Canadian Internal Medicine Ultrasound (CIMUS) consensus statement: recommendations for mandatory ultrasound competencies for ultrasound-guided thoracentesis, paracentesis, and central venous catheterization

OBJECTIVES

To develop a Canadian Internal Medicine Ultrasound (CIMUS) consensus statement on recommended mandatory point-of-care ultrasound (POCUS) competencies for ultrasound-guided thoracentesis, paracentesis, and central venous catheterizations (CVC) for internal medicine physicians.

METHODS

The 2022 CIMUS group consists of 27 voting members, with representations from all 17 Canadian academic institutions across 8 provinces. Members voted in 3 rounds on 46 procedural competencies as "mandatory, must include", "optional, could include" or "superfluous, do not include". These 46 competencies included 6 general competencies that apply to all POCUS-guided procedures, 11 competencies for thoracentesis, 10 competencies for paracentesis, and 19 competencies for CVC.

RESULTS

In the first round, members reached consensus on 27 competencies (5 general, 6 thoracentesis, 8 paracentesis, 8 CVC). In the second round, 10 competencies (1 general, 2 thoracentesis, 1 paracentesis, 6 CVC) reached consensus. In the third round, 2 additional competencies (1 paracentesis, 1 CVC) reached consensus for being mandatory and 3 as optional (1 thoracentesis and 2 CVC). Overall, a total of 28 competencies reached consensus as mandatory, 3 as optional, while 11 competencies reached consensus as superfluous. Four competencies did not reach consensus for either inclusion or exclusion.

CONCLUSIONS

The CIMUS group recommends 28 competencies be considered mandatory and 3 as optional for internal medicine physicians performing POCUS guided thoracentesis, paracentesis, and CVC placement. National curriculum development and implementation efforts should include training these mandatory competencies.

Point-of-Care Lung Ultrasound in Emergency Medicine: A Scoping Review With an Interactive Database

BACKGROUND

This scoping review was conducted to provide an overview of the evidence of point-of-care lung ultrasound (LUS) in emergency medicine. By emphasizing clinical topics, time trends, study designs, and the scope of the primary outcomes, a map is provided for physicians and researchers to guide their future initiatives.

RESEARCH QUESTION

Which study designs and primary outcomes are reported in published studies of LUS in emergency medicine?

STUDY DESIGN AND METHODS

We performed a systematic search in the PubMed/MEDLINE, Embase, Web of Science, Scopus, and Cochrane Library databases for LUS studies published prior to May 13, 2023. Study characteristics were synthesized quantitatively. The primary outcomes in all papers were categorized into the hierarchical Fryback and Thornbury levels.

RESULTS

A total of 4,076 papers were screened and, following selection and handsearching, 406 papers were included. The number of publications doubled from January 2020 to May 2023 (204 to 406 papers). The study designs were primarily observational (n = 375 [92%]), followed by randomized (n = 18 [4%]) and case series (n = 13 [3%]). The primary outcome measure concerned diagnostic accuracy in 319 papers (79%), diagnostic thinking in 32 (8%), therapeutic changes in 4 (1%), and patient outcomes in 14 (3%). No increase in the proportions of randomized controlled trials or the scope of primary outcome measures was observed with time. A freely available interactive database was created to enable readers to search for any given interest (https://public.tableau.com/app/profile/blinded/viz/LUSinEM_240216/INFO).

INTERPRETATION

Observational diagnostic studies have been produced in abundance, leaving a paucity of research exploring clinical utility. Notably, research exploring whether LUS causes changes to clinical decisions is imperative prior to any further research being made into patient benefits.

Implementing ultrasound-guided nerve blocks in the emergency department: A low-cost, low-fidelity training approach

Background

Managing acute pain is a common challenge in the emergency department (ED). Though widely used in perioperative settings, ED-based ultrasound-guided nerve blocks (UGNBs) have been slow to gain traction. Here, we develop a low-cost, low-fidelity, simulation-based training curriculum in UGNBs for emergency physicians to improve procedural competence and confidence.

Methods

In this pre-/postintervention study, ED physicians were enrolled to participate in a 2-h, in-person simulation training session composed of a didactic session followed by rotation through stations using handmade pork-based UGNB models. Learner confidence with performing and supervising UGNBs as well as knowledge and procedural-based competence were assessed pre- and posttraining via electronic survey quizzes. One-way repeated-measures ANOVAs and pairwise comparisons were conducted. The numbers of nerve blocks performed clinically in the department pre- and postintervention were compared.

Results

In total, 36 participants enrolled in training sessions, eight participants completed surveys at all three data collection time points. Of enrolled participants, 56% were trainees, 39% were faculty, 56% were female, and 53% self-identified as White. Knowledge and competency scores increased immediately postintervention (mean ± SD t0 score 66.9 ± 8.9 vs. t1 score 90.4 ± 11.7; p < 0.001), and decreased 3 months postintervention but remained elevated above baseline (t2 scores 77.2 ± 11.5, compared to t0; p = 0.03). Self-reported confidence in performing UGNBs increased posttraining (t0 5.0 ± 2.3 compared to t1 score 7.1 ± 1.5; p = 0.002) but decreased to baseline levels 3 months postintervention (t2 = 6.0 ± 1.9, compared to t0; p = 0.30).

Conclusions

A low-cost, low-fidelity simulation curriculum can improve ED provider procedural-based competence and confidence in performing UGNBs in the short term, with a trend toward sustained improvement in knowledge and confidence. Curriculum adjustments to achieve sustained improvement in confidence performing and supervising UGNBs long term are key to increased ED-based UGNB use.

The association of attentional foci and image interpretation accuracy in novices interpreting lung ultrasound images: an eye-tracking study

It is unclear, where learners focus their attention when interpreting point-of-care ultrasound (POCUS) images. This study seeks to determine the relationship between attentional foci metrics with lung ultrasound (LUS) interpretation accuracy in novice medical learners. A convenience sample of 14 medical residents with minimal LUS training viewed 8 LUS cineloops, with their eye-tracking patterns recorded. Areas of interest (AOI) for each cineloop were mapped independently by two experts, and externally validated by a third expert. Primary outcome of interest was image interpretation accuracy, presented as a percentage. Eye tracking captured 10 of 14 participants (71%) who completed the study. Participants spent a mean total of 8 min 44 s ± standard deviation (SD) 3 min 8 s on the cineloops, with 1 min 14 s ± SD 34 s spent fixated in the AOI. Mean accuracy score was 54.0% ± SD 16.8%. In regression analyses, fixation duration within AOI was positively associated with accuracy [beta-coefficients 28.9 standardized error (SE) 6.42, P = 0.002). Total time spent viewing the videos was also significantly associated with accuracy (beta-coefficient 5.08, SE 0.59, P < 0.0001). For each additional minute spent fixating within the AOI, accuracy scores increased by 28.9%. For each additional minute spent viewing the video, accuracy scores increased only by 5.1%. Interpretation accuracy is strongly associated with time spent fixating within the AOI. Image interpretation training should consider targeting AOIs.

