Evaluation of Interdisciplinary Emergency Ultrasound Workshop for Primary Care Physicians in Nepal

Knowledge and Perspectives of Healthcare Professionals on Point-of-Care Ultrasound in Prehospital Emergency Care in Portugal

Introduction Point-of-care ultrasound (POCUS) is an innovative and valuable tool in prehospital emergency medicine, facilitating faster and more accurate diagnoses while minimizing the need for invasive procedures. This study aimed to explore the knowledge and perspectives of prehospital emergency physicians and nurses in Portugal regarding POCUS and to assess the perceived benefits and barriers to its implementation in prehospital emergency care. Methods An online survey was conducted among prehospital emergency physicians and nurses in Portugal between November 2023 and January 2024. The questionnaire assessed respondents' knowledge of POCUS, its use in both hospital and prehospital settings, and their perceptions of its relevance and feasibility in emergency care. Results A total of 110 responses were received. Of these, 105 (95.5%) acknowledged the benefits of POCUS. While 66 (60%) reported having knowledge of POCUS, only five (4.5%) used it in prehospital care. The primary barriers to its use were the lack of equipment and specialized training. Most respondents gained their POCUS knowledge through self-funded courses or self-learning. Nineteen (18.1%) indicated insufficient knowledge for its application. Despite these limitations, 102 (92.7%) considered the inclusion of POCUS in prehospital services to be relevant. Conclusions Prehospital physicians and nurses in Portugal recognize the value of POCUS, but its application is hindered by a lack of equipment and structured training. Strategic investments in training programs and portable ultrasound devices are essential to support its broader implementation in prehospital emergency care.

Physicians' clinical experience and perspectives following a pilot, blended learning, point of care ultrasound course in Ghana- a mixed methods analysis

BACKGROUND

Point of Care ultrasound (POCUS) is rapidly gaining popularity in resource constrained settings. Optimising training is important to ensure safe and effective implementation. To expand POCUS expertise in Ghana, we co-developed and piloted a context specific, multi-disciplinary, blended learning programme, targeted at physicians of any grade or speciality providing acute care in the public health sector. In this retrospective mixed method study, we capture the "real world" experience of participants, using POCUS in their daily practice, as well as the barriers and enablers they perceived to implementation.

RESULTS

Eight emergency and internal medicine specialists and residents participated, working across three teaching hospitals, treating both general and specialist patients. They implemented each POCUS application taught, with cardiac indications, inferior vena cava (IVC) assessment, deep venous thrombosis (DVT) diagnosis, lung/pleural assessment and peripheral vascular access being most frequent at 3-6 times/week. An estimated 40% of patients could not have afforded any other diagnostic tests. They considered the pilot curriculum adequate for general practice and the majority of applications of low difficulty (71%). For cases sent for second opinion, they are self-reported that their findings were confirmed in 60-78% of cases. Perceptions about the relative advantage of POCUS over the usual approaches to diagnosing patients enabled implementation. Generally, they believed that POCUS improved their clinical decision making and that more certified training courses need to be run at lower cost to make them more accessible. All participants valued ongoing connections after training to ask for help and consolidate their skills. Continued evaluation and reflection on their POCUS practice to improve quality was unanimously reported as important, yet none had a formal system for this. The strongest barrier was access to equipment and maintenance. A lack of training opportunities and local mentors, and negative beliefs from other departments and hospital administration were further barriers.

CONCLUSION

Our new blended learning curriculum met the needs of physicians caring for patients with general and specialist presentations, with strong reported positive experience of improved bedside diagnostic capabilities, especially for the large proportion of patients unable to afford or access alternative diagnostic tests. Their experience drives the need for further training and for solutions to current barriers of equipment availability, training costs and lack of quality assurance mechanisms.

Delphi Consensus Recommendations for the Development of the Emergency Medicine Point of Care Ultrasound (POCUS) Curriculum in Nepal

Introduction: Emergency Medicine Point of Care Ultrasound (EM-POCUS) is a diagnostic bedside tool for quick and accurate clinical decision-making. Comprehensive training in POCUS is a mandatory part of EM training in developed countries. In Nepal, we need to build an educational curriculum based on the local medical system, available resources, and educational environment. We used the modified Delphi method to develop a EM-POCUS curriculum. Methods: We formed an EM-POCUS core working group based on expertise in key identified areas. The core working group developed criteria for expert panelist selection and synthesized the data for panelists after each Delphi round. We recruited 46 expert panelists to participate in a series of electronic surveys. The literature review and the results of the first Delphi round identified a set of competencies. Quantitative methodology was performed for subsequent surveys. Data analysis of the frequency, percentage, median, and interquartile range of the 9-point Likert scale was performed. We deemed a minimum threshold of 80% agreement to retain items across Delphi rounds. The result of every round was disseminated before subsequent rounds for the expert panelists to review responses in light of the group's response. Results: We identified 10 specific global competency categories and 132 objectives (Round 1, response rate 85%). Rounds 2 and 3 (response rates 78% and 81% respectively) developed consensus on 45 core objectives (34%). The list of EM-POCUS competencies with the median (IQR) was finalized. Conclusion: This expert, consensus-generated EM-POCUS curriculum provides detailed guidance for EM-POCUS education and applications in clinical practice in Nepal.

Teaching Seasoned Doctors New Technology: An Intervention to Reduce Barriers and Improve Comfort With Clinical Ultrasound

Introduction Although clinical ultrasound (CUS) is a core skill that is a requirement for emergency medicine (EM) residency graduation, only a fraction of EM practitioners who trained prior to this requirement are certified in CUS. The objective of the study was to implement a CUS workshop for practicing EM physicians, identify barriers to utilization, and assess comfort with the machine, obtaining and interpreting images, and incorporating CUS into clinical practice. Methods This was a prospective descriptive cohort study of EM physician faculty who participated in an interactive 5-hour CUS workshop intervention that introduced four core CUS modalities via didactics and hands-on scanning stations. Pre- and post-surveys were administered to identify barriers to utilization and assess perceived comfort with CUS using a 5-point Likert scale. Results were analyzed using Fisher's exact and paired t-tests. Results Thirty-five EM physicians participated with a 100% survey response rate. Only five of the physicians were ultrasound certified at the time of the workshop. On average, physicians were 16 years post-residency. Prior to the workshop, 29% had minimal ultrasound experience and 43% had not performed more than 50 ultrasounds. In the pre-course survey, every physician expressed at least one barrier to CUS utilization. Post-workshop, physicians felt significantly more comfortable using the ultrasound machine (p=0.0008), obtaining and interpreting images (p=0.0009 and p=0.0004), and incorporating CUS into clinical practice (p=0.002). Conclusion This workshop is an effective tool to expose practicing physicians to core concepts of CUS, improve their comfort level, and reduce barriers to ultrasound utilization.

Needs Assessment and Identification of the Multifaceted COPD Care Bundle in the Emergency Department of a Tertiary Hospital in Nepal

Purpose

Acute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting.

Methods

We conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care.

Results

The AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43-4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11-3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362-6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation.

Conclusion

The current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.