CORONA (COre ultRasOund of covid in iNtensive care and Acute medicine) study: National service evaluation of lung and heart ultrasound in intensive care patients with suspected or proven COVID-19.

Background: Combined Lung Ultrasound (LUS) and Focused UltraSound for Intensive Care heart (FUSIC Heart - formerly Focused Intensive Care Echocardiography, FICE) can aid diagnosis, risk stratification and management in COVID-19. However, data on its application and results are limited to small studies in varying countries and hospitals. This United Kingdom (UK) national service evaluation study assessed how combined LUS and FUSIC Heart were used in COVID-19 Intensive Care Unit (ICU) patients during the first wave of the pandemic. Method: Twelve trusts across the UK registered for this prospective study. LUS and FUSIC Heart data were obtained, using a standardised data set including scoring of abnormalities, between 1st February 2020 to 30th July 2020. The scans were performed by intensivists with FUSIC Lung and Heart competency as a minimum standard. Data was anonymised locally prior to transfer to a central database. Results: 372 studies were performed on 265 patients. There was a small but significant relationship between LUS score >8 and 30-day mortality (OR 1.8). Progression of score was associated with an increase in 30-day mortality (OR 1.2). 30-day mortality was increased in patients with right ventricular (RV) dysfunction (49.4% vs 29.2%). Severity of LUS score correlated with RV dysfunction (p < 0.05). Change in management occurred in 65% of patients following a combined scan. Conclusions: In COVID-19 patients, there is an association between lung ultrasound score severity, RV dysfunction and mortality identifiable by combined LUS and FUSIC Heart. The use of 12-point LUS scanning resulted in similar risk score to 6-point imaging in the majority of cases. Our findings suggest that serial combined LUS and FUSIC Heart on COVID-19 ICU patients may aid in clinical decision making and prognostication.

Guest Editorial - Enhanced Care: Developing the resource within Acute Medicine.

Critical Care Units provide care to those patients who traditionally need "organ support". There is variation in provision and "admission criteria" across the UK, and although Level 2 admissions have been increasing this often reflects increasing perioperative demand and largely ignores the unmet and often unmeasured medical need.

Enhanced Care Units: Guidance on development and implementation within Acute Medicine.

The Society for Acute Medicine (SAM) and Intensive Care Society (ICS) have produced joint guidance on the standards of care and infrastructure required to deliver enhanced care within Acute Medicine. The cohort of patients this relates to are in the most part already being looked after on the AMU, but co-location and providing enhanced monitoring and nursing input will ensure safe, high-quality care can be delivered to them. We strongly support the development of enhanced care units, whilst clearly acknowledging that they are not a replacement for critical care where that is indicated. Enhanced care and critical care complement each other and will help foster the close working between the two specialties that modern acute care requires. This guidance draws on expertise and existing relevant guidance from the two societies, alongside that from the Faculty of Intensive Care Medicine (FICM), British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE) and NHS England / Improvement (NHSE/I). We recognise this is an area with limited evidence and so will aim to review it regularly as the knowledge and experience in this area increases.

Geographic variation in point of care ultrasound provision: results from a national audit.

BACKGROUND: There is an emerging consensus that point-of-care ultrasound is an essential skill in acute care. This is reflected in recent changes to the Acute Internal Medicine curriculum in the UK. The need to develop and maintain specific ultrasound competencies is now a mandatory component of training. There is a degree of uncertainty as to how existing training infrastructure can best accommodate these changes. METHODS: Data were obtained from the latest annual Society for Acute Medicine Benchmarking Audit 2021. All Acute Medical Units in the UK are eligible to participate. Data pertaining to the number of ultrasound machines and number of clinicians that regularly use point of care ultrasound were collected. This was used to develop a series of maps demonstrating variation in provision at the national level. RESULTS: In total, 123 AMUs responded to the questions related to ultrasound prevalence and numbers of trained clinicians. Of these, 78.9% (97/123) reported having access to at least one ultrasound machine. There was at least one clinician that regularly used ultrasound in 81 responding hospitals (65.9%). There was significant geographic heterogeneity in the use of ultrasound and availability of accredited supervisors. At a regional level, ultrasound expertise is typically concentrated within a relatively small number of hospitals. CONCLUSION: Geographic variation in the use of ultrasound and availability of registered supervisors represents a significant challenge to ultrasound training provision at the national level. Targeted interventions in areas with less developed training infrastructure, such as regional training hubs may be required to ensure more equitable access to training opportunities.