Lung ultrasound: A comparison of image interpretation accuracy between curvilinear and phased array transducers

Introduction

Both curvilinear and phased array transducers are commonly used to perform lung ultrasound (LUS). This study seeks to compare LUS interpretation accuracy of images obtained using a curvilinear transducer with those obtained using a phased array transducer.

Methods

We invited 166 internists and trainees to interpret 16 LUS images/cineloops of eight patients in an online survey: eight curvilinear and eight phased array, performed on the same lung location. Images depicted normal lung, pneumothorax, pleural irregularities, consolidation/hepatisation, pleural effusions and B-lines. Primary outcome for each participant is the difference in image interpretation accuracy scores between the two transducers.

Results

A total of 112 (67%) participants completed the survey. The mean paired accuracy score difference between the curvilinear and phased array images was 3.0% (95% CI: 0.6 to 5.4%, P = 0.015). For novices, scores were higher on curvilinear images (mean difference: 5.4%, 95% CI: 0.9 to 9.9%, P = 0.020). For non-novices, there were no differences between the two transducers (mean difference: 1.4%, 95% CI: -1.1 to 3.9%, P = 0.263). For pleural-based findings, the mean of the paired differences between transducers was higher in the novice group (estimated mean difference-in-differences: 9.5%, 95% CI: 0.6 to 18.4%; P = 0.036). No difference in mean accuracies was noted between novices and non-novices for non-pleural-based pathologies (estimated mean difference-in-differences: 0.6%, 95% CI to 5.4-6.6%; P = 0.837).

Conclusions

Lung ultrasound images obtained using the curvilinear transducer are associated with higher interpretation accuracy than the phased array transducer. This is especially true for novices interpreting pleural-based pathologies.

Association between physician continuity of care and patient outcomes in clinical teaching units: a cohort analysis

BACKGROUND

Hospital-based clinical teaching units (CTUs) are supervised by rotating attending physicians. Physician hand-offs in other contexts have been associated with worse patient outcomes, presumably through communication gaps. We aimed to determine the association between attending physician hand-offs on CTUs and patient outcomes including escalation of care, readmission and mortality.

METHODS

We conducted a retrospective, multicentre cohort study using data from 3 tertiary care hospitals in Calgary between Jan. 1, 2015, and Dec. 31, 2017. We included hospital admissions in the top 10 case-mix groups. Our exposure variable was the number of attending physicians seen by a patient. Outcome measures were admission to intensive care unit (ICU); inpatient 7- and 30-day mortality; and 7- and 30-day readmission rate. We used multivariable regression statistical models adjusted for patient age, sex, length of stay, Charlson Comorbidity Index, case-mix groups, senior resident presence, team handovers and team transfers.

RESULTS

Our cohort included 4324 unique patients. There were no significant differences in the incidence rate ratios (IRRs) of admission to ICU, inpatient 7- and 30-day mortality, and 7- and 30-day readmission rates among 1 or 2 physicians. However, we noted a significant increase in 30-day readmission rate (IRR 1.37, 95% confidence interval 1.05-1.78) in patients who had 3 or more attending physicians compared with those who had 1 attending physician.

INTERPRETATION

We found that 2 or more physician hand-offs on CTUs had a modestly greater association with patient readmission at 30 days. More research is needed to explore this finding and to evaluate associated patient and resource outcomes with physician hand-offs.

Novice-performed point-of-care ultrasound for home-based imaging

Patient-performed point-of-care ultrasound (POCUS) may be feasible for use in home-based healthcare. We investigated whether novice users can obtain lung ultrasound (LUS) images via self-scanning with similar interpretability and quality as experts. Adult participants with no prior medical or POCUS training, who were capable of viewing PowerPoint slides in their home and who could hold a probe to their chest were recruited. After training, volunteers self-performed 8-zone LUS and saved images using a hand-held POCUS device in their own home. Each 8-zone LUS scan was repeated by POCUS experts. Clips were independently viewed and scored by POCUS experts blinded to performing sonographers. Quality and interpretability scores of novice- and expert-obtained LUS images were compared. Thirty volunteers with average age of 42.8 years (Standard Deviation (SD) 15.8), and average body mass index of 23.7 (SD 3.1) were recruited. Quality of novice and expert scans did not differ (median score 2.6, interquartile range (IQR) 2.3-2.9 vs. 2.8, IQR 2.3-3.0, respectively p = 0.09). Individual zone quality also did not differ (P > 0.05). Interpretability of LUS was similar between expert and novice scanners (median 7 zones interpretable, IQR 6-8, for both groups, p = 0.42). Interpretability of novice-obtained scans did not differ from expert scans (median 7 out of 8 zones, IQR 6-8, p = 0.42). Novice-users can self-obtain interpretable, expert-quality LUS clips with minimal training. Patient-performed LUS may be feasible for outpatient home monitoring.

An overview of Internal Medicine Point-of-Care Ultrasound rotations in Canada

Background

Point-of-care ultrasound (POCUS) is a growing part of internal medicine training programs. Dedicated POCUS rotations are emerging as a particularly effective tool in POCUS training, allowing for longitudinal learning and emphasizing both psychomotor skills and the nuances of clinical integration. In this descriptive paper, we set out to review the state of POCUS rotations in Canadian Internal Medicine training programs.

Results

We identify five programs currently offering a POCUS rotation. These rotations are offered over two to thirteen blocks each year, run over one to four weeks and support one to four learners. Across all programs, these rotations are set up as a consultative service that offers POCUS consultation to general internal medicine inpatients, with some extension of scope to the hospitalist service or surgical subspecialties. The funding model for the preceptors of these rotations is predominantly fee-for-service using consultation codes, in addition to concomitant clinical work to supplement income. All but one program has access to hospital-based archiving of POCUS exams. Preceptors dedicate ten to fifty hours to the rotation each week and ensure that all trainee exams are reviewed and documented in the patient’s medical records in the form of a consultation note. Two of the five programs also support a POCUS fellowship. Only two out of five programs have established learner policies. All programs rely on In-Training Evaluation Reports to provide trainee feedback on their performance during the rotation.

Conclusions

We describe the different elements of the POCUS rotations currently offered in Canadian Internal Medicine training programs. We share some lessons learned around the elements necessary for a sustainable rotation that meets high educational standards. We also identify areas for future growth, which include the expansion of learner policies, as well as the evolution of trainee assessment in the era of competency-based medical education. Our results will help educators that are endeavoring setting up POCUS rotations achieve success.

