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Thứ Tư, 2 tháng 6, 2021

How to implement POCUS at your hospital

By Amerigo Allegretto, AuntMinnie.com staff writer


June 1, 2021 -- So, you want to integrate point-of-care ultrasound (POCUS) into your hospital enterprise image network. But how? Breaking down what goes into a successful POCUS implementation was the subject of a May 26 talk at the Society for Imaging Informatics in Medicine meeting.


Successfully implementing POCUS requires swift strategy and teamwork, including taking advantage of existing imaging technology, according to registered nurse Laurie Perry from Cincinnati Children's Hospital in Ohio.

"Point-of-care ultrasound is only going to grow, and there will be divisions that continually need to be implemented. You'll need to do that quickly," she said.

POCUS has been looked at in recent years as a convenient clinical tool that can bring imaging to a patient's bedside. Advantages include portability and cost-effectiveness.

However, there are some limitations to POCUS, Perry said. One is that images remain on the ultrasound device and are not clinically available to anyone else taking care of the patient. POCUS images also can't be compared with other specialty images, and there are challenges to getting reimbursed.

Although many divisions at Cincinnati Children's Hospital wanted to use POCUS, Perry said they were unable to bill for the procedure until providers had been credentialed and images stored in the enterprise archive.

"If you're not storing images, you cannot bill for the ultrasound," Perry said.

To integrate POCUS with the rest of the enterprise, the implementation team needed to create a standard POCUS workflow within the electronic health record. Then, it needed to work with business managers to help them to understand the process for billing imaging studies.

The team that was assembled for this included clinical and business leaders from clinical divisions, imaging informatics professionals, electronic medical records analysts, a project manager, a trainer, and an enterprise imaging physician leader.

The group solved the existing challenges by working with clinical leaders and business managers in creating a process that fits into the existing workflow. Team members utilized ad-hoc order creation and automated as many steps as possible. They also worked with the radiology business director to identify and create appropriate procedure codes.

"All radiology and cardiology, including ultrasound, is sent to the hospital's enterprise archive. We've acquired and sent over 5,000 POCUS studies to the archive," Perry said. "We have billed more than $2.25 million of new services for our organization."

Children's Hospital began using POCUS for anesthesia in 2015 and has expanded its use in other care units and departments, such as emergency, pediatric intensive care, and cardiac intensive care among others. The hospital is currently working on implementing POCUS for physical medicine and rehab and its gastrointestinal division.

Perry said the hospital has used the following guiding principles over the years to successfully implement POCUS into its departments:

  • Take advantage of DICOM to power workflow.
  • Automate workflow for providers as much as possible.
  • Provide a link to the images in the electronic medical record, preferably within the appropriate context for the division.
  • The goal should be to create a standard, reproducible process.

Perry also said implementation teams should evaluate a division's current ultrasound machines for such things as WiFi capability, DICOM capability, and security requirements. Credentialing providers, as well as determining procedures and billing, developing the electronic medical record, and training users are also needed.

Thứ Bảy, 29 tháng 5, 2021

Special training not needed for COVID lung ultrasound scoring

By Amerigo Allegretto, AuntMinnie.com staff writer


May 26, 2021 -- Although there were some variations in performance, it may not be necessary for users of ultrasound scanners to receive special training before scoring lung exams of patients with COVID-19, according to research published May 21 in Nature.

group of researchers led by Dr. Markus Lerchbaumer from Charité Institute of Radiology in Berlin, Germany found that while different types of observers had "fair to moderate" interobserver agreement in interpreting specific lung findings in patients with COVID-19, a little background in lung ultrasound goes a long way.

"As long as observers have some experience in lung ultrasound, no specific clinical background is needed for scoring the findings, even though specific expertise is often reported as a requirement," the authors wrote.

Examining the lungs in patients is usually performed with nonenhanced CT scans, but point-of-care ultrasound (POCUS) is being looked at as a safer method since patients infected with the SARS-CoV-2 virus would not need to be transferred, and risk of exposure for medical staff would decrease.

The researchers said lung ultrasound may have a big advantage for COVID-19 due to its widespread availability and cost-effectiveness.

"Additionally, lung ultrasound has emerged over the last two decades as a noninvasive tool for the fast differential diagnosis of pulmonary diseases and is now used in different settings in intensive care," they wrote.

In the current study, 10 observers from three different medical specialties participated in rating 100 lung ultrasound images from 13 patients. These included observers specializing in intensive care medicine, emergency medicine, and physiology.

Images were acquired by a radiologist using a hand-held POCUS system (Viamo sv7, Canon Medical Systems) performed at the bedside. Ultrasound presets were optimized for lung ultrasound.

Through an online tool, observers could use multiple-choice options with predefined answers for rating the scans. Options included typical COVID-19-associated lung ultrasound findings; these included the following:

  • Pleural thickening and fragmentation
  • Presence of B-lines subclassified in single or confluent, subpleural consolidations
  • Positive air bronchogram

Selecting none of these pathologies was also an option.

The team found that observers in the intensive care unit tended to interpret B-lines more accurately, while physiology researchers and emergency physicians more often categorized B-lines as confluent rather than single. This tendency became even stronger over the course of viewing instances, probably explaining the poorer than expected overall inter- and intraobserver agreement.

"We assume that ICU observers have greater clinical experience with patients with severe ARDS or cardiogenic edema and their corresponding lung ultrasound findings, especially compared to scientists whose experience relies on lung ultrasound in rodents," they wrote.

ICU observers, on the other hand, differed from the latter two groups regarding the identification of pleural thickening.

Meanwhile, agreement was highest for more distinct lung ultrasound findings such as air bronchograms and subpleural consolidations, as well as more severe lung ultrasound scores.

The researchers wrote that training lung ultrasound users may improve agreement and clinical feasibility. They also suggest that training material used for lung ultrasound in POCUS should pay better attention to areas such as B-line quantification and differentiation of intermediate scores, which revealed only "mediocre" agreement in the study.