A Tool to Assess Competence in Critical Care Ultrasound Based on Entrustable Professional Activities.

Background: Existing assessment tools for competence in critical care ultrasound (CCUS) have limited scope and interrupt clinical workflow. The framework of entrustable professional activities (EPAs) is well suited to developing an assessment tool that is comprehensive and readily integrated into the intensive care unit (ICU) training environment. Objective: This study sought to design an EPA-based tool to assess competence in CCUS for pulmonary and critical care fellows and to assess the validity and reliability of the tool. Methods: Eight experts in CCUS met to define the core EPAs for CCUS. A nominal group technique was used to reach consensus. An assessment tool was created based on the EPAs with a modified Ottawa entrustability scale. Trained faculty evaluated pulmonary and critical care fellows using this tool in the ICU over a 6-month study period at a single institution. An assessment of validity of the EPA-based tool is made with four sources of validity evidence: content, response process, reliability, and relation to other variables. Reliability and response process data were generated using generalizability theory analysis to estimate sources of variance in entrustment scores. Analysis of response process validity and validity by relation to other variables was performed using regression models. Results: Fifty-four assessments were recorded during the study period, conducted on 23 trainees by 13 faculty. Content validity of the tool was demonstrated using expert consensus and published guidelines from critical care societies to define the EPAs. Response process validity was demonstrated by the low variance in entrustment scores due to evaluators (0.086 or 6%) and high agreement between score and trainee self-assessment (regression coefficient, 0.82; P < 0.0001). Reliability was demonstrated by the high "true" variance in entrustment score attributable to the trainee: 0.674 or 45%. Validity by relation to other variables was demonstrated using regression analysis to show correlation between entrustment score and the number of times a fellow has performed an EPA (regression coefficient, 0.023; P < 0.0001). Conclusion: An EPA-based assessment tool for competence in CCUS was created. We obtained sufficient validity evidence on three of the diagnostic EPAs. Procedural EPAs were infrequently assessed, limiting generalizability in this subgroup.

A consensus list of ultrasound competencies for graduating emergency medicine residents.

Objectives: Emergency ultrasound (EUS) is a critical component of emergency medicine (EM) resident education. Currently, there is no consensus list of competencies for EUS training, and graduating residents have varying levels of skill and comfort. The objective of this study was to define a widely accepted comprehensive list of EUS competencies for graduating EM residents through a modified Delphi method. Methods: We developed a list of EUS applications through a comprehensive literature search, the American College of Emergency Physicians list of core EUS benchmarks, and the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound consensus document. We assembled a multi-institutional expert panel including 15 faculty members from diverse practice environments and geographical regions. The panel voted on the list of competencies through two rounds of a modified Delphi process using a modified Likert scale (1 = not at all important, 5 = very important) to determine levels of agreement for each application-with revisions occurring between the two rounds. High agreement for consensus was set at >80%. Results: Fifteen of 15 panelists completed the first-round survey (100%) that included 359 topics related to EUS. After the first round, 195 applications achieved high agreement, four applications achieved medium agreement, and 164 applications achieved low agreement. After the discussion, we removed three questions and added 13 questions. Fifteen of 15 panelists completed the second round of the survey (100%) with 209 of the 369 applications achieving consensus. Conclusion: Our final list represents expert opinion on EUS competencies for graduating EM residents. We hope to use this consensus list to implement a more consistent EUS curriculum for graduating EM residents and to standardize EUS training across EM residency programs.

Implementation of an Electronic Health Record Integrated Clinical Pathway Improves Adherence to COVID-19 Hospital Care Guidelines.

BACKGROUND: During the COVID-19 pandemic, frequently changing guidelines presented challenges to emergency department (ED) clinicians. The authors implemented an electronic health record (EHR)-integrated clinical pathway that could be accessed by clinicians within existing workflows when caring for patients under investigation (PUI) for COVID-19. The objective was to examine the association between clinical pathway utilization and adherence to institutional best practice treatment recommendations for COVID-19. METHODS: The authors conducted an observational analysis of all ED patients seen in a health system inclusive of seven EDs between March 18, 2020, and April 20, 2021. They implemented the pathway as an interactive flow chart that allowed clinicians to place orders while viewing the most up-to-date institutional guidance. Primary outcomes were proportion of admitted PUIs receiving dexamethasone and aspirin in the ED, and secondary outcome was time to delivering treatment. RESULTS: A total of 13 269 patients were admitted PUIs. The pathway was used by 40.6% of ED clinicians. When clinicians used the pathway, patients were more likely to be prescribed aspirin (OR, 7.15; 95% CI, 6.2-8.26) and dexamethasone (10.4; 8.85-12.2). For secondary outcomes, clinicians using the pathway had statistically significant ( P < 0.0001) improvement in timeliness of ordering medications and admission to the hospital. Aspirin, dexamethasone, and admission order time were improved by 103.89, 94.34, and 121.94 minutes, respectively. CONCLUSIONS: The use of an EHR-integrated clinical pathway improved clinician adherence to changing COVID-19 treatment guidelines and timeliness to associated medication administration. As pathways continue to be implemented, their effects on improving patient outcomes and decreasing disparities in patient care should be further examined.

