Characterizing Point-of-Care Ultrasound Credentialing in Pediatric Emergency Departments.

OBJECTIVE: It is unclear which pediatric emergency departments (PEDs) have a point-of-care ultrasound (POCUS) credentialing process or if this process is consistent per expert guidelines. Our objective was to describe formalized POCUS credentialing processes across PEDs that are active in the pediatric emergency medicine POCUS (P2) Network. METHODS: A survey was developed from nationally recommended credentialing guidelines. This anonymous survey was sent out to the P2 Network comprising more than 230 members involved in pediatric POCUS. The survey was analyzed using descriptive analysis with counts and percentages. RESULTS: A total of 36 PEDs responded to the survey. All departments had a faculty member in charge of maintaining the credentialing process, and all faculty members had POCUS education available; 88.6% of education was scheduled didactics or bedside teaching. There were 80.6% of PEDs that had a process for internally credentialing faculty. Some PEDs offered protected education for POCUS, however, 44.8% had <50% of their faculty credentialed. There were 4 PEDs that offered incentives for completion of POCUS credentialing including salary bonuses; only 1 offered shift buy down as incentive. That PED had 100% of its faculty credentialed. All PEDs performed quality assurance on POCUS scans done in the ED, most done weekly. Billing for scans occurred in 26 PEDs. Skin/soft tissue and focused assessment with sonography for trauma were the 2 most common applications credentialed. CONCLUSIONS: Among PEDs surveyed, there was a lack of standardization of POCUS resources and components of credentialing. Incentives may be beneficial in improving credentialing faculty and standardizing the credentialing process.

Point-of-care ultrasound needs assessment in a paediatric acute care setting in Malawi.

OBJECTIVE: To describe the use of point-of-care ultrasound (POCUS) in an acute-care paediatric setting in Malawi, including clinical indications, types of examinations and frequency of positive findings. METHODS: Retrospective, cross-sectional study of a convenience sample of POCUS examinations performed in one tertiary referral hospital in Lilongwe, Malawi over 1 year. POCUS examinations were performed by Paediatric Emergency Medicine physician consultants as part of routine clinical practice and at the request of local clinicians. Images were saved along with the clinical indication and physician interpretation for quality review. Ultrasounds performed by the radiology department and those examinations that were technically faulty, missing clinical application or interpretation were excluded. RESULTS: In total, 225 ultrasounds of 142 patients were analysed. The most common clinical indications for which examinations were completed were respiratory distress (23%), oedema (11.7%) and shock/arrest (6.2%). The most common examinations performed were cardiac (41.8%) and lung (15.1%), focused assessment with sonography in trauma (FAST; 12.9%) and ultrasound-guided procedural examinations (9.8%). Pathology was identified in 68% of non-procedural examinations. Cardiac examinations demonstrated significant pathology, including reduced cardiac function (12.8%), gross cardiac structural abnormality (11.8%) and pericardial effusion (10.3%). CONCLUSIONS: POCUS was used for both clinical decision-making and procedural guidance, and a significant number of POCUS examinations yielded positive findings. Thus, we propose that cardiopulmonary, FAST and procedural examinations should be considered in future for the POCUS curriculum in this setting.

Diagnosing Acute Heart Failure in the Pediatric Emergency Department Using Point-of-Care Ultrasound.

BACKGROUND: Acute heart failure (AHF) in children is associated with significant disease burden with high rates of morbidity, mortality, and resource utilization. These children often present to the emergency department with clinical features that mimic common childhood illnesses. Cardiac point-of-care ultrasound (POCUS) can be an effective tool for rapidly identifying abnormal cardiac function. CASE REPORTS: This case series documents 10 children presenting with AHF between 2016 and 2019 and demonstrates how pediatric emergency physicians used cardiac POCUS to expedite their diagnosis, management, and disposition. All cardiac POCUS was performed before comprehensive echocardiograms were completed. One case is described in detail; the other cases are summarized in a Table. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition of AHF is critical to reduce pediatric morbidity and mortality. With proper training, cardiac POCUS can be an effective adjunct and should be considered for the early diagnosis and treatment of infants and children with AHF.

