Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Variations in chest compression time, ventilation time and rescuers' heart rate during conventional cardiopulmonary resuscitation in trained male rescuers

OBJECTIVE: This study was conducted to determine why rescuers could maintain adequate chest compression depth for longer periods during conventional cardiopulmonary resuscitation (CPR).METHODS: Various CPR parameters, including average compression depth (ACD), average compression rate, average ventilation time (AVT), and rescuers’ heart rates were recorded in real-time when 20 health care providers performed 10 minutes of conventional CPR during a simulation experiment.RESULTS: The ACD was maintained above 50 mm and was not significantly different during 19 consecutive CPR cycles. The average compression rate increased from 114.9±10.0/min (2nd cycle) to 120.1±13.8/min (18th cycle) (P=0.007), and the AVT increased from 8.7±1.5 seconds (3rd cycle) to 10.1±2.6 seconds (18th cycle) (P=0.002). The rescuers’ heart rates also increased gradually for 10 min; however, they increased rapidly and were highest during the ventilation phase. Their heart rates then decreased and were lowest during the early chest compression phases of each CPR cycle. Decreases in heart rates were significant in all CPR cycles (average decrease: 14.5±4.5 beats/min, P<0.001).CONCLUSION: The ACD was maintained adequately during 10 minutes of conventional CPR. However, the AVT increased significantly during the 10-minute period. The rescuers’ heart rates increased and decreased throughout all CPR cycles. These results showed that the ventilation phase might play a role as a resting period and be a reason for the maintenance of adequate chest compression depth for prolonged periods during conventional CPR.

Which Fingers Should We Perform Two-Finger Chest Compression Technique with When Performing Cardiopulmonary Resuscitation on an Infant in Cardiac Arrest?

This study compared the effectiveness two-finger chest compression technique (TFCC) performed using the right vs. left hand and the index-middle vs. middle-ring fingers. Four different finger/hand combinations were tested randomly in 30 healthcare providers performing TFCC (Test 1: the right index-middle fingers; Test 2: the left index-middle fingers; Test 3: the right middle-ring fingers; Test 4: the left middle-ring fingers) using two cross-over trials. The "patient" was a 3-month-old-infant-sized manikin. Each experiment consisted of cardiopulmonary resuscitation (CPR) consisting of 2 minutes of 30:2 compression: ventilation performed by one rescuer on a manikin lying on the floor as if in cardiac arrest. Ventilations were performed using the mouth-to-mouth method. Compression and ventilation data were collected during the tests. The mean compression depth (MCD) was significantly greater in TFCC performed with the index-middle fingers than with the middle-ring fingers regardless of the hand (95% confidence intervals; right hand: 37.8-40.2 vs. 35.2-38.6 mm, P = 0.002; left hand: 36.9-39.2 vs. 35.5-38.1 mm, P = 0.003). A deeper MCD was achieved with the index-middle fingers of the right versus the left hand (P = 0.004). The ratio of sufficiently deep compressions showed the same patterns. There were no significant differences in the other data. The best performance of TFCC in simulated 30:2 compression: ventilation CPR performed by one rescuer on an infant in cardiac arrest lying on the floor was obtained using the index-middle fingers of the right hand. Clinical Trial Registry at the Clinical Research Information Service (KCT0001515).

Letter to the Editor: Chest Compression Rate, Rescuer's Fatigue and Patient's Survival

No abstract available.

Investigation of Emergency Department Violence: Resident Survey

PURPOSE: The Korean Intern Resident Association and Korean Society of Emergency Medicine announced the 'Hospital violence response system' to secure patient safety and provide a health care provider countermeasures against hospital violence. The aim of this study is to investigate the response to hospital violence in the ER and which measures could improve the current status. METHODS: Emergency medicine residents in the Seoul, Incheon, Kyung-gi area participated in the survey. The questionnaire included 4 categories (1. Awareness of protocol, 2. Experience and countermeasure for hospital violence, 3. Understanding of protocol, 4. Suggestions to improve against hospital violence) RESULTS: Among 362 candidates, 236 (65.2%) participated in the survey. Only 7.6% of residents have not experienced hospital violence. In the group of people who were aware of the protocol, participants tended to be more familiar with processes of the hospital violence response protocol, and willing to deal with violence using a better systematic support. People did not counteract to hospital violence because the process was thought to be too complicated. Only 63 participants were actively involved in an official course for countermeasure. Participants suggested that police should deal more appropriately with hospital violence. CONCLUSION: The hospital violence response protocol is thought to have a positive effect on appropriate management of hospital violence. However, a multi-disciplinary approach to hospital violence from the hospital, police, and judicial authority should be developed.

