Nilam J. Soni, MD, MS

Affiliations

Section of Pulmonary and Critical Care Medicine, South Texas Veterans Health Care System and University of Texas Health Science Center

[email protected]

Given name(s)

Nilam J.

Family name

Soni

Degrees

MD, MS

Point-of-Care Ultrasound for Hospitalists: A Position Statement of the Society of Hospital Medicine

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Author(s)

Many hospitalists incorporate point-of-care ultrasound (POCUS) into their daily practice because it adds value to their bedside evaluation of patients. However, standards for training and assessing hospitalists in POCUS have not yet been established. Other acute care specialties, including emergency medicine and critical care medicine, have already incorporated POCUS into their graduate medical education training programs, but most internal medicine residency programs are only beginning to provide POCUS training.¹

Several features distinguish POCUS from comprehensive ultrasound examinations. First, POCUS is designed to answer focused questions, whereas comprehensive ultrasound examinations evaluate all organs in an anatomical region; for example, an abdominal POCUS exam may evaluate only for presence or absence of intraperitoneal free fluid, whereas a comprehensive examination of the right upper quadrant will evaluate the liver, gallbladder, and biliary ducts. Second, POCUS examinations are generally performed by the same clinician who generates the relevant clinical question to answer with POCUS and ultimately integrates the findings into the patient’s care.² By contrast, comprehensive ultrasound examinations involve multiple providers and steps: a clinician generates a relevant clinical question and requests an ultrasound examination that is acquired by a sonographer, interpreted by a radiologist, and reported back to the requesting clinician. Third, POCUS is often used to evaluate multiple body systems. For example, to evaluate a patient with undifferentiated hypotension, a multisystem POCUS examination of the heart, inferior vena cava, lungs, abdomen, and lower extremity veins is typically performed. Finally, POCUS examinations can be performed serially to investigate changes in clinical status or evaluate response to therapy, such as monitoring the heart, lungs, and inferior vena cava during fluid resuscitation.

The purpose of this position statement is to inform a broad audience about how hospitalists are using diagnostic and procedural applications of POCUS. This position statement does not mandate that hospitalists use POCUS. Rather, it is intended to provide guidance on the safe and effective use of POCUS by the hospitalists who use it and the administrators who oversee its use. We discuss POCUS (1) applications, (2) training, (3) assessments, and (4) program management. This position statement was reviewed and approved by the Society of Hospital Medicine (SHM) Executive Committee in March 2018.

APPLICATIONS

Common diagnostic and procedural applications of POCUS used by hospitalists are listed in Table 1. Selected evidence supporting the use of these applications is described in the supplementary online content (Appendices 1–8 available at http://journalofhospitalmedicine.com) and SHM position statements on specific ultrasound-guided bedside procedures.^3,4 Additional applications not listed in Table 1 that may be performed by some hospitalists include assessment of the eyes, stomach, bowels, ovaries, pregnancy, and testicles, as well as performance of regional anesthesia. Moreover, hospitalists caring for pediatric and adolescent patients may use additional applications besides those listed here. Currently, many hospitalists already perform more complex and sophisticated POCUS examinations than those listed in Table 1. The scope of POCUS use by hospitalists continues to expand, and this position statement should not restrict that expansion.

As outlined in our earlier position statements,^3,4 ultrasound guidance lowers complication rates and increases success rates of invasive bedside procedures. Diagnostic POCUS can guide clinical decision making prior to bedside procedures. For instance, hospitalists may use POCUS to assess the size and character of a pleural effusion to help determine the most appropriate management strategy: observation, medical treatment, thoracentesis, chest tube placement, or surgical therapy. Furthermore, diagnostic POCUS can be used to rapidly assess for immediate postprocedural complications, such as pneumothorax, or if the patient develops new symptoms.

TRAINING

Basic Knowledge

Basic knowledge includes fundamentals of ultrasound physics; safety;⁴ anatomy; physiology; and device operation, including maintenance and cleaning. Basic knowledge can be taught by multiple methods, including live or recorded lectures, online modules, or directed readings.

Image Acquisition

Training should occur across multiple types of patients (eg, obese, cachectic, postsurgical) and clinical settings (eg, intensive care unit, general medicine wards, emergency department) when available. Training is largely hands-on because the relevant skills involve integration of 3D anatomy with spatial manipulation, hand-eye coordination, and fine motor movements. Virtual reality ultrasound simulators may accelerate mastery, particularly for cardiac image acquisition, and expose learners to standardized sets of pathologic findings. Real-time bedside feedback on image acquisition is ideal because understanding how ultrasound probe manipulation affects the images acquired is essential to learning.

Image Interpretation

Training in image interpretation relies on visual pattern recognition of normal and abnormal findings. Therefore, the normal to abnormal spectrum should be broad, and learners should maintain a log of what abnormalities have been identified. Giving real-time feedback at the bedside is ideal because of the connection between image acquisition and interpretation. Image interpretation can be taught through didactic sessions, image review sessions, or review of teaching files with annotated images.

Clinical Integration

Learners must interpret and integrate image findings with other clinical data considering the image quality, patient characteristics, and changing physiology. Clinical integration should be taught by instructors that share similar clinical knowledge as learners. Although sonographers are well suited to teach image acquisition, they should not be the sole instructors to teach hospitalists how to integrate ultrasound findings in clinical decision making. Likewise, emphasis should be placed on the appropriate use of POCUS within a provider’s skill set. Learners must appreciate the clinical significance of POCUS findings, including recognition of incidental findings that may require further workup. Supplemental training in clinical integration can occur through didactics that include complex patient scenarios.

Pathways

Clinical competency can be achieved with training adherent to five criteria. First, the training environment should be similar to where the trainee will practice. Second, training and feedback should occur in real time. Third, specific applications should be taught rather than broad training in “hospitalist POCUS.” Each application requires unique skills and knowledge, including image acquisition pitfalls and artifacts. Fourth, clinical competence must be achieved and demonstrated; it is not necessarily gained through experience. Fifth, once competency is achieved, continued education and feedback are necessary to ensure it is maintained.

Residency-based POCUS training pathways can best fulfill these criteria. They may eventually become commonplace, but until then alternative pathways must exist for hospitalist providers who are already in practice. There are three important attributes of such pathways. First, administrators’ expectations about learners’ clinical productivity must be realistically, but only temporarily, relaxed; otherwise, competing demands on time will likely overwhelm learners and subvert training. Second, training should begin through a local or national hands-on training program. The SHM POCUS certificate program consolidates training for common diagnostic POCUS applications for hospitalists.⁶ Other medical societies offer training for their respective clinical specialties.⁷ Third, once basic POCUS training has begun, longitudinal training should continue ideally with a local hospitalist POCUS expert.

In some settings, a subgroup of hospitalists may not desire, or be able to achieve, competency in the manual skills of POCUS image acquisition. Nevertheless, hospitalists may still find value in understanding POCUS nomenclature, image pattern recognition, and the evidence and pitfalls behind clinical integration of specific POCUS findings. This subset of POCUS skills allows hospitalists to communicate effectively with and understand the clinical decisions made by their colleagues who are competent in POCUS use.

The minimal skills a hospitalist should possess to serve as a POCUS trainer include proficiency of basic knowledge, image acquisition, image interpretation, and clinical integration of the POCUS applications being taught; effectiveness as a hands-on instructor to teach image acquisition skills; and an in-depth understanding of common POCUS pitfalls and limitations.

ASSESSMENTS

Assessment methods for POCUS can include the following: knowledge-based questions, image acquisition using task-specific checklists on human or simulation models, image interpretation using a series of videos or still images with normal and abnormal findings, clinical integration using “next best step” in a multiple choice format with POCUS images, and simulation-based clinical scenarios. Assessment methods should be aligned with local availability of resources and trainers.

Basic Knowledge

Basic knowledge can be assessed via multiple choice questions assessing knowledge of ultrasound physics, image optimization, relevant anatomy, and limitations of POCUS imaging. Basic knowledge lies primarily in the cognitive domain and does not assess manual skills.

Image Acquisition

Image acquisition can be assessed by observation and rating of image quality. Where resources allow, assessment of image acquisition is likely best done through a combination of developing an image portfolio with a minimum number of high quality images, plus direct observation of image acquisition by an expert. Various programs have utilized minimum numbers of images acquired to help define competence with image acquisition skills.^6–8 Although minimums may be a necessary step to gain competence, using them as a sole means to determine competence does not account for variable learning curves.⁹ As with other manual skills in hospital medicine, such as ultrasound-guided bedside procedures, minimum numbers are best used as a starting point for assessments.^3,10 In this regard, portfolio development with meticulous attention to the gain, depth, and proper tomographic plane of images can monitor a hospitalist’s progress toward competence by providing objective assessments and feedback. Simulation may also be used as it allows assessment of image acquisition skills and an opportunity to provide real-time feedback, similar to direct observation but without actual patients.

Image Interpretation

Image interpretation is best assessed by an expert observing the learner at bedside; however, when bedside assessment is not possible, image interpretation skills may be assessed using multiple choice or free text interpretation of archived ultrasound images with normal and abnormal findings. This is often incorporated into the portfolio development portion of a training program, as learners can submit their image interpretation along with the video clip. Both normal and abnormal images can be used to assess anatomic recognition and interpretation. Emphasis should be placed on determining when an image is suboptimal for diagnosis (eg, incomplete exam or poor-quality images). Quality assurance programs should incorporate structured feedback sessions.

Clinical Integration

Assessment of clinical integration can be completed through case scenarios that assess knowledge, interpretation of images, and integration of findings into clinical decision making, which is often delivered via a computer-based assessment. Assessments should combine specific POCUS applications to evaluate common clinical problems in hospital medicine, such as undifferentiated hypotension and dyspnea. High-fidelity simulators can be used to blend clinical case scenarios with image acquisition, image interpretation, and clinical integration. When feasible, comprehensive feedback on how providers acquire, interpret, and apply ultrasound at the bedside is likely the best mechanism to assess clinical integration. This process can be done with a hospitalist’s own patients.

General Assessment

A general assessment that includes a summative knowledge and hands-on skills assessment using task-specific checklists can be performed upon completion of training. A high-fidelity simulator with dynamic or virtual anatomy can provide reproducible standardized assessments with variation in the type and difficulty of cases. When available, we encourage the use of dynamic assessments on actual patients that have both normal and abnormal ultrasound findings because simulated patient scenarios have limitations, even with the use of high-fidelity simulators. Programs are recommended to use formative and summative assessments for evaluation. Quantitative scoring systems using checklists are likely the best framework.^11,12

CERTIFICATES AND CERTIFICATION

A certificate of completion is proof of a provider’s participation in an educational activity; it does not equate with competency, though it may be a step toward it. Most POCUS training workshops and short courses provide certificates of completion. Certification of competency is an attestation of a hospitalist’s basic competence within a defined scope of practice (Table 2).¹³ However, without longitudinal supervision and feedback, skills can decay; therefore, we recommend a longitudinal training program that provides mentored feedback and incorporates periodic competency assessments. At present, no national board certification in POCUS is available to grant external certification of competency for hospitalists.

External Certificate

Certificates of completion can be external through a national organization. An external certificate of completion designed for hospitalists includes the POCUS Certificate of Completion offered by SHM in collaboration with CHEST.⁶ This certificate program provides regional training options and longitudinal portfolio development. Other external certificates are also available to hospitalists.^7,14,15

Most hospitalists are boarded by the American Board of Internal Medicine or the American Board of Family Medicine. These boards do not yet include certification of competency in POCUS. Other specialty boards, such as emergency medicine, include competency in POCUS. For emergency medicine, completion of an accredited residency training program and certification by the national board includes POCUS competency.

Internal Certificate

There are a few examples of successful local institutional programs that have provided internal certificates of competency.^12,14 Competency assessments require significant resources including investment by both faculty and learners. Ongoing evaluation of competency should be based on quality assurance processes.

Credentialing and Privileging

The American Medical Association (AMA) House of Delegates in 1999 passed a resolution (AMA HR. 802) recommending hospitals follow specialty-specific guidelines for privileging decisions related to POCUS use.¹⁷ The resolution included a statement that, “ultrasound imaging is within the scope of practice of appropriately trained physicians.”

Some institutions have begun to rely on a combination of internal and external certificate programs to grant privileges to hospitalists.¹⁰ Although specific privileges for POCUS may not be required in some hospitals, some institutions may require certification of training and assessments prior to granting permission to use POCUS.

Hospitalist programs are encouraged to evaluate ongoing POCUS use by their providers after granting initial permission. If privileging is instituted by a hospital, hospitalists must play a significant role in determining the requirements for privileging and ongoing maintenance of skills.

Maintenance of Skills

All medical skills can decay with disuse, including those associated with POCUS.^12,18 Thus, POCUS users should continue using POCUS regularly in clinical practice and participate in POCUS continuing medical education activities, ideally with ongoing assessments. Maintenance of skills may be confirmed through routine participation in a quality assurance program.

PROGRAM MANAGEMENT

Use of POCUS in hospital medicine has unique considerations, and hospitalists should be integrally involved in decision making surrounding institutional POCUS program management. Appointing a dedicated POCUS director can help a program succeed.⁸

Equipment and Image Archiving

Several factors are important to consider when selecting an ultrasound machine: portability, screen size, and ease of use; integration with the electronic medical record and options for image archiving; manufacturer’s service plan, including technical and clinical support; and compliance with local infection control policies. The ability to easily archive and retrieve images is essential for quality assurance, continuing education, institutional quality improvement, documentation, and reimbursement. In certain scenarios, image archiving may not be possible (such as with personal handheld devices or in emergency situations) or necessary (such as with frequent serial examinations during fluid resuscitation). An image archive is ideally linked to reports, orders, and billing software.^10,19 If such linkages are not feasible, parallel external storage that complies with regulatory standards (ie, HIPAA compliance) may be suitable.²⁰

Documentation and Billing

Components of documentation include the indication and type of ultrasound examination performed, date and time of the examination, patient identifying information, name of provider(s) acquiring and interpreting the images, specific scanning protocols used, patient position, probe used, and findings. Documentation can occur through a standalone note or as part of another note, such as a progress note. Whenever possible, documentation should be timely to facilitate communication with other providers.

