Hospitalist performance of cardiac hand-carried ultrasound after focused training

The effectiveness of a blended POCUS curriculum on achieving basic focused bedside transthoracic echocardiography (TTE) proficiency. A formalized pilot study

Objective

The study objective is to evaluate the effeteness of an existing educational platform blending didactic presentation and hands-on simulation for university doctoral SRNAs in the area of basic, 4 view identification and performance of transthoracic echocardiography (TTE).

Methods

Following IRB approval, SRNAs were exposed to a pre test to evaluate existing skills, then they were exposed to a graphic rich, live presentation of basic 4 view TTE. The presentation was then followed by hands on simulation and performance of the 4 basic TTE views on live models.

Results

Pretest scores averaged 58% and post tests scores rose to 95%. See Table 1.

Conclusion

Our results support the concept that the existing blended platform is effective to train university SRNAs in basic 4 view, bedside transthoracic echocardiography.

Ensuring competency in focused cardiac ultrasound: a systematic review of training programs

BACKGROUND

Focused cardiac ultrasound (FoCUS) is a valuable skill for rapid assessment of cardiac function and volume status. Despite recent widespread adoption among physicians, there is limited data on the optimal training methods for teaching FoCUS and metrics for determining competency. We conducted a systematic review to gain insight on the optimal training strategies, including type and duration, that would allow physicians to achieve basic competency in FoCUS.

METHODS

Embase, PubMed, and Cochrane Library databases were searched from inception to June 2020. Included studies described standardized training programs for at least 5 medical students or physicians on adult FoCUS, followed by an assessment of competency relative to an expert. Data were extracted, and bias was assessed for each study.

RESULTS

Data were extracted from 23 studies on 292 learners. Existing FoCUS training programs remain varied in duration and type of training. Learners achieved near perfect agreement (κ > 0.8) with expert echocardiographers on detecting left ventricular systolic dysfunction and pericardial effusion with 6 h each of didactics and hands-on training. Substantial agreement (κ > 0.6) on could be achieved in half this time.

CONCLUSION

A short training program will allow most learners to achieve competency in detecting left ventricular systolic dysfunction and pericardial effusion by FoCUS. Additional training is necessary to ensure skill retention, improve efficiency in image acquisition, and detect other pathologies.

Development of a Focused Cardiac Ultrasound Image Acquisition Assessment Tool

Background: Focused cardiac ultrasound (FCU) is widely used by healthcare providers to answer specific questions about cardiac structure and function at the bedside. Currently, no widely accepted FCU image acquisition checklist exists to assess learners with varying skill levels from different specialties.

Objective: The primary objective of this project was to develop a consensus-based FCU image acquisition checklist using a multispecialty group of point-of-care ultrasound (POCUS) experts.

Methods: The essential components of an FCU examination were identified on the basis of published recommendations from echocardiography and international ultrasound societies. A checklist of the essential components of an FCU examination was drafted. A panel of POCUS experts from different medical specialties in the United States and Canada was convened to vote on each checklist item by answering two questions: 1) Is this item important to include in a checklist of essential FCU skills applicable to any medical specialty? and 2) Should the learner be required to successfully complete this item to be considered competent? A modified Delphi approach was used to assess the level of agreement for each checklist item during four rounds of voting. Checklist items that achieved an agreement of 80% or greater were included in the final checklist.

Results: Thirty-one POCUS experts from seven different medical specialties voted on sixty-five items to be included in the FCU image acquisition assessment tool. The majority of POCUS experts (61%) completed all four rounds of voting. During the first round of voting, 59 items reached consensus, and after revision and revoting, an additional 3 items achieved 80% or greater consensus. A total of 62 items were included in the final checklist, and 57 items reached consensus as a requirement for demonstration of competency.

Conclusion: We have developed a multispecialty, consensus-based FCU image acquisition checklist that may be used to assess the skills of learners from different specialties. Future steps include studies to develop additional validity evidence for the use of the FCU assessment tool and to evaluate its utility for the translation of skills into clinical practice.

Prognostic Implications of a Point-of-Care Ultrasound Examination on Hospital Ward Admission

OBJECTIVES

Few data exist regarding the use of ultrasound (US) to risk stratify ward admissions. Therefore, we evaluated associations between a cardiopulmonary limited ultrasound examination (CLUE) on admission and subsequent hospital outcomes.

