Ambulatory Use of Handheld Point-of-Care Ultrasound (HH-POCUS) in Rural Brandenburg – A Pilot Study

Abstract

Purpose This study aims to evaluate the use of handheld ultrasound devices (HHUS) for point-of-care ultrasound (POCUS) to improve outpatient care in rural Brandenburg.

Materials and Methods A group of general practitioners (n = 9), palliative care physicians (n = 6), emergency physicians (n = 4), and nurses from palliative care services (n = 5) participated in this study. Following a 3-hour workshop and 2 weeks of individual training, participants performed POCUS using HHUS (HH-POCUS). Indications, examination results, and resulting treatment changes (e. g., acute interventions, new medication) were documented in a standardized data entry form.

Results 19 physicians with different ultrasound experience and 5 palliative care nurses attended the workshop program and took part in the study. Three of the participating physicians were out of training in ultrasound and received prolonged supervision. Among 427 HH-POCUS examinations, the FAST scan and kidney scan were performed most often. Pain and dyspnea were the most common indications for HH-POCUS. Among the examinations performed by physicians (n = 311), ascites was the most common pathology (27 % of cases). Using a simplified examination protocol, palliative care nurses diagnosed fluid collections, hydronephrosis and transurethral catheter position or urinary retention. In 80.4 % of physician-performed cases, HH-POCUS made a valuable impact on patient management. HH-POCUS contributed to treatment decisions in 49.5 % of cases, including a change of medication in 29.6 % and performance of therapeutic interventions in 19.9 %. Hospital admission or referral to an ambulatory specialist was initiated due to HH-POCUS findings in 17.7 % of patients.

Conclusion HH-POCUS helped doctors in rural areas to optimize patient care through rapid on-site collection of therapeutically relevant findings. In addition, it was shown that specialized and motivated nurses can independently detect simple ultrasound findings and thus provide clinically relevant information to doctors.

Zusammenfassung

Ziel In der Studie wird der Einsatz des Handheld-Ultraschalls (HHUS) in der ambulanten Point-of-Care (POCUS)-Versorgung in Brandenburg, einem Flächenland geringer Bevölkerungsdichte, evaluiert.

Material und Methode Hausärzte (n = 9), Palliativärzte (n = 6), Notärzte (n = 4) und Palliativpflegekräfte (n = 5) wurden eingeschlossen. Nach einem 3-stündigen Workshop und einem 2-wöchigen Individualtraining führten die Teilnehmer selbstständig ambulante POCUS-Untersuchungen mit HHUS-Geräten (HH-POCUS) durch. Indikationen, Befunde und resultierende Behandlungsänderungen (Akutintervention, Medikationsänderung) wurden in einem Erhebungsbogen dokumentiert.

Ergebnisse 19 Ärzte mit unterschiedlicher Ultraschallerfahrung und 5 Palliativpflegekräfte nahmen an Workshop und Studie teil. Unter 427 HH-POCUS-Untersuchungen waren FAST- und Nierensonografie die häufigsten. Die häufigsten Indikationen waren Schmerz und Luftnot. Bei den 311 ärztlichen Untersuchungen war Aszites die häufigste Pathologie (27 %). Unter Anwendung eines deutlich vereinfachten Untersuchungsprotokolls diagnostizierten Palliativpflegekräfte Flüssigkeitsansammlungen, Harnstauung sowie die Position transurethraler Katheter bzw. Harnverhalt. In 80,4 % der ärztlichen Fälle hatte HH-POCUS Einfluss auf das weitere Patientenmanagement. In 49,5 % der Fälle trug HH-POCUS zur Therapieänderung bei, wobei es in 29,6 % zur Medikationsänderung kam und in 19,9 % eine therapeutische Intervention veranlasst wurde. Eine Krankenhauseinweisung oder Vorstellung in einer Spezialambulanz wurde aufgrund der HH-POCUS-Befunde bei 17,7 % der Patienten veranlasst.

Schlussfolgerungen HH-POCUS half Ärzten in ländlichen Gebieten, die ambulante Betreuung durch rasche Vor-Ort-Erhebung therapeutisch relevanter Befunde zu optimieren. Darüber hinaus wurde gezeigt, dass spezialisierte und motivierte Pflegekräfte selbstständig einfache Ultraschallbefunde detektieren und so Ärzten klinisch relevante Informationen liefern können.

Key words

point of care - palliative medicine - management decision - outpatient care - handheld ultrasound devices