Optimizing Lung Ultrasound: The Effect of Depth, Gain and Focal Position on Sonographic B-Lines

Ultrasonographic B-lines are artifacts present in alveolar-interstitial syndromes. We prospectively investigated optimal depth, gain, focal position and transducer type for B-line visualization and image quality. B-Lines were assessed at a single rib interspace with curvilinear and linear transducers. Video clips were acquired by changing parameters: depth (6, 12, 18 and 24 cm for curvilinear transducer, 4 and 8 cm for linear transducer), gain (10%, 50% and 90%) and focal position (at the pleural line or half the scanning depth). Clips were scored for B-lines and image quality. Five hundred sixteen clips were obtained and analyzed. The curvilinear transducer improved B-line visualization (63% vs. 37%, p < 0.0001), with higher image quality (3.52 ± 0.71 vs. 3.31 ± 0.86, p = 0.0047) compared with the linear transducer. B-Lines were better visualized at higher gains (curvilinear: gain of 50% vs. 10%, odds ratio = 7.04, 95% confidence interval: 4.03-12.3; gain of 90% vs. 10%, odds ratio = 9.48, 95% confidence interval: 5.28-17.0) and with the focal point at the pleural line (odds ratio = 1.64, 95% confidence interval: 1.02-2.63). Image quality was highest at 50% gain (p = 0.02) but decreased at 90% gain (p < 0.0001) and with the focal point at the pleural line (p < 0.0001). Image quality was highest at depths of 12-18 cm. B-Lines are best visualized using a curvilinear transducer with at least 50% gain and focal position at the pleural line. Gain less than 90% and image depth between 12 and 18 cm improve image quality.

Lung Ultrasound for Pleural Line Abnormalities, Confluent B-Lines, and Consolidation: Expert Reproducibility and a Method of Standardization

OBJECTIVES

Discrete B-lines have clear definitions, but confluent B-lines, consolidations, and pleural line abnormalities are less well defined. We proposed definitions for these and determined their reproducibility using COVID-19 patient images obtained with phased array probes.

METHODS

Two raters collaborated to refine definitions, analyzing disagreements on 107 derivation scans from 10 patients. Refined definitions were used by those raters and an independent rater on 1260 validation scans from 105 patients. Reliability was evaluated using intraclass correlation coefficients (ICC) or Cohen's kappa.

RESULTS

The agreement was excellent between collaborating raters for B-line abnormalities, ICC = 0.97 (95% confidence interval [CI] 0.97-0.98) and pleural line to consolidation abnormalities, ICC = 0.90 (95% CI 0.87-0.92). The independent rater's agreement for B-line abnormalities was excellent, ICC = 0.97 (95% CI 0.96-0.97) and for pleural line to consolidation was good, ICC = 0.88 (95% CI 0.84-0.91). Agreement just on pleural line abnormalities was weak (collaborators, κ = 0.54, 95% CI 0.48-0.60; independent, κ = 0.54, 95% CI 0.49-0.59).

CONCLUSION

With proposed definitions or via collaboration, overall agreement on confluent B-lines and pleural line to consolidation abnormalities was robust. Pleural line abnormality agreement itself was persistently weak and caution should be used interpreting pleural line abnormalities with only a phased array probe.

International consensus conference recommendations on ultrasound education for undergraduate medical students

OBJECTIVES

The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students.

METHODS

64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting.

RESULTS

A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care.

CONCLUSIONS

The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice.

Association Between Health System Factors and Utilization of Routine Laboratory Tests in Clinical Teaching Units: a Cohort Analysis

BACKGROUND

Few studies have looked at health system factors associated with laboratory test use.

OBJECTIVE

To determine the association between health system factors and routine laboratory test use in medical inpatients.

DESIGN

We conducted a retrospective cohort study on adult patients admitted to clinical teaching units over a 3-year period (January 2015 to December 2017) at three tertiary care hospitals in Calgary, Alberta.

PARTICIPANTS

Patients were assigned to a Case Mix Group+ (CMG+) category based on their clinical characteristics, and patients in the top 10 CMG+ groups were included in the cohort.

EXPOSURES

The examined health system factors were (1) number of primary attending physicians seen by a patient, (2) number of attending medical teams seen by a patient, (3) structure of the medical team, and (4) day of the week.

MAIN MEASURES

The primary outcome was the total number of routine laboratory tests ordered on a patient during their admission. Statistical models were adjusted for age, sex, length of stay, Charlson comorbidity index, and CMG+ group.

RESULTS

The final cohort consisting of 36,667 patient-days in hospital (mean (SD) age 62.5 (18.4) years) represented 5071 unique hospitalizations and 4324 unique patients. Routine laboratory test use was increased when patients saw multiple attending physicians; with an adjusted incidence rate ratio (IRR) of 1.46 (95% CI, 1.37-1.55) for two attending physicians, and 2.50 (95% CI, 2.23-2.79) for three or more attending physicians compared to a single attending physician. The number of routine laboratory tests was slightly lower on weekends (IRR 0.98, 95% CI, 0.96-0.99) and on teams without a senior resident as part of their team structure (IRR 0.89, 95% CI 0.830.96).

CONCLUSIONS

The associations observed in this study suggest that breaks in continuity of care, including increased frequency in patient transfer of care, may impact the utilization of routine laboratory tests.

Empowering the willing: the feasibility of tele-mentored self-performed pleural ultrasound assessment for the surveillance of lung health

Background

SARS-CoV-2 infection, manifesting as COVID-19 pneumonia, constitutes a global pandemic that is disrupting health-care systems. Most patients who are infected are asymptomatic/pauci-symptomatic can safely self-isolate at home. However, even previously healthy individuals can deteriorate rapidly with life-threatening respiratory failure characterized by disproportionate hypoxemic failure compared to symptoms. Ultrasound findings have been proposed as an early indicator of progression to severe disease. Furthermore, ultrasound is a safe imaging modality that can be performed by novice users remotely guided by experts. We thus examined the feasibility of utilizing common household informatic-technologies to facilitate self-performed lung ultrasound.

Methods

A lung ultrasound expert remotely mentored and guided participants to image their own chests with a hand-held ultrasound transducer. The results were evaluated in real time by the mentor, and independently scored by three independent experts [planned a priori]. The primary outcomes were feasibility in obtaining good-quality interpretable images from each anatomic location recommended for COVID-19 diagnosis.

Results

Twenty-seven adults volunteered. All could be guided to obtain images of the pleura of the 8 anterior and lateral lung zones (216/216 attempts). These images were rated as interpretable by the 3 experts in 99.8% (647/648) of reviews. Fully imaging one’s posterior region was harder; only 108/162 (66%) of image acquisitions was possible. Of these, 99.3% of images were interpretable in blinded evaluations. However, 52/54 (96%) of participants could image their lower posterior lung bases, where COVID-19 is most common, with 99.3% rated as interpretable.

Conclusions

Ultrasound-novice adults at risk for COVID-19 deterioration can be successfully mentored using freely available software and low-cost ultrasound devices to provide meaningful lung ultrasound surveillance of themselves that could potentially stratify asymptomatic/paucisymptomatic patients with early risk factors for serious disease. Further studies examining practical logistics should be conducted.