Billing is supported through the AMA Current Procedural Terminology codes for “focused” or “limited” ultrasound examinations (Appendix 9). The following three criteria must be satisfied for billing. First, images must be permanently stored. Specific requirements vary by insurance policy, though current practice suggests a minimum of one image demonstrating relevant anatomy and pathology for the ultrasound examination coded. For ultrasound-guided procedures that require needle insertion, images should be captured at the point of interest, and a procedure note should reflect that the needle was guided and visualized under ultrasound.²¹ Second, proper documentation must be entered in the medical record. Third, local institutional privileges for POCUS must be considered. Although privileges are not required to bill, some hospitals or payers may require them.

Quality Assurance

Published guidelines on quality assurance in POCUS are available from different specialty organizations, including emergency medicine, pediatric emergency medicine, critical care, anesthesiology, obstetrics, and cardiology.^8,22–28 Quality assurance is aimed at ensuring that physicians maintain basic competency in using POCUS to influence bedside decisions.

Quality assurance should be carried out by an individual or committee with expertise in POCUS. Multidisciplinary QA programs in which hospital medicine providers are working collaboratively with other POCUS providers have been demonstrated to be highly effective.¹⁰ Oversight includes ensuring that providers using POCUS are appropriately trained,^10,22,28 using the equipment correctly,^8,26,28 and documenting properly. Some programs have implemented mechanisms to review and provide feedback on image acquisition, interpretation, and clinical integration.^8,10 Other programs have compared POCUS findings with referral studies, such as comprehensive ultrasound examinations.

CONCLUSIONS

Practicing hospitalists must continue to collaborate with their institutions to build POCUS capabilities. In particular, they must work with their local privileging body to determine what credentials are required. The distinction between certificates of completion and certificates of competency, including whether those certificates are internal or external, is important in the credentialing process.

External certificates of competency are currently unavailable for most practicing hospitalists because ABIM certification does not include POCUS-related competencies. As internal medicine residency training programs begin to adopt POCUS training and certification into their educational curricula, we foresee a need to update the ABIM Policies and Procedures for Certification. Until then, we recommend that certificates of competency be defined and granted internally by local hospitalist groups.

Given the many advantages of POCUS over traditional tools, we anticipate its increasing implementation among hospitalists in the future. As with all medical technology, its role in clinical care should be continuously reexamined and redefined through health services research. Such information will be useful in developing practice guidelines, educational curricula, and training standards.

Acknowledgments

The authors would like to thank all members that participated in the discussion and finalization of this position statement during the Point-of-care Ultrasound Faculty Retreat at the 2018 Society of Hospital Medicine Annual Conference: Saaid Abdel-Ghani, Brandon Boesch, Joel Cho, Ria Dancel, Renee Dversdal, Ricardo Franco-Sadud, Benjamin Galen, Trevor P. Jensen, Mohit Jindal, Gordon Johnson, Linda M. Kurian, Gigi Liu, Charles M. LoPresti, Brian P. Lucas, Venkat Kalidindi, Benji Matthews, Anna Maw, Gregory Mints, Kreegan Reierson, Gerard Salame, Richard Schildhouse, Daniel Schnobrich, Nilam Soni, Kirk Spencer, Hiromizu Takahashi, David M. Tierney, Tanping Wong, and Toru Yamada.

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References

1. Schnobrich DJ, Mathews BK, Trappey BE, Muthyala BK, Olson APJ. Entrusting internal medicine residents to use point of care ultrasound: Towards improved assessment and supervision. Med Teach. 2018:1-6. doi:10.1080/0142159X.2018.1457210.
2. Soni NJ, Lucas BP. Diagnostic point-of-care ultrasound for hospitalists. J Hosp Med. 2015;10(2):120-124. doi:10.1002/jhm.2285.
3. Lucas BP, Tierney DM, Jensen TP, et al. Credentialing of hospitalists in ultrasound-guided bedside procedures: a position statement of the society of hospital medicine. J Hosp Med. 2018;13(2):117-125. doi:10.12788/jhm.2917.
4. Dancel R, Schnobrich D, Puri N, et al. Recommendations on the use of ultrasound guidance for adult thoracentesis: a position statement of the society of hospital medicine. J Hosp Med. 2018;13(2):126-135. doi:10.12788/jhm.2940.
5. National Council on Radiation Protection and Measurements, The Council. Implementation of the Principle of as Low as Reasonably Achievable (ALARA) for Medical and Dental Personnel.; 1990.
6. Society of Hospital Medicine. Point of Care Ultrasound course: https://www.hospitalmedicine.org/clinical-topics/ultrasonography-cert/. Accessed February 6, 2018.
7. Critical Care Ultrasonography Certificate of Completion Program. CHEST. American College of Chest Physicians. http://www.chestnet.org/Education/Advanced-Clinical-Training/Certificate-of-Completion-Program/Critical-Care-Ultrasonography. Accessed February 6, 2018.
8. American College of Emergency Physicians Policy Statement: Emergency Ultrasound Guidelines. 2016. https://www.acep.org/Clinical---Practice-Management/ACEP-Ultrasound-Guidelines/. Accessed February 6, 2018.
9. Blehar DJ, Barton B, Gaspari RJ. Learning curves in emergency ultrasound education. Acad Emerg Med. 2015;22(5):574-582. doi:10.1111/acem.12653.
10. Mathews BK, Zwank M. Hospital medicine point of care ultrasound credentialing: an example protocol. J Hosp Med. 2017;12(9):767-772. doi:10.12788/jhm.2809.
11. Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. J Hosp Med. 2009;4(7):397-403. doi:10.1002/jhm.468.
12. Mathews BK, Reierson K, Vuong K, et al. The design and evaluation of the Comprehensive Hospitalist Assessment and Mentorship with Portfolios (CHAMP) ultrasound program. J Hosp Med. 2018;13(8):544-550. doi:10.12788/jhm.2938.
13. Soni NJ, Tierney DM, Jensen TP, Lucas BP. Certification of point-of-care ultrasound competency. J Hosp Med. 2017;12(9):775-776. doi:10.12788/jhm.2812.
14. Ultrasound Certification for Physicians. Alliance for Physician Certification and Advancement. APCA. https://apca.org/. Accessed February 6, 2018.
15. National Board of Echocardiography, Inc. https://www.echoboards.org/EchoBoards/News/2019_Adult_Critical_Care_Echocardiography_Exam.aspx. Accessed June 18, 2018.
16. Tierney DM. Internal Medicine Bedside Ultrasound Program (IMBUS). Abbott Northwestern. http://imbus.anwresidency.com/index.html. Accessed February 6, 2018.
17. American Medical Association House of Delegates Resolution H-230.960: Privileging for Ultrasound Imaging. Resolution 802. Policy Finder Website. http://search0.ama-assn.org/search/pfonline. Published 1999. Accessed February 18, 2018.
18. Kelm D, Ratelle J, Azeem N, et al. Longitudinal ultrasound curriculum improves long-term retention among internal medicine residents. J Grad Med Educ. 2015;7(3):454-457. doi:10.4300/JGME-14-00284.1.
19. Flannigan MJ, Adhikari S. Point-of-care ultrasound work flow innovation: impact on documentation and billing. J Ultrasound Med. 2017;36(12):2467-2474. doi:10.1002/jum.14284.
20. Emergency Ultrasound: Workflow White Paper. https://www.acep.org/uploadedFiles/ACEP/memberCenter/SectionsofMembership/ultra/Workflow%20White%20Paper.pdf. Published 2013. Accessed February 18, 2018.
21. Ultrasound Coding and Reimbursement Document 2009. Emergency Ultrasound Section. American College of Emergency Physicians. http://emergencyultrasoundteaching.com/assets/2009_coding_update.pdf. Published 2009. Accessed February 18, 2018.
22. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050-1060. doi:10.1378/chest.08-2305.
23. Frankel HL, Kirkpatrick AW, Elbarbary M, et al. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part I: general ultrasonography. Crit Care Med. 2015;43(11):2479-2502. doi:10.1097/ccm.0000000000001216.
24. Levitov A, Frankel HL, Blaivas M, et al. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part ii: cardiac ultrasonography. Crit Care Med. 2016;44(6):1206-1227. doi:10.1097/ccm.0000000000001847.
25. ACR–ACOG–AIUM–SRU Practice Parameter for the Performance of Obstetrical Ultrasound. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/us-ob.pdf. Published 2013. Accessed February 18, 2018.
26. AIUM practice guideline for documentation of an ultrasound examination. J Ultrasound Med. 2014;33(6):1098-1102. doi:10.7863/ultra.33.6.1098.
27. Marin JR, Lewiss RE. Point-of-care ultrasonography by pediatric emergency medicine physicians. Pediatrics. 2015;135(4):e1113-e1122. doi:10.1542/peds.2015-0343.
28. Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26(6):567-581. doi:10.1016/j.echo.2013.04.001.

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¹Division of General & Hospital Medicine, The University of Texas Health San Antonio, San Antonio, Texas; ²Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas; ³Divisions of General Internal Medicine and Hospital Pediatrics, University of Minnesota, Minneapolis, Minnesota; ⁴Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota; ⁵Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota; ⁶Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California; ⁷Division of Hospital Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; ⁸Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina; ⁹Department of Hospital Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California; ¹⁰Division of Hospital Medicine, Oregon Health & Science University, Portland, Oregon; ¹¹Division of Hospital Medicine, Weill Cornell Medicine, New York, New York; ¹²Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ¹³Division of Hospital Medicine, Zucker School of Medicine at Hofstra Northwell, New Hyde Park, New York; ¹⁴Hospitalist Program, Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; ¹⁵Division of Hospital Medicine, University of California Davis, Davis, California; ¹⁶Division of Hospital Medicine, Alameda Health System-Highland Hospital, Oakland, California; ¹⁷Louis Stokes Cleveland Veterans Affairs Hospital, Cleveland, Ohio; ¹⁸Case Western Reserve University School of Medicine, Cleveland, Ohio; ¹⁹Division of Hospital Medicine, University of Miami, Miami, Florida; ²⁰Division of Hospital Medicine, Legacy Healthcare System, Portland, Oregon; ²¹Division of Hospital Medicine, University of Colorado, Aurora, Colorado; ²²Department of Medicine, University of Central Florida, Naples, Florida; ²³White River Junction VA Medical Center, White River Junction, Vermont; ²⁴Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire.

Funding

Nilam Soni: Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative Grant (HX002263-01A1). Brian P Lucas: Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, National Center for Translational Science (UL1TR001086)

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APPLICATIONS

TRAINING

Basic Knowledge

Image Acquisition

Image Interpretation

Clinical Integration

Pathways

ASSESSMENTS

Basic Knowledge

Image Acquisition

Image Interpretation

Clinical Integration

General Assessment

CERTIFICATES AND CERTIFICATION

External Certificate

Internal Certificate

Credentialing and Privileging

Maintenance of Skills

PROGRAM MANAGEMENT

Equipment and Image Archiving

Documentation and Billing

Quality Assurance

CONCLUSIONS

Acknowledgments

APPLICATIONS

TRAINING

Basic Knowledge

Image Acquisition

Image Interpretation

Clinical Integration

Pathways

ASSESSMENTS

Basic Knowledge

Image Acquisition

Image Interpretation

Clinical Integration

General Assessment

CERTIFICATES AND CERTIFICATION

External Certificate

Internal Certificate

Credentialing and Privileging

Maintenance of Skills

PROGRAM MANAGEMENT

Equipment and Image Archiving

Documentation and Billing

Quality Assurance

CONCLUSIONS

Acknowledgments

References

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Published Online Only January 2, 2019. doi: 10.12788/jhm.3079

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Corresponding Author: Nilam J. Soni, MD MS; E-mail: [email protected]; Telephone: 210-743-6030.

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Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine

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Author(s)

Joel Cho, MD RDMS RDCS

Trevor P. Jensen, MD MS

Kreegan Reierson, MD

Benji K. Mathews, MD

Anjali Bhagra, MD

Ricardo Franco-Sadud, MD

Loretta Grikis, MLS

Michael Mader, MS

Ria Dancel, MD

Brian P. Lucas, MD MS

Society of Hospital Medicine Point-of-care Ultrasound Task Force

Nilam J. Soni, MD, MS

Abdominal paracentesis is a common and increasingly performed procedure in the United States. According to Medicare Physician Supplier Procedure Summary Master Files, an estimated 150,000 paracenteses were performed on Medicare fee-for-service beneficiaries in 2008 alone; such a number represents more than a two-fold increase from the same service population in 1993.¹ This increasing trend was again noted by the Nationwide Inpatient Sample data, which identified a 10% increase in hospitalized patients with a diagnosis of cirrhosis receiving paracentesis from 2004 (50%) to 2012 (61%; P < .0001).²

Although these data demonstrate that paracentesis is being performed frequently, paracentesis may be underutilized in hospitalized cirrhotics with ascites. In addition, in-hospital mortality of cirrhotics with ascites is higher among those who do not undergo paracentesis than among those who do (9% vs 6%; P = .03).^3,4

While complications associated with paracentesis are rare, serious complications, including death, have been documented.^5-10 The most common serious complication of paracentesis is bleeding, although puncture of the bowel and other abdominal organs has also been observed. Over the past few decades, ultrasound has been increasingly used with paracentesis due to the ability of ultrasound to improve detection of ascites^11,12 and to avoid blood vessels^10,13-15 and bowels.¹⁶

Three-quarters of all paracenteses are currently performed by interventional radiologists.¹ However, paracenteses are often required off-hours,¹⁷ when interventional radiologists are less readily available. Weekend admissions have less frequent performance of early paracentesis than weekday admissions, and delaying paracentesis may increase mortality.^3,18 High proficiency in ultrasound-guided paracentesis is achievable by nonradiologists^19-28 with equal or better patient outcomes after appropriate training.²⁹

The purpose of this guideline is to review the literature and present evidence-based recommendations on the performance of ultrasound-guided paracentesis at the bedside by practicing hospitalists.

