Improved diagnostic accuracy of pathology with the implementation of a perioperative point-of-care ultrasound service: quality improvement initiative

IntroductionThe utility of perioperative point-of-care ultrasound (P-POCUS) is rapidly growing. The successful implementation of a comprehensive P-POCUS curriculum, Focused PeriOperative Risk Evaluation Sonography Involving Gastro-abdominal, Hemodynamic, and Trans-thoracic Ultrasound (FORESIGHT), has been demonstrated. This project sought to further evaluate the utility of P-POCUS with the following aims: (1) to assess the ability to train the FORESIGHT curriculum via a free, open-access, online platform; (2) to launch a P-POCUS clinical service as a quality improvement (QI) initiative; (3) to evaluate the diagnostic accuracy of the P-POCUS examinations to formal diagnostic studies; and (4) to compare the P-POCUS diagnostic accuracy with the diagnostic accuracy of traditional assessment (TA).MethodsThis study was launched as a QI project for the implementation of a P-POCUS service. A group of attending and resident anesthesiologists completed P-POCUS training supported by an online curriculum. After training, a P-POCUS service was launched. The P-POCUS service was available for any perioperative event, and specific triggers were also identified. All examinations were documented on a validated datasheet. The diagnostic accuracy of the two index tests, P-POCUS and TA, were compared with formal diagnostic testing. TA was defined as a combination of the anesthesiologist’s bedside assessment and physical examination. The primary outcome marker was a comparison in the accuracy of new diagnosis detected by P-POCUS service versus the TA performed by the primary anesthesiologist.ResultsA total of 686 P-POCUS examinations were performed with 466 examinations having formal diagnostic studies for comparison. Of these, 92 examinations were detected as having new diagnoses. Performance for detection of a new diagnosis demonstrated a statistically higher sensitivity for the P-POCUS examinations (p<0.0001). Performance comparison of all P-POCUS examinations that were matched to formal diagnostic studies (n=466) also demonstrated a significantly higher sensitivity. These findings were consistent across cardiovascular, pulmonary and abdominal P-POCUS categories (p<0.01). Additionally, multiple pathologies demonstrated complete agreement between the P-POCUS examination and the formal study.ConclusionA P-POCUS service can be developed after training facilitated by an online curriculum. P-POCUS examinations can be performed by anesthesiologists with a high degree of accuracy to formal studies, which is superior to TA.

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Usefulness of point-of-care ultrasound in military medical emergencies performed by young military medicine residents

Journal of the Royal Army Medical Corps ◽

10.1136/jramc-2018-001132 ◽

2019 ◽

pp. jramc-2018-001132

Author(s):

Pierre Perrier ◽

J Leyral ◽

O Thabouillot ◽

D Papeix ◽

G Comat ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Clinical Examination ◽

Point Of Care ◽

Military Medicine ◽

Final Diagnosis ◽

Absolute Difference ◽

Point Of Care Ultrasound ◽

Medical Emergencies ◽

The Mean ◽

A Prospective Study

IntroductionTo evaluate the usefulness of point-of-care ultrasound (POCUS) performed by young military medicine residents after short training in the diagnosis of medical emergencies.MethodsA prospective study was performed in the emergency department of a French army teaching hospital. Two young military medicine residents received ultrasound training focused on gall bladder, kidneys and lower limb veins. After clinical examination, they assigned a ‘clinicaldiagnostic probability’ (CP) on a visual analogue scale from 0 (definitely not diagnosis) to 10 (definitive diagnosis). The same student performed ultrasound examination and assigned an ‘ultrasounddiagnostic probability’ (UP) in the same way. The absolute difference between CP and UP was calculated. This result corresponded to the Ultrasound Diagnostic Index (UDI), which was positive if UP was closer to the final diagnosis than CP (POCUS improved the diagnostic accuracy), and negative conversely (POCUS decreased the diagnostic accuracy).ResultsForty-eight patients were included and 48 ultrasound examinations were performed. The present pathologies were found in 14 patients (29%). The mean UDI value was +3 (0–5). UDI was positive in 35 exams (73%), zero in 12 exams (25%) and negative in only one exam (2%).ConclusionPOCUS performed after clinical examination increases the diagnostic accuracy of young military medicine residents.

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Point-of-care ultrasound modalities in terms of diagnosing acute decompensated heart failure in emergency department; a diagnostic accuracy study

Internal and Emergency Medicine ◽

10.1007/s11739-019-02233-x ◽

2019 ◽

Vol 15 (3) ◽

pp. 491-499 ◽

Cited By ~ 1

Author(s):

Shervin Farahmand ◽

Ali Abdolhoseini ◽

Ehsan Aliniagerdroudbari ◽

Sepideh Babaniamansour ◽

Alireza Baratloo ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Diagnostic Accuracy ◽

Acute Decompensated Heart Failure ◽

Point Of Care ◽

Decompensated Heart Failure ◽

Point Of Care Ultrasound ◽

Diagnostic Accuracy Study ◽

Accuracy Study

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Diagnostic accuracy of point-of-care knee ultrasound for evaluation of meniscus and collateral ligaments pathology in comparison with MRI

