Education leads to confidence for new POCUS users

By Amerigo Allegretto, AuntMinnie.com staff writer

June 9, 2021 -- Instructional training increases confidence among family medicine residents using point-of-care ultrasound (POCUS), according to a study published June 4 in Family Medicine.

A team of researchers from the University of New Mexico led by Dr. Jerica Johnson found residents felt "significantly more confident" in their ability to perform and interpret a POCUS exam after a curriculum was implemented and that baseline attitudes toward POCUS were "very" favorable in both the pre- and postintervention surveys.

"Our residents and faculty have all been very excited to use POCUS. There are of course barriers to adoption of any new technology," Johnson told AuntMinnie.com. "The most significant barrier has been residents and faculty feeling that they are trained well enough to use POCUS and that there is not enough time to obtain this training."

The use of POCUS in family medicine residency training is increasing. However, researchers said attitudes about the technology, including confidence levels with performing and interpreting POCUS exams, are unknown.

The team wanted to find out attitudes and confidence levels of family medicine residents before and after the implementation of a new POCUS curriculum.

Residents in their postgraduate years at the University of New Mexico Family Medicine Residency Program were trained with POCUS in a yearlong program. The university's current POCUS curriculum was implemented in 2017.

"We had a loose curriculum with limited POCUS experiences prior to this when we made intentional changes to create a robust POCUS curriculum," Johnson said.

Attitudes and confidence levels with various POCUS exams were assessed through pre and postintervention surveys. On a 5-point confidence scale, a score of 1 meant strong disagreement while 5 indicated strong agreement.

The research team held a three-hour, hands-on workshop for residents, an 18-hour workshop for faculty and residents who participated as volunteer models, and 30-minute sessions every other week for residents who were rotating on the program's inpatient service.

Twenty-one residents responded to the preintervention survey. The average confidence scale score for education on ultrasound principles for performing and interpreting POCUS exams was 4.38. For the postintervention survey, which included 25 residents, that score was 3.96 (p = 0.05).

While agreement was high among residents when it came to ready access to ultrasound equipment and hands-on training, the results did not achieve statistical significance.

The team wrote that future research opportunities include investigating the effectiveness of different POCUS training technologies among family medicine residents and effects on patient-oriented outcomes.

Johnson told AuntMinnie.com that the team is hoping to implement an outpatient-based curriculum for the university's family medicine residents that is geared toward POCUS applications that are useful in the outpatient clinic.

"We are hoping to demonstrate that minimal training interventions can lead to improved revenue generation from the POCUS exams and essentially provide evidence that POCUS training for family medicine residents 'pays for itself,'" she said. "We hope that this outpatient-based curriculum can then be shared and applied by other family medicine residency programs.

SHORTER LUNG U S exams can help kidney disease patients

By Amerigo Allegretto, AuntMinnie.com staff writer

June 4, 2021 -- Lung ultrasound with an abbreviated scanning protocol can efficiently diagnose pulmonary congestion caused by fluid overload in hemodialysis patients, according to research published June 3 in the American Journal of Kidney Diseases.

A team of researchers led by Dr. Nathaniel Reisinger from the University of Pennsylvania found that several abbreviated lung ultrasound protocols that focus on a limited number of lung zones (4, 6, or 8-zone) performed similarly to comprehensive 28-zone studies among patients with kidney failure on hemodialysis seeking care in an emergency department.

The researchers also did not find any differences in mortality between patients with no-to-mild and moderate-to-severe pulmonary congestion.

"Abbreviated lung ultrasound protocols take less time, are less bothersome to patients, and are nearly as accurate," Reisinger told AuntMinnie.com.

Pulmonary congestion from fluid overload is common among patients with kidney failure on hemodialysis and contributes to excess morbidity and mortality in patients. The team said that physical examination is an insensitive approach to detecting pulmonary congestion.

Lung ultrasound with a comprehensive 28-zone protocol has been shown to be sensitive for detecting pulmonary congestion, according to previous research. However, the 28-zone technique requires complete disrobing of the patient and longer scanning times for operators.

"In the constrained environment of the emergency department, this commitment is prohibitive to both patients and providers," the authors wrote.

Reisinger and his team wanted to see if abbreviated forms of lung ultrasound could produce similar results while saving time for operators and providing a more comfortable experience for patients.

The group started with research by Buessler and colleagues that studied the use of four-, six-, and eight-zone scanning for heart failure patients, as well as mapped the specific lung zones that would be most equivalent to a 28-zone study. The researchers noted that previous research has found that the regional distribution of pulmonary edema on imaging based on clinical condition has been well-demonstrated.

They then tested the protocol in 98 patients in the U.S. with kidney failure on hemodialysis participated, with a follow-up time of 30 days. Out of those, 84 were African American and 97 were non-Hispanic or Latino in ethnicity.

The team found high correlation and good agreement between 28-zone and abbreviated lung ultrasound studies. Each of the short-form studies was able to discriminate between no-to-mild pulmonary congestion versus moderate-to-severe pulmonary congestion when compared with the long-form 28-zone study, the authors wrote.

For short-form studies, the highest sensitivities were seen in 6C, 8C, and 8D zone ultrasound studies at 93.0%, 95.8%, and 98.6% respectively. Meanwhile, 6C and 8A studies had the highest specificities, at 96.3% and 100% respectively. Finally, 6C, 8C, and 8D studies had the highest area under the curve (AUC), at 0.95, 0.94, and 0.94 respectively.

Of the four-zone studies, lung zone 4C had the highest sensitivity at 90.1%, specificity at 92.6%, and AUC at 0.91.

"With AUC values of greater than 0.88, any of the 8-zone studies clearly seems sufficient for clinical use," the study authors wrote. "Similarly, the 4C pattern can easily be performed without removing a patient's shirt, while still achieving a point estimate of AUC greater than 0.90, demonstrating accuracy better than the current standard-of-care assessment of pulmonary congestion."

However, Reisinger said that despite the promise, abbreviated lung ultrasound protocols are "slightly less accurate" than more comprehensive tests and may miss focal pathology such as pneumonia.

He told AuntMinnie.com that the research team is looking at randomized controlled trials as the next step in investigating whether lung ultrasound-guided ultrafiltration therapy improves outcomes in patients with end-stage kidney disease chronically on hemodialysis.