The Frequency of POCUS in the Treatment of Sepsis in the Emergency Department: A Retrospective Cohort Study.

Background: Point of care ultrasound (POCUS) is ubiquitous in the modern emergency department (ED). POCUS can be helpful in the management of patients with sepsis in many ways including determining the cause of sepsis, assessing fluid status, guiding resuscitation, and performing procedures. However, the frequency and manner in which POCUS is incorporated into the care of septic patients in community emergency medicine remains unclear. Objective: To evaluate POCUS frequency and exam types used in the care of patients with sepsis in two community EDs in Southern California. Methods: We performed a retrospective analysis of 5,264 ED visits with a diagnosis of sepsis at two community emergency departments between January 2014 and December 2018. Patients 18 years or older who were diagnosed with sepsis and had either lactate ≥ 4 mmol, a documented mean arterial pressure (MAP) < 65 mmHg, or a systolic blood pressure (SBP) < 90 mmHg were included. Charts were reviewed to determine if POCUS was used during the ED evaluation. Primary outcomes were frequency of POCUS use in the cohort, change in POCUS use over the study period, and the types of exams performed. Results: POCUS was used in 21% of encounters meeting inclusion criteria and was positively correlated with ED arrival year (OR = 1.09; CI 1.04, 1.15; p=0.001). The most common POCUS exam was ultrasound-guided central line placement, with the next most common exams being cardiac, followed by inferior vena cava (IVC). Only the frequency of cardiac, IVC, lung and Focused Assessment with Sonography in Trauma (FAST) exams were found to increase significantly over the study period. Conclusions: Total POCUS use increased significantly in this cohort of septic patients over the study period due to more cardiac, IVC, lung and FAST exams being performed.

Standardizing evaluation of patient-specific 3D printed models in surgical planning: development of a cross-disciplinary survey tool for physician and trainee feedback.

BACKGROUND: 3D printed models are becoming increasingly popular in healthcare as visual and tactile tools to enhance understanding of anatomy and pathology in medical trainee education, provide procedural simulation training, and guide surgical procedures. Patient-specific 3D models are currently being used preoperatively for trainee medical education in planning surgical approaches and intraoperatively to guide decision-making in several specialties. Our study group utilized a modified Delphi process to create a standardized assessment for trainees using patient-specific 3D models as a tool in medical education during pre-surgical planning. METHODS: A literature review was conducted to identify survey questions administered to clinicians in published surgical planning studies regarding the use of patient-specific 3D models. A core study team reviewed these questions, removed duplicates, categorized them, mapped them to overarching themes, and, where applicable, modified individual questions into a form generalizable across surgical specialties. The core study panel included a physician, physician-scientist, social scientist, engineer/medical student, and 3D printing lab manager. A modified Delphi process was then used to solicit feedback on the clarity and relevance of the individual questions from an expert panel consisting of 12 physicians from specialties including anesthesiology, emergency medicine, radiology, urology, otolaryngology, and obstetrics/gynecology. When the Radiological Society of North America (RSNA)/American College of Radiology (ACR) 3D Printing Registry Data Dictionary was released, additional survey questions were reviewed. A final cross-disciplinary survey of the utility of 3D printed models in surgical planning medical education was developed. RESULTS: The literature review identified 100 questions previously published in surveys assessing patient-specific 3D models for surgical planning. Following the review, generalization, and mapping of survey questions from these studies, a list of 24 questions was generated for review by the expert study team. Five additional questions were identified in the RSNA/ACR 3D Printing Registry Data Dictionary and included for review. A final questionnaire consisting of 20 questions was developed. CONCLUSIONS: As 3D printed models become more common in medical education, the need for standardized assessment is increasingly essential. The standardized questionnaire developed in this study reflects the interests of a variety of stakeholders in patient-specific 3D models across disciplines.

Curriculum Development by Design Thinking: Analyzing a Program for Social Determinants of Health Screening by Pre-Clerkship Medical Students.

