Sound Decision-Making: Leveraging POCUS in Rural Healthcare
A 30-year-old female who is 14 weeks pregnant comes into your rural free-standing emergency department (FSED) complaining of abdominal pain and “a gush of blood” after a low-speed motor vehicle accident. She has not yet had an ultrasound to confirm intrauterine pregnancy. Physical exam demonstrates a mildly tender lower abdomen. The cervical os is closed with scant blood. The patient’s vital signs show a heart rate of 95 beats per minute, blood pressure of 97/55 mm Hg, and normal respiratory rate, oxygen saturation and temperature. The nearest tertiary hospital is 4 hours away. The next available outpatient obstetrics (OB) appointment is in 3 days. The next available radiology appointment for ultrasound is in 2 days. What is the best course of action in this scenario where intraabdominal trauma, miscarriage, and an ectopic pregnancy are all on the differential?
What are the high-yield applications of POCUS in a rural setting?
Point-of-care ultrasound (POCUS) can be extremely useful in settings where access to diagnostic imaging and specialty consultations is limited by proximity or availability. This tool has been shown to improve diagnostic certainty, aiding in medical decision-making, as well as safety during certain procedures such as paracentesis. It also improves efficiency by decreasing length-of-stay, unnecessary transfers, and missed days from work. Check out our prior post on POCUS benefits here.
The decision to utilize resources to transport a patient for hours to a tertiary-care center cannot be made lightly. Patients have been left financially responsible for large bills when insurance companies choose not to cover these costs.[1] POCUS helps clinicians make more informed decisions in such situations. Additional evidence to support non-emergent follow-up may help healthy patients avoid unnecessary cost and missed days from family and work. Emergent findings can prompt immediate intervention and more appropriate transfer.
For this patient, the Focused Assessment with Sonography in Trauma (FAST) exam and OB ultrasound can yield important information to guide medical management. The FAST exam has demonstrated a high sensitivity and even greater specificity when evaluating for hemoperitoneum and can be performed within 5 minutes. It has nearly 100% sensitivity in hypotensive trauma patients.[2, 3] A positive FAST would lead to emergent resuscitation and transfer.
OB POCUS training is already implemented in Ob/Gyn and emergency medicine residency programs. Curriculums have been developed and published as free open-access medical education (FOAM).[4] As with all POCUS, a focused examination is best used to answer specific questions. Emergency medicine curriculums focus on identifying intrauterine pregnancy (IUP) and measuring a fetal heart rate if late enough in pregnancy. By ruling in an IUP, ectopic pregnancy can be safely ruled out in low-risk patients.
POCUS can also be instrumental in diagnosing and managing the following acute and chronic conditions:
· Abdominal aortic aneurysm
· Lower extremity deep vein thrombosis
· Cholecystitis and cholelithiasis
· Retinal and vitreous detachment
· Increased intracranial pressure
· Hydronephrosis
· Urinary retention
· Abscess and cellulitis
· Achilles tendon rupture
· Shoulder dislocation
· Pneumonia/ COVID-19
· Congestive heart failure
How do I overcome my already limited resources?
Barriers
In a rural setting, resources may already be strained. Obstacles to POCUS integration into clinical care may include fewer providers with formal POCUS training, lack of POCUS leadership, or lack of funds for the purchase of ultrasound machines. While these may seem unsurmountable, emerging technologies have made access to POCUS easier. Learn more about barriers to successful POCUS programs here.
Training
Providers can seek training in-person and online. In-person workshops are the gold standard and are increasingly offered in various disciplines. These intensive courses are taught by providers with formal postgraduate education in ultrasound. A great way to supplement an in-person workshop is taking advantage FOAM resources and AI-powered protocols on the POCUS devices. Some online POCUS educational programs provide learners with a more structured journey and an opportunity to test their knowledge. This particular one, for example, also offers continuous medical education (CME) credit. In addition, there are now simulation tools that are available to gain experience in image acquisition and interpretation.
