Point-of-Care Ultrasound in Established Settings

Sustained effects of bladder point-of-care ultrasound simulation exercise on nursing students: A prospective cohort study

BACKGROUND

Point-of-care ultrasound (POCUS) can be used in a variety of clinical settings and is a safe and powerful tool for ultrasound-trained healthcare providers, such as physicians and nurses; however, the effectiveness of ultrasound education for nursing students remains unclear. This prospective cohort study aimed to examine the sustained educational impact of bladder ultrasound simulation among nursing students.

METHODS

To determine whether bladder POCUS simulation exercises sustainably improve the clinical proficiency regarding ultrasound examinations among nursing students, evaluations were conducted before and after the exercise and were compared with those after the 1-month follow-up exercise. A bladder urine volume measurement simulator and a portable ultrasound device were used during the exercise. Nursing student volunteers participated in this prospective observational study. The primary outcome was the Objective Structured Assessment of Ultrasound Skills (OSAUS) score. The secondary outcomes were the Self-Directed Learning Readiness Scale (SDLRS) and Student Satisfaction and Self-Confidence in Learning (SSSCLS) scores. Differences were analyzed using one-way analysis of variance with repeated measures.

RESULTS

Data from 12 students were analyzed. The percentages of total OSAUS scores increased from 34.3% after the initial bladder POCUS simulation exercise to 51.0% after the 1-month follow-up exercise (p < 0.001). The OSAUS scores for several subdomains, including image optimization, systematic reviews, image interpretation, test documentation, and medical decision-making, increased significantly. In addition, the SDLRS significantly increased from 204.4 before the exercise to 233.6 after the 1-month follow-up exercise (p < 0.001), and the SSSCLS confidence scores also increased from 33.7 after the initial exercise to 36.4 after the 1-month follow-up exercise (p < 0.005).

CONCLUSION

The bladder POCUS simulation exercise is effective in continuously improving the clinical performance of nursing students for ultrasound examinations even at 1-month follow-up, increasing their confidence and promoting a self-directed learning attitude.

The prevalence of ultrasound curricula in a sampling of U.S. physician assistant programs and recommendations for common ultrasound objectives: A national survey

An increasing number of practicing physician assistants (PAs) are using ultrasound (US) in clinical settings. However, a lack of US learning objectives for PA students limits the optimal integration of this imaging modality in PA curricula. This study surveyed PA program directors across the United States to create a list of US learning objectives for PA students and to gauge their attitudes toward integrating US into anatomy curricula. Thirty-one of the 280 PA program directors responded to the survey. While 87% of participants reported that their institution includes ultrasound in its curriculum, 71% disagreed that the state of the use of ultrasound throughout their PA curriculum is fine and needs no modification. Based on the responses of the survey participants, this study categorized US learning objectives into high, medium, low, and no agreement for integration in PA curricula. As over half of the learning objectives (73%, 43/59) had high agreement for inclusion in curricula, this study demonstrates an opportunity for educators to include US in PA curricula.

Artificial intelligence evaluation of focused assessment with sonography in trauma

BACKGROUND

The focused assessment with sonography in trauma (FAST) is a widely used imaging modality to identify the location of life-threatening hemorrhage in a hemodynamically unstable trauma patient. This study evaluates the role of artificial intelligence in interpretation of the FAST examination abdominal views, as it pertains to adequacy of the view and accuracy of fluid survey positivity.

METHODS

Focused assessment with sonography for trauma examination images from 2015 to 2022, from trauma activations, were acquired from a quaternary care level 1 trauma center with more than 3,500 adult trauma evaluations, annually. Images pertaining to the right upper quadrant and left upper quadrant views were obtained and read by a surgeon or radiologist. Positivity was defined as fluid present in the hepatorenal or splenorenal fossa, while adequacy was defined by the presence of both the liver and kidney or the spleen and kidney for the right upper quadrant or left upper quadrant views, respectively. Four convolutional neural network architecture models (DenseNet121, InceptionV3, ResNet50, Vgg11bn) were evaluated.

RESULTS

A total of 6,608 images, representing 109 cases were included for analysis within the "adequate" and "positive" data sets. The models relayed 88.7% accuracy, 83.3% sensitivity, and 93.6% specificity for the adequate test cohort, while the positive cohort conferred 98.0% accuracy, 89.6% sensitivity, and 100.0% specificity against similar models. Augmentation improved the accuracy and sensitivity of the positive models to 95.1% accurate and 94.0% sensitive. DenseNet121 demonstrated the best accuracy across tasks.

CONCLUSION

Artificial intelligence can detect positivity and adequacy of FAST examinations with 94% and 97% accuracy, aiding in the standardization of care delivery with minimal expert clinician input. Artificial intelligence is a feasible modality to improve patient care imaging interpretation accuracy and should be pursued as a point-of-care clinical decision-making tool.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level III.

Deep Learning for FAST Quality Assessment

OBJECTIVES

To determine the feasibility of using a deep learning (DL) algorithm to assess the quality of focused assessment with sonography in trauma (FAST) exams.