Point-of-care ultrasound rapidly and reliably diagnoses renal tract obstruction in patients admitted with acute kidney injury.

Point-of-care ultrasound (POCUS) is increasingly being used in the management of the acutely unwell patient. Its role in the breathless and shocked patient is well established, but less so for those patients with acute kidney injury (AKI). This local quality improvement project looked at the diagnostic accuracy of a protocolised POCUS versus departmental ultrasound. It provides the first data within the internal medicine setting to suggest that POCUS can rapidly and reliably diagnose renal tract obstruction, showing a sensitivity of 90% and a specificity of 100%. Additionally, negative predictive value was 99% suggesting it is a tool which can reduce the need for departmental ultrasound. More work is needed to see if this data is generalisable to other internal medicine settings, and to assess potential outcomes on patient management and length of stay.

Should point-of-care ultrasound become part of healthcare worker testing for COVID?

The NHS in England has rapidly expanded staff testing for COVID-19 in order to allow healthcare workers who would otherwise be isolating with symptoms suspicious of COVID-19 to be cleared to work. However, the high false negative rate associated with current RT-PCR tests could put other staff, family members and patients at risk. We believe combining swab testing with real-time lung ultrasound (LUS) would improve the ability to rule-in COVID-19 infection in those requiring screening.

British Thoracic Society Training Standards for Thoracic Ultrasound (TUS).

INTRODUCTION: The British Thoracic Society (BTS) responded to a call from the pleural community to establish this new Training Standard to detail the capabilities in practice for thoracic ultrasound (TUS), which will build on the previous curricula and extend the remit to include training for the emergency provision of TUS. METHODS: BTS convened a working group to produce a set of Training Standards. RESULTS: This document provides a comprehensive Training Standard for TUS facilitating timely and improved management of patients with respiratory presentations, particularly (but not exclusively) pleural pathologies. DISCUSSION: The Training Standards document will be widely disseminated.

Point-of-care ultrasound (POCUS): unnecessary gadgetry or evidence-based medicine?

Over the last decade there has been increasing interest and enthusiasm in point-of-care ultrasound (POCUS) as an aide to traditional examination techniques in assessing acutely unwell adult patients. However, it currently remains the domain of a relatively small handful of physicians within the UK. There are numerous reasons for this, notably a lack of training pathways and supervisors but also a lack of understanding of the evidence base behind this imaging modality. This review article aims to explore some of the evidence base behind POCUS for a number of medical pathologies, and where possible compare it to evidenced traditional examination techniques. We discuss the issues around training in bedside ultrasound and recommend a push to integrate POCUS training into internal medicine curricula and support trainers to comprehensively deliver this.

Do medical admission pro formas -improve the completeness of documentation? A multisite observational study.

There is little evidence as to whether clerking pro formas are more or less effective than continuation sheets for the acute medical admission clerking process. This two site audit aimed to assess the effect of introducing clerking pro formas on the completeness of documentation in 32 areas. Data were collected at two sites both pre- and post-introduction of two different clerking pro formas, and a two-tailed z-test used to assess the significance in changes in documentation at each individual site and combined across both sites. Site one showed improvements in 23/32 areas, with 7/32 (21.9%) being significant; three areas saw a decline and 1/32 showed a statistically significant decline. Site two showed improvement across 25/32 sites with 19 (59.4%) being significant; there were no areas showing less complete documentation. Cross-site analysis showed improvements in 30/32 categories, with 15 (46.9%) being significant; one area showed a non-significant decline. The greatest percentage improvement was seen in documentation of cardiopulmonary resuscitation / escalation decisions - an important consideration in this clinically unstable population. The introduction of clerking pro formas across two sites improved the completeness of documentation in a number of areas. This data supports the widespread introduction of clerking pro formas as a tool to improve the completeness of admission documentation.

