Adding point of care ultrasound to assess volume status in heart failure patients in a nurse-led outpatient clinic. A randomised study

Integration of point-of-care ultrasound in a nurse practitioner-led heart failure clinic

BACKGROUND

Despite improved survival, one in five patients with heart failure (HF) is readmitted within 30 days of discharge. Assessing fluid status is challenging, with an estimated 50% accuracy when relying on physical examination alone. Pulmonary congestion is a risk factor for readmission and can manifest weeks before symptoms occur.

PURPOSE

To conduct a pilot study to assess for pleural effusion with point-of-care ultrasound (POCUS) and to evaluate inferior vena cava (IVC) noncollapsibility as a marker of volume status.

METHODS

A convenience sample of adults with HF (n = 21) were seen in a nurse practitioner (NP)-led postdischarge clinic within 12 days of hospitalization. The setting was a large tertiary care hospital. Inclusion criteria were patients with an HF diagnosis and Medicare insurance. The NP measured IVC diameter, assessed for collapsibility, and examined pleural cavities using a VSCAN POCUS device. Data were analyzed descriptively.

RESULTS

Pleural effusions were identified in three (14.3%) patients with POCUS and referred for thoracentesis. Inferior vena cava was noncollapsible in 5 (23.8%) patients; each of these patients required intervention for volume overload.

CONCLUSIONS

Point-of-care ultrasound can be used by NPs to identify patients with pleural effusions who may benefit from thoracentesis. Inferior vena cava noncollapsibility may be a predictor for volume overload.

IMPLICATIONS

Point-of-care ultrasound equips NPs with an extra tool to effectively manage HF.

Revolutionizing Bladder Health: Artificial-Intelligence-Powered Automatic Measurement of Bladder Volume Using Two-Dimensional Ultrasound

INTRODUCTION

Measuring elevated post-void residual volume is important for diagnosing urinary outflow tract obstruction and cauda equina syndrome. Catheter placement is exact but painful, invasive, and may cause infection, whereas an ultrasound is accurate, painless, and safe.

AIM

The purpose of this single-center study is to evaluate the accuracy of a module for artificial-intelligence (AI)-based fully automated bladder volume (BV) prospective measurement using two-dimensional ultrasound images, as compared with manual measurement by expert sonographers.

METHODS

Pairs of transverse and longitudinal bladder images were obtained from patients evaluated in an urgent care clinic. The scans were prospectively analyzed by the automated module using the prolate ellipsoid method. The same examinations were manually measured by a blinded expert sonographer. The two methods were compared using the Pearson correlation, kappa coefficients, and the Bland-Altman method.

RESULTS

A total of 111 pairs of transverse and longitudinal views were included. A very strong correlation was found between the manual BV measurements and the AI-based module with r = 0.97 [95% CI: 0.96-0.98]. The specificity and sensitivity for the diagnosis of an elevated post-void residual volume using a threshold ≥200 mL were 1.00 and 0.82, respectively. An almost-perfect agreement between manual and automated methods was obtained (kappa = 0.85). Perfect reproducibility was found for both inter- and intra-observer agreements.

CONCLUSION

This AI-based module provides an accurate automated measurement of the BV based on ultrasound images. This novel method demonstrates a very strong correlation with the gold standard, making it a potentially valuable decision-support tool for non-experts in acute settings.

The use of ultrasonography in education for undergraduate nursing students: A literature review

AIM

The incorporation of ultrasonography into nursing practice is becoming more common, but how ultrasonography is used or applied in nursing student education is still unclear. This study aimed to review and synthesize relevant literature on the use of ultrasonography in education for undergraduate nursing students.

METHODS

An electronic literature search was conducted in June 2022 (updated in June 2023) using MEDLINE, CINAHL, Scopus, and Ichushi-Web databases. Two researchers independently screened/assessed the eligibility of the studies, synthesized extracted data using a narrative synthesis (due to anticipated heterogeneity across studies), and evaluated the methodological quality of quantitative studies using the Medical Education Research Study Quality Instrument.

RESULTS

Thirteen peer-reviewed articles were included in the review. All of the studies were conducted in high-income countries, and the majority of them employed an uncontrolled single-group design. Ultrasonography was used mainly for visualizing the vascular system to improve students' puncture skills, but it was also used with various other applications. The included studies were predominantly of moderate quality and heterogeneous, but all of them reported at least some benefits in nursing student education, such as enhancing knowledge and understanding of subcutaneous anatomical structures, and improving confidence in and/or skills of venipuncture and other visualization/assessment methods.

CONCLUSIONS

This review provides a broad perspective and highlights the potential use of ultrasonography in education for undergraduate nursing students. Further research is needed to develop standardized teaching methods/curriculum and competency assessments in order to ensure minimum competency standards for students and to improve clinical outcomes for patients.

Effectiveness of nurse-led heart failure clinic: A systematic review

Objectives

Heart failure is a stage of various cardiovascular diseases and constitutes a growing major public health problem worldwide. Nurse-led heart failure clinics play an important role in managing heart failure. All nurse-led heart failure clinic services are clinic-based. We conducted a systematic review to describe the contents and impact of nurse-led heart failure clinics.

Methods

A review of nurse-led heart failure clinic research was undertaken in PubMed, Embase, Web of Science, and Cochrane Library. The search was initially conducted on October 23, 2022 and updated on November 21, 2023. Articles were appraised using the Joanna Briggs Institute Appraisal criteria by two independent reviewers. This review was registered on PROSPERO (CRD42022352209).

Results

Twelve articles were included in this systematic review. The nurse-led heart failure clinic contents were: medication uptitration, educational counselling, evidence-based transitional care, psychosocial support, physical examination and mental well-being assessment, therapy monitoring and adjustment, follow-up, and phone consultations. Most studies reported largely positive clinical outcomes in nurse-led heart failure clinics. Four studies examined the quality of life and reported conflicting results; four studies examined medication titration efficacy, and the results were generally positive. Only two studies examined cost-effectiveness.

Conclusions

Nurse-led heart failure clinics have shown a largely positive impact on patient outcomes, quality of life, and medication titration efficacy. More randomised controlled trials and other studies are needed to obtain more robust conclusions.

Point of Care Ultrasound for Diagnosis and Management in Heart Failure: A Targeted Literature Review

BACKGROUND

Cardiac point of care ultrasound (POCUS) has shown increasing utility as a tool for diagnosing and managing heart failure (HF). Within cardiology, intravascular volume assessment leveraging visualization of the inferior vena cava (IVC) is a central aspect of care, as IVC size correlates with central venous pressure. This targeted literature review aimed to examine the existing literature assessing the use of POCUS in diagnosis and management of HF patients utilizing POCUS-based IVC measurement either alone or in combination with secondary methods.