METHODS

Our dataset consists of 441 FAST exams, classified as good-quality or poor-quality, with 3161 videos. We first used convolutional neural networks (CNNs), pretrained on the Imagenet dataset and fine-tuned on the FAST dataset. Second, we trained a CNN autoencoder to compress FAST images, with a 20-1 compression ratio. The compressed codes were input to a two-layer classifier network. To train the networks, each video was labeled with the quality of the exam, and the frames were labeled with the quality of the video. For inference, a video was classified as poor-quality if half the frames were classified as poor-quality by the network, and an exam was classified as poor-quality if half the videos were classified as poor-quality.

RESULTS

The results with the encoder-classifier networks were much better than the transfer learning results with CNNs. This was primarily because the Imagenet dataset is not a good match for the ultrasound quality assessment problem. The DL models produced video sensitivities and specificities of 99% and 98% on held-out test sets.

CONCLUSIONS

Using an autoencoder to compress FAST images is a very effective way to obtain features that can be used to predict exam quality. These features are more suitable than those obtained from CNNs pretrained on Imagenet.

Development of a Point-of-Care Ultrasound Track for Internal Medicine Residents

BACKGROUND

Point-of-care ultrasound (POCUS) training has been increasing among internal medicine (IM) residency programs, but few programs can provide longitudinal training due to barriers such as lack of trained faculty.

AIM

Describe the development of a longitudinal POCUS track for IM residents using local and external resources, including a national POCUS certificate program.

SETTING

University-based IM residency program affiliated with a public and veterans affairs hospital.

PARTICIPANTS

Twelve IM residents from 2018 to 2021.

PROGRAM DESCRIPTION

Residents complete a national POCUS certificate program by attending live courses and completing online modules, an image portfolio, and final knowledge/skills assessments. Locally, residents participate in 1-month procedure and diagnostic POCUS rotations and provide peer-to-peer POCUS teaching of residents and medical students.

PROGRAM EVALUATION

The POCUS track increased residents' use and comfort with diagnostic and procedural applications. All residents rated being satisfied or very satisfied with the track and would recommend it to prospective applicants (100%). The most commonly reported barriers to utilizing POCUS per residents were time constraints (83%), lack of available ultrasound equipment (83%), and lack of trained faculty (58%).

DISCUSSION

IM residency programs with limited faculty expertise in POCUS can leverage external resources to provide longitudinal POCUS training to its residents.

PAs and point-of-care ultrasound: A scoping review

OBJECTIVE

Point-of-care ultrasound (POCUS) has rapidly emerged as a valuable tool in the bedside assessment of patients. This scoping review summarizes existing literature covering clinical use and educational integration of POCUS by physician assistants (PAs), with the overall goal of identifying gaps in POCUS research involving the PA profession.

METHODS

Keyword searches of PubMed, EMBASE, Medline, and Google Scholar were conducted. Studies assessing PA POCUS use or accuracy; those evaluating extent, method, or value of POCUS educational integration; and those assessing the effect of POCUS training interventions were included.

RESULTS

Of the 717 studies retrieved, 30 met inclusion criteria. Studies generally demonstrated that PAs can use a fairly wide range of POCUS applications with high accuracy, but that POCUS integration into PA programs remains limited because of a number of identified barriers.

CONCLUSIONS

Machine availability and insufficient POCUS training and education opportunities limit widespread clinical use of POCUS by PAs.

Ultrasound Training in Radiology Residency Programs: A National Survey

OBJECTIVES

Comprehensive training in ultrasound (US) imaging during radiology residency is crucial if radiologists are expected to maintain a substantial role in this widely used imaging modality. This study aimed to evaluate the current curriculum of US training among radiology residency programs across the country via a nationwide survey.

METHODS

A 28-question survey was distributed among all academic radiology departments in the United States and their radiology residents. The survey consisted of 4 sections: general demographic information, training information, clinical competency, and adequacy of training (perspective). The Student t test and 1-way analyses of variance were performed to assess statistical significance.

RESULTS

Overall, 256 residents from 32 states completed the questionnaire. Only 114 (45%) residents reported having a dedicated rotation for performing US studies. Although 228 (89%) of trainees believed they received adequate experience for interpreting US studies, only 66 (26%) of them had the same belief about performing them. Only 116 (45%) of the residents were comfortable operating the US machines in their departments. Higher years of residency training, having a dedicated rotation for performing US studies, and having more than 10 hours per year of didactic lectures and/or more than 5 hours per year of case conferences dedicated to US had a positive impact on the residents' clinical competency and perspective (all P < .05).

CONCLUSIONS

Most radiology residents do not feel confident in performing US examinations by themselves. However, higher clinical competency was reported in the residents who had dedicated rotations for performing US studies and received more hours of US lectures and case conferences throughout their residency.

