Current Use, Training, and Barriers to Point-of-Care Ultrasound Use in ICUs in the Department of Veterans Affairs

• DOI: 10.1016/j.chstcc.2023.100012
• Publication Date: 2023-08-08T00:58:45Z
• Authors: Christopher K. Sc...; Erin Wetherbee; Rahul Khosla; Robert Nathanson; Jason P. Williams; Michael J. Mader; Elizabeth K. Haro; Dean Kellogg; Abraham Rodriguez; Kevin C. Proud; Jeremy S. Boyd; Brian Bales; Harald Sauthoff; Zahir Basrai; Dana Resop; Brian P. Lucas; Marcos I. Restrepo; Nilam J. Soni
• Keywords: Veterans Affairs

BackgroundPoint-of-care ultrasound (POCUS) has become an integral part of critical care medicine for procedural guidance, bedside diagnostics, and assessing response to treatment. Multiple societies recommend POCUS use, training been a requirement fellowship since 2012. Yet, current practice patterns use in ICUs are not well known.Research QuestionThis study aimed characterize needs, barriers among intensivists.Study Design MethodsA prospective observational all Veterans Affairs (VA) medical centers was conducted between June 2019 March 2020 using web-based survey chiefs staff ICU chiefs. These data were compared with those from similar 2015.ResultsChiefs 130 VA surveyed 100% 94% rates, respectively. At least one physician currently uses 93% ICUs, 62% individual physicians estimated be POCUS. The most common applications guidance (59%), cardiac (55%), thoracic (56%) . Most (80%) reported teaching trainees their ICU. frequently lack trained providers (48%), funding (45%), opportunities (37%), image archiving (34%). From 2015 through 2020, increased across increase desire seen.InterpretationPOCUS but significant gaps remain. Without deliberate investment infrastructure practice, institutions unlikely benefit fully standardized ICUs. Point-of-care known. This intensivists. A 2015. Chiefs seen. Take-home PointsStudy Question: How do point-of-care (POCUS), which desired training, what exist clinical ICUs?Results: national demonstrated that (62%) cardiac, lung exams is the same because greatest barrier use.Interpretation: Although reportedly important adoption remain, including some now considered standard care, needed overcome implementation. Study ICUs? Results: use. Interpretation: Over last 2 decades, medicine. In can rapidly diagnose life-threatening conditions, aid urgent decision-making, guide invasive procedures.1Volpicelli G. Elbarbary M. Blaivas et al.International evidence-based recommendations ultrasound.Intensive Care Med. 2012; 38: 577-591Google Scholar, 2Díaz-Gómez J.L. Mayo P.H. Koenig S.J. ultrasonography.N Engl J 2021; 385: 1593-1602Google 3Lau Y.H. See K.C. critically-ill patients: mini-review key diagnostic features protocols.World Crit 2022; 11: 70-84Google Scholar Numerous professional organizations have endorsed critically ill patients.4Mayo Beaulieu Y. Doelken P. al.American College Chest Physicians/La Societe de Reanimation Langue Francaise statement on competence ultrasonography.Chest. 2009; 135: 1050-1060Google 5Frankel H.L. Kirkpatrick A.W. al.Guidelines appropriate general ultrasonography evaluation patients—part I: ultrasonography.Crit 2015; 43: 2479-2502Google 6Levitov A. Frankel II: 2016; 44: 1206-1227Google 7Expert Round Table Echocardiography ICUInternational consensus standards advanced echocardiography.Intensive 2014; 40: 654-666Google 8Arntfield R. Millington S. Ainsworth C. al.Canadian competency.Can Respir J. 21: 341-345Google 9Abboud P.A. Kendall Ultrasound vascular access.Emerg Med Clin North Am. 2004; 22: 749-773Google 10Expert expert ultrasonography.Intensive 2011; 37: 1077-1083Google To ensure essential, especially like echocardiography ultrasound. Accreditation Council Graduate Medical Education emphasized both made pulmonary 2012.11Accreditation Education, ACGME program requirements graduate education medicine, website. Accessed 23 January 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/156_pccm_2022_tcc.pdf.Google Despite these recommendations, implementation inconsistencies heterogeneity training.12Stowell J.R. Kessler Lewiss R.E. al.Critical ultrasound: specialties.J Ultrasound. 