Development of a Focused Cardiac Ultrasound Image Acquisition Assessment Tool.

Background: Focused cardiac ultrasound (FCU) is widely used by healthcare providers to answer specific questions about cardiac structure and function at the bedside. Currently, no widely accepted FCU image acquisition checklist exists to assess learners with varying skill levels from different specialties. Objective: The primary objective of this project was to develop a consensus-based FCU image acquisition checklist using a multispecialty group of point-of-care ultrasound (POCUS) experts. Methods: The essential components of an FCU examination were identified on the basis of published recommendations from echocardiography and international ultrasound societies. A checklist of the essential components of an FCU examination was drafted. A panel of POCUS experts from different medical specialties in the United States and Canada was convened to vote on each checklist item by answering two questions: 1) Is this item important to include in a checklist of essential FCU skills applicable to any medical specialty? and 2) Should the learner be required to successfully complete this item to be considered competent? A modified Delphi approach was used to assess the level of agreement for each checklist item during four rounds of voting. Checklist items that achieved an agreement of 80% or greater were included in the final checklist. Results: Thirty-one POCUS experts from seven different medical specialties voted on sixty-five items to be included in the FCU image acquisition assessment tool. The majority of POCUS experts (61%) completed all four rounds of voting. During the first round of voting, 59 items reached consensus, and after revision and revoting, an additional 3 items achieved 80% or greater consensus. A total of 62 items were included in the final checklist, and 57 items reached consensus as a requirement for demonstration of competency. Conclusion: We have developed a multispecialty, consensus-based FCU image acquisition checklist that may be used to assess the skills of learners from different specialties. Future steps include studies to develop additional validity evidence for the use of the FCU assessment tool and to evaluate its utility for the translation of skills into clinical practice.

Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine.

PREPROCEDURE: 1)We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure. 2)We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures. 3)We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection. 4)We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation. TECHNIQUES: General Techniques 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures. 6)We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience. 7)We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures. 8)We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation. 9)To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. Central Venous Access Techniques 10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion. 11)We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion. 12)We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates. 13)We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques. 14)We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates. Peripheral Venous Access Techniques 15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques. 16)We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access. 17)We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access. Arterial Access Techniques 18)We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques. 19)We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications. 20)We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques. POSTPROCEDURE: 21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs. 22)We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise. TRAINING: 23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients. 24)We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency. 25)We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important. 26)We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically. 27)We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools. 28)We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation. 29)We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.

Hospitalist-Operated Compression Ultrasonography: a Point-of-Care Ultrasound Study (HOCUS-POCUS).

BACKGROUND: Venous thromboembolism includes deep vein thrombosis (DVT) and pulmonary embolism. Compression ultrasonography is the most common way to evaluate DVT and is typically performed by sonographers and interpreted by radiologists. Yet there is evidence that ultrasound examinations can be safely and accurately performed by clinicians at the bedside. OBJECTIVE: To measure the operating characteristics of hospital medicine providers performing point-of-care ultrasound (POCUS) for evaluation of DVT. DESIGN: This is a prospective cohort study enrolling a convenience sample of patients. Hospital medicine providers performed POCUS for DVT and the results were compared with the corresponding formal vascular study (FVS) interpreted by radiologists. PARTICIPANTS: Hospitalized non-ICU patients at four tertiary care hospitals for whom a DVT ultrasound was ordered. MAIN MEASURES: The primary outcomes were the sensitivity, specificity, and predictive values of the POCUS compression ultrasound compared with a FVS. The secondary outcome was the elapsed time between order and the POCUS study compared with the time the FVS was ordered to when the formal radiology report was finalized. KEY RESULTS: One hundred twenty-five limbs from 73 patients were scanned. The prevalence of DVT was 6.4% (8/125). The sensitivity of POCUS for DVT was 100% (95% CI 74-100%) and specificity was 95.8% (95% CI 91-98%) with a positive predictive value of 61.5% (95% CI 35-84%) and a negative predictive value of 100% (95% CI 98-100%). The median time from order to POCUS completion was 5.8 h versus 11.5 h median time from order until the radiology report was finalized (p = 0.001). CONCLUSION: Hospital medicine providers can perform compression-only POCUS for DVT on inpatients with accuracy similar to other specialties and settings, with results available sooner than radiology. The observed prevalence of DVT was lower than expected. POCUS may be reliable in excluding DVT but further study is required to determine how to incorporate a positive POCUS DVT result into clinical practice.