METHODS

Over a 22-month period in a 300-bed hospital, CLUE data reviewed from a series of nonelective ward admissions were correlated with the composite outcome of a hospital stay of longer than 2 days, disposition to hospice, or death. The CLUE included 5 quick-look signs of left ventricular dysfunction, left atrial enlargement, lung B-lines, pleural effusions, and inferior vena cava plethora and had been performed as warranted by 1 of 31 US-trained admitting residents and then repeated by a cardiologist as the reference standard. The admitting condition, medical history, results of routine admission testing, and CLUE were assessed for an association with the outcome in univariate and multivariable models.

RESULTS

Of 547 patients, the mean age ± SD was 62.9 ± 15.5 years; 59% were male; and the mean stay was 5.6 ± 8.1 days, with 355 (65%) lasting longer than 2 days and 21 (4%) having hospice disposition or death. An abnormal CLUE exam was found in 368 (67%) of patients, was related to the outcome (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.23-2.68; P = .001) when obtained by a resident or cardiologist, and was included in a best-fit multivariable model with renal failure (OR, 2.44; 95% CI, 1.44-4.14; P < .001), infection/sepsis (OR, 2.25; 95% CI, 1.17-4.32; P = .02), and chest pain (OR, 0.36; 95% CI, 0.21-0.61; P < .001).

CONCLUSIONS

An abnormal admission point of care ultrasound exam was related to complex hospitalization, specifically a longer length of stay.

Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice

Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.

Focus cardiac ultrasound core curriculum and core syllabus of the European Association of Cardiovascular Imaging

There is a growing trend of using ultrasound examination of the heart as a first-line diagnostic tool for initial patient evaluation in acute settings. Focus cardiac ultrasound (FoCUS) is a standardized but restricted cardiac ultrasound examination that may be undertaken by a range of medical professionals with diverse backgrounds. The intention of this core curriculum and syllabus is to define a unifying framework for educational and training processes/programmes that should result in competence in FoCUS for various medical professionals dealing with diagnostics and treatment of cardiovascular emergencies. The European Association of Cardiovascular Imaging prepared this document in close cooperation with representatives of the European Society of Anaesthesiology, the European Association of Cardiothoracic Anaesthesiology, the Acute Cardiovascular Care Association of the European Society of Cardiology and the World Interactive Network Focused On Critical Ultrasound. It aims to provide the key principles and represents a guide for teaching and training of FoCUS. We offer this document to the emergency and critical care community as a reference outline for teaching materials and courses related to FoCUS, for promoting teamwork and encouraging the development of the field.

Consensus Document of the SEMI, semFYC, SEN, and SEC on Focused Cardiac Ultrasound in Spain

This document summarizes the concept of focused cardiac ultrasound, the basic technical aspects related to this technique, and its diagnostic objectives. It also defines training requisites in focused cardiac ultrasound. This consensus document has been endorsed by the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of Neurology (SEN), and the Spanish Society of Cardiology (SEC).

Implementation of a point-of-care ultrasound skills practicum for hospitalists

Introduction

Point-of-care ultrasound is recognized as a safe and valuable diagnostic tool for patient evaluation. Hospitalists are prime candidates for advancing the point-of-care ultrasound field given their crucial role in inpatient medicine. Despite this, there is a notable lack of evidence-based ultrasound training for hospitalists. Most research focuses on diagnostic accuracy rather than the training required to achieve it. This study aims to improve hospitalists' point-of-care ultrasound knowledge and skills through a hands-on skills practicum.

Methods

Four skill practicums were conducted with pre-course, post-course, and six-month evaluations and knowledge assessments.

Results

The mean pre- vs. post-course knowledge assessment scores significantly improved, 41.7% vs. 75.9% (SD 16.1% and 12.7%, respectively, p < 0.0001). The mean ultrasound skills confidence ratings on a 10-point Likert scale significantly increased post-course (2.60 ± 1.66 vs. 6.33 ± 1.63, p < 0.0001), but decreased at six months (6.33 ± 1.63 vs. 4.10 ± 2.22, p < 0.0001). The greatest limitations to usage pre-course and at six months were knowledge/skills and lack of machine access. While knowledge/skills decreased from pre-course (82.0%) as compared to six-months (64.3%), lack of machine access increased from pre-course (15.8%) to six-months (28.6%) (p = 0.28).