A Distance-Learning Approach to Point-of-Care Ultrasound Training (ADAPT): A Multi-Institutional Educational Response During the COVID-19 Pandemic.

PROBLEM: The COVID-19 pandemic significantly disrupted point-of-care ultrasound (POCUS) education. Medical schools and residency programs placed restrictions on bedside teaching and clinical scanning as part of risk mitigation. In response, POCUS faculty from 15 institutions nationwide collaborated on an alternative model of ultrasound education, A Distance-learning Approach to POCUS Training (ADAPT). APPROACH: ADAPT was repeated monthly from April 1 through June 30, 2020. It accommodated 70 learners, who included 1- to 4-week rotators and asynchronous learners. The curriculum included assigned prework and learning objectives covering 20 core POCUS topics. A rotating group of 30 faculty and fellows delivered daily virtual teaching sessions that included gamification to increase learner engagement and hands-on instruction through teleguidance. After participation, faculty and learners completed anonymous surveys. OUTCOMES: Educators reported a significant decrease in preparatory time (6.2 vs 3.1 hours per week, P < .001) dedicated to ultrasound education after implementing ADAPT. The majority of 29 learners who completed surveys felt "somewhat confident" or "very confident" in their ability to acquire (n = 25, 86.2%) and interpret (n = 27, 93.1%) ultrasound images after the intervention; the majority of 22 educators completing surveys rated the program "somewhat effective" or "very effective" at contributing to learner's ability to acquire (n = 13, 59.1%) and interpret (n = 20, 90.9%) images. Most learners (n = 28, 96.6%) and all educators (n = 22, 100%) were "satisfied" or "very satisfied" with ADAPT as a whole, and the large majority of educators were "very likely" (n = 18, 81.8%) to recommend continued use of this program. NEXT STEPS: A virtual curriculum that pools the efforts of multiple institutions nationwide was implemented rapidly and effectively while satisfying educational expectations of both learners and faculty. This collaborative framework can be replicated and may be generalizable to other educational objectives.

Paramedic-performed Prehospital Point-of-care Ultrasound for Patients with Undifferentiated Dyspnea: A Pilot Study.

INTRODUCTION: Thoracic ultrasound is frequently used in the emergency department (ED) to determine the etiology of dyspnea, yet its use is not widespread in the prehospital setting. We sought to investigate the feasibility and diagnostic performance of paramedic acquisition and assessment of thoracic ultrasound images in the prehospital environment, specifically for the detection of B-lines in congestive heart failure (CHF). METHODS: This was a prospective observational study of a convenience sample of adult patients with a chief complaint of dyspnea. Paramedics participated in a didactic and hands-on session instructing them how to use a portable ultrasound device. Paramedics assessed patients for the presence of B-lines. Sensitivity and specificity for the presence of bilateral B-lines and any B-lines were calculated based on discharge diagnosis. Clips archived to the ultrasound units were reviewed and paramedic interpretations were compared to expert sonologist interpretations. RESULTS: A total of 63 paramedics completed both didactic and hands-on training, and 22 performed ultrasounds in the field. There were 65 patients with B-line findings recorded and a discharge diagnosis for analysis. The presence of bilateral B-lines for diagnosis of CHF yielded a sensitivity of 80.0% (95% confidence interval [CI], 51.4-94.7%) and specificity of 72.0% (95% CI, 57.3-83.3), while presence of any B-lines was 93.3% sensitive (95% CI, 66.0-99.7%), and 50% specific (95% CI, 35.7-64.2%) for CHF. Paramedics archived 117 ultrasound clips of which 63% were determined to be adequate for interpretation. Comparison of paramedic and expert sonologist interpretation of images showed good inter-rater agreement for detection of any B-lines (k = 0.60; 95% CI, 0.36-0.84). CONCLUSION: This observational pilot study suggests that prehospital lung ultrasound for B-lines may aid in identifying or excluding CHF as a cause of dyspnea. The presence of bilateral B-lines as determined by paramedics is reasonably sensitive and specific for the diagnosis of CHF and pulmonary edema, while the absence of B lines is likely to exclude significant decompensated heart failure. The study was limited by being a convenience sample and highlighted some of the difficulties related to prehospital research. Larger funded trials will be needed to provide more definitive data.

