For example, to evaluate a patient with undifferentiated hypotension, a multisystem POCUS examination of the heart, inferior vena cava, lungs, abdomen, and lower extremity veins is typically performed. Finally, POCUS examinations can be performed serially to investigate changes in clinical status or evaluate response to therapy, such as monitoring the heart, lungs, and inferior vena cava during fluid resuscitation.
The purpose of this position statement is to inform a broad audience about how hospitalists are using diagnostic and procedural applications of POCUS. Rather, it is intended to provide guidance on the safe and effective use of POCUS by the hospitalists who use it and the administrators who oversee its use. Moreover, hospitalists caring for pediatric and adolescent patients may use additional applications besides those listed here.
Currently, many hospitalists already perform more complex and sophisticated POCUS examinations than those listed in Table 1. The scope of POCUS use by hospitalists continues to expand, and this position statement should not restrict that expansion. As outlined in our earlier position statements, 3,4 ultrasound guidance lowers complication rates and increases success rates of invasive bedside procedures.
Point of Care Ultrasound for Emergency Medicine and Resuscitation
For instance, hospitalists may use POCUS to assess the size and character of a pleural effusion to help determine the most appropriate management strategy: observation, medical treatment, thoracentesis, chest tube placement, or surgical therapy. Furthermore, diagnostic POCUS can be used to rapidly assess for immediate postprocedural complications, such as pneumothorax, or if the patient develops new symptoms. Basic knowledge includes fundamentals of ultrasound physics; safety; 4 anatomy; physiology; and device operation, including maintenance and cleaning.
Basic knowledge can be taught by multiple methods, including live or recorded lectures, online modules, or directed readings. Training should occur across multiple types of patients eg, obese, cachectic, postsurgical and clinical settings eg, intensive care unit, general medicine wards, emergency department when available. Training is largely hands-on because the relevant skills involve integration of 3D anatomy with spatial manipulation, hand-eye coordination, and fine motor movements.
Virtual reality ultrasound simulators may accelerate mastery, particularly for cardiac image acquisition, and expose learners to standardized sets of pathologic findings. Real-time bedside feedback on image acquisition is ideal because understanding how ultrasound probe manipulation affects the images acquired is essential to learning.
Training in image interpretation relies on visual pattern recognition of normal and abnormal findings. Therefore, the normal to abnormal spectrum should be broad, and learners should maintain a log of what abnormalities have been identified. Giving real-time feedback at the bedside is ideal because of the connection between image acquisition and interpretation. Image interpretation can be taught through didactic sessions, image review sessions, or review of teaching files with annotated images.
Learners must interpret and integrate image findings with other clinical data considering the image quality, patient characteristics, and changing physiology. Clinical integration should be taught by instructors that share similar clinical knowledge as learners.
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Although sonographers are well suited to teach image acquisition, they should not be the sole instructors to teach hospitalists how to integrate ultrasound findings in clinical decision making. Learners must appreciate the clinical significance of POCUS findings, including recognition of incidental findings that may require further workup. Supplemental training in clinical integration can occur through didactics that include complex patient scenarios.
Clinical competency can be achieved with training adherent to five criteria. First, the training environment should be similar to where the trainee will practice. Second, training and feedback should occur in real time. Fourth, clinical competence must be achieved and demonstrated; it is not necessarily gained through experience. Fifth, once competency is achieved, continued education and feedback are necessary to ensure it is maintained. They may eventually become commonplace, but until then alternative pathways must exist for hospitalist providers who are already in practice.
There are three important attributes of such pathways. Second, training should begin through a local or national hands-on training program. In some settings, a subgroup of hospitalists may not desire, or be able to achieve, competency in the manual skills of POCUS image acquisition.
Nevertheless, hospitalists may still find value in understanding POCUS nomenclature, image pattern recognition, and the evidence and pitfalls behind clinical integration of specific POCUS findings. The minimal skills a hospitalist should possess to serve as a POCUS trainer include proficiency of basic knowledge, image acquisition, image interpretation, and clinical integration of the POCUS applications being taught; effectiveness as a hands-on instructor to teach image acquisition skills; and an in-depth understanding of common POCUS pitfalls and limitations.
Assessment methods should be aligned with local availability of resources and trainers. View our Job Openings. Shasta Community Health Center. Phone: Medical: Google Map. Phone: Medical: Dental: Ext. Phone: Medical: Dental: Google Map.
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TABLE 1. TABLE 2. TABLE 3. TABLE 4. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: A systematic review. Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years. Crit Care Med ; — Cited Here Fluid resuscitation in septic shock : A positive fluid balance and elevated central venous pressure are associated with increased mortality.
Prehospital intravenous access and fluid resuscitation in severe sepsis: An observational cohort study.
Crit Care ; Cited Here Effect of an early resuscitation protocol on in-hospital mortality among adults with sepsis and hypotension: A randomized clinical trial. Both positive and negative fluid balance may be associated with reduced long-term survival in the critically ill. Crit Care Med ; e—e Cited Here Patterns and outcomes associated with timeliness of initial crystalloid resuscitation in a prospective sepsis and septic shock cohort. Fluid administration in severe sepsis and septic shock , patterns and outcomes: An analysis of a large national database.
Intensive Care Med ; — Cited Here Time to treatment and mortality during mandated emergency care for sepsis. Early goal-directed resuscitation for patients with severe sepsis and septic shock : A meta-analysis and trial sequential analysis. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality: A propensity-matched cohort study. Anesth Analg ; — Cited Here Association between intravenous chloride load during resuscitation and in-hospital mortality among patients with SIRS.
Trials ; Cited Here Saline versus balanced crystalloids for intravenous fluid therapy in the emergency department : Study protocol for a cluster-randomized, multiple-crossover trial. The SALT randomized trial. Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: A critical analysis of the evidence. Chest ; — Cited Here Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects.
The effectiveness of right heart catheterization in the initial care of critically ill patients. Comprehensive bedside point of care testing in critical ED patients: A before and after study. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients.
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Effect of focused bedside ultrasonography in hypotensive patients on the clinical decision of emergency physicians. Emerg Med Int ; Cited Here Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Echocardiography as a guide for fluid management. Bedside ultrasound reduces diagnostic uncertainty and guides resuscitation in patients with undifferentiated hypotension.
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