145 Point of care lung ultrasound in patient triage: integration of ultrasound into a streaming pathway for COVID-19

Aims/Objectives/BackgroundRapid risk stratification of patients is vital for Emergency Department (ED) streaming during the COVID-19 pandemic. Ideally, patients should be split into red (suspected/confirmed COVID-19) and green (non COVID-19) zones in order to minimise the risk of patient-to-patient and patient-to-staff transmission. A robust yet rapid streaming system combining clinician impression with point-of-care diagnostics is therefore necessary.Point of care ultrasound (POCUS) findings in COVID-19 have been shown to correlate well with computed tomography (CT) findings, and it therefore has value as a front-door diagnostic tool. At University Hospital Lewisham (a district general hospital in south London), we recognised the value of early POCUS and its potential for use in patient streaming.Methods/DesignWe developed a training programme, ‘POCUS for COVID’ and subsequently integrated POCUS into streaming of our ED patients. The training involved Zoom lectures, a face to face practical, a 10 scan sign off process followed by a final triggered assessment. Patient outcomes were reviewed in conjunction with their scan reports.Results/ConclusionsCurrently, we have 21 ED junior doctors performing ultrasound scans independently, and all patients presenting to our department are scanned either in triage or in the ambulance. A combination of clinical judgement and scan findings are used to stream the patient to an appropriate area.Service evaluation with analysis of audit data has found our streaming to be 94% sensitive and 79% specific as an indicator of COVID 19. Further analysis is ongoing.Here we present both the structure of our training programme and our integrated streaming pathway along with preliminary analysis results.

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Gamification versus Face-to-Face Learning Approach in Point-of-Care Ultrasound Training: A Randomized Controlled Trial

10.21203/rs.3.rs-18768/v1 ◽

2020 ◽

Author(s):

Keng Sheng Chew ◽

Aaron Kuo Huo Lai ◽

Abdul Muhaimin Noor Azhar ◽

Aidawati Bustam ◽

Xun Ting Tiong ◽

...

Keyword(s):

Test Score ◽

Point Of Care ◽

T Test ◽

Junior Doctors ◽

Point Of Care Ultrasound ◽

Face To Face ◽

Post Test ◽

Face To Face Learning ◽

Student’S T ◽

Student’S T Test

Abstract Background: Although gamification increases user engagement, its effectiveness in point-of-care ultrasound training may yet to be fully established. This study was conducted with the primary outcome of evaluating its effectiveness in point-of-care ultrasound training workshop as compared to conventional face-to-face learning. Methods: Participants (who were junior doctors between 2 – 4 years of clinical experience) were randomized into either the (1) gamification or the (2) face-to-face learning arms. Similar educational intervention was implemented to participants in both arms but the in-gamification arm, the theory assessment was administered in the form of live quizzes with real time leaderboards, and the practical assessment was administered in the form of 3 games, i.e., ultrasound minefield, ultrasound pong and ultrasound game. Pre-test, post-test and 2 months post-training theory and practical assessments were conducted. Results: A total 32 junior doctors participated in this study (16 participants in each arm). For theory assessment, paired student’s t-test showed significant improvement in both face-to-face learning (pre-test score: 12.38 vs post-test score: 19.88; 95% CI [5.35, 9.65] p < 0.001) and gamification arms (pre-test score: 13.38 vs post-test score: 20.81; 95% CI [5.93, 8.94] p < 0.001). For the practical assessment, paired student’s t-test showed significant improvement in gamification arm (pre-test score: 12.56 vs post-test score: 18.13; 95% CI [2.44, 8.69] p<0.001) but not the in the face-to-face learning arm (pre-test score: 16.00 vs post-test score: 18.38; 95% CI [-0.17, 4.92] p<0.065). When re-tested 2 months post-training, both face-to-face learning and gamification arms showed significant improvement for both theory and practical assessment. Conclusions: Gamification approach could be an effective alternative or more effective than face-to-face learning in point-of-care ultrasound training.