PROBLEM: Health systems science (HSS) curricula in medical schools facilitate an understanding of social determinants of health (SDOH) and their impact on health outcomes. After implementation of an experiential, patient-centered program based around SDOH screening, however, our medical college noted poor student receptivity and engagement. In order to improve the program, we chose a design thinking approach based on the perceived value of actively engaging learners in the design of education. The role of design thinking in curricular quality improvement, however, remains unclear. INTERVENTION: We sought to determine if a current educational model for SDOH screening could be improved by reforming the curriculum using a design thinking workshop involving student and faculty stakeholders. CONTEXT: The current study is a retrospective analysis of first-year medical student, end-of-year evaluations of the Clinical Experience (CE) program at the Sidney Kimmel Medical College before (2018-19) and after (2019-20) implementation of the design thinking workshop and subsequent curriculum changes. IMPACT: Overall positive results significantly increased across all survey questions after the curricular intervention (p < 0.01), indicating increased student satisfaction with the revised curriculum. LESSONS LEARNED: Few studies assess outcomes of design thinking-driven curricular changes. The current study of an SDOH screening program details the implementation of initiatives that originated from a design thinking sprint and assesses program evaluations following these curricular changes. Most of the well-received curricular changes concerned improvements in student training, patient screening and follow-up, and the leveraging of existing technology. The study reinforces the importance of co-creation among stakeholders when redesigning medical curricula.

The impact of COVID-19 on the sensitivity of D-dimer for pulmonary embolism.

OBJECTIVE: This study seeks to evaluate the test characteristics of D-dimer for pulmonary embolism (PE) in patients with a concurrent diagnosis of COVID-19. We hypothesized that the sensitivity of D-dimer for PE at current institutional cut points would be similar to those without COVID-19. METHODS: This is a multicenter retrospective observational cohort study across five urban and suburban EDs in the same health care system. The electronic health record was queried for all computed tomography pulmonary angiography (CTPA) studies from December 1, 2019, to October 22, 2020. All ED patients who underwent CTPA had D-dimer and COVID-19 testing completed in a single encounter were included in the study. Baseline demographics were obtained. Test characteristics of D-dimer for PE were calculated for patients with and without COVID-19. Additionally, receiver operator characteristics (ROC) curves were constructed for two different D-dimer assays. RESULTS: There were 1158 patient encounters that met criteria for analysis. Performance of D-dimer testing for PE was similar between COVID-19-positive and -negative patients. In COVID-19-positive patients, the sensitivity was 100% (95% confidence interval [CI] = 87.6%-100%), specificity was 11.9% (95% CI = 7.9%-17.1%), and negative predictive value (NPV) was 100%. In COVID-19-negative patients the sensitivity was 97.6% (95% CI = 91.5%-99.7%), specificity was 14.4% (95% CI = 12.1%-17%), and NPV was 98.3% (95% CI = 93.8%-99.6%). For assay 1 the area under the curve (AUC) for COVID-19-positive patients was 0.76 (95% CI = 0.68-0.83), and for COVID-19-negative patients, 0.73 (95% CI = 0.69-0.77). For assay 2, AUC for COVID-19-positive patients was 0.85 (95% CI = 0.77-0.92), and for COVID-19-negative patients, 0.80 (95% CI = 0.77-0.84). Inspection of the ROC curve for assay 1 revealed that 100% sensitivity was maintained up to a threshold of 0.67 FEU (fibrinogen equivalent units; from 0.50 FEU) with an increase in specificity to 29% (from 18.7%), and for assay 2, 100% sensitivity was maintained up to a threshold of 662 D-dimer units (DDU; from 230 DDU) with an increased specificity to 59% (from 6.1%). CONCLUSION: Results from this multicenter retrospective study did not find a significant difference in sensitivity of D-dimer for PE due to concomitant COVID-19 infection. Further study is required to determine if PE can safely be excluded based on D-dimer results alone in patients with suspected or proven COVID-19 or if adjusted D-dimer levels could have a role in management.

Point-of-Care Ultrasound in the Evaluation of COVID-19.