2018; 46: 167-177Google Specifically, cited perspective faculty.13Yorkgitis B.K. Bryant E.A. Brat G.A. Kelly E. Askari Ra J.H. Ultrasonography utilization surgical fellowships: director's survey.J Surg Res. 2017; 218: 292-297Google 14Carver T.W. fellowship: directors.J Educ. 75: 1250-1255Google 15Brady A.K. Spitzer C.R. Kelm D. Brosnahan S.B. Latifi Burkart K.M. Pulmonary fellows' self-reported learning during training: results survey.Chest. 160: 231-237Google 16Cheng Arntfield Training strategies point ICU.Curr Opin Anaesthesiol. 34: 654-658Google 17Jarwan W. Alshamrani A.A. Alghamdi al.Point-of-care assessment interns' needs training.Cureus. 2020; 12e11209Google 18Galarza L. Wong Malbrain state Europe: trainers comparison available accreditation programmes.Anaesthesiol Intensive Ther. 49: 382-386Google programs 2017 revealed 46% lacked formal curriculum.15Brady residencies identified as area concern, where 58% had curriculum despite efficacy such curricula.13Yorkgitis Scholar,19Tripu Lauerman M.H. Haase al.Graduating residents ultrasound.J 582-588Google Scholar,20Townsend N.T. Barnett Robinson T. An effective focused echocardiography: establishing curve residents.J 73: 190-196Google Beyond requirements, limited learn continuing courses or programs.21Greenstein Y.Y. Littauer Narasimhan Effectiveness course.Chest. 151: 34-40Google 22Mosier J.M. Malo Stolz L.A. US Care. 29: 645-649Google 23Wong Galarza Duska F. Critical systematic review international competencies program.Crit 2019; 47: e256-e262Google 24Schott C.K. LoPresti C.M. Boyd J.S. al.Retention skills practicing physicians: findings National Program.Am 134: 391-399.e398Google shown clinicians acquire retain novel cognitive psychomotor required POCUS.24Schott 25Soni N.J. Mints al.Comparison in-person versus tele-ultrasound COVID-19 pandemic.Ultrasound 13: 39Google 26Yamada Minami Soni al.Skills acquisition novice learners after course: does rank matter?.BMC 18: 202Google However, remains commonly multiple specialties.16Cheng Scholar,27Wong Montague Wallace al.Barriers internists six American institutions.Ultrasound 12: 19Google 28Williams J.P. Nathanson al.Current hospital medicine: hospitals.J Hosp 17: 601-608Google 29Resop D.M. Basrai Z. emergency departments 2020: hospitals.Am Emerg 2023; 63: 142-146Google Currently, it known how intensivists United States. 142 Europe found 55% examinations performed 36% patients. Thus, two-thirds patients never evaluated POCUS.30Zieleskiewicz Muller Lakhal K. intensive units: 1073 procedures multicentric, prospective, study.Intensive 41: 1638-1647Google Another used only 2% fluid management ICUs.31Cecconi Hofer Teboul al.Fluid challenges care: FENICE study: global inception cohort 1529-1537Google studies suggest substantial number frequency better understand States, we at health system. survey. multidisciplinary Technical Advisory Group internal collaborated VA's Healthcare Analysis Information develop disseminate system wide (Verint Systems, Inc.). reviewed by institutional board University Texas Health Science Center San Antonio deemed nonresearch (Identifier: HSC20210630NRR). included questions support, equipment, Question types choice, forced choice (yes no), open-ended numerical free-text entry, boxes when "other" selected. For prevalence, respondents provided option answer few (1%-25%), (26%-50%), many (51%-75%), (76%-99%), (100%). Some conditional skip display logic. deployed two phases. First, distributed (n = 130) nationwide August October 2019. chief-of-staff 10 about facility-level competency, policies, contact information (e-Appendix 1). Second, follow-up 25 sent each facility obtain service-level workflows, equipment availability 2). behalf service specialty respective center. period started December ended early pandemic. 2015, centers. Instead querying chiefs, forwarded who believed account this difference collection, subgroup analysis 39 services answered surveys assess trends We paired t test compare years percentage facilities desiring categories applications. Current averaged body category. McNemar changes processes resources. P value < .05 statistically significant. Data presented percent change 2020. All completed regarding policies (100% rate). 