Acta Radiologica ◽

10.1177/02841851211058280 ◽

2021 ◽

pp. 028418512110582

Author(s):

Ahmed Elshimy ◽

Ahmed M Osman ◽

Mohamed El Sayed Awad ◽

Mohamed M Abdel Aziz

Keyword(s):

Diagnostic Accuracy ◽

Predictive Value ◽

Point Of Care ◽

Operative Procedure ◽

Point Of Care Ultrasound ◽

Collateral Ligaments ◽

Collateral Ligament ◽

Diagnostic Modality ◽

Cross Sectional ◽

Portable Ultrasonography

Background Although magnetic resonance imaging (MRI) is often the “gold standard” for diagnosing knee problems, it has many limitations. Therefore, ultrasonography has been suggested as an effective rapid alternative in many knee abnormalities, especially after injuries of the meniscus and collateral ligaments. Purpose To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) in detecting injuries of the meniscus and collateral ligament compared to MRI. Material and Methods An observational cross-sectional blinded study was conducted of 60 patients with clinically suspicious meniscus and collateral ligament injuries who were planned for an arthroscopy and or operative procedure. These patients underwent both blinded POCUS and MRI of the knees before the intervention procedure and results of both imaging modalities were compared according to the operative and arthroscopic findings. Results The preoperative reliability of POCUS compared to MRI for the assessment of meniscus injuries was sensitivity (92.9% vs. 90.5%), specificity (88.9% vs. 83.3%), positive predictive value (PPV; 95.1% vs. 92.7%), negative predictive value (NPV; 84.2% vs. 79%), and overall accuracy (91.7% vs. 88.3%). However, for diagnosing collateral ligament injures, POCUS versus MRI assessed sensitivity (92.3% vs. 88.5%), specificity (100% vs. 97.1%), PPV (100% vs. 95.8%), NPV (94.4% vs. 91.7%), and overall accuracy (96.7% vs. 93.3%). Conclusion Ultrasonography is a useful screening tool for the initial diagnosis of meniscal and collateral ligament pathology compared to or even with potential advantages over MRI, especially when MRI is unavailable or contraindicated. As newly advanced portable ultrasonography becomes available, it could be considered as a point-of-injury diagnostic modality.

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Do combined ultrasound and electrocardiogram-rhythm findings predict survival in emergency department cardiac arrest patients? The Second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED2) study

CJEM ◽

10.1017/cem.2019.397 ◽

2019 ◽

Vol 21 (6) ◽

pp. 739-743 ◽

Cited By ~ 1

Author(s):

Nicole Beckett ◽

Paul Atkinson ◽

Jacqueline Fraser ◽

Ankona Banerjee ◽

James French ◽

...

Keyword(s):

Emergency Department ◽

Cardiac Arrest ◽

Hospital Discharge ◽

Point Of Care ◽

Cardiac Activity ◽

Pulseless Electrical Activity ◽

Spontaneous Circulation ◽

Point Of Care Ultrasound ◽

Electrocardiogram Ecg ◽

Higher Sensitivity

ABSTRACTObjectivesPoint-of-care ultrasound (POCUS) is used increasingly during resuscitation. The aim of this study was to assess whether combining POCUS and electrocardiogram (ECG) rhythm findings better predicts outcomes during cardiopulmonary resuscitation in the emergency department (ED).MethodsWe completed a health records review on ED cardiac arrest patients who underwent POCUS. Primary outcome measurements included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge.ResultsPOCUS was performed on 180 patients; 45 patients (25.0%; 19.2%–31.8%) demonstrated cardiac activity on initial ECG, and 21 (11.7%; 7.7%–17.2%) had cardiac activity on initial POCUS; 47 patients (26.1%; 20.2%–33.0%) achieved ROSC, 18 (10.0%; 6.3%–15.3%) survived to admission, and 3 (1.7%; 0.3%–5.0%) survived to hospital discharge. As a predictor of failure to achieve ROSC, ECG had a sensitivity of 82.7% (95% CI 75.2%–88.7%) and a specificity of 46.8% (32.1%–61.9%). Overall, POCUS had a higher sensitivity of 96.2% (91.4%–98.8%) but a similar specificity of 34.0% (20.9%–49.3%). In patients with ECG-asystole, POCUS had a sensitivity of 98.18% (93.59%–99.78%) and a specificity of 16.00% (4.54%–36.08%). In patients with pulseless electrical activity, POCUS had a sensitivity of 86.96% (66.41%–97.22%) and a specificity of 54.55% (32.21%–75.61%). Similar patterns were seen for survival to admission and discharge. Only 0.8% (0.0–4.7%) of patients with ECG-asystole and standstill on POCUS survived to hospital discharge.ConclusionThe absence of cardiac activity on POCUS, or on both ECG and POCUS together, better predicts negative outcomes in cardiac arrest than ECG alone. No test reliably predicted survival.

