Emergency physician-performed ultrasound to diagnose cholelithiasis: a systematic review

The effect of a simulation training package on skill acquisition for duplex arterial stenosis detection

OBJECTIVES

In vascular surgery, duplex ultrasonography is a valuable diagnostic tool in patients with peripheral vascular disease, and there is increasing demand for vascular surgeons to be able to perform duplex scanning. This study evaluates the role of a novel simulation training package on vascular ultrasound (US) skill acquisition.

MATERIALS AND METHODS

A total of 19 novices measured predefined stenosis in a simulated pulsatile vessel using both peak systolic velocity ratio (PSVR) and diameter reduction (DR) methods before and after a short period of training using a simulated training package. The training package consisted of a simulated pulsatile vessel phantom, a set of instructional videos, duplex ultrasound objective structured assessment of technical skills (DUOSATS) tool, and a portable US scanner. Quantitative metrics (procedure time, percentage error using PSVR and DR methods, DUOSAT scores, and global rating scores) before and after training were compared.

RESULTS

Subjects spent a median time of 144 mins (IQR: 60-195) training using the simulation package. Subjects exhibited statistically significant improvements when comparing pretraining and posttraining DUOSAT scores (pretraining = 17 [16-19.3] vs posttraining = 30 [27.8-31.8]; p < 0.01), global rating score (pretraining = 1 [1-2] vs posttraining = 4 [3.8-4]; p < 0.01), percentage error using both the DR (pretraining = 12.6% [9-29.6] vs posttraining = 10.3% [8.9-11.1]; p = 0.03) and PSVR (pretraining = 60% [40-60] vs posttraining = 20% [6.7-20]; p < 0.01) methods.

CONCLUSION

In this study, subjects with no previous practical US experience developed the ability to both acquire and interpret arterial duplex images in a pulsatile simulated phantom following a short period of goal direct training using a simulation training package. A simulation training package may be a valuable tool for integration into a vascular training program. However, further work is needed to explore whether these newly attained skills are translated into clinical assessment.

Summative clinical competency assessment: A survey of ultrasound practitioners' views

Clinical competency and the assessment of core skills is a crucial element of any programme leading to an award with a clinical skills component. This has become a more prominent feature of current reports on quality health care provision. This project aimed to determine ultrasound practitioners' opinions about how best to assess clinical competency. An on-line questionnaire was sent to contacts from the Consortium for the Accreditation of Sonographic Education and details distributed at the British Medical Ultrasound Society conference in 2011. One hundred and sixteen responses were received from a range of clinical staff with an interest in ultrasound assessment. The majority of respondents suggested that competency assessments should take place in the clinical departments with or without an element of assessment at the education centre. Moderation was an important area highlighted by respondents, with 84% of respondents suggesting that two assessors were required and 66% of those stating some element of external moderation should be included. The findings suggest that respondents' preference is for some clinical competency assessments to take place on routine lists within the clinical department, assessed by two people one of which would be an external assessor. In view of recent reports relating to training and assessment of health care professionals, the ultrasound profession needs to begin the debate about how best to assess clinical competence and ensure appropriate first post-competency of anyone undertaking ultrasound examinations.

Accuracy of bedside emergency physician performed ultrasound in diagnosing different causes of acute abdominal pain: a prospective study

OBJECTIVE

Abdominal pain is a common complaint in the emergency department and accurate diagnosis of its etiology may affect the patient's outcome.

METHOD

Patients with abdominal pain underwent ultrasound study first by trained emergency physicians and then by radiologists blinded to emergency physician's results.

RESULT

Emergency physician who performed bedside ultrasound had 78% diagnostic accuracy. Emergency physicians showed better results in diagnosing some entities (abdominal aortic aneurysm and renal stones) than the others (acute appendicitis, cholelithiasis, and cholecystitis).

CONCLUSION

Bedside ultrasound can accurately identify the etiology of acute nontraumatic abdominal pain in the hands of emergency physicians.

My patient has got abdominal pain: identifying biliary problems

Right upper quadrant and epigastric abdominal pain are common presenting complaints in the emergency department. With increasing access to point-of-care ultrasound, emergency physicians now have an added tool to help identify biliary problems as a cause of a patient's right upper quadrant pain. Point-of-care ultrasound has a sensitivity of 89.8% (95% CI 86.4-92.5%) and specificity of 88.0% (83.7-91.4%) for cholelithiasis, very similar to radiology-performed ultrasonography. In addition to assessment for cholelithiasis and cholecystitis, point-of-care ultrasound can help emergency physicians to determine whether the biliary system is the source of infection in patients with suspected sepsis. Use of point-of-care ultrasound for the assessment of the biliary system has resulted in more rapid diagnosis, decreasing costs, and shorter emergency department length of stay.

Utility of point-of-care biliary ultrasound in the evaluation of emergency patients with isolated acute non-traumatic epigastric pain

To determine the utility of emergency physician-performed point-of-care biliary ultrasound in the evaluation of emergency department (ED) patients with isolated acute non-traumatic epigastric pain. This was a multi-center prospective observational study of adult patients presenting to the ED with isolated acute non-traumatic epigastric pain. Patients with abdominal tenderness at any site other than the epigastric region, or with a history of gall stones, cholecystectomy, gastrointestinal bleeding, chronic abdominal pain, trauma, or altered mental status were excluded. Emergency physician investigators performed point-of-care biliary ultrasound after clinical assessment. Demographic information, history, physical examination findings, laboratory results, additional diagnostic tests, and disposition data were collected. A total of 51 patients (39 women, 12 men) were enrolled. The mean age of the patients was 36.4 years ± 13.6 (SD). All subjects had isolated epigastric tenderness. Gallstones were found in 20/51 (39%, 95% CI 26-52%) on point-of-care biliary ultrasound. Of the 20 patients who had gallstones, eight had sonographic signs of chloecystitis. The treating emergency physicians' initial evaluation did not plan to include an ultrasound in 17/20 patients with gallstones. 19/20 patients were initially given a GI cocktail by the treating emergency physicians. Point-of-care biliary ultrasound detected gall stones in more than one-third of ED patients with isolated acute non-traumatic epigastric pain. All patients presenting to the ED with non-traumatic epigastric pain should be evaluated for biliary disease with an ultrasound imaging study. Bedside ultrasound can avoid misdiagnosis and expedite management in these patients.

Emergency care and health systems: consensus-based recommendations and future research priorities

The theme of the 14th annual Academic Emergency Medicine consensus conference was "Global Health and Emergency Care: A Research Agenda." The goal of the conference was to create a robust and measurable research agenda for evaluating emergency health care delivery systems. The concept of health systems includes the organizations, institutions, and resources whose primary purpose is to promote, restore, and/or maintain health. This article further conceptualizes the vertical and horizontal delivery of acute and emergency care in low-resource settings by defining specific terminology for emergency care platforms and discussing how they fit into broader health systems models. This was accomplished through discussion surrounding four principal questions touching upon the interplay between health systems and acute and emergency care. This research agenda is intended to assist countries that are in the early stages of integrating emergency services into their health systems and are looking for guidance to maximize their development and health systems planning efforts.