METHODS

Detailed methods are described in Appendix 1. The Society of Hospital Medicine (SHM) Point-of-care Ultrasound (POCUS) Task Force was assembled to carry out this guideline development project under the direction of the SHM Board of Directors, Director of Education, and Education Committee. All expert panel members were physicians or advanced-practice providers with expertise in POCUS. Expert panel members were divided into working group members, external peer reviewers, and a methodologist, and all Task Force members were required to disclose any potential conflicts of interests (Appendix 2). The literature search was conducted in two independent phases. The first phase included literature searches conducted by the five working group members themselves. Key clinical questions and draft recommendations were then prepared, and a systematic literature search was conducted by a medical librarian based on the findings of the initial literature search and draft recommendations. The Medline, Embase, CINAHL, and Cochrane medical databases were initially searched from 1975 to October 2015. Google Scholar was also searched without limiters. An updated search was conducted from November 2015 to November 2017, search strings for which are included in Appendix 3. All article abstracts were first screened for relevance by at least two members of the working group. Full-text versions of screened articles were reviewed and articles on ultrasound guidance for paracentesis were selected. The following article types were excluded: non-English language, nonhuman, age <18 years, meeting abstracts, meeting posters, letters, and editorials. All relevant systematic reviews, meta-analyses, randomized controlled trials, and observational studies of ultrasound-guided paracentesis were screened and selected. Final article selection was based on working group consensus. The selected literature was incorporated into the draft recommendations.

We used the RAND Appropriateness Method that required panel judgment and consensus to establish recommendations.³⁰ The voting members of the SHM POCUS Task Force reviewed and voted on the draft recommendations considering five transforming factors: (1) problem priority and importance; (2) level of quality of evidence; (3) benefit/harm balance; (4) benefit/burden balance; and (5) certainty/concerns about preferences/equity acceptability/feasibility. Panel members participated in two rounds of electronic voting using an internet-based electronic data collection tool (Redcap™) during February 2018 and April 2018 (Appendix 4) and voting on appropriateness was conducted using a 9-point Likert scale. The three zones based on the 9-point Likert scale were inappropriate (1-3 points), uncertain (4-6 points), and appropriate (7-9 points), and the degree of consensus was assessed using the RAND algorithm (Appendix 1, Figure 1, and Table 1). Establishing a recommendation required at least 70% agreement that a recommendation was “appropriate.” A strong recommendation required 80% of the votes within one integer of the median, following RAND rules, and disagreement was defined as >30% of panelists voting outside of the zone of the median.

Recommendations were classified as strong or weak/conditional based on preset rules defining the panel’s level of consensus, which determined the wording for each recommendation (Tables 1 and 2). The revised consensus-based recommendations underwent internal and external review by POCUS experts from different subspecialties, and a final review of the guideline document was performed by members of the SHM POCUS Task Force, SHM Education Committee, and SHM Board of Directors. The SHM Board of Directors endorsed the document prior to submission to the Journal of Hospital Medicine.

RESULTS

Literature search

A total of 794 references were pooled and screened from literature searches conducted by a certified medical librarian in October 2015 (604 citations) and updated in November 2017 (118 citations), and working group members’ personal bibliographies and searches (72 citations; Appendix 3, Figure 2). Final selection included 91 articles that were abstracted into a data table and incorporated into the draft recommendations.

RECOMMENDATIONS

Four domains (terminology, clinical outcomes, technique, and training) with 13 draft recommendations were generated based on the literature review by the paracentesis working group. After two rounds of panel voting, one recommendation did not achieve consensus based on the RAND rules, and 12 statements received final approval. The degree of consensus based on the median score and dispersion of voting around the median are shown in Appendix 5. All 12 statements achieved consensus as strong recommendations. The strength of each recommendation and degree of consensus are summarized in Table 3.

Terminology

Abdominal paracentesis is a procedure in which fluid is aspirated from the intraperitoneal space by percutaneous insertion of a needle with or without a catheter through the abdominal wall. Throughout this document, the term “paracentesis” refers to “abdominal paracentesis.”

In this document, ultrasound-guided paracentesis refers to the use of static ultrasound guidance to mark a needle insertion site immediately prior to performing the procedure. Real-time (dynamic) ultrasound guidance refers to tracking of the needle tip with ultrasound as it traverses the abdominal wall to enter the peritoneal cavity. Landmark-based paracentesis refers to paracentesis based on physical examination alone.

RECOMMENDATIONS

Clinical outcomes

1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding.

Rationale. The occurrence of both minor and serious life-threatening complications from paracentesis has been well described.^5-10,31,32 A recent retrospective study that evaluated 515 landmark-guided paracenteses noted that the most common minor complication was persistent ascites leakage (5%) and that the most common serious complication was postprocedural bleeding (1%).⁸ Studies have shown that abdominal wall hematoma and hemoperitoneum are common hemorrhagic complications of paracentesis, although inferior epigastric artery pseudoaneurysm has also been described.^9,33,34

Current literature suggests that ultrasound-guided paracentesis is a safe procedure, even with reduced platelet counts or elevated international normalized ratio.^35-42 Most comparative studies have shown that ultrasound guidance reduces the risk of bleeding complications compared with the use of landmarks alone,^{7,31,32,43-45} although a few studies did not find a significant difference between techniques.^20,36,46 One large retrospective observational study that analyzed the administrative data of 69,859 paracenteses from more than 600 hospitals demonstrated that ultrasound guidance reduced the odds of bleeding complications by 68% (OR, 0.32; 95% CI, 0.25–0.41). Bleeding complication rates with and without the use of ultrasound guidance were 0.27% (CI 0.26-0.29) versus 1.25% (CI 1.21-1.29; P < .0001), respectively. More importantly, in this study, paracentesis complicated by bleeding was associated with a higher in-hospital mortality rate compared to paracentesis that were not complicated by bleeding (12.9% vs 3.7%; P < .0001).⁴³

2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain.

Rationale. Abdominal physical examination is not a reliable method for determining the presence or volume of intraperitoneal free fluid, as no specific physical examination finding has consistently shown both high sensitivity and specificity for detecting intraperitoneal free fluid.^{11,12,20,31,47-51} Patient factors limiting the diagnostic accuracy of physical examination include body habitus, abdominal wall edema, and gaseous bowel distention.

In comparative studies, ultrasound has been found to be significantly more sensitive and specific than physical examination in detecting peritoneal free fluid.^11,12 Ultrasound can detect as little as 100 mL of peritoneal free fluid,^52,53 and larger volumes of fluid have higher diagnostic accuracy.^53-55 In one randomized trial of 100 patients suspected of having ascites, patients were randomized to landmark-based and ultrasound-guided paracentesis groups. Of the 56 patients in the ultrasound-guided group, 14 patients suspected of having ascites on physical examination were found to have no or an insufficient volume of ascites to attempt paracentesis.²⁰ Another study with 41 ultrasound examinations on cancer patients suspected of having intraperitoneal free fluid by history and physical examination demonstrated that only 19 (46%) were considered to have a sufficient volume of ascites by ultrasound to attempt paracentesis.³⁸

3. We recommend that ultrasound guidance should be used for paracentesis to improve the success rates of the overall procedure.

Rationale. In addition to avoiding drainage attempts in patients with an insufficient volume of intraperitoneal free fluid, ultrasound can increase the success rate of attempted procedures by localizing the largest fluid collection and guiding selection of an optimal needle insertion site. The success rates of landmark-based paracentesis in patients suspected of having intraperitoneal free fluid by physical examination are not well described in the literature, but multiple studies report success rates of 95%-100% for paracentesis when using ultrasound guidance to select a needle insertion site.^20,38,56,57 In one randomized trial comparing ultrasound-guided versus landmark-based paracentesis, ultrasound-guided paracentesis revealed a significantly higher success rate (95% of procedures performed) compared with landmark-based parancentesis (61% of procedures performed). Moreover, 87% of the initial failures in the landmark-based group underwent subsequent successful paracentesis when ultrasound guidance was used. Ultrasound revealed that the rest of the patients (13%) did not have enough fluid to attempt ultrasound-guided paracentesis.²⁰

Technique

4. We recommend that ultrasound should be used to assess the characteristics of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed.

Rationale. The presence and characteristics of intraperitoneal fluid collections are important determinants of whether paracentesis, another procedure, or no procedure should be performed in a given clinical scenario. One study reported that the overall diagnostic accuracy of physical examination for detecting ascites was only 58%,⁵⁰ and many providers are unable to detect ascites by physical examination until 1L of fluid has accumulated. One small study showed that at least 500 ml of fluid must accumulate before shifting dullness could be detected.⁵⁸ By contrast, ultrasound has been shown to reliably detect as little as 100 mL of peritoneal free fluid ^52,53 and has been proven to be superior to physical examination in several studies.^11,12 Therefore, ultrasound can be used to qualitatively determine whether a sufficient volume of intraperitoneal free fluid is present to safely perform paracentesis.

Studies have shown that ultrasound can also be used to differentiate ascites from other pathologies (eg, matted bowel loops, metastases, abscesses) in patients with suspected ascites on history and physical examination.¹⁶ In addition, ultrasound can help to better understand the etiology and distribution of the ascites.^59-61 Sonographic measurements allow semiquantitative assessment of the volume of intraperitoneal free fluid, which may correlate with the amount of fluid removed in therapeutic paracentesis procedures.^62,63 Furthermore, depth of a fluid collection by ultrasound may be an independent risk factor for the presence of spontaneous bacterial peritonitis (SBP), with one small study showing a higher risk of SBP with larger fluid collections than with small ones.⁶⁴

5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs.

Rationale. When providers perform paracentesis using ultrasound guidance, any fluid collection that is directly visualized and accessible may be considered for drainage. The presence of ascites using ultrasound is best detected using a low-frequency transducer, such as phased array or curvilinear transducer, which provides deep penetration into the abdomen and pelvis to assess peritoneal free fluid.^{13,14,45,51,65} An optimal needle insertion site should be determined based on a combination of visualization of largest fluid collection, avoidance of underlying abdominal organs, and thickness of abdominal wall.^13,31,66,67

6. We recommend the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory.

Rationale. The anatomy of the superficial blood vessels of the abdominal wall, especially the lateral branches, varies greatly.^68-70 Although uncommon, inadvertent laceration of an inferior epigastric artery or one of its large branches is associated with significant morbidity and mortality.^{10,15,69,71-73} A review of 126 cases of rectus sheath hematomas, which most likely occur due to laceration of the inferior or superior epigastric artery, at a single institution from 1992 to 2002 showed a mortality rate of 1.6%, even with aggressive intervention.⁷⁴ Besides the inferior epigastric arteries, several other blood vessels are at risk of injury during paracentesis, including the inferior epigastric veins, thoracoepigastric veins, subcostal artery and vein branches, deep circumflex iliac artery and vein, and recanalized subumbilical vasculature.^75-77 Laceration of any of the abdominal wall blood vessels could result in catastrophic bleeding.

Identification of abdominal wall blood vessels is most commonly performed with a high-frequency transducer using color flow Doppler ultrasound.^10,13-15 A low-frequency transducer capable of color flow Doppler ultrasound may be utilized in patients with a thick abdominal wall.

Studies suggest that detection of abdominal wall blood vessels with ultrasound may reduce the risk of bleeding complications. One study showed that 43% of patients had a vascular structure present at one or more of the three traditional landmark paracentesis sites.⁷⁸ Another study directly compared bleeding rates between an approach utilizing a low-frequency transducer to identify the largest collection of fluid only versus a two-transducer approach utilizing both low and high-frequency transducers to identify the largest collection of fluid and evaluate for any superficial blood vessels. In this study, which included 5,777 paracenteses, paracentesis-related minor bleeding rates were similar in both groups, but major bleeding rates were less in the group utilizing color flow Doppler to evaluate for superficial vessels (0.3% vs 0.08%); differences found between groups, however, did not reach statistical significance (P = .07).⁷⁹

7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory.

Rationale. Most ultrasound machines have a slice thickness of <4 mm at the focal zone.⁸⁰ Considering that an ultrasound beam represents a very thin 2-dimentional cross-section of the underlying tissues, visualization in only one plane could lead to inadvertent puncture of nearby critical structures such as loops of bowel or edges of solid organs. Therefore, it is important to evaluate the needle insertion site and surrounding areas in multiple planes by tilting the transducer and rotating the transducer to orthogonal planes.⁶¹ Additionally, evaluation with color flow Doppler could be performed in a similar fashion to ensure that no large blood vessels are along the anticipated needle trajectory.

8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure.

Rationale. Free-flowing peritoneal fluid and abdominal organs, especially loops of small bowel, can easily shift when a patient changes position or takes a deep breath.^13,16,53 Therefore, if the patient changes position or there is a delay between marking the needle insertion site and performing the procedure, the patient should be reevaluated with ultrasound to ensure that the marked needle insertion site is still safe for paracentesis.⁷⁸ After marking the needle insertion site, the skin surface should be wiped completely clean of gel, and the probe should be removed from the area before sterilizing the skin surface.

9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access.

Rationale. Use of real-time ultrasound guidance for paracentesis has been described to drain abdominal fluid collections.^13,20,62 Several studies have commented that real-time ultrasound guidance for paracentesis may be necessary in obese patients, in patients with small fluid collections, or when performing the procedure near critical structures, such as loops of small bowel, liver, or spleen.^57,81 Real-time ultrasound guidance for paracentesis requires additional training in needle tracking techniques and specialized equipment to maintain sterility.

Training

10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis.

