Evaluation of Adherence to Emergency Department Point-of-Care Ultrasound Documentation and Billing Following Intervention.

Background: Over the past few years, both the scope and utility of point-of-care ultrasound (POCUS) have tremendously expanded in the clinical setting. Despite this growth, few studies have evaluated the compliance, documentation, and billing of POCUS in the emergency department (ED). The objective of this study was to evaluate the compliance of billing and documentation of POCUS and determine if a single, individualized e-mail feedback can help improve billing and documentation. Methods: We performed a 6-week prospective review of ED POCUSs performed. Following this review, all emergency physicians were sent an individualized e-mail regarding their ultrasound performance including the total number of ultrasounds, ultrasounds per shift, and breakdown of specific ultrasound types. Following this intervention, we collected data from an additional 6 weeks regarding ultrasound billing performance. Results: A total of 1532 POCUS scans were recorded for data collection. Eight hundred and five scans were enrolled in the preintervention group and 727 scans in the postintervention group. Twelve different types of POCUS scans were recorded. The preintervention group had documented 484/805 scans resulting in a 60.1% (confidence interval [CI] 56.7%-63.5%) documentation ratio. The postintervention group had documented 521/727 resulting in a 71.7% (CI 68.2%-74.9%) documentation ratio. Conclusion: The implementation of timely quality assurance with continuous billing reminders is essential for the maintenance and fiscal sustainability of an emergency medicine ultrasound program. Future studies should further elucidate and quantify the financial impact of modifiable factors within EDs' ultrasound documentation and billing practices.

Application of Point-of-care Ultrasound for Screening Climbers at High Altitude for Pulmonary B-lines.

INTRODUCTION: High-altitude pulmonary edema (HAPE) occurs as a result of rapid ascent to altitude faster than the acclimatization processes of the body. Symptoms can begin at an elevation of 2,500 meters above sea level. Our objective in this study was to determine the prevalence and trend of developing B-lines at 2,745 meters above sea level among healthy visitors over four consecutive days. METHODS: We performed a prospective case series on healthy volunteers at Mammoth Mountain, CA, USA. Subjects underwent pulmonary ultrasound for B-lines over four consecutive days. RESULTS: We enrolled 21 male and 21 female participants. There was an increase in the sum of B-lines at both lung bases from day 1 to day 3, with a subsequent decrease from day 3 to day 4(P<0.001). By the third day at altitude, B-lines were detectable at base of lungs of all participants. Similarly, B-lines increased at apex of lungs from day 1 to day 3 and decreased on day 4 (P=0.004). CONCLUSION: By the third day at 2,745 meters altitude, B-lines were detectable in the bases of both lungs of all healthy participants in our study. We assume that increasing the number of B-lines could be considered an early sign of HAPE. Point-of-care ultrasound could be used to detect and monitor B-lines at altitude to facilitate early detection of HAPE, regardless of pre-existing risk factors.

A Case Report on Detecting Porcelain Gallbladder form Wall-Echo-Shadow Sign on Point-of-Care Ultrasound.

Point-of-Care Ultrasound (POCUS) is a rapidly growing means of accelerated diagnosis for various conditions. This case report demonstrates POCUS use to differentiate porcelain gallbladder (PGB) from wall-echo-shadow (WES) sign. A 75-year-old female presented for evaluation of elevated liver function tests (LFTs). Upon arrival, she had no acute complaints with unremarkable vital signs, aside from elevated blood pressure of 155/79 mmHg. Review of LFTs demonstrated elevation of total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP). Physical examination and review of systems were unremarkable. POCUS revealed common bile duct dilatation with cholelithiasis and sludge. While these findings may be confused with a WES sign, POCUS also revealed a hyperechoic gallbladder wall (GBW) with shadowing and irregular clumps of echo. The hyperechoic GBW with irregular shadowing heightened the suspicion for PGB. Computed tomography scan confirmed the presence of PGB. The patient had a stent placed near the common hepatic duct stricture and was advised to return for cholecystectomy. She was readmitted three months later due to bacteremia, likely caused by gallbladder obstruction in the setting of gallbladder cancer. Point of care ultrasound can be used to identify PGB. Because PGB has been associated with gallbladder carcinoma, prompt diagnosis is vital in early and aggressive treatment. In this case report, we demonstrate a reliable method in properly diagnosing PGB through POCUS. Topics: Point-of-care ultrasound, ultrasound, porcelain gallbladder, WES sign, wall-echo-shadow sign.

A Case Report on Distinguishing Emphysematous Pyelitis and Pyelonephritis on Point-of-care Ultrasound.

INTRODUCTION: Point-of-care ultrasound (POCUS) in the emergency department (ED) is being performed with increasing frequency. The objective of this study was to demonstrate how utilization of POCUS can help the emergency physician recognize emphysematous pyelitis (EP) and emphysematous pyelonephritis (EPN). CASE REPORT: A 60-year-old female presented to the ED with normal vital signs and intermittent left-sided flank pain that radiated to her groin. She also had a history of obstructive nephrolithiasis. Within 20 minutes of arrival she became febrile (101.2°Fahrenheit), tachycardic (114 beats per minute), tachypneic (21 breaths per minute), and had a blood pressure of 114/82 millimeters mercury. POCUS was conducted revealing heterogeneous artifact with "dirty shadowing" within the renal pelvis, which was strongly suggestive of air. The emergency physician ordered a computed tomography (CT) to confirm the suspicion for EP and started the patient on broad-spectrum antibiotics. The CT showed a 1.3-centimeter calculus and hydronephrosis with foci of air. The patient received intravenous antibiotics and had an emergent nephrostomy tube placed. Urine cultures tested positive for pan-sensitive Escherichia Coli. Urology was consulted and a repeat CT was obtained to show correct drainage and decreased renal pelvis dilation. CONCLUSION: Distinctly different forms of treatment are used for EP and EPN, despite both having similar pathophysiology. In EP, air can be seen in the renal pelvis on POCUS, as in this case study, which distinguishes it from EPN. In the case of our patient, the use of POCUS was useful to aid in rapid differentiation between EP and EPN.