The images were then transferred from Q-Path to the hospital picture archiving and communication system where they are visible to all hospital providers. Finally, the findings were documented under the “Procedures” section of the ED provider note, and referenced in the medical decision-making portion of the note as appropriate.All faculty were credentialed in accordance with ACEP guidelines. Under this policy, residents may perform the ultrasound exam under supervision of credentialed faculty and submit scans to count toward their own credentialing.At the beginning of the study, we performed a qualitative needs assessment with a work group, including the authors of the study, residency leadership, QI leadership, and unstructured interviews with residents. We generated potential contributors to the observation that residents rarely use POCUS on shift and summarized them in a “fish-bone” diagram . Based on this list, we created a survey of residents to help further elucidate residents’ attitude towards POCUS and the leading barriers to POCUS use on shift . Participation in the survey was voluntary, and we received responses from 27/35 residents with comparable contribution from residents at all three levels of training. We found that 30% of all residents reported never using POCUS on shift, 52% reported using POCUS approximately once per shift, and 18% used POCUS more than once per shift. When asked about general attitudes toward ultrasound use and training, most residents somewhat agreed or strongly agreed that ultrasound is an important skill for residents to learn and practice in our ED . Most residents also somewhat agreed or strongly agreed that POCUS will be important in their future practice . However, indoor grow facility responses were somewhat tempered in considering whether availability of POCUS would be important in their search for future employment: 63% somewhat or strongly agreed, while 7% somewhat disagreed .
In assessing barriers to on-shift use of ultrasound we found that the “inability to use results in documentation” received the highest weighted average rating of 3.7 on a five-point Likert scale with 41% and 25% of residents, respectively, reporting that this was a significant and extreme barrier. Time barriers, including time to complete/optimize exams and time required to initiate an exam were also rated highly with weighted averages of 3.6 and 3.2. Barriers pertaining to tools and technology such as Q-Path navigation, inability to find the machine, space on the machine, and gel availability were generally ranked as only “slight barriers” with weighted average scores of 2.2, 2.1, 1.8, and 1.6, respectively . Finally, we attempted to assess potential incentives that would help residents overcome the barriers above. We found that increased attending support was the top perceived incentivizer for residents with a weighted average of 4. Residents also felt that clear guidelines on charting were likely to incentivize scanning . Ultrasound training is a core feature of EM residency training. However, there is a considerable variability in the form this training takes throughout residencies in the United States.In order to characterize POCUS training of EM residents, Hayward et al. applied Ericsson’s deliberate practice model of acquiring procedural proficiency. This model divides learners into novice, intermediate, expert, and advanced expert levels who are able to learn the basics, apply them efficiently, apply them intuitively, and apply advanced applications of the procedure respectively.To advance trainees from intermediate sonographers to expert sonographers , one must have a detailed understanding of the barriers to such a transition. To the best of our knowledge, this study is the first attempt to systematically define and address these barriers in a resident population. Our data highlight a number of key findings, likely relevant to curriculum and POCUS workflow design:First, we found that residents’ perception of ultrasound and its importance in modern EM training is overwhelmingly positive with 96% of residents believing that ultrasound is an important skill to learn during their training.
Despite this, only 63% of residents believed that ultrasound availability would be an important feature for them in their future job search. This discrepancy likely underscores the larger problem posed above: While residents are enthusiastic and competent in image acquisition and interpretation, next level training in methods of integrating ultrasound into daily practice is lacking. Second, we were somewhat surprised that the major barrier identified by residents at the time of our study was the perceived inability to use ultrasound for medical decision making rather than conventional barriers of time available in the ED or equipment malfunction. However, when viewed through the lens of the deliberate practice model of transitioning from intermediate to advanced competency, it makes sense that our residents’ grasp on how to use ultrasound in daily practice was the major perceived barrier. Third, our finding that implementation and education of a documentation policy is associated with increased integration of ultrasound in clinical decision-making has significant implications for resident education and its integration into subsequent ED ultrasound billing workflows. Recent studies have demonstrated that a continuous workflow quality improvement efforts for all staff also significantly increased the proportion of reported and billed ultrasound studies. Another recent study found that resident education of billing practices significantly increased RVU billable by resident encounters.Taken together, this body of literature suggests that educational interventions such as ours can have a quantifiable effect on ED revenue and future EP documentation practices. A potential confounder in the before-after design of our study was a concomitant push for faculty credentialing, which was underway in our department during the study period. To assess whether the increase in the patients scanned may have been due to this confounder we also analyzed the number of POCUS studies uploaded to PACS by faculty without resident involvement.