BACKGROUND: The novel coronavirus SARS-CoV-2 has caused a pandemic, overwhelming health care systems around the world. Hospitals around the world, including the United States, have been struggling to adapt to the influx of patients with COVID-19, the illness caused by SARS-CoV2, given limited resources and high demand for medical care. OBJECTIVES: This article seeks to provide emergency physicians with a guide to sonographic findings in COVID-19 and an algorithm by which point-of-care lung ultrasound may assist emergency physicians caring for these patients during the SARS-CoV-2 pandemic. DISCUSSION: The studies currently being published have established a typical set of ultrasound findings in COVID-19. Point-of-care lung ultrasound is rapid and accessible in most emergency departments in the United States, and even in many resource-poor settings. CONCLUSION: Point-of-care ultrasound provides numerous benefits to emergency providers caring for patients with COVID-19, including decreasing resource utilization, assisting in diagnosis, guiding management of the critically ill patient, and aiding in rapid triage of patients under investigations for COVID-19.

Relationship of the Built Environment on Nursing Communication Patterns in the Emergency Department: A Task Performance and Analysis Time Study.

INTRODUCTION: The physical layout of the emergency department affects the way in which patients and providers move within the space and can cause substantial changes in workflow and, therefore, affect communication patterns between providers. There is no 1 ED design that enables the best patient care, and quantitative studies looking at ED design are limited. The goal of this study was to examine how different ED designs, centralized and decentralized, are associated with communication patterns among health care professionals. METHODS: A task performance, direct observation time study was used. By developing a novel tablet-based digital mapping tool using a cloud-based mapping platform (ArcGIS), data on provider actions and interactions were collected and mapped to a precise location within the emergency department throughout an entire nursing shift. RESULTS: The difference in the duration of nurse-physician interactions between the 2 ED designs was statistically significant. Within the centralized design, nurse-physician interactions totaled 14 minutes and 38 seconds compared with 30 minutes and 11 seconds in the decentralized design (t = 2.31, P = 0.02). More conversations between nurses and physicians occurred inside the patient's room in the decentralized design. DISCUSSION: Our findings suggest that the ED design affects communication patterns among health care providers and that the design has the potential to affect the quality of patient care.

Carotid Ultrasound to Predict Fluid Responsiveness: A Systematic Review.

OBJECTIVES: To perform a systematic review of the accuracy of carotid ultrasound measures in determining volume responsiveness in adults. METHODS: We conducted a systematic review of Ovid MEDLINE and Scopus from conception until January 1, 2019. Two independent reviewers used an iterative process to identify relevant articles and abstract information from them. The quality and risk of bias were assessed with the Quality Assessment of Diagnostic Accuracy Studies version 2 tool. RESULTS: We identified 17 relevant articles with 956 patients. The 2 most frequently cited carotid measures of fluid responsiveness were corrected flow time and peak velocity or change in peak velocity with respiration (ΔCDPV). Accordingly, the diagnostic characteristics of corrected flow time in these studies varied widely, with sensitivities from 60% to 73%, specificities from 82% to 92%, and areas under the receiver operating characteristic curves from 0.75 to 0.88. Optimal cutoff values for ΔCDPV ranged from 9.1% to 14%, with areas under the receiver operating characteristic curves from 0.81 to 0.91, sensitivities from 73% to 86%, and specificities from 78% to 86%. Other measures, such as carotid blood flow and carotid diameter, had limited data to support their use. Heterogeneity of the studies prohibited a meta-analysis. Most studies had a moderate risk of bias and high applicability. CONCLUSIONS: Preliminary research suggests that carotid ultrasound measures may be useful adjunct measures of fluid status; however, they should not be interpreted as absolute and should be placed in a clinical context. The most well-defined and supported measure currently is ΔCDPV, with cutoffs from 9% to 14%. Corrected flow time shows promise, because of heterogeneity of how this value is measured, an optimal cutoff has not been established.

Ultrasonography in Undergraduate Medical Education: A Systematic Review.