METHODS

A targeted PubMed and Ovid database search up until August 28, 2023 using a keyword search was completed. Studies that did not include IVC assessment with POCUS in HF were excluded.

RESULTS

The initial search using both PubMed and Ovid resulted in 370 journal publications. After exclusion criteria were used 15 studies were included in the review. Studies were grouped into three categories: 1) how well POCUS was able to identify HF, 2) whether POCUS-based findings correlated with other measures evaluating HF and was able to predict the effect of diuretic administration, and 3) whether POCUS-based findings served as a good prognostic indicator. The 5 studies that evaluated HF identification with POCUS found that both diagnostic sensitivity and specificity may reach 90%-100% when IVC measurement was coupled with a lung ultrasound assessing the presence of B-lines or pleural effusion. Five studies assessing POCUS findings correlating with other HF measures and diuretic effect found that IVC diameter changed significantly with diuretic administration (p<0.05). All 6 studies assessing POCUS as a predictor of long-term mortality or hospital readmission found measures that achieved statistical significance with p<0.05.

CONCLUSIONS

Including POCUS as standard-of-care - both as a diagnostic tool in the emergency department and a management tool in in-patient and out-patient facilities - may improve the treatment of HF.

Hand-Held Echocardiography by Advanced Practice Providers in Patients with Congestive Heart Failure

OBJECTIVES

The performed hand-held echocardiography (HHE) was evaluated and interpreted by trained advanced practice providers (APPs) on hospitalized CHF patients for image quality and interpretation by comparing with expert echocardiographer and SE findings.

BACKGROUND

Congestive heart failure (CHF) is associated with increased hospital admissions and mortality. While a standard echocardiogram (SE) is the gold standard for cardiac assessment, it is not readily available. Hospitalized CHF patients require rapid assessment for expedited treatment.

METHODS

Over 6 months, five trained APPs performed HHE on hospitalized CHF patients and interpreted: (a) left ventricular (LV) size, (b) LV ejection fraction (LVEF), and (c) right atrial pressure (RAP). The study echocardiographer reviewed and blindly interpreted the HHE images and compared them with APPs and SE findings. Kappa statistics determined the degree of agreement between APPs and the study echocardiographer's interpretation of the HHE images and SE.

RESULTS

A total of 80 CHF patients (age 73 ± 14 years, 58% males; LVEF (by SE) 45 ± 19%; 36.3% body mass indexes ≥ 30 kg/m2) were enrolled. HHE interpretation by APPs had a good agreement for LVEF (kappa 0.79) with the study echocardiographer and SE (kappa 0.74) and a good agreement for RAP (kappa 0.67) with the study echocardiographer. The correlation between the absolute LVEF interpretation by the study echocardiographer on HHE and SE was r = 0.88 (p < 0.0001).

CONCLUSIONS

Trained APPs obtained diagnostic-quality HHE images and interpreted the LV function and RAP in CHF patients in good agreement with the study echocardiographer. LVEF by HHE correlated with LVEF by SE. Our study suggests trained APPs can use HHE to evaluate LVEF and RAP in CHF patients, leading to expedited and optimized treatment.

Evaluation of the image quality and validity of handheld echocardiography for stroke volume and left ventricular ejection fraction quantification: a method comparison study

Bedside quantification of stroke volume (SV) and left ventricular ejection fraction (LVEF) is valuable in hemodynamically compromised patients. Miniaturized handheld ultrasound (HAND) devices are now available for clinical use. However, the performance level of HAND devices for quantified cardiac assessment is yet unknown. The aim of this study was to compare the validity of HAND measurements with standard echocardiography (SE) and three-dimensional echocardiography (3DE). Thirty-six patients were scanned with HAND, SE and 3DE. LVEF and SV quantification was done with automated software for the HAND, SE and 3DE dataset. The image quality of HAND and SE was evaluated by scoring segmental endocardial border delineation (2 = good, 1 = poor, 0 = invisible). LVEF and SV of HAND was evaluated against SE and 3DE using correlation and Bland-Altman analysis. The correlation, bias, and limits of agreement (LOA) between HAND and SE were 0.68 [0.46:0.83], 1.60% [- 2.18:5.38], and 8.84% [- 9.79:12.99] for LVEF, and 0.91 [0.84:0.96], 1.32 ml [- 0.36:4.01], 15.54 ml [- 18.70:21.35] for SV, respectively. Correlation, bias, and LOA between HAND and 3DE were 0.55 [0.6:0.74], - 0.56% [- 2.27:1.1], and 9.88% [- 13.29:12.17] for LVEF, and 0.79 [0.62:0.89], 6.78 ml [2.34:11.21], 12.14 ml [- 26.32:39.87] for SV, respectively. The image quality scores were 9.42 ± 2.0 for the apical four chamber views of the HAND dataset and 10.49 ± 1.7 for the SE dataset and (P < 0.001). Clinically acceptable accuracy, precision, and image quality was demonstrated for HAND measurements compared to SE. In comparison to 3DE, HAND showed a clinically acceptable accuracy and precision for LVEF quantification.

Building Consensus on the Point-of-Care Ultrasound Skills Required for Effective Healthcare Service Delivery at District Hospitals in South Africa: A Delphi Study

BACKGROUND

Despite the widespread availability of ultrasound machines in South African district hospitals, there are no guidelines on the competency in point-of-care ultrasound (POCUS) use required by generalist doctors in this setting. This study aimed to define the required POCUS competencies by means of consensus via the Delphi method.

METHODS

An online Delphi process was initiated in June 2022, using the existing American Academy of Family Physicians' ultrasound curriculum (84 skillsets) as the starting questionnaire. Panelists were selected across the country, including two from district hospitals in each province and two from each academic family medicine department in South Africa (N = 36). In each iterative round, the participants were asked to identify which POCUS skillsets were essential, optional (region-specific), or non-essential for South African district hospitals. This process continued until consensus (>70% agreement) was achieved on all of the skillsets.

RESULTS

Consensus was achieved on 81 of the 84 skillsets after 5 iterative rounds (96.4%), with 3 skillsets that could not achieve consensus (defined as <5% change over more than 2 consecutive rounds). The final consensus identified 38 essential, 28 optional, and 15 non-essential POCUS skillsets for the South African district hospital context.