Rationale. Healthcare providers must gain multiple skills to safely perform ultrasound-guided paracentesis. Trainees must learn how to operate the ultrasound machine to identify the most appropriate needle insertion site based on the abdominal wall thickness, fluid collection size, proximity to nearby abdominal organs, and presence of blood vessels. Education regarding the use of ultrasound guidance for paracentesis is both desired ^82,83 and being increasingly taught to health care providers who perform paracentesis.^20,84-86

Several approaches have shown high uptake of essential skills to perform ultrasound-guided paracentesis after short training sessions. One study showed that first-year medical students can be taught to use POCUS to accurately diagnose ascites after three 30-minute teaching sessions.¹⁹ Another study showed that emergency medicine residents can achieve high levels of proficiency in the preprocedural ultrasound evaluation for paracentesis with only one hour of didactic training.²⁰ Other studies also support the concept that adequate proficiency is achievable within brief, focused training sessions.^21-28 However, these skills can decay significantly over time without ongoing education.⁸⁷

11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasound-guided paracentesis.

Rationale. Simulation-based practice should be used when available, as it has been shown to increase competence in bedside diagnostic ultrasonography and procedural techniques for ultrasound-guided procedures, including paracentesis.^{22,25,29,88,89} One study showed that internal medicine residents were able to achieve a high level of proficiency to perform ultrasound-guided paracentesis after a three-hour simulation-based mastery learning session.⁸⁸ A follow-up study suggested that, after sufficient simulation-based training, a nonradiologist can perform ultrasound-guided paracentesis as safely as an interventional radiologist.²⁹

12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.

Rationale. Competence in ultrasound-guided paracentesis requires acquisition of clinical knowledge of paracentesis, skills in basic abdominal ultrasonography, and manual techniques to perform the procedure. Competence in ultrasound-guided paracentesis cannot be assumed for those graduating from internal medicine residency in the United States. While clinical knowledge of paracentesis remains a core competency of graduating internal medicine residents per the American Board of Internal Medicine, demonstration of competence in performing ultrasound-guided or landmark-based paracentesis is not currently mandated.⁹⁰ A recent national survey of internal medicine residency program directors revealed that the curricula and resources available to train residents in bedside diagnostic ultrasound and ultrasound-guided procedures, including paracentesis, remain quite variable. ⁸³

While it has not been well studied, competence in ultrasound for paracentesis, as with all other skills involved in bedside procedures, is likely best evaluated through direct observation on actual patients.⁹¹ As such, individualized systems to evaluate competency in ultrasound-guided paracentesis should be established for each site where it is performed. A list of consensus-derived ultrasound competencies for ultrasound-guided paracentesis has been proposed, and this list may serve as a guide for both training curriculum development and practitioner evaluation.^86,91,92

KNOWLEDGE GAPS

In the process of developing these recommendations, we identified several important gaps in the literature regarding the use of ultrasound guidance for paracentesis.

First, while some data suggest that the use of ultrasound guidance for paracentesis may reduce the inpatient length of stay and overall costs, this suggestion has not been studied rigorously. In a retrospective review of 1,297 abdominal paracenteses by Patel et al., ultrasound-guided paracentesis was associated with a lower incidence of adverse events compared with landmark-based paracentesis (1.4% vs 4.7%; P = .01). The adjusted analysis from this study showed significant reductions in adverse events (OR 0.35; 95%CI 0.165-0.739; P = .006) and hospitalization costs ($8,761 ± $5,956 vs $9,848 ± $6,581; P < .001) for paracentesis with ultrasound guidance versus without such guidance. Additionally, the adjusted average length of stay was 0.2 days shorter for paracentesis with ultrasound guidance versus that without guidance (5.6 days vs 5.8 days; P < .0001).⁴⁴ Similar conclusions were reached by Mercaldi et al., who conducted a retrospective study of 69,859 patients who underwent paracentesis. Fewer bleeding complications occurred when paracentesis was performed with ultrasound guidance (0.27%) versus without ultrasound guidance (1.27%). Hospitalization costs increased by $19,066 (P < .0001) and length of stay increased by 4.3 days (P < .0001) for patients when paracentesis was complicated by bleeding.⁴³ Because both of these studies were retrospective reviews of administrative databases, associations between procedures, complications, and use of ultrasound may be limited by erroneous coding and documentation.

Second, regarding technique, it is unknown whether the use of real-time ultrasound guidance confers additional benefits compared with use of static ultrasound to mark a suitable needle insertion site. In clinical practice, real-time ultrasound guidance is used to sample small fluid collections, particularly when loops of bowel or a solid organ are nearby. It is possible that higher procedural success rates and lower complication rates may be demonstrated in these scenarios in future studies.

Third, the optimal approach to train providers to perform ultrasound-guided paracentesis is unknown. While short training sessions have shown high uptake of essential skills to perform ultrasound-guided paracentesis, data regarding the effectiveness of training using a comprehensive competency assessment are limited. Simulation-based mastery learning as a means to obtain competency for paracentesis has been described in one study,⁸⁸ but the translation of competency demonstrated by simulation to actual patient outcomes has not been studied. Furthermore, the most effective method to train providers who are proficient in landmark-based paracentesis to achieve competency in ultrasound-guided paracentesis has not been well studied.

Fourth, the optimal technique for identifying blood vessels in the abdominal wall is unknown. We have proposed that color flow Doppler should be used to identify and avoid puncture of superficial vessels, but power Doppler is three times more sensitive at detecting blood vessels, especially at low velocities, such as in veins independent of direction or flow.⁹³ Hence using power Doppler instead of color flow Doppler may further improve the ability to identify and avoid superficial vessels along the needle trajectory.⁹²

Finally, the impact of ultrasound use on patient experience has yet to be studied. Some studies in the literature show high patient satisfaction with use of ultrasound at the bedside,^94,95 but patient satisfaction with ultrasound-guided paracentesis has not been compared directly with the landmark-based technique.

CONCLUSIONS

The use of ultrasound guidance for paracentesis has been associated with higher success rates and lower complication rates. Ultrasound is superior to physical examination in assessing the presence and volume of ascites, and determining the optimal needle insertion site to avoid inadvertent injury to abdominal wall blood vessels. Hospitalists can attain competence in ultrasound-guided paracentesis through the use of various training methods, including lectures, simulation-based practice, and hands-on training. Ongoing use and training over time is necessary to maintain competence.

Acknowledgments

The authors thank all the members of the Society of Hospital Medicine Point-of-care Ultrasound Task Force and the Education Committee members for their time and dedication to develop these guidelines.

SHM Point-of-care Ultrasound Task Force: CHAIRS: Nilam Soni, Ricardo Franco Sadud, Jeff Bates. WORKING GROUPS: Thoracentesis Working Group: Ria Dancel (chair), Daniel Schnobrich, Nitin Puri. Vascular Access Working Group: Ricardo Franco (chair), Benji Matthews, Saaid Abdel-Ghani, Sophia Rodgers, Martin Perez, Daniel Schnobrich. Paracentesis Working Group: Joel Cho (chair), Benji Mathews, Kreegan Reierson, Anjali Bhagra, Trevor P. Jensen. Lumbar Puncture Working Group: Nilam J. Soni (chair), Ricardo Franco, Gerard Salame, Josh Lenchus, Venkat Kalidindi, Ketino Kobaidze. Credentialing Working Group: Brian P Lucas (chair), David Tierney, Trevor P. Jensen PEER REVIEWERS: Robert Arntfield, Michael Blaivas, Richard Hoppmann, Paul Mayo, Vicki Noble, Aliaksei Pustavoitau, Kirk Spencer, Vivek Tayal. METHODOLOGIST: Mahmoud El Barbary. LIBRARIAN: Loretta Grikis. SOCIETY OF HOSPITAL MEDICINE EDUCATION COMMITTEE: Daniel Brotman (past chair), Satyen Nichani (current chair), Susan Hunt. SOCIETY OF HOSPITAL MEDICINE STAFF: Nick Marzano.

Collaborators of the Society of Hospital Medicine Point-of-care Ultrasound Task Force

Saaid Abdel-Ghani, Robert Arntfield, Jeffrey Bates, Michael Blaivas, Dan Brotman, Carolina Candotti, Richard Hoppmann, Susan Hunt, Venkat Kalidindi, Ketino Kobaidze, Josh Lenchus, Paul Mayo, Satyen Nichani, Vicki Noble, Martin Perez, Nitin Puri, Aliaksei Pustavoitau, Sophia Rodgers, Gerard Salame, Daniel Schnobrich, Kirk Spencer, Vivek Tayal, David M. Tierney

Disclaimer

The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

All 5 appendices are viewable online at https://www.journalofhospitalmedicine.com.

