POCUS

Point-of-care-Ultrasound (POCUS) / Pocket Ultrasound in health care in rural areas in the context of demographic and structural change

Dieter Nürnberg; Vilmar Frauendorf; Hendra Lo

Introduction

Due to demographic change, urbanization and the shortage of doctors, there is an increasing threat of medical shortage of the aging population, especially in rural areas of Germany. The point-of-care ultrasound (POCUS) has been playing an important role in many countries, especially in the initial assessment of trauma and acute situations. i. In other areas, such as palliativ care, the ultrasound-assisted implementation of therapeutic measures, such as an effusion aspiration, can ensure improved outpatient care, which can also ease the burden on the healthcare system ii, iii. In countries such as Australia or Kenya, portable ultrasound has been successfully used for years due to the low density of physicians and the large distances iv v vi.

Ultraschallgerät

Figure 4. Architecture of the Sono-Teleconsulting concept

Objective and Study design

The aim of the Digilog project was to clarify whether the use of the point-of-care ultrasound (POCUS) is applicable in rural areas and can contribute to improved patient care.
In order to be able to better investigate the possible applications and possible additional benefits in various areas, a breakdown into different groups of participants took place as such:

  1. palliative care physician;
  2. general practitioner;
  3. emergency physician;
  4. nurses (for example, palliative care nurse).

In a first step (learning period 1), a structured training program was tested. In order to provide an initial introduction to the methodology and the study, a three-hour workshop certified by the State Medical Association was held. In addition to a concise presentation of the study, the basics of POCUS were also conveyed in practical examples. Since the priorities and the previous knowledge of ultrasound differed in the everyday patient care of palliative care physician, general practitioner, emergency physician and nursing staff, the emphasis was placed on a respective adaptation of the theoretical and practical content. Afterwards, the participants were able to gain initial experience with the use of portable VScan ultrasound equipment from GE by means of examination of several subjects (hands-on-training).
During the joint training, the study leaders were given an overview of the respective level of knowledge of the participants.
In a second step (learning period 2) there was a guided self-exercise phase of 10 to 14 days initially without documentation but with consultation by the study instructor.
Following (learning period 3) in a third step, a targeted application was made in the pre-stationary, primarily home, general- and palliative care by participating physicians. Using a standardized questionnaire, it was examined in which situations POCUS is particularly often used. At the end of the questionnaire, participating physicians assessed the impact of sonographic findings on further treatment, which should assess the impact on quality of care.

During the eight- to twelve-week survey phase, the participants received further support through targeted consultations with the study guides in the form of telephone consultations or other on-site instructions. Thus, a sufficient examination security (result quality) was achieved regardless of prior knowledge.

POCUS-Erhebungsbogen

Figure 2. standardized POCUS questionnaire, on which besides the acute symptoms, the current examination results as well as the influence on the further treatment should be collected.

Conclusions

Of the 96 general practicioners and palliative care physicians in Nordwestbrandenburg, 14 were initially involved in the training program. For a study participation with application in the medical practice altogether 11 physicians in the period between March and October 2018 could be recruited. Of these, 7 participants had sufficient ultrasound knowledge. For 4 ultrasound inexperienced physicians, a more intensive support was provided by supervision of outpatient examinations. It showed a very heterogeneous application behavior.

Figure 3 For the participation in the study, a total of 11 physicians were recruited in the medical practice in Nordwestbrandenburg. Of these, 7 participants had sufficient ultrasound knowledge, 4 participants were ultrasound-inexperienced

In total, more than 110 patients in the group of general practicioners and palliative care physicians were examined during home visits by means of ultrasound.
Until October 2018, 64 questionnaires from general- and palliative care physicians had been evaluated, with the most frequent symptoms being shortness of breath and pain. According to the complaints, the lung and abdomen were most frequently examined. In the case of pathological findings, the presence of ascites or pleural effusions was frequently evident, which is due to the large number of palliative patients. Further results are shown in Table 1.
Although direct targeted interventions (punctures) were only performed in 10 times, the ultrasound examination had an influence on further treatment in more than two thirds of all cases, in particular on the decision on medication (dose adjustment) and on inpatient admission.
Wenngleich nur in 10 Einsätzen direkte gezielte Interventionen (Punktionen) erfolgten, hatte die gezielte Ultraschalluntersuchung doch in mehr als 2/3 aller Fälle einen Einfluss auf die weitere Behandlung, insbesondere auf die Entscheidung zur Medikation (Dosisanpassung) sowie bezüglich einer stationären Einweisung.

