pulmonary & Critical Care Medicine, San Antonio, TX, USA.
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Schroeder AR, Lucas BP, Garber MD, McCulloh RJ, Joshi-Patel AA, Biondi EA. Negative Urinalyses in Febrile Infants Age 7 to 60 Days Treated for Urinary Tract Infection. J Hosp Med 2019; 14:101-104. [PMID: 30785417 DOI: 10.12788/jhm.3120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The role of the urinalysis (UA) in the management of young, febrile infants is controversial. To assess how frequently infants are treated for urinary tract infection (UTI) despite having normal UA values and to compare the characteristics of infants treated for UTI who have positive versus negative UAs, we reviewed 20,570 wellappearing febrile infants 7-60 days of age evaluated at 124 hospitals in the United States who were included in a national quality improvement project. Of 19,922 infants without bacteremia and meningitis, 2,407 (12.1%) were treated for UTI, of whom 2,298 (95.5%) had an initial UA performed. UAs were negative in 337/2,298 (14.7%) treated subjects. The proportion of infants treated for UTI with negative UAs ranged from 0%-35% across hospitals. UA-negative subjects were more likely to have respiratory symptoms and less likely to have abnormal inflammatory markers than UA+ subjects, indicating that they are mounting less of an inflammatory response to their underlying illness and/or might have contaminated specimens or asymptomatic bacteriuria.
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Affiliation(s)
- Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA.
| | - Brian P Lucas
- Department of Medicine, White River Junction Vermont VAMC and Geisel Medicine School at Dartmouth, Hanover, New Hampshire, USA
| | - Matthew D Garber
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Russell J McCulloh
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, Missouri, USA
| | | | - Eric A Biondi
- Department of Pediatrics, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Cho J, Jensen TP, Reierson K, Mathews BK, Bhagra A, Franco-Sadud R, Grikis L, Mader M, Dancel R, Lucas BP, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:E7-E15. [PMID: 30604780 PMCID: PMC8021127 DOI: 10.12788/jhm.3095] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding. 2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. 3. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure. 4. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed. 5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs. 6. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory. 7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory. 8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure. 9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access. 10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis. 11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasoundguided paracentesis. 12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.
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Affiliation(s)
- Joel Cho
- Department of Hospital Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA.
| | - Trevor P Jensen
- Division of Hospital Medicine, University of California San Francisco Medical Center at Parnassus, San Francisco, California, USA
| | - Kreegan Reierson
- Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota, USA
| | - Benji K Mathews
- Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota, USA
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Anjali Bhagra
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ricardo Franco-Sadud
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Loretta Grikis
- White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Michael Mader
- Divisions of General and Hospital Medicine and Pulmonary and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Ria Dancel
- Division of Hospital Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Brian P Lucas
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | | | - Nilam J Soni
- Divisions of General and Hospital Medicine and Pulmonary and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
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Soni NJ, Schnobrich D, Mathews BK, Tierney DM, Jensen TP, Dancel R, Cho J, Dversdal RK, Mints G, Bhagra A, Reierson K, Kurian LM, Liu GY, Candotti C, Boesch B, LoPresti CM, Lenchus J, Wong T, Johnson G, Maw AM, Franco-Sadud R, Lucas BP. Point-of-Care Ultrasound for Hospitalists: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:E1-E6. [PMID: 30604779 PMCID: PMC8021128 DOI: 10.12788/jhm.3079] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Many hospitalists incorporate point-of-care ultrasound (POCUS) into their daily practice to answer specific diagnostic questions or to guide performance of invasive bedside procedures. However, standards for hospitalists in POCUS training and assessment are not yet established. Most internal medicine residency training programs, the major pipeline for incoming hospitalists, have only recently begun to incorporate POCUS in their curricula. The purpose of this document is to inform a broad audience on what POCUS is and how hospitalists are using it. This document is intended to provide guidance for the hospitalists who use POCUS and administrators who oversee its use. We discuss POCUS 1) applications, 2) training, 3) assessments, and 4) program management. Practicing hospitalists must continue to collaborate with their local credentialing bodies to outline requirements for POCUS use. Hospitalists should be integrally involved in decision-making processes surrounding POCUS program management.
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Affiliation(s)
- Nilam J Soni
- Division of General and Hospital Medicine, The University of Texas Health San Antonio, San Antonio, Texas, USA.
