Acute Care POCUS Elective

Acute Care Point-of-Care Ultrasound Elective

1. Introduction

The use of POCUS as an adjunct to the practice of medicine is now well established.  Despite its modest beginnings, the scope of POCUS practice has surpassed the basic applications as physicians have identified clinical problems where POCUS was able to aid in patient evaluation and to guide invasive procedures.

In addition to the established fundamental applications, mounting evidence corroborates the utility of advanced POCUS applications: advanced cardiac assessment, advanced thoracic application, assessment of renal systems, soft tissue assessment and identification of a deep vein thrombosis.  In everyday practice, the physicians regularly face challenges in trying to identify serious pathology or to reduce adverse consequences during procedures in a timely manner.

This elective is based in the Emergency Department and aims to equip physicians with the means to accomplish these goals by utilizing POCUS in advanced assessment and management of the acutely sick patient. It is eligible for learners of all disciplines.

2. Elective Structure and Responsibilities

Though the exact focus of the elective will depend on learner interest, and resource availability, discussion with program director will occur at start of rotation to identify learning needs and goals of the rotation

  • There will be sit down sessions each week to discuss a topic of the day and review images generated on rotation for QI
  • Dedicated clinical ED Team POCUS scanning on patients in the ED during the week with oversight from either POCUS fellow or staff
  • Scheduled clinical shifts assigned with advanced POCUS faculty
  • Weekly hands-on with POCUS expert on a focused topic to review
  • An expectation to archive images (Qpath) and complete reports on all studies to allow for quality assurance, feedback and pushed to EMR
  • Self-study: Each learner is expected to review the relevant modules and chapters related to their studies, which will be provided to the learners as part of the rotational requirements
  • Scholarly Presentation: Summary of a case or review of a focused POCUS topic relevant to learner goals done at sit down session, or as a screencast
  • Attendance at monthly POCUS journal club and multidisciplinary POCUS rounds

3. Objectives

Specifically designed for rotators of different specialties, the Acute Care POCUS elective focuses on the following main areas:

Medical Expert

  • Understand physical principles and instrumentation of ultrasound, including M-mode, two-dimensional B-mode, pulse wave (PW), continuous wave (CW) and colour doppler
  • Select Advanced ‘knobology’ of the ultrasound machine
  • Understanding of ultrasound physics and how they relate to image generation and common artifacts including mirror, side-lobe,
  • Proper ultrasound technique including probe manipulation and image optimization
  • Proficiency at image generation and interpretation for advanced scanning techniques
  • Importance of rejecting indeterminate scans
  • Clinical integration of exam findings into the care of patients
  • Demonstrate proficiency at interpretation and generation of images including:
    • Advanced cardiac assessment
      • Assessment of ventricular systolic function
      • Evaluation of the sonographic features of tamponade
      • Evaluation of relative chamber size
      • Basic valvular assessment for catastrophic valvulopathy
    • IVC for CVP assessment
    • Advanced Thoracic
      • Assessment for A and B lines
      • Pleural effusions
      • Presence/absence of lung sliding in the evaluation of pneumothorax.
    • Leg veins for signs of deep vein thrombosis (DVT)
    • Renal Ultrasound for assessing hydronephrosis
    • Biliary Ultrasound for assessing cholecystitis
    • Soft tissue for assessment of cellulitis, abscess
    • Joints for assessment of effusions and possible aspiration
    • Procedural Guidance including central and peripheral vascular access
    • Other applications (ocular for optic nerve diameter, airway, aorta, fractures, etc.) depending on personal objectives and cases that present

Communicator

  • Communicate using a patient-centered approach that highlights patient trust and autonomy, and is characterized by empathy, respect and compassion
  • Optimizes physical environment for patient comfort and privacy
  • Integrate POCUS effectively into patient encounter
  • Demonstrate the ability to communicate ultrasound findings to healthcare team members
  • Document and share POCUS findings in an accurate, complete, timely and accessible manner that optimizes patient safety and privacy

Collaborator

  • Understand how POCUS contributes to the overall care of the patient
  • Work with colleagues and other specialties to assess, plan, provide and integrate care of patients, especially in areas where comprehensive imaging and POCUS overlap
  • Demonstrate safe handover of care, using both oral and written communication of POCUS findings and procedures, during patient transition to a different care professional, setting, or stage of care

Manager

  • Apply the science of quality improvement as it relates to patient care and learn the importance of a quality improvement program
  • Demonstrate proper image archiving of ultrasound scans and timely reporting of findings
  • Utilizes time effectively to incorporate ultrasound scanning into shifts and obtain required scans
  • Understand the process for disinfection/infection control for a POCUS program

Health Advocate

  • Respond to an individual patient’s health needs by advocating with the patient within and beyond the clinical environment
  • Identifies the need for ultrasound equipment for all areas of acute care, including the emergency department
  • Learn proper maintenance. cleaning and care of ultrasound machines and transducers in the acute care setting

Scholar

  • Critically evaluate the integrity, reliability and applicability of POCUS literature and research
  • Engage in collaborative learning to continuously improve personal practice and contribute to collective improvements in practice
  • Integrate evidence into decision-making in their practice
  • Provide feedback to enhance learning and performance

Professional

  • Demonstrate a commitment to patient safety and quality improvement
  • Exhibit self-awareness and manage influences on person well-being and professional performance
  • Recognize and respond to unprofessional and unethical behaviours in physicians and other colleagues in the healthcare profession
  • Fulfill and adhere to the professional and ethical codes of the hospital and CMPA
  • Understand the role and indications for POCUS in the care of the acutely sick patient with the presentation of shock/hypotension.
  • Discover the benefits and limitations of these techniques as they apply to the practice of the acute care setting.
  • Increase familiarity and competence with select advanced ultrasound applications.
  • Learn to maintain and clean POCUS machines in the emergency setting

4. Evaluation Tools

  • Trainee Evaluation:
    • Competency-based tools will be provided to assess progression for the learner through the rotation including direct observation (mini-CEX)
    • The trainee must demonstrate proficiency by completing a minimum of
      • 25 scans in Advanced Cardiac
      • 25 scans in Advanced Thoracic
      • 25 scan in Abdominal/Renal
      • 10 scan in DVT
  • Online exam at the end of rotation utilizing online Moodle platform with unlimited attempts
  • Trainer Evaluation:
    • The rotation coordinator is responsible for evaluations and completing Elantra CBME milestones

5. Resource Material

There are obviously hundreds of resources available online. A library of POCUS resources will be provided to the learner including an online portal to modules and textbook chapters. Pertinent chapters should be reviewed in relevant applications during rotation and modules watched prior to the start of rotation at a minimum.

6. Contact

Elective requests, applications and questions sent to:

Name: Susan Pierson
Position: Administrative Assistant
Email: Susan.Pierson@lhsc.on.ca

Name: Dr. Frank Myslik
Position: POCUS Program Director
Email: Frank.Myslik@lhsc.on.ca

Address: London Health Sciences Centre, Victoria Hospital
Room E1-102, 800 Commissioners Rd East
London, Ontario
N6A 5W9

A downloadable version of the above can be found here