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The Introduction of An Intravenous Fluid Bundle to Improve the Prescribing of Intravenous Fluids Within a District General Hospital (Preprint)

10.2196/preprints.36304 ◽

2022 ◽

Author(s):

Abdul-Rahman Gomaa ◽

Sharan Sambhwani ◽

Jonathan Wilkinson

Keyword(s):

Point Of Care ◽

Kidney Injury ◽

District General Hospital ◽

Good Clinical Practice ◽

Point Prevalence ◽

Grand Round ◽

Junior Doctors ◽

Improvement Project ◽

Increased Risk ◽

The Impact

BACKGROUND Intravenous (IV) fluids are some of the most commonly prescribed day-to-day drugs. Evidence suggests that such prescriptions are rarely ever done correctly despite the presence of clear guidelines (NICE CG174). This is believed to be due to lack of knowledge and experience, which often breeds confusion and places patients at increased risk of harm. It also incurs avoidable costs to hospitals. OBJECTIVE This quality improvement project (QIP) aims to ensure that IV fluid prescriptions are: safe, appropriate and adhere to evidence-based NICE guidance. The project’s aims will be achieved through implementing multiple interventions that are categorised under: educational, changing prescribing habits and raising awareness. METHODS Review and improve the prescribing process of “IV fluid prescribing” via three simultaneous approaches. Teaching sessions were delivered to all junior doctors in order to improve knowledge and awareness of appropriate IV fluid prescribing and promote familiarity with the current NICE IV fluid guidelines. This included a ‘feature session’ at our local hospital Grand Round. A point-of-care aide-memoire containing a summary of the information needed for correct prescription was designed and printed. This complimented the teaching sessions and supported good clinical practice. Using serial Plan-Do-Study-Act (PDSA) cycles, a novel “IV fluid bundle” was developed, fine-tuned and trialled on five wards, (three surgical, two medical). The aim of the bundle was to ensure that patients were clinically reviewed in order to assess their volaemic status in order that appropriate IV fluids could then be selected and prescribed safely. The impact of these interventions was assessed on the trial wards via a weekly point prevalence audit of the IV fluid bundles for the duration of the trial. Parameters looked at were: incidence of deranged U&E’s, incidence of AKI and the number of days between the latest U&E’s and the patient’s IV fluid prescription. RESULTS These interventions were assessed on trial wards via a weekly point prevalence audit of the new IV fluid prescription chart (bundle; IFB) for the duration of the trial. Parameters monitored were: incidence of deranged U&E’s, incidence of acute kidney injury (AKI) and the number of days between the latest U&E’s and the patient’s IV fluid prescription. Of all of the patients on the IV fluid bundle, 100% had a documented weight, review of both fluid status and balance. The incidence of deranged U&E’s decreased from 48% to 35%. Incidence of AKI decreased from 24% to 10%. The average number of days between the latest U&E’s and a fluid prescription decreased from 2.2 days to 0.6 day. CONCLUSIONS Prescribing IV fluids is a complex task that requires significant improvement both locally and nationally. With 85% uptake of the IFB, we were able to significantly improve all measured outcomes. Through carefully structured interventions geared towards tackling the confounding issues identified from previous audits and process mapping we have shown that prescribing IV fluids can be made safer.

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Development and implementation of a structured leadership programme for junior doctors

BMJ Leader ◽

10.1136/leader-2020-000281 ◽

2020 ◽

pp. leader-2020-000281

Author(s):

Anum Pervez ◽

Aaisha Saqib ◽

Sarah Hare

Keyword(s):

Leadership Skills ◽

District General Hospital ◽

Training Programme ◽

Junior Doctors ◽

Leadership Roles ◽

Self Assessment ◽

Leadership And Management ◽

Business Cases ◽

Do So

IntroductionHealthcare performance and quality of care have been shown to improve when clinicians actively participate in leadership roles. However, the training for junior doctors in leadership and management is either not formally provided or requires out of programme training. In this article, we discuss how we devised a leadership training programme for junior doctors at our district general hospital and reflections on how it can be implemented elsewhere.MethodsA junior doctors leadership programme was developed involving workshops and guidance through delivery of quality improvement projects. A precourse and postcourse questionnaire assessing preparedness to lead was given to trainees to assess the effectiveness of the course.ResultsUsing a Likert Scale, trainees provided quantitative self-assessment for precourse and postcourse changes in their leadership skills. There was an overall increase in confidence across key areas such as communication, preparing business cases and understating hierarchies of management teams.DiscussionThe structure of this leadership programme has provided the opportunity to address gaps in leadership skills that trainees encounter, without the need to extend training. This programme is easily reproducible and offers other trusts a guide on how to do so.