Deep Learning-Based Automated Echocardiographic Quantification of Left Ventricular Ejection Fraction: A Point-of-Care Solution.

BACKGROUND: We have recently tested an automated machine-learning algorithm that quantifies left ventricular (LV) ejection fraction (EF) from guidelines-recommended apical views. However, in the point-of-care (POC) setting, apical 2-chamber views are often difficult to obtain, limiting the usefulness of this approach. Since most POC physicians often rely on visual assessment of apical 4-chamber and parasternal long-axis views, our algorithm was adapted to use either one of these 3 views or any combination. This study aimed to (1) test the accuracy of these automated estimates; (2) determine whether they could be used to accurately classify LV function. METHODS: Reference EF was obtained using conventional biplane measurements by experienced echocardiographers. In protocol 1, we used echocardiographic images from 166 clinical examinations. Both automated and reference EF values were used to categorize LV function as hyperdynamic (EF>73%), normal (53%-73%), mildly-to-moderately (30%-52%), or severely reduced (<30%). Additionally, LV function was visually estimated for each view by 10 experienced physicians. Accuracy of the detection of reduced LV function (EF<53%) by the automated classification and physicians' interpretation was assessed against the reference classification. In protocol 2, we tested the new machine-learning algorithm in the POC setting on images acquired by nurses using a portable imaging system. RESULTS: Protocol 1: the agreement with the reference EF values was good (intraclass correlation, 0.86-0.95), with biases <2%. Machine-learning classification of LV function showed similar accuracy to that by physicians in most views, with only 10% to 15% cases where it was less accurate. Protocol 2: the agreement with the reference values was excellent (intraclass correlation=0.84) with a minimal bias of 2.5±6.4%. CONCLUSIONS: The new machine-learning algorithm allows accurate automated evaluation of LV function from echocardiographic views commonly used in the POC setting. This approach will enable more POC personnel to accurately assess LV function.

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.

Trends in Diagnostic Point-of-Care Ultrasonography Reimbursement for Medicare Beneficiaries Among the US Emergency Medicine Workforce, 2012 to 2016.

STUDY OBJECTIVE: Point-of-care ultrasonography allows rapid diagnosis in the emergency department. A previous study found that a low prevalence of emergency medicine clinicians received point-of-care ultrasonography reimbursement in 2012 (0.7%). We determine nationwide point-of-care ultrasonography reimbursement patterns for 4 subsequent years. METHODS: We performed a cross-sectional study using 2012 to 2016 data from the Centers for Medicare & Medicaid Fee-for-Service Provider Utilization and Payment Data Part B, defining point-of-care ultrasonographic examinations using Current Procedural Terminology codes. The emergency medicine workforce was defined by emergency medicine, family medicine, internal medicine, critical care, and advanced practice providers who received emergency medicine-specific reimbursements. We compared patterns of point-of-care ultrasonography reimbursement among emergency physicians in 2012 versus 2016 through a 2-sample test of proportions. RESULTS: In 2012, 342 (0.7% of total) emergency medicine workforce clinicians were reimbursed for diagnostic point-of-care ultrasonography versus 801 (1.3%) in 2016. Emergency physicians represented an increasing proportion of the total workforce, increasing from 86.0% (95% confidence interval 82.3% to 89.6%) in 2012 (N=294) to 94.6% (95% confidence interval 93.1% to 96.2%) in 2016 (N=758). From 2012 to 2016, total point-of-care ultrasonography reimbursements increased from 13,697 to 31,717, with significant growth from echocardiograms (4,127 to 14,978), abdominal examinations (3,682 to 7,140), and thoracic examinations (801 to 5,278). CONCLUSION: The proportion of emergency medicine workforce clinicians receiving diagnostic point-of-care ultrasonography reimbursements, as well as the number of point-of-care ultrasonographic studies, more than doubled from 2012 to 2016. Efforts are needed to understand barriers to adoption of point-of-care ultrasonography because only a small proportion of the emergency medicine clinician workforce was reimbursed in any year.

Guiding Cardiopulmonary Resuscitation with Focused Echocardiography: A Report of Five Cases.

