A point-of-care thoracic ultrasound protocol for hospital medical emergency teams (METUS) improves diagnostic accuracy

M J Blans, E Bousie, J G van der Hoeven, F H Bosch, M J Blans, E Bousie, J G van der Hoeven, F H Bosch

Abstract

Background: Point-of-care ultrasound (POCUS) has proven itself in many clinical situations. Few data on the use of POCUS during Medical Emergency Team (MET) calls exist. In this study, we hypothesized that the use of POCUS would increase the number of correct diagnosis made by the MET and increase MET's certainty.

Methods: Single-center prospective observational study on adult patients in need for MET assistance. Patients were included in blocks (weeks). During even weeks, the MET physician performed a clinical assessment and registered an initial diagnosis. Subsequently, the POCUS protocol was performed and a second diagnosis was registered (US+). During uneven weeks, no POCUS was performed (US-). A blinded expert reviewed the charts for a final diagnosis. The number of correct diagnoses was compared to the final diagnosis between both groups. Physician's certainty, mortality and possible differences in first treatment were also evaluated.

Results: We included 100 patients: 52 in the US + and 48 in the US- group. There were significantly more correct diagnoses in the US+ group compared to the US- group: 78 vs 51% (P = 0.006). Certainty improved significantly with POCUS (P < 0.001). No differences in 28-day mortality and first treatment were found.

Conclusions: The use of thoracic POCUS during MET calls leads to better diagnosis and increases certainty.

Trial registration: ClinicalTrials.gov. Registered 12 July 2017, NCT03214809 https://www.clinicaltrials.gov/ct2/show/NCT03214809?term=metus&cntry=NL&draw=2&rank=1.

Conflict of interest statement

None.

Figures

Fig. 1
Fig. 1
Flowchart of patient study enrollment
Fig. 2
Fig. 2
Difference in certainty before and after US in US− weeks after the use of POCUS

