Rachel Liu

Point-of-Care Focused Cardiac Ultrasound for Prediction of Pulmonary Embolism Adverse Outcomes

BACKGROUND In patients with pulmonary embolism (PE), right ventricular strain (RVS) on transthoracic echocardiography by Cardiology has been shown to be an independent predictor of 30-day adverse outcomes. However, it is not known how emergency practitioner-performed point-of-care focused cardiac ultrasound (FOCUS) with assessment for RVS compares with other prognostic methods in the Emergency Department (ED). OBJECTIVES To determine whether RVS on FOCUS is a significant predictor of in-hospital adverse outcomes when compared to other risk factors and scoring systems. METHODS Retrospective chart review of patients who were diagnosed with PE and had a FOCUS examination during January 1, 2007 through January 1, 2011 in an urban, academic center with a well-developed ultrasound program. Adverse outcomes were defined as shock, respiratory failure requiring intubation, death, recurrent venous thromboembolism, transition to higher level of care, or major bleeding during hospital admission. Statistical analysis included univariate and multivariate analysis to assess for prognostic significance. RESULTS One hundred sixty-one patients were included in the final analysis. A total of 25 (16%) patients had an adverse outcome during hospitalization. On univariate analysis, only the presence of altered mental status conferred a higher positive likelihood ratio (6.4 vs. 4.0) than RVS, whereas absence of RVS had the lowest negative likelihood ratio (0.45). On multivariate analysis, RVS and cardiopulmonary disease were the only predictors of adverse outcomes that achieved statistical significance, with odds ratio of 9.2 and 3.4, respectively. CONCLUSION In this retrospective chart review, a FOCUS examination for RVS performed by emergency care practitioners of varying experience level was a significant predictor of in-hospital adverse outcomes among patients diagnosed with PE in the ED. Future research should be directed at exploring ways to incorporate RVS assessment into ED prognostic models for pulmonary embolism.

Emergency physician focused cardiac ultrasound improves diagnosis of ascending aortic dissection

STUDY OBJECTIVE Ascending aortic dissection (AAD) is an uncommon, time-sensitive, and deadly diagnosis with a nonspecific presentation. Ascending aortic dissection is associated with aortic dilation, which can be determined by emergency physician focused cardiac ultrasound (EP FOCUS). We seek to determine if patients who receive EP FOCUS have reduced time to diagnosis for AAD. METHODS We performed a retrospective review of patients treated at 1 of 3 affiliated emergency departments, March 1, 2013, to May 1, 2015, diagnosed as having AAD. All autopsies were reviewed for missed cases. Primary outcome measure was time to diagnosis. Secondary outcomes were time to disposition, misdiagnosis rate, and mortality. RESULTS Of 386547 ED visits, targeted review of 123 medical records and 194 autopsy reports identified 32 patients for inclusion. Sixteen patients received EP FOCUS and 16 did not. Median time to diagnosis in the EP FOCUS group was 80 (interquartile range [IQR], 46-157) minutes vs 226 (IQR, 109-1449) minutes in the non-EP FOCUS group (P = .023). Misdiagnosis was 0% (0/16) in the EP FOCUS group vs 43.8% (7/16) in the non-EP FOCUS group (P = .028). Mortality, adjusted for do-not-resuscitate status, for EP FOCUS vs non-EP FOCUS was 15.4% vs 37.5% (P = .24). Median rooming time to disposition was 134 (IQR, 101-195) minutes for EP FOCUS vs 205 (IQR, 114-342) minutes for non-EP FOCUS (P = .27). CONCLUSIONS Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared with patients who do not receive EP FOCUS. We recommend assessment of the thoracic aorta be performed routinely during cardiac ultrasound in the emergency department.