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Ambulance service call handler and clinician identification of stroke in North East Ambulance Service

British Paramedic Journal ◽

10.29045/14784726.2021.09.6.2.59 ◽

2021 ◽

Vol 6 (2) ◽

pp. 59-65

Author(s):

Graham McClelland ◽

Emma Burrow

Keyword(s):

Acute Stroke ◽

Early Recognition ◽

Stroke Care ◽

Service Evaluation ◽

Ambulance Service ◽

Stroke Patients ◽

Face To Face ◽

North East ◽

Audit Data ◽

Suspected Stroke

Introduction: Emergency medical services (EMS) are the first point of contact for most acute stroke patients. The EMS response is triggered by ambulance call handlers who triage calls and then an appropriate response is allocated. Early recognition of stroke is vital to minimise the call to hospital time as the availability and effectiveness of reperfusion therapies are time dependent. Minimising the pre-hospital phase by accurate call handler stroke identification, short EMS on-scene times and rapid access to specialist stroke care is vital. The aims of this study were to evaluate stroke identification by call handlers and clinicians in North East Ambulance Service (NEAS) and report on-scene times for suspected stroke patients.Methods: A retrospective service evaluation was conducted linking routinely collected data between 1 and 30 November 2019 from three sources: NEAS Emergency Operations Centre; NEAS clinicians; and hospital stroke diagnoses.Results: The datasets were linked resulting in 2214 individual cases. Call handler identification of acute stroke was 51.5% (95% CI 45.3‐57.8) sensitive with a positive predictive value (PPV) of 12.8% (95% CI 11.4‐14.4). Face-to-face clinician identification of stroke was 76.1% (95% CI 70.4‐81.1) sensitive with a PPV of 27.4% (95% CI 25.3‐29.7). The median on-scene time was 33 (IQR 25‐43) minutes, with call handler and clinician identification of stroke resulting in shorter times.Conclusion: This service evaluation using ambulance data linked with national audit data showed that the sensitivity of NEAS call handler and clinician identification of stroke are similar to figures published on other systems but the PPV of call handler and clinician identification stroke could be improved. However, sensitivity is paramount while timely identification of suspected stroke patients and rapid transport to definitive care are the primary functions of EMS. Call handler identification of stroke appears to affect the time that clinicians spend at scene with suspected stroke patients.

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A Simple Fask Protocol as an Effective Screening Tool for Patients With Abdominal Distention

10.21203/rs.3.rs-52530/v1 ◽

2020 ◽

Author(s):

Wan-Ching Lien ◽

Jia-Yu Chen ◽

Pei-Hsiu Wang ◽

Dean-An Ling ◽

An-Fu Lee ◽

...

Keyword(s):

Predictive Value ◽

Screening Tool ◽

Point Of Care ◽

Abdominal Distention ◽

University Hospital ◽

Admission Diagnosis ◽

Point Of Care Ultrasound ◽

Effective Screening ◽

Critical Patients ◽

Sensitivity Specificity

Abstract Background: The retrospective study aimed to investigate the effect of point-of-care ultrasound (PoCUS) by a designated protocol for patients with abdominal distention.Methods: Non-traumatic adult patients with abdominal distention were included at the emergency department (ED) of the National Taiwan University Hospital between July 2015 and July 2017. A sonographic scanning protocol (FASK, the focused assessment with sonography in trauma plus the renal US) was included in the post-graduate year and residency US training. The primary outcome included the diagnostic accuracy of the FASK protocol. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the protocol were calculated that discharge/admission diagnosis was as the standard. The secondary outcomes included ED LOS and the rate of ED discharge using the FASK protocol.Results: A total of 512 patients were included. The accuracy of the FASK protocol was 99.0% (507/512), whatever the level of the performer. The sensitivity, specificity, PPV, and NPV were 99.4% (95% CIs, 98.2-99.9%), 100% (95% CIs, 100%), 99.6% (95% CIs, 98.6-100%), and 99% (95% CIs, 97.7-99.7%), respectively. 397 patients (78%) were discharged with the median LOS of 126 minutes (IQR, 84-236 minutes) after receiving PoCUS and proper management. PoCUS was performed approximately 3 hours earlier than CT (median, 179 minutes; IQR, 90-468 minutes; p<0.0001).Conclusions: A simple FASK protocol could be an effective screening tool for non-critical patients with abdominal distention. Being an adjunct of physical examination and management, PoCUS exhibited characteristics of efficacy, timeliness, and safety.Trial registration: NCT04149041 at ClinicalTrials.gov.