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Daniel Schnobrich
- Divisions of General Internal Medicine and Hospital Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Benji K Mathews
- Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota, USA
| | - David M Tierney
- Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Trevor P Jensen
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Ria Dancel
- Division of Hospital Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Joel Cho
- Department of Hospital Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California; USA
| | - Renee K Dversdal
- Division of Hospital Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Gregory Mints
- Division of Hospital Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Anjali Bhagra
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kreegan Reierson
- Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota, USA
| | - Linda M Kurian
- Division of Hospital Medicine, Zucker School of Medicine at Hofstra Northwell, New Hyde Park, New York, USA
| | - Gigi Y Liu
- Hospitalist Program, Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Carolina Candotti
- Division of Hospital Medicine, University of California Davis, Davis, California, USA
| | - Brandon Boesch
- Division of Hospital Medicine, Alameda Health System-Highland Hospital, Oakland, California, USA
| | - Charles M LoPresti
- Louis Stokes Cleveland Veterans Affairs Hospital, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Joshua Lenchus
- Division of Hospital Medicine, University of Miami, Miami, Florida, USA
| | - Tanping Wong
- Division of Hospital Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Gordon Johnson
- Division of Hospital Medicine, Legacy Healthcare System, Portland, Oregon, USA
| | - Anna M Maw
- Division of Hospital Medicine, University of Colorado, Aurora, Colorado, USA
| | | | - Brian P Lucas
- White River Junction VA Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
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Lucas BP, Tierney DM, Jensen TP, Dancel R, Cho J, El-Barbary M, Franco-Sadud R, Soni NJ. Credentialing of Hospitalists in Ultrasound-Guided Bedside Procedures: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2018; 13:117-125. [PMID: 29340341 DOI: 10.12788/jhm.2917] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Ultrasound guidance is used increasingly to perform the following 6 bedside procedures that are core competencies of hospitalists: abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis. Yet most hospitalists have not been certified to perform these procedures, whether using ultrasound guidance or not, by specialty boards or other institutions extramural to their own hospitals. Instead, hospital privileging committees often ask hospitalist group leaders to make ad hoc intramural certification assessments as part of credentialing. Given variation in training and experience, such assessments are not straightforward "sign offs." We thus convened a panel of experts to conduct a systematic review to provide recommendations for credentialing hospitalist physicians in ultrasound guidance of these 6 bedside procedures. Pathways for initial and ongoing credentialing are proposed. A guiding principle of both is that certification assessments for basic competence are best made through direct observation of performance on actual patients.
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Affiliation(s)
- Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA.
| | - David M Tierney
- Abbott Northwestern Hospital, Department of Medical Education, Minneapolis, Minnesota, USA
| | - Trevor P Jensen
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Ria Dancel
- Division of Hospital Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Joel Cho
- Division of Hospital Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mahmoud El-Barbary
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Ricardo Franco-Sadud
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nilam J Soni
- Division of General & Hospital Medicine, The University of Texas School of Medicine at San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
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Dancel R, Schnobrich D, Puri N, Franco-Sadud R, Cho J, Grikis L, Lucas BP, El-Barbary M, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Adult Thoracentesis: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2018; 13:126-135. [PMID: 29377972 DOI: 10.12788/jhm.2940] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Executive Summary: 1) We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax. 2) We recommend that ultrasound guidance should be used to increase the success rate of thoracentesis. 3) We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators. 4) We suggest that ultrasound guidance be used to reduce the risk of complications from thoracentesis in mechanically ventilated patients. 5) We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site. 6) We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making. 7) We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage. 8) We suggest that ultrasound be used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth. 9) We suggest that ultrasound be used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax. 10) We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis. 11) We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure. 12) We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique. 13) We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients. 14) Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution.
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Affiliation(s)
- Ria Dancel
- Division of Hospital Medicine, University of North Carolina, Chapel Hill, North Carolina, USA.
- Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Schnobrich
- Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nitin Puri
- Division of Critical Care Medicine Services, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Ricardo Franco-Sadud
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joel Cho
- Department of Hospital Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Loretta Grikis
- White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Brian P Lucas
- White River Junction VA Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Mahmoud El-Barbary
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | | | - Nilam J Soni
- Division of General & Hospital Medicine, The University of Texas School of Medicine at San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
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Abstract
OBJECTIVES Variability exists in the treatment of neonates with urinary tract infection (UTI), potentially reflecting an overuse of resources. A cross-sectional vignette survey was designed to examine variability in physician preferences for intravenous (IV) antibiotic duration, genitourinary imaging, and prophylactic antibiotics and to evaluate drivers of resource use. METHODS The survey was administered to a random sample of pediatricians through the American Medical Association's Physician Masterfile. Respondents were provided with a case vignette of a 2-week-old neonate with a febrile UTI and asked to indicate preferences for IV antibiotic duration and rank drivers of this decision. Respondents were also asked whether they would obtain a voiding cystourethrogram (VCUG) and, regardless of preference, randomly presented with a normal result or bilateral grade II vesicoureteral reflux. The survey was delivered electronically to facilitate skip logic and randomization. RESULTS A total of 279 surveys were completed. Preference for total IV antibiotic duration differed significantly (P < .001) across specialty, with a median duration of 2 days for general pediatricians/hospitalists, 7 days for neonatologists, and 5 days for infectious disease pediatricians. For the 47% (n = 131) who did not want a VCUG, 24/61 (39%) wanted prophylactic antibiotics when presented with grade II vesicoureteral reflux (P < .001). CONCLUSIONS Subspecialty status appeared to be the most influential driver of IV antibiotic duration in the treatment of UTI. A substantial proportion of pediatricians who initially expressed a preference against ordering a VCUG wished to prescribe prophylactic antibiotics when results were abnormal, which suggests that even unwanted diagnostic test results drive treatment decisions.