Changes of One-handed Chest Compression Qualities According to Rescuer Fatigue and the Effects of Alternating Hands in the Prehospital Setting: Prospective Randomized Pilot Study using Pediatric Manikin Simulation Trial

PURPOSE: One-handed chest compression (OHCC) technique is performed by one hand. Therefore chest compression (CC) depth might decrease rapidly. This study will evaluate the patterns of CC depth decaying in performing OHCC and assess the effects of alternating the hand which performs CC on the patterns of CC depth decaying. METHODS: This study was designed as a prospective randomized manikin simulation trial. Students of medical college participated. First, 10 students performed OHCC (chest compression:ventilation=30:2) in a pediatric manikin lying on a hard floor for 5 minutes (baseline study). After the baseline study, 32 students were recruited and randomized to group A and B. Group A performed OHCC with hand shift every other cycle (test 1). Group B performed OHCC with hand shift when they feel fatigue (test 2). The compression data were collected using the CPRmeter. The mean compression depths (MCD) were calculated at one minute intervals using the Q-CPR review software. The heart rates were monitored and the fatigue scales were collected every 1 minute. RESULTS: The MCD values were decreased significantly after 1 minute in the baseline study (p<0.05). However they were not changed in test 1 and decreased significantly after 4 minutes in test 2 (p<0.05). The heart rate and the fatigue scales were increased significantly with time in all tests (p<0.05). CONCLUSION: When OHCC was performed without shifting the hand which performed CC, the MCD decreased significantly after 1 minute. However, we could delay the time of decreasing MCD by shifting the hand which performed CC.

Effects of Counting Chest Compressions on the Performance of Cardiopulmonary Resuscitation: Prospective Randomized Pilot Study Using Manikin Simulation Trial

PURPOSE: This study compared the effects of counting chest compressions verbally and silently on the performance of cardiopulmonary resuscitation (CPR). METHODS: Forty-six medical students were enrolled in this study. After the participants performed a two-min CPR (Test 1), during which they counted each compression silently, they were divided randomly into Groups A and B. After a 30-min rest, the participants took Test 2. In Test 2, Group A performed two-min CPR, during which the participants counted the number of chest compressions verbally (Test 2A), and in Group B, CPR was performed using the same methods as detailed for Test 1 (i.e., with silent enumeration; Test 2B). Each student counted the number of chest compressions aloud from one to 30 in Test 2A. RESULTS: No significant differences were observed for either test (Tests 1 and 2) between Groups A and B. Although the mean compression rate (MCR) was increased significantly from 107.2+/-15.4 to 116.3+/-15.9/min between Tests 1 and 2B in Group B (p<0.01), a similar result was also obtained in Group A. In the individual interviews conducted with the Group A participants, all members reported having difficulty breathing while counting the number of chest compressions verbally when compared with silent enumeration. CONCLUSION: Tallying the numbers of chest compressions verbally did not significantly alter the performance of CPR.

Effects of Audio Tone Guidance on Performance of Positive-pressure Ventilation using a Bag-valve Device

PURPOSE: The 2010 guidelines for cardiopulmonary resuscitation recommend a ventilation rate of 8 to 10/min for patients with an advanced airway; however, hyperventilation occurs in most cases. This study was conducted as an attempt to determine the effects of feedback under audio tone guidance on performance of positive-pressure ventilation using a bag-valve device and to apply this technique in clinical practice in order to reduce hyperventilation. METHODS: A total of 36 seniors at our medical school participated in the study. After receiving instruction in performance of positive-pressure ventilation using a bag-valve device, they performed ventilation using a cardiac arrest model with an advanced airway (Test 1). After they took Test 1 without any feedback, they were randomly assigned to the feedback group (Group A) and the control group (Group B) and took Test 2. In Group A, a high-pitched sound was delivered every 7 s for guidance of ventilation. RESULTS: In Group A, ventilation rate approximated feedback rate, whereas, in Group B, it showed a significant decrease, from 8.3+/-2.0 to 7.7+/-2.0/min (p<0.01). The mean ventilation volume did not differ between pre- and post-feedback. The mean inspiration time showed a decrease in both groups. However, no significant difference in mean inspiration time was observed between the two groups. CONCLUSION: Audio tone guidance can control the ventilation rate accurately without any significant change in ventilation volume and inspiration time.