Emergency physician performed tricuspid annular plane systolic excursion in the evaluation of suspected pulmonary embolism

Objectives: The primary objectives were to describe the diagnostic characteristics tricuspid annular plane systolic excursion (TAPSE) for pulmonary embolism (PE) and to optimize the measurement cutoff of TAPSE for the diagnosis of PE. Secondary objectives included assessment of interrater reliability and the quantitative visual estimation of TAPSE. Methods: This is a prospective observational cohort study involving a convenience sample of patients at an urban academic emergency department. Patients underwent focused right heart echocardiogram (FOCUS) before computed tomographic angiography (CTA) for suspected PE. Results: A total of 150 patients were enrolled, 32 of whom (21.3%) were diagnosed as having a PE. A receiver operating characteristic curve analysis yielded 2.0 cm as the optimal cutoff for TAPSE in the diagnosis of PE, with a sensitivity of 72% (95% confidence interval [CI], 53‐86), a specificity of 66% (95% CI, 57‐75), and an area under the curve of 0.73 (95% CI, 0.65‐0.83). In patients with tachycardia or hypotension, post hoc analysis demonstrated that FOCUS is 100% (95% CI, 80‐100) sensitive for PE, whereas TAPSE is 94% (95% CI, 71‐99) sensitive for PE. The intraclass correlation coefficient was 0.87 (95% CI, 0.79‐0.93). Emergency physicians with training in echocardiography accurately visually estimated TAPSE, with a &kgr; statistic of 0.94 (95% CI, 0.87‐0.98). Conclusions: Emergency physicians with training in echocardiography can reliably measure TAPSE and are able to accurately visually estimate TAPSE as either normal or abnormal. When using an abnormal cutoff of less than 2.0 cm, TAPSE has moderate diagnostic value in patients with suspected PE. On post hoc analysis, TAPSE and FOCUS appear to be highly sensitive for PE in patients with tachycardia or hypotension.

Use of Point-of-Care Ultrasound in the Emergency Department Insights From the 2012 Medicare National Payment Data Set

Point‐of‐care ultrasound is a valuable tool with potential to expedite diagnoses and improve patient outcomes in the emergency department. However, little is known about national patterns of adoption. This study examined nationwide point‐of‐care ultrasound reimbursement among emergency medicine (EM) practitioners and examined regional and practitioner level variations.

Goal-directed Focused Ultrasound Milestones Revised: A Multiorganizational Consensus

In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 (PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision.

SonoGames: Effect of an Innovative Competitive Game on the Education, Perception, and Use of Point-of-Care Ultrasound: Impact of SonoGames on Ultrasound Education

Gamification is a powerful tool in medical education. SonoGames is a competitive games‐based event designed to educate and inspire emergency medicine (EM) residents about point‐of‐care ultrasound. We sought to describe: (1) the perceived effectiveness of a competitive event on both immediate learning and long‐term education; and (2) the resultant attitudes of participants and program directors regarding ultrasound training.

The Practice and Implications of Finding Fluid During Point-of-Care Ultrasonography: A Review

Importance Point-of-care ultrasonography (POCUS) is an increasingly affordable and portable technology that is an important part of 21st-century medicine. When appropriately used, POCUS has the potential to expedite diagnosis and improve procedural success and safety. POCUS is now being adopted in medical education as early as the first year of medical school. While potentially powerful and versatile, POCUS is a user-dependent technology that has not been formalized or standardized yet within internal medicine residency training programs. Physicians and residency directors are trying to determine whether to incorporate POCUS, and if so, how. In this systematic review, basic concepts and applications of POCUS are examined, as are issues surrounding training and implementation. Observations A key use of POCUS is to detect fluid, and this is a cornerstone of POCUS teaching. Even in inexperienced hands, POCUS has shown to be more sensitive and specific than physical examination for conditions such as ascites, pleural effusion, and pericardial effusion. Detecting fluid requires a basic understanding of ultrasonography operation, sonographic anatomy, and probe orientation. Once fluid is localized, ultrasonographic guidance can increase success and decrease complications of common procedures such as thoracentesis or paracentesis. Conclusions and Relevance POCUS can augment physical examination and procedural efficacy but requires appropriate education and program setup. As POCUS continues to spread, internal medicine physicians need to clarify how they intend to use this technology. Equipment is now increasingly accessible, but programs need to determine how to allocate time and resources to training, clinical use, and quality assurance. Programs that develop robust implementation processes that establish proper scope of practice and include quality assurance that use image archival and feedback can ensure POCUS will positively impact patient care across hospital systems.