From revered to commiserated: the changing role of the medical registrar.

The role of the medical registrar has changed significantly over the last few years, and in many respects this has not been for the better. Both the perception and the realities of the general internal medicine component of higher specialist training have led to significant pressures on recruitment to specialty training posts. Core trainees do not feel prepared to become the medical registrar and those in the role highlight substantial problems that impact on the quality of care they can deliver. This article aims to explore some of these difficulties and where possible suggest potential solutions; there needs to be urgent action undertaken to stave off a potential crisis in registrar recruitment and retention. Despite this, the role of the medical registrar remains a hugely fulfilling part of a physician's career, and there is much to be celebrated and embraced about the qualities a registrar brings to the successful functioning of both general and specialist medical teams.

When is a stroke not a stroke? An unusual mimic presenting to AMU.

INTRODUCTION: Creutzfeldt-Jakob disease (CJD) is a rare prion disease classically manifesting with rapidly progressive dementia, abnormal movements and typical electroencephalographic (EEG) changes. CASE REPORT: A 74 year-old Caucasian man was recently discharged from another centre diagnosed with a stroke. He re-presented to our acute medical unit with worsening symptoms, and stroke remained the working diagnosis. Collateral history revealed a progressive cognitive decline and unilateral myoclonus. Further investigations supported the diagnosis of probable CJD, confirmed by the national CJD surveillance centre. DISCUSSION: Signs and symptoms atypical of stroke should raise the possibility of alternative diagnoses, including prion disease. CJD can present with unilateral symptoms, EEG and MRI changes. Early diagnosis prevents unnecessary investigations and treatments, allowing early palliative care input, where appropriate.

Focused Acute Medicine Ultrasound (FAMUS) - point of care ultrasound for the Acute Medical Unit.

Point of care ultrasound (POCU) is becoming increasingly popular as an extension to clinical examination techniques. Specific POCU training pathways have been developed in specialties such as Emergency and Intensive Care Medicine (CORE Emergency Ultrasound and Core UltraSound Intensive Care, for example), but until this time there has not been a curriculum for the acutely unwell medical patient outside of Critical Care. We describe the development of Focused Acute Medicine Ultrasound (FAMUS), a curriculum designed specifically for the Acute Physician to learn ultrasound techniques to aid in the management of the unwell adult patient. We detail both the outline of the curriculum and the process involved for a candidate to achieve FAMUS accreditation. It is anticipated this will appeal to both Acute Medical Unit (AMU) clinicians and general physicians who deal with the unwell or deteriorating medical or surgical patient. In time, the aspiration is for FAMUS to become a core part of the AIM curriculum.

Acute Internal Medicine Trainee Survey 2015.

OBJECTIVES: To ascertain current Acute Internal Medicine (AIM) trainees' opinions on their training programme, practical procedures, specialist skills and AIM as a specialty. This can then be used to feedback to the national training committee to help shape training priorities. METHODS: Online survey sent to all AIM Higher Specialty Trainees registered on the Society for Acute Medicine database, and advertised through e-mail communication and social media. RESULTS: The majority of trainees (55.5%) were quite happy or very happy with their training currently, although significant difficulties were highlighted with time off for specialist skill training and difficulty achieving certain procedural skills. The majority of trainees believe ultrasound should form a core component of AIM training (82.3%). A high proportion of trainees would recommend AIM as a specialty despite these difficulties. CONCLUSIONS: A number of issues were highlighted causing difficulties within AIM training, despite which the vast majority of trainees would recommend AIM as a career choice. The results were fed back to the training committee in March.