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UCDMC Ultrasound

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by

Stanley Sady

on 1 September 2014

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Transcript of UCDMC Ultrasound

UCDMC Point of Care Ultrasound Program
FOCUS Ultrasound
FOCUS Transthoracic Ultrasound (TTE)

Regional
TEE
Emergency Medicine
Anesthesiology and Pain Medicine
Critical Care Medicine
Selfie
PLAX
Let's Get FOCUSed!!!
Faculty Disclosure
I have no financial interest/affiliation that may affect this presentation.

No ASA statement/policies

No ASE credentialing

Pattern recognition vs visualization in 3D

Repetition
No formal training in TTE
CAVEATS
Board Certified in TEE not TTE

No animals were harmed in the preparation of this lecture.

Peer Review Session
Questions??
There are no dumb questions.

Ask questions anytime.

However....
5 Views
PSLAX
PSLAX
PSAX
KISS
(Keep It Simple Stupid)
Volume ?
Function ?
Department specific FOCUS TTE Proposal

Strong departmental and other leadership support

Specific policies and procedures

Residents/Fellows/Faculty

QA/QI

A point-of-care ultrasound examination is performed according to standardized but restricted scanning protocol

Does not replace and is not equivalent to the diagnostic echocardiographic study


Add information to the physical examination

Performed by an operator not necessarily fully trained in echocardiography but appropriately trained in FoCUS, who is at the same time usually responsible for immediate decision-making and/or treatment.

SCIVC
A4C
SC4C
“Goal-focused” transthoracic echocardiography
Is a limited scope (as compared with comprehensive examination) echocardiographic examination

Performed by the treating physician in acute care medical practice

Aimed at addressing specific clinical concerns

Other pathologic diagnoses may be suspected on FOCUS, but additional evaluation, including referral for comprehensive echocardiography or cardiology consultation, is recommended.

Intracardiac masses
LV thrombus
Valvular dysfunction
Endocarditis,
Aortic dissection

Further hemodynamic assessment of intracardiac pressures, valvular pathology, and diastolic function requires additional training in comprehensive echocardiography techniques
Alphabetic Soup
POCUS (Point of Care Ultrasound)
BLEEP (Bedside Limited Echo for Emergency Physician)
CLUE (Cardiovascular Limited Ultrasound Examination)
FAST (Focused Assessment with Sonography in Trauma)
e-FAST (Extended FAST)
RUSH (Rapid Ultrasound in Shock)
UPH (Ultrasound Hypotensive Protocol)
FATE (Focus Assessed Transthoracic Echo)
RACE (Rapid Assessment by Cardiac Echo)
FEEL (Focused Echocardiography in Life Support)
HEART (Hemodynamic Echo Assessment in Real Time)
INBU (Intensivist Bedside Ultrasound)
FCU (Focused Cardiac Ultrasound)

Academic Institution
Research
In anesthesiology, there are few data evaluating the effect of echocardiography diagnosis on clinical decision-making, and these are mostly series of case reports or proof-of-concept observational studies.

Research

Simulator vs real patient learning
Residents vs Faculty
TEE trained vs novice
TTE vs TEE

Service
Clinical
In anesthesiology, there are few data evaluating the effect of echocardiography diagnosis on clinical decision-making, and these are mostly series of case reports or proof-of-concept observational studies.

Research
Simulator vs real patient learning
Residents vs Faculty
TEE trained vs novice
TTE vs TEE

A Modest Proposal
Politics

Competence in critical care ultrasonography is based on the identification of distinct patterns that are associated with clinical syndromes, but not on a state-of- the-art examination.


Basic-level critical care echocardiography favors specificity over sensitivity: definite findings may lead to changes in patient management, whereas uncertain findings require consultation.

Diagnostic ultrasound (including cardiovascular ultrasound)
Has the potential to contribute much to patient care, and restricting its use is neither feasible nor fair to patients.

On the other hand, used poorly, it has the potential to contribute to misdiagnosis, need- less downstream testing or treatment and possible patient harm.

There is a wide body of literature that Royse et al. cited, which demonstrates that teaching basic ultrasound to novices can be achieved.

However, it must be ensured that before taking it to the next level, practitioners are minted in a manner that achieves excellence.

“Opposing the wider use of ultrasound is not appropriate or realistic”.

Other
Surgery
General
Cardiothoracic
Vascular
Trauma
Why a "Modest Proposal"?
Policies
Credentialing and Privileges
Supervision
Scope of practice
Machine maintenance
Continuing education
Billing

Barriers
Time

Cost

Equipment

Administrative support

Quality Assurance/Improvement
Image archiving (DICOM)

Standardize documentation

Image Review

My Proposal for Focus TTE
Credentialing and Privileges

Didactic lecture (60 mins)
Anatomy
Pathology
Ultrasound Modules (CME)
Two online modules
Core concepts in ultrasound
Safety
Machine use
Physics of ultrasound
Hands-on
Simulator (30 mins)
Supervised Patients(n= 10)
Non-supervised Patients(n=10)

Policies and Procedures

Documentation form

Team
Core group
Interested
Advocates
United front
Protocols
Practice style
Reinforcing the rules
Non Core group
Chair buys in to promote US
Fund training push
Require minimum skill set
Team US plays supportive, positive role
Residents
Fellows
Students

Requirements
Faculty, Fellows, Residents

General tools for the assessment of competency in FoCUS currently do not exist and each respective specialty should be encouraged to work on defining and implementing them in the training process.

In patients who are critically ill, FCU has been shown to be helpful to traditional bedside assessment in determining volume status and LV systolic function.

In patients who are hemodynamically unstable, FCU diagnoses may impact therapy in terms of the use of volume repletion, vasopressors, and inotropes, as well as diuretics and vasodilators.

Thank you
http://pie.med.utoronto.ca/TTE/TTE_content/assets/applications/FOCUS/index.htm


(J Am Soc Echocardiogr 2014;27:683.e1-e33.)
Full transcript