The ultrasound competency assessment tool for four-view cardiac POCUS.

BACKGROUND: Point-of-care ultrasound (POCUS) has been recognized as an essential skill across medicine. However, a lack of reliable and streamlined POCUS assessment tools with demonstrated validity remains a significant barrier to widespread clinical integration. The ultrasound competency assessment tool (UCAT) was derived to be a simple, entrustment-based competency assessment tool applicable to multiple POCUS applications. When used to assess a FAST, the UCAT demonstrated high internal consistency and moderate-to-excellent inter-rater reliability. The objective of this study was to validate the UCAT for assessment of a four-view transthoracic cardiac POCUS. RESULTS: Twenty-two trainees performed a four-view transthoracic cardiac POCUS in a simulated environment while being assessed by two observers. When used to assess a four-view cardiac POCUS the UCAT retained its high internal consistency ([Formula: see text] and moderate-to-excellent inter-rater reliability (ICCs = 0.61-0.91; p's ≤ 0.01) across all domains. The regression analysis suggestion that level of training, previous number of focused cardiac ultrasound, previous number of total scans, self-rated entrustment, and intent to pursue certification statistically significantly predicted UCAT entrustment scores [F (5,16) = 4.06, p = 0.01; R2 = 0.56]. CONCLUSION: This study confirms the UCAT is a valid assessment tool for four-view transthoracic cardiac POCUS. The findings from this work and previous studies on the UCAT demonstrate the utility and flexibility of the UCAT tool across multiple POCUS applications and present a promising way forward for POCUS competency assessment.

Code Status Documentation Availability and Accuracy Among Emergency Patients with End-stage Disease.

INTRODUCTION: Some patients with end-stage disease who may neither want nor benefit from aggressive resuscitation receive such treatment if they cannot communicate in an emergency. Timely access to patients' current resuscitation wishes, or "code status," should be a key metric of electronic health records (EHR). We sought to determine what percentage of a cohort of patients with end-stage disease who present to the emergency department (ED) have accessible, code status documents, and for those who do, how quickly can this documentation be retrieved. METHODS: In this cross-sectional study of ED patients with end-stage disease (eg, palliative care, metastatic malignancy, home oxygen, dialysis) conducted during purposefully sampled random accrual times we performed a standardized, timed review of available health records, including accompanying transfer documents. We also interviewed consenting patients and substitute decision makers to compare available code status documents to their current wishes. RESULTS: Code status documentation was unavailable within 15 minutes of ED arrival in most cases (54/85, or 63%). Retrieval time was under five minutes in the rest, especially when "one click deep" in the EHR. When interviewed, 20/32 (63%) expressed "do not resuscitate" wishes, 10 of whom had no supporting documentation. Patients from assisted-living (odds ratio [OR] 6.7; 95% confidence interval [CI], 1.7-26) and long-term care facilities (OR 13; 95% CI, 2.5-65) were more likely to have a documented code status available compared to those living in the community. CONCLUSION: The majority of patients with end-stage disease, including half of those who would not wish resuscitation from cardiorespiratory arrest, did not have code status documents readily available upon arrival to our tertiary care ED. Patients living in the community with advanced disease may be at higher risk for unwanted resuscitative efforts should they present to hospital in extremis. While easily retrievable code status documentation within the EHR shows promise, its accuracy and validity remain important considerations.

The Ultrasound Competency Assessment Tool (UCAT): Development and Evaluation of a Novel Competency-based Assessment Tool for Point-of-care Ultrasound.

