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356 Inter-Rater Reliability of Doppler Echocardiography Assessment of Cardiac Output by Emergency Physicians
Research Forum Abstracts
EMF-357
Selection, Sonography, and SelfAssessment: Implementation of a Novel Bedside Ultrasound Protocol
Minnigan H, Kline J/Indiana University, Indianapolis, IN
356
Inter-Rater Reliability of Doppler Echocardiography Assessment of Cardiac Output by Emergency Physicians
Lee L, Tewalde S, Allison M, Witting M, Euerle B/University of Maryland Medical Center, Baltimore, MD; University of Maryland School of Medicine, Baltimore, MD
Study Objectives: Rapid evaluation of volume responsiveness is essential in the resuscitation of a critically ill patient. This assessment can be challenging based on clinical examination alone, so emergency physicians often administer fluid empirically or rely on invasive hemodynamic monitoring techniques. These strategies, however, are often time consuming (if fluid administration is not beneficial, or if catheters must be placed and equipment set up), expensive, may not be widely available, and not without risk to the patient. Doppler ultrasound has long been used by cardiologists to quantify cardiac output (CO) noninvasively; this information could potentially be used to guide resuscitations by providing real-time feedback on the effects of fluid administration. However, before a new technique can be recommended for widespread adoption, it must be shown to produce reliable and reproducible data. This study aims to demonstrate whether emergency physicians can use Doppler ultrasound reliably to measure CO. Methods: This prospective observational study was performed at an urban tertiary care hospital. Eighty emergency department patients were enrolled as a convenience sample, and each patient underwent separate focused cardiac ultrasound examinations by an emergency ultrasound fellow and an emergency cardiology fellow. Both fellows underwent apprenticeship-style training with echocardiography technicians, and the ultrasound fellow attended additional classes. In the focused cardiac exams, the left ventricular outflow tract (LVOT) diameter and LVOT velocity time integral (VTI) were measured. These measurements were used, along with heart rate, to calculate CO. For the primary outcome measure, we estimated the proportion of patients in whom the two measurements agreed within 15% using a Bland-Altman analysis. Fifteen percent is a commonly clinically significant change in CO in the resuscitation of a critically ill patient. The correlations of LVOT and VTI measurements were determined as the secondary outcome measures. Results: The CO values determined by the two physicians were within 15% of the average in 52.5% of the patients (95% CI, 41%‒64%). Pearson correlation for CO was 0.82. The LVOT correlation was 0.76 and VTI correlation was 0.66 (Figure). Conclusion: Our study found that two emergency physicians with specialized training and interest in cardiac ultrasound had agreement within a clinically range in 52.5% of cases. Because of this low level of precision, we do not recommend the routine use of Doppler echocardiography by emergency physicians for measurement of CO until standardized training is established and further study is performed.
S126 Annals of Emergency Medicine
Study Objective: Implement a bedside ultrasound protocol that includes pretest probability assessment before imaging, and sonographer self-assessment after imaging. This will test the hypothesis that in patients with low to moderate pretest probability of disease, bedside ultrasound imaging that is judged as high quality by the sonographer will safely exclude five disease processes (pneumothorax, hydronephrosis, lower extremity DVT, systolic cardiac failure, and right ventricular strain). Methods: Observational study, at two large urban academic medical centers with an emergency medicine (EM) residency program. Online educational modules were prepared to instruct participating sonographers in how to enroll patients, perform the five imaging studies, and how to complete case report forms. After the asynchronous learning sessions, the study PI reviewed study imaging at the bedside with each participating sonographer. Results: Over the initial three-month period of the study, an open call by email were made to faculty and senior residents to participate in the in the project study imaging. This resulted in enrollment by a small subset of faculty, primarily ultrasound core faculty. Repeated offers to participate in the study had little impact on study participation. Residents and faculty were then personally contacted and offered training to participate. There was a positive response to the direct and personal offer of online and bedside training with this direct method. Fifty-seven patients have been enrolled to date (51% female, 49% male, range 16-93), by 13 different sonographers. Three sonographers accounted for 39/57 (68%) of the enrollment. Ultrasound core faculty performed 37 studies (68%). Individual studies performed were hydronephrosis - 26 (46%), DVT - 17 (30%), pneumothorax - 9 (16%), cardiac 5 (9%). Conclusions: Implementation of a structured ultrasound protocol was more difficult than anticipated. Discussion: Our experience has identified impediments to enrollment. These include a generalized poor response to group emails, and the requirement for self-study before enrolling patients. Before the study was begun, we believed that the opportunity to learn new ultrasound skills would motivate physicians to view the online modules and learn the imaging protocols. Although this may be true, it is likely that there is significant inertia to becoming involved in the study for emergency department providers. The initial approach of publicizing the study via group emails and announcements has been modified to target potentially interested individuals directly, and work with them on a one-on-one level. This has been somewhat successful increasing enrollment.
358
What is the Frequency that Pain Medications are not Given to Emergency Department Patients With a SelfReported Very High Pain Score?