CONCLUSIONS

The list of essential POCUS skillsets provided by this study highlights the predominance of obstetric- and trauma-based skillsets required for generalist healthcare workers in South African district hospitals. The findings will require priority setting and revalidation prior to their implementation across the country.

Inferior vena cava diameter and risk of acute decompensated heart failure rehospitalisations

OBJECTIVES

Inferior vena cava (IVC) diameter may be a surrogate for volume status in acute decompensated heart failure (ADHF). The utility of IVC diameter measurement is under studied. The aim of this study was to assess the relationship between IVC diameter, clinical variables and ADHF rehospitalisations.

METHODS

Retrospective chart review of 200 patients admitted for ADHF from 2018 to 2019 with transthoracic echocardiogram during index hospitalisation. Charts were assessed for ADHF rehospitalisation within 1 year.

RESULTS

The median age was 64, 30.5% were female, and average left ventricular ejection fraction was 41%±20%. IVC diameter correlated to pulmonary arterial (PA) pressure (R=0.347, p<0.001) and body surface area (BSA) (R=0.424 p<0.001). IVC diameter corrected for BSA correlated to PA pressure (R=0.287, p<0.001) and log N-terminal B-type natriuretic peptide (NT-proBNP) (R=0.247, p≤0.01). Patients rehospitalised within 1 year had significantly greater mean IVC diameter compared with those not rehospitalised (p<0.001) while there was no difference in mean net weight lost during index hospitalisation or mean log NT-proBNP. Patients with IVC diameter greater than 2.07 cm had significantly increased ADHF rehospitalisation (85.6% vs 49.3%, log rank p<0.001) with HR 2.44 (95% CI 1.85 to 3.23, p<0.001). In multivariable Cox regression only IVC diameter (p<0.001), presence of tricuspid regurgitation (p=0.02) and NYHA class III/IV (p<0.001) independently predicted ADHF rehospitalisation within 1 year.

CONCLUSIONS

IVC diameter is predictive of rehospitalisation in patients with ADHF and may identify patients in need of greater monitoring and diuresis.

Inferior vena cava diameter is associated with prognosis in patients with chronic heart failure independent of tricuspid regurgitation velocity

AIMS

A high, Doppler-derived, tricuspid regurgitation velocity (TRV) indicates pulmonary hypertension, which may contribute to right ventricular dysfunction and worsening tricuspid regurgitation leading to systemic venous congestion, reflected by an increase in inferior vena cava (IVC) diameter. We hypothesized that venous congestion rather than pulmonary hypertension would be more strongly associated with prognosis.

METHODS AND RESULTS

895 patients with chronic heart failure (CHF) (median (25th and 75th centile) age 75 (67-81) years, 69% men, LVEF 44 (34-55)% and NT-proBNP 1133 (423-2465) pg/ml) were enrolled. Compared to patients with normal IVC (< 21 mm) and TRV (≤ 2.8 m/s; n = 504, 56%), those with high TRV but normal IVC (n = 85, 9%) were older, more likely to be women and to have LVEF ≥ 50%, whilst those with dilated IVC but normal TRV (n = 142, 16%) had more signs of congestion and higher NT-proBNP. Patients (n = 164, 19%) with both dilated IVC and high TRV had the most signs of congestion and the highest NT-proBNP. During follow-up of 860 (435-1121) days, 239 patients died. Compared to those with both normal IVC and TRV (reference), patients with high TRV but normal IVC did not have a significantly increased mortality (HR: 1.41; CI: 0.87-2.29; P = 0.16). Risk was higher for patients with a dilated IVC but normal TRV (HR: 2.51; CI: 1.80-3.51; P < 0.001) or both a dilated IVC and elevated TRV (HR: 3.27; CI: 2.40-4.46; P < 0.001).

CONCLUSION

Amongst ambulatory patients with CHF, a dilated IVC is more closely associated with an adverse prognosis than an elevated TRV.

Heart Failure with Reduced Ejection Fraction: The Role of Cardiovascular and Lung Ultrasound beyond Ejection Fraction

Heart failure with reduced ejection fraction (HFrEF) is considered a major health care problem with frequent decompensations, high hospitalization and mortality rates. In severe heart failure (HF), the symptoms are refractory to medical treatment and require advanced therapeutic strategies. Early recognition of HF sub- and decompensation is the cornerstone of the timely treatment intensification and, therefore, improvement in the prognosis. Echocardiography is the gold standard for the assessment of systolic and diastolic functions. It allows one to obtain accurate and non-invasive measurements of the ventricular function in HF. In severely compromised HF patients, advanced cardiovascular ultrasound modalities may provide a better assessment of intracardiac hemodynamic changes and subclinical congestion. Particularly, cardiovascular and lung ultrasound allow us to make a more accurate diagnosis of subclinical congestion in HFrEF. The aim of this review was to summarize the advantages and limitations of the currently available ultrasound modalities in the ambulatory monitoring of patients with HFrEF.

Point-of-Care Ultrasonography in a Pulmonary Hypertension Clinic: A Randomized Pilot Study

Pulmonary arterial hypertension (PAH) is a rare condition with the potential to progress to right heart failure. Point-of-Care Ultrasonography (POCUS), used and interpreted in real time at the bedside to further the cardiopulmonary assessment, has the potential to improve the longitudinal care of PAH patients in the ambulatory setting. Patients from PAH clinics at two academic medical centers were randomized to either a POCUS assessment cohort or non-POCUS standard care (ClinicalTrials.gov identifier NCT05332847). The POCUS group received blinded heart, lung, and vascular ultrasound assessments. Thirty-six patients were randomized to the study and followed over time. Mean age was 65 in both groups and majority female (76.5% and 88.9% females in POCUS and control, respectively). Median time for POCUS assessment was 11 min (range 8-16). There were significantly more changes in management in the POCUS group than control (73% vs. 27%, p-value < 0.001). Multivariate analysis revealed that management changes were more likely to occur with a POCUS assessment, with an odds ratio (OR) of 12 when POCUS was added to physical exam vs. OR of 4.6 compared to physical examination alone (p < 0.001). POCUS in the PAH clinic is feasible and, when combined with physical examination, increases the number of findings and results in changes in management without significantly prolonging visit encounters. POCUS may help support clinical evaluation and decision making in ambulatory PAH clinics.