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Affiliation(s)
- Neha S Joshi
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California;
| | - Brian P Lucas
- White River Junction Veteran's Affairs Medical Center, Hartford, Vermont; and.,Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
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Lucas BP, D’Addio A, Clark J, Block C, Manning H, Remillard B, Leiter JC. Reproducibility of point-of-care ultrasonography for central vein diameter measurement: Separating image acquisition from interpretation. J Clin Ultrasound 2017; 45:488-496. [PMID: 28880382 PMCID: PMC5599119 DOI: 10.1002/jcu.22491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 03/04/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE Central vein point-of-care ultrasonography must be reproducible to detect intravascular volume changes. We sought to determine which measurement step, image acquisition or interpretation, could be more compromising for reproducibility. METHODS Three investigators each acquired inferior vena cava (IVC) and internal jugular (IJV) vein ultrasonographic sequences (US) from a convenience sample of 21 hospitalized general medicine participants and then interpreted each US three separate times. We partitioned the random errors of acquisition and interpretation, attributing wider dispersions of each to larger reductions in reproducibility. RESULTS We analyzed 351 interpretations of 39 IVC and 432 interpretations of 48 IJV US. Reproducibility of the maximum (standard error of measurement 3.3 mm [95% confidence interval, CI 2.7-4.2 mm]) and minimum (4.8 mm [3.9-6.3 mm]) IVC diameter measurements were worse than that of the mediolateral (2.5 mm [2.0-3.2 mm]) and anteroposterior (2.5 mm [2.0-3.1 mm]) IJV diameters. The dispersions of random measurement errors were wider among acquisitions than interpretations. CONCLUSIONS Among our investigators, central vein diameter measurements obtained by point-of-care ultrasonography are not sufficiently reproducible to distinguish clinically meaningful intravascular volume changes from measurement errors. Reproducibility could be most effectively improved by reducing the random measurement errors of acquisition. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:488-496, 2017.
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Affiliation(s)
- Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | | | - Jennifer Clark
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Clay Block
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Harold Manning
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Brian Remillard
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - JC Leiter
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Abstract
Many hospitalists are routinely granted hospital privileges to perform invasive bedside procedures, but criteria for privileging are not well described. We conducted a survey of 21 hospitalist procedure experts from the Society of Hospital Medicine Point-of-Care Ultrasound Task Force to better understand current privileging practices for bedside procedures and how those practices are perceived. Only half of all experts reported their hospitals require a minimum number of procedures performed to grant initial (48%) and ongoing (52%) privileges for bedside procedures. Regardless, most experts thought minimums should be higher than those in current practice and should exist alongside direct observation of manual skills. Experts reported that the use of ultrasound guidance was nearly universal for paracentesis, thoracentesis, and central venous catheter placement, but only 10% of hospitals required the use of ultrasound for initial privileging of these procedures.
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Affiliation(s)
- Trevor P Jensen
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
| | - Nilam J Soni
- Division of Hospital Medicine, Department of Medicine, University of Texas Health School of Medicine at San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - David M Tierney
- Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Brian P Lucas
- Pathology and Laboratory Medicine Service, White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
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Affiliation(s)
- Nilam J Soni
- Division of General & Hospital Medicine, The University of Texas School of Medicine at San Antonio, San Antonio, Texas, USA.