Trial Registration: ID ISRCTN/77929274 on 07/03/2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-021-00250-6.

Critical care ultrasound training: a survey exploring the "education gap" between potential and reality in Canada

Background

Critical care ultrasound (CCUS) is now a core competency for Canadian critical care medicine (CCM) physicians, but little is known about what education is delivered, how competence is assessed, and what challenges exist. We evaluated the Canadian CCUS education landscape and compared it against published recommendations.

Methods

A 23-item survey was developed and incorporated a literature review, national recommendations, and expert input. It was sent in the spring of 2019 to all 13 Canadian Adult CCM training programs via their respective program directors. Three months were allowed for data collection and descriptive statistics were compiled.

Results

Eleven of 13 (85%) programs responded, of which only 7/11 (64%) followed national recommendations. Curricula differed, as did how education was delivered: 8/11 (72%) used hands-on training; 7/11 (64%) used educational rounds; 5/11 (45%) used image interpretation sessions, and 5/11 (45%) used scan-based feedback. All 11 employed academic half-days, but only 7/11 (64%) used experience gained during clinical service. Only 2/11 (18%) delivered multiday courses, and 2/11 (18%) had mandatory ultrasound rotations. Most programs had only 1 or 2 local CCUS expert-champions, and only 4/11 (36%) assessed learner competency. Common barriers included educators receiving insufficient time and/or support.

Conclusions

Our national survey is the first in Canada to explore CCUS education in critical care. It suggests that while CCUS education is rapidly developing, gaps persist. These include variation in curriculum and delivery, insufficient access to experts, and support for educators.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-021-00249-z.

Comparing accuracy of bedside ultrasound examination with physical examination for detection of pleural effusion

BACKGROUND

In detecting pleural effusion, bedside ultrasound (US) has been shown to be more accurate than auscultation. However, US has not been previously compared to the comprehensive physical examination. This study seeks to compare the accuracy of physical examination with bedside US in detecting pleural effusion.

METHODS

This study included a convenience sample of 34 medical inpatients from Calgary, Canada and Spokane, USA, with chest imaging performed within 24 h of recruitment. Imaging results served as the reference standard for pleural effusion. All patients underwent a comprehensive lung physical examination and a bedside US examination by two researchers blinded to the imaging results.

RESULTS

Physical examination was less accurate than US (sensitivity of 44.0% [95% confidence interval (CI) 30.0-58.8%], specificity 88.9% (95% CI 65.3-98.6%), positive likelihood (LR) 3.96 (95% CI 1.03-15.18), negative LR 0.63 (95% CI 0.47-0.85) for physical examination; sensitivity 98% (95% CI 89.4-100%), specificity 94.4% (95% CI 72.7-99.9%), positive LR 17.6 (95% CI 2.6-118.6), negative LR 0.02 (95% CI 0.00-0.15) for US). The percentage of examinations rated with a confidence level of 4 or higher (out of 5) was higher for US (85% of the seated US examination and 94% of the supine US examination, compared to 35% of the PE, P < 0.001), and took less time to perform (P < 0.0001).

CONCLUSIONS

US examination for pleural effusion was more accurate than the physical examination, conferred higher confidence, and required less time to complete.

Canadian Internal Medicine Ultrasound (CIMUS) Expert Consensus Statement on the Use of Lung Ultrasound for the Assessment of Medical Inpatients With Known or Suspected Coronavirus Disease 2019

OBJECTIVES

To develop a consensus statement on the use of lung ultrasound (LUS) in the assessment of symptomatic general medical inpatients with known or suspected coronavirus disease 2019 (COVID-19).

METHODS

Our LUS expert panel consisted of 14 multidisciplinary international experts. Experts voted in 3 rounds on the strength of 26 recommendations as "strong," "weak," or "do not recommend." For recommendations that reached consensus for do not recommend, a fourth round was conducted to determine the strength of those recommendations, with 2 additional recommendations considered.

RESULTS

Of the 26 recommendations, experts reached consensus on 6 in the first round, 13 in the second, and 7 in the third. Four recommendations were removed because of redundancy. In the fourth round, experts considered 4 recommendations that reached consensus for do not recommend and 2 additional scenarios; consensus was reached for 4 of these. Our final recommendations consist of 24 consensus statements; for 2 of these, the strength of the recommendations did not reach consensus.

CONCLUSIONS

In symptomatic medical inpatients with known or suspected COVID-19, we recommend the use of LUS to: (1) support the diagnosis of pneumonitis but not diagnose COVID-19, (2) rule out concerning ultrasound features, (3) monitor patients with a change in the clinical status, and (4) avoid unnecessary additional imaging for patients whose pretest probability of an alternative or superimposed diagnosis is low. We do not recommend the use of LUS to guide admission and discharge decisions. We do not recommend routine serial LUS in patients without a change in their clinical condition.

Video Recording in Veterinary Medicine OSCEs: Feasibility and Inter-rater Agreement between Live Performance Examiners and Video Recording Reviewing Examiners

The Objective Structured Clinical Examination (OSCE) is a valid, reliable assessment of veterinary students' clinical skills that requires significant examiner training and scoring time. This article seeks to investigate the utility of implementing video recording by scoring OSCEs in real-time using live examiners, and afterwards using video examiners from within and outside the learners' home institution. Using checklists, learners (n=33) were assessed by one live examiner and five video examiners on three OSCE stations: suturing, arthrocentesis, and thoracocentesis. When stations were considered collectively, there was no difference between pass/fail outcome between live and video examiners (χ² = 0.37, p = .55). However, when considered individually, stations (χ² = 16.64, p < .001) and interaction between station and type of examiner (χ² = 7.13, p = .03) demonstrated a significant effect on pass/fail outcome. Specifically, learners being assessed on suturing with a video examiner had increased odds of passing the station as compared with their arthrocentesis or thoracocentesis stations. Internal consistency was fair to moderate (0.34-0.45). Inter-rater reliability measures varied but were mostly moderate to strong (0.56-0.82). Video examiners spent longer assessing learners than live raters (mean of 21 min/learner vs. 13 min/learner). Station-specific differences among video examiners may be due to intermittent visibility issues during video capture. Overall, video recording learner performances appears reliable and feasible, although there were time, cost, and technical issues that may limit its routine use.

Description of a Multi-faceted COVID-19 Pandemic Physician Workforce Plan at a Multi-site Academic Health System

BACKGROUND

The evolving COVID-19 pandemic has and continues to present a threat to health system capacity. Rapidly expanding an existing acute care physician workforce is critical to pandemic response planning in large urban academic health systems.