OBJECTIVES: The purpose of this study was to conduct a systematic review of the evidence of educational outcomes associated with teaching ultrasonography (US) to medical students. METHODS: A review of databases through 2016 was conducted for research studies that reported data on teaching US to medical students. Each title and abstract were reviewed by teams of 2 independent abstractors to determine whether the article would be ordered for full-text review and subsequently by 2 independent authors for inclusion. Data were abstracted with a form developed a priori by the authors. RESULTS: Ninety-five relevant unique articles were included (of 6936 identified in the databases). Survey data showed that students enjoyed the US courses and desired more US training. Of the studies that assessed US-related knowledge and skill, most of the results were either positive (16 of 25 for knowledge and 24 of 58 for skill) or lacked a control (8 of 25 for knowledge and 27 of 58 for skill). The limited evidence (14 of 95 studies) of the effect of US training on non-US knowledge and skill (eg, anatomy knowledge or physical examination skill) was mixed. CONCLUSIONS: There is ample evidence that students can learn US knowledge and skills and that they enjoy and want US training in medical school. The evidence for the effect of US on external outcomes is limited, and there is insufficient evidence to recommend it for this purpose at this time.

Transthoracic Echocardiography for Diagnosing Pulmonary Embolism: A Systematic Review and Meta-Analysis.

OBJECTIVE: Pulmonary embolism (PE) is a common diagnosis with significant mortality if not appropriately treated. The use of transthoracic echocardiography in patients with PE is common; however, its diagnostic capabilities in this use are unclear. With the increased use of ultrasonography in medical settings, it is important to understand the strengths and limitations of echocardiography for the diagnosis of PE. METHODS: We conducted a systematic review of PubMed, CINAHL, and EMBASE through 2016 for articles assessing the diagnostic accuracy of transthoracic echocardiography for PE. Two authors independently abstracted relevant data from the studies. We assessed quality using the QUADAS-2 tool for diagnostic studies. RESULTS: Undefined "right heart strain" was the most common sign used, and it had a sensitivity of 53% (95% CI, 45%-61%) and a specificity of 83% (95% CI, 74%-90%). Eleven other distinct signs were identified: ventricle size ratio, abnormal septal motion, tricuspid regurgitation, 60/60 sign, McConnell's sign, right heart thrombus, right ventricle hypokinesis, pulmonary hypertension, right ventricular end-diastolic diameter, tricuspid annular plane systolic excursion, and right ventricular systolic pressure. CONCLUSIONS: Studies show a consistently high specificity and low sensitivity for echocardiography in the diagnosis of PE, making it potentially adequate as a rule-in test at the bedside in critical care settings such as the emergency department and intensive care unit for patients with a suspicion of PE, especially those unable to get other confirmatory studies. Future research may continue to clarify the role of bedside echocardiography in conjunction with other tests and imaging in the overall management of PE.

Emergency Medicine Resident Assessment of the Emergency Ultrasound Milestones and Current Training Recommendations.

OBJECTIVES: Emergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment. METHODS: This study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents. RESULTS: There were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM. CONCLUSIONS: EM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.

Ultrasound measurement of inferior vena cava collapse predicts propofol-induced hypotension.