A clinical decision rule for the use of ultrasound in children presenting with acute inflammatory neck masses.

OBJECTIVE: To identify the association between clinical and ultrasound findings and surgical drainage in children with inflammatory neck masses and to create a clinical decision rule that allows for reduction of unnecessary use of ultrasound in inflammatory neck masses. MATERIALS AND METHODS: We reviewed data on patients ≤18 years who visited our emergency department between 2012 and 2014 with inflammatory neck swelling and who underwent ultrasound examinations of the neck. We used multivariate logistic regression to identify factors associated with drainage within 24 h of ultrasound study (early drainage). Recursive partitioning was used for risk stratification. RESULTS: Of 341 consecutive patients included in this study, 37 patients underwent early drainage and all had purulent material drained. All patients but one with non-suppurative adenitis and 95% (97/102) of those with suppurative adenitis or early/suspicious abscess on ultrasound were initially treated medically. Of those with a definite diagnosis of abscess/fluid collection, 89% (32/36) underwent early drainage. Patients who underwent drainage were more likely to be younger, female and have a longer duration of neck swelling, with fluctuance and erythema on exam. Recursive partitioning analysis revealed that among children with neck swelling >3 days and ≤3 days, the rate of early drainage was 24.3% and 4.4%, respectively. None of the children >7 months with neck swelling ≤3 days underwent early drainage. CONCLUSION: Children older than 1 year with inflammatory neck swelling ≤3 days are at low risk of having ultrasound findings that require drainage. In this subgroup of patients, ultrasound could be avoided unless the patient fails to improve after a trial of antibiotic therapy.

Who is monitoring your infections: shouldn't you be?

BACKGROUND: In the era of pay for performance and outcome comparisons among institutions, it is imperative to have reliable and accurate surveillance methodology for monitoring infectious complications. The current monitoring standard often involves a combination of prospective and retrospective analysis by trained infection control (IC) teams. We have developed a medical informatics application, the Surgical Intensive Care-Infection Registry (SIC-IR), to assist with infection surveillance. The objectives of this study were to: (1) Evaluate for differences in data gathered between the current IC practices and SIC-IR; and (2) determine which method has the best sensitivity and specificity for identifying ventilator-associated pneumonia (VAP). METHODS: A prospective analysis was conducted in two surgical and trauma intensive care units (STICU) at a level I trauma center (Unit 1: 8 months, Unit 2: 4 months). Data were collected simultaneously by the SIC-IR system at the point of patient care and by IC utilizing multiple administrative and clinical modalities. Data collected by both systems included patient days, ventilator days, central line days, number of VAPs, and number of catheter-related blood steam infections (CR-BSIs). Both VAPs and CR-BSIs were classified using the definitions of the U.S. Centers for Disease Control and Prevention. The VAPs were analyzed individually, and true infections were defined by a physician panel blinded to methodology of surveillance. Using these true infections as a reference standard, sensitivity and specificity for both SIC-IR and IC were determined. RESULTS: A total of 769 patients were evaluated by both surveillance systems. There were statistical differences between the median number of patient days/month and ventilator-days/month when IC was compared with SIC-IR. There was no difference in the rates of CR-BSI/1,000 central line days per month. However, VAP rates were significantly different for the two surveillance methodologies (SIC-IR: 14.8/1,000 ventilator days, IC: 8.4/1,000 ventilator days; p = 0.008). The physician panel identified 40 patients (5%) who had 43 VAPs. The SIC-IR identified 39 and IC documented 22 of the 40 patients with VAP. The SIC-IR had a sensitivity and specificity of 97% and 100%, respectively, for identifying VAP and for IC, a sensitivity of 56% and a specificity of 99%. CONCLUSIONS: Utilizing SIC-IR at the point of patient care by a multidisciplinary STICU team offers more accurate infection surveillance with high sensitivity and specificity. This monitoring can be accomplished without additional resources and engages the physicians treating the patient.