Assessment of Volume Status in Hospitalized Patients With Chronic Heart Failure

Assessment of volume status in hospitalized patients with heart failure is a critically important diagnostic skill that clinicians utilize frequently. However, accurate assessment is challenging and there is often significant inter-provider disagreement. This review serves as an appraisal of current methods of volume assessment amongst different categories of evaluation including patient history, physical exam, laboratory analysis, imaging, and invasive procedures. Within each category, this review highlights methods that are particularly sensitive or specific, or those that carry impactful positive or negative likelihood ratios. Utilization of the information that this review provides will allow clinicians to determine volume status of hospitalized heart failure patients more accurately and more precisely in order to provide appropriate and effective therapies.

Evaluation of simulation-based ultrasound education using a bladder simulator for medical students in Japan: a prospective observational study

PURPOSE

This study aimed to investigate the usefulness of ultrasound education for medical students using a bladder simulator.

METHODS

This prospective observational study included volunteer fifth- and sixth-year medical students. An intravesical urine volume measurement simulator and a pocket-sized hand-held ultrasound device were used. The ultrasound education comprised pre-learning, briefing, simulation, debriefing, and learning summary. The simulation consisted of two tests: bladder simulator cube evaluation and scenario-based clinical application. A self-rated confidence score of 0-10 points along with reasons for the scores was recorded before and after the ultrasound education.

RESULTS

Twelve participants (median age, 23 years; female, 75%) met the inclusion criteria and were examined. Participants' bladder simulator cube evaluation and scenario-based clinical application test results were good, and the educational difficulty level was appropriate. The mean confidence scores for main unit operation, probe control, image acquisition, image evaluation and clinical application before the ultrasound education were 1.0, 1.8, 1.3, 0.8 and 0.1 points, respectively. The mean confidence scores after the ultrasound education were 5.8, 5.9, 5.4, 5.5 and 5.1, respectively, with significant increases for all items (p < 0.01). The positive impression categories that affected confidence scores after ultrasound education were related to device operation, image acquisition, image evaluation, clinical application and learning.

CONCLUSION

Ultrasound education using a bladder simulator increases confidence scores by imparting competencies related to device operation, image acquisition, image evaluation and clinical application, and it improves students' learning impression. This is a useful method for introductory ultrasound education for medical students.

Real-time automatic quantification of left ventricular function by hand-held ultrasound devices in patients with suspected heart failure: a feasibility study of a diagnostic test with data from general practitioners, nurses and cardiologists

OBJECTIVES

To evaluate the feasibility and reliability of hand-held ultrasound (HUD) examinations with real-time automatic decision-making software for ejection fraction (autoEF) and mitral annular plane systolic excursion (autoMAPSE) by novices (general practitioners), intermediate users (registered cardiac nurses) and expert users (cardiologists), respectively, compared to reference echocardiography by cardiologists in an outpatient cohort with suspected heart failure (HF).

DESIGN

Feasibility study of a diagnostic test.

SETTING AND PARTICIPANTS

166 patients with suspected HF underwent HUD examinations with autoEF and autoMAPSE measurements by five novices, three intermediate-skilled users and five experts. HUD results were compared with a reference echocardiography by experts. A blinded cardiologist scored all HUD recordings with automatic measurements as (1) discard, (2) accept, but adjust the measurement or (3) accept the measurement as it is.

PRIMARY OUTCOME MEASURE

The feasibility of automatic decision-making software for quantification of left ventricular function.

RESULTS

The users were able to run autoEF and autoMAPSE in most patients. The feasibility for obtaining accepted images (score of ≥2) with automatic measurements ranged from 50% to 91%. The feasibility was lowest for novices and highest for experts for both autoEF and autoMAPSE (p≤0.001). Large coefficients of variation and wide coefficients of repeatability indicate moderate agreement. The corresponding intraclass correlations (ICC) were moderate to good (ICC 0.51-0.85) for intra-rater and poor (ICC 0.35-0.51) for inter-rater analyses. The findings of modest to poor agreement and reliability were not explained by the experience of the users alone.

CONCLUSION

Novices, intermediate and expert users were able to record four-chamber views for automatic assessment of autoEF and autoMAPSE using HUD devices. The modest feasibility, agreement and reliability suggest this should not be implemented into clinical practice without further refinement and clinical evaluation.

TRIAL REGISTRATION NUMBER

NCT03547076.

User experience and image quality influence on performance of automated real-time quantification of left ventricular function by handheld ultrasound devices: a diagnostic accuracy study with data from general practitioners, nurses and cardiologists

BACKGROUND AND OBJECTIVES

Echocardiography is the cornerstone of heart failure (HF) diagnosis, but expertise is limited. Non-experts using handheld ultrasound devices (HUDs) challenge the clinical yield. Left ventricular (LV) ejection fraction (EF) is used for assessment and grading of HF. Mitral annular plane systolic excursion (MAPSE) reflects LV long-axis shortening. Automatic tools for quantification of EF (autoEF) and MAPSE (autoMAPSE) are available on HUDs. We aimed to explore the importance of user experience and image quality for autoEF and autoMAPSE on HUDs, and how image quality influences the feasibility, agreement and reliability in patients with suspected HF.

METHODS

General practitioners, registered cardiac nurses and cardiologists represented the novice, intermediate and expert users, respectively, in this diagnostic accuracy study. 2543 images were evaluated by an external, blinded cardiologist by a five-parameter, prespecified score (four-chamber view, LV alignment, apical mispositioning, mitral annular assessment and number of visible endocardial segments) graded 0-6.

RESULTS

Feasibility was higher with increasing image quality. In all recordings, irrespective of user, the average image quality score and the five prespecified scores were associated with the feasibility of autoEF and autoMAPSE (all p<0.001). Image quality was more important for the feasibility of autoMAPSE than autoEF. Image quality was not important for the agreement of autoEF (R2 2%) and autoMAPSE (R2 7%). Combining all user groups, the reliability was lower with larger within-patient variability in image quality of the repeated recordings (p≤0.005). Similar associations were not found in user group specific analyses (p≥0.16). Patients' characteristics were only weakly associated with image quality score (R2≤4%).

DISCUSSION

Image quality was important for feasibility but does not explain the low agreement with reference or the modest within-patient reliability of automatic decision-support software on HUDs for all user groups in patients with suspected HF.

Focused Cardiac Ultrasound Training for Non-cardiologists: An Overview and Recommendations for a Lower Middle-Income Country

Poor outcomes among the critically ill in low- and middle-income countries (LMICs) have been attributed in part to the challenge of diagnostic delays caused by lack of skilled personnel. Focused cardiac ultrasound (FoCUS) by non-cardiologists may mitigate the shortage of echocardiography experts to perform emergency echocardiography at the point of care in these settings. It is however crucial that FoCUS training for non-cardiologists in LMICs be based on robust evidence to support training delivery if diagnostic accuracy is to be assured.