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Point of Care Ultrasound (POCUS) Training in an Internal Medicine Residency Program - A Quality Improvement Initiative

10.1164/ajrccm-conference.2020.201.1_meetingabstracts.a1420 ◽

2020 ◽

Author(s):

R.P. Manglani ◽

A. Kofahi ◽

K. Nada ◽

M. Kasubhai

Keyword(s):

Internal Medicine ◽

Quality Improvement ◽

Residency Program ◽

Point Of Care ◽

Internal Medicine Residency ◽

Quality Improvement Initiative ◽

Point Of Care Ultrasound ◽

Internal Medicine Residency Program

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LO22: Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHoC-ED investigators

CJEM ◽

10.1017/cem.2019.65 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S15

Author(s):

P. Atkinson ◽

M. Peach ◽

S. Hunter ◽

A. Kanji ◽

L. Taylor ◽

...

Keyword(s):

Cardiogenic Shock ◽

Diagnostic Accuracy ◽

Diagnostic Performance ◽

Primary Outcome ◽

Point Of Care ◽

Statistical Tests ◽

Controlled Study ◽

Point Of Care Ultrasound ◽

Randomized Controlled ◽

Significant Difference

Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.

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Simple Pneumonia or Something More?: A Case Report and Discussion of Unexpected Empyema Identified by Point-of-Care Ultrasound

CJEM ◽

10.1017/cem.2015.71 ◽

2015 ◽

Vol 18 (5) ◽

pp. 391-394

Author(s):

Michael Romano ◽

Tomislav Jelic ◽

Jordan Chenkin

Keyword(s):

Emergency Department ◽

Point Of Care ◽

Fluid Collection ◽

Chest Ct ◽

Point Of Care Ultrasound ◽

X Ray ◽

Level Of Consciousness ◽

Chest X Ray ◽

Ultrasound Assessment ◽

Higher Sensitivity

AbstractThere is evidence to suggest that point-of-care ultrasound assessment of the lungs has a higher sensitivity and specificity than chest radiography for the diagnosis of pneumonia. It is unknown if the same is true for pneumonia complications. We present and discuss the case of a 61-year-old woman who presented to the emergency department with confusion, decreased level of consciousness, and signs of sepsis. A chest x-ray revealed a right sided infiltrate. An ultrasound of the patient’s lungs was performed, and revealed a complex loculated fluid collection consistent with an empyema. A chest CT confirmed the diagnosis, and immediate percutaneous drainage was performed.

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P041: Accuracy of medical student-performed point-of-care ultrasound in the diagnosis of distal radius fractures in adults

CJEM ◽

10.1017/cem.2016.217 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S92-S92

Author(s):

L. Farnell ◽

A.K. Hall ◽

C. McKaigney

Keyword(s):

Medical Students ◽

Diagnostic Accuracy ◽

Distal Radius ◽

Point Of Care ◽

Distal Radius Fractures ◽

Point Of Care Ultrasound ◽

Radiographic Imaging ◽

Radius Fractures ◽

Wide Range ◽

Test Probability

Introduction: Previous investigations of the diagnostic accuracy of point-of-care ultrasound (POCUS) in distal radius fractures (DRF) report a wide range of sensitivities (71%-98%) and specificities (73%-100%) when performed by medical professionals, which may reflect inconsistencies in POCUS training or sonographer experience. The purpose of this study was to determine the accuracy of POCUS performed by pre-clerkship medical students with minimal POCUS training compared to standard radiography in diagnosing DRF in adult patients with traumatic wrist injuries, in order to assess POCUS as an alternative to traditional radiographic imaging. Methods: This prospective observational study was conducted from June to September 2015. The study population consisted of adults presenting to the emergency department (ED) with distal forearm pain secondary to traumatic injury within the past seven days and for whom radiographic imaging was ordered. Patients were evaluated using POCUS performed by medical students with no prior experience who had received one hour of POCUS training taught by an emergency ultrasound fellowship-trained ED physician. A pre-test probability of fracture was stratified as low or high and documented independently by the treating physician. Students were blinded to pre-test probability and radiography results. Results: Of the 52 patients enrolled, 18 had DRF diagnosed by radiographic imaging. Compared to radiography, student-performed POCUS had 72% overall sensitivity (95% CI, 47%-90%) and 85% specificity (95% CI, 69%-95%), with 81% overall accuracy. In the high pre-test probability group (N = 20), POCUS had 80% sensitivity (95% CI, 52%-96%) and 60% specificity (95% CI, 15%-95%). In the low pre-test probability group (N = 32), POCUS had 33% sensitivity (95% CI, 1%-91%) and 90% specificity (95% CI, 73%-98%). Conclusion: POCUS performed by medical students demonstrated reasonable success in diagnosing DRF, with overall sensitivity and specificity in keeping with published data. Within the low pre-test probability group, the diagnostic accuracy of POCUS suggests that ultrasound was an unreliable alternative to radiographic imaging for DRF in this cohort. Future analysis of the factors leading to DRF missed by POCUS as being related to adequacy of POCUS training, image capture, or sonographer experience will further explore the utility of POCUS as a diagnostic alternative.

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