Objective. To test the influence of personalized ultrasound (PersUS) on patient management in critical care. Design of the Study. Prospective, observational, and critical care setting. Four substudies compared PersUS and mobile ultrasound, work distribution, and diagnostic and procedural quality. Patients and Interventions. 640 patient ultrasound exams including 548 focused diagnostic exams and 92 interventional procedures. Main Outcome Measures. Number of studies, physician’s judgement of feasibility, time of usage per patient, and referrals to echo lab. Results. Randomized availability of PersUS increased its application in ICU work shifts more than twofold from 33 to 68 exams mainly for detection and therapy of effusions. Diagnostic and procedural quality was rated as excellent/very good in PersUS-guided puncture in 95% of cases. Integrating PersUS within an initial physical examination of 48 randomized cases in an emergency department, PersUS extended the examination time by 100 seconds. Interestingly, PersUS integration into 53 randomized regular ward rounds of 1007 patients significantly reduced average contact time per patient by 103 seconds from 8.9 to 7.2 minutes. Moreover, it lowered the patient referral rate to an echo lab from 20% to 2% within the study population. Conclusions. We propose the development of novel ultrasound-based clinical pathways by integration of PersUS. 1. Introduction Point-of-care ultrasound has become more popular in the environment of acute and critical care medicine [1, 2]. Various recommendations on its use mainly address clinical indications related to acute or severe dyspnoea, hypotension and shock, trauma, and abdominal pain [1–4]. The technical concept of a “personal ultrasound imager” and an “ultrasonic stethoscope” is more than 30 years old [5]. There is a strong interest in the integration of ultrasound into clinical pathways and many context-based protocols are available. A novel technology was born when the initial idea of a personalized ultrasound device (PersUS) used like a physician’s generic stethoscope was realized [5, 6], a paradigm shift that now supports real point-of-care clinical pathway concepts. In 1978 it was suggested that bringing the echo lab to the patient would be a major step forward [5]. Previously, ultrasound labs contained stationary ultrasound systems, while mobile and hand-carried ultrasound was kept at facilities like emergency departments or intensive care units, making the technology available for multiple users. In fact, “personalized” refers to the size and quick application of
References
[1]
American College of Emergency Physicians, “ACEP emergency ultrasound guidelines–2001,” Annals of Emergency Medicine, vol. 38, no. 4, pp. 470–481, 2001.
[2]
Expert Round Table on Ultrasound in ICU, “International expert statement on training standards for critical care ultrasonography,” Intensive Care Medicine, vol. 37, no. 7, pp. 1077–1083, 2011.
[3]
R. Sicari, M. Galderisi, J.-U. Voigt et al., “The use of pocket-size imaging devices: a position statement of the European association of echocardiography,” The European Journal of Echocardiography, vol. 12, no. 2, pp. 85–87, 2011.
[4]
J. B. Seward, P. S. Douglas, R. Erbel et al., “Hand-carried cardiac ultrasound (HCU) device: recommendations regarding new technology. A report from the echocardiography task force on new technology of the nomenclature and standards committee of the American Society of Echocardiography,” Journal of the American Society of Echocardiography, vol. 15, no. 4, pp. 369–373, 2002.
[5]
J. Roelandt, J. W. Wladimiroff, and A. M. Baars, “Ultrasonic real time imaging with a hand-held-scanner. Part II. Initial clinical experience,” Ultrasound in Medicine and Biology, vol. 4, no. 2, pp. 93–97, 1978.
[6]
J. Kluger, “The 50 Best Inventions of 2009,” Time, 2009.
[7]
K. Skjetne, T. Graven, B. O. Haugen, ？. Salvesen, J. O. Kleinau, and H. Dalen, “Diagnostic influence of cardiovascular screening by pocket-size ultrasound in a cardiac unit,” The European Journal of Echocardiography, vol. 12, no. 10, pp. 737–743, 2011.
[8]
B. P. Cholley, A. Vieillard-Baron, and A. Mebazaa, “Echocardiography in the ICU: time for widespread use!,” Intensive Care Medicine, vol. 32, no. 1, pp. 9–10, 2006.
[9]
A. E. Jones, V. S. Tayal, D. M. Sullivan, and J. A. Kline, “Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients,” Critical Care Medicine, vol. 32, no. 8, pp. 1703–1708, 2004.
[10]
M. X. Joseph, P. J. Disney, R. da Costa, and S. J. Hutchison, “Transthoracic echocardiography to identify or exclude cardiac cause of shock,” Chest, vol. 126, no. 5, pp. 1592–1597, 2004.
[11]
S. L. Kobal, S. Atar, and R. J. Siegel, “Hand-carried ultrasound improves the bedside cardiovascular examination,” Chest, vol. 126, no. 3, pp. 693–701, 2004.
[12]
A. C. Sisley, G. S. Rozycki, R. B. Ballard, N. Namias, J. P. Salomone, and D. V. Feliciano, “Rapid detection of traumatic effusion using surgeon-performed ultrasonography,” Journal of Trauma, vol. 44, no. 2, pp. 291–297, 1998.
[13]
D. Plummer, D. Brunette, R. Asinger, and E. Ruiz, “Emergency department echocardiography improves outcome in penetrating cardiac injury,” Annals of Emergency Medicine, vol. 21, no. 6, pp. 709–712, 1992.
[14]
A. W. Kirkpatrick, M. Sirois, K. B. Laupland et al., “Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST),” Journal of Trauma, vol. 57, no. 2, pp. 288–295, 2004.
[15]
R. Breitkreutz, F. Walcher, and F. H. Seeger, “Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm,” Critical Care Medicine, vol. 35, no. 5, pp. S150–S161, 2007.