The Effectiveness of a Repeatedly Checked Alvarado Score as a Screening Tool for Acute Appendicitis

PURPOSE: Acute appendicitis is one of the more challenging disease entities to diagnose. Early and correct diagnosis is necessary to decrease morbidity and mortality. The diagnosis of acute appendicitis does not depend on a single modality because it is often difficult and the symptoms of appendicitis can change with time. The Alvarado score is a sensitive and specific tool for diagnosis of appendicitis. But the effectiveness of a single Alvarado score for diagnosis of acute appendicitis can be less meaningful due to diagnostic difficulties. The purpose of this study was to evaluate the usefulness of repeatedly checked Alvarado scores in acute abdomen patients as a diagnostic tool for acute appendicitis. METHODS: A total of 196 patents who visited our ER with acute abdominal pain between March 2008 and February 2009 were enrolled. Emergency physicians checked the initial Alvarado score and re-checked that score after 3 hours of observation. We prospectively compared the results between (a) the initial and the 3 hours Alvarado scores and (b) the final pathology. RESULTS: We measured diagnostic for the initial Alvarado score and the 3 hours Alvarado score groups. The sensitivities of the two groups for detecting appendcitis were 85.1% and 92.0%, respectively; specificities were 81.6% and 89.0%; positive predictive values were 78.7% and 87.0%; negative predictive values were 87.3% and 93.3%; accuracy scores were 83.2% and 90.3%. All diagnostic values of the 3 hours Alvarado score group were superior to those of the initial Alvarado score group. CONCLUSION: Repeatedly checked Alvarado scores provides a superior diagnostic accuracy to the initial Alvarado score alone. Thus, we can say that repeatedly checked 3 hours Alvarado scores are more useful for diagnosing acute appendicitis than an initial, one-time checking of the Alvarado score. This new scoring system will be particularly useful to physicians who are working in health care facilities where computerized tomography or ultra-sonography is not available.

Traumatic Rupture of Hepatocellular Carcinoma

A 45-year-old man presented at the emergency department with severe whole abdominal pain. He was struck on the abdomen by a soccer ball in the soccer game 12 hours ago. Initial vital signs were unstable, but stabilized soon after fluid resuscitation. CT scans were performed to diagnose injury to the intraabdominal organs. CT scans showed hemoperitoneum and rupture of hepatocellular carcinoma (HCC). Transarterial chemoembolization and catheter drainage were performed. He was discharged on the 22th day. Rupture of HCC is mostly occurred in the advanced stage of HCC, but very rarely happened after abdominal trauma. Treatment of choice for traumatic rupture of HCC was not established yet. In our case, the patient was cured by transarterial chemoembolization without laparotomy. Considering that the treatment for traumatic liver injury is supportive care or laparotomy, emergency physician should remember that traumatic rupture of HCC also can cause hemoperitoneum after abdominal trauma.

A Case of Omental Infarct with Right Lower Quadrant Pain

A 56-year-old man was transferred to the emergency department complaining of right lower quadrant pain of 3 days duration. The Maximal tender area was the slightly upper part of the abdomen up to McBurney's point. We ordered CT to evaluate for several disease such as appendicitis, diverticulitis and primary epiploic appendagitis, and the patient was diagnosed with omental infarct based on the CT finding. After five days of supportive care, the symptoms were resolved. Omental infarct is a rare cause of acute abdominal pain, which is often misdiagnosed as acute appendicitis when it presents with right lower quadrant pain. Although surgical resection is required in severe cases, most cases are successfully managed with supportive treatment. The emergency physician should consider omental infarct as a differential diagnosis in patients with right lower quadrant pain.