When to incorporate point-of-care ultrasound (POCUS) into the initial assessment of acutely ill patients: a pilot crossover study to compare 2 POCUS-assisted simulation protocols.

BACKGROUND: The purpose of this study was to determine the ideal timing for providers to perform point-of-care ultrasound (POCUS) with the least increase in workload. METHODS: We conducted a pilot crossover study to compare 2 POCUS-assisted evaluation protocols for acutely ill patients: sequential (physical examination followed by POCUS) vs parallel (POCUS at the time of physical examination). Participants were randomly assigned to 2 groups according to which POCUS-assisted protocol (sequential vs parallel) was used during simulated scenarios. Subsequently, the groups were crossed over to complete assessment by using the other POCUS-assisted protocol in the same patient scenarios. Providers' workloads, measured with the National Aeronautics and Space Administration Task Load Index (NASA-TLX) and time to complete patient evaluation, were compared between the 2 protocols. RESULTS: Seven providers completed 14 assessments (7 sequential and 7 parallel). The median (IQR) total NASA-TLX score was 30 (30-50) in the sequential and 55 (50-65) in the parallel protocol (P = .03), which suggests a significantly lower workload in the sequential protocol. When individual components of the NASA-TLX score were evaluated, mental demand and frustration level were significantly lower in the sequential than in the parallel protocol (40 [IQR, 30-60] vs 50 [IQR, 40-70]; P = .03 and 25 [IQR, 20-35] vs 60 [IQR, 45-85]; P = .02, respectively). The time needed to complete the assessment was similar between the sequential and parallel protocols (8.7 [IQR, 6-9] minutes vs 10.1 [IQR, 7-11] minutes, respectively; P = .30). CONCLUSIONS: A sequential POCUS-assisted protocol posed less workload to POCUS operators than the parallel protocol.

Improving Diagnostic Fidelity: An Approach to Standardizing the Process in Patients With Emerging Critical Illness.

OBJECTIVE: To reliably improve diagnostic fidelity and identify delays using a standardized approach applied to the electronic medical records of patients with emerging critical illness. PATIENTS AND METHODS: This retrospective observational study at Mayo Clinic, Rochester, Minnesota, conducted June 1, 2016, to June 30, 2017, used a standard operating procedure applied to electronic medical records to identify variations in diagnostic fidelity and/or delay in adult patients with a rapid response team evaluation, at risk for critical illness. Multivariate logistic regression analysis identified predictors and compared outcomes for those with and without varying diagnostic fidelity and/or delay. RESULTS: The sample included 130 patients. Median age was 65 years (interquartile range, 56-76 years), and 47.0% (52 of 130) were women. Clinically significant diagnostic error or delay was agreed in 23 (17.7%) patients (κ=0.57; 95% CI, 0.40-0.74). Median age was 65.4 years (interquartile range, 60.3-74.8) and 9 of the 23 (30.1%) were female. Of those with diagnostic error or delay, 60.9% (14 of 23) died in the hospital compared with 19.6% (21 of 107) without; P<.001. Diagnostic error or delay was associated with higher Charlson comorbidity index score, cardiac arrest triage score, and do not intubate/do not resuscitate status. Adjusting for age, do not intubate/do not resuscitate status, and Charlson comorbidity index score, diagnostic error or delay was associated with increased mortality; odds ratio, 5.7; 95% CI, 2.0-17.8. CONCLUSION: Diagnostic errors or delays can be reliably identified and are associated with higher comorbidity burden and increased mortality.