Bedside POCUS during ward emergencies is associated with improved diagnosis and outcome: an observational, prospective, controlled study

Abstract

Background: Rapid response teams are intended to improve early diagnosis and intervention in ward patients who develop acute respiratory or circulatory failure. A management protocol including the use of a handheld ultrasound device for immediate point-of-care ultrasound (POCUS) examination at the bedside may improve team performance. The main objective of the study was to assess the impact of implementing such a POCUS-guided management on the proportion of adequate immediate diagnoses in two groups. Secondary endpoints included time to treatment and patient outcomes.

Methods: A prospective, observational, controlled study was conducted in a single university hospital. Two teams alternated every other day for managing in-hospital ward patients developing acute respiratory and/or circulatory failures. Only one of the team used an ultrasound device (POCUS group).

Results: We included 165 patients (POCUS group 83, control group 82). Proportion of adequate immediate diagnoses was 94% in the POCUS group and 80% in the control group (p = 0.009). Time to first treatment/intervention was shorter in the POCUS group (15 [10-25] min vs. 34 [15-40] min, p < 0.001). In-hospital mortality rates were 17% in the POCUS group and 35% in the control group (p = 0.007), but this difference was not confirmed in the propensity score sample (29% vs. 34%, p = 0.53).

Conclusion: Our study suggests that protocolized use of a handheld POCUS device at the bedside in the ward may improve the proportion of adequate diagnosis, the time to initial treatment and perhaps also survival of ward patients developing acute respiratory or circulatory failure. Clinical Trial Registration NCT02967809. Registered 18 November 2016, https://clinicaltrials.gov/ct2/show/NCT02967809 .

Keywords: Handheld ultrasound device; In-hospital emergencies; POCUS; Rapid response team.

Fig. 1

POCUS-guided managements: ultrasound protocol. (a) Circulatory failure protocol. Use of the HHUD (Vscan Dual Probe extend^™, General Electric Healthcare): Cardiac assessment with sector transducer to access the LV and RV function: (1) subcostal view or (2) apical four-chamber view–Pulmonary assessment with the linear transducer: (1) anterior chest based between the clavicle to the diaphragm and the mid-axillary line (2) pleural bases. Abbreviations: EFLV, ejection fraction left ventricular; IVC, inferior vena cave; LV, left ventricular; RA, right auricle; RV, right function. (b) Respiratory failure protocol. Use of the HHUD (Vscan Dual Probe extend^™, General Electric Healthcare): Pulmonary assessment with the linear transducer: (1) anterior chest based between the clavicule to the diaphragm and the mid-axillary line (2) pleural bases. Cardiac assessment with the sector transducer to assess the right ventricular function: (1) subcostal view or n apical four-chamber view. Deep venous assessment with the linear transducer to identify thrombosis: femoral and popliteal veins. The visual EFLV helps to differentiate between cardiogenic edema (EFLV altered) and acute interstitial lung disease (non-cardiogenic edema) (EFLV not altered). Abbreviations: EFLV, ejection fraction left ventricular; COPD, chronic obstructive pulmonary disease

Fig. 2

Flowchart. * p = 0.009, ** p = 0.007. Details of excluded patients by groups: control group: 4 immediate withholding and withdrawal of life-sustaining treatments; 2 twice inclusion; 4 missing data; 2 transplant’s patients; 1 cardiac arrest. POCUS group: 3 immediate withholding and withdrawal of life-sustaining treatments; 8 missing data; 3 twice inclusion; 1 cardiac arrest