Routinely adding ultrasound examinations by pocket-sized ultrasound devices improves inpatient diagnostics in a medical department

doi:10.1016/j.ejim.2011.10.009

European Journal of Internal Medicine

Volume 23, Issue 2, March 2012, Pages 185-191

https://doi.org/10.1016/j.ejim.2011.10.009 Get rights and content

Abstract

Background

We aimed to investigate the potential benefit of adding a routine cardiac and abdominal diagnostic examination by pocket-sized ultrasound device in patients admitted to a medical department.

Methods

A random sample of 196 patients admitted to the medical department at a non-university hospital in Norway between March and September 2010 was studied. The patients underwent cardiac and abdominal screening with a pocket-sized ultrasound device with B-mode and color flow imaging after a principal diagnosis was set. Three internists/cardiologists experienced in ultrasonography performed the examinations. Diagnostic corrections were made and findings were confirmed by high-end echocardiography and examinations at the radiologic department.

Results

196 patients were included (male = 56.6%, mean ± SD; 68.1 ± 15.0 years old). The time spent doing the ultrasound screening was mean ± SD 4.3 ± 1.6 min for the cardiac screening and 2.5 ± 1.1 min for the abdominal screening. In 36 (18.4%) patients this examination resulted in a major change in the primary diagnosis. In 38 (19.4%) patients the diagnosis was verified and in 18 (9.2%) patients an important additional diagnosis was made.

Conclusion

By adding a pocket-sized ultrasound examination of < 10 min to usual care, we corrected the diagnosis in almost 1 of 5 patients admitted to a medical department, resulting in a completely different treatment strategy without delay in many of the patients. Routinely adding a cardiac and abdominal ultrasound screening has the potential to rearrange inpatients workflow and diagnosis.

Introduction

Despite the heavy arsenal of diagnostic modalities available in hospitals, autopsies have revealed major diagnostic errors on 30% of patients [1], [2]. Thus, there is a need for improvement in diagnostic accuracy. Ultrasonography performed bedside (point-of-care ultrasonography) by the clinician can rapidly provide diagnostic images as a supplement to clinical findings. This may decrease medical errors [3].

The last two decades have dramatically changed the quality and portability of ultrasound scanners [4], [5], [6]. In the hands of experts, echocardiography with hand-carried and the new pocket-sized ultrasound devices have been shown to be feasible and accurate [7], [8], [9], [10], [11], [12]. Pocket-sized ultrasound devices fit in a white coat pocket, they are priced below $10,000 and they can be operated easier than a standard smart-phone. These devices may serve as efficient tools during busy ward rounds and thus, may provide a more efficient diagnostic algorithm and have the potential to rearrange inpatient workflow. However, clinical evaluation studies are scarce.

Thus, we aimed to study the diagnostic influence of focused cardiac and abdominal screening with pocket-sized ultrasound devices in an unselected group of patients admitted to a medical department.

Section snippets

Study population

Patients admitted to the department of medicine at the non-university Levanger Hospital in Norway were screened with a pocket-sized ultrasound device. The department is sectioned into wards for cardiology, nephrology, gastroenterology, hematology and infectious diseases, pulmonary diseases, and geriatric and cerebrovascular diseases. The inclusion of patients was restricted to preset dates where one of three participating internists/cardiologists was the specialist on call for general medicine.

Results

Table 1 shows the baseline data of the 196 patients included in the study (111 men and 85 women). Mean ± SD (range) age was 68.1 ± 15.0 (20–95) years. The distribution of age was positively skewed compared to a normal distribution. Atrial fibrillation was present in 32 (16%) of the patients at admission, hypertension was present in 69 (35%) patients and 32 (16%) had known diabetes mellitus. Cardiovascular disease defined as at least one of the following diagnoses; myocardial infarction, angina

Discussion

By routinely adding a cardiac and focused abdominal ultrasound screening to the standard diagnostic examinations performed in the emergency room, the principal diagnosis, and thereby the treatment, was significantly corrected in nearly 1 in 5 (18%) of patients. Additionally, 20% had their primary diagnosis verified and in 9% an additional diagnosis of certain importance was made. Overall, the pocket-sized ultrasound screening of mean 6.8 min was of diagnostic importance in approximately half of

Conclusion

By adding a pocket-sized ultrasound examination with B-mode and color flow imaging of < 10 min to usual care diagnostics, we made important diagnostic changes in 1 of 5 patients admitted to a medical department, resulting in a completely different treatment strategy without time delay. Routinely adding a cardiac and abdominal ultrasound screening has the potential to rearrange inpatient workflow and diagnosis.