Nguyen T, Husk G, Lowery S, Faustini A, Heller M/Beth Israel Medical Center, New York, NY
Study Objective: The documentation of pain assessment is mandated by The Joint Commission. A verbal rating scale (1-10) is often used to assess the level of the patient’s pain and does assist in the timely administration of pain medication when the high pain score is flagged in the electronic medical record (EMR). We question the validity of this
Volume 64, no. 4s : October 2014
EMF-357
Selection, Sonography, and SelfAssessment: Implementation of a Novel Bedside Ultrasound Protocol
Minnigan H, Kline J/Indiana University, Indianapolis, IN
356
Inter-Rater Reliability of Doppler Echocardiography Assessment of Cardiac Output by Emergency Physicians
Lee L, Tewalde S, Allison M, Witting M, Euerle B/University of Maryland Medical Center, Baltimore, MD; University of Maryland School of Medicine, Baltimore, MD
Study Objectives: Rapid evaluation of volume responsiveness is essential in the resuscitation of a critically ill patient. This assessment can be challenging based on clinical examination alone, so emergency physicians often administer fluid empirically or rely on invasive hemodynamic monitoring techniques. These strategies, however, are often time consuming (if fluid administration is not beneficial, or if catheters must be placed and equipment set up), expensive, may not be widely available, and not without risk to the patient. Doppler ultrasound has long been used by cardiologists to quantify cardiac output (CO) noninvasively; this information could potentially be used to guide resuscitations by providing real-time feedback on the effects of fluid administration. However, before a new technique can be recommended for widespread adoption, it must be shown to produce reliable and reproducible data. This study aims to demonstrate whether emergency physicians can use Doppler ultrasound reliably to measure CO. Methods: This prospective observational study was performed at an urban tertiary care hospital. Eighty emergency department patients were enrolled as a convenience sample, and each patient underwent separate focused cardiac ultrasound examinations by an emergency ultrasound fellow and an emergency cardiology fellow. Both fellows underwent apprenticeship-style training with echocardiography technicians, and the ultrasound fellow attended additional classes. In the focused cardiac exams, the left ventricular outflow tract (LVOT) diameter and LVOT velocity time integral (VTI) were measured. These measurements were used, along with heart rate, to calculate CO. For the primary outcome measure, we estimated the proportion of patients in whom the two measurements agreed within 15% using a Bland-Altman analysis. Fifteen percent is a commonly clinically significant change in CO in the resuscitation of a critically ill patient. The correlations of LVOT and VTI measurements were determined as the secondary outcome measures. Results: The CO values determined by the two physicians were within 15% of the average in 52.5% of the patients (95% CI, 41%‒64%). Pearson correlation for CO was 0.82. The LVOT correlation was 0.76 and VTI correlation was 0.66 (Figure). Conclusion: Our study found that two emergency physicians with specialized training and interest in cardiac ultrasound had agreement within a clinically range in 52.5% of cases. Because of this low level of precision, we do not recommend the routine use of Doppler echocardiography by emergency physicians for measurement of CO until standardized training is established and further study is performed.
S126 Annals of Emergency Medicine
Study Objective: Implement a bedside ultrasound protocol that includes pretest probability assessment before imaging, and sonographer self-assessment after imaging. This will test the hypothesis that in patients with low to moderate pretest probability of disease, bedside ultrasound imaging that is judged as high quality by the sonographer will safely exclude five disease processes (pneumothorax, hydronephrosis, lower extremity DVT, systolic cardiac failure, and right ventricular strain). Methods: Observational study, at two large urban academic medical centers with an emergency medicine (EM) residency program. Online educational modules were prepared to instruct participating sonographers in how to enroll patients, perform the five imaging studies, and how to complete case report forms. After the asynchronous learning sessions, the study PI reviewed study imaging at the bedside with each participating sonographer. Results: Over the initial three-month period of the study, an open call by email were made to faculty and senior residents to participate in the in the project study imaging. This resulted in enrollment by a small subset of faculty, primarily ultrasound core faculty. Repeated offers to participate in the study had little impact on study participation. Residents and faculty were then personally contacted and offered training to participate. There was a positive response to the direct and personal offer of online and bedside training with this direct method. Fifty-seven patients have been enrolled to date (51% female, 49% male, range 16-93), by 13 different sonographers. Three sonographers accounted for 39/57 (68%) of the enrollment. Ultrasound core faculty performed 37 studies (68%). Individual studies performed were hydronephrosis - 26 (46%), DVT - 17 (30%), pneumothorax - 9 (16%), cardiac 5 (9%). Conclusions: Implementation of a structured ultrasound protocol was more difficult than anticipated. Discussion: Our experience has identified impediments to enrollment. These include a generalized poor response to group emails, and the requirement for self-study before enrolling patients. Before the study was begun, we believed that the opportunity to learn new ultrasound skills would motivate physicians to view the online modules and learn the imaging protocols. Although this may be true, it is likely that there is significant inertia to becoming involved in the study for emergency department providers. The initial approach of publicizing the study via group emails and announcements has been modified to target potentially interested individuals directly, and work with them on a one-on-one level. This has been somewhat successful increasing enrollment.
358
What is the Frequency that Pain Medications are not Given to Emergency Department Patients With a SelfReported Very High Pain Score?
Nguyen T, Husk G, Lowery S, Faustini A, Heller M/Beth Israel Medical Center, New York, NY
Study Objective: The documentation of pain assessment is mandated by The Joint Commission. A verbal rating scale (1-10) is often used to assess the level of the patient’s pain and does assist in the timely administration of pain medication when the high pain score is flagged in the electronic medical record (EMR). We question the validity of this
Volume 64, no. 4s : October 2014