A road map for point-of-care ultrasound training in internal medicine residency.

BACKGROUND: Ever-expanding uses have been developed for ultrasound, including its focused use at the bedside, often referred to as point-of-care ultrasound (POCUS). POCUS has been well developed and integrated into training in numerous fields, but remains relatively undefined in internal medicine training. This training has been shown to be desirable to both educators and trainees, but has proven difficult to implement. We sought to create a road map for internal medicine residency programs looking to create a POCUS program. RESULTS: Four internal medicine residency programs that have successfully integrated POCUS training describe their programs, as well as the principles and concepts underlying program development and execution. Review of educational teaching and assessment methods is outlined, as well as suggestions for integration into an already busy residency curriculum. Commonly reported barriers to POCUS implementation such as faculty development, equipment purchasing, resident supervision and quality assurance are addressed. Specific POCUS applications to target are touched upon, and a comparison of applications taught within these four programs suggest that there may be enough similarities to suggest a common curriculum. Finally, future needs are discussed. CONCLUSIONS: POCUS can be successfully taught to internal medicine residents as a part of internal medicine training. Many common elements and principles are evident on review of these four described successful programs. Future support, in the form of endorsed medical society guidelines, will be needed before POCUS is universally incorporated across internal medicine residency training programs.

Recommendations on the Use of Ultrasound Guidance for Adult Lumbar Puncture: A Position Statement of the Society of Hospital Medicine.

EXECUTIVE SUMMARY: When ultrasound equipment is available, along with providers who are appropriately trained to use it, we recommend that ultrasound guidance should be used for site selection of lumbar puncture to reduce the number of needle insertion attempts and needle redirections and increase the overall procedure success rates, especially in patients who are obese or have difficult-to-palpate landmarks. We recommend that ultrasound should be used to more accurately identify the lumbar spine level than physical examination in both obese and nonobese patients. We suggest using ultrasound for selecting and marking a needle insertion site just before performing lumbar puncture in either a lateral decubitus or sitting position. The patient should remain in the same position after marking the needle insertion site. We recommend that a low-frequency transducer, preferably a curvilinear array transducer, should be used to evaluate the lumbar spine and mark a needle insertion site. A high-frequency linear array transducer may be used in nonobese patients. We recommend that ultrasound should be used to map the lumbar spine, starting at the level of the sacrum and sliding the transducer cephalad, sequentially identifying the lumbar spine interspaces. We recommend that ultrasound should be used in a transverse plane to mark the midline of the lumbar spine and in a longitudinal plane to mark the interspinous spaces. The intersection of these two lines marks the needle insertion site. We recommend that ultrasound should be used during a preprocedural evaluation to measure the distance from the skin surface to the ligamentum flavum from a longitudinal paramedian view to estimate the needle insertion depth and ensure that a spinal needle of adequate length is used. We recommend that novices should undergo simulation-based training, where available, before attempting ultrasound-guided lumbar puncture on actual patients. We recommend that training in ultrasound-guided lumbar puncture should be adapted based on prior ultrasound experience, as learning curves will vary. We recommend that novice providers should be supervised when performing ultrasound-guided lumbar puncture before performing the procedure independently on patients.

Point-of-Care Ultrasound for Hospitalists: A Position Statement of the Society of Hospital Medicine.

Many hospitalists incorporate point-of-care ultrasound (POCUS) into their daily practice to answer specific diagnostic questions or to guide performance of invasive bedside procedures. However, standards for hospitalists in POCUS training and assessment are not yet established. Most internal medicine residency training programs, the major pipeline for incoming hospitalists, have only recently begun to incorporate POCUS in their curricula. The purpose of this document is to inform a broad audience on what POCUS is and how hospitalists are using it. This document is intended to provide guidance for the hospitalists who use POCUS and administrators who oversee its use. We discuss POCUS 1) applications, 2) training, 3) assessments, and 4) program management. Practicing hospitalists must continue to collaborate with their local credentialing bodies to outline requirements for POCUS use. Hospitalists should be integrally involved in decision-making processes surrounding POCUS program management.

Point-of-Care Ultrasound in the Inpatient Setting: A Tale of Four Patients.