INTERVENTION

The Medical Emergency-Pandemic Operations Command (MEOC)-a multi-specialty team of physicians, operational leaders, and support staff within an academic Department of Medicine in Calgary, Canada-partnered with its provincial health system to rapidly develop a comprehensive, scalable pandemic physician workforce plan for non-ventilated inpatients with COVID-19 across multiple hospitals. The MEOC Pandemic Plan comprised seven components, each with unique structure and processes.

METHODS

In this manuscript, we describe MEOC's Pandemic Plan that was designed and implemented from March to May 2020 and re-escalated in October 2020. We report on the plan's structure and process, early implementation outcomes, and unforeseen challenges. Data sources included MEOC documents, health system, public health, and physician engagement implementation data.

KEY RESULTS

From March 5 to October 26, 2020, 427 patients were admitted to COVID-19 units in Calgary hospitals. In the initial implementation period (March-May 2020), MEOC communications reached over 2500 physicians, leading to 1446 physicians volunteering to provide care on COVID-19 units. Of these, 234 physicians signed up for hospital shifts, and 227 physicians received in-person personal protective equipment simulation training. Ninety-three physicians were deployed on COVID-19 units at four large acute care hospitals. The resurgence of cases in September 2020 has prompted re-escalation including re-activation of COVID-19 units.

CONCLUSIONS

MEOC leveraged an academic health system partnership to rapidly design, implement, and refine a comprehensive, scalable COVID-19 acute care physician workforce plan whose components are readily applicable across jurisdictions or healthcare crises. This description may guide other institutions responding to COVID-19 and future health emergencies.

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

Use of Critical Items in Determining Point-of-Care Ultrasound Competence

We previously developed a workplace-based tool for assessing point of care ultrasound (POCUS) skills and used a modified Delphi technique to identify critical items (those that learners must successfully complete to be considered competent). We performed a standard setting procedure to determine cut scores for the full tool and a focused critical item tool. This study compared ratings by 24 experts on the two checklists versus a global entrustability rating. All experts assessed three videos showing an actor performing a POCUS exam on a patient. The performances were designed to show a range of competences and one included potentially critical errors. Interrater reliability for the critical item tool was higher than for the full tool (intraclass correlation coefficient = 0.84 [95% confidence interval [CI] 0.42-0.99] vs. 0.78 [95% CI 0.25-0.99]). Agreement with global ratings of competence was higher for the critical item tool (κ = 0.71 [95% CI 0.55-0.88] vs 0.48 [95% CI 0.30-0.67]). Although sensitivity was higher for the full tool (85.4% [95% CI 72.2-93.9%] vs. 81.3% [95% CI 67.5-91.1%]), specificity was higher for the critical item tool (70.8% [95% CI 48.9-87.4%] vs. 29.2% [95% CI 12.6-51.1%]). We recommend the use of critical item checklists for the assessment of POCUS competence.

The Potential for Remotely Mentored Patient-Performed Home Self-Monitoring for New Onset Alveolar-Interstitial Lung Disease

Purpose: Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is an acute respiratory illness. Although most infected persons are asymptomatic or have only mild symptoms, some patients progress to devastating disease; such progression is difficult to predict or identify in a timely manner. COVID-19 patients who do not require hospitalization can self-isolate at home. Calls from one disease epicenter identify the need for homebased isolation with telemedicine surveillance to monitor for impending deterioration. Methodology: Although the dominant approach for these asymptomatic/paucisymptomatic patients is to monitor oxygen saturation, we suggest additionally considering the potential merits and utility of home-based imaging. Chest computed tomography is clearly impractical, but ultrasound has shown comparable sensitivity for lung involvement, with major advantages of short and simple procedures, low cost, and excellent repeatability. Thoracic ultrasound may thus allow remotely identifying the development of pneumonitis at an early stage of illness and potentially averting the risk of insidious deterioration to severe pneumonia and critical illness while in home isolation. Conclusions: Lung sonography can be easily performed by motivated nonmedical caregivers when directed and supervised in real time by experts. Remote mentors could thus efficiently monitor, counsel, and triage multiple home-based patients from their "control center." Authors believe that this approach deserves further attention and study to reduce delays and failures in timely hospitalization of home-isolated patients.

The Canadian Medical Student Ultrasound Curriculum: A Statement From the Canadian Ultrasound Consensus for Undergraduate Medical Education Group

OBJECTIVES

This study sought to establish by expert review a consensus-based, focused ultrasound curriculum, consisting of a foundational set of focused ultrasound skills that all Canadian medical students would be expected to attain at the end of the medical school program.

METHODS

An expert panel of 21 point-of-care ultrasound and educational leaders representing 15 of 17 (88%) Canadian medical schools was formed and participated in a modified Delphi consensus method. Experts anonymously rated 195 curricular elements on their appropriateness to include in a medical school curriculum using a 5-point Likert scale. The group defined consensus as 70% or more experts agreeing to include or exclude an element. We determined a priori that no more than 3 rounds of voting would be performed.

RESULTS

Of the 195 curricular elements considered in the first round of voting, the group reached consensus to include 78 and exclude 24. In the second round, consensus was reached to include 4 and exclude 63 elements. In our final round, with 1 additional item added to the survey, the group reached consensus to include an additional 3 and exclude 8 elements. A total of 85 curricular elements reached consensus to be included, with 95 to be excluded. Sixteen elements did not reach consensus to be included or excluded.

CONCLUSIONS

By expert opinion-based consensus, the Canadian Ultrasound Consensus for Undergraduate Medical Education Group recommends that 85 curricular elements be considered for inclusion for teaching in the Canadian medical school focused ultrasound curricula.

Journey of candidates who were unmatched in the Canadian Residency Matching Service (CaRMS): A phenomenological study

BACKGROUND

Each year, a number of medical students are unmatched in the Canadian Residency Matching Service (CaRMs) match. Blog posts from previous unmatched students suggest that being unmatched is associated with significant stress. However, no studies have explored the collective experiences of candidates who are unmatched. This study seeks to explore the experiences of Canadian students who were unmatched in the first iteration of their CaRMS applications.

METHODS

This was an interview-based qualitative study using a phenomenology approach to explore the perspectives of 15 Canadian participants from seven universities who had previously experienced being unmatched between 2011 and 2017 in CaRMS. Telephone interviews were conducted using a semi-structured guide focusing on the experiences in the following domains: the overall unmatched experience; perceived reasons leading to their unmatched status; resources employed; barriers experienced; recommendations; and, their eventual career outcomes. Field notes were analyzed independently by all authors using thematic analysis and authors independently identified major themes. To reconcile divergent impressions and better situate qualitative impressions of our participants, we used publicly available quantitative data from CaRMS to calculate relevant odds ratios.

RESULTS

Our participants universally reported negative emotions, concerns regarding privacy and confidentiality breaches, and stigma faced. Systemic challenges faced by our participants included: lack of information, pressures perceived from undergraduate medical education to apply in the second iteration to specialties that they did not want, and logistical issues such as financial challenges, licensing and scheduling issues. The utility of peer support differed for individual participants, but all those who had support from other unmatched candidates felt that to be useful.