Conclusion

Hospitalists agree that point-of-care ultrasound has utility in the diagnostic and therapeutic management of patients, though the lack of training is a significant limitation. Our study demonstrated that a brief skills practicum significantly improves hospitalists' confidence and knowledge regarding ultrasound image acquisition and interpretation in the short term. Long-term confidence and usage wanes, which appears to be due to the lack of machine access.

Simulation for competency assessment in vascular and cardiac ultrasound

Healthcare providers who use peripheral vascular and cardiac ultrasound require specialized training to develop the technical and interpretive skills necessary to perform accurate diagnostic tests. Assessment of competence is a critical component of training that documents a learner's progress and is a requirement for competency-based medical education (CBME) as well as specialty certification or credentialing. The use of simulation for CBME in diagnostic ultrasound is particularly appealing since it incorporates both the psychomotor and cognitive domains while eliminating dependency on the availability of live patients with a range of pathology. However, successful application of simulation in this setting requires realistic, full-featured simulators and appropriate standardized metrics for competency testing. The principal diagnostic parameter in peripheral vascular ultrasound is measurement of peak systolic velocity (PSV) on Doppler spectral waveforms, and simulation of Doppler flow detection presents unique challenges. The computer-based duplex ultrasound simulator developed at the University of Washington uses computational fluid dynamics modeling and presents real-time color-flow Doppler images and Doppler spectral waveforms along with the corresponding B-mode images. This simulator provides a realistic scanning experience that includes measuring PSV in various arterial segments and applying actual diagnostic criteria. Simulators for echocardiography have been available since the 1990s and are currently more advanced than those for peripheral vascular ultrasound. Echocardiography simulators are now offered for both transesophageal echo and transthoracic echo. These computer-based simulators have 3D graphic displays that provide feedback to the learner and metrics for assessment of technical skill that are based on transducer tracking data. Such metrics provide a motion-based or kinematic analysis of skill in performing cardiac ultrasound. The use of simulation in peripheral vascular and cardiac ultrasound can provide a standardized and readily available method for training and competency assessment.

Integrating Scaffolding and Deliberate Practice Into Focused Cardiac Ultrasound Training: A Simulator Curriculum

INTRODUCTION

Focused cardiac ultrasound (FoCUS) is widely used for the point-of-care evaluation of basic cardiac pathology, and there is a need for efficient and consistent training in this modality. We designed a simulator-based FoCUS curriculum that integrates instructional scaffolding and deliberate practice to create a directed, self-regulated learning experience for novices. The goal of this strategy was to guide the novice's learning efforts more efficiently and moderate cognitive load while retaining the benefits of independent learning.

METHODS

The complex task of learning cardiac ultrasound is broken into discrete steps, with focused didactic information immediately followed by targeted simulator practice for each module. The practice complexity increases through successive modules, and learners ultimately apply their skills by completing unassisted simulator cases. Immediate visual and quantitative feedback is provided by the simulator whenever an ultrasound image was captured during practice. The entire curriculum is self-guided.

RESULTS

Sixteen nurse practitioners and resident physicians completed this FoCUS curriculum. In comparison to a previously validated, lecture-before-practice-style curriculum, the average time to completion decreased from 8.0 ± 2.5 hours to 4.7 ± 1.9 hours (p < .0001). There was no difference in posttraining cognitive or psychomotor outcomes between the curricula as measured by a simulator posttest.

DISCUSSION

A curriculum integrating scaffolding and deliberate practice provides a more efficient, but equally effective, means of teaching psychomotor and cognitive skills in FoCUS. These instructional design principles may translate to other operational learning tasks and allow novices to build skills and reach basic competency more rapidly.