Point of-care ultrasound (POCUS) has become a mainstream bedside tool for clinicians in several specialties and is gaining recognition in hospital medicine. There are many clinical applications in which the inpatient practitioner can use POCUS to improve his or her diagnosis, monitoring, and treatment of patients. POCUS is valuable in many clinical scenarios, including acute renal failure, increasing lower extremity edema, change in inpatient clinical status, and acute dyspnea. The medical literature has demonstrated the ability of nonradiologists to accurately detect conditions, including hydronephrosis; extremes of central venous pressure; deep venous thrombosis; pericardial effusion with tamponade; and several pulmonary pathologic states, including pulmonary edema, pleural effusion, consolidation, and pneumothorax. Further development of POCUS in hospital medicine is highly likely given increased awareness and exposure among medical trainees, a developing literature base, and growing engagement from specialty societies.

Entrusting internal medicine residents to use point of care ultrasound: Towards improved assessment and supervision.

Background: Internal medicine physicians and trainees are increasingly using, and seeking training in, diagnostic point of care ultrasound (POCUS). Numerous internal medicine training programs have described their curricula, but little has been written about how learners should be assessed, supervised, and allowed to progress toward independent practice, yet these practices are imperative for safe and effective use. Entrustable professional activities (EPAs) offer a practical method to assess observable units of professional work and make supervision decisions. Methods: An EPA for POCUS is used as a framework to assess and determine appropriate levels of supervision in an internal medicine residency program. Results: All learners have been able to advance to level 2 with a mandatory introductory boot camp course. Learners have been able to advance to higher levels of independence, often after taking formal elective programmatic coursework. However, not all learners taking the same coursework have been granted the same level of independence. Conclusions: It is feasible to assess and supervise internal medicine residents' ability to use diagnostic point of care ultrasound using an EPA.

Recommendations on the Use of Ultrasound Guidance for Adult Thoracentesis: A Position Statement of the Society of Hospital Medicine.

Executive Summary: 1) We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax. 2) We recommend that ultrasound guidance should be used to increase the success rate of thoracentesis. 3) We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators. 4) We suggest that ultrasound guidance be used to reduce the risk of complications from thoracentesis in mechanically ventilated patients. 5) We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site. 6) We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making. 7) We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage. 8) We suggest that ultrasound be used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth. 9) We suggest that ultrasound be used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax. 10) We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis. 11) We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure. 12) We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique. 13) We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients. 14) Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution.

Ultrasound guidance for lumbar puncture.

PURPOSE OF REVIEW: To review the literature and describe techniques to use ultrasound to guide performance of lumbar puncture (LP). RECENT FINDINGS: Ultrasound evaluation of the lumbar spine has been shown in randomized trials to improve LP success rates while reducing the number of attempts and the number of traumatic taps. SUMMARY: Ultrasound mapping of the lumbar spine reveals anatomical information that is not obtainable by physical examination, including depth of the ligamentum flavum, width of the interspinous spaces, and spinal bone abnormalities, including scoliosis. Using static ultrasound, the lumbar spine anatomy is visualized in transverse and longitudinal planes and the needle insertion site is marked. Using real-time ultrasound guidance, the needle tip is tracked in a paramedian plane as it traverses toward the ligamentum flavum. Future research should focus on efficient methods to train providers, cost-effectiveness of ultrasound-guided LP, and the role of new needle-tracking technologies to facilitate the procedure.

Point-of-care ultrasonography improves the diagnosis of splenomegaly in hospitalized patients.

BACKGROUND: It is important to detect splenomegaly as it can have important diagnostic implications. Previous studies, however, have shown that the traditional physical examination is limited in its ability to rule in or rule out splenomegaly. OBJECTIVE: To determine if performing point-of-care ultrasonography (POCUS) in addition to the traditional physical examination improves the sensitivity and specificity for diagnosing splenomegaly. METHODS: This was a prospective trial of diagnostic accuracy. Physical and sonographic examinations for splenomegaly were performed by students, residents and attending physicians enrolled in an ultrasound training course. Participants received less than 1 h training for ultrasound diagnosis of splenomegaly. The findings were compared to radiographic interpretation of gold standard studies. SETTING/PATIENTS: Hospitalized adult patients at an academic medical center without severe abdominal pain or recent surgery who had abdominal CT, MRI or ultrasound performed within previous 48 h. RESULTS: Thirty-nine subjects were enrolled. Five patients had splenomegaly (12.5 %). The physical examination for splenomegaly had a sensitivity of 40 % (95 % CI 12-77 %) and specificity of 88 % (95 % CI 74-95 %) while physical examination plus POCUS had a sensitivity of 100 % (95 % CI 57-100 %) and specificity of 74 % (95 % CI 57-85 %). Physical examination alone for splenomegaly had an LR+ of 3.4 (95 % CI 0.83-14) and LR- of 0.68 (95 % CI 0.33-1.41); for physical exam plus POCUS the LR+ was 3.8 (2.16-6.62) and LR- was 0. CONCLUSIONS: Point-of-care ultrasonography significantly improves examiners' sensitivity in diagnosing splenomegaly.