l

Leitsymptom

n

%

Untersuchungsschwerpunkt

n

%

Luftnot

29

44,6

Abdomen

49

75,4

Schmerz

28

43,1

Lunge

40

61,5

Übelkeit/ Erbrechen

13

20,0

Urogenital

32

49,2

Obstipation/Meteorismus

8

12,3

Herz

25

38,5

Fieber

4

6,2

Extremitäten

10

15,4

Harnverhalt

3

4,6

Ikterus

2

3,1

Auswirkung auf Behandlung

n

%

Extremitätenschwellung

2

3,1

ja

44

67,7

Schock

1

1,5

nein

18

27,7

Bewegungseinschränkung

1

1,5

k. A.

2

3,1

Sonstiges

4

6,2

Interventionen (Punktion)

10

15,4

k. A.

3

4,6

Änderung der Medikation

23

35,4

Stationäre Einweisung

9

13,8

Table 1.

Results - Main symptoms, main focus and effect of portable sonographic findings on further treatment

For various reasons, not enough patients could be included from the emergency medicine. The use in this group was considerably hampered by bureaucratic hurdles and after overcoming the same only a low frequency of use (7) within 8 weeks.

A structured training program for the group of non-physicians, in this case palliative care sisters in the SAPV operation has meanwhile started. An evaluation is in progress. The motivation for the application and feasibility in limited issues is given initial impression high.

Perspectives

Shortage of highly qualified medical staff in rural areas could pose difficulties in the implementation of POCUS. The presented concept of the Sono-Teleconsulting of the IHP (Ortmann et al.) at the 42nd Dreiländertreffen SGUM, DEGUM, ÖGUM allows the use of a mobile ultrasound device with additional live conference call to an ultrasound expert who remains in his clinic.

Not only will the ultrasound images be transmitted live to an expert, it will simultaneously enable a visual impression of the patient, the handling of the ultrasound device, the guidance of the probe as well as a voice connection in a live conference between the on-site practitioner (possibly Non-physician) and the ultrasound expert.

Sono-Teleconsulting

Figure 4. Architecture of the Sono-Teleconsulting concept

A first wired application was successfully implemented with the ultrasound device from the American manufacturer Interson. A wireless use of the VScan device by General Electrics is being tested in the state of Brandenburg in the Ruppiner Kliniken Neuruppin and the MOL clinics in Wriezen and Strausberg. The Sono-Teleconsulting can already be implemented technically with 30% utilization of a 3G mobile radio connection. The mobile radio network in Brandenburg has had gaps for years, which could be difficult for the nationwide implementation of the concept. For example, dead-spots reported by the website https://www.funkloch-brandenburg.de are currently being registered and stored on the basis of geo-coordinates in order to get those responsible in the state government and mobile operators to quickly find solutions.

Conclucion

Based on the present study, it has been shown to date that an individually adapted training program is well suited to enable even less experienced physicians to safely handle a portable ultrasound device to answer simple clinical questions. Due to the high level of readiness on the part of the participating physicians, we hope to gain a diagnostic advantage in the pre-hospital phase and thus improved patient care in rural areas. To assess this, it requires a broader application with final evaluation of pending further investigations including additional areas of outpatient medicine.

References

Nürnberg, D. et al., Ultrasound in palliative care medicine. I. Z Gastroenterol, 2015. 53(5): 409-16
Nürnberg, D., et al., Ultrasound in palliative care medicine II. Z Gastroenterol, 2017. 55(6): 582-591
Bell, G., et al., A pilot training program for point-of-care ultrasound in Kenya. Afr J Emerg Med. 2016 Sep. 6(3): 132-137.
Wanjiku, G.W., et al., Assesing a novel point-of-care ultrasound training program for rural healthcare providers in Kenya. BMC Health Serv Res. 2018 Aug 6. 18(1): 607.
Dietrich, C.F., et al, Point of Care Ultrasound: A WFUMB Posistion Paper. Ultrasound Med Biol. 2017 Jan. 43(1): 48-58
Ortmann, S., et al., Sono-Teleconsulting. Ultraschall in Med. 2018. 39(S 01): S21

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