Corrected flow time: a noninvasive ultrasound measure to detect preload reduction by nitroglycerin

OBJECTIVE Monitoring of patients intravascular volume status without invasive measures remains challenging and unreliable. Our objective was to determine if corrected flow time (FTc) measurement could detect preload reduction with administration of nitroglycerin (NTG) as a surrogate for volume loss. METHODS Post hoc FTc analysis was performed for a prospective cohort study of pulsed wave spectral Doppler measurements before and after administration of NTG. Patients enrolled were eligible for inclusion if they were admitted to a chest pain center for cardiac evaluation. Descriptive statistics, t tests, bivariate regression, and intraclass correlation coefficient were performed as appropriate. RESULTS Fifty-four patients had Doppler measurements available for review. Mean FTc decreased from 339 milliseconds (95% confidence interval, 332-346) to 325 milliseconds (95% confidence interval, 318-331) with administration of 0.3 mg of sublingual NTG (P=.0001). Mean heart rate increased 5 beats/min with administration of NTG (P<.0001); however, there was no significant change in systolic or diastolic blood pressure. CONCLUSION Corrected flow time was able to detect a significant difference in preload reduction with 0.3 mg of NTG. The FTc may be an early reliable noninvasive measure to detect changes in intravascular volume status.

Direct Observation Assessment of Milestones: Problems with Reliability

Introduction Emergency medicine (EM) milestones are used to assess residents’ progress. While some milestone validity evidence exists, there is a lack of standardized tools available to reliably assess residents. Inherent to this is a concern that we may not be truly measuring what we intend to assess. The purpose of this study was to design a direct observation milestone assessment instrument supported by validity and reliability evidence. In addition, such a tool would further lend validity evidence to the EM milestones by demonstrating their accurate measurement. Methods This was a multi-center, prospective, observational validity study conducted at eight institutions. The Critical Care Direct Observation Tool (CDOT) was created to assess EM residents during resuscitations. This tool was designed using a modified Delphi method focused on content, response process, and internal structure validity. Paying special attention to content validity, the CDOT was developed by an expert panel, maintaining the use of the EM milestone wording. We built response process and internal consistency by piloting and revising the instrument. Raters were faculty who routinely assess residents on the milestones. A brief training video on utilization of the instrument was completed by all. Raters used the CDOT to assess simulated videos of three residents at different stages of training in a critical care scenario. We measured reliability using Fleiss’ kappa and interclass correlations. Results Two versions of the CDOT were used: one used the milestone levels as global rating scales with anchors, and the second reflected a current trend of a checklist response system. Although the raters who used the CDOT routinely rate residents in their practice, they did not score the residents’ performances in the videos comparably, which led to poor reliability. The Fleiss’ kappa of each of the items measured on both versions of the CDOT was near zero. Conclusion The validity and reliability of the current EM milestone assessment tools have yet to be determined. This study is a rigorous attempt to collect validity evidence in the development of a direct observation assessment instrument. However, despite strict attention to validity evidence, inter-rater reliability was low. The potential sources of reducible variance include rater- and instrument-based error. Based on this study, there may be concerns for the reliability of other EM milestone assessment tools that are currently in use.

Systemwide Clinical Ultrasound Program Development: An Expert Consensus Model

Clinical ultrasound (CUS) is integral to the practice of an increasing number of medical specialties. Guidelines are needed to ensure effective CUS utilization across health systems. Such guidelines should address all aspects of CUS within a hospital or health system. These include leadership, training, competency, credentialing, quality assurance and improvement, documentation, archiving, workflow, equipment, and infrastructure issues relating to communication and information technology. To meet this need, a group of CUS subject matter experts, who have been involved in institution- and/or systemwide clinical ultrasound (SWCUS) program development convened. The purpose of this paper was to create a model for SWCUS development and implementation.