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35. Cervini P, Hesley GK, Thompson RL, Sampathkumar P, Knudsen JM. Incidence of infectious complications after an ultrasound-guided intervention. AJR Am J Roentgenol. 2010;195(4):846-850. doi: 10.2214/AJR.09.3168.
36. Wiese SS, Mortensen C, Bendtsen F. Few complications after paracentesis in patients with cirrhosis and refractory ascites. Dan Med Bull. 2011;58(1):A4212.
37. Jakobson DJ, Shemesh I. Merging ultrasound in the intensive care routine. Isr Med Assoc J. 2013;15(11):688-692.
38. Landers A, Ryan B. The use of bedside ultrasound and community-based paracentesis in a palliative care service. J Prim Health Care. 2014;6(2):148-151.
39. Lin CH, Shih FY, Ma MH, Chiang WC, Yang CW, Ko PC. Should bleeding tendency deter abdominal paracentesis? Dig Liver Dis. 2005;37(12):946-951. doi: 10.1016/j.dld.2005.07.009.
40. Kurup AN, Lekah A, Reardon ST, et al. Bleeding rate for ultrasound-guided paracentesis in thrombocytopenic patients. J Ultrasound Med. 2015;34(10):1833-1838. doi: 10.7863/ultra.14.10034.
41. Reardon S, Atwell TD, Lekah A. Major bleeding complication rate of ultrasound-guided paracentesis in thrombocytopenic patients. J Vasc Interv Radiol. 2013;24(4):S56. doi: 10.1016/j.jvir.2013.01.129.
42. Czul F, Prager M, Lenchus J. Intra-procedural risk of bleeding associated with ultrasound guided paracentesis in patients with abnormal coagulation studies: 1907. Hepatology. 2011;54(4):1259A.
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44. Patel PA, Ernst FR, Gunnarsson CL. Evaluation of hospital complications and costs associated with using ultrasound guidance during abdominal paracentesis procedures. J Med Econ. 2012;15(1):1-7. doi: 10.3111/13696998.2011.628723.
45. Nicolaou S, Talsky A, Khashoggi K, Venu V. Ultrasound-guided interventional radiology in critical care. Crit Care Med. 2007;35(5 Suppl):S186-197. doi: 10.1097/01.CCM.0000260630.68855.DF.
46. Conduit B, Wesley E, Christie J, Thalheimer U. PTU-002 Large volume paracentesis (LVP) can be safely performed by junior doctors without ultrasound guidance. Gut. 2013;62:A42. doi: 10.1136/gutjnl-2013-304907.095.
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52. Von Kuenssberg Jehle D, Stiller G, Wagner D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg Med. 2003;21(6):476-478. doi: 10.1016/S0735-6757(03)00162-1
53. Goldberg BB, Goodman GA, Clearfield HR. Evaluation of ascites by ultrasound. Radiology. 1970;96(1):15-22. doi: 10.1148/96.1.15.
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55. Paajanen H, Lahti P, Nordback I. Sensitivity of transabdominal ultrasonography in detection of intraperitoneal fluid in humans. Eur Radiol. 1999;9(7):1423-1425. doi: 10.1007/s003300050861.
56. Prabhakar A, Thabet A, Mueller P, Gee MS. Image-guided peritoneal access for fluid infusion in oncology patients: Indications, technique, and outcomes. J Vasc Interv Radiol. 2014;25(3):S41. doi: 10.1016/j.jvir.2013.12.100.
57. McGahan JP, Anderson MW, Walter JP. Portable real-time sonographic and needle guidance systems for aspiration and drainage. AJR Am J Roentgenol. 1986;147(6):1241-1246. doi: 10.2214/ajr.147.6.1241.
58. Moses WR. Shifting dullness in the abdomen. South Med J. 1946;39(12):985-987.
59. Edell SL, Gefter WB. Ultrasonic differentiation of types of ascitic fluid. AJR Am J Roentgenol. 1979;133(1):111-114. doi: 10.2214/ajr.133.1.111.
60. Doust BD, Thompson R. Ultrasonography of abdominal fluid collections. Gastrointest Radiol. 1978;3(3):273-279. doi: 10.1007/BF01887079.
61. Beaulieu Y, Marik PE. Bedside ultrasonography in the ICU: part 2. Chest. 2005;128(3):1766-1781. doi: 10.1378/chest.128.3.1766.
62. Irshad A, Ackerman SJ, Anis M, Campbell AS, Hashmi A, Baker NL. Can the smallest depth of ascitic fluid on sonograms predict the amount of drainable fluid? J Clin Ultrasound. 2009;37(8):440-444. doi: 10.1002/jcu.20616.
63. Inadomi J, Cello JP, Koch J. Ultrasonographic determination of ascitic volume. Hepatology. 1996;24(3):549-551. doi: 10.1002/hep.510240314.
64. Sideris A, Patel P, Charles HW, Park J, Feldman D, Deipolyi AR. Imaging and clinical predictors of spontaneous bacterial peritonitis diagnosed by ultrasound-guided paracentesis. Proc (Bayl Univ Med Cent). 2017;30(3):262-264. https://doi.org/10.1080/08998280.2017.11929610
65. Hatch N, Wu TS, Barr L, Roque PJ. Advanced ultrasound procedures. Crit Care Clin. 2014;30(2):305-329. doi: 10.1016/j.ccc.2013.10.005.
66. Ross GJ, Kessler HB, Clair MR, Gatenby RA, Hartz WH, Ross LV. Sonographically guided paracentesis for palliation of symptomatic malignant ascites. AJR Am J Roentgenol. 1989;153(6):1309-1311. doi: 10.2214/ajr.153.6.1309.
67. Russell KW, Mone MC, Scaife CL. Umbilical paracentesis for acute hernia reduction in cirrhotic patients. BMJ Case Rep. 2013;2013. doi: 10.1136/bcr-2013-201304.
68. Epstein J, Arora A, Ellis H. Surface anatomy of the inferior epigastric artery in relation to laparoscopic injury. Clin Anat. 2004;17(5):400-408. doi: 10.1002/ca.10192.
69. Suzuki J, Sekiguchi H. Laceration of inferior epigastric artery resulting in abdominal compartment syndrome: a fatal complication of paracentesis. Am J Respir Crit Care Med. 2012;185:A5974. doi: 10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A5974
70. Saber AA, Meslemani AM, Davis R, Pimentel R. Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels. Ann Surg. 2004;239(2):182-185. doi: 10.1097/01.sla.0000109151.53296.07.
71. Webster ST, Brown KL, Lucey MR, Nostrant TT. Hemorrhagic complications of large volume abdominal paracentesis. Am J Gastroenterol. 1996;91(2):366-368.
72. Todd AW. Inadvertent puncture of the inferior epigastric artery during needle biopsy with fatal outcome. Clin Radiol. 2001;56(12):989-990. doi: 10.1053/crad.2001.0175.
73. Seidler M, Sayegh K, Roy A, Mesurolle B. A fatal complication of ultrasound-guided abdominal paracentesis. J Clin Ultrasound. 2013;41(7):457-460. doi: 10.1002/jcu.22050.
74. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore). 2006;85(2):105-110. doi: 10.1097/01.md.0000216818.13067.5a.
75. Oelsner DH, Caldwell SH, Coles M, Driscoll CJ. Subumbilical midline vascularity of the abdominal wall in portal hypertension observed at laparoscopy. Gastrointest Endosc. 1998;47(5):388-390. doi: 10.1016/S0016-5107(98)70224-X.
76. Krupski WC, Sumchai A, Effeney DJ, Ehrenfeld WK. The importance of abdominal wall collateral blood vessels. Planning incisions and obtaining arteriography. Arch Surg. 1984;119(7):854-857. doi: 10.1001/archsurg.1984.01390190092021.
77. Rozen WM, Ashton MW, Taylor GI. Reviewing the vascular supply of the anterior abdominal wall: redefining anatomy for increasingly refined surgery. Clin Anat. 2008;21(2):89-98. doi: 10.1002/ca.20585.
78. Adams A, Roggio A, Wilkerson RG. 368 Sonographic assessment of inadvertent vascular puncture during paracentesis using the traditional landmark approach. Ann Emerg Med. 2015;66:S132-S133. doi: 10.1016/j.annemergmed.2015.07.404
79. Barsuk JH, Rosen BT, Cohen ER, Feinglass J, Ault MJ. Vascular ultrasonography: a novel method to reduce paracentesis related major bleeding. J Hosp Med. 2018;13(1):30-33. doi: 10.12788/jhm.2863.
80. Skolnick ML. Estimation of ultrasound beam width in the elevation (section thickness) plane. Radiology. 1991;180(1):286-288. doi: 10.1148/radiology.180.1.2052713.
81. Keil-Rios D, Terrazas-Solis H, Gonzalez-Garay A, Sanchez-Avila JF, Garcia-Juarez I. Pocket ultrasound device as a complement to physical examination for ascites evaluation and guided paracentesis. Intern Emerg Med. 2016;11(3):461-466. doi: 10.1007/s11739-016-1406-x.
82. Kessler C, Bhandarkar S. Ultrasound training for medical students and internal medicine residents--a needs assessment. J Clin Ultrasound. 2010;38(8):401-408. doi: 10.1002/jcu.20719.
83. Schnobrich DJ, Gladding S, Olson AP, Duran-Nelson A. Point-of-care ultrasound in internal medicine: a national survey of educational leadership. J Grad Med Educ. 2013;5(3):498-502. doi: 10.4300/JGME-D-12-00215.1.
84. Eisen LA, Leung S, Gallagher AE, Kvetan V. Barriers to ultrasound training in critical care medicine fellowships: a survey of program directors. Crit Care Med. 2010;38(10):1978-1983. doi: 10.1097/CCM.0b013e3181eeda53.
85. Neri L, Storti E, Lichtenstein D. Toward an ultrasound curriculum for critical care medicine. Crit Care Med. 2007;35(5 Suppl):S290-304. doi: 10.1097/01.CCM.0000260680.16213.26.
86. Ma I, Arishenkoff S, Wiseman J, et al. Internal medicine point-of-care ultrasound curriculum: consensus recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group. J Gen Intern Med. 2017;32(9):1052-1057. doi: 10.1007/s11606-017-4071-5.
87. Kelm D, Ratelle J, Azeem N, et al. Longitudinal ultrasound curriculum improves long-term retention among internal medicine residents. J Grad Med Educ. 2015;7(3):454-457. doi: 10.4300/JGME-14-00284.1.
88. Barsuk JH, Cohen ER, Vozenilek JA, O’Connor LM, McGaghie WC, Wayne DB. Simulation-based education with mastery learning improves paracentesis skills. J Grad Med Educ. 2012;4(1):23-27. doi: 10.4300/JGME-D-11-00161.1.
89. Lenchus JD. End of the “see one, do one, teach one” era: the next generation of invasive bedside procedural instruction. J Am Osteopath Assoc. 2010;110(6):340-346. doi: 10.7556/jaoa.2010.110.6.340.
90. American Board of Internal Medicine. Policies and Procedures for Certification. Philadelphia, PA: ABIM; 2006.
91. Lucas BP, Tierney DM, Jensen TP, et al. Credentialing of hospitalists in ultrasound-guided bedside procedures: a position statement of the Society of Hospital Medicine. J Hosp Med. 2018;13(2):117-125. doi: 10.12788/jhm.2917.
92. Brown GM, Otremba M, Devine LA, Gray C, Millington SJ, Ma IW. Defining competencies for ultrasound-guided bedside procedures: consensus opinions from Canadian physicians. J Ultrasound Med. 2016;35(1):129-141. doi: 10.7863/ultra.15.01063.
93. Babcock DS, Patriquin H, LaFortune M, Dauzat M. Power doppler sonography: basic principles and clinical applications in children. Pediatr Radiol. 1996;26(2):109-115. doi: 10.1007/BF01372087.
94. Howard ZD, Noble VE, Marill KA, et al. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014;46(1):46-53. doi: 10.1016/j.jemermed.2013.05.044.
95. Lindelius A, Torngren S, Nilsson L, Pettersson H, Adami J. Randomized clinical trial of bedside ultrasound among patients with abdominal pain in the emergency department: impact on patient satisfaction and health care consumption. Scand J Trauma Resusc Emerg Med. 2009;17:60. doi: 10.1186/1757-7241-17-60.

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¹Department of Hospital Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California; ²Division of Hospital Medicine, University of California San Francisco Medical Center at Parnassus, San Francisco, California; ³Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota; ⁴Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, Minnesota; ⁵Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ⁶Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; ⁷White River Junction VA Medical Center, White River Junction, Vermont; ⁸Divisions of General & Hospital Medicine and Pulmonary & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas; ⁹Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas; ¹⁰Division of Hospital Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; ¹¹Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina; ¹²Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire; ¹³Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont.

Disclosures

Mr. Mader reports grants from Department of Veterans Affairs during the conduct of the study. Dr. Soni reports grants from the Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative Grant (HX002263-01A1) outside of the submitted work. In addition, Dr. Soni receives royalties from Elsevier-Saunders. All other authors have nothing to disclose.

Funding

Brian P Lucas: Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, National Center for Translational Science (UL1TR001086). Nilam Soni: Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative Grant (HX002263-01A1), outside the submitted work. )

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Joel Cho, MD RDMS RDCS

Trevor P. Jensen, MD MS

Kreegan Reierson, MD

Benji K. Mathews, MD

Anjali Bhagra, MD

Ricardo Franco-Sadud, MD

Loretta Grikis, MLS

Michael Mader, MS

Ria Dancel, MD

Brian P. Lucas, MD MS

Society of Hospital Medicine Point-of-care Ultrasound Task Force

Nilam J. Soni, MD, MS

Author(s)

Joel Cho, MD RDMS RDCS

Trevor P. Jensen, MD MS

Kreegan Reierson, MD

Benji K. Mathews, MD

Anjali Bhagra, MD

Ricardo Franco-Sadud, MD

Loretta Grikis, MLS

Michael Mader, MS

Ria Dancel, MD

Brian P. Lucas, MD MS

Society of Hospital Medicine Point-of-care Ultrasound Task Force

Nilam J. Soni, MD, MS

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METHODS

RESULTS

Literature search

RECOMMENDATIONS

Terminology

RECOMMENDATIONS

Clinical outcomes

1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding.

2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain.

3. We recommend that ultrasound guidance should be used for paracentesis to improve the success rates of the overall procedure.

Technique

4. We recommend that ultrasound should be used to assess the characteristics of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed.

5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs.

6. We recommend the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory.

7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory.

8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure.

9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access.

Training

10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis.

11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasound-guided paracentesis.

12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.

KNOWLEDGE GAPS

In the process of developing these recommendations, we identified several important gaps in the literature regarding the use of ultrasound guidance for paracentesis.

CONCLUSIONS

Acknowledgments

Collaborators of the Society of Hospital Medicine Point-of-care Ultrasound Task Force

Disclaimer

The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

All 5 appendices are viewable online at https://www.journalofhospitalmedicine.com.

METHODS

RESULTS

Literature search

RECOMMENDATIONS

Terminology

RECOMMENDATIONS

Clinical outcomes

1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding.

2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain.

3. We recommend that ultrasound guidance should be used for paracentesis to improve the success rates of the overall procedure.

Technique

4. We recommend that ultrasound should be used to assess the characteristics of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed.

5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs.

6. We recommend the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory.

7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory.

8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure.

9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access.

Training

10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis.

11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasound-guided paracentesis.

12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.

KNOWLEDGE GAPS

In the process of developing these recommendations, we identified several important gaps in the literature regarding the use of ultrasound guidance for paracentesis.

CONCLUSIONS

Acknowledgments

Collaborators of the Society of Hospital Medicine Point-of-care Ultrasound Task Force

Disclaimer

The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

All 5 appendices are viewable online at https://www.journalofhospitalmedicine.com.

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Published Online Only January 2, 2019. doi: 10.12788/jhm.3095

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Hospital Privileging Practices for Bedside Procedures: A Survey of Hospitalist Experts

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Author(s)

Trevor P. Jensen, MD, MS

Nilam J. Soni, MD, MS

David M. Tierney, MD

Brian P. Lucas, MD, MS

Performance of 6 bedside procedures (paracentesis, thoracentesis, lumbar puncture, arthrocentesis, central venous catheter [CVC] placement, and arterial line placement) are considered core competencies for hospitalists.¹ Yet, the American Board of Internal Medicine (ABIM) no longer requires demonstration of manual competency for bedside procedures, and graduates may enter the workforce with minimal or no experience performing such procedures.² As such, the burden falls on hospital privileging committees to ensure providers have the necessary training and experience to competently perform invasive procedures before granting institutional privileges to perform them.³ Although recommendations for privileging to perform certain surgical procedures have been proposed,^4,5 there are no widely accepted guidelines for initial or ongoing privileging of common invasive bedside procedures performed by hospitalists, and current privileging practices vary significantly.

In 2015, the Society of Hospital Medicine (SHM) set up a Point-of-Care Ultrasound (POCUS) Task Force to draft evidence-based guidelines on the use of ultrasound to perform bedside procedures. The recommendations for certification of competency in ultrasound-guided procedures may guide institutional privileging. The purpose of this study was to better understand current hospital privileging practices for invasive bedside procedures both with and without ultrasound guidance and how current practices are perceived by experts.

METHODS

Study Design, Setting, and Participants

After approval by the University of Texas Health Science Center at San Antonio Institutional Review Board, we conducted a survey of hospital privileging processes for bedside procedures from a convenience sample of hospitalist procedure experts on the SHM POCUS Task Force. All 21 hospitalists on the task force were invited to participate, including the authors of this article. These hospitalists represent 21 unique institutions, and all have clinical, educational, and/or research expertise in ultrasound-guided bedside procedures.

Survey Design

A 26-question, electronic survey on privileging for bedside procedures was conducted (Appendix A). Twenty questions addressed procedures in general, such as minimum numbers of procedures required and use of simulation. Six questions focused on the use of ultrasound guidance. To provide context, many questions were framed to assess a privileging process being drafted by the task force. Answers were either multiple choice or free text.

Data Collection and Analysis

All members of the task force were invited to complete the survey by e-mail during November 2016. A reminder e-mail was sent on the day after initial distribution. No compensation was offered, and participation was not required. Survey results were compiled electronically through Research Electronic Data Capture, or “REDCap”^TM(Nashville, Tennessee), and data analysis was performed with Stata version 14 (College Station, Texas). Means of current and recommended minimum thresholds were calculated by excluding responses of “I don’t know,” and responses of “no minimum number threshold” were coded as 0.

RESULTS

The survey response rate was 100% (21 of 21). All experts were hospitalists, but 2 also identified themselves as intensivists. Experts practiced in a variety of hospital settings, including private university hospitals (43%), public university hospitals (19%), Veterans Affairs teaching hospitals (14%), community teaching hospitals (14%), and community nonteaching hospitals (10%). Most hospitals (90%) were teaching hospitals for internal medicine trainees. All experts have personally performed bedside procedures on a regular basis, and most (86%) had leadership roles in teaching procedures to students, residents, fellows, physician assistants, nurse practitioners, and/or physicians. Approximately half (57%) were involved in granting privileges for bedside procedures at their institutions.

