Recent studies have shown that point of care ultrasound is a valuable tool in the assessment and management of shock in the Emergency Department (ED). Despite proven utility, data is limited on the current utilization and quality assurance of POCUS in ED management of shock. The aim of this study was to determine the rate of POCUS use, characterize data collection methods and determine rate of quality assurance in both the ED and Intensive Care Unit (ICU) of a tertiary care academic center.
The study included all patients who visited the ED from Jan-Jun 2015 that were transferred to the ICU, and were in shock, as determined by sBP <90, diagnostic code or vasopressor use. Patient charts, as well as wirelessly archived ultrasound studies were reviewed to determine which patients had POCUS performed, and how the results were recorded. By reviewing formal worksheets archived online, it could be determined if a management change was recommended, if studies were over-read for quality assurance and if improvement was recommended to image acquisition or interpretation.
Both departments used POCUS in roughly half of patients presenting in shock (53% ED, 41% ICU) with no statistical difference in usage (Δ12, 95% CI −0.01 to 0.25; p=0.06). Most ED studies (87%), had some form of documentation either on paper or online, however few (9%) had a formal worksheet completed. In comparison 71% of ICU studies had a worksheet. There was no difference in the number of performed scans that were saved electronically (66% ED vs 71% ICU; Δ5%, 95%CI −0.13 to 0.21; p=0.60).In the ICU the majority (77%) of the formal reports recommended a management change as a direct result of scan findings. Furthermore, of worksheets submitted for quality assurance (88%), over half the reviews (55%) suggested an improvement in image acquisition or interpretation.
To our knowledge, our study is the first to demonstrate that POCUS is only utilized in about half of the shock cases in ED and ICU. Given that the majority of the formally reported studies in the ICU that were over-read for quality assurance found areas for potential improvement and given that the majority of ED studies were reported informally, it stands to reason that POCUS operators in the ED could benefit from a formalized quality assurance program. Future studies should explore potential barriers to implementation of such a program.