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

Results

Between the two academic hospitals, there were a total of 18 M&M conferences (nine per each hospital) over the 12-month period. These were reviewed by 15 different PGY-4 residents; three residents reviewed cases for two different conferences. There was a 100% response rate among residents.

Of the 667 cases reviewed 75 cases were determined to have patient care concerns. POCUS was used in 27% (20/75, 95% CI, 17–38%) and not used in 73% (55/75, 95% CI, 62–83%) (Figure 1). 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, 95% CI, 32–59%) There was a kappa value of 0.85 between the PGY-4 residents and the fellowship-trained EM attending in making this assessment. The US EM attending would have clinically used POCUS in 52% (13/25, 95% CI, 31%–72%) of these cases.

Figure 1.

Flow diagram of morbidity and mortality cases.
POCUS, point-of-care ultrasound; M&M, morbidity and mortality.

The most common chief complaints were shortness of breath 23% (17/75), trauma 15% (11/75), and cardiac arrest 12% (9/75) (Table 1). Thirty-six percent (27/75) were deaths within the ED. Of the 45% (25/55) of cases in which POCUS was not used but was felt would have likely prevented the M&M, the most common presentations were chest pain (75%, 6/8), shortness of breath (47%, 8/17), and trauma (36%, 4/11). The most common vital sign abnormalities were tachycardia 49% (37/75) and hypoxia 26% (20/75). Of the cases with these abnormalities, POCUS was felt likely to have made an impact if it had been used in 40% (8/20, 95% CI, 19–64%), of the hypoxic cases and 30% (11/37, 95% CI, 16–47%), of the tachycardic cases.

The perceived benefit of POCUS in preventing M&M was varied. POCUS often had the potential to have improved care by multiple different mechanisms. Mechanisms by which POCUS might have prevented the M&M were as follows: identified a missed diagnosis (92%, 23/25, 95% CI, 74–99%); decreased time to diagnosis (92%, 23/25, 95%, CI 74–99%); improved triage to an area of higher level of care (80%, 20/25, 95% CI, 59–93%); guided appropriate treatment (60%, 15/25, 95% CI, 39–79%); earlier consultation (24%, 6/25, 95% CI, 9–45%); and prevented inappropriate imaging (24%, 6/25, 95% CI, 9–45%). The POCUS applications that would have helped the most were cardiac (32%, 8/25, 95% CI, 15–54%), and lung (32%, 8/25, 95% CI 15–54%). This data is summarized in Figure 2.

Figure 2.

Perceived impact of point-of-care ultrasound: applications versus mechanism by which POCUS may have reduced or prevented morbidity ad mortality (N = 25 cases, multiple mechanisms per case were possible).
FAST, focused assessment with sonography in trauma.

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. The cases were classified by type to characterize the errors. Of these errors, in four POCUS was incorrectly integrated into clinical care, in two POCUS was incorrectly performed, and in two POCUS was incorrectly interpreted. These cases are summarized in Table 2.

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