[16]
J. P. Nolan, J. Soar, D. A. Zideman et al., “European Resuscitation Council guidelines for resuscitation 2010 section 1. Executive summary,” Resuscitation, vol. 81, no. 10, pp. 1219–1276, 2010.
[17]
C. D. Deakin, J. P. Nolan, J. Soar et al., “European Resuscitation Council guidelines for resuscitation 2010 section 4. Adult advanced life support,” Resuscitation, vol. 81, no. 10, pp. 1305–1352, 2010.
[18]
A. J. Labovitz, V. E. Noble, M. Bierig et al., “Focused cardiac ultrasound in the emergent setting: a consensus statement of the American society of echocardiography and American college of emergency physicians,” Journal of the American Society of Echocardiography, vol. 23, no. 12, pp. 1225–1230, 2010.
[19]
M. Blaivas, L. Brannam, and D. Theodoro, “Ultrasound image quality comparison between an inexpensive handheld emergency department (ED) ultrasound machine and a large mobile ED ultrasound system,” Academic Emergency Medicine, vol. 11, no. 7, pp. 778–781, 2004.
[20]
C. Prinz and J. U. Voigt, “Diagnostic accuracy of a hand-held ultrasound scanner in routine patients referred for echocardiography,” Journal of the American Society of Echocardiography, vol. 24, no. 2, pp. 111–116, 2011.
[21]
M. J. Liebo, R. L. Israel, E. O. Lillie, M. R. Smith, D. S. Rubenson, and E. J. Topol, “Is pocket mobile echocardiography the next-generation stethoscope? a cross-sectional comparison of rapidly acquired images with standard transthoracic echocardiography,” Annals of Internal Medicine, vol. 155, no. 1, pp. 33–38, 2011.
[22]
N. P. Symbas, P. F. Bongiorno, and P. N. Symbas, “Blunt cardiac rupture: the utility of emergency department ultrasound,” Annals of Thoracic Surgery, vol. 67, no. 5, pp. 1274–1276, 1999.
[23]
A. R. Manasia, H. M. Nagaraj, R. B. Kodali et al., “Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients,” Journal of Cardiothoracic and Vascular Anesthesia, vol. 19, no. 2, pp. 155–159, 2005.
[24]
P. Ferrada, R. J. Anand, J. Whelan et al., “Limited transthoracic echocardiogram: so easy any trauma attending can do it,” Journal of Trauma, vol. 71, no. 5, pp. 1327–1331, 2011.
[25]
R. Breitkreutz, S. Price, H. V. Steiger et al., “Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial,” Resuscitation, vol. 81, no. 11, pp. 1527–1533, 2010.
[26]
F. Walcher, M. Weinlich, G. Conrad et al., “Prehospital ultrasound imaging improves management of abdominal trauma,” The British Journal of Surgery, vol. 93, no. 2, pp. 238–242, 2006.
[27]
M. Dijos, Y. Pucheux, and M. Lafitte, “Fast track echo of abdominal aortic aneurysm using a real pocket-ultrasound device at bedside,” Echocardiography, vol. 29, no. 3, pp. 285–290, 2012.
[28]
C. A. Frederiksen, P. Juhl-Olsen, U. T. Larsen, D. G. Nielsen, B. Eika, and E. Sloth, “New pocket echocardiography device is interchangeable with high-end portable system when performed by experienced examiners,” Acta Anaesthesiologica Scandinavica, vol. 54, no. 10, pp. 1217–1223, 2010.
[29]
F. Lapostolle, T. Petrovic, G. Lenoir et al., “Usefulness of hand-held ultrasound devices in out-of-hospital diagnosis performed by emergency physicians,” The American Journal of Emergency Medicine, vol. 24, no. 2, pp. 237–242, 2006.
[30]
N. Cardim, C. Fernandez Golfin, D. Ferreira et al., “Usefulness of a new miniaturized echocardiographic system in outpatient cardiology consultations as an extension of physical examination,” Journal of the American Society of Echocardiography, vol. 24, no. 2, pp. 117–124, 2011.
[31]
J. Reuss, H. Weiss, T. Wanner, and H.-G. Leser, “Time requirements of medical and non-medical personnel for ultrasound studies,” Ultraschall in der Medizin, vol. 19, no. 3, pp. 126–129, 1998.
[32]
M. Rugolotto, B. S. Hu, D. H. Liang, and I. Schnittger, “Rapid assessment of cardiac anatomy and function with a new hand-carried ultrasound device (OptiGo): a comparison with standard echocardiography,” The European Journal of Echocardiography, vol. 2, no. 4, pp. 262–269, 2001.
[33]
T. Xie, A. J. Chamoun, M. McCulloch, N. Tsiouris, Y. Birnbaum, and M. Ahmad, “Rapid screening of cardiac patients with a miniaturized hand-held ultrasound imager—comparisons with physical examination and conventional two-dimensional echocardiography,” Clinical Cardiology, vol. 27, no. 4, pp. 241–245, 2004.
[34]
K. Greaves, P. Jeetley, M. Hickman et al., “The use of hand-carried ultrasound in the hospital setting-A cost-effective analysis,” Journal of the American Society of Echocardiography, vol. 18, no. 6, pp. 620–625, 2005.
[35]
E. C. Vourvouri, L. Y. Koroleva, F. J. Ten Cate et al., “Clinical utility and cost effectiveness of a personal ultrasound imager for cardiac evaluation during consultation rounds in patients with suspected cardiac disease,” Heart, vol. 89, no. 7, pp. 727–730, 2003.
[36]
G. Giannotti, S. Mondillo, M. Galderisi et al., “Hand-held echocardiography: added value in clinical cardiological assessment,” Cardiovascular Ultrasound, vol. 3, article 7, 2005.
