A case for mandatory ultrasound training for rural general practitioners: a commentary
Arnold AC, Fleet R, Lim D. A case for mandatory ultrasound training for rural general practitioners: a commentary . Rural and Remote Health 2021; 21:6328. Full text is open access:: https://doi.org/10.22605/RRH6328
Don’t disagree. Increasing access to cheaper devices (e.g. Butterfly) and multiple training opportunities including Postgraduate Certificate in Clinician-Performed Ultrasound (PGCertCPU) will hopefully open up this diagnostic modality to more clinicians and patients. Multiple GPs and rural hospital docs have now done PGCertCPU.
Adequate peer-review and credentialing for clinicians, especially those in isolated practices/facilities, remains an issue.
Context: Point-of-care ultrasound is a rapidly evolving technology that enables rapid diagnostic imaging to be performed at a patient’s bedside, reducing time to diagnosis and minimising the need for patient transfers. This has significant applications for rural emergency and general practice, and could potentially prevent unnecessary transfers of patients from rural communities to more urban centres for the purpose of diagnostic imaging, reducing costs and preventing disruption to patients’ lives. Meta-analyses on point-of-care ultrasound have reported extremely high sensitivity and specificity when detecting lung pathology, and the potential applications of the technology are substantial. A significant application of the technology is in the care of rural paediatric patients, where acute lower respiratory pathology is the most common cause of preventable deaths, hospitalisations, and emergency medical retrievals from remote communities for children under five.
Issues: Although widely available, point-of-care ultrasound technology is not widely utilised in Australian emergency departments and general practices. Issues with comprehensive training, maintenance of skills, upskilling and quality assurance programs prevent physicians from feeling confident when utilising the technology. In Canada, point-of-care ultrasound training is part of the core competency training in the Royal College of Physicians of Canada emergency medicine fellowship program. Point-of-care ultrasound is widely used in rural practice, although lack of training, funding, maintenance of skills and quality assurance were still listed as barriers to use.
Lessons learned: Point-of-care ultrasound is a highly sensitive and specific technology with wide potential applications. Issues with quality control and maintenance of skills are preventing widespread use. Coupling point-of-care ultrasound with telemedicine could help increase the usability and accessibility of the technology by reducing the issues associated with maintenance of skills and quality assurance.
Australia, diagnostic imaging, paediatric diagnostic imaging, patient transfers, point-of-care ultrasound, rural medicine, telemedicine, training protocol.
Thanks to Fiona Doolan-Noble for forwarding this paper.
POCUS influences clinical management – part 394.
Nixon G, Blattner K, Finnie W, Lawrenson R, Kerse N. Use of point‐of‐care ultrasound for the assessment of intravascular volume in five rural New Zealand hospitals. Can J Rural Med 2019;24:109‐14.
Another of Garry’s papers on POCUS, again showing it alters clinical decisions, this time for assessing intravascular volume.
Introduction: Measuring the diameter of the inferior vena cava (IVC) or the height of the jugular venous pressure (JVP) with point‐of‐care ultrasound (POCUS) is a practical alternative method for estimating a patient’s intravascular volume in the rural setting. This study aims to determine whether or not POCUS of the IVC or JVP generates additional useful clinical information over and above routine physical examination in this context.
Methods: Twenty generalist physicians, working in five New Zealand rural hospitals, recorded their estimation of a patient’s intravascular volume based on physical examination and then again after performing POCUS of the IVC or JVP, using a visual scale from 1 to 11.
Results: Data were available for 150 assessments. There was an only moderate agreement between the pre‐ and post‐test findings (Spearman’s correlation coefficient = 0.46). In 28% (42/150) of cases, the difference was four or more points on the scale, and therefore, had the potential to be clinically significant.
Conclusion: In the rural context, POCUS provides new information that frequently alters the clinician’s estimation of a patient’s intravascular volume.
Nixon G, Blattner K, Muirhead J, Kiuru S, Kerse N. Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care. Rural and Remote Health 2019; 19: 5027.
Open access: https://doi.org/10.22605/RRH5027
Subgroup analysis of a larger study into Point-of-care ultrasound in rural NZ hospitals. This study looked at AAA and FAST scans performed by rural clinicians. Scans were correctly interpreted 91% in AAA scans and 97% in the case of FAST. Management was changed on the basis of this scan in 25% of cases for AAA scans and 20% for FAST. This is consistent with international emergency department literature.
This series of papers from this rural POCUS dataset continues to show the utility and benefits of bedside imaging. What was life like BU?
Introduction: Point-of-care ultrasound (POCUS) has the potential to improve access to diagnostic imaging for rural communities. This article evaluates the sensitivity and specificity, impact on patient care, quality and safety of two common POCUS examinations – focused assessment with sonography in trauma (FAST) and aortic aneurysm (AAA) – in the rural context.