Ultrasound in the diagnosis and management of pleural effusions.

We review the literature on the use of point-of-care ultrasound to evaluate and manage pleural effusions. Point-of-care ultrasound is more sensitive than physical exam and chest radiography to detect pleural effusions, and avoids many negative aspects of computerized tomography. Additionally, point-of-care ultrasound can assess pleural fluid volume and character, revealing possible underlying pathologies and guiding management. Thoracentesis performed with ultrasound guidance has lower risk of pneumothorax and bleeding complications. Future research should focus on the clinical effectiveness of point-of-care ultrasound in the routine management of pleural effusions and how new technologies may expand its clinical utility.

Feasibility and acceptability of a structured curriculum in teaching procedural and basic diagnostic ultrasound skills to internal medicine residents.

BACKGROUND: Point-of-care ultrasound has emerged as a powerful diagnostic tool and is also being increasingly used by clinicians to guide procedures. Many current and future internists desire training, yet no formal, multiple-application, program-wide teaching interventions have been described. INTERVENTION: We describe a structured 30-hour ultrasound training course in diagnostic and procedural ultrasound implemented during intern orientation. Internal medicine interns learned basic ultrasound physics and machine skills; focused cardiac, great vessel, pulmonary, and abdominal ultrasound diagnostic examinations; and procedural applications. RESULTS: In postcourse testing, learners demonstrated the ability to acquire images, had significantly increased knowledge scores (P < .001), and demonstrated good performance on practical scenarios designed to test abilities in image acquisition, interpretation, and incorporation into medical decision making. In the postcourse survey, learners strongly agreed (4.6 of 5.0) that ultrasound skills would be valuable during residency and in their careers. CONCLUSIONS: A structured ultrasound course can increase knowledge and can result in learners who have skills in image acquisition, interpretation, and integration in management. Future work will focus on refining and improving these skills to allow these learners to be entrusted with the use of ultrasound independently for patient care decisions.

Point-of-Care Ultrasound in Internal Medicine: A National Survey of Educational Leadership.

BACKGROUND: Ultrasound is a valuable tool in the safe performance of an increasing number of procedures. It has additionally emerged as a powerful instrument for point-of-care assessment by offering internists an opportunity to extend their traditional physical examination. OBJECTIVE: This study explored how internal medicine (IM) educators perceive the use of ultrasound for procedures and point-of-care assessments, the extent to which curricula for teaching IM residents ultrasound skills exist, and perceived barriers to teaching its use. METHODS: In February 2012, we administered a 27-question survey to all members of the Association of Program Directors in Internal Medicine, eliciting their opinions about the use of point-of-care ultrasound. RESULTS: Of 2200 surveys distributed electronically, 234 were returned (a 11% response rate), including 167 by program directors or assistant program directors. Respondents highly rated the usefulness of ultrasound for central-line placement, thoracentesis, paracentesis, and diagnosis of pleural effusions. Evaluation of vena cava and heart, and placement of radial artery catheters received somewhat lower usefulness scores. Forty-five respondents (25%) reported having formal curricula to teach point-of-care ultrasound, and 46 respondents without current ultrasound programs were planning to initiate them in the next 12 months. Potential barriers to teaching and use of ultrasound included the time and cost to train faculty, the cost of ultrasound machines, and the time required to train residents. CONCLUSIONS: Educational leaders in IM view point-of-care ultrasound as a valuable tool in diagnosis and procedures, and many residency programs are teaching these skills to their learners.

The DnaK chaperone system facilitates 30S ribosomal subunit assembly.

Functional Escherichia coli 30S ribosomal subunits can be reconstituted in vitro. However, slow kinetics and sharp temperature dependence suggest additional assembly factors are present in vivo. Extract activation of in vitro assembly results in association of DnaK/hsp70 chaperone components with pre-30S particles. Purified DnaK, its cochaperones DnaJ and GrpE, and ATP can facilitate reconstitution of functional 30S subunits under otherwise nonpermissive conditions. A link has been observed between DnaK, 30S subunit components, and ribosome biogenesis in vivo as well as in vitro. These studies reveal a novel role for the DnaK/hsp70 chaperone system, in addition to its well-documented role in protein folding, and suggest that 30S subunit assembly can be facilitated.