Infrastructure
In creating a reliable POCUS program, clear clinical pathways must be established to ensure appropriate use of POCUS with full understanding of its limitations. Credentialing protocols must be in place to assure competency standard among the providers according to institutional, governmental, and organizational guidelines. Additionally, providers should be required to continue their POCUS education by completing virtual CME or taking refresher workshops. Quality assurance process is essential to provide feedback to providers and ensure high quality of the program. Learn more about key steps of POCUS program implementation in our previous blog post.
POCUS Devices
Ultrasound machines remain an important cost deterrent for many providers, especially in rural hospitals.[5] However, studies have shown cost savings in rural hospitals after implementation of ultrasonography due to quicker decision-making and more efficient treatment plans.[6] The long-term clinical benefits and savings should persuade administrators of rural medical facilities to implement POCUS. Furthermore, in the last few years hand-held POCUS devices have flooded the market and can be purchased for as low as $2,700 USD.
In Conclusion
In a setting with limited resources, any additional clinical evidence can help make the most appropriate decision to initiate a resource-heavy transfer to a tertiary care center or to send the patient to a distant imaging center. When POCUS reveals emergent findings, such as hemoperitoneum, providers can appropriately engage resources to transfer patients immediately. On the other hand, reassuring findings of an intrauterine pregnancy (IUP) can be helpful in managing pregnant patient in first or second trimester locally. POCUS offers additional clinical data with quick and easy techniques that can be readily taught to novice users in rural medical practices to help them take more informed and efficient care of their patients while saving costs.
Case Resolution
Over the past 5 years, your FSED has established a strong POCUS program. Because you have completed your institution’s credentialing program and obtained POCUS privileges, you were able perform a FAST exam and a transabdominal OB ultrasound on the patient. On your scan, there is no free fluid in the pelvis. You identified an IUP with a fetal heart rate of 174bpm. You observe the patient in your ED and repeated POCUS examination that was unchanged. Your patient’s abdominal pain resolved after treatment with acetaminophen, and you safely discharged her. On follow-up with the Ob/Gyn, the patient was found to have a normal, healthy pregnancy.
Key Takeaways
1. POCUS significantly improves patient care and resource utilization in rural settings.
2. There are important barriers to implementing an effective POCUS program, such as lack of POCUS leadership and funding, in rural medical facilities.
3. There are multiple strategies to overcome those barriers by utilizing latest technologies such as simulation and AI-powered device protocols.
Authored by Jason Wang DO, MBS
Edited by Tatiana Havryliuk, MD
References
[1] “Insurance refused to pay for her baby’s air ambulance ride : Shots - Health News : NPR.” Accessed: Mar. 28, 2024. [Online]. Available: https://www.npr.org/sections/health-shots/2024/03/25/1239206451/a-moms-97-000-question-how-was-an-air-ambulance-ride-not-medically-necessary
[2] W. S. Pearl and K. H. Todd, “Ultrasonography for the initial evaluation of blunt abdominal trauma: A review of prospective trials,” Ann Emerg Med, vol. 27, no. 3, pp. 353–361, Mar. 1996, doi: 10.1016/s0196-0644(96)70273-1.
[3] “Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma - PubMed.” Accessed: Mar. 06, 2024. [Online]. Available: https://pubmed.ncbi.nlm.nih.gov/8656471/
[4] J. Stone et al., “Curriculum and competency assessment program for training maternal-fetal medicine fellows in the performance of the detailed obstetric ultrasound examination: A consensus report,” American Journal of Obstetrics and Gynecology, vol. 228, no. 2, pp. B2–B9, Feb. 2023, doi: 10.1016/j.ajog.2022.08.008.
[5] M. Mengarelli, A. Nepusz, and T. Kondrashova, “A Comparison of Point-of-Care Ultrasonography Use in Rural Versus Urban Emergency Departments Throughout Missouri,” Mo Med, vol. 115, no. 1, pp. 56–60, 2018.
[6] B. M. Peña, G. A. Taylor, S. J. Fishman, and K. D. Mandl, “Costs and effectiveness of ultrasonography and limited computed tomography for diagnosing appendicitis in children,” Pediatrics, vol. 106, no. 4, pp. 672–676, Oct. 2000, doi: 10.1542/peds.106.4.672.