Publication History

Received: 15 July 2020

Accepted: 11 January 2021

Article published online:
24 February 2021

• References

• 1 Bhagra A, Tierney DM, Sekiguchi H. et al. Point-of-Care Ultrasonography for Primary Care Physicians and General Internists. Mayo Clin Proc 2016; 91: 1811-1827
• 2 Wagner M, Shen-Wagner J, Zhang KX. et al. Point-of-Care Ultrasound Applications in the Outpatient Clinic. South Med J 2018; 111: 404-410
• 3 Spencer JK, Adler RS. Utility of portable ultrasound in a community in Ghana. J Ultrasound Med 2008; 27: 1735-1743
• 4 Becker DM, Tafoya CA, Becker SL. et al. The use of portable ultrasound devices in low- and middle-income countries: a systematic review of the literature. Trop Med Int Health 2016; 21: 294-311
• 5 Wright J, Noriega O, Ho H. The application of hand-held ultrasound scanner in teaching of telemedicine and rural medicine. Donald Schoo J Ultrasound Obstet Gynecol 2014; 8: 87-91
• 6 Piscaglia F, Dietrich CF, Nolsoe C. et al. Birth of echoscopy. Ultraschall in Med 2013; 34: 92
• 7 Nuernberg D, Jenssen C, Frohlich E. et al. Ultrasound in palliative care medicine, Part II. Z Gastroenterol 2017; 55: 582-591
• 8 Robertson TE, Levine AR, Verceles AC. et al. Remote tele-mentored ultrasound for non-physician learners using FaceTime: A feasibility study in a low-income country. J Crit Care 2017; 40: 145-148
• 9 Levine AR, McCurdy MT, Zubrow MT. et al. Tele-intensivists can instruct non-physicians to acquire high-quality ultrasound images. J Crit Care 2015; 30: 871-875
• 10 Levine AR, Buchner JA, Verceles AC. et al. Ultrasound images transmitted via FaceTime are non-inferior to images on the ultrasound machine. J Crit Care 2016; 33: 51-55
• 11 Shah S, Noble VE, Umulisa I. et al. Development of an ultrasound training curriculum in a limited resource international setting: successes and challenges of ultrasound training in rural Rwanda. Int J Emerg Med 2008; 1: 193-196
• 12 Adler D, Mgalula K, Price D. et al. Introduction of a portable ultrasound unit into the health services of the Lugufu refugee camp, Kigoma District, Tanzania. Int J Emerg Med 2008; 1: 261-266
• 13 Shmueli H, Burstein Y, Sagy I. et al. Briefly trained medical students can effectively identify rheumatic mitral valve injury using a hand-carried ultrasound. Echocardiography 2013; 30: 621-626
• 14 Flick D. Bedside Ultrasound Education in Primary Care. J Ultrasound Med 2016; 35: 1369-1371
• 15 Mjolstad OC, Snare SR, Folkvord L. et al. Assessment of left ventricular function by GPs using pocket-sized ultrasound. Fam Pract 2012; 29: 534-540
• 16 Prager R, Sedgwick C, Lund A. et al. Prospective Evaluation of Point-of-Care Ultrasound at a Remote, Multi-Day Music Festival. Prehosp Disaster Med 2018; 33: 484-489
• 17 Nixon G, Blattner K, Muirhead J. et al. Scope of point-of-care ultrasound practice in rural New Zealand. J Prim Health Care 2018; 10: 224-236
• 18 Olgers TJ, Azizi N, Blans MJ. et al. Point-of-care Ultrasound (PoCUS) for the internist in Acute Medicine: a uniform curriculum. Neth J Med 2019; 77: 168-176
• 19 Leschyna M, Hatam E, Britton S. et al. Current State of Point-of-care Ultrasound Usage in Canadian Emergency Departments. Cureus 2019; 11: e4246
• 20 Leger P, Fleet R, Maltais-Giguere J. et al. A majority of rural emergency departments in the province of Quebec use point-of-care ultrasound: a cross-sectional survey. BMC Emerg Med 2015; 15: 36
• 21 Adler AC, Brown KA, Conlin F. et al. Cardiac and Lung Point of Care Ultrasound in Pediatric Anesthesia and Critical Care Medicine: Uses, Pitfalls, and Future Directions to optimize pediatric care. Paediatr Anaesth 2019; 8: 790-798
• 22 Frohlich E, Beller K, Muller R. et al. Point of Care Ultrasound in Geriatric Patients: Prospective Evaluation of a Portable Handheld Ultrasound Device. Ultraschall in Med 2019; 41: 308-316
• 23 Sabatino V, Caramia MR, Curatola A. et al. Point-of-care ultrasound (POCUS) in a remote area of Sierra Leone: impact on patient management and training program for community health officers. J Ultrasound 2020; 23: 521-527
• 24 Epstein D, Petersiel N, Klein E. et al. Pocket-size point-of-care ultrasound in rural Uganda – A unique opportunity “to see”, where no imaging facilities are available. Travel Med Infect Dis 2018; 23: 87-93
• 25 Nurnberg D, Jenssen C, Cui X. et al. Ultrasound in palliative care medicine. Z Gastroenterol 2015; 53: 409-416
• 26 Brass P, Hellmich M, Kolodziej L. et al. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev 2015; 1: Cd011447
• 27 Statement from the DEGUM board regarding the editorial entitled “Who's Doing Your Scan? A European Perspective on Ultrasound Services.”. Ultraschall in Med 2018; 40: 11-13
• 28 Nielsen MB, Cantisani V, Sidhu PS. et al. The Use of Handheld Ultrasound Devices – An EFSUMB Position Paper. Ultraschall in Med 2019; 40: 30-39
• 29 Dietrich CF, Goudie A, Chiorean L. et al. Point of Care Ultrasound: A WFUMB Position Paper. Ultrasound Med Biol 2017; 43: 49-58
• 30 Nürnberg D, Esfahani AH, Boten D. et al. Sono-Teleconsulting (USTeleCon) – update 2019. Ultraschall in Med 2019; 40 (Suppl. 01) 54