Most hospitals do not require the use of ultrasound guidance for the privileging of any procedure, but ultrasound guidance was reported to be routinely used for paracentesis (100%), thoracentesis (95%), and CVC placement (95%). Ultrasound guidance was less common for arterial line placement (57%), lumbar puncture (33%), and arthrocentesis (29%). There was strong agreement that ultrasound guidance ought to be required for initial and ongoing privileging of CVC placement, thoracentesis, and paracentesis. But there was less agreement for arterial line placement, arthrocentesis, and lumbar puncture (Figure 1).

Only half of the experts reported that their hospitals required a minimum number of procedures to earn initial (48%) or ongoing (52%) privileges to perform bedside procedures. Nevertheless, most experts thought there ought to be minimum numbers of procedures for initial (81%) and ongoing (81%) privileging, recommending higher minimums for both initial and ongoing privileging than are currently required at their hospitals (Figure 2).

The average difference between suggested and current minimum numbers of procedures required for initial privileging was 4.7 for paracentesis, 5.8 for thoracentesis, 5.8 for CVC catheter insertion, 5.4 for lumbar puncture, 4.8 for arterial line insertion, and 3.6 for arthrocentesis. The average difference between suggested and current minimum numbers of yearly procedures required for ongoing privileging was 2.0 for paracentesis, 2.8 for thoracentesis, 2.9 for CVC catheter insertion, 1.9 for lumbar puncture, 2.1 for arterial line insertion, and 2.5 for arthrocentesis (Appendix B).

Most hospitalist procedure experts thought that simulation training (67%) and direct observation of procedural skills (71%) should be core components of an initial privileging process. Many of the experts who did not agree with direct observation or simulation training as core components of initial privileging had concerns about feasibility with respect to manpower, availability of simulation equipment, and costs. In contrast, the majority (67%) did not think it was necessary to directly observe providers for ongoing privileging when routine monitoring was in place for periprocedural complications, which all experts (100%) agreed should be in place.

DISCUSSION

Our survey identified 3 distinct differences between hospitalist procedure experts’ recommendations and their own hospitals’ current privileging practices. First, whereas experts recommended ultrasound guidance for thoracentesis, paracentesis, and CVC placement, it is rarely a current requirement. Second, experts recommend requiring minimum numbers of procedures for both initial and ongoing privileging even though such minimums are not currently required at half of their hospitals. Third, recommended minimum numbers were generally higher than those currently in place.

The routine use of ultrasound guidance for thoracentesis, paracentesis, and CVC placement is likely a result of increased adoption based on the literature showing clinical benefits.^6-9Thus, the expert recommendations for required use of ultrasound guidance for these procedures seems both appropriate and feasible. The procedure minimums identified in our study are similar to prior ABIM guidelines when manual competency was required for board certification in internal medicine and are comparable to recent minimums proposed by the Society of Critical Care Medicine, both of which recommended a minimum of 5 to 10 per procedure.^10,11 Nevertheless, no commonly agreed-upon minimum number of procedures currently exists for certification of competency, and the variability seen in the experts’ responses further supports the idea that no specific number will guarantee competence. Thus, while requiring minimum numbers of procedures was generally considered necessary by our experts, minimums alone were also considered insufficient for initial privileging because most recommended that direct observation and simulation should be part of an initial privileging process.

These findings encourage more rigorous requirements for both initial and ongoing privileging of procedures. Nevertheless, our findings were rarely unanimous. The most frequently cited reason for disagreement on our findings was feasibility and capacity for direct observation, and the absence of ultrasound equipment or simulators, particularly in resource-limited clinical environments.

Our study has several strengths and limitations. One strength is the recruitment of study experts specifically composed of hospitalist procedure experts from diverse geographic and hospital settings. Yet, we acknowledge that our findings may not be generalizable to other specialties. Another strength is we obtained 100% participation from the experts surveyed. Weaknesses of this study include the relatively small number of experts who are likely to be biased in favor of both the use of ultrasound guidance and higher standards for privileging. We also relied on self-reported data about privileging processes rather than direct observation of those practices. Finally, questions were framed in the context of only 1 possible privileging pathway, and experts may respond differently to a different framing.

CONCLUSION

Our findings may guide the development of more standardized frameworks for initial and ongoing privileging of hospitalists for invasive bedside procedures. In particular, additional privileging requirements may include the routine use of ultrasound guidance for paracentesis, thoracentesis, and CVC insertion; simulation preceding direct observation of manual skills if possible; and higher required minimums of procedures for both initial and ongoing privileging. The goal of a standardized framework for privileging should be directed at improving the quality and safety of bedside procedures but must consider feasibility in diverse clinical settings where hospitalists work.

Acknowledgments

The authors thank the hospitalists on the SHM POCUS Task Force who provided data about their institutions’ privileging processes and requirements. They are also grateful to Loretta M. Grikis, MLS, AHIP, at the White River Junction Veterans Affairs Medical Center for her assistance as a medical librarian.

Disclosure

Brian P. Lucas (U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Dartmouth SYNERGY, and the National Institutes of Health National Center for Advancing Translational Sciences [UL1TR001086]). Nilam Soni (U.S. Department of Veterans Affairs and Quality Enhancement Research Initiative Partnered Evaluation Initiative grant [HX002263-01A1]). The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.

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References

1. Nichani S, Jonathan Crocker, MD, Nick Fitterman, MD, Michael Lukela, MD, Updating the core competencies in hospital medicine—2017 revision: Introduction and methodology. J Hosp Med 2017;12(4);283-287. PubMed
2. American Board of Internal Medicine. Policies and Procedures for Certification. http://www.abim.org/certification/policies/imss/im.aspx - procedures. Published July 2016. Accessed on November 8, 2016.
3. Department of Health & Human Services. Centers for Medicare & Medicaid Services (CMS) Requirements for Hospital Medical Staff Privileging. Centers for Medicare and Medicaid Services website. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter05-04.pdf. Published November 12, 2004. Accessed on November 8, 2016.
4. Blackmon SH, Cooke DT, Whyte R, et al. The Society of Thoracic Surgeons Expert Consensus Statement: A tool kit to assist thoracic surgeons seeking privileging to use new technology and perform advanced procedures in general thoracic surgery. Ann Thorac Surg. 2016;101(3):1230-1237. PubMed
5. Bhora FY, Al-Ayoubi AM, Rehmani SS, Forleiter CM, Raad WN, Belsley SG. Robotically assisted thoracic surgery: proposed guidelines for privileging and credentialing. Innovations (Phila). 2016;11(6):386-389. PubMed
6. Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest. 2013;143:532-538. PubMed
7. Patel PA, Ernst FR, Gunnarsson CL. Ultrasonography guidance reduces complications and costs associated with thoracentesis procedures. J Clin Ultrasound. 2012;40:135-141. PubMed
8. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev. 2015;1:CD006962. DOI: 10.1002/14651858.CD006962.pub2. PubMed
9. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev. 2015;1:CD011447. DOI: 10.1002/14651858.CD011447. PubMed
10. American Board of Internal Medicine. Policies and Procedures. Philadelphia, PA; July 1990.
11. Society of Critical Care Medicine Ultrasound Certification Task Force. Recommendations for Achieving and Maintaining Competence and Credentialing in Critical Care Ultrasound with Focused Cardiac Ultrasound and Advanced Critical Care Echocardiography. http://journals.lww.com/ccmjournal/Documents/Critical%20Care%20Ultrasound.pdf. Published 2013. Accessed November 8, 2016.

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Certification of Point-of-Care Ultrasound Competency

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Nilam J. Soni, MD, MS

David M. Tierney, MD

Trevor P. Jensen, MD, MS

Brian P. Lucas, MD, MS

Any conversation about point-of-care ultrasound (POCUS) inevitably brings up discussion about credentialing, privileging, and certification. While credentialing and privileging are institution-specific processes, competency certification can be extramural through a national board or intramural through an institutional process.

Currently, no broadly accepted national board certification for POCUS exists; however, some specialty boards, such as emergency medicine, already include competency in POCUS. Thus, many institutions grant POCUS privileges to emergency medicine physicians based solely on their national board certification. In contrast, most hospitalists are certified by the American Board of Internal Medicine, which does not include competency in POCUS. Some hospitalists have pursued extramural certificate programs offered by professional organizations, such as the American College of Chest Physicians. The currently available extramural certificate programs can certify basic competency in POCUS knowledge and skills. But none of them can deem a provider competent in POCUS, which requires mastery of knowledge, image acquisition, image interpretation, and clinical integration (Figure). Image acquisition and interpretation skills are learned at varying rates. Those skills, followed by an understanding of how to integrate POCUS findings into clinical care of patients, are ones that cannot be acquired after a weekend training course.¹

Some institutions have begun to develop intramural certification pathways for POCUS competency in order to grant privileges to hospitalists. In this edition of the Journal of Hospital Medicine, Mathews and Zwank² describe a multidisciplinary collaboration to provide POCUS training, intramural certification, and quality assurance for hospitalists at one hospital in Minnesota. This model serves as a real-world example of how institutions are addressing the need to certify hospitalists in basic POCUS competency. After engaging stakeholders from radiology, critical care, emergency medicine, and cardiology, institutional standards were developed and hospitalists were assessed for basic POCUS competency. Certification included assessments of hospitalists’ knowledge, image acquisition, and image interpretation skills. The model described by Mathews did not assess competency in clinical integration but laid the groundwork for future evaluation of clinical outcomes in the cohort of certified hospitalists.

Although experts may not agree on all aspects of competency in POCUS, most will agree with the basic principles outlined by Mathews and Zwank. Initial certification should be based on training and an initial assessment of competency. Components of training should include ultrasound didactics, mentored hands-on practice, independent hands-on practice, and image interpretation practice. Ongoing certification should be based on quality assurance incorporated with an ongoing assessment of skills. Additionally, most experts will agree that competency can be recognized, and formative and summative assessments that combine a gestalt of provider skills with quantitative scoring systems using checklists are likely the best approach.

The real question is, what is the goal of certification of POCUS competency? Development of an institutional certification process demands substantive resources of the institution and time of the providers. Institutions would have to invest in equipment and staff to operate a full-time certification program, given the large number of providers that use POCUS and justify why substantive resources are being dedicated to certify POCUS skills and not others. Providers may be dissuaded from using POCUS if certification requirements are burdensome, which has potential negative consequences, such as reverting back to performing bedside procedures without ultrasound guidance or referring all patients to interventional radiology.

Conceptually, one may speculate that certification is required for providers to bill for POCUS exams, but certification is not required to bill, although institutions may require certification before granting privileges to use POCUS. However, based on the emergency medicine experience, a specialty that has been using POCUS for more than 20 years, billing may not be the main driver of POCUS use. A recent review of 2012 Medicare data revealed that <1% of emergency medicine providers received reimbursement for limited ultrasound exams.³ Despite the Accreditation Council for Graduate Medical Education (ACGME) requirement for POCUS competency of all graduating emergency medicine residents since 2001 and the increasing POCUS use reported by emergency medicine physicians,^4,5 most emergency medicine physicians are not billing for POCUS exams. Maybe use of POCUS as a “quick look” or extension of the physical examination is more common than previously thought. Although billing for POCUS exams can generate some clinical revenue, the benefits for the healthcare system by expediting care,^6,7 reducing ancillary testing,^8,9 and reducing procedural complications^10,11 likely outweigh the small gains from billing for limited ultrasound exams. As healthcare payment models evolve to reward healthcare systems that achieve good outcomes rather than services rendered, certification for the sole purpose of billing may become obsolete. Furthermore, concerns about billing increasing medical liability from using POCUS are likely overstated because few lawsuits have resulted from missed diagnoses by POCUS, and most lawsuits have been from failure to perform a POCUS exam in a timely manner.^12,13

Many medical students graduating today have had some training in POCUS¹⁴ and, as this new generation of physicians enters the workforce, they will likely view POCUS as part of their routine bedside evaluation of patients. If POCUS training is integrated into medical school and residency curricula, and national board certification incorporates basic POCUS competency, then most institutions may no longer feel obligated to certify POCUS competency locally, and institutional certification programs, such as the one described by Mathews and Zwank, would become obsolete.

For now, until all providers enter the workforce with basic competency in POCUS and medical culture accepts that ultrasound is a diagnostic tool available to any trained provider, hospitalists may need to provide proof of their competence through intramural or extramural certification. The work of Mathews and Zwank provides an example of how local certification processes can be established. In a future edition of the Journal of Hospital Medicine, the Society of Hospital Medicine Point-of-Care Ultrasound Task Force will present a position statement with recommendations for certification of competency in bedside ultrasound-guided procedures.