OBJECTIVES: Point-of-care ultrasound (POCUS) has become an integral diagnostic and interventional tool. Barriers to POCUS training persist, and it continues to remain heterogeneous across training programs. Structured POCUS assessment tools exist, but remain limited in their feasibility, acceptability, reliability, and validity; none of these tools are entrustment-based. The objective of this study was to derive a simple, entrustment-based POCUS competency assessment tool and pilot it in an assessment setting. METHODS: This study was composed of two phases. First, a three-step modified Delphi design surveyed 60 members of the Canadian Association of Emergency Physicians Emergency Ultrasound Committee (EUC) to derive the anchors for the tool. Subsequently, the derived ultrasound competency assessment tool (UCAT) was used to assess trainee (N = 37) performance on a simulated FAST examination. The intraclass correlation (ICC) for inter-rater reliability and Cronbach's alpha for internal consistency were calculated. A statistical analysis was performed to compare the UCAT to other competency surrogates. RESULTS: The three-round Delphi had 22, 26, and 26 responses from the EUC members. Consensus was reached, and anchors for the domains of preparation, image acquisition, image optimization, and clinical integration achieved approval rates between 92 and 96%. The UCAT pilot revealed excellent inter-rater reliability (with ICC values of 0.69-0.89; p < 0.01) and high internal consistency (α = 0.91). While UCAT scores were not impacted by level of training, they were significantly impacted by the number of previous POCUS studies completed. CONCLUSIONS: We developed and successfully piloted the UCAT, an entrustment-based bedside POCUS competency assessment tool suitable for rapid deployment. The findings from this study indicate early validity evidence for the use of the UCAT as an assessment of trainee POCUS competence on FAST. The UCAT should be trialed in different populations performing several POCUS study types.

Differences in Gaze Fixation Location and Duration Between Resident and Fellowship Sonographers Interpreting a Focused Assessment With Sonography in Trauma.

OBJECTIVES: We quantified the gaze fixation duration of resident and fellowship sonographers interpreting a prerecorded focused assessment with sonography in trauma (FAST). We hypothesized that all sonographers would fixate on each relevant anatomic relationship but that the duration of fixation would differ. METHODS: We conducted a cross-sectional study collecting and analyzing the gaze fixations of a convenience sample of current resident and fellowship sonographers. All sonographers viewed a standardized FAST video, and their gaze fixations were recorded using a Tobii X3-120 eye-tracking bar. Gaze fixations over nine anatomic regions of interest (ROIs) were identified. These were assessed for normality and analyzed using the Wilcoxon rank sum test at an alpha of 0.05 and Bonferroni correction p value of <0.0034. The chi-square test and Pearson's correlation were performed to assess statistical association. RESULTS: The gaze fixation recordings of 24 resident and eight fellowship sonographers were suitable for analysis. Fourteen of the 24 resident sonographers viewed all ROIs in the FAST, whereas all eight fellowship sonographers viewed each of the nine relevant ROIs. Five ROIs were identified over which at least one resident sonographer did not have a gaze fixation. No statistically significant difference was identified between groups. Resident sonographers gaze fixated over the left upper quadrant (LUQ) splenorenal interface for a median (interquartile range) of 10.64 (9.73-11.60) seconds. The fellowship group viewed the same ROI for 8.43 (6.64-8.95) seconds (p < 0.003). All participants viewed this ROI. No other ROIs had a statistical difference. CONCLUSION: Five ROIs were identified that were not visually interrogated by all resident sonographers. Only 14 of 24 resident sonographers visually interrogated every area in the FAST, whereas all fellowship sonographers interrogated every ROI. A statistically significant difference was found in gaze fixation duration between resident and fellowship sonographers in one ROI. Further study is required for gaze fixation assessment to become a tool for the interpretation component of point-of-care ultrasound.

Impact of night shifts on emergency medicine resident resuscitation performance.

AIM: Emergency medicine (EM) trainees often work nightshifts. We sought to measure how this circadian disruption affects EM resident performance during simulated resuscitations. METHODS: This retrospective cohort study enrolled EM residents at a single Canadian academic centre over a six-year period. Residents completed twice-annual simulation-based resuscitation-focused objective structured clinical examinations (OSCEs) with assessment in four domains (primary assessment, diagnostic actions, therapeutic actions and communication), and a global assessment score (GAS). Primary and secondary exposures of interest were the presence of a nightshift (late-evening shifts ending between midnight and 03h00 or overnight shifts ending after 06h00) the day before or within three days before an OSCE. A random effects linear regression model was used to quantify the association between nightshifts and OSCE scores. RESULTS: From 57 residents, 136 OSCE scores were collected. Working a nightshift the day before an OSCE did not affect male trainee scores but was associated with a significant absolute decrease in mean total scores (-6% [95% CI -12% to 0%]), GAS (-7% [-13% to 0%]), and communication (-9% [-16% to -2%]) scores among women. Working any nightshift within three days before an OSCE lowered absolute mean total scores by 4% [-7% to 0%] and communication scores by 5% [-5% to 0%] irrespective of gender. CONCLUSION: Our results suggest that shift work may impact EM resident resuscitation performance, particularly in the communication domain. This impact may be more significant in women than men, suggesting a need for further investigation.