122) (94% rate) availability. Among responding 48 34 40 medical-surgical Six medical-cardiac analyzed primarily conditions based responses (Table 1, (86%) categorized "high complexity," 53% having level 1 designated levels though 4 complexity, indicates highest degree complexity. Geographically, urban areas (94%), received southern region (40%). median nine attendings per five certified medicine.Table 1Characteristics Centers SurveyedCharacteristicAll FacilitiesMICUaFacilities MICU/cardiac unit counted MICU, patient characteristics.SICUMed-Surg ICUNo. facilities93473440Internal plus surgery beds 10060 (65)22 (47)11 (32)35 (88) ≥ 10033 (35)25 (53)23 (68)5 (12)Internal 7563 (68)23 (49)14 (41)36 (90) 7530 (32)24 (51)20 (59)4 (10)Surgery 2549 (53)18 (38)7 (21)28 (70) 2544 (47)29 (62)27 (79)12 (30)VHA complexity levelbHigh-complexity high volume, risk, specialists, teaching, research. Low-complexity medium low volume little High80 (86)44 (94)34 (100)30 (75) Low13 (14)3 (6)0 (0)10 (25)VHA 149 (53)32 (68)30 (88)14 (35) 215 (16)7 (15)2 (6)7 (18) 322 (24)5 (11)2 (6)15 (38) 44 (4)2 (4)0 (0)2 (5) Not available3 (3)1 (2)0 (5)Region Northeast16 (17)7 (15)5 (15)7 Midwest23 (25)12 (26)8 (24)11 (28) South37 (40)20 (43)16 (47)13 (33) West17 (18)8 (17)5 (15)9 (23)Location Urban87 (94)46 (98)33 (97)36 (90)Data No. (%), unless otherwise indicated. Med-Surg ICU; MICU SICU Affairs; VHA Administration.a Facilities characteristics.b High-complexity Open table new tab 2Characteristics Intensivists, Use, SurveyedVariableAll 122)MICUaFacilities characteristics. 48)SICU 34)Med-Surg 40)Characteristics attending ICUbNo. working CCM chief.Median (IQR)9 (5-12)9 (6-12)5 (4-11)10 (5-13)Mean ± SD12.8 21.411.4 11.618.0 37.610.1 5.4 Board CCMcNo. board-certified (IQR)5 (2-9)7 (4-10)4 (2-5)3 (1-6)Mean SD5.7 5.07.6 5.34.2 3.24.6 5.1Current Intensivists POCUS, %, weighted mean SD62 3479 2545 3164 36 POCUS113 (93)46 (96)31 (91)36 resuscitation, %None42 (34)9 (19)12 (35)21 (53)Some (1%-50%)52 (43)25 (52)10 (30)17 (42)Most (> 50%)28 (23)14 (29)12 (35)2 perform TEE9 (7)1 (2)6 (18)2 (5)POCUS %Via CMENone27 (22)6 (13)12 (35)9 (23)Some (1%-50%)63 (52)26 (54)13 (39)24 (60)Most 50%)32 (26)16 (33)9 (26)7 Via residency fellowshipNone26 (21)10 (21)8 (24)8 (20)Some (1%-50%)61 (50)25 (30)26 (65)Most 50%)35 (29)13 (27)16 (47)6 (15) training97 (80)41 (85)24 (71)32 (80) process training45 (37)22 (46)11 (32)12 (30) Residents fellows ICU69 (57)36 (75)16 (47)17 (43) confident supervising fellowsBedside proceduresNone21 (10)5 (15)11 (27)Some (1%-50%)28 (23)5 (10)8 (24)15 (38)Most 50%)73 (60)38 (79)21 (62)14 (35)DiagnosticsNone22 (18)5 (15)12 (30)Some (1%-50%)41 (34)13 (27)12 (35)16 (40)Most 50%)59 (48)30 (63)17 (50)12 (30)Data medicine; CME education; IQR interquartile range; ultrasound; TEE transesophageal echocardiography.a chief.c chief. Administration. echocardiography. either purposes. average (79% 45% 64% ICUs). 23% resuscitations, notable seen (5% > 50% resuscitations) (29%) (35%) (59%) followed (56%), abdominal (30%) (Fig central line placement, arterial peripheral IV paracentesis, thoracentesis, chest tube insertion 3, e-Fig applications, pericardial effusions, left ventricular systolic function, status, whereas hemodynamic Only 7% report 59% different specific 85% 73% 61% 54% placement. Common 70% effusion, 80% pleural pneumothorax, edema e-Figs 2, 3). machine available. 113 reporting total 353 machines devices three vast majority (84%) dedicated cart-based (ie, shared another service). 174 127 other services. handheld 16 13 personally eight e-Table 14% saving images. mostly (63% 56%, respectively), less even distribution ways training) contrast, none (22%) (21%). gap, defined greater than (cardiac, 8%; vascular, abdominal, 3%). 37% physicians. e-Appendix 3 (e-Figs 1-4). Regarding trainees, Further details fellows, residents, students, nurse practitioner assistant nursing students (e-Table (57%) providing 43% rotation toward graduation requirements. (60%) felt trainees' 48% When separated type, more feeling 17% did any Lack training-related 67% along related (35%). Specific one-third (34%) 3).Table 3Barriers Use ICUsBarrierNo. Reporting Barrier 122)Training providers59 (48) training55 (45) opportunities45 (37) travel40 listed above82 (67)Infrastructure archiving42 (34) No clinician champion33 (27) support staff32 (26) form25 (20) simulation space25 privileging criteria22 leadership support16 (13) above72 (59)Equipment equipment36 equipment25 above43 (35)Other identified21 (17) perceived benefit10 (8)POCUS