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - David M Tierney
- Abbott Northwestern Hospital, Department of Medical Education, Minneapolis, Minnesota, USA
| | - Trevor P Jensen
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
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Abstract
BACKGROUND Evaluation of the clinical importance of outcomes in research studies is an essential element of clinical decision making. OBJECTIVE To understand how clinicians and trainees weigh the importance of different types of clinical outcomes in drug trials. METHODS A self-administered paper survey contained 4 scenarios asking participants to rate (1, "no proof" to 10, "good proof") the extent to which 4 study outcomes provided "proof that the new drug might help people." Outcomes included (1) a surrogate outcome; (2) a surrogate-enriched composite outcome; (3) stroke mortality; and (4) all-cause mortality. The primary study metrics were mean ratings for each of the 4 outcome types, and the proportion ranking outcome importance of all-cause mortality > stroke mortality > surrogate-enriched composite or surrogate alone. RESULTS A convenience sample of 549 clinicians and trainees at 2 medical centers completed the survey (response rate: 87% medical students, 80% internal medicine residents, 69% general medicine faculty, and 41% physician experts). The surrogate-enriched composite outcome and stroke mortality were rated the most important evidence for benefit (6.6 and 6.4, respectively), with all-cause mortality and a surrogate outcome being rated significantly lower (5.2 and 4.6, respectively). In addition, 48% of clinicians rated improvement in all-cause mortality as more valuable than an improvement in a surrogate marker. Only 21% rated all-cause mortality as more valuable than a surrogate-enriched composite outcome. CONCLUSIONS These findings raise concerns that clinicians and trainees may not interpret trial evidence in a way that promotes the best care for patients.
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Affiliation(s)
- Tanner J. Caverly
- Corresponding author: Tanner J. Caverly, MD, MPH, Veterans Affairs Medical Center, IIID, 2215 Fuller Road, Ann Arbor, MI 48105, 734.222.8958,
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Tchernodrinski S, Lucas BP, Athavale A, Candotti C, Margeta B, Katz A, Kumapley R. Inferior vena cava diameter change after intravenous furosemide in patients diagnosed with acute decompensated heart failure. J Clin Ultrasound 2015; 43:187-193. [PMID: 24897939 DOI: 10.1002/jcu.22173] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 03/03/2014] [Accepted: 05/06/2014] [Indexed: 06/03/2023]
Abstract
PURPOSE Measurement of the inferior vena cava (IVC) diameters may improve decision-making for patients hospitalized with acute decompensated heart failure. Nevertheless, little is known about how the IVC is affected by loop diuretics. We sought to determine if bolus infusions of intravenous furosemide affect IVC diameters measured by hand-carried ultrasonography. METHODS We conducted a prospective cohort study at a public teaching hospital from September 2009 through June 2010. Physician investigators performed IVC ultrasonography on a convenience sample of 70 hospitalized adults who were prescribed intravenous furosemide for the diagnosis of acute decompensated heart failure. RESULTS Participants' median baseline IVC diameter was 2.38 cm (interquartile range, 1.91-2.55 cm). At 1-2 hours after furosemide, IVC diameters decreased an average of 0.21 cm (95% CI, 0.13-0.29 cm) and remained significantly below baseline at 2-3 hours after furosemide by an average of 0.15 cm (95% CI, 0.07-0.22 cm). CONCLUSIONS IVC diameters of adults diagnosed with acute decompensated heart failure become measurably smaller after single doses of intravenous furosemide. Whether this represents a true change in volume status has not been studied.
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Abstract
We review the literature on diagnostic point-of-care ultrasound applications most relevant to hospital medicine and highlight gaps in the evidence base. Diagnostic point-of-care applications most relevant to hospitalists include cardiac ultrasound for left ventricular systolic function, pericardial effusion, and severe mitral regurgitation; lung ultrasound for pneumonia, pleural effusion, pneumothorax, and pulmonary edema; abdominal ultrasound for ascites, aortic aneurysm, and hydronephrosis; and venous ultrasound for central venous volume assessment and lower extremity deep venous thrombosis. Hospitalists and other frontline providers, as well as physician trainees at various levels of training, have moderate to excellent diagnostic accuracy after brief training programs for most of these applications. Despite the evidence supporting the diagnostic accuracy of point-of-care ultrasound, experimental evidence supporting its clinical use by hospitalists is limited to cardiac ultrasound.