CONCLUSIONS

Our participants reported significant challenges faced after being unmatched. Based on these experiences, we identified key areas of support needed for candidates through their unmatched journey.

Performance of the Ebel standard-setting method in spring 2019 Royal College of Physicians and Surgeons of Canada internal medicine certification examination consisted of multiple-choice questions

PURPOSE

It aimed to know the performance of the Ebel standard-setting method in in spring 2019 Royal College of Physicians and Surgeons of Canada internal medicine certification examination consisted of multiple-choice questions. Specifically followings were searched: the inter-rater agreement; the correlation between Ebel scores and item facility indices; raters' knowledge of correct answers' impact on the Ebel score; and affection of rater's specialty on theinter-rater agreement and Ebel scores.

METHODS

Data were drawn from a Royal College of Physicians and Surgeons of Canada certification exam. Ebel's method was applied to 203 MCQs by 49 raters. Facility indices came from 194 candidates. We computed Fleiss' kappa and the Pearson correlation between Ebel scores and item facility indices. We investigated differences in the Ebel score (correct answers provided or not) and differences between internists and other specialists with t-tests.

RESULTS

Kappa was below 0.15 for facility and relevance. The correlation between Ebel scores and facility indices was low when correct answers were provided and negligible when they were not. The Ebel score was the same, whether the correct answers were provided or not. Inter-rater agreement and Ebel scores was not differentbetween internists and other specialists.

CONCLUSION

Inter-rater agreement and correlations between item Ebel scores and facility indices wee consistently low; furthermore, raters' knowledge of correct answer and rater specialty had no effect on Ebel scores in the present setting.

Barriers to learning and using point-of-care ultrasound: a survey of practicing internists in six North American institutions

Background

Point-of-care ultrasound (POCUS) is increasingly used in internal medicine, but a lack of trained faculty continues to limit the spread of POCUS education. Using a framework based on organizational change theories, this study sought to identify barriers and enablers for hospital-based practicing internists to learn and use POCUS in clinical practice.

Methods

We invited practicing internists at six North American institutions to participate in an electronic survey on their opinions regarding 39 barriers and enablers.

Results

Of the 342 participants invited, 170 participated (response rate 49.3%). The top barriers were lack of training (79%), lack of handheld ultrasound devices (78%), lack of direct supervision (65%), lack of time to perform POCUS during rounds (65%), and lack of quality assurance processes (53%). The majority of participants (55%) disagreed or strongly disagreed with the statement “My institution provides funding for POCUS training.” In general, participants’ attitudes towards POCUS were favourable, and future career opportunities and the potential for billing were not considered significant factors by our participants in the decision to learn or use POCUS.

Conclusions

This survey confirms the perceived importance of POCUS to practicing internists. To assist in closing faculty development gap, interventions should address training, supervision, quality assurance processes, availability of handheld devices, as well as dedicated time to perform POCUS during clinical care.

Consensus-Based Expert Development of Critical Items for Direct Observation of Point-of-Care Ultrasound Skills

BACKGROUND

Point-of-care ultrasound (POCUS) is increasingly used in a number of medical specialties. To support competency-based POCUS education, workplace-based assessments are essential.

OBJECTIVE

We developed a consensus-based assessment tool for POCUS skills and determined which items are critical for competence. We then performed standards setting to set cut scores for the tool.

METHODS

Using a modified Delphi technique, 25 experts voted on 32 items over 3 rounds between August and December 2016. Consensus was defined as agreement by at least 80% of the experts. Twelve experts then performed 3 rounds of a standards setting procedure in March 2017 to establish cut scores.

RESULTS

Experts reached consensus for 31 items to include in the tool. Experts reached consensus that 16 of those items were critically important. A final cut score for the tool was established at 65.2% (SD 17.0%). Cut scores for critical items are significantly higher than those for noncritical items (76.5% ± SD 12.4% versus 53.1% ± SD 12.2%, P < .0001).

CONCLUSIONS

We reached consensus on a 31-item workplace-based assessment tool for identifying competence in POCUS. Of those items, 16 were considered critically important. Their importance is further supported by higher cut scores compared with noncritical items.

Applicant gender and matching to first-choice discipline: a cross-sectional analysis of data from the Canadian Resident Matching Service (2013-2019)

BACKGROUND

Previous studies examining potential sex and gender bias in the Canadian Resident Matching Service (CaRMS) match have had conflicting results. We examined the results of the CaRMS match over the period 2013-2019 to determine the potential association between applicants' gender and the outcome of matching to their first-choice discipline.

METHODS

In this cross-sectional analysis, we determined the risk of matching to one's first-choice discipline in CaRMS by applicant gender and year, for all Canadian medical students who participated in the first iteration of the R-1 match for the years 2013 to 2019. We analyzed data in 3 categories of disciplines according to CaRMS classifications: family medicine, nonsurgical disciplines and surgical disciplines. We excluded disciplines with fewer than 10 applicants.

RESULTS

Match results were available for 20 033 participants, of whom 11 078 (55.3%) were female. Overall, female applicants were significantly more likely to match to their first-choice discipline (relative risk [RR] 1.03, 95% confidence interval [CI] 1.02-1.04). After adjustment for match year and stratification by discipline categories, we found that female applicants were more likely to match to family medicine as their first choice (RR 1.04, 95% CI 1.03-1.05) and less likely to match to a first-choice surgical discipline (RR 0.95, 95% CI 0.91-1.00) than their male peers. There was no significant difference between the genders in matching to one's first-choice nonsurgical discipline (RR 1.01, 95% CI 0.99-1.03).

INTERPRETATION

These results suggest an association between an applicant's gender and the probability of matching to one's first-choice discipline. The possibility of gender bias in the application process for residency programs should be further evaluated and monitored.

Correction to: Internal Medicine Point of Care Ultrasound: Indicators It's Here to Stay

This editorial, "Internal Medicine Point of Care Ultrasound: Indicators It's Here to Stay" (DOI: 10.1007/s11606-019-05268-0), was intended to accompany "Education Indicators for Internal Medicine Point-of-Care Ultrasound: a Consensus Report from the Canadian Internal Medicine Ultrasound (CIMUS) Group".

Expert Recommendations on Frequency of Utilization of Common Laboratory Tests in Medical Inpatients: a Canadian Consensus Study

BACKGROUND

Repetitive inpatient laboratory testing in the face of clinical stability is a marker of low-value care. However, for commonly encountered clinical scenarios on medical units, there are no guidelines defining appropriate use criteria for laboratory tests.

OBJECTIVE

This study seeks to establish consensus-based recommendations for the utilization of common laboratory tests in medical inpatients.

DESIGN

This study uses a modified Delphi method. Participants completed two rounds of an online survey to determine appropriate testing frequencies for selected laboratory tests in commonly encountered clinical scenarios. Consensus was defined as agreement by at least 80% of participants.