Methods: This study is a subgroup analysis of a larger study into POCUS in rural New Zealand. Twenty-eight physicians in six New Zealand rural hospitals, with limited access to formal diagnostic imaging, completed a questionnaire before and after POCUS scans to assess the extent to which it altered diagnostic certainty and patient disposition (discharge v admission to rural hospital v transfer to urban hospital). The investigators and a specialist panel reviewed images for technical quality and accuracy of interpretation, and patient clinical records, to determine accuracy of the POCUS findings and their impact on patient care.
Results: For FAST and AAA scans respectively, sensitivities were 75% and 100%, and specificities 100% and 93%; rural doctors correctly interpreted their POCUS images for 97% and 91% of scans. The proportions of scans that had either a ‘significant’ or ‘major’ impact on patient care were 17% and 31%. POCUS resulted in the disposition being de-escalated for 15% and 10% of patients and escalated for 5% and 3% of patients.
Conclusions: In the rural context, POCUS AAA is a reliable ‘rule out’ test for ruptured abdominal aortic aneurysm and FAST scan has a role as a ‘rule in’ test for solid organ injury. These findings are consistent with larger studies in the emergency medicine literature.
Rural point-of-care ultrasound of the kidney and bladder: quality and effect on patient management
Nixon Garry, Blattner Katharina, Muirhead Jill, Kerse Ngaire (2018) Rural point-of-care ultrasound of the kidney and bladder: quality and effect on patient management. Journal of Primary Health Care , -.
POCUS really is a incredible tool that makes a large difference to clinicians and patients. No suprise here to see bladder and kidney scans having high sens and spec for urinary retention and hydronephrosis amongst rural hospital doctors. There needs to be a national credentialling service for rural clinicians to tap into.
INTRODUCTION: Point-of-care ultrasound (POCUS) of the kidney and bladder are among the most commonly performed POCUS scans in rural New Zealand (NZ).AIM: To determine the quality, safety and effect on patient care of POCUS of the kidney and bladder in rural NZ.METHODS: Overall, 28 doctors in six NZ rural hospitals completed a questionnaire both before and after undertaking a POCUS scan over a 9-month period. The clinical records and saved ultrasound images were reviewed by a specialist panel.
RESULTS: The 28 participating doctors undertook 138 kidney and 60 bladder scans during the study. POCUS of the bladder as a test for urinary retention had a sensitivity of 100% (95% CI 88–100) and specificity of 100% (95% CI 93–100). POCUS of the kidney as a test for hydronephrosis had a sensitivity 90% (95% CI 74–96) and specificity of 96% (95% CI 89–98). The accuracy of other findings such as renal stones and bladder clot was lower. POCUS of the bladder appeared to have made a positive contribution to patient care in 92% of cases without evidence of harm. POCUS of the kidney benefited 93% of cases, although in three cases (2%), it may have had a negative effect on patient care.
DISCUSSION: POCUS as a test for urinary retention and hydronephrosis in the hands of rural doctors was technically straightforward, improved diagnostic certainty, increased discharges and overall had a positive effect on patient care.
excuse the pun...
Nixon Garry, Blattner Kati, Muirhead Jillian, Finnie Wendy, Lawrenson Ross, Kerse Ngaire (2018) Scope of point-of-care ultrasound practice in rural New Zealand. Journal of Primary Health Care , -.
New article from UOO rural POCUS group. Not surprising that POCUS used with a broad scope of practice by rural generalists. Central governance good idea.
INTRODUCTION: Point-of-care ultrasound (POCUS) is an increasingly common adjunct to the clinical assessment of patients in rural New Zealand.
AIM: To describe the scope of POCUS being practiced by rural generalist hospital doctors and gain insights, from their perspective, into its effect.
METHODS: This was a mixed-methods descriptive study. Main outcome measures were type and frequency of POCUS being undertaken. A questionnaire was given to POCUS-active rural hospital doctors to survey the effect of POCUS on clinical practice and assess issues of quality assurance.
RESULTS: The most commonly performed scans were: cardiac (18%) and volume scans (inferior vena cava and jugular venous pressure) (14%), followed by gallbladder (13%), kidney (11%), Focused Assessment with Sonography in Trauma (FAST) (7%), bladder (6%), leg veins (6%) and lungs (5%). There was large variation in frequency of scan types between the study hospitals that could not be accounted for by differences in training.
DISCUSSION: Rural generalists consider the broad scope of POCUS they practise to be an important but challenging skill set. Clinical governance, including an agreed scope and standards, may increase the benefits and improve the safety of rural POCUS.