Point-of-care Ultrasound in Morbidity and Mortality Cases in Emergency Medicine: Who Benefits the Most?

Who Benefits the Most?

Andrew J. Goldsmith, MD, MBA; Hamid Shokoohi, MD MPH; Michael Loesche, MD, PhD; Ravish C. Patel; Heidi Kimberly, MD; Andrew Liteplo, MD

Disclosures

Western J Emerg Med. 2020;21(6):172-178. 

In This Article

Abstract and Introduction

Abstract

Introduction: Point-of-care ultrasound (POCUS) is an essential tool in the timely evaluation of an undifferentiated patient in the emergency department (ED). Our primary objective in this study was to determine the perceived impact of POCUS in high-risk cases presented at emergency medicine (EM) morbidity and mortality (M&M) conferences. Additionally, we sought to identify in which types of patients POCUS might be most useful, and which POCUS applications were considered to be highest yield.

Methods: This was a retrospective survey of cases submitted to M&M at an EM residency program that spans two academic EDs, over one academic year. Postgraduate year 4 (PGY) residents who presented M&M cases at departmental sessions were surveyed on perceived impacts of POCUS on individual patient outcomes. We evaluated POCUS use and indications while the POCUS was used.

Results: Over the 12-month period, we reviewed 667 cases from 18 M&M sessions by 15 PGY-4 residents and a supervising EM attending physician who chairs the M&M committee. Of these cases, 75 were selected by the M&M committee for review and presentation. POCUS was used in 27% (20/75) of the cases and not used in 73% (55/75). In cases where POCUS was not used, retrospective review determined that if POCUS had been used it would have "likely prevented the M&M" in 45% (25/55). Of these 25 cases, the majority of POCUS applications that could have helped were cardiac (32%, 8/25) and lung (32%, 8/25) ultrasound. POCUS was felt to have greatest potential in identifying missed diagnoses (92%, 23/25), and decreasing the time to diagnosis (92%, 23/25). Patients with cardiopulmonary chief complaints and abnormal vital signs were most likely to benefit. There were seven cases (35%, 7/20, 95% CI 15–59%) in which POCUS was performed and thought to have possibly adversely affected the outcome of the M&M.

Conclusion: POCUS was felt to have the potential to reduce or prevent M&M in 45% of cases in which it was not used. Cardiac and lung POCUS were among the most useful applications, especially in patients with cardiopulmonary complaints and in those with abnormal vital signs.

Introduction

Medical errors have been reported to be the third leading cause of death in the United States.[1] Specifically, diagnostic errors account for an estimated 40,000–80,000 annual deaths in this country.[2] In critical care patients this is further exemplified as one study showed that upwards of 10% of intensive care unit (ICU) patients had lethal misdiagnoses on autopsy.[3] Diagnostic errors are under-reported and underemphasized; this is an understudied area of patient-safety that can affect the well-being of providers involved with the errors.[4]

Point-of-care ultrasound (POCUS) is an essential tool in the timely evaluation of critically ill patients and those with undifferentiated diagnoses. For this reason, POCUS training is a growing part of medical education, particularly in emergency medicine (EM) where accreditation training requirements exist, and residents are required by the Accreditation Council for Graduate Medical Education to demonstrate POCUS competency.[4] Additionally, the American College of Emergency Physicians has released a policy statement including guidelines and recommendations for POCUS education for emergency physicians.[5] Successful implementation of POCUS requires emergency physicians to acquire and interpret images, as well as apply and integrate these interpretations into clinical practice.

There is an ever-growing body of literature describing the diagnostic utility of POCUS for specific diseases.[6–8] Further, there is extensive research describing how experienced practitioners can improve diagnostic certainty in undifferentiated hypotensive patients.[9] For example, in hypotensive trauma patients, a positive focused assessment with sonography in trauma (FAST) exam in the ED has shown to decrease time to the operating room and length of stay with very high specificity.[10] Also, POCUS evaluation of patients with acute dyspnea has shown to reduce diagnostic time with good concordance with admission diagnosis.[11] In the ED, POCUS plays an increasingly important role in a patient's ultimate timely diagnosis and thereby treatment.[6,10–12] This has led practitioners to believe that POCUS may improve patient outcomes.

Departmental morbidity and mortality (M&M) conferences are routinely held to investigate individual and systematic errors that contribute to preventable medical errors that lead to patient morbidity and mortality. M&M review has been used in the past to draw meaningful data about preventable deaths and trends in the care of these patients.[13] In this paper, we use similar methodology to review M&M cases for the purpose of assessing the impact that POCUS might have on patient outcomes.

Our primary goal was to determine the perceived role of POCUS on affecting clinical outcomes on M&M cases by performing a descriptive analysis of the use of POCUS in cases reviewed for M&M. We also sought to determine which POCUS applications and in which types of patients ultrasound had the most perceived value. Having this information could guide emergency physicians as to what POCUS to perform and in whom. Our goal was to improve patient care by sharing and examining our collective experiences in high-yield M&M cases for using POCUS. Despite recognition that clinical integration is essential, there is limited published data on actual patterns of usage of POCUS by emergency physicians. To our knowledge no study has examined the potential role of POCUS on cases reviewed in two emergency departments' (ED) M&M conferences.

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