Does Ultrasound Matter at the Bedside: A Multi-Center Prospective Cohort Trial
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The Emergency Department is a Chaotic Place - Presented at the Fourth Annual Barsan Emergency Medicine Research Forum
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Does Ultrasound Matter at the Bedside: A Multi-Center Prospective Cohort Trial
- 1. Comparison of a Primary ED Physician Performed Point of Care Ultrasound to a Dedicated ED Ultrasound Team in the Initial Evaluation of Undifferentiated Dyspnea and Hypotension Alexander Beyer, Christopher Wallace, Christopher Hebert, Vivian Lam, Sheng Dong, Jim Cranford, Michael Cover, Nicole Seleno, Robert Huang, Allen Makjrzak, Nik Theyyunni
- 4. Portable Diagnostic and Therapeutic Fast
- 8. 4 . Pericardial Tamponade …among others
- 9. Average time needed US diagnosis: 24 mins ± 10 mins Average time needed ED diagnosis (Non-US): 186 mins ± 72 mins
- 11. What is the effectiveness of POCUS in narrowing diagnostic uncertainty by treating physicians versus A dedicated ultrasound team?
- 12. Multicenter • University Hospital • Saint Joseph Mercy Ann Arbor • Systolic Blood Pressure <90 mmHg • Adults Age (18+) Undifferentiated Hypotension or Dyspnea (Shortness of Breath) Systolic Blood Pressure <90 mmHg Adults Age (18+)
- 13. Convenient sample of patients will be enrolled into two groups: Group 1 treating team of primary providers, who also perform the ultrasound. (Non-specialized) Group 2 treating team of primary providers, ultrasound performed by dedicated US team. (Fellowship trained/Specialized)
- 14. In both groups, attendings will be filling out a pre-US survey and a post-US survey to assess the utility of the US scan.
- 15. Pre-Test Most Likely Diagnosis (Choose 1), then other differentials Pre-Test Ratings of Confidence US Views Ordered Pre-Test Management Strategies
- 16. Post-Test Most Likely Diagnosis (Choose 1), then other differentials Post-Test Ratings of Confidence US Views Ordered Post-Test Management Strategies
- 18. 1. POCUS lead to a change in diagnosis Primary Provider Only (Group 1): 41.2% of cases Dedicated US Team (Group 2): 44.4% of cases 2. Providers narrowed their differential diagnosis : Primary Provider Only (Group 1): 1.88 Dedicated US Team (Group 2): 2 Preliminary Findings (Dyspnea; n=26/150)
- 19. Preliminary Findings (Dyspnea; n=26/150) Power Calculation Non-Inferiority N=150 Power of= 80% Less than 20% Difference
- 20. 1. POCUS led to both groups did see a decrease in differential diagnosis Primary Provider (Group 1): 62.5% Dedicated US Team (Group 2): 100% 2. POCUS changed management: Decrease in IV Fluid Increase in Vasopressor Use Preliminary Findings (Hypotension; n=12)
- 21. 1. Ultrasound also can quickly identify rare cases of hypotension. May also be beneficial in Identifying the source of infection Serial Evaluations Preliminary Findings (Hypotension; n=12)
Editor's Notes
- In our job we are responsible for many patients, and have to juggle multiple responsibilities at the same time
- Our patients are Undifferentiated Managing Diagnostic Uncertainty is a core skill of an emergency department physician We know that cognitive load is a problem in the emergency departement, we only have so much mental capital that we can spend on our shift.
- POCUS is useful in reducing diagnostic uncertainty and thereby reducing a provider’s cognitive load by rapidly ruling out other etiologies
- US picture/Effusion/ Transition to each photo of each illness Pleural effusion Alveolar consolidation Alveolar-interstitial syndrome Pneumonia Pneumothorax
- US picture/Effusion/ Transition to each photo of each illness Pleural effusion Alveolar consolidation Alveolar-interstitial syndrome Pneumonia Pneumothorax
- US picture/Effusion/ Transition to each photo of each illness Pleural effusion Alveolar consolidation Alveolar-interstitial syndrome Pneumonia Pneumothorax
- US picture/Effusion/ Transition to each photo of each illness Pleural effusion Alveolar consolidation Alveolar-interstitial syndrome Pneumonia Pneumothorax
- Pneumonia, Pleural Effusion, PTX CHF and Pericardial effusion/Tamponade Zanobetti Chest 2017 Not representative of treating physician settings without access to US team Fellowship Trained US Operators Differences in US experience/number of scans performed Limited Generalizability
- You have to be comfortable with the probe and interpreting results, you need to be able to take the time to perform the scan. When there is 100 things that need to be done in the ED, does POCUS actually provide value to the practitioner?
- Prospective Cohort Study
- Primary team has other clinical responsibilities other than ultrasound, would be more difficult for them to do dedicated scan. Looking at quality of scans considering this.
- Did their management change via ultrasound Able to look at how sick the patient was on presentation, as well as medications and interventions Compared to final diagnosis to evaluate for accuracy of POCUS Finally, we look at the quality of images captured and the length of time spent scanning to see if quality of images matter for initial management, and to look at how much time is needed to invest in US to decrease diagnostic uncertainty
- Analysis of initial 4 months of enrollment for a proposed 1 year trial: Play with a graphic/visual representation
- Power calculation for non inferiority If there is truly no difference between the two groups, then 150 patients are required to be 80% sure that the upper limit of a one-sided 95% confidence interval will exclude a difference in favor of the standard group of more than 20%
- Analysis of initial 4 months of enrollment for a proposed 1 year trial: Really didn’t change diagnosis, but did help change management 25% of cases providers changed from initially IV fluids. Two cases transitioned to using vasopressors. However, POCUS seldom led to changes in diagnosis Primary Provider (Group 1): 25% Dedicated US Team (Group 2): 0% This is similar the the SHOC-ED trial published in Annals.
- The benefits of idenitfying these cases are hard to quantify since they are so rare (in other studies tamponade is <2% of total diagnosis) Ruptured AAA also important to identify Secret cardiogenic shock… Intraabdominal sepsis from cholecystitis. Will not change differential on survey, but may lead to drastically different management Serial evaluations to guide management
- Managing a department is hard, Anything that can decrease the cognitive load can help contribute to patient care Faster Diagnosis- Faster treatment= Better Management Narrowing differential = moving mental capital to apply to other aspects of the departments or patient care