Protocol for a Delphi Consensus Study to Determine the Essential and Optional Ultrasound Skills for Medical Practitioners Working in District Hospitals in South Africa

With increasing access to point of care ultrasound (POCUS) at district hospitals in South Africa, there is a lack of standardisation of skillsets among medical practitioners working at this level of care. This study protocol aims to use the Delphi process to achieve expert consensus on the essential and optional ultrasound skills required for medical practitioners working in district hospitals in South Africa. In alignment with the Delphi method, several iterative rounds will be implemented from June to November 2022. Purposive sampling will be conducted, through the recruitment of two representatives from each academic department of family medicine and two medical doctors working in district hospitals in each province in the country (N = 36). The POCUS skillsets published by the American Academy of Family Physicians will be circulated in the first iterative round, following which participants may suggest further additions. Once a consensus target of 70% has been achieved, the Delphi process will be finalised. The Delphi process and data analysis will be facilitated by an online Delphi platform. Findings from the study will provide insight into the design of the curriculum for POCUS training for medical practitioners in district hospitals and registrars in family medicine departments across the country.

Hospital at home for acute medical illness: The 21st century acute medical unit for a changing population

Recent trends across Europe show a year-on-year increase in the number of patients with acute medical illnesses presenting to hospitals, yet there are no plans for a substantial expansion in acute hospital infrastructure or staffing to address demand. Strategies to meet increasing demand need to consider the fact that there is limited capacity in acute hospitals and focus on new care models in both hospital and community settings. Increasing the efficiency of acute hospital provision by reducing the length of stay entails supporting acute ambulatory care, where patients receive daily acute care interventions but do not stay overnight in the hospitals. This approach may entail daily transfer between home and an acute setting for ongoing treatment, which is unsuitable for some patients living with frailty. Acute hospital at home (HaH) is a care model which, thanks to advances in point of care diagnostic capability, can provide a credible model of acute medical assessment and treatment without the need for hospital transfer. Investment and training to support scaling up of HaH are key strategic aims for integrated healthcare systems.

Portable ultrasound assessment of jugular venous pressure is an accurate method for estimating volaemic status in patients with cardiac disease

PURPOSE

The objective of this study was to determine whether ultrasound-measured jugular venous pressure (U-JVP) could accurately estimate central venous pressure (CVP).

METHODS

This prospective, diagnostic, single-centre study was performed at the Cardiac Intensive Care Unit of the Northern General Hospital, Sheffield, UK. Post-cardiac surgery patients were recruited from January to May 2019. The investigators were blinded to the central venous pressure when measuring the jugular venous pressure. U-JVP and direct CVP were measured simultaneously. Measurements were taken whilst the patient was ventilated and then repeated when the patient was extubated, providing non-ventilated readings.

RESULTS

One-hundred and fourteen consecutive participants with a male predominance of 71% and mean age of 65 ± 12 years were included in the analysis. Bland-Altman plots revealed that U-JVP marginally overestimated CVP by 0.91 mmHg (95% limits of agreement were -2.936 to 4.754) in ventilated patients and by 0.11 mmHg (95% limits of agreement between -2.481 and 2.695) in non-ventilated patients. Reasonable sensitivity and specificity of ultrasound-measured jugular venous pressure was achieved for low and high central venous pressure in both ventilated and non-ventilated patients.

CONCLUSION

U-JVP accurately estimates cardiac filling pressure and fluid status in patients after cardiac surgery, irrespective of their ventilatory status. Jugular venous pressure measurement by insonation is a reliable technique that can be taught to medical students and other health professionals to non-invasively estimate central venous pressure and may be useful for assessment of volaemic status in patients with heart failure.

TRIAL REGISTRATION

ClinicalTrials.gov public (identifier NCT03815188).

Inferior Vena Cava Edge Tracking Echocardiography: A Promising Tool with Applications in Multiple Clinical Settings

Ultrasound (US)-based measurements of the inferior vena cava (IVC) diameter are widely used to estimate right atrial pressure (RAP) in a variety of clinical settings. However, the correlation with invasively measured RAP along with the reproducibility of US-based IVC measurements is modest at best. In the present manuscript, we discuss the limitations of the current technique to estimate RAP through IVC US assessment and present a new promising tool developed by our research group, the automated IVC edge-to-edge tracking system, which has the potential to improve RAP assessment by transforming the current categorical classification (low, normal, high RAP) in a continuous and precise RAP estimation technique. Finally, we critically evaluate all the clinical settings in which this new tool could improve current practice.

The role of non-invasive devices for the telemonitoring of heart failure patients

Heart failure (HF) patients represent one of the most prevalent as well as one of the most fragile population encountered in the cardiology and internal medicine departments nowadays. Estimated to account for around 26 million people worldwide, diagnosed patients present a poor prognosis and quality of life with a clinical history accompanied by repeated hospital admissions caused by an exacerbation of their chronic condition. The frequent hospitalizations and the extended hospital stays mean an extremely high economic burden for healthcare institutions. Meanwhile, the number of chronically diseased and elderly patients is continuously rising, and a lack of specialized physicians is evident. To cope with this health emergency, more efficient strategies for patient management, more accurate diagnostic tools, and more efficient preventive plans are needed. In recent years, telemonitoring has been introduced as the potential answer to solve such needs. Different methodologies and devices have been progressively investigated for effective home monitoring of cardiologic patients. Invasive hemodynamic devices, such as CardioMEMS™, have been demonstrated to be reducing hospitalizations and mortality, but their use is however restricted to limited cases. The role of external non-invasive devices for remote patient monitoring, instead, is yet to be clarified. In this review, we summarized the most relevant studies and devices that, by utilizing non-invasive telemonitoring, demonstrated whether beneficial effects in the management of HF patients were effective.

Kidney Replacement Therapy for Fluid Management

Emerging evidence from observational studies suggests that both slower and faster net ultrafiltration rates during kidney replacement therapy are associated with increased mortality in critically ill patients with acute kidney injury and fluid overload. Faster rates are associated with ischemic organ injury. The net ultrafiltration rate should be prescribed based on patient body weight in milliliters per kilogram per hour, with close monitoring of patient hemodynamics and fluid balance. Randomized trials are required to examine whether moderate net ultrafiltration rates compared with slower and faster rates are associated with reduced risk of hemodynamic instability, organ injury, and improved outcomes.