STUDY OBJECTIVES: Hypotension is a common side effect of propofol, but there are no reliable methods to determine which patients are at risk for significant propofol-induced hypotension (PIH). Ultrasound has been used to estimate volume status by visualization of inferior vena cava (IVC) collapse. This study explores whether IVC assessment by ultrasound can assist in predicting which patients may experience significant hypotension. METHODS: This was a prospective observational study conducted in the operating suite of an urban community hospital. A convenience sample of consenting adults planned to receive propofol for induction of anesthesia during scheduled surgical procedures were enrolled. Bedside ultrasound was used to measure maximum (IVCmax) and minimum (IVCmin) IVC diameters. IVC-CI was calculated as [(IVCmax-IVCmin)/IVCmax × 100%]. The primary outcome was significant hypotension defined as systolic blood pressure (BP) below 90mmHg and/or administration of a vasopressor to increase BP during surgery. RESULTS: The study sample comprised 40 patients who met inclusion criteria. Mean age was 55years, (95%CI, 49-60) with 53% female. 55% of patients had significant hypotension after propofol administration. 76% of patients with IVC-CI≥50% had significant hypotension compared to 39% with IVC-CI<50%, P=.02. IVC-CI≥50% had a specificity of 77.27% (95%CI, 64.29%-90.26%) and sensitivity of 66.67% (95%CI, 52.06%-81.28%) in predicting PIH. The odds ratio for PIH in patients with IVC-CI≥50% was 6.9 (95%CI, 1.7-27.5). CONCLUSION: Patients with IVC-CI≥50% were more likely to develop significant hypotension from propofol. IVC ultrasound may be a useful tool to predict which patients are at increased risk for PIH.

The ability of renal ultrasound and ureteral jet evaluation to predict 30-day outcomes in patients with suspected nephrolithiasis.

STUDY OBJECTIVE: We sought to identify findings on bedside renal ultrasound that predicted need for hospitalization in patients with suspected nephrolithiasis. METHODS: A convenience sample of patients with suspected nephrolithiasis was prospectively enrolled and underwent bedside ultrasound of the kidneys and bladder to determine the presence and degree of hydronephrosis and ureteral jets. Sonologists were blinded to any other laboratory and imaging data. Patients were followed up at 30 days by phone call and review of medical records. RESULTS: Seventy-seven patients with suspected renal colic were included in the analysis. Thirteen patients were admitted. Reasons for admission included intractable pain, infection, or emergent urologic intervention. All 13 patients requiring admission had hydronephrosis present on initial bedside ultrasound. Patients with moderate hydronephrosis had a higher admission rate (36%) than those with mild hydronephrosis (24%), P<.01. Of patients without hydronephrosis, none required admission within 30 days. The sensitivity and specificity of hydronephrosis for predicting subsequent hospitalization were 100% and 44%, respectively. Loss of the ipsilateral ureteral jet was not significantly associated with subsequent hospital admission and did not improve the predictive value when used in combination with the degree of hydronephrosis. CONCLUSIONS: No patients with suspected renal colic and absence of hydronephrosis on bedside ultrasound required admission within 30 days. Ureteral jet evaluation did not help in prediction of 30-day outcomes and may not be useful in the emergency department management of renal colic.

Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis.

OBJECTIVES: Open wounds with the potential for retained foreign bodies are frequently seen in the emergency department (ED). Common foreign bodies, such as wood or glass, are often missed on physical examination and conventional radiography. The increased use of ultrasonography (US) in the ED presents an opportunity to better identify retained soft tissue foreign bodies, and understanding of its test characteristics is desirable. The authors set out to determine the test characteristics of US for detection of soft tissue foreign bodies by performing a systematic review and meta-analysis of the existing literature. METHODS: This was a thorough, systematic review of OVID Medline, SCOPUS, and Cochrane databases and a limited review of Directory of Open Access Journals, Google Scholar, and ClinicalTrials.gov to identify clinical studies examining the diagnostic accuracy of US in the identification of retained soft tissue foreign bodies. Studies were selected for full-text review by two independent reviewers to determine if they met inclusion criteria. Results were pooled for test characteristics using STATA and assessed for risk of bias and applicability using the QUADAS-2 tool. RESULTS: This systematic search strategy identified 5,059 unique articles, and 17 articles met inclusion criteria. Pooled sensitivity and specificity were, respectively, 72% (95% confidence interval [CI] = 57% to 83%) and 92% (95% CI = 88% to 95%). Overall quality of the studies was low and interstudy heterogeneity was high (I(2)  = 90%, 95% CI = 80% to 100%). CONCLUSIONS: Ultrasonography is highly specific and moderately sensitive in the identification of retained soft tissue foreign bodies; however, studies to date have a high degree of heterogeneity and a high risk of bias.