Diagnosing Early Cardiac Tamponade in Patient with JAK2+ Myeloproliferative Syndrome with Point of Care Ultrasound

Point of care ultrasound (POCUS) is a diagnostic modality growing in popularity and use in medicine in both the acute and chronic management settings. Its utility lies in its non-invasive application, direct user interface, and portability, especially in handheld devices, allowing for quick assessment and triage. Herein is a case of POCUS diagnosing life threatening cardiac tamponade in a patient with a new diagnosis of JAK2+ myeloproliferative syndrome prompting urgent intervention with pericardiocentesis. This case illustrates the utility of POCUS through its ability to serve as a quick diagnostic tool that can hasten intervention for potentially life-threatening conditions.   

Analysis of lawsuits related to diagnostic errors from point-of-care ultrasound in internal medicine, paediatrics, family medicine and critical care in the USA

PURPOSE

The purpose of this study is to identify the extent of diagnostic error lawsuits related to point-of-care ultrasound (POCUS) in internal medicine, paediatrics, family medicine and critical care, of which little is known.

METHODS

We conducted a retrospective review of the Westlaw legal database for indexed state and federal lawsuits involving the diagnostic use of POCUS in internal medicine, paediatrics, family medicine and critical care. Retrieved cases were reviewed independently by three physicians to identify cases relevant to our study objective. A lawyer secondarily reviewed any cases with discrepancies between the three reviewers.

RESULTS

Our search criteria returned 131 total cases. Ultrasound was mentioned in relation to the lawsuit claim in 70 of the cases returned. In these cases, the majority were formal ultrasounds performed and reviewed by the radiology department, echocardiography studies performed by cardiologists or obstetrical ultrasounds. There were no cases of internal medicine, paediatrics, family medicine or critical care physicians being subjected to adverse legal action for their diagnostic use of POCUS.

CONCLUSION

Our results suggest that concerns regarding the potential for lawsuits related to POCUS in the fields of internal medicine, paediatrics, family medicine and critical care are not substantiated by indexed state and federal filed lawsuits.

Ultrasound Curriculum Implementation into a State-Wide Family Medicine Clerkship

INTRODUCTION

While point of care ultrasound (POCUS) integration into clinical clerkships provides unique educational experiences for students, there are barriers to implementation, particularly in a distributed campus medical school model in clerkships where the faculty do not often perform POCUS, like family medicine (FM). The objective of this paper is to describe the implementation and evaluation of a POCUS curriculum in an FM core clinical clerkship in a state-wide medical school campus model.

METHODS

Seventeen Philips Lumify Ultrasound Systems were used in 20 clerkship sites with the requirement that students obtain abdominal aortic and inferior vena cava (IVC) images on patients evaluated during their rotation. Images were de-identified, transmitted to a university cloud-based storage account, and scored by medical school ultrasound faculty.

RESULTS

Students were able to obtain adequate images of the aorta and IVC without direct ultrasound-trained faculty at the performance site. Of the 183 students, 119 (65%) were able to successfully submit images for scoring with failure to upload to the cloud-based storage account as the most common reason students were unsuccessful (42%). The majority of students (62%) scored in the top quartile of image quality scoring with the percentage of those scoring in the top quartile improving during the academic year from 57% in the first four rotations to 67% in the last four rotations.

CONCLUSION

Barriers to implementation of a POCUS curriculum into a FM clerkship in a distributed campus medical school model can be challenging due to equipment availability and issues around the successful transmission of images. These challenges can be overcome however with sufficient attention to implementation design that includes equipment sharing protocols and technical options that enhance the ease of image transmission.

The 10 commandments of exsanguinating pelvic fracture management

Background:

Unstable pelvic fractures are highly lethal injuries.

Objective:

The review aims to summarize the landmark management changes in the past two decades.

Methods:

Structured review based on pertinent published literatures on severe pelvic fracture was performed.

Results:

Ten key management points were identified.

Conclusion:

These 10 recommendations help diminish and prevent the mortality. (1) Before the ABCDE management, preparedness, protection, and decision are essential to optimize patient outcome and to conserve resources. (2) Do not rock the pelvis to check stability, avoid logrolling but prophylactic pelvic binder can be life-saving. (3) Computed tomography scanner can be the tunnel to death for hemodynamically unstable patients. (4) Correct application of pelvic binder at the greater trochanter level to achieve the most effective compression. (5) Choose the suitable binder (BEST does not exist, always look for BETTER) to facilitate body examination and therapeutic intervention. (6) Massive transfusion protocol is only a temporizing measure to sustain the circulation for life maintenance. (7) Damage control operation aims to promptly stop the bleeding to restore the physiology by combating the trauma lethal triad to be followed by definitive anatomical repair. (8) Protocol-driven teamwork management expedites the completion of the multi-phase therapy including external pelvic fixation, pre-peritoneal pelvic packing, and angio-embolization, preceded by laparotomy when indicated. (9) Resuscitation endovascular balloon occlusion of aorta can reduce the pelvic bleeding while awaiting hospital transfer or operation theater access. (10) Operation is the definitive therapy for trauma but prevention is the best treatment, comprising primary, secondary, and tertiary levels.