Hospital Medicine Point of Care Ultrasound Credentialing: An Example Protocol

Though the use of point-of-care ultrasound (POCUS) has increased over the last decade, formal hospital credentialing for POCUS may still be a challenge for hospitalists. This document details the Hospital Medicine Department Ultrasound Credentialing Policy from Regions Hospital, which is part of the HealthPartners organization in Saint Paul, Minnesota. National organizations from internal medicine and hospital medicine (HM) have not published recommended guidelines for POCUS credentialing. Revised guidelines for POCUS have been published by the American College of Emergency Physicians, though these are not likely intended to guide hospitalists when working with credentialing committees and medical boards. This document describes the scope of ultrasound in HM and our training, credentialing, and quality assurance program. This report is intended to be used as a guide for hospitalists as they work with their own credentialing committees and will require modification for each institution. However, the overall process described here should assist in the establishment of POCUS at various institutions.

Actual use of pocket-sized ultrasound devices for cardiovascular examination by trained physicians during a hospitalist rotation

Background

In actual clinical practice as opposed to published studies, the application of bedside ultrasound requires a perception of need, confidence in one's skills, and convenience.

Objective

As the frequency of ultrasound usage is evidence to its perceived value in patient care, we observed the pattern of autonomous use of a pocket-sized device (PSD) by ultrasound-trained residents during a night hospitalist rotation.

Methods

Consecutive internal medicine residents (n=24), trained in a cardiac limited ultrasound examination (CLUE) as a mandatory part of their curriculum, were sampled on their PSD use after their admitting nights, regarding perceived necessity, deterring factors, detected abnormalities, and imaging difficulties. A detailed analysis was performed with one resident who used a PSD on every admission to compare the proportion of abnormal CLUEs and utility in patients with and without a perceived need.

Results

Residents admitted 542 patients (mean age: 55±17 years, range: 17–95 years) during 101 shifts and performed CLUE on 230 patients (42%, range: 17–85%). Residents elected not to scan 312 (58%) patients due to 1) lack of perceived necessity (231, 74%), 2) time constraints (44, 14%), and 3) patient barriers (37, 12%). In the detailed analysis (n=71), the resident felt CLUE was necessary in 32 (45%) patients versus unnecessary in 39 (55%) patients, with abnormality rates of 50% versus 20.5% (p=0.01) and utility rates of 28.1% versus 15.4% (p=0.25), respectively.

Conclusion

When unbiased residents acting as hospitalists are provided with a PSD to augment initial cardiac examination, usage is frequent and suggests clinical value in hospital medicine.

Image-based resuscitation of the hypotensive patient with cardiac ultrasound: An evidence-based review

This article is a detailed review of the literature regarding the use of cardiac ultrasound for the resuscitation of hypotensive patients. In addition, figures regarding windows and description of how to perform the test are included.

Thoracentesis

Pleural effusions are common and account for high morbidity and mortality in a range of patients. Thoracentesis can provide significant symptom relief and improvement in physiologic parameters including dyspnea, exercise, and sleep. Recent advances, including the use of ultrasound and dedicated procedural teams, have improved the safety of thoracentesis. This has allowed thoracentesis to be performed on higher-risk individuals including those with elevated bleeding risk and bilateral pleural effusions. This review will summarize recent advances in thoracentesis procedural safety, symptom relief following thoracentesis, and understanding of the physiologic basis for such improvements.

The Preoperative Patient With a Systolic Murmur

Context:

Patients with undifferentiated systolic murmurs present commonly during the perioperative period. Traditional bedside assessment and auscultation has not changed significantly in almost 200 years and relies on interpreting indirect acoustic events as a means of evaluating underlying cardiac pathology. This is notoriously inaccurate, even in expert cardiology hands, since many different valvular and cardiac diseases present with a similar auditory signal.

Evidence Acquisition:

The data on systolic murmurs, physical examination, perioperative valvular disease in the setting of non-cardiac surgery is reviewed.

Results:

Significant valvular heart disease increases perioperative risk in major non-cardiac surgery and increases long term patient morbidity and mortality. We propose a more modern approach to physical examination that incorporates the use of focused echocardiography to allow direct visualization of cardiac structure and function. This improves the diagnostic accuracy of clinical assessment, allows rational planning of surgery and anaesthesia technique, risk stratification, postoperative monitoring and appropriate referral to physicians and cardiologists.