We found that faculty uploaded 124 vs 138 studies, which were done without resident involvement, during the pre- and post-intervention phases of the study, an absolute increase of 6%, while resident scans uploaded to PACS increased by 78% . Thus, it appears that the increase in scans performed was primarily resident-driven. Finally, while it is difficult to infer causation in this observational, before-after study, it does provide a suggestion that incentivization of residents and faculty might be linked. Our secondary outcome demonstrated that the resident-based intervention increased scanning among non-fellowship trained faculty, more so than among ultrasound fellowship-trained faculty. As methods of faculty credentialing and education continue to advance, it may be useful to integrate resident and faculty education. Future inquiry into the effect and interplay of faculty and resident incentivization may help make the transition from intermediate to advanced sonographer more robust and efficient.This study was performed at a single academic center with an EM residency program, and as such may be limited in external applicability. However as mentioned earlier, our institution faces many of the same problems and barriers that have been reported by other institutions in the literature. These include the low rate of POCUS utilization, need for deliberate practice, implementation of intuitive documentation processes, and lack of time in a busy ED.While we did solicit feedback from residency leadership and residents, within the limitations of a single-center quality improvement study, we did not perform separate validation of the survey. The survey portion was also subject to sampling bias, since we had only a 77% response rate. However, we believe that voluntary and anonymous reporting on the survey provides a sufficient advantage. Our low sample size, given its single-center nature, is an important limitation as it limits the statistical power of the study, and it would be useful to repeat this study on a nationwide level. The survey itself includes closed-ended questions, which may introduce response bias; however, write-in,indoor grow rack free-text responses were allowed. In regard to our primary outcome, our study may be limited by the assumption that the number of exams uploaded to PACS is an accurate marker for the number of scans used in the medical decision-making process. Indeed, the survey responses suggest that 82% of residents used POCUS one or more times per shift, but even after the intervention there were only 5.8 scans documented per resident. This suggests that a large proportion of POCUS studies are never documented . In addition, this surrogate marker also relies on the cooperation of the appropriate attending, as residents did not have ability to upload images to PACS. However, the survey does identify lack of documentation ability as an important barrier, and documentation of POCUS studies is essential to appropriate medical decision-making and billing as laid out in ACEP’s clinical guideline on POCUS use. Thus, our study’s primary outcome is relevant to the key objective of the study .
Another key limitation of our study is the before after design, which introduces a number of confounders. During the study period faculty received ongoing reminders and were actively incentivized to increase clinical use of POCUS. It is unlikely that the increase in scans is due solely to our intervention; however, we found that the increase in resident-performed POCUS studies is disproportionate to the number of studies done by faculty alone, suggesting that resident involvement in POCUS documentation should be a key factor in improving the quality of POCUS use in clinical decision-making.Long-term cognitive impairment , defined as new or worsening deficit in cognition that persists following acute illness, is a well described phenomenon occurring in an estimated 16% of older adults who are acutely ill.This often leads to increased disability, loss of independence, and decreased quality of life. Currently no effective therapies, especially those that can be administered early in the acute illness course, exist to prevent or treat LTCI following acute illness. While the mechanism of LTCI has not been fully elucidated, it is hypothesized that systemic proinflammatory cytokines, in response to an acute medical illness such as sepsis,lead to increased central nervous system inflammation, microglial activation, and neuronal injury and death.Vitamin D is a pleotropic hormone that modulates systemic and CNS inflammatory responses.Therefore, patients with Vitamin D deficiency may be particularly vulnerable to LTCI following an acute illness. Several observational studies have suggested that Vitamin D deficiency is associated with poorer long-term cognition among community-dwelling adults.However, the relationship between Vitamin D deficiency in the setting of acute illness and subsequent development of LTCI remains unknown in acutely ill patients, especially in the emergency department setting. Therefore, we sought to determine whether serum Vitamin D at ED presentation was associated with poorer six-month cognition in acutely ill older adults. This study was an observational secondary analysis within the DELINEATE prospective cohort study, which enrolled ED patients age 65 years and older who were subsequently admitted the hospital for an acute illness at a large, academic, tertiary care hospital.This study enrolled patients from March 2012 – November 2014. The local institutional review board reviewed and approved this study. Details and rationale of the selection of participants have been described previously.Briefly, we included patients if they were 65 years or older and in the ED for less than four hours at the time of enrollment. Patients were excluded if they were non-English speaking; previously enrolled; deaf, comatose, non-verbal or unable to follow simple commands prior to their current illness; were considered unsuitable for enrollment by the treating physician or nurse; were unavailable for enrollment within the four-hour time limit secondary to clinical care ; or were discharged home from the ED. Patients were included for this analysis if they had blood specimen available for Vitamin D measurement and had a surrogate available to complete a short form Informant Questionnaire on Cognitive Decline in the Elderly obtained at enrollment to establish pre-illness cognition. Pre-illness and six-month cognition were measured using the short form IQCODE in patients who had a surrogate in the ED who knew the patient for greater than 10 years. It ranges from 1 to 5 . This surrogate-based cognitive screen was used because patient-based measurements in the ED may not accurately reflect true baseline cognition especially in the setting of delirium.The IQCODE is also a validated measure of cognition, which has been previously used to assess cognitive decline.At time of study enrollment, informants were asked to assess the patients’ pre-illness cognition at two weeks prior to ED presentation, and followup assessment at six months over telephone with all attempts made to have the same person complete the IQCODE questionnaire as the individual who completed the pre-illness questionnaire.