Thierry Fumeaux

Background: Due to its diagnostic accuracy, point-of-care ultrasound (POCUS) is becoming more frequently used in the emergency department (ED), but the feasibility of its use by in-training residents and the potential clinical impact have not been assessed. Objective: This study aimed to assess the feasibility of implementing a structured POCUS training program for in-training ED residents, as well as the clinical impact of their use of POCUS in the management of patients in the ED. Methods: IMPULSE (Impact of a Point-of Care Ultrasound Examination) is a before-and-after implementation study evaluating the impact of a structured POCUS training program for ED residents on the management of patients admitted with acute respiratory failure (ARF) and/or circulatory failure (ACF) in a Swiss regional hospital. The training curriculum was organized into 3 steps and consisted of a web-based training course; an 8-hour, practical, hands-on session; and 10 supervised POCUS examinations. ED residents who successfully completed the curriculum participated in the postimplementation phase of the study. Outcomes were time to ED diagnosis, rate and time to correct diagnosis in the ED, time to prescribe appropriate treatment, and in-hospital mortality. Standard statistical analyses were performed using chi-square and Mann-Whitney U tests as appropriate, supplemented by Bayesian analysis, with a Bayes factor (BF)>3 considered significant. Results: A total of 69 and 54 patients were included before and after implementation of the training program, respectively. The median time to ED diagnosis was 25 (IQR 15‐60) minutes after implementation versus 30 (IQR 10‐66) minutes before implementation, a difference that was significant in the Bayesian analysis (BF=9.6). The rate of correct diagnosis was higher after implementation (51/54, 94% vs 36/69, 52%; P <.001), with a significantly shorter time to correct diagnosis after implementation (25, IQR 15‐60 min vs 43, IQR 11‐70 min; BF=5.0). The median time to prescribe the appropriate therapy was shorter after implementation (47, IQR 25‐101 min vs 70, IQR 20‐120 min; BF=2.0). Finally, there was a significant difference in hospital mortality (9/69, 13% vs 3/54, 6%; BF=15.7). Conclusions: The IMPULSE study shows that the implementation of a short, structured POCUS training program for ED residents is not only feasible but also has a significant impact on their initial evaluation of patients with ARF and/or ACF, improving diagnostic accuracy, time to correct diagnosis, and rate of prescribing the appropriate therapy and possibly decreasing hospital mortality. These results should be replicated in other settings to provide further evidence that implementation of a short, structured POCUS training curriculum could significantly impact ED management of patients with ARF and/or ACF.

Summary: Background: Despite its diagnostic accuracy, the clinical impact of the use of Point-of-care Ultrasound (POCUS) in the emergency department (ED) is not well described, especially when performed by junior in-training residents. Aim of the study: to assess the effect of a short, structured POCUS training program on the management of ED patients by in-training residents. Method: IMPULSE is a before-and-after implementation study, evaluating the impact of a structured POCUS training program for ED in-training residents on the management of patients admitted for acute respiratory and/or circulatory failure in a Swiss regional hospital. The training curriculum was organized in three stages and combined an on-line training course, an 8-hour practical hands-on session, and 10 supervised POCUS exams. The ED residents who successfully completed the curriculum participated in the study. Observed outcomes were time to ED diagnosis, rate of correct diagnosis made during the ED stay and time needed to reach it, time to prescribe an appropriate treatment, and hospital mortality. Standard statistical analyses were performed with the use of Chi-square and Mann-Whitney U tests as appropriate, completed by a Bayesian analysis, with a Bayes Factor (BF) > 3 considered as significant. Results: Sixty-nine patients were included before the training program implementation and 54 after. After implementation, the median time to ED diagnosis was 25 minutes (IQR 44) vs 30 minutes (IQR 56) before implementation, a difference that was significant (BF 9.6). The rate of correct diagnosis was higher (95 vs 52 %) (p<0.001) and the time to make this correct diagnosis was significantly shorter after implementation (25 minutes, IQR 45, vs 43, IQR 60) (BF 5.0). This had an impact on the median time to prescribe the appropriate therapy, with a trend toward a shorter delay (47 minutes, IQR 76, vs 70, IQR 100) (BF 2.0). Eventually, there was a significant difference in hospital mortality (13 % vs 5.5 %, BF 15.7). Conclusion: the IMPULSE study shows that the implementation of a short, structured POCUS training program for ED residents to use ultrasound for the initial evaluation of acute respiratory and circulatory failure patients has an impact on diagnostic accuracy, on time to make a correct diagnosis and to prescribe an appropriate therapy, and eventually possibly on hospital mortality. If these results are reproduced in other settings, POCUS use by ED residents after short, structured training curriculum could become the standard of care for these patients.

The top 9 list of the Swiss Society for Intensive Care Medicine (SSICM) was published in 2017. What is the status of this initiative in terms of its implementation in Swiss intensive care units, its impact on patient care and on the costs of intensive care medicine? What developments in the published evidence justify updating the list and what measures are needed to continue this initiative in the coming years? This article provides an up-to-date overview of the SSICM's Choosing Wisely (R) initiative.

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