Sonographic Accuracy as a Novel Tool for Point-of-care Ultrasound Competency Assessment.

OBJECTIVES: The Focused Assessment with Sonography in Trauma (FAST) is a point-of-care ultrasound (PoCUS) study that is routine in trauma patient assessment. Many organizations have published training guidelines, which grant competency through the completion of a fixed number of observed scans. This approach is incongruent with current trends in competency-based medical education. We aim to objectively quantify probe motion and user accuracy to differentiate groups of PoCUS operators. METHODS: Emergency medicine residents were recruited in two groups. The novice group (n = 15) had limited PoCUS experience, whereas the intermediate group (n = 14) had completed at least 50 supervised FAST examinations. Both groups underwent assessment on a live human model. Residents from the novice group returned (n = 9) after completing a curriculum and repeated the assessment using the identical experimental construct. RESULTS: Significant differences (p < 0.05) were found between the novice and both the intermediate and the novice returned groups in time, path length, and points of interest (POIs) scanned. Novices required more time to complete the full examination (290.82 seconds vs. 197.41 seconds vs. 271.79 seconds), utilized more motion (9392.07 mm vs. 4052.73 mm vs. 4985.05 mm), and imaged fewer POIs (48.13% vs. 95.00% vs. 100.00%) when compared to intermediates and returning novices, respectively. No difference was found between the intermediate and novice returned groups for the complete examination. Spearman's correlation was calculated between variables within each group. Correlations between time and path length were statistically significant (p < 0.05) with novice, intermediate, and novice returned values of 0.67, 0.65, and 0.90. Interestingly, neither time nor path length consistently correlated with POIs scanned in any group. CONCLUSION: Differences in probe motion efficiency and POIs scanned between novices and intermediate or returning novice users show promise for use as a quantitative objective assessment tool. Unlike in surgical literature, accuracy did not correlate with path length or time to examination completion.

Development and Evaluation of a Simulation-based Curriculum for Ultrasound-guided Central Venous Catheterization.

OBJECTIVE: To develop a simulation-based curriculum for residents to learn ultrasound-guided (USG) central venous catheter (CVC) insertion, and to study the volume and type of practice that leads to technical proficiency. METHODS: Ten post-graduate year two residents from the Departments of Emergency Medicine and Anesthesiology completed four training sessions of two hours each, at two week intervals, where they engaged in a structured program of deliberate practice of the fundamental skills of USG CVC insertion on a simulator. Progress during training was monitored using regular hand motion analysis (HMA) and performance benchmarks were determined by HMA of local experts. Blinded assessment of video recordings was done at the end of training to assess technical competence using a global rating scale. RESULTS: None of the residents met any of the expert benchmarks at baseline. Over the course of training, the HMA metrics of the residents revealed steady and significant improvement in technical proficiency. By the end of the fourth session six of 10 residents had faster procedure times than the mean expert benchmark, and nine of 10 residents had more efficient left and right hand motions than the mean expert benchmarks. Nine residents achieved mean GRS scores rating them competent to perform independently. CONCLUSION: We successfully developed a simulation-based curriculum for residents learning the skills of USG CVC insertion. Our results suggest that engaging residents in three to four distributed sessions of deliberate practice of the fundamental skills of USG CVC insertion leads to steady and marked improvement in technical proficiency with individuals approaching or exceeding expert level benchmarks.

E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction.

