At the Point of Care: Point-of-Care Ultrasound in Core Internal Medicine and GIM Residency Programs in Canada

Transcription

1 At the Point of Care: Point-of-Care Ultrasound in Core Internal Medicine and GIM Residency Programs in Canada Author: Jonathan Ailon, MDCM Date: October 20 th, 2012

2 I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. Je n ai aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d appareils médicaux ou un cabinet de communication. Author: Jonathan Ailon, MDCM Date: October 20 th, 2012

3 Outline 1. What is point-of-care ultrasound (PCUS)? 2. PCUS and Internal Medicine 3. PCUS education in Canadian IM residency programs 4. Can we develop curricula for PCUS? 3

4 Point of Care Ultrasound Moore CL, Copel JA. NEJM

5 Point of Care Ultrasound Definition: Point-of-care ultrasonography is defined as ultrasonography brought to the patient and performed by the provider in real time Sonosite S Series GE Vscan Mobisante MobiUS Smartphone Moore CL, Copel JA. NEJM

6 How Could PCUS Help Patient Care? PCUS shown to:» Improve diagnostic accuracy 1» Decrease patient anxiety and discomfort 2» Reduce procedure-related complications 3 Agency of Healthcare Research and Quality» use of real-time ultrasound guidance is a safety practice that is highly rated to decrease medical error 1 Moore CL, Copel JA. NEJM McGee DG, Gould MK. NEJM Feller-Kopman D, Chest AHRQ publication no. 01-E058 6

7 Moore CL, Copel JA. NEJM Paper Session: Teaching and learning in residency education Dr. Jonathan Ailon Uses of PCUS 7

8 Moore CL, Copel JA. NEJM Paper Session: Teaching and learning in residency education Dr. Jonathan Ailon Uses of PCUS in Internal Medicine 8

9 Potential Applications of PCUS for GIM Diagnosis: Procedures: 1. Abnormal fluid 1. The -centesis 1. Abnormal consistencies 2. Central Line insertion 2. Abnormal dimensions 3. IV insertion 4. Marking for lumbar punctures 9

10 The Research Question 1. What is the current use of and training for PCUS in Canadian IM residency programs? 2. What potential barriers are there to the implementation of PCUS curricula? 10

11 PCUS in Canadian GIM Residency Programs Online survey of all Canadian core and general internal medicine programs from October to November 2011» GIM program directors» GIM division directors» Core internal medicine program directors» 53% response rate (of 32 possible responders) 11

12 Incorporation of PCUS into residency training program: No 53% Yes 47% 12

13 Current Use of PCUS in GIM Diagnostic US Procedural US 13

14 Does your curriculum include formal training on PCUS? No 75% Yes 25% 14

15 Should PCUS be used by residents and staff on the GIM service? Yes 100% 15

16 Barriers to PCUS Implementation Reported barriers:» 87% lack of faculty trained in PCUS» 47% lack of regular access to US machine 47% own a dedicated machine 33% have limited access to a machine» 40% financial reasons» 27% opposition from US-certified physicians 16

17 Survey Summary 100% of responders feel that PCUS should be incorporated into residency training curricula 47% report to have PCUS training as part of residency program 25% offer formal training in PCUS 17

18 Proposed PCUS Curriculum 1. Online PCUS modules» Developed collaboratively with GIM specialist, echocardiologist, radiologist» Plan to make modules open-source for easy content sharing 2. Hands on training session with focused competencies» Diagnosis: Ascites, pleural effusion, hemodynamic status» Procedural: Paracentesis, thoracentesis, lumbar puncture 18

19 Proposed PCUS Curriculum 3. Dedicated academic half day» Reinforce ultrasound teaching and provide additional supervised hands on training 3. Supervised PCUS scans and procedure logging» PCUS supervision of trainees performing scans» Online submission of studies for formal review 4. Standardized formal competency assessment» Standardized patients for diagnostic skills» PCUS simulators for procedural competencies 19

20 1. Online Modules 20

21 2. Hands on Training 21

22 3. Procedure Logging 22

23 4. Simulated Assessment 23

24 Credits and Thanks Dr. Jonathan Ailon Dr. Heather McDonald-Blumer Dr. Mark Bonta Dr. Ryan Brydges Dr. Rodrigo Cavalcanti Dr. Jordan Chenkin Dr. Mark Cheung Dr. Vince Chien Dr. Chi-Ming Chow Dr. Shelly Dev Dr. Luke Devine Dr. Jeremy Edwards Dr. David Frost Dr. Natalie Ho Dr. Janice Kwan Benjamin Li Dr. Lauren Lapointe-Shaw Mauren McClenaghan Dr. Ann Marie McKenna Dr. Ophyr Mourad Dr. Graham Slaughter Dr. Lynfa Stroud Dr. Adina Weinerman Dr. Brian Wong 24

25 References 1. Moore CL, Copel JA. Point of Care Ultrasonography. N Engl J Med 2011;364: McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348: Feller-Kopman D. Ultrasound-guided thoracentesis. Chest 2006;129: Kohn KT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press, Making health care safer: a critical analysis of patient safety practices. Rock- ville, MD: Agency for Healthcare Re- search and Quality. (AHRQ publication no. 01- E058.) 6. Blue Phantom. Midscapular Thoracentesis Ultrasound Training Model, (2012) (visited Oct 4, 2012). 7. Diagnostic and Interventional Cardiology. Mount Sinai School of Medicine Gives Pocket Ultrasound Devices to Its Students, (18, Sep., 2012) (visited Oct 1, 2012). 25

26 Additional Slides 26

27 Limitations of Our Study Small sample size Response bias PCUS standard of care Over representation of PCUS usage influenced by larger programs 27

28 The Curriculum To Date: Attending Staff ultrasound leads identified at each University of Toronto site trained 181 residents enrolled in research pilot 105 have started modules ~ 60 have completed hands on training sessions Initiating on-line logging in October 2012 Plan for simulated assessment Spring

29 PCUS in the Media Mount Sinai School of Medicine Gives Pocket Ultrasound Devices to Its Students Class of 2016 medical students to participate in point-of-care imaging research study we expect that using handheld ultrasound will bring our students education to an innovative new level Diagnostic and Interventional Cardiology

30 PCUS the new Stethoscope? 2 medical students trained for 18 hours on PCUS Performed PCUS exams on 61 patients in cardiology clinic Compared to Staff cardiologists (physical exam) Med Students Cardiologists 0 Accuracy Specificity Sensitivity Detecting Diastolic Murmurs Echocardiography. 23(6):439-46, 2006 Jul. 30

31 PCUS the new Stethoscope? 9 PGY-1/2 residents Trained for 15 hours didactic echo with 5 hours hands-on Assessed 72 consecutive patients admitted to GIM Accuracy Inadequate scans and misinterpretation are potential pitfalls of PCUS 0 Major Findings Minor Findings Echocardiography. 23(6):439-46, 2006 Jul. 31

32 PCUS the new Stethoscope? 42 patients randomized to PCUS-guided LP or standard technique No major differences in patient demographics Success rates: Blind PCUS 20 0 All Patients Obese Subset J Ultrasound Med Oct;26(10):

33 PCUS a make work project? PCUS echocardiogram on 103 consecutive patients admitted to GIM service 70% had no clinical indication for echo All went on to have formal echocardiogram High false positive rate (PPV only 32%) However, 17% had clinical significant findings that would have otherwise been missed on physical exam alone J Am Soc Echo. 16(9), 901-5, 2003, Jun. 33

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