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The Accuracy of Point of Care Ultrasound Performed by Emergency Physicians in Detecting Hydronephrosis in Patients with Renal Colic

Sultan Qaboos University Medical Journal [SQUMJ] ◽

10.18295/squmj.9.2021.130 ◽

2021 ◽

Author(s):

Abdulaziz Al-Balushi ◽

Amal Al-Shibli ◽

Abdullah Al-Reesi ◽

Qazi Zia Ullah ◽

Waleed Al-Shukaili ◽

...

Keyword(s):

Likelihood Ratio ◽

Renal Colic ◽

Point Of Care ◽

Positive Likelihood Ratio ◽

Negative Likelihood Ratio ◽

University Hospital ◽

Point Of Care Ultrasound ◽

Diagnostic Study ◽

Adult Males ◽

Emergency Physicians

Objectives: to determine the accuracy of renal point of care ultrasound (POCUS) performed by emergency physicians in detecting hydronephrosis in patients with renal colic. Methods: We conducted a prospective cross-sectional diagnostic study at Sultan Qaboos University Hospital, emergency department (ED), from February 2017 to October 2018. All adult patients with suspected renal colic and who can give informed consent were included. The emergency physicians perform POCUS on both kidneys and graded hydronephrosis as none, mild, moderate, or severe cases. We compared POCUS grade to non-contrast computed tomography (NCCT) grade. Results: Three hundred and three participants were enrolled in the analysis. Most of the study population are adult males, 247 (81.5%), and the mean age is 39 years. Among the samples, 71.2% of patients had a degree of hydronephrosis based on CT findings. Ultrasound performed by emergency physicians had a sensitivity of 75.8% (95% CI: 69.5‒81.4), the specificity of 55.2% (95% CI: 44.1‒65.8), the positive likelihood ratio of 1.69 (95% CI: 1.32‒2.16), and negative likelihood ratio 0.43 (95% CI: 0.32‒0.59) for hydronephrosis using CT as the criterion standard. Conclusions: When evaluating patients with suspected renal colic, a bedside renal POCUS performed by emergency physicians (EP) has a moderate sensitivity to detect hydronephrosis and grade its severity. It should be utilized in the ED to screen patients for hydronephrosis. More training is required to improve the test's accuracy, as this might help as a screening tool in ED.Keywords: Hematuria; Hydronephrosis; Nephrolithiasis; Point-of-care testing; Renal colic; Ultrasonography.

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Letter to the editor: Acute Medicine Journal

Acute Medicine Journal ◽

10.52964/amja.0800 ◽

2020 ◽

Vol 19 (1) ◽

pp. 56-56

Author(s):

Adam Williamson ◽

Keyword(s):

Internal Medicine ◽

Point Of Care ◽

Training Programme ◽

Point Of Care Ultrasound ◽

Internal Medicine Training ◽

Acute Medicine ◽

Front Door ◽

Medicine Journal ◽

Wide Range ◽

Training Programmes

Editor- I note with interest that the Joint Royal College of Physicians Training Board curriculum for Acute Internal Medicine (AIM) has been reviewed and circulated for comment and consideration of implementation in August 2022. The proposed curriculum hopes to produce doctors with generic professional and specialty specific capabilities needed to manage patients presenting with a wide range of medical symptoms and conditions. It aims to produce a workforce that reflects the current trends of increasing patient attendances to bothprimary care and emergency departments- one that has a high level of diagnostic reasoning, the ability to manage uncertainty, deal with comorbidities and recognise when specialty input is require in a variety of settings, including ambulatory and critical care. The new curriculum moves away from each trainee being required to develop a specialist skill, such as medical education, echocardiography or endoscopy throughout their training1, to trainees acquiring competencies in a specialist theme for their final 24 to 30 months of their training programme after they have completed their Point of Care Ultrasound certification. The current curriculum allows trainees to have regular dedicated time to develop interests inside or outside acute medicine to supplement their professional experience and training. This often allows trainees time away from the ‘front door’, can be welcomed break from high intensity acute care and uniquely offers trainee physicians flexibility in their training programmes and curriculum requirements. This sets acute medicine training apart from other physician training programmes and can attract trainees to apply to the specialty. It also addresses Shape of Training recommendations, which suggest more flexibility and choice in career structure for postgraduate doctors.2 Point of Care Ultrasound will undoubtedly be a welcome addition to the curriculum and will benefit patients, trainees and front door services up and down the country.3 However, concerns regarding supervision and maintenance of competency exist.4 More importantly, time spent gaining competency in this before pursuing an interest in an additional area or procedure will offer trainees less time to attain accreditation in some of the existing specialist skills currently available. With ongoing concerns regarding recruitment and retention in Acute Internal Medicine5 we should be careful that we do not lose a unique selling point that acute internal medicine training offers.