Conclusions:

With a thorough preoperative assessment incorporating focused echocardiography, anaesthetists are in the unique position to enhance their role as perioperative physicians and influence short and long term outcomes of their patients.

Focused cardiac ultrasound: where do we stand?

Focused cardiac ultrasound (FCU) is a bedside examination of the heart performed with a small, portable ultrasound platform by a physician as an adjunct to their physical examination. The goal is to recognize a narrow list of abnormalities that are both detectable by physicians with limited ultrasound training and have high clinical assessment value. Results from the FCU examination are integrated with traditional bedside assessment (physical examination and history) to provide early management plans and patient triage in settings when echocardiography cannot be obtained or is not immediately available.

Learning curves in emergency ultrasound education

OBJECTIVES

Proficiency in the use of bedside ultrasound (US) has become standard in emergency medicine residency training. While milestones have been established for this training, supporting data for minimum standard experience are lacking. The objective of this study was to characterize US learning curves to identify performance plateaus for both image acquisition and interpretation, as well as compare performance characteristics of learners to those of expert sonographers.

METHODS

A retrospective review of an US database was conducted at a single academic institution. Each examination was scored for agreement between the learner and expert reviewer interpretation and given a score for image quality. A locally weighted scatterplot smoothing method was used to generate a model of predicted performance for each individual examination type. Performance characteristics for expert sonographers at the site were also tracked and used in addition to performance plateaus as benchmarks for learning curve analysis.

RESULTS

There were 52,408 US examinations performed between May 2007 and January 2013 and included for analysis. Performance plateaus occurred at different points for different US protocols, from 18 examinations for soft tissue image quality to 90 examinations for right upper quadrant image interpretation. For the majority of examination types, a range of 50 to 75 examinations resulted in both excellent interpretation (sensitivity > 84% and specificity > 90%) and good image quality (90% the image quality benchmark of expert sonographers).

CONCLUSIONS

Educational performance benchmarks occur at variable points for image interpretation and image quality for different examination types. These data should be considered when developing training standards for US education as well as experience requirements for US credentialing.

International evidence-based recommendations for focused cardiac ultrasound

BACKGROUND

Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use.

METHODS

The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method.

RESULTS

During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients.

CONCLUSIONS

This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Diagnostic point-of-care ultrasound for hospitalists

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.

Focus cardiac ultrasound: the European Association of Cardiovascular Imaging viewpoint

The concept of point-of-care, problem-oriented focus cardiac ultrasound examination (FoCUS) is increasingly applied in the settings of medical emergencies, including cardiac diseases. The European Association of Cardiovascular Imaging (EACVI) recognizes that cardiologists are not the only medical professionals dealing with cardiovascular emergencies. In reality, emergency cardiac diagnostics and treatment are also carried out by a wide range of specialists. For the benefit of the patients, the EACVI encourages any medical professional, sufficiently trained to obtain valuable information from FoCUS, to use it in emergency settings. These medical professionals need to have the necessary knowledge to understand the obtained information entirely, and to use it correctly, thoughtfully and with care. In this document, the EACVI underlines major differences between echocardiography and FoCUS, and underscores the need for specific education and training in order to fully utilize advantages and minimize drawbacks of this type of cardiac ultrasound examination in the critically ill patients.

Hospitalists' ability to use hand-carried ultrasound for central venous pressure estimation after a brief training intervention: a pilot study

BACKGROUND

Access to hand-carried ultrasound technology for noncardiologists has increased significantly, yet development and evaluation of training programs are limited.

OBJECTIVE

We studied a focused program to teach hospitalists image acquisition of inferior vena cava (IVC) diameter and IVC collapsibility index with interpretation of estimated central venous pressure (CVP).

METHODS

Ten hospitalists completed an online educational module prior to attending a 1-day in-person training session that included directly supervised IVC imaging on volunteer subjects. In addition to making quantitative assessments, hospitalists were also asked to visually assess whether the IVC collapsed more than 50% during rapid inspiration or a sniff maneuver. Skills in image acquisition and interpretation were assessed immediately after training on volunteer patients and prerecorded images, and again on volunteer patients at least 6 weeks later.