PARTICIPANTS

Participants were 36 experts in internal medicine across Canada defined as internists in independent practice for ≥ 5 years with experience in medical education, quality improvement, or both. Experts represented 8 of the 10 Canadian provinces and 13 of 17 academic institutions.

MAIN MEASURES

Laboratory tests and clinical scenarios included were those that were considered common on medical units. The final survey contained a total of 45 clinical scenarios looking at the utilization of six laboratory tests (complete blood count, electrolytes, creatinine, urea, international normalized ratio, and partial thromboplastin time). The possible frequency choices were every 2-4 h, 6-8 h, twice a day, daily, every 2-3 days, weekly, or none unless there was specific diagnostic suspicion. These scenarios were reviewed by two internists with training in quality improvement and survey methods.

KEY RESULTS

Of the 45 initial clinical scenarios included, we reached consensus on 17 scenarios. We reached weak consensus on an additional 19 scenarios by combining two adjacent frequency categories.

CONCLUSIONS

A Canadian expert panel of internists has provided frequency recommendations on the utilization of six common laboratory tests in medical inpatients. These recommendations need validation in prospective studies to assess whether restrictive versus liberal laboratory test ordering impacts patient outcomes.

The development of a provincial multidisciplinary framework of consensus-based standards for Point of Care Ultrasound at the University of Saskatchewan

OBJECTIVES

The development and adoption of Point-of-Care Ultrasound (POCUS) across disciplines have created challenges and opportunities in implementing training and utilization standards. Within the context of a large, geographically disparate province, we sought to develop a multidisciplinary POCUS framework outlining consensus-based standards.

METHODS

A core working group of local POCUS leaders from Anesthesia, Emergency Medicine, Family Medicine, Intensive Care, Internal Medicine, Pediatrics, and Trauma, in collaboration with western Canadian colleagues, developed a list of key domains for the framework along with a range of potential standards for each area. The members of the working group and the registrants for a multidisciplinary Roundtable discussion at the University of Saskatchewan's annual POCUS conference (SASKSONO19, Saskatoon, Saskatchewan, March 2nd, 2019) were invited to complete a survey on POCUS standards for each domain. The survey results were presented to and discussed by participants at the Roundtable discussion at SASKSONO19 who reached consensus on modified standards for each domain. The modified standards were considered for endorsement by all conference attendees using an audience-response system.

RESULTS

The working group proposed standards in eight domains: scope of use, credentialing and privileges, documentation, quality assurance, leadership and governance, teaching, research, and equipment maintenance. Consensus on modified standards was achieved in the 18 participant Roundtable. Each standard was then endorsed by > 90% of conference respondents.

CONCLUSION

The resulting framework will inform the utilization of POCUS within Saskatchewan. Both this process and its outcomes could inform the development of multidisciplinary POCUS standards within other jurisdictions.

Education Indicators for Internal Medicine Point-of-Care Ultrasound: a Consensus Report from the Canadian Internal Medicine Ultrasound (CIMUS) Group

BACKGROUND

Curriculum development and implementation for internal medicine point-of-care ultrasound (IM POCUS) continues to be a challenge for many residency training programs. Education indicators may provide a useful framework to support curriculum development and implementation efforts across programs in order to achieve a consistent high-quality educational experience.

OBJECTIVE

This study seeks to establish consensus-based recommendations for education indicators for IM POCUS training programs in Canada.

DESIGN

This consensus study uses a modified nominal group technique for voting in the initial round, followed by two additional rounds of online voting, with consensus defined as agreement by at least 80% of the participants.

PARTICIPANTS

Participants were 22 leaders with POCUS and/or education expertise from 13 Canadian internal medicine residency programs across 7 provinces.

MAIN MEASURES

Education indicators considered were those that related to aspects of the POCUS educational system, could be presented by a single statistical measure, were readily understood, could be reliably measured to provide a benchmark for measuring change, and represented a policy issue. We excluded a priori indicators with low feasibility, are impractical, or assess learner reactions. Candidate indicators were drafted by two academic internists with post-graduate training in POCUS and medical education. These indicators were reviewed by two internists with training in quality improvement prior to presentation to the expert participants.

KEY RESULTS

Of the 52 candidate education indicators considered, 6 reached consensus in the first round, 12 in the second, and 4 in the third round. Only 5 indicators reached consensus to be excluded; the remaining indicators did not reach consensus.

CONCLUSIONS

The Canadian Internal Medicine Ultrasound (CIMUS) group recommends 22 education indicators be used to guide and monitor internal medicine POCUS curriculum development efforts in Canada.

Transthoracic sonographic assessment of B-line scores during ascent to altitude among healthy trekkers

Sonographic B-lines can indicate pulmonary interstitial edema. We sought to determine the incidence of subclinical pulmonary edema measured by sonographic B-lines among lowland trekkers ascending to high altitude in the Nepal Himalaya. Twenty healthy trekkers underwent portable sonographic examinations and arterial blood draws during ascent to 5160 m over ten days. B-lines were identified in twelve participants and more frequent at 4240 m and 5160 m compared to lower altitudes (P < 0.03). There was a strong negative correlation between arterial oxygen saturation and the number of B-lines at 5160 m (ρ = -0.75, P = 0.008). Our study contributes to the growing body of literature demonstrating the development of asymptomatic pulmonary edema during ascent to high altitude. Portable lung sonography may have utility in fieldwork contexts such as trekking at altitude, but further research is needed in order to clarify its potential clinical applicability.

Integrating point-of-care ultrasound in the ED evaluation of patients presenting with chest pain and shortness of breath

OBJECTIVE

The differential diagnoses of patients presenting with chest pain (CP) and shortness of breath (SOB) are broad and non-specific. We aimed to 1) determine how use of point-of-care ultrasound (POCUS) impacted emergency physicians' differential diagnosis, and 2) evaluate the accuracy of POCUS when compared to chest radiograph (CXR) and composite final diagnosis.

METHODS

We conducted a prospective observational study in a convenience sample of patients presenting with CP and SOB to the Emergency Department (ED). Treating physicians selected possible diagnoses from a pre-indexed list of possible diagnoses of causes of CP and SOB. The final composite diagnosis from a chart review was determined as the reference standard for the diagnosis. The primary analysis involved calculations of sensitivity and specificity for POCUS identifiable diagnoses in detecting cause of CP and SOB. Additional comparative accuracy analysis with CXRs were conducted.

RESULTS

128 patients with a mean age of 64 ± 17 years were included in the study. Using a reference standard of composite final diagnoses, POCUS had equal or higher specificity to CXR for all indications for which it was used, except for pneumonia. POCUS correctly identified all patients with pneumothorax, pleural effusion and pericardial effusion. In patients with a normal thoracic ultrasound, CXR never provided any actionable clinical information. Adding POCUS to the initial evaluation causes a significant narrowing of the differential diagnoses in which the median differential diagnosis from 5 (IQR 3-6) to 3 (IQR 2-4) p < 0.001.