Disclosure

Nilam Soni receives support from the U.S. Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative Grant (HX002263-01A1). Brian P. Lucas receives support from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Dartmouth SYNERGY, National Institutes of Health, National Center for Translational Science (UL1TR001086). The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

References

1. Bahner DP, Hughes D, Royall NA. I-AIM: a novel model for teaching and performing focused sonography. J Ultrasound Med. 2012;31:295-300. PubMed

2. Mathews BK, Zwank M. Hospital Medicine Point of Care Ultrasound Credentialing: An Example Protocol. J Hosp Med. 2017;12(9):767-772. PubMed

3. Hall MK, Hall J, Gross CP, et al. Use of Point-of-Care Ultrasound in the Emergency Department: Insights From the 2012 Medicare National Payment Data Set. J Ultrasound Med. 2016;35:2467-2474. PubMed

4. Amini R, Wyman MT, Hernandez NC, Guisto JA, Adhikari S. Use of Emergency Ultrasound in Arizona Community Emergency Departments. J Ultrasound Med. 2017;36(5):913-921. PubMed

5. Herbst MK, Camargo CA, Jr., Perez A, Moore CL. Use of Point-of-Care Ultrasound in Connecticut Emergency Departments. J Emerg Med. 2015;48:191-196. PubMed

6. Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011;139:538-542. PubMed

7. Lucas BP, Candotti C, Margeta B, et al. Hand-carried echocardiography by hospitalists: a randomized trial. Am J Med. 2011;124:766-774. PubMed

8. Oks M, Cleven KL, Cardenas-Garcia J, et al. The effect of point-of-care ultrasonography on imaging studies in the medical ICU: a comparative study. Chest. 2014;146:1574-1577. PubMed

9. Koenig S, Chandra S, Alaverdian A, Dibello C, Mayo PH, Narasimhan M. Ultrasound assessment of pulmonary embolism in patients receiving CT pulmonary angiography. Chest. 2014;145:818-823. PubMed

10. Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest. 2013;143:532-538. PubMed

11. Patel PA, Ernst FR, Gunnarsson CL. Ultrasonography guidance reduces complications and costs associated with thoracentesis procedures. J Clin Ultrasound. 2012;40:135-141. PubMed

12. Stolz L, O’Brien KM, Miller ML, Winters-Brown ND, Blaivas M, Adhikari S. A review of lawsuits related to point-of-care emergency ultrasound applications. West J Emerg Med. 2015;16:1-4. PubMed

13. Blaivas M, Pawl R. Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period. Am J Emerg Med. 2012;30:338-341. PubMed

14. Bahner DP, Goldman E, Way D, Royall NA, Liu YT. The state of ultrasound education in U.S. medical schools: results of a national survey. Acad Med. 2014;89:1681-1686. PubMed

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IVC and Mortality in ADHF

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Admission inferior vena cava measurements are associated with mortality after hospitalization for acute decompensated heart failure

Author(s)

Pilar Cubo‐Romano, MD

Juan Torres‐Macho, PhD

Nilam J. Soni, MD, MS

Luis F. Reyes, MD

Ana Rodríguez‐Almodóvar, MD

Juan Manuel Fernández‐Alonso, MD

Rosa González‐Davia, MD

José Manuel Casas‐Rojo, MD

Marcos I. Restrepo, MD, MS

Gonzalo García de Casasola, PhD

Heart failure costs the United States an excess of $30 billion annually, and costs are projected to increase to nearly $70 billion by 2030.[1] Heart failure accounts for over 1 million hospitalizations and is the leading cause of hospitalization in patients >65 years of age.[2] After hospitalization, approximately 50% of patients are readmitted within 6 months of hospital discharge.[3] Mortality rates from heart failure have improved but remain high.[4] Approximately 50% of patients diagnosed with heart failure die within 5 years, and the overall 1‐year mortality rate is 30%.[1]

Prognostic markers and scoring systems for acute decompensated heart failure (ADHF) continue to emerge, but few bedside tools are available to clinicians. Age, brain natriuretic peptide, and N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) levels have been shown to correlate with postdischarge rates of readmission and mortality.[5] A study evaluating the prognostic value of a bedside inferior vena cava (IVC) ultrasound exam demonstrated that lack of improvement in IVC distention from admission to discharge was associated with higher 30‐day readmission rates.[6] Two studies using data from comprehensive transthoracic echocardiograms in heart failure patients demonstrated that a dilated, noncollapsible IVC is associated with higher risk of mortality; however, it is well recognized that obtaining comprehensive transthoracic echocardiograms in all patients hospitalized with heart failure is neither cost‐effective nor practical.[7]

In recent years, multiple studies have emerged demonstrating that noncardiologists can perform focused cardiac ultrasound exams with high reproducibility and accuracy to guide management of patients with ADHF.[8, 9, 10, 11, 12, 13, 14] However, it is unknown whether IVC characteristics from a focused cardiac ultrasound exam performed by a noncardiologist can predict mortality of patients hospitalized with ADHF. The aim of this study was to assess whether a hospitalist‐performed focused ultrasound exam to measure the IVC diameter at admission and discharge can predict mortality in a general medicine ward population hospitalized with ADHF.

METHODS

Study Design

A prospective, observational study of patients admitted to a general medicine ward with ADHF between January 2012 and March 2013 was performed using convenience sampling. The setting was a 247‐bed, university‐affiliated hospital in Madrid, Spain. Inclusion criteria were adult patients admitted with a primary diagnosis of ADHF per the European Society of Cardiology (ESC) criteria.[15] Exclusion criteria were admission to the intensive care unit for mechanical ventilation, need for chronic hemodialysis, or a noncardiac terminal illness with a life expectancy of less than 3 months. All patients provided written informed consent prior to enrollment. This study complies with the Declaration of Helsinki and was approved by the local ethics committee.

The primary outcome was all‐cause mortality at 90 days after hospitalization. The secondary outcomes were hospital readmission at 90 and 180 days, and mortality at 180 days. Patients were prospectively followed up at 30, 60, 90, and 180 days after discharge by telephone interview or by review of the patient's electronic health record. Patients who died within 90 days of discharge were categorized as nonsurvivors, whereas those alive at 90 days were categorized as survivors.

The following data were recorded on admission: age, gender, blood pressure, heart rate, functional class per New York Heart Association (NYHA) classification, comorbidities (hypertension, diabetes mellitus, atrial fibrillation, chronic obstructive pulmonary disease), primary etiology of heart failure, medications, electrocardiogram, NT‐terminal pro‐BNP, hemoglobin, albumin, creatinine, sodium, measurement of performance of activities of daily living (modified Barthel index), and comorbidity score (age‐adjusted Charlson score). A research coordinator interviewed subjects to gather data to calculate a modified Barthel index.[16] Age‐adjusted Charlson comorbidity scores were calculated using age and diagnoses per International Classification of Diseases, Ninth Revision coding.[17]

IVC Measurement

An internal medicine hospitalist with expertise in point‐of‐care ultrasonography (G.G.C.) performed all focused cardiac ultrasound exams to measure the IVC diameter and collapsibility at the time of admission and discharge. This physician was not involved in the inpatient medical management of study subjects. A second physician (N.J.S.) randomly reviewed 10% of the IVC images for quality assurance. Admission IVC measurements were acquired within 24 hours of arrival to the emergency department after the on‐call medical team was contacted to admit the patient. Measurement of the IVC maximum (IVC_max) and IVC minimum (IVC_min) diameters was obtained just distal to the hepatic veinIVC junction, or 2 cm from the IVCright atrial junction using a long‐axis view of the IVC. Measurement of the IVC diameter was consistent with the technique recommended by the American Society of Echocardiography and European Society of Echocardiography guidelines.[18, 19] The IVC collapsibility index (IVCCI) was calculated as (IVC_maxIVC_min)/IVC_max per guidelines.[18] Focused cardiac ultrasound exams were performed using a General Electric Logiq E device (GE Healthcare, Little Chalfont, United Kingdom) with a 3.5 MHz curvilinear transducer. Inpatient medical management by the primary medical team was guided by protocols from the ESC guidelines on the treatment of ADHF.[15] A comprehensive transthoracic echocardiogram (TTE) was performed on all study subjects by the echocardiography laboratory within 24 hours of hospitalization as part of the study protocol. One of 3 senior cardiologists read all comprehensive TTEs. NT‐proBNP was measured on admission and discharge by electrochemiluminescence.

Statistical Analysis

We calculated the required sample size based on published mortality and readmission rates. For our primary outcome of 90‐day mortality, we calculated a required sample size of 64 to achieve 80% power based on 90‐day and 1‐year mortality rates of 21% and 33%, respectively, among Spanish elderly patients (age 70 years) hospitalized with ADHF.[20] For our secondary outcome of 90‐day readmissions, we calculated a sample size of 28 based on a 41% readmission rate.[21] Therefore, our target subject enrollment was at least 70 patients to achieve a power of 80%.

Statistical analyses were performed using SPSS 17.0 statistical package (SPSS Inc., Chicago, IL). Subject characteristics that were categorical variables (demographics and comorbidities) were summarized as counts and percentages. Continuous variables, including IVC measurements, were summarized as means with standard deviations. Differences between categorical variables were analyzed using the Fisher exact test. Survival curves with log‐rank statistics were used to perform survival analysis. The nonparametric Mann‐Whitney U test was used to assess associations between the change in IVCCI, and readmissions and mortality at 90 and 180 days. Predictors of readmission and death were evaluated using a multivariate Cox proportional hazards regression analysis. Given the limited number of primary outcome events, we used age, IVC diameter, and log NT‐proBNP in the multivariate regression analysis based on past studies showing prognostic significance of these variables.[6, 22, 23, 24, 25, 26, 27, 28] Optimal cutoff values for IVC diameter for death and readmission prediction were determined by constructing receiver operating characteristic (ROC) curves and calculating the area under the curve (AUC) for different IVC diameters. NT‐proBNP values were log‐transformed to minimize skewing as reported in previous studies.[29]

RESULTS

Patient Characteristics

Ninety‐seven patients admitted with ADHF were recruited for the study. Optimal acoustic windows to measure the IVC diameter were acquired in 90 patients (93%). Because measurement of discharge IVC diameter was required to calculate the change from admission to discharge, 8 patients who died during initial hospitalization were excluded from the final data analysis. An additional two patients were excluded due to missing discharge NT‐proBNP measurement or missing comprehensive echocardiogram data. The study cohort from whom data were analyzed included 80 of 97 total patients (82%).

Baseline demographic, clinical, laboratory, and comprehensive echocardiographic characteristics of nonsurvivors and survivors at 90 days are demonstrated in Table 1. Eleven patients (13.7%) died during the first 90 days postdischarge, and all deaths were due to cardiovascular complications. Nonsurvivors were older (86 vs 76 years; P = 0.02), less independent in performance of their activities of daily living (Barthel index of 58.1 vs 81.9; P = 0.01), and were more likely to have advanced heart failure with an NYHA functional class of III or IV (72% vs 33%; P = 0.016). Atrial fibrillation (90% vs 55%; P = 0.008) and lower systolic blood pressure (127 mm Hg vs 147 mm Hg; P = 0.01) were more common in nonsurvivors than survivors, and fewer nonsurvivors were taking a ‐blocker (18% vs 59%; P = 0.01). Baseline comprehensive echocardiographic findings were similar between the survivors and nonsurvivors, except left atrial diameter was larger in nonsurvivors versus survivors (54 mm vs 49 mm; P = 0.04).

Table 1.Baseline Characteristics of the Study Population
	Total Cohort, n = 80	Nonsurvivors, n = 11	Survivors, n = 69	P Value
NOTE: Abbreviations: ACE, angiotensin‐converting enzyme; ARB, angiotensin receptor blocker; COPD, chronic obstructive pulmonary disease; eGFR, estimate glomerular filtration rate; IVC, inferior vena cava; IVCCI, IVC collapsibility index; LA, left atrium; LVEF, left ventricular ejection fraction; NYHA: New York Heart Association; NT‐proBNP, N‐terminal pro‐brain natriuretic peptide; PASP, Pulmonary artery systolic pressure; RVDD, right ventricular diastolic diameter; SBP, systolic blood pressure; TAPSE, tricuspid annular plane systolic excursion. *Mean standard derivation. Barthel Index (0100); higher scores correspond with greater independence in performing activities of daily living;
Demographics
Age, y*	78 (13)	86 (7)	76 (14)	0.02
Men, n (%)	34 (42)	3 (27)	26 (38)	0.3
Vital signs*
Heart rate, beats/min	94 (23)	99 (26)	95 (23)	0.5
SBP, mm Hg	141 (27)	127 (22)	147 (25)	0.01
Comorbidities, n (%)
Hypertension	72 (90)	10 (91)	54 (78)	0.3
Diabetes mellitus	35 (44)	3 (27)	26 (38)	0.3
Atrial fibrillation	48 (60)	10 (90)	38 (55)	0.008
COPD	22 (27)	3 (27)	16 (23)	0.5
Etiology of heart failure
Ischemic	20 (25)	1 (9)	16 (23)	0.1
Hypertensive	22 (27)	2 (18)	18 (26)	0.4
Valvulopathy	29 (36)	7 (64)	19 (27)	0.07
Other	18 (22)	1 (9)	16 (23)	0.09
NYHA IIIIV	38 (47)	8 (72)	23 (33)	0.016
Charlson score*	7.5 (2)	9.0 (3)	7.1 (2)	0.02
Barthel index*	76 (31)	58 (37)	81.9 (28)	0.01
Medications
‐blocker	44 (55)	2 (18)	41 (59)	0.01
ACE inhibitor/ARB	48 (60)	3 (27)	35 (51)	0.1
Loop diuretic	78 (97)	10 (91)	67 (97)	0.9
Aldosterone antagonist	31 (39)	4 (36)	21 (30)	0.4
Lab results*
Sodium, mmol/L	137 (4.8)	138 (6)	139 (4)	0.6
Creatinine, umol/L	1.24 (0.4)	1.40 (0.5)	1.17 (0.4)	0.1
eGFR, mL/min	57.8 (20)	51.2 (20)	60.2 (19)	0.1
Albumin, g/L	3.4 (0.4)	3.3 (0.38)	3.5 (0.41)	0.1
Hemoglobin, g/dL	12.0 (2)	10.9 (1.8)	12.5 (2.0)	0.01
Echo parameters*
LVEF, %	52.1 (15)	51.9 (17)	51.6 (15)	0.9
LA diameter, mm	50.1 (10)	54 (11)	49 (11)	0.04
RVDD, mm	32.0 (11)	34 (10)	31 (11)	0.2
TAPSE, mm	18.5 (7)	17.4 (4)	18.8 (7)	0.6
PASP, mm Hg	51.2 (16)	53.9 (17)	50.2 (17)	0.2
Admission*
NT‐proBNP, pg/mL	8,816 (14,260)	9,413 (5,703)	8,762 (15,368)	0.81
Log NT‐proBNP	3.66 (0.50)	3.88 (0.31	3.62 (0.52)	0.11
IVC_max, cm	2.12 (0.59)	2.39 (0.37)	2.06 (0.59)	0.02
IVC_min, cm	1.63 (0.69)	1.82 (0.66)	1.56 (0.67)	0.25
IVCCI, %	25.7 (0.16)	25.9 (17.0)	26.2 (16.0)	0.95
Discharge*
NT‐proBNP, pg/mL	3,132 (3,093)	4,693 (4,383)	2,909 (2,847)	0.08
Log NT‐proBNP	3.27 (0.49)	3.51 (0.37)	3.23 (0.50)	0.08
IVC_max, cm	1.87 (0.68)	1.97 (0.54)	1.81 (0.66)	0.45
IVC_min, cm	1.33 (0.75)	1.40 (0.65)	1.27 (0.71)	0.56
IVCCI, %	33.1 (0.20)	32.0 (21.0)	34.2 (19.0)	0.74

From admission to discharge, the total study cohort demonstrated a highly statistically significant reduction in NT‐proBNP (8816 vs 3093; P < 0.001), log NT‐proBNP (3.66 vs 3.27; P < 0.001), IVC_max (2.12 vs 1.87; P < 0.001), IVC_min (1.63 vs 1.33; P < 0.001), and IVCCI (25.7% vs 33.1%; P < 0.001). The admission and discharge NT‐proBNP and IVC characteristics of the survivors and nonsurvivors are displayed in Table 2. The only statistically significant difference between nonsurvivors and survivors was the admission IVC_max (2.39 vs 2.06; P = 0.02). There was not a statistically significant difference in the discharge IVC_max between nonsurvivors and survivors.