Feasibility and Accuracy of Tele-Echocardiography, With Examinations by Nurses and Interpretation by an Expert via Telemedicine, in an Outpatient Heart Failure Clinic

OBJECTIVES

To study the feasibility and accuracy of focused echocardiography by nurses supported by near-real-time interpretation via telemedicine by an experienced cardiologist.

METHODS

Fifty consecutive patients were included from an outpatient heart failure (HF) clinic. Limited echocardiography was performed by 1 of 3 specialized nurses. The echocardiograms were transferred by a secure transfer model for near-real-time interpretation to 1 out-of-hospital cardiologist, assessing, among others, the left ventricular (LV) internal diameter, end-diastolic volume, ejection fraction, left atrial (LA) indexed end-systolic volume, mitral early inflow velocity (E), the ratio of E to mitral late inflow, and the ratio of E to the mitral annular early diastolic velocity. The reference method was echocardiography by 1 of 4 experienced cardiologists.

RESULTS

The median age of the population (46% women) was 79 (range, 33-95) years. The assessment and quantification of LA and LV dimensions, volumes, and functional indices were feasible in 94% or more via the telemedical approach. The agreement with reference measurements was very high by the telemedical approach. The mean duration ± SD of the complete telemedical approach from the start of echocardiography until the cardiologist's report was received by the caregiving nurse was 1.32 ± 0.36 (range, 1.58) hours. The correlations with reference to the above-specified indices were r = 0.75 to 0.94.

CONCLUSIONS

Limited echocardiography by nurses in an outpatient heart failure clinic, supported by interpretation by an out-of-hospital cardiologist, was feasible and reliable. This may reduce geographic disparities and allow more patients to benefit from the advantages of implementing focused echocardiography by noncardiologists in diagnostics and follow-up.

Ultrasound imaging of congestion in heart failure: examinations beyond the heart

Congestion, related to pressure and/or fluid overload, plays a central role in the pathophysiology, presentation and prognosis of heart failure and is an important therapeutic target. While symptoms and physical signs of fluid overload are required to make a clinical diagnosis of heart failure, they lack both sensitivity and specificity, which might lead to diagnostic delay and uncertainty. Over the last decades, new ultrasound methods for the detection of elevated intracardiac pressures and/or fluid overload have been developed that are more sensitive and specific, thereby enabling earlier and more accurate diagnosis and facilitating treatment strategies. Accordingly, we considered that a state-of-the-art review of ultrasound methods for the detection and quantification of congestion was timely, including imaging of the heart, lungs (B-lines), kidneys (intrarenal venous flow), and venous system (inferior vena cava and internal jugular vein diameter).

Optimisation of Heart Failure Management in Nursing Homes Using Point-of-Care Ultrasonography: Harmonious Trial Rationale and Design

Introduction

Heart failure is common in the nursing home population and presents many diagnostic and therapeutic challenges. Point-of-care ultrasonography is a bedside method that can be used to assess volume status more reliably than clinical examination. This trial was conceived to test whether point-of-care ultrasonography-guided management improves heart failure outcomes among nursing home residents.

Methods

Nursing home residents with heart failure will be enrolled in a multi-centre, prospective, randomised controlled trial. Residents will first be screened for heart failure. Patients with heart failure will be randomised in 1:1 fashion into two groups. Nursing home physicians will adjust diuretic therapy according to volume status for six months. Point-of-care ultrasonography will be used in the test group and clinical examination in the control group. The primary endpoint will be heart failure deterioration, defined as a composite of any of the following four events: the need for an intravenous diuretic application, the need for an emergency service intervention, the need for unplanned hospitalisation for non-injury causes, or death from whatever cause.

Expected results

The expected prevalence of heart failure among nursing home residents is above 10%. Point-of-care ultrasonography-guided heart failure management will reduce the number of deteriorations of heart failure in the nursing home population.

Conclusion

This study will explore the usefulness of point-of-care ultrasonography for heart failure management in the nursing home population.

Diagnosis of Acute Heart Failure Using Inferior Vena Cava Ultrasound: Systematic Review and Meta-analysis

OBJECTIVES

The utility of bedside inferior vena cava (IVC) ultrasound (US) in the diagnosis of heart failure (HF) is unclear. The aim of this study was to determine whether IVC parameters in patients with acute heart failure (AHF) are statistically different from those without HF.

METHODS

The MEDLINE database of English-language publications from 1966 to August 2018 was searched. Retrospective and prospective studies that included either IVC expiratory diameter (IVC_exp ) or IVC collapsibility index (IVC-CI) values were collected in patients with and without HF. to determine whether there was a statistical difference in the IVC parameters between these groups.

RESULTS

A total of 27 articles with a total of 1472 patients with AHF were included. The standard mean differences for the IVC_exp and IVC-CI for the control group versus the AHF group were found to be statistically significant (P < .0001). The combined mean IVC_exp values were 15.11 mm (95% confidence interval [CI], 14.19-16.02 mm) for the control group and 20.26 mm (95% CI, 14.82-25.71 mm) for the AHF group. The combined mean IVC-CI values were 61.6% (95% CI, 48.4%-74.7%) for the control group and 30.5% (95% CI, 26.4%-34.6%) for the AHF group.

CONCLUSIONS

Bedside IVC US showed that a statistically significant difference existed in the IVC parameters between patients with and without AHF. Based on mean calculations, an IVC_exp of greater than 2.0 cm and an IVC-CI of less than 30% are reasonable cutoffs to suggest that a patient with acute dyspnea is more likely to have AHF than a non-AHF condition. Given the high degree of heterogeneity across the studies and the high risk of bias, larger randomized studies are warranted to explore the use of IVC US in patients with HF.

Point-of-care ultrasound in pediatric anesthesia: perioperative considerations

PURPOSE OF REVIEW

To review the perioperative applications of point-of-care ultrasound (POCUS).

RECENT FINDINGS

The role of point-of-care ultrasonography for perioperative care is expanding with respect to perioperative application. The imaging approach can complement the physical exam and provide additional information for decision-making in pediatric perioperative medicine. This review will focus on applications in the following organ systems: airway, cardiac, pulmonary and gastric. Specifically, POCUS of the airway has been used to optimize endotracheal tube depth, aid in tube size selection and predict difficulty with laryngoscopy and intubation. Lung POCUS has been used to assess for causes hypoxemia as well as to optimize ventilatory mechanics. Cardiac POCUS has been used for assessment of hemodynamics, valvular and ventricular function. Gastric ultrasound has emerged as an evaluative mechanism of gastric content in the setting of fasting as well as to confirm placement of gastric tubes. The applications of POCUS in the perioperative setting continue to evolve as a reliable diagnostic tool that can assist in timely diagnosis, improve procedural safety and has the potential to improve patient outcomes.