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Affiliation(s)
- Nilam J Soni
- Department of Medicine, University of Texas Health Science Center, San Antonio, Texas
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Caverly TJ, Prochazka AV, Combs BP, Lucas BP, Mueller SR, Kutner JS, Binswanger I, Fagerlin A, McCormick J, Pfister S, Matlock DD. Doctors and numbers: an assessment of the critical risk interpretation test. Med Decis Making 2014; 35:512-24. [PMID: 25378297 DOI: 10.1177/0272989x14558423] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 09/26/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Risk interpretation affects decision making. Yet, there is no valid assessment of how clinicians interpret the risk data that they commonly encounter. OBJECTIVE To establish the reliability and validity of a 20-item test of clinicians' risk interpretation. METHODS The Critical Risk Interpretation Test (CRIT) measures clinicians' abilities to 1) modify the interpretation based on meaningful differences in the outcome (e.g., disease specific v. all-cause mortality) and time period (e.g., lifetime v. 10-year mortality), 2) maintain a stable interpretation for different risk framings (e.g., relative v. absolute risk), and 3) correctly interpret how diagnostic testing modifies risk. There were 658 clinicians and medical trainees who participated: 116 nurse practitioners (NPs) at a national conference, 273 medical students at 1 institution, 148 residents in internal medicine at 2 institutions, and 121 internists at 1 institution. Participants completed a self-administered paper test during educational conferences. Seventeen evidence-based medicine experts took the test online and formally assessed content validity. Eighteen second-year medical students were recruited to take the test and a retest 3 weeks later to explore test-retest correlation. RESULTS Expert review supported test clarity and content validity. Factor analysis supported that the CRIT identifies at least 3 separable areas of clinician knowledge. Test-retest correlation was fair (intraclass correlation coefficient = 0.65; standard error = 0.15). Scores on our test correlated with other tests of related abilities. Mean test scores varied among groups, with differences in prior evidence-based medicine training and experience (93 for NPs, 101 for medical students, 101 for residents, 103 for academic internists, and 110 for physician experts; P < 0.001). CONCLUSIONS Our results provide supporting evidence for the reliability and validity of the CRIT as an index of critical risk interpretation abilities, which is acceptable and feasible to administer in an educational setting.
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Affiliation(s)
- Tanner J Caverly
- Veterans Affairs Center for Clinical Management Research, Ann Arbor Veterans Affairs Health System, University of Michigan Medical School, Ann Arbor, MI (TJC, AF)
| | - Allan V Prochazka
- Internal Medicine, University of Colorado School of Medicine, Aurora, CO (AVP, BPC, SRM, JSK, IB, DDM),Ambulatory Care, Denver Veterans Affairs Medical Center, Denver, CO (AVP, JM, SP)
| | - Brandon P Combs
- Internal Medicine, University of Colorado School of Medicine, Aurora, CO (AVP, BPC, SRM, JSK, IB, DDM)
| | - Brian P Lucas
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL (BPL)
| | - Shane R Mueller
- Internal Medicine, University of Colorado School of Medicine, Aurora, CO (AVP, BPC, SRM, JSK, IB, DDM)
| | - Jean S Kutner
- Internal Medicine, University of Colorado School of Medicine, Aurora, CO (AVP, BPC, SRM, JSK, IB, DDM)
| | - Ingrid Binswanger
- Internal Medicine, University of Colorado School of Medicine, Aurora, CO (AVP, BPC, SRM, JSK, IB, DDM)
| | - Angela Fagerlin
- Veterans Affairs Center for Clinical Management Research, Ann Arbor Veterans Affairs Health System, University of Michigan Medical School, Ann Arbor, MI (TJC, AF)
| | - Jacqueline McCormick
- Ambulatory Care, Denver Veterans Affairs Medical Center, Denver, CO (AVP, JM, SP)
| | - Shirley Pfister
- Ambulatory Care, Denver Veterans Affairs Medical Center, Denver, CO (AVP, JM, SP)
| | - Daniel D Matlock
- Internal Medicine, University of Colorado School of Medicine, Aurora, CO (AVP, BPC, SRM, JSK, IB, DDM)
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Baru JS, Lucas BP, Martinez C, Brauner D. Organ Donation among Undocumented Hispanic Immigrants: An Assessment of Knowledge and Attitudes. The Journal of Clinical Ethics 2013. [DOI: 10.1086/jce201324407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Lucas BP, Trick WE, Evans AT, Mba B, Smith J, Das K, Clarke P, Varkey A, Mathew S, Weinstein RA. Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial. JAMA 2012; 308:2199-207. [PMID: 23212497 DOI: 10.1001/jama.2012.36522] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Data are sparse on the effect of varying the durations of internal medicine attending physician ward rotations. OBJECTIVE To compare the effects of 2- vs 4-week inpatient attending physician rotations on unplanned patient revisits, attending evaluations by trainees, and attending propensity for burnout. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized crossover noninferiority trial, with attending physicians as the unit of crossover randomization and 4-week rotations as the active control, conducted in a US university-affiliated teaching hospital in academic year 2009. Participants were 62 attending physicians who staffed at least 6 weeks of inpatient service, the 8892 unique patients whom they discharged, and the 147 house staff and 229 medical students who evaluated their performance. INTERVENTION Assignment to random sequences of 2- and 4-week rotations. MAIN OUTCOME MEASURES Primary outcome was 30-day unplanned revisits (visits to the hospital's emergency department or urgent ambulatory clinic, unplanned readmissions, and direct transfers from neighboring hospitals) for patients discharged from 2- vs 4-week within-attending-physician rotations. Noninferiority margin was a 2% increase (odds ratio [OR] of 1.13) in 30-day unplanned patient revisits. Secondary outcomes were length of stay; trainee evaluations of attending physicians; and attending physician reports of burnout, stress, and workplace control. RESULTS Among the 8892 patients, there were 2437 unplanned revisits. The percentage of 30-day unplanned revisits for patients of attending physicians on 2-week rotations was 21.2% compared with 21.5% for 4-week rotations (mean difference, -0.3%; 95% CI, -1.8% to +1.2%). The adjusted OR of a patient having a 30-day unplanned revisit after 2- vs 4-week rotations was 0.97 (1-sided 97.5% upper confidence limit, 1.07; noninferiority P = .007). Average length of stay was not significantly different (geometric means for 2- vs 4-week rotations were 67.2 vs 67.5 hours; difference, -0.9%; 95% CI, -4.7% to +2.9%). Attending physicians were more likely to score lower in their ability to evaluate trainees after 2- vs 4-week rotations by both house staff (41% vs 28% rated less than perfect; adjusted OR, 2.10; 95% CI, 1.50-3.02) and medical students (82% vs 69% rated less than perfect; adjusted OR, 1.41; 95% CI, 1.06-2.10). They were less likely to report higher scores of both burnout severity (16% vs 35%; adjusted OR, 0.39; 95% CI, 0.26-0.58) and emotional exhaustion (19% vs 37%; adjusted OR, 0.45; 95% CI, 0.31 to 0.64) after 2- vs 4-week rotations. CONCLUSIONS The use of 2-week inpatient attending physician rotations compared with 4-week rotations did not result in an increase in unplanned patient revisits. It was associated with better self-rated measures of attending physician burnout and emotional exhaustion but worse evaluations by trainees. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00930111.
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Affiliation(s)
- Brian P Lucas
- Department of Medicine, Cook County Health and Hospitals System and Rush Medical College, 1900 W Polk St, Room 520, Chicago, IL 60612, USA.
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Lucas BP, Candotti C, Margeta B, Mba B, Kumapley R, Asmar A, Franco-Sadud R, Baru J, Acob C, Borkowsky S, Evans AT. Hand-carried echocardiography by hospitalists: a randomized trial. Am J Med 2011; 124:766-74. [PMID: 21663885 DOI: 10.1016/j.amjmed.2011.03.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 03/03/2011] [Accepted: 03/09/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hospitalists can use hand-carried echocardiography for accurate point-of-care information, but patient outcome data for its application are sparse. METHODS We performed an unblinded, parallel-group randomized trial between July 2008 and March 2009 at one teaching hospital in Chicago, Illinois. We randomly assigned adult general medicine inpatients referred for standard echocardiography with indications investigatable by hand-carried echocardiography to care guided by hand-carried echocardiography or usual care. The main outcome measure was length of stay on the referring hospitalist's service. Secondary outcomes included a before-after analysis of reported changes in management due to hand-carried echocardiography and the diagnostic accuracy of hand-carried echocardiography. RESULTS The difference in length of stay between 226 participants randomized to care guided by hand-carried echocardiography (geometric mean 46.1 hours, interquartile range 29.0-70.9 hours) and 227 participants randomized to usual care (46.9 hours, interquartile range 34.1-68.3 hours) corresponded to a 1.7% reduction in length of stay that was not statistically significant (95% confidence interval, -12.1 to 9.8%). In post hoc subgroup analyses, care guided by hand-carried echocardiography reduced length of stay in participants who were referred for heart failure (P=.0008). Among participants who underwent both hand-carried and standard echocardiography, hospitalists changed management due to hand-carried echocardiography in 37%. Despite the favorable diagnostic accuracy of hand-carried echocardiography, most changes to the timing of hospital discharge occurred after standard echocardiography. CONCLUSION Hospitalist care guided by hand-carried echocardiography for unselected general medicine patients does not meaningfully affect length of stay. Whether or not it affects care quality remains unstudied.
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Affiliation(s)
- Brian P Lucas
- Department of Medicine, Stroger Hospital of Cook County and Rush Medical College, Chicago, IL, USA.
