Use of ultrasound guidance for central venous catheter placement: survey from the American Board of Emergency Medicine Longitudinal Study of Emergency Physicians.

OBJECTIVES: The objective was to survey practicing emergency physicians (EPs) across the United States regarding the frequency of using ultrasound (US) guidance in central venous catheter (CVC) placement and, secondarily, to determine factors associated with the use or barriers to the use of US guidance. METHODS: This was a cross-sectional survey mailed to presumed practicing EPs as part of the American Board of Emergency Medicine (ABEM)'s longitudinal study of EPs. The selection process used stratified, random sampling of cohorts thought to represent four different stages within the development of the specialty of emergency medicine (EM). Multivariable logistic regression was used to identify independent factors associated with both high comfort using US guidance and high-percentage usage of US guidance. RESULTS: The survey was mailed to 1,165 subjects, and the response rate was 79%. The median number of years of practice was 20 (interquartile range [IQR]=7 to 28 years). As their primary practice setting, 64% work in private or community hospitals, 60% received training in US-guided vascular access, and 44% never use US guidance in placing CVCs. Barriers differed in those who never use US and those who sometimes or always used US guidance. In those who never use US, top barriers were insufficient training (67%) and lack of equipment (25%). In those who use US, top barriers were the perceptions that US was too time-consuming (27%) and that the preferred site was not amenable to US (24%). Independent factors associated with high comfort and high-percentage use of US guidance were training in US-guided vascular access (adjusted odds ratio=5.1 [high comfort]; 95% confidence interval [CI]=2.6 to 10.1; adjusted odds ratio 11.1=(high percentage); 95% CI=5.0 to 24.8) and being a recent residency graduate. CONCLUSIONS: Among EPs, the translation of evidence to clinical practice regarding the benefits of US guidance for CVC placement is poor and still faces many barriers. Training and education are potentially the best ways to overcome such barriers.

E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction.

OBJECTIVES: Rapid assessment of left ventricular ejection fraction (LVEF) may be critical among emergency department (ED) patients. This study examined the predictive relationship between ED physician performed bedside mitral-valve E-point septal separation (EPSS) measurements to the quantitative, calculated LVEF. We further evaluated the relationship between ED physician visual estimates of global cardiac function (GCF) and calculated LVEF values. METHODS: A prospective observational study was conducted on a sequential convenience sample of patients receiving comprehensive transthoracic echocardiography (TTE). Three ED ultrasound fellows performed bedside ultrasound examinations to obtain both EPSS measurements and subjective visual GCF estimates. A linear regression analysis was conducted to examine the relation of EPSS to the calculated LVEF from the comprehensive TTE. Agreement (modified Cohen κ) between ED ultrasound fellow GCF estimates and the calculated LVEF was also assessed. RESULTS: Linear regression analyses revealed a significant correlation (r=0.73, P<.001) between bedside EPSS and the calculated LVEF. The sensitivity and specificity of an EPSS measurement of greater than 7 mm for severe systolic dysfunction (LVEF≤30%) were 100.0% (95% confidence interval, 62.9-100.0) and 51.6% (95% confidence interval, 38.6-64.5), respectively. Subjective estimates of GCF were moderately correlated with calculated LVEF (Cohen κ=0.58). CONCLUSIONS: Measurements of EPSS by ED physicians were significantly associated with the calculated measurements of LVEF from comprehensive TTE. Subjective visual estimates of GCF, however, demonstrated only moderate agreement with the calculated LVEF. An EPSS measurement greater than 7 mm was uniformly sensitive at identifying patients with severely reduced LVEF.