Learning points

•
Despite a wide array of diagnostic modalities, clinical diagnostics are still sub-optimal and autopsy studies have revealed major diagnostic errors in a significant amount of patients treated at hospital.
•
Point-of-care ultrasound performed by clinicians may be a useful supplement in the treatment and assessment of certain patients.
•
By adding a cardiovascular and focused abdominal ultrasound examination of mean 6.8 min by pocket-sized ultrasound, we correctly assessed cardiac and abdominal

Conflict of interest

None declared.

Acknowledgements

We thank the physicians and nurses at Levanger hospital for assistance with inclusions and data collection. The Norwegian University of Science and Technology and Nord-Trondelag Health Trust, both Norway, funded this study. OC Mjolstad, H Dalen and BO Haugen hold positions at the Medical Imaging Laboratory, NTNU, a Centre of Research-based Innovation that is funded by the Research Council of Norway and industry. One of the industry partners is GE Vingmed Ultrasound. The Centre has a total

References (28)

J.L. Burton et al.
Clinical, educational, and epidemiological value of autopsy
Lancet
(2007)
J. Roelandt et al.
Ultrasonic real time imaging with a hand-held-scanner. Part II—initial clinical experience
Ultrasound Med Biol
(1978)
J.R. Roelandt
Ultrasound stethoscopy
Eur J Intern Med
(2004)
C. Prinz et al.
Diagnostic accuracy of a hand-held ultrasound scanner in routine patients referred for echocardiography
J Am Soc Echocardiogr
(2011)
J.M. Brennan et al.
Reappraisal of the use of inferior vena cava for estimating right atrial pressure
J Am Soc Echocardiogr
(2007)
L.D. Martin et al.
Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination?
Am J Med
(2009)
N. Cardim et al.
Usefulness of a new miniaturized echocardiographic system in outpatient cardiology consultations as an extension of physical examination
J Am Soc Echocardiogr
(2011)
D.W. Baker et al.
Screening for left ventricular systolic dysfunction among patients with risk factors for heart failure
Am Heart J
(2003)
P.C. Spittell et al.
Screening for abdominal aortic aneurysm during transthoracic echocardiography in a hypertensive patient population
J Am Soc Echocardiogr
(1997)
A. Soultati et al.
The burden of incidental findings in clinical practice in a tertiary care center
Eur J Intern Med
(2010)

S. Lafitte et al.

Validation of the smallest pocket echoscopic device's diagnostic capabilities in heart investigation

Ultrasound Med Biol

(2011)

A. Combes et al.

Clinical and autopsy diagnoses in the intensive care unit: a prospective study

Arch Intern Med

(2004)

C.L. Moore et al.

Point-of-care ultrasonography

N Engl J Med

(2011)

J.R. Roelandt

Ultrasound stethoscopy: a renaissance of the physical examination?

Heart

(2003)

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Original articleRoutinely adding ultrasound examinations by pocket-sized ultrasound devices improves inpatient diagnostics in a medical department

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study population

Results

Discussion

Conclusion

Learning points

Conflict of interest

Acknowledgements

Lancet

Ultrasound Med Biol

Eur J Intern Med

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am J Med

J Am Soc Echocardiogr

Am Heart J

J Am Soc Echocardiogr

Eur J Intern Med

Ultrasound Med Biol

Clinical and autopsy diagnoses in the intensive care unit: a prospective study

Arch Intern Med

Point-of-care ultrasonography

N Engl J Med

Ultrasound stethoscopy: a renaissance of the physical examination?

Heart

Original article
Routinely adding ultrasound examinations by pocket-sized ultrasound devices improves inpatient diagnostics in a medical department