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Lucas BP, Mendes de Leon CF, Prineas RJ, Bienias JL, Evans DA. Relation of cardiac ventricular repolarization and global cognitive performance in a community population. Am J Cardiol 2010; 106:1169-73. [PMID: 20920659 PMCID: PMC2955511 DOI: 10.1016/j.amjcard.2010.06.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 06/02/2010] [Accepted: 06/02/2010] [Indexed: 11/21/2022]
Abstract
Atherosclerosis is a risk factor for dementia. However, little is known about the association between cognitive performance and a widely used indicator of coronary heart disease, at rest electrocardiography. We identified 839 older residents (mean age 81 years, 58% black) from a geographically defined biracial community in Chicago, Illinois, who had undergone extensive cognitive performance testing and met the electrocardiographic eligibility criteria, including a QRS duration of < 120 ms. We then examined multivariate regression coefficients that described the associations between global cognitive performance and 4 novel descriptors of ventricular repolarization waveforms. All analyses were adjusted for age, gender, education, and race. The T wave nondipolar voltage had a significant association with global cognitive performance (p = 0.01), and this association largely remained after adjustment for cardiovascular disease risk factors (p = 0.03). In contrast, global cognitive performance was not significantly associated with the rate-adjusted QT interval, the voltage change from the beginning to end of the ST segment in lead V(5), or the spatial angle between the mean QRS and T wave vectors. In conclusion, the strengths of the associations varied between the novel electrocardiographic descriptors of ventricular repolarization and global cognitive performance. Nevertheless, the significant association observed with T wave nondipolar voltage suggests that the cardiac effects of heart disease are associated with cognitive declines.
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Affiliation(s)
- Brian P Lucas
- Department of Medicine, Cook County Hospital, Chicago, Illinois, USA.
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Lucas BP, Asbury JK, Franco-Sadud R. Training future hospitalists with simulators: a needed step toward accessible, expertly performed bedside procedures. J Hosp Med 2009; 4:395-6. [PMID: 19753567 DOI: 10.1002/jhm.602] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Lucas BP, Candotti C, Margeta B, Evans AT, Mba B, Baru J, Asbury JK, Asmar A, Kumapley R, Patel M, Borkowsky S, Fung S, Charles-Damte M. Diagnostic accuracy of hospitalist-performed hand-carried ultrasound echocardiography after a brief training program. J Hosp Med 2009; 4:340-9. [PMID: 19670355 DOI: 10.1002/jhm.438] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The duration of training needed for hospitalists to accurately perform hand-carried ultrasound echocardiography (HCUE) is uncertain. OBJECTIVE To determine the diagnostic accuracy of HCUE performed by hospitalists after a 27-hour training program. DESIGN Prospective cohort study. SETTING Large public teaching hospital. PATIENTS A total of 322 inpatients referred for standard echocardiography (SE) between March and May 2007. INTERVENTION Blinded to SE results, attending hospitalist physicians performed HCUE within hours of SE. MEASUREMENTS Diagnostic characteristics of HCUE as a test for 6 cardiac abnormalities assessed by SE: left ventricular (LV) systolic dysfunction; severe mitral regurgitation (MR); moderate or severe left atrium (LA) enlargement; moderate or severe LV hypertrophy; medium or large pericardial effusion; and dilatation of the inferior vena cava (IVC). RESULTS A total of 314 patients underwent both SE and HCUE within a median time of 2.8 hours (25th to 75th percentiles, 1.4 to 5.1 hours). Positive and negative likelihood ratios for HCUE increased and decreased, respectively, the prior odds by 5-fold or more for LV systolic dysfunction, severe MR regurgitation, and moderate or large pericardial effusion. Likelihood ratios changed the prior odds by 2-fold or more for moderate or severe LA enlargement, moderate or severe LV hypertrophy, and IVC dilatation. Indeterminate HCUE results occurred in 2% to 6% of assessments. CONCLUSIONS The diagnostic accuracy of HCUE performed by hospitalists after a brief training program was moderate to excellent for 6 important cardiac abnormalities.
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Affiliation(s)
- Brian P Lucas
- Department of Medicine, Stroger Hospital of Cook County and Rush Medical College, Chicago, Illinois, USA.