RESULTS

Eight of 10 hospitalists acquired adequate IVC images and interpreted them correctly on 5 of the 5 volunteer subjects and interpreted all 10 prerecorded images correctly at the end of the 1-day training session. At 7.4 ± 0.7 weeks (range, 6.9-8.6 weeks) follow-up, 9 of 10 hospitalists accurately acquired and interpreted all IVC images in 5 of 5 volunteers. Hospitalists were also able to accurately determine whether the IVC collapsibility index was more than 50% by visual assessment in 180 of 198 attempts (91% of the time).

CONCLUSIONS

After a brief training program, hospitalists acquired adequate skills to perform and interpret hand-carried ultrasound IVC images and retained these skills in the near term. Though calculation of the IVC collapsibility index is more accurate, coupling a qualitative assessment with the IVC maximum diameter measurement may be acceptable in aiding bedside estimation of CVP.

Prevalence of asymptomatic left ventricular systolic dysfunction in at-risk medical inpatients

BACKGROUND

Asymptomatic left ventricular systolic dysfunction is an important risk factor for heart failure and death. Given the availability of patients, trained personnel, and equipment, the hospital is an ideal setting to identify and initiate treatment for left ventricular systolic dysfunction. The purpose of this study was to determine the prevalence of asymptomatic left ventricular systolic dysfunction in patients 45 years of age or older with at least one clinical heart failure risk factor admitted to a general medical service.

METHODS

Bedside, hand-carried echocardiography provided quantitative assessment of left ventricular systolic function in 217 medical inpatients 45 years of age or older who had at least one heart failure risk factor. Patients with known or suspected heart failure or with an assessment of left ventricular function in the past 5 years were excluded. We measured the prevalence of asymptomatic left ventricular systolic dysfunction, defined by left ventricular ejection fraction of 50% or lower, and its association with heart failure risk factors.

RESULTS

Of 207 patients with interpretable images, 11 (5.3%) had a left ventricular ejection fraction of 50% or lower. Patients with left ventricular systolic dysfunction had more heart failure risk factors than those without left ventricular systolic dysfunction (3.09±0.8 vs 2.5±1.0, P=.04). The total number of heart failure risk factors trended towards an association with a greater prevalence of asymptomatic left ventricular systolic dysfunction, but this did not reach significance (odds ratio 1.74; 95% confidence interval, 0.97-3.12, P=.06).

CONCLUSIONS

Asymptomatic left ventricular systolic dysfunction is present in about 1 of every 20 general medical inpatients with at least one risk factor for heart failure. Because treatment of asymptomatic left ventricular systolic dysfunction may reduce morbidity, further studies examining the costs and benefits of using hand-carried ultrasound to identify this important condition in general medical inpatients are warranted.

Limited intervention improves technical skill in focus assessed transthoracic echocardiography among novice examiners

BACKGROUND

Previous studies addressing teaching and learning in point-of-care ultrasound have primarily focussed on image interpretation and not on the technical quality of the images. We hypothesized that a limited intervention of 10 supervised examinations would improve the technical skills in Focus Assessed Transthoracic Echocardiography (FATE) and that physicians with no experience in FATE would quickly adopt technical skills allowing for image quality suitable for interpretation.

METHODS

Twenty-one physicians with no previous training in FATE or echocardiography (Novices) participated in the study and a reference group of three examiners with more than 10 years of experience in echocardiography (Experts) was included. Novices received an initial theoretical and practical introduction (2 hours), after which baseline examinations were performed on two healthy volunteers. Subsequently all physicians were scheduled to a separate intervention day comprising ten supervised FATE examinations. For effect measurement a second examination (evaluation) of the same two healthy volunteers from the baseline examination was performed.

RESULTS

At baseline 86% of images obtained by novices were suitable for interpretation, on evaluation this was 93% (p = 0.005). 100% of images obtained by experts were suitable for interpretation. Mean global image rating on baseline examinations was 70.2 (CI 68.0-72.4) and mean global image rating after intervention was 75.0 (CI 72.9-77.0), p = 0.0002. In comparison, mean global image rating in the expert group was 89.8 (CI 88.8-90.9).

CONCLUSIONS

Improvement of technical skills in FATE can be achieved with a limited intervention and upon completion of intervention 93% of images achieved are suitable for clinical interpretation.