CONCLUSION

In evaluation of patients with CP and SOB, POCUS is a highly feasible diagnostic test which can assist in narrowing down the differential diagnoses. In patients with a normal thoracic ultrasound, the added value of a CXR may be minimal.

Point of care ultrasound training for internal medicine: a Canadian multi-centre learner needs assessment study

BACKGROUND

Significant gaps currently exist in the Canadian internal medicine point-of-care ultrasound (POCUS) curriculum. From a learner's perspective, it remains unknown what key POCUS skills should be prioritized. This needs assessment study seeks to establish educational priorities for POCUS for internal medicine residents at five Canadian residency training programs.

METHODS

All internal medicine trainees [postgraduate year (PGY) 1-5] from five internal medicine residency training programs in Canada (n = 598) were invited to complete an online survey on 15 diagnostic POCUS applications, 9 bedside procedures, and 18 POCUS knowledge items. For POCUS applications and procedures, participants were asked how applicable they are to patient care in internal medicine and the participants' reported skills in those domains. Self-reported knowledge and skills were rated on a 5-point Likert scale, where 1 = very poor and 5 = very good. Applicability was rated, where 1 = not at all applicable and 5 = very applicable.

RESULTS

A total of 253 of 598 residents (42%) participated in our study. Data from one centre (n = 15) was removed because of low response rate (15%) and significant baseline differences between those trainees and the remaining participants. Of the remaining analyzable data from four training programs (n = 238), participants reported highest applicability to internal medicine for the following applications and procedures: identifying ascites/free fluid [mean applicability score of 4.9 ± standard deviation (SD) 0.4]; gross left ventricular function (mean 4.8 ± SD 0.5) and pericardial effusion (mean 4.7 ± SD 0.5); thoracentesis (mean score 4.9 ± SD 0.3), central line insertion (mean 4.9 ± SD 0.3), and paracentesis (mean 4.9 ± SD 0.3), respectively. Overall reported knowledge/skills was low, with skill gaps being the highest for identifying deep vein thrombosis (mean gap 2.7 ± SD 1.1), right ventricular strain (mean 2.7 ± SD 1.1), and gross left ventricular function (mean 2.7 ± SD 1.0).

CONCLUSIONS

Many POCUS applications and procedures were felt to be applicable to the practice of internal medicine. Significant skill gaps exist in the four Canadian training programs included in the study. POCUS curriculum development efforts should target training based on these perceived skill gaps.

Comparing Physical Examination With Sonographic Versions of the Same Examination Techniques for Splenomegaly

OBJECTIVES

To determine whether sonographic versions of physical examination techniques can accurately identify splenomegaly, Castell's method (Ann Intern Med 1967; 67:1265-1267), the sonographic Castell's method, spleen tip palpation, and the sonographic spleen tip technique were compared with reference measurements.

METHODS

Two clinicians trained in bedside sonography patients recruited from an urban hematology clinic. Each patient was examined for splenomegaly using conventional percussion and palpation techniques (Castell's method and spleen tip palpation, respectively), as well as the sonographic versions of these maneuvers (sonographic Castell's method and sonographic spleen tip technique). Results were compared with a reference standard based on professional sonographer measurements.

RESULTS

The sonographic Castell's method had greater sensitivity (91.7% [95% confidence interval, 61.5% to 99.8%]) than the traditional Castell's method (83.3% [95% confidence interval, 51.6% to 97.9%]) but took longer to perform [mean ± SD, 28.8 ± 18.6 versus 18.8 ± 8.1 seconds; P = .01). Palpable and positive sonographic spleen tip results were both 100% specific, but the sonographic spleen tip method was more sensitive (58.3% [95% confidence interval, 27.7% to 84.8%] versus 33.3% [95% confidence interval, 9.9% to 65.1%]).

CONCLUSIONS

Sonographic versions of traditional physical examination maneuvers have greater diagnostic accuracy than the physical examination maneuvers from which they are derived but may take longer to perform. We recommend a combination of traditional physical examination and sonographic techniques when evaluating for splenomegaly at the bedside.

Internal Medicine Point-of-Care Ultrasound Curriculum: Consensus Recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group

Bedside point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. At present, no consensus exists for what POCUS curriculum is appropriate for internal medicine residency training programs. This document details the consensus-based recommendations by the Canadian Internal Medicine Ultrasound (CIMUS) group, comprising 39 members, representing 14 institutions across Canada. Guiding principles for selecting curricular content were determined a priori. Consensus was defined as agreement by at least 80% of the members on POCUS applications deemed appropriate for teaching and assessment of trainees in the core (internal medicine postgraduate years [PGY] 1-3) and expanded (general internal medicine PGY 4-5) training programs. We recommend four POCUS applications for the core PGY 1-3 curriculum (inferior vena cava, lung B lines, pleural effusion, and abdominal free fluid) and three ultrasound-guided procedures (central venous catheterization, thoracentesis, and paracentesis). For the expanded PGY 4-5 curriculum, we recommend an additional seven applications (internal jugular vein, lung consolidation, pneumothorax, knee effusion, gross left ventricular systolic function, pericardial effusion, and right ventricular strain) and four ultrasound-guided procedures (knee arthrocentesis, arterial line insertion, arterial blood gas sampling, and peripheral venous catheterization). These recommendations will provide a framework for training programs at a national level.

Using the Entrustable Professional Activities Framework in the Assessment of Procedural Skills

BACKGROUND

The entrustable professional activity (EPA) framework has been identified as a useful approach to assessment in competency-based education. To apply an EPA framework for assessment, essential skills necessary for entrustment to occur must first be identified.

OBJECTIVE

Using an EPA framework, our study sought to (1) define the essential skills required for entrustment for 7 bedside procedures expected of graduates of Canadian internal medicine (IM) residency programs, and (2) develop rubrics for the assessment of these procedural skills.

METHODS

An initial list of essential skills was defined for each procedural EPA by focus groups of experts at 4 academic centers using the nominal group technique. These lists were subsequently vetted by representatives from all Canadian IM training programs through a web-based survey. Consensus (more than 80% agreement) about inclusion of each item was sought using a modified Delphi exercise. Qualitative survey data were analyzed using a framework approach to inform final assessment rubrics for each procedure.

RESULTS

Initial lists of essential skills for procedural EPAs ranged from 10 to 24 items. A total of 111 experts completed the national survey. After 2 iterations, consensus was reached on all items. Following qualitative analysis, final rubrics were created, which included 6 to 10 items per procedure.

CONCLUSIONS

These EPA-based assessment rubrics represent a national consensus by Canadian IM clinician educators. They provide a practical guide for the assessment of procedural skills in a competency-based education model, and a robust foundation for future research on their implementation and evaluation.