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Lucas BP, Kumapley R, Mba B, Nisar I, Lee K, Ofori-Ntow S, Borkowsky S, Asmar A, Lewis T, Bienias JL. A hospitalist-run short-stay unit: features that predict length-of-stay and eventual admission to traditional inpatient services. J Hosp Med 2009; 4:276-84. [PMID: 19504489 DOI: 10.1002/jhm.386] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Short-stay units (SSUs) provide an alternative to traditional inpatient services for patients with short anticipated hospital stays. Yet little is known about which patient types predict SSU success. OBJECTIVE To describe patients admitted to our hospitalist-run SSU and explore predictors of length-of-stay (LOS) and eventual admission to traditional inpatient services. DESIGN Prospective observational cohort study. SETTING Large public teaching hospital. PATIENTS Consecutive admissions (n = 755) to the SSU over 4 months. INTERVENTION Hospitalist attending physicians prospectively collected data from patients' histories, physical exams, and medical records upon admission and discharge. MEASUREMENTS Risk assessments were made for patients with our most common provisional diagnoses: possible acute coronary syndrome (ACS) and heart failure. Patient stays were considered successful when LOS was less than 72 hours and eventual admission to traditional inpatient services was not required. RESULTS Of 738 eligible patients, 79% (n = 582) had successful SSU stays. In a multivariable model, the provisional diagnosis of heart failure predicted stays longer than 72 hours (P = 0.007) but risk assessments were unimportant. Patients who received specialty consultations were most likely to need eventual admission (odds ratio [OR], 13.1; 95% confidence interval [CI], 6.9-24.9), and the likelihood of long stays was inversely proportional to the accessibility of diagnostic tests. CONCLUSIONS In our hospitalist-run SSU, the inaccessibility of diagnostic tests and the need for specialty consultations were the most important predictors of unsuccessful stays. Designs for other SSUs that care for mostly low-risk patients should focus on matching patients' diagnostic and consultative needs with readily accessible services.
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Affiliation(s)
- Brian P Lucas
- Division of Hospital Medicine, Department of Medicine, Stroger Hospital of Cook County and Rush Medical College, Chicago, Illinois, USA.
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Lucas BP, Asbury JK, Wang Y, Lee K, Kumapley R, Mba B, Borkowsky S, Asmar A. Impact of a bedside procedure service on general medicine inpatients: A firm-based trial. J Hosp Med 2007; 2:143-9. [PMID: 17549745 DOI: 10.1002/jhm.159] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Procedure services may improve the training of bedside procedures. However, little is known about how procedure services may affect the demand for and success of procedures performed on general medicine inpatients. OBJECTIVE Determine whether a procedure service affects the number and success of 4 bedside procedures (paracentesis, thoracentesis, lumbar puncture, and central venous catheterization) attempted on general medicine inpatients. DESIGN Prospective cohort study. SETTING Large public teaching hospital. PATIENTS Nineteen hundred and forty-one consecutive admissions to the general medicine service. INTERVENTION A bedside procedure service was offered to physicians from 1 of 3 firms for 4 weeks. This service then crossed over to physicians from the other 2 firms for another 4 weeks. MEASUREMENTS Data on all procedure attempts were collected daily from physicians. We examined whether the number of attempts and the proportion of successful attempts differed based on whether firms were offered the beside procedure service. RESULTS The number of procedure attempts was 48% higher in firms offered the service (90 versus 61 per 1000 admissions; RR 1.48, 95% CI 1.06-2.10; P = .030). More than 85% of the observed increase was a result of procedures with therapeutic indications. There were no differences between firms in the proportions of successful attempts or major complications. CONCLUSIONS The availability of a procedure service may increase the overall demand for bedside procedures. Further studies should refine the indications for and anticipated benefits from these commonly performed invasive procedures.
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Affiliation(s)
- Brian P Lucas
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, and Rush Medical College, Chicago, Illinois 60612, USA.
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Abstract
Next to nothing is known about physical findings' impact on patient care.
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Abstract
OBJECTIVE Previous studies have shown that most medical inpatients receive treatment supported by strong evidence (evidence-based treatment), but they have not assessed whether and how physicians actually use evidence when making their treatment decisions. We investigated whether physicians would change inpatient treatment if presented with the results of a literature search. DESIGN Before-after study. SETTING Large public teaching hospital. PARTICIPANTS Random sample of 146 inpatients cared for by 33 internal medicine attending physicians. INTERVENTIONS After physicians committed to a specific diagnosis and treatment plan, investigators performed standardized literature searches and provided the search results to the attending physicians. MEASUREMENTS AND MAIN RESULTS The primary study outcome was the number of patients whose attending physicians would change treatment due to the literature searches. These changes were evaluated by blinded peer review. A secondary outcome was the proportion of patients who received evidence-based treatment before and after the literature searches. Attending physicians changed treatment for 23 (18%) of 130 eligible patients (95% confidence interval, 12% to 24%) as a result of the literature searches. Overall, 86% of patients (112 of 130) received evidence-based treatments before the searches and 87% (113 of 130) after the searches. Changes were not related to whether patients were receiving evidence-based treatment before the search (P =.6). Panels of peer reviewers judged the quality of patient care as improved or maintained for 18 (78%) of the 23 patients with treatment changes. CONCLUSIONS Searching the literature could improve the treatment of many medical inpatients, including those already receiving evidence-based treatment.
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Affiliation(s)
- Brian P Lucas
- Department of Medicine, John H Stroger, Jr. Hospital of Cook County and Rush Medical College, Chicago, IL 60612, USA.
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