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Research: Emergency medicine residents’ acquisition of point-of-care ultrasound knowledge and their satisfaction with the flipped classroom andragogy

POCUS Journal ◽

10.24908/pocus.v3i1.13301 ◽

2018 ◽

Vol 3 (1) ◽

pp. 2-5

Author(s):

Khalid Bashir, MD ◽

Aftab Azad, MD ◽

Kaleelullah Saleem Farook, MD ◽

Shahzad Anjum, MD ◽

Sameer Pathan, MD ◽

...

Keyword(s):

Emergency Medicine ◽

Flipped Classroom ◽

Teaching Method ◽

Point Of Care ◽

Teaching Model ◽

Point Of Care Ultrasound ◽

Post Intervention ◽

Face To Face ◽

Teaching Models ◽

The Difference

Background: One of the traditional approaches for knowledge transfer in medical education is through face-to-face (F2F) teaching. We aimed to evaluate the acquisition of knowledge about point-of-care ultrasound (POCUS) and learner’s satisfaction with the flipped classroom (FC) teaching approach. Methods: This was a prospective, mixed-method, crossover study and included 29 emergency medicine (EM) residents in current training program. Over a period of three months, each resident was exposed to F2F and FC teaching models in a crossover manner. There was a multiple-choice questions (MCQ) test before and after each educational intervention (F2F & FC). Two months after each educational intervention a final MCQ test was administered to assess the retention of knowledge between the two approaches. After each educational approach feedback was sought from a selected group of residents concerning the acceptability of the two educational approaches through a semi structured interview. Results: A total of 29 EM residents participated in this study. The numbers of residents by year of post-graduation training were seven (24.14%) PGY-1, eight (27.59%) PGY-2, six (20.69%) PGY-3, and eight (27.59%) PGY-4. The baseline mean score was 15.82 using MCQs test mean scores. For the face-to-face teaching model, the difference between pre and post-intervention scores was 2.7 (95% CI 2.1 to 3.3, p=0.001); whereas, for the flipped classroom teaching model, the difference was 3.93 (95% CI 3.2 to 4.5, p= 0.001). At two months post-intervention, for face-to-face teaching model, the MCQ assessment showed an increase of 1.7 (95% CI 1.1 to 2.2, p= 0.001) mean scores when compared to the pre-intervention mean scores; whereas, for the flipped classroom model this difference was significantly higher, recorded as 4.48 (95% CI 3.7 to 5.1, p= 0.001). Finally, the difference between mean scores for F2F and FC teaching models was 2.75 (95% CI 1.87 to 3.64, p=0.001) at two months post-intervention. Overall, the participants expressed a preference for the FC teaching methodology. Conclusion: Both F2F and FC teaching methods resulted in significant and sustained improvements in POCUS knowledge base. The FC teaching method accomplished higher test scores than the F2F teaching method both at the end of the teaching and after two months of completing the educational program.

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Echocardiography in the Intensive Care Unit: Current Position, Future Directions

Journal of the Intensive Care Society ◽

10.1177/175114371001100204 ◽

2010 ◽

Vol 11 (2) ◽

pp. 90-97 ◽

Cited By ~ 6

Author(s):

Craig Morris ◽

Sean Bennett ◽

Steven Burn ◽

Conn Russell ◽

Bob Jarman ◽

...

Keyword(s):

Point Of Care ◽

Training Programme ◽

British Society ◽

Point Of Care Ultrasound ◽

Current Position ◽

Future Directions ◽

Level Of Training ◽

National Training ◽

The Uk ◽

And Training

There are many indications for the use of echocardiography in the critically ill and little consensus about how best to provide training for intensivists in its use. There are a profusion of opinions, courses and accreditation pathways available for training in the UK. The National Point of Care Ultrasound working group aims to facilitate learning and training in both echocardiography and ultrasound. In this article, an intermediate level of training suitable for most general UK-based intensivists, that provides more depth than focused resuscitation-based protocols but less depth than British Society of Echocardiography accreditation pathways, is proposed which, if endorsed by Royal Colleges and specialist societies, could be developed into a viable national training programme within five years.

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