Handcarried echocardiography to assess hemodynamics in acute decompensated heart failure

Heart failure is a major source of cardiovascular morbidity, including acute decompensations requiring hospitalization. Because most therapeutic interventions in acute heart failure target optimization of cardiac output and volume status, accurate assessment of these parameters at the point of care is critical to guide management. However, physician bedside assessments of left ventricular (LV) function and volume status have limited accuracy. Traditional echocardiographic platforms, while useful for assessing ventricular and valvular function and volume status, have limitations for bedside use or frequent serial evaluation. Handcarried cardiac ultrasound devices, with their substantially lower costs, portability, and ease of use, circumvent many of the limitations of traditional echocardiographic platforms. The diagnostic capabilities of handcarried devices provide the opportunity for ultrasound assessment of LV function and serial bedside evaluation of volume status in patients with acutely decompensated heart failure.

The pocket echocardiograph: validation and feasibility

BACKGROUND

A new, miniaturized ultrasound device, the pocket echocardiograph (PE), is highly portable and can be carried inside a lab-coat pocket. Studies of this device are limited and have not examined the use by novice echocardiographers. We hypothesize that a novice echocardiographer can use PE to produce interpretable cardiac images, and that both novice and expert echocardiographers can use PE to accurately quantify ejection fraction.

METHODS

Unselected subjects (n = 40) in an echocardiography laboratory underwent blinded formal transthoracic echocardiography (TTE) and PE (Acuson P10, Siemens, Mountain View, CA, USA). A cardiology fellow with 2 months of echocardiography training acquired PE images. The fellow and an experienced echocardiographer interpreted the PE studies offline in a blinded fashion. To assess adequacy, studies were graded as technically adequate, limited, or inadequate. A visual estimation of ejection fraction was made. Comparisons were made to the formal reported TTE.

RESULTS

Subjects were heterogeneous, 43% male; age 64 ± 17 years, and ejection fraction 52.4%± 12.3%. All PE studies were interpretable, and the vast majority of PE and TTE images were considered technically adequate (77.5% and 85% respectively; P = 0.32). Ejection fraction showed a good correlation, bias, and limits of agreement for the fellow's interpretation (r = 0.78, -5.9%, ±16.6%) with stronger association for the experienced echocardiographer (r = 0.88, -0.8%, ±11.4%).

CONCLUSION

Novice echocardiographers using the PE can produce adequate quality images. Both expert and novice echocardiographers can use PE to quantify ejection fraction over a broad range of patients. The device's low cost and portability may greatly expand the availability of bedside echocardiography for routine or urgent cardiovascular assessment.

Turning a blind eye: the mobilization of radiology services in resource-poor regions

While primary care, obstetrical, and surgical services have started to expand in the world's poorest regions, there is only sparse literature on the essential support systems that are required to make these operations function. Diagnostic imaging is critical to effective rural healthcare delivery, yet it has been severely neglected by the academic, public, and private sectors. Currently, a large portion of the world's population lacks access to any form of diagnostic imaging. In this paper we argue that two primary imaging modalities--diagnostic ultrasound and X-Ray--are ideal for rural healthcare services and should be scaled-up in a rapid and standardized manner. Such machines, if designed for resource-poor settings, should a) be robust in harsh environmental conditions, b) function reliably in environments with unstable electricity, c) minimize radiation dangers to staff and patients, d) be operable by non-specialist providers, and e) produce high-quality images required for accurate diagnosis. Few manufacturers are producing ultrasound and X-Ray machines that meet the specifications needed for rural healthcare delivery in resource-poor regions. A coordinated effort is required to create demand sufficient for manufacturers to produce the desired machines and to ensure that the programs operating them are safe, effective, and financially feasible.

