Towards quality assurance: implementation of a POCUS image archiving system in a high-volume community emergency department.

BACKGROUND: Quality assurance review is an integral part of point-of-care ultrasound (POCUS) programs but may not be routine practice in community hospitals. Lack of image acquisition and documentation can result in suboptimal patient care. In cases with an adverse outcome and no record of images, there is no mechanism for quality improvement. OBJECTIVES: Our goal was to implement a system of POCUS image archiving in a community hospital. Our SMART (Specific, Measurable, Actionable, Realistic, Timely) aim was to have > 50% of emergency department (ED) POCUS users archiving scans, and > 80% of all billed POCUS scans archived, measuring improvements bi-weekly over a period of 9 months. METHODS: The study was conducted at a single-community ED between August 2020 and April 2021. The POCUS archiving workflow was developed and refined through multiple plan-do-study-act (PDSA) cycles. Surveys, stakeholder meetings, audits, and feedback were used to generate and re-evaluate the interventions. These included introduction of QPathE© software, streamlining of the workflow process, strategic machine placement, POCUS rounds, use of a website for POCUS workflow instructions, and dissemination of audit results. Scans were tracked biweekly, and indexed by the number of scans billed. The primary outcome measure was the number of POCUS scans archived per 100 scans billed. RESULTS: Over a 9-month period, spanning 72,986 ED visits, 550 scans were archived. The percentage of POCUS users who changed practice to consistently archiving scans was 51%. The rate of POCUS scans archived per 100 scans billed was > 80%, compared to no archiving at baseline. CONCLUSION: We were able to transition from a system with entirely unarchived POCUS scanning, to one with > 80% of scans archived over a period of 9 months. This is the first published paper documenting implementation of a POCUS image archiving system in a Canadian Community ED.

RéSUMé: CONTEXTE: L'examen de l'assurance qualité fait partie intégrante des programmes d'échographie au point d'intervention (POCUS), peut ne pas être une pratique courante dans les hôpitaux communautaires. L'absence d'acquisition et de documentation d'images peut entraîner des soins sous-optimaux pour le patient. Dans les cas où l'issue est défavorable et où il n'y a pas d'enregistrement des images, il n'existe aucun mécanisme d'amélioration de la qualité. OBJECTIFS: Notre objectif était de mettre en place un système d'archivage des images POCUS dans un hôpital communautaire. Notre objectif SMART (Specific, Measurable, Actionable, Realistic, Timely) était de faire en sorte que > 50% des utilisateurs de POCUS aux urgences archivent les scans, et que > 80% de tous les scans POCUS facturés soient archivés, en mesurant les améliorations toutes les deux semaines sur une période de 9 mois. MéTHODES: L'étude a été menée dans une seule urgence communautaire entre août 2020 et avril 2021. Le flux de travail de l'archivage POCUS a été développé et affiné à travers de multiples cycles Planification- Exécution­Étude­Action (PEEA) [en anglais Plan-Do-Study-Act (PDSA)]. Des sondages, des réunions de parties prenantes, des audits et des commentaires ont été utilisés pour générer et réévaluer les interventions. Il s'agit notamment de l'introduction du logiciel QPathE©, de la rationalisation du processus de flux de travail, de l'emplacement stratégique des machines, des tournées POCUS, de l'utilisation d'un site web pour les instructions de flux de travail POCUS et de la diffusion des résultats des audits. Les scans étaient suivis toutes les deux semaines et indexés en fonction du nombre de scans facturés. Le principal critère d'évaluation était le nombre de scans POCUS archivés pour 100 scans facturés. RéSULTATS: Sur une période de 9 mois, couvrant 72 986 visites aux urgences, 550 scanners ont été archivés. Le pourcentage d'utilisateurs de POCUS qui ont changé de pratique pour archiver systématiquement les scans était de 51 %. Le taux de scanners POCUS archivés pour 100 scanners facturés était > 80%, par rapport à l'absence d'archivage au départ. CONCLUSION: Nous avons pu passer d'un système où les scanners POCUS n'étaient pas du tout archivés à un système où plus de 80% des scanners ont été archivés sur une période de 9 mois. Il s'agit du premier article publié sur la mise en œuvre d'un système d'archivage d'images POCUS dans une urgence communautaire canadienne.

Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents.

OBJECTIVE: Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents. METHODS: A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs. RESULTS: Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED). CONCLUSIONS: Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

Dose- and route-dependent teratogenicity, toxicity, and pharmacokinetic profiles of the hedgehog signaling antagonist cyclopamine in the mouse.

The Hedgehog (Hh) signaling pathway is an essential regulator of embryonic development and appears to play important roles in postnatal repair and cancer progression and metastasis. The teratogenic Veratrum alkaloid cyclopamine is a potent Hh antagonist and is used experimentally both in vitro and in vivo to investigate the role of Hh signaling in diverse biological processes. Here, we set out to establish an administration regimen for cyclopamine-induced teratogenicity in the mouse. The dysmorphogenic concentration of cyclopamine was determined in vitro via mouse whole-embryo culture assays to be 2.0 microM. We administered cyclopamine to female C57BL/6J mice at varied doses by oral gavage, ip injection, or osmotic pump infusion and assessed toxicity and pharmacokinetic (PK) models. Bolus administration was limited by toxicity and rapid clearance. In vivo cyclopamine infusion at 160 mg/kg/day yielded a dam serum steady-state concentration of approximately 2 microM with a corresponding amniotic fluid concentration of approximately 1.5 microM. Gross facial defects were induced in 30% of cyclopamine-exposed litters, with affected embryos exhibiting cleft lip and palate. This is the first report describing the PKs and teratogenic potential of cyclopamine in the mouse and demonstrates that transient Hh signaling inhibition induces facial clefting anomalies in the mouse that mimic common human birth defects.