OBJECTIVES: Rapid assessment of left ventricular ejection fraction (LVEF) may be critical among emergency department (ED) patients. This study examined the predictive relationship between ED physician performed bedside mitral-valve E-point septal separation (EPSS) measurements to the quantitative, calculated LVEF. We further evaluated the relationship between ED physician visual estimates of global cardiac function (GCF) and calculated LVEF values. METHODS: A prospective observational study was conducted on a sequential convenience sample of patients receiving comprehensive transthoracic echocardiography (TTE). Three ED ultrasound fellows performed bedside ultrasound examinations to obtain both EPSS measurements and subjective visual GCF estimates. A linear regression analysis was conducted to examine the relation of EPSS to the calculated LVEF from the comprehensive TTE. Agreement (modified Cohen κ) between ED ultrasound fellow GCF estimates and the calculated LVEF was also assessed. RESULTS: Linear regression analyses revealed a significant correlation (r=0.73, P<.001) between bedside EPSS and the calculated LVEF. The sensitivity and specificity of an EPSS measurement of greater than 7 mm for severe systolic dysfunction (LVEF≤30%) were 100.0% (95% confidence interval, 62.9-100.0) and 51.6% (95% confidence interval, 38.6-64.5), respectively. Subjective estimates of GCF were moderately correlated with calculated LVEF (Cohen κ=0.58). CONCLUSIONS: Measurements of EPSS by ED physicians were significantly associated with the calculated measurements of LVEF from comprehensive TTE. Subjective visual estimates of GCF, however, demonstrated only moderate agreement with the calculated LVEF. An EPSS measurement greater than 7 mm was uniformly sensitive at identifying patients with severely reduced LVEF.

Hepatic abscess: case report and review.

Hepatic abscess is an uncommon occurrence in North America, but can be a diagnostic challenge for emergency department physicians. The clinical signs and symptoms may vary, leading to delays in diagnosis and higher morbidity. We present a case of a 35-year old male with a hepatic abscess initially misdiagnosed as pneumonia. On subsequent return to the ED for back pain complaints, a bedside ultrasound led to the appropriate diagnosis. This case report and discussion will attempt to review the literature on the etiology, diagnosis and treatment of hepatic abscess for the emergency physician.

DNA from probiotic bacteria modulates murine and human epithelial and immune function.

BACKGROUND & AIMS: The intestinal epithelium must discriminate between pathogenic and nonpathogenic bacteria and respond accordingly. The aim of this study was to examine whether bacterial DNA can serve as the molecular basis for bacterial recognition. METHODS: HT-29 monolayers were treated with various bacterial DNA and interleukin (IL)-8 secretion measured by enzyme-linked immunosorbent assay, nuclear factor kappaB activation by electrophoretic mobility shift assay and reporter assays, and IkappaB levels by Western blotting. Cytokine secretion in response to bacterial DNA was measured in murine colonic segments and splenocytes. IL-10-deficient mice were fed DNA from VSL probiotic compound daily for 2 weeks. Colons were removed and analyzed for cytokine production and inflammation. RESULTS: HT-29 cells responded with IL-8 secretion to bacterial DNA in a differential manner. In the presence of proinflammatory stimuli, VSL3 DNA inhibited IL-8 secretion, reduced p38 mitogen-activated protein kinase activation, delayed nuclear factor kappaB activation, stabilized levels of IkappaB, and inhibited proteasome function. VSL3 DNA inhibited colonic interferon (IFN)-gamma secretion in mouse colons and also attenuated a Bacteroides vulgatus-induced IFN-gamma release from murine splenocytes. In mice, VSL3 DNA attenuated a systemic release of tumor necrosis factor alpha in response to Escherichia coli DNA injection. Treatment of IL-10-deficient mice with oral VSL3 DNA resulted in a reduction in mucosal secretion of tumor necrosis factor alpha and IFN-gamma and an improvement in histologic disease. CONCLUSIONS: DNA from probiotic bacteria can limit epithelial proinflammatory responses in vivo and in vitro. Systemic and oral administration of VSL3 DNA ameliorates inflammatory responses.