SUMMARY

The utility of perioperative POCUS has been well demonstrated, specifically for examination of the airway, stomach and cardiopulmonary system. It is advisable for the novice sonographer to perform POCUS within the guidelines set by the American Society of Echocardiography regarding basic POCUS. As with all diagnostic modalities, understanding the limitations of ultrasound and POCUS as well as continuous self-assessment is crucial.

Point-of-care ultrasound with pocket-size devices in emergency department

Point-of-care ultrasound is a useful tool for clinicians in the management of patients. Particularly in emergency department, the role of point-of-care ultrasound is strongly increasing due to the need for a rapid assessment of critically ill patients and to speed up the diagnostic process. Hand-carried ultrasound devices are particularly useful in emergency setting and allow rapid assessment of patient even in prehospital setting. This article will review the role of point-of-care ultrasonography, performed with pocket-size devices, in the management of patients presenting with acute onset of undifferentiating dyspnea, chest pain, and shock in emergency department.

Handheld Ultrasound and Focused Cardiovascular Echography: Use and Information

The availability of miniaturized ultrasound machines has changed our approach to many cardiovascular diseases. Handheld ultrasound imaging can be performed at the bedside, it is easy to use, and the information provided, although limited, is of unquestionable importance for a quick diagnosis that leads to early treatment. They have unique characteristics: Low cost, wide availability, safety, accuracy, and can be used in different clinical scenarios and by operators with different backgrounds. Image acquisition and interpretation is rapid and provides, in each situation, useful information for diagnosis, prognosis, and clinical and therapeutic management. This review focuses on the use of handheld ultrasound devices, describes differences with other equipment, their limitations, and the numerous advantages derived from their use.

Ability of non-physicians to perform and interpret lung ultrasound: A systematic review

BACKGROUND

Lung ultrasound is a useful tool in the assessment of pulmonary congestion in heart failure that is typically performed and interpreted by physicians at the point-of-care.

AIMS

To investigate the ability of nurses, students, and paramedics to accurately identify B-lines and pleural effusions for the detection of pulmonary congestion in heart failure and to examine the training necessary.

METHODS AND RESULTS

We conducted a systematic review and searched online databases for studies that investigated the ability of nurses, students, and paramedics to perform lung ultrasound and detect B-lines and pleural effusions. Of 979 studies identified, 14 met our inclusion criteria: five in nurses, eight in students, and one in paramedics. After 0-12 h of didactic training and 58-62 practice lung ultrasound examinations, nurses were able to identify B-lines and pleural effusions with a sensitivity of 79-98% and a specificity of 70-99%. In image adequacy studies, medical students with 2-9 h of training were able to acquire adequate images for B-lines and pleural effusions in 50-100%. Only one eligible study investigated paramedic-performed lung ultrasound which did not support the ability of paramedics to adequately acquire and interpret lung ultrasound images after 2 h of training.

CONCLUSIONS

Our findings suggest that nurses and students can accurately acquire and interpret lung ultrasound images after a brief training period in a majority of cases. The examination of heart failure patients with lung ultrasound by non-clinicians appears feasible and warrants further investigation.

Focused Cardiac Ultrasonography: Current Applications and Future Directions

Focused cardiac ultrasonography is performed by clinicians at the bedside and is used in time-sensitive scenarios to evaluate a patient's cardiovascular status when comprehensive echocardiography is not immediately available. This simplified cardiac ultrasonography is often performed by noncardiologists using small, portable devices to augment the physical examination, triage patients, and direct management in both critical care and outpatient settings. However, as the use of focused cardiac ultrasonography continues to expand, careful consideration is required regarding training, scope of practice, impact on patient outcomes, and medicolegal implications. In this review, we examine some of the challenges with rapid uptake of this technique and explore the benefits and potential risk of focused cardiac ultrasonography. We propose possible mechanisms for cross-specialty collaboration, quality improvement, and oversight.

Ultrasonography in Heart Failure: A Story that Matters

Heart failure (HF) is a clinical syndrome caused by structural and/or functional cardiac abnormalities, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress. It is the leading cause of hospitalization in Internal Medicine departments. This article aims at reviewing evidence of the importance of ultrasound in HF both for hospitalized patients and in the follow-up. Ultrasound may be used as a recovery monitoring instrument at the bedside and also as a global cardiovascular assessment tool for these patients. HF represents an exciting opportunity to create an integrative ultrasound approach in Internal Medicine and/or Geriatric departments. The authors plan a five-step ultrasound examination to evaluate and monitor HF patients during hospitalization and follow-up. They call this examination: the "ABCDE" score. It includes the evaluations of A, the ankle-brachial index, B, the B-lines, C, the carotid intima media thickness, D, the diameter of the abdominal aorta and of the inferior cava vein and E, the echocardiographic assessment of the ejection fraction. This score may represent an integrative ultrasound approach in Internal Medicine and/or Geriatric departments.

The Potential of Clinical Phenotyping of Heart Failure With Imaging Biomarkers for Guiding Therapies: A Focused Update

The need for noninvasive assessment of cardiac volumes and ejection fraction (EF) ushered in the use of cardiac imaging techniques in heart failure (HF) trials that investigated the roles of pharmacological and device-based therapies. However, in contrast to HF with reduced EF (HFrEF), modern HF pharmacotherapy has not improved outcomes in HF with preserved EF (HFpEF), largely attributed to patient heterogeneity and incomplete understanding of pathophysiological insights underlying the clinical presentations of HFpEF. Modern cardiac imaging methods offer insights into many sets of changes in cardiac tissue structure and function that can precisely link cause with cardiac remodeling at organ and tissue levels to clinical presentations in HF. This has inspired investigators to seek a more comprehensive understanding of HF presentations using imaging techniques. This article summarizes the available evidence regarding the role of cardiac imaging in HF. Furthermore, we discuss the value of cardiac imaging techniques in identifying HF patient subtypes who share similar causes and mechanistic pathways that can be targeted using specific HF therapies.