Background: Focused transthoracic echocardiography has been used to determine etiologies of cardiac arrest and evaluate utility of continuing resuscitation after cardiac arrest. Few guidelines exist advising ultrasound timing within the advanced cardiac life support algorithm. Natural timing of echocardiography occurs during the pulse check, when views are unencumbered by stabilization equipment or vigorous movements. However, recent studies suggest that ultrasound performance during pulse checks prolongs the pause duration of cardiopulmonary resuscitation. Transesophageal echocardiography studies have demonstrated benefits in this regard, but there have been no transthoracic echocardiography studies assessing the physical performance of compressions during cardiopulmonary resuscitation. Objective: The purpose of this study was to describe cases where echocardiography performed at the beginning of the cardiac arrest algorithm offers actionable information to cardiopulmonary resuscitation itself without delaying provision of compressions. Conclusion: Providers using focused echocardiography to evaluate cardiac arrest patients should consider initiating scans at the start of compressions to identify the optimal location for compression delivery and to detect inadequate compressions. Subsequent visualization of full left ventricular compression may be seen after a location change, and combined with end tidal carbon dioxide values, gives indication for improved forward circulatory flow. Although it is not possible in all patients, doing so hastens provision of quality compressions that affect hemodynamic parameters without causing prolongations to the pulse check pause. Further research is needed to determine patient outcomes from both out-of-hospital and in-hospital cardiac arrest when cardiopulmonary resuscitation is visually guided by focused echocardiography.

Point-of-Care Ultrasound: Does it Affect Scores on Standardized Assessment Tests Used Within the Preclinical Curriculum?

OBJECTIVES: An increasing number of medical schools are incorporating point-of-care ultrasound (POCUS) into preclinical and clinical curricula. The ultimate effect of this teaching is unclear, and there has been no distinct link between ultrasound (US) learning and existing standardized student assessments. Additionally, neither optimal timing nor methods of POCUS integration have been established. We aimed to demonstrate the effect of US teaching on standardized objective assessments that already exist within the curriculum and, in doing so, discern a route for POCUS curricular integration. METHODS: A longitudinal POCUS pilot curriculum was started in 2013, with the class of 2017. We collected basic science course results, standardized objective structured clinical examination scores, and United States Medical Licensing Examination step 1 scores from both the pilot group (n = 34) and matched control participants (n = 34) from the classes of 2017 and 2018. Scores between POCUS students and controls were analyzed by Student t tests. RESULTS: Students participating in the longitudinal POCUS program scored significantly higher on the physical examination portion of their clinical skill objective structured clinical examination assessment than the control group (mean score, 89.2 versus 85.7; P < .05). This parameter was the only area with a statistically significant difference. CONCLUSIONS: Point-of-care US program implementation may improve students' overall physical examination understanding and performance, even when US performance itself is not being tested. Introducing a POCUS curriculum may work best when designed in conjunction with the physical examination thread of a medical school curriculum.

SonoGames: Effect of an Innovative Competitive Game on the Education, Perception, and Use of Point-of-Care Ultrasound.

OBJECTIVES: Gamification is a powerful tool in medical education. SonoGames is a competitive games-based event designed to educate and inspire emergency medicine (EM) residents about point-of-care ultrasound. We sought to describe: (1) the perceived effectiveness of a competitive event on both immediate learning and long-term education; and (2) the resultant attitudes of participants and program directors regarding ultrasound training. METHODS: The SonoGames Organizational Committee designed 2 surveys: 1 for SonoGames V EM resident participants and a second for EM program directors. Survey questions used a 5-point Likert scale to assess overall perceptions and attitudes about ultrasound, changes in self-reported content knowledge and competency, effects on clinical use, and perceived impacts of a competitive game format on education. RESULTS: Seventy-three resident participants and 42 program directors responded to the survey. Ninety-four percent of participants thought that the competitive gaming format of SonoGames was effective in making the event an educational experience. Participants reported that their ultrasound knowledge increased (81%), their enthusiasm for ultrasound increased (87%), and their clinical use of ultrasound increased (61%). Residency program directors reported similar increases to a lesser degree. Greater advancement through the event was associated with more positive responses. Residencies that participated in the event saw greater increases in the use of ultrasound by residents than those that did not. CONCLUSIONS: A competitive games-based educational event focused on point-of-care ultrasound is an effective educational tool. SonoGames increases EM residents' knowledge, enthusiasm, and clinical use of ultrasound both during and after the event.