References

    1. Hillman KM, Chen J, Jones D. Rapid response systems. Med J Aust. 2014;201(9):519–521. doi: 10.5694/mja14.01088.
    1. Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MG, Smorenburg SM, de Rooij SE, Adams R, et al. Outcomes associated with the nationwide introduction of rapid response systems in The Netherlands. Crit Care Med. 2015;43(12):2544–2551. doi: 10.1097/CCM.0000000000001272.
    1. Narula J, Chandrashekhar Y, Braunwald E. Time to add a fifth pillar to bedside physical examination: inspection, palpation, percussion, auscultation, and insonation. JAMA Cardiol. 2018;3(4):346–350. doi: 10.1001/jamacardio.2018.0001.
    1. Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care. 2015;19:254. doi: 10.1186/s13054-015-0973-y.
    1. Shokoohi H, Boniface KS, Pourmand A, Liu YT, Davison DL, Hawkins KD, et al. Bedside ultrasound reduces diagnostic uncertainty and guides resuscitation in patients with undifferentiated hypotension. Crit Care Med. 2015;43(12):2562–2569. doi: 10.1097/CCM.0000000000001285.
    1. Sekiguchi H, Schenck LA, Horie R, Suzuki J, Lee EH, McMenomy BP, et al. Critical care ultrasonography differentiates ARDS, pulmonary edema, and other causes in the early course of acute hypoxemic respiratory failure. Chest. 2015;148(4):912–918. doi: 10.1378/chest.15-0341.
    1. Bataille B, Riu B, Ferre F, Moussot PE, Mari A, Brunel E, et al. Integrated use of bedside lung ultrasound and echocardiography in acute respiratory failure: a prospective observational study in ICU. Chest. 2014;146(6):1586–1593. doi: 10.1378/chest.14-0681.
    1. Pontet J, Yic C, Diaz-Gomez JL, Rodriguez P, Sviridenko I, Mendez D, et al. Impact of an ultrasound-driven diagnostic protocol at early intensive-care stay: a randomized-controlled trial. Ultrasound J. 2019;11(1):24. doi: 10.1186/s13089-019-0139-2.
    1. Laursen CB, Sloth E, Lassen AT, Christensen R, Lambrechtsen J, Madsen PH, et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med. 2014;2(8):638–646. doi: 10.1016/S2213-2600(14)70135-3.
    1. Silva S, Biendel C, Ruiz J, Olivier M, Bataille B, Geeraerts T, et al. Usefulness of cardiothoracic chest ultrasound in the management of acute respiratory failure in critical care practice. Chest. 2013;144(3):859–865. doi: 10.1378/chest.13-0167.
    1. Pirozzi C, Numis FG, Pagano A, Melillo P, Copetti R, Schiraldi F. Immediate versus delayed integrated point-of-care-ultrasonography to manage acute dyspnea in the emergency department. Crit Ultrasound J. 2014;6(1):5. doi: 10.1186/2036-7902-6-5.
    1. Volpicelli G, Lamorte A, Tullio M, Cardinale L, Giraudo M, Stefanone V, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med. 2013;39(7):1290–1298. doi: 10.1007/s00134-013-2919-7.
    1. Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med. 2004;32(8):1703–1708. doi: 10.1097/01.CCM.0000133017.34137.82.
    1. Zieleskiewicz L, Lopez A, Hraiech S, Baumstarck K, Pastene B, Di Bisceglie M, et al. Bedside POCUS during ward emergencies is associated with improved diagnosis and outcome: an observational, prospective, controlled study. Crit Care. 2021;25(1):34. doi: 10.1186/s13054-021-03466-z.
    1. Mullins CF, Psirides A. Activities of a Medical Emergency Team: a prospective observational study of 795 calls. Anaesth Intensive Care. 2016;44(1):34–43. doi: 10.1177/0310057X1604400107.
    1. Blans MJ, Pijl MEJ, van de Water JM, Poppe HJ, Bosch FH The implementation of POCUS and POCUS training for residents: the Rijnstate approach. Neth J Med. 2020;78(3):116–124.
    1. Blans MJ, Bosch FH, van der Hoeven JG. A practical approach to critical care ultrasound. J Crit Care. 2019;51:156–164. doi: 10.1016/j.jcrc.2019.01.002.
    1. Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117–125. doi: 10.1378/chest.07-2800.
    1. Hobby JL, Tom BD, Todd C, Bearcroft PW, Dixon AK. Communication of doubt and certainty in radiological reports. Br J Radiol. 2000;73(873):999–1001. doi: 10.1259/bjr.73.873.11064655.
    1. Mantuani D, Frazee BW, Fahimi J, Nagdev A. Point-of-Care Multi-Organ Ultrasound Improves Diagnostic Accuracy in Adults Presenting to the Emergency Department with Acute Dyspnea. West J Emerg Med. 2016;17(1):46–53. doi: 10.5811/westjem.2015.11.28525.
    1. Jones AE, Tayal VS, Kline JA. Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study. Acad Emerg Med. 2003;10(10):1054–1058. doi: 10.1197/S1069-6563(03)00346-4.
    1. Clay RD, Lee EC, Kurtzman MF, Dversdal RK. Teaching the internist to see: effectiveness of a 1-day workshop in bedside ultrasound for internal medicine residents. Crit Ultrasound J. 2016;8(1):11. doi: 10.1186/s13089-016-0047-7.
    1. Mjolstad OC, Andersen GN, Dalen H, Graven T, Skjetne K, Kleinau JO, et al. Feasibility and reliability of point-of-care pocket-size echocardiography performed by medical residents. Eur Heart J Cardiovasc Imaging. 2013;14(12):1195–1202. doi: 10.1093/ehjci/jet062.
    1. Kimura BJ, Amundson SA, Phan JN, Agan DL, Shaw DJ. Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination. J Hosp Med. 2012;7(7):537–542. doi: 10.1002/jhm.1944.
    1. Croft LB, Duvall WL, Goldman ME. A pilot study of the clinical impact of hand-carried cardiac ultrasound in the medical clinic. Echocardiography. 2006;23(6):439–446. doi: 10.1111/j.1540-8175.2006.00240.x.
    1. Vignon P, Dugard A, Abraham J, Belcour D, Gondran G, Pepino F, et al. Focused training for goal-oriented hand-held echocardiography performed by noncardiologist residents in the intensive care unit. Intensive Care Med. 2007;33(10):1795–1799. doi: 10.1007/s00134-007-0742-8.
    1. Vignon P, Mucke F, Bellec F, Marin B, Croce J, Brouqui T, et al. Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents. Crit Care Med. 2011;39(4):636–642. doi: 10.1097/CCM.0b013e318206c1e4.
    1. Yamada T, Minami T, Soni NJ, Hiraoka E, Takahashi H, Okubo T, et al. Skills acquisition for novice learners after a point-of-care ultrasound course: does clinical rank matter? BMC Med Educ. 2018;18(1):202. doi: 10.1186/s12909-018-1310-3.
    1. Sen S, Acash G, Sarwar A, Lei Y, Dargin JM. Utility and diagnostic accuracy of bedside lung ultrasonography during medical emergency team (MET) activations for respiratory deterioration. J Crit Care. 2017;40:58–62. doi: 10.1016/j.jcrc.2017.03.007.
    1. Sklar DP, Hauswald M, Johnson DR. Medical problem solving and uncertainty in the emergency department. Ann Emerg Med. 1991;20(9):987–991. doi: 10.1016/S0196-0644(05)82977-4.

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