Focused transthoracic echocardiography

Caring for critically ill patients requires rapid and accurate diagnosis followed by prompt interventions. The physical examination remains an important part of the assessment of such patients, but it has been shown to have a low sensitivity and specificity in judging left ventricular function and intravascular volume. Invasive hemodynamic monitoring has similarly been shown to have significant limitations and has failed to demonstrate a mortality benefit in several recent studies. In some studies, it has been shown to be harmful. Focused transthoracic echocardiography (TTE) has emerged as a noninvasive and portable imaging technique that is capable of providing rapid and accurate information about the heart at the bedside. It can be used to complement the physical examination and result in marked improvement in diagnostic accuracy. Focused TTE can be used as a screening and monitoring tool. Studies have shown that clinicians can be trained to determine left ventricular function, detect pericardial effusions, predict intravenous fluid responsiveness, and identify important valvular defects in a relatively short period. This article describes the indications for focused TTE, provides evidence that clinicians can be rapidly taught the technique, reviews how the focused studies affect management, and discusses the advantages and limitations of this tool.

Hospitalist use of hand-carried ultrasound: preparing for battle

Hand-carried ultrasound (HCU) is a burgeoning technology at a critical point in its development as a general diagnostic technique. Despite the known safety and accuracy of ultrasound in radiology and echocardiography, the use of HCU to augment physical diagnosis by all physicians has yet unrealized potential. In order to incorporate ultrasound into a diagnostic model of routine bedside application, simple imaging and training protocols must first be derived and validated. Simplified cardiac ultrasound exams have already been validated to detect evidence-based targets such as subclinical atherosclerosis, heart failure, and elevated central venous pressures. However, for general examination of the acutely ill patient, it is the internist-hospitalist who should derive a full-body ultrasound examination, balancing training requirements with the numerous clinical applications potentially available. As the hospital's leading diagnostician with ultrasound expertise available in-house, the hospitalist could develop HCU so as to triage and refer more appropriately and limit unnecessary testing and hospital stays. Active involvement by hospitalists now in the planning of outcome, validation, and training studies, will be invaluable in the formation of an "ultrasound-assisted" physical examination in the future and will promote competent, cost-effective applications of HCU within general medical practice.

"On the other hand ...": the evidence does not support the use of hand-carried ultrasound by hospitalists

In the right hands, ultrasound is a safe and helpful diagnostic imaging tool. However, evidence supporting the use of hand-carried ultrasound (HCU) by hospitalist physicians has not kept pace with expanding application of these devices. In spite of its strategic point-of-care benefit, use of this technology by hospitalists may not ultimately translate into improved efficiency and better clinical outcomes. Optimal levels of training in image acquisition and interpretation remain to be established. Novelty, availability, and the results of a few small studies lacking patient-centered outcomes remain insufficient grounds to justify the expanded clinical utilization of these medical imaging devices by nonspecialists.

Diagnostic accuracy of hospitalist-performed hand-carried ultrasound echocardiography after a brief training program

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.

Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination?

OBJECTIVE

The traditional physical examination of the heart is relatively inaccurate. There is little information regarding whether cardiac hand-carried ultrasound performed by noncardiologists adds to the accuracy of physical examinations. The purpose of this study was to determine whether hand-carried ultrasound can add to the accuracy of hospitalists' cardiac physical examinations.

METHODS

During a focused training program in hand-carried echocardiography, 10 hospitalists performed cardiac examinations of 354 general medical inpatients first by physical examination and then by hand-carried ultrasound. Eligible inpatients included those for whom a conventional hospital echocardiogram was ordered. We measured how frequently the hospitalists' cardiac examination with or without hand-carried ultrasound matched or came within 1 scale level of an expert cardiologist's interpretation of the hospital echocardiogram.

RESULTS

Adding hand-carried ultrasound to the physical examination improved hospitalists' assessment of left ventricular function, cardiomegaly, and pericardial effusion. For left ventricular function, using hand-carried ultrasound increased the percentage of exact matches with the expert cardiologist's assessment from 46% to 59% (P=.005) and improved the percentage of within 1-level matches from 67% to 88% (P=.0001). The addition of hand-carried ultrasound failed to improve the assessments of aortic stenosis, aortic regurgitation, and mitral regurgitation.

CONCLUSION

Adding hand-carried ultrasound to physical examination increases the accuracy of hospitalists' assessment of left ventricular dysfunction, cardiomegaly, and pericardial effusion, and fails to improve assessment of valvular heart disease. The clinical benefit achieved by improved immediacy of this information has not been determined. An important limitation is that the study assessed only 1 level of training in hand-carried ultrasound.