Positioning document on incorporating point-of-care ultrasound in Internal Medicine departments

This positioning document describes the most important aspects of clinical ultrasonography in the internal medicine setting, from its fundamental indications to the recommended training period. There is no question as to the considerable usefulness of this tool in the standard clinical practice of internists in numerous clinical scenarios and settings (emergencies, hospital ward, general and specific consultations and home care). Ultrasonography has a relevant impact on the practitioner's ability to resolve issues, increasing diagnostic reliability and safety and providing important information on the prognosis and progression. In recent years, ultrasonography has been incorporated as a tool in undergraduate teaching, with excellent results. The use of ultrasonography needs to be widespread. To accomplish this, we must encourage structured training and the acquisition of equipment. This document was developed by the Clinical Ultrasonography Workgroup and endorsed by the Spanish Society of Internal Medicine.

Assessment of Volume Status Using Ultrasonography

Ultrasonography is a first-line diagnostic tool when evaluating volume status in the critical care patient population. Ultrasonography leads to a prompt diagnosis and more appropriate management plan, while decreasing health care costs, time to diagnosis, hospital length of stay, time to definitive operation, and mortality. It is recommended that critical care providers treating critically ill patients be skilled and competent in critical care ultrasonography. As the critical care population and the shortage of critical care physicians increases, advanced practice providers are becoming more prevalent in critical care areas and should be competent in this skill as well.

Patient-reported outcomes and associations with pleural effusion in outpatients with heart failure: an observational cohort study

OBJECTIVES

We aimed to study whether patient-reported outcomes, measured by quality of life (QoL) and functional class, are sensitive to pleural effusion (PLE) in patients with heart failure (HF), and to study changes in QoL and functional class during follow-up of PLE.

METHODS

A cohort of 62 patients from an outpatient HF clinic was included. The amount of PLE was quantified using a pocket-sized ultrasound imaging device. Self-reports of QoL and functional class were collected using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the New York Heart Association (NYHA) functional classification.

RESULTS

At baseline, 26 (42%) patients had PLE of which 19 (31%) patients had moderate to severe amounts of PLE. Patients with no to mild PLE had a lower MLHFQ score (mean 42, SD 21) compared with patients with a moderate to severe amount of PLE (mean 55, SD 24), p=0.03. For 28 patients (45%) with follow-up data, we observed a linear improvement of the MLHFQ-score (3.2, 95% CI 1.2 to 5.1) with each centimetre reduction of PLE. Correspondingly, patient-reported NYHA-class followed the same pattern as the MLHFQ-score.

CONCLUSIONS

Our study indicates that patient-reported outcome measures as MLHFQ may be sensitive tools to identify patients with HF at highest risk of symptomatic PLE and that treatment targeting reduction of PLE during follow-up is essential to improvement of QoL and functional capacity of outpatients with HF.

TRIAL REGISTRATION NUMBER

NCT01794715; Results.

The effects of short-term omission of daily medication on the pathophysiology of heart failure

Aims

Pharmacological therapies for heart failure (HF) aim to improve congestion, symptoms, and prognosis. Failing to take medication is a potential cause of worsening HF. Characterizing the effects of short‐term medication omission could inform the development of better technologies and strategies to detect and interpret the reasons for worsening HF. We examined the effect of planned HF medication omission for 48 h on weight, echocardiograms, transthoracic bio‐impedance, and plasma concentrations of NT‐proBNP.

Methods and results

Outpatients with stable HF and an LVEF <45% were assigned to take or omit their HF medication for 48 h in a randomized, crossover trial. Twenty patients (16 men, LVEF 32 ± 9%, median NT‐proBNP 962 ng/L) were included. Compared with regular medication, omission led to an increase in NT‐proBNP by 99% (from 962 to 1883 ng/L, P < 0.001), systolic blood pressure by 16% (from 131 to 152 mmHg, P < 0.001), and left atrial volume by 21% (from 69 to 80 mL, P = 0.001), and reductions in transthoracic bio‐impedance by 10% (from 33 to 30 Σ, P = 0.001) and serum creatinine by 8% (from 135 to 118 µmol/L, P = 0.012). No significant changes in body weight, heart rate, or LVEF were observed.

Conclusions

The characteristic pattern of response to short‐term medication omission is of increasing congestion but, in contrast to the pattern reported for disease progression, with a rise in blood pressure and improved renal function. In stable HF, weight is not a sensitive marker of short‐term diuretic omission.

Precision Medicine With Point-of-Care Ultrasound: The Future of Personalized Pediatric Emergency Care

The Precision Medicine Initiative spearheaded by the National Institute of Health has pioneered a new model of health care focused on health care delivery that is tailored to an individual. Medical advances have already provided clinicians with the tools to better predict treatment outcomes based on the individual needs of each patient's disease process. Three-dimensional printing allows medical devices and implants to be custom made-to-order. Technological advances in preoperative imaging have augmented the ability for surgeons to plan a specific surgical approach for each patient. In a similar vein, point-of-care ultrasound offers the emergency care provider an opportunity to move beyond protocols and provide precise medical care tailored to the acute needs of each ill or injured emergent patient. In this article, we explore several cutting-edge applications of point-of-care ultrasound that can help providers develop a personalized approach to resuscitation and emergent procedures in pediatrics.

Point-of-Care Ultrasonography for Primary Care Physicians and General Internists

Point-of-care ultrasonography (POCUS) is a safe and rapidly evolving diagnostic modality that is now utilized by health care professionals from nearly all specialties. Technological advances have improved the portability of equipment, enabling ultrasound imaging to be executed at the bedside and thereby allowing internists to make timely diagnoses and perform ultrasound-guided procedures. We reviewed the literature on the POCUS applications most relevant to the practice of internal medicine. The use of POCUS can immediately narrow differential diagnoses by building on the clinical information revealed by the traditional physical examination and refining clinical decision making for further management. We describe 2 common patient scenarios (heart failure and sepsis) to highlight the impact of POCUS performed by internists on efficiency, diagnostic accuracy, resource utilization, and radiation exposure. Using POCUS to guide procedures has been found to reduce procedure-related complications, along with costs and lengths of stay associated with these complications. Despite several undisputed advantages of POCUS, barriers to implementation must be considered. Most importantly, the utility of POCUS depends on the experience and skills of the operator, which are affected by the availability of training and the cost of ultrasound devices. Additional system barriers include availability of templates for documentation, electronic storage for image archiving, and policies and procedures for quality assurance and billing. Integration of POCUS into the practice of internal medicine is an inevitable change that will empower internists to improve the care of their patients at the bedside.