Table 2.Admission and Discharge BNP and IVC Characteristics of Nonsurvivors (n = 11) and Survivors (n = 69)
	Admission			Discharge			Difference (DischargeAdmission)
	Nonsurvivors	Survivors	P Value	Nonsurvivors	Survivors	P Value	Nonsurvivors	Survivors	P Value
NOTE: Abbreviations: BNP, brain natriuretic peptide; NT‐proBNP, N‐terminal pro‐brain natriuretic peptide; IVC, inferior vena cava; IVCCI, inferior vena cava collapsibility index.
NT‐proBNP, pg/mL	9,413 (5,703)	8,762 (15,368)	0.81	4,693 (4,383)	2,909 (2,847)	0.08	3,717 5,043	5,026 11,507	0.7
Log NT‐proBNP	3.88 0.31	3.62 0.52	0.11	3.51 0.37	3.23 0.50	0.08	0.29 0.36	0.38 0.37	0.4
IVC_max, cm	2.39 0.37	2.06 0.59	0.02	1.97 0.54	1.81 0.66	0.45	0.39 0.56	0.25 0.51	0.4
IVC_min, cm	1.82 0.66	1.56 0.67	0.25	1.40 0.65	1.27 0.71	0.56	0.37 0.52	0.30 0.64	0.7
IVCCI, %	25.9 17.0	26.2 16.0	0.95	32.0 21.0	34.2 19.0	0.74	3.7 7.9	8.3 22	0.5

Outcomes

For the primary outcome of 90‐day mortality, the ROC curves showed a similar AUC for the admission IVC_max diameter (AUC: 0.69; 95% confidence interval [CI]: 0.53‐0.85), log NT‐proBNP at discharge (AUC: 0.67; 95% CI: 0.49‐0.85), and log NT‐proBNP at admission (AUC: 0.69; 95% CI: 0.52‐0.85). The optimal cutoff value for the admission IVC_max diameter to predict mortality was 1.9 cm (sensitivity 100%, specificity 38%) based on the ROC curves (see Supporting Information, Appendices 1 and 2, in the online version of this article). An admission IVC_max diameter 1.9 cm was associated with a higher mortality rate at 90 days (25.4% vs 3.4%; P = 0.009) and 180 days (29.3% vs 3.4%; P = 0.003). The Cox survival curves showed significantly lower survival rates in patients with an admission IVC_max diameter 1.9 cm (74.1 vs 96.7%; P = 0.012) (Figures 1 and 2). Based on the multivariate Cox proportional hazards regression analysis with age, IVC_max diameter, and log NT‐proBNP at admission, the admission IVC_max diameter and age were independent predictors of 90‐ and 180‐day mortality. The hazard ratios for death by age, admission IVC_max diameter, and log NT‐proBNP are shown in Table 3.

Table 3.Cox Proportional Hazards Regression Analysis
Endpoint	Variable	HR (95% CI)	P Value
NOTE: Abbreviations: CI, confidence interval; HR, hazard ratio; IVC, inferior vena cava; NT‐proBNP, N‐terminal pro‐brain natriuretic protein.
90‐day mortality	Age	1.14 (1.031.26)	0.009
	IVC diameter at admission	5.88 (1.2128.1)	0.025
	Log NT‐proBNP at admission	1.00 (1.001.00)	0.910
90‐day readmission	Age	1.06 (1.001.12)	0.025
	IVC diameter at admission	3.20 (1.248.21)	0.016
	Log NT‐proBNP at discharge	1.00 (1.001.00)	0.910
180‐day mortality	Age	1.12 (1.031.22)	0.007
	IVC diameter at admission	4.77 (1.2118.7)	0.025
	Log NT‐proBNP at admission	1.00 (1.001.00)	0.610
180‐day readmission	Age	1.06 (1.011.11)	0.009
	IVC diameter at admission	2.56 (1.145.74)	0.022
	Log NT‐proBNP at discharge	1.00 (1.001.00)	0.610

Survival curves of the time to mortality (A) or readmission (B) in patients hospitalized with acute decompensated heart failure with a maximum inferior vena cava (IVC) diameter ≥1.9 cm versus <1.9 cm on admission.

Rates of death (A) or readmission (B) in patients with a maximum inferior vena cava (IVC) diameter ≥1.9 cm versus <1.9 cm on admission.

For the secondary outcome of 90‐day readmissions, 19 patients (24%) were readmitted, and the mean index admission IVC_max diameter was significantly greater in patients who were readmitted (2.36 vs 1.98 cm; P = 0.04). The ROC curves for readmission at 90 days showed that an index admission IVC_max diameter of 1.9 cm had the greatest AUC (0.61; 95% CI: 0.49‐0.74). The optimal cutoff value of an index admission IVC_max to predict readmission was also 1.9 cm (sensitivity 94%, specificity 42%) (see Supporting Information, Appendices 1 and 2, in the online version of this article). The Cox survival analysis showed that patients with an index admission IVC_max diameter 1.9 cm had a higher readmission rate at 90 days (30.8% vs 10.7%; P = 0.04) and 180 days (38.0 vs 14.3%; P = 0.02) (Figures 1 and 2). Using a multivariate Cox proportional regression analysis, the hazard ratios for the variables of age, admission IVC_max diameter, and log NT‐proBNP are shown in Table 3.

DISCUSSION

Our study found that a dilated IVC at admission is associated with a poor prognosis after hospitalization for ADHF. Patients with a dilated IVC 1.9 cm at admission had higher mortality and readmission rates at 90 and 180 days postdischarge.

The effect of a dilated IVC on mortality may be mediated through unrecognized right ventricular disease with or without significant pulmonary hypertension, supporting the notion that right heart function is an important determinant of prognosis in patients with ADHF.[30, 31] Similar to elevated jugular venous distension, bedside ultrasound examination of the IVC diameter can serve as a rapid and noninvasive measurement of right atrial pressure.[32] Elevated right atrial pressure is most often due to elevated left ventricular filling pressure transmitted via the pulmonary vasculature, but it is important to note that right‐ and left‐sided cardiac pressures are often discordant in heart failure patients.[33, 34]

Few studies have evaluated the prognostic value of IVC diameter and collapsibility in patients with heart failure. Nath et al.[24] evaluated the prognostic value of IVC diameter in stable veterans referred for outpatient echocardiography. Patients with a dilated IVC >2 cm that did not collapse with inspiration had higher 90‐day and 1‐year mortality rates. A subsequent study by Pellicori et al.[22] investigated the relationship between IVC diameter and other prognostic markers in stable cardiac patients. Pellicori et al. demonstrated that IVC diameter and serum NT‐proBNP levels were independent predictors of a composite endpoint of cardiovascular death or heart failure hospitalization at 1 year.[22] Most recently, Lee et al.[23] evaluated whether a dilated IVC in patients with a history of advanced systolic heart failure with a reduced ejection fraction of 30% and repeated hospitalizations (2) predicted worsening renal failure and adverse cardiovascular outcomes (death or hospitalization for ADHF). The study concluded that age, IVC diameter >2.1 cm, and worsening renal failure predicted cardiovascular death or hospitalization for ADHF.[23]

Our study demonstrated that an admission IVC_max 1.9 cm in hospitalized ADHF patients predicted higher postdischarge mortality at 90 and 180 days. Our findings are consistent with the above‐mentioned studies with a few important differences. First, all of our patients were hospitalized with acute decompensated heart failure. Nath et al. and Pellicori et al. evaluated stable ambulatory patients seen in an echocardiography lab and cardiology clinic, respectively. Only 12.1% of patients in the Nath study had a history of heart failure, and none were reported to have ADHF. More importantly, our study improves our understanding of patients with heart failure with a preserved ejection fraction, an important gap in the literature. The mean ejection fraction of patients in our study was 52% consistent with heart failure with preserved ejection fraction, whereas patients in the Pellicori et al. and Lee et al. studies had heart failure with reduced (42%) or severely reduced (30%) ejection fraction, respectively. We did not anticipate finding heart failure with preserved ejection fraction in the majority of patients, but our study's findings will add to our understanding of this increasingly common type of heart failure.

Compared to previous studies that utilized a registered diagnostic cardiac sonographer to obtain a comprehensive TTE to prognosticate patients, our study utilized point‐of‐care ultrasonography. Nath et al. commented that obtaining a comprehensive echocardiogram on every patient with ADHF is unlikely to be cost‐effective or feasible. Our study utilized a more realistic approach with a frontline internal medicinetrained hospitalist acquiring and interpreting images of the IVC at the bedside using a basic portable ultrasound machine.

Our study did not show that plasma natriuretic peptides levels are predictive of death or readmission after hospitalization for ADHF as shown in previous studies.[22, 35, 36] The small sample size, relatively low event rate, or predominance of heart failure with preserved ejection fraction may explain this inconsistency with prior studies.

Previous studies have reported hospital readmission rates for ADHF of 30% to 44% after 1 to 6 months.[6, 37] Goonewardena et al. showed a 41.3% readmission rate at 30 days in patients with severely reduced left ventricular ejection fraction (mean 29%), and readmitted patients had an IVC_max diameter >2 cm and an IVC collapsibility <50% on admission and discharge.[6] Carbone et al. demonstrated absence of improvement in the minimum IVC diameter from admission to discharge using hand‐carried ultrasound in patients with ischemic heart disease (ejection fraction 33%) predicted readmission at 60 days.[38] Hospital readmission rates in our study are consistent with these previously published studies. We found readmission rates for patients with ADHF and an admission IVC_max 1.9 cm to be 30.8% and 38.0% after 90 and 180 days, respectively.

Important limitations of our study are the small sample size and single institution setting. A larger sample size may have demonstrated that change in IVC diameter and NT‐proBNP levels from admission to discharge to be predictive of mortality or readmission. Further, we found an IVC_max diameter 1.9 cm to be the optimal cutoff to predict mortality, which is less than an IVC_max diameter >2.0 cm reported in other studies. The relatively smaller IVC diameter in Spanish heart failure patients may be explained by the lower body mass index of this population. An IVC_max diameter 1.9 cm was found to be the optimal cutoff to predict an elevated right atrial pressure >10 mm Hg in a study of Japanese cardiac patients with a relatively lower body mass index.[39] Another limitation is the timing of the admission IVC measurement within the first 24 hours of arrival to the hospital rather than immediately upon arrival to the emergency department. We were not able to control for interventions given in the emergency department prior to the measurement of the admission IVC, including doses of diuretics. Further, unlike the comprehensive TTEs in the United States, TTEs in Spain do not routinely include an assessment of the IVC. Therefore, we were not able to compare our bedside IVC measurements to those from a comprehensive TTE. An important limitation of our regression analysis is the inclusion of only 3 variables. The selection of variables (age, NT‐proBNP, and IVC diameter) was based on prior studies demonstrating their prognostic value.[6, 22, 25] Due to the low event rate (n = 11), we could not include in the regression model other variables that differed significantly between nonsurvivors and survivors, including NYHA class, presence of atrial fibrillation, and use of ‐blockers.

Perhaps in a larger study population the admission IVC_max diameter may not be as predictive of 90‐day mortality as other variables. The findings of our exploratory analysis should be confirmed in a future study with a larger sample size.

The clinical implications of our study are 3‐fold. First, our study demonstrates that IVC images acquired by a hospitalist at the bedside using a portable ultrasound machine can be used to predict postdischarge mortality and readmission of patients with ADHF. Second, the predominant type of heart failure in our study was heart failure with preserved ejection fraction. Currently, approximately 50% of patients hospitalized with ADHF have heart failure with preserved ejection fraction.[40] Our study adds to the understanding of prognosis of these patients whose heart failure pathophysiology is not well understood. Finally, palliative care services are underutilized in patients with advanced heart failure.[41, 42] IVC measurements and other prognostic markers in heart failure may guide discussions about goals of care with patients and families, and facilitate timely referrals for palliative care services.

CONCLUSIONS

Point‐of‐care ultrasound evaluation of IVC diameter at the time of admission can be used to prognosticate patients hospitalized with acute decompensated heart failure. An admission IVC_max diameter 1.9 cm is associated with a higher rate of 90‐day and 180‐day readmission and mortality after hospitalization. Future studies should evaluate the combination of IVC characteristics with other markers of severity of illness to prognosticate patients with heart failure.

Disclosures

This study was supported by a grant from the Madrid‐Castilla la Mancha Society of Internal Medicine. Dr. Restrepo is partially supported by award number K23HL096054 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health. The authors report no conflicts of interest.

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Journal of Hospital Medicine

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Author(s)

Pilar Cubo‐Romano, MD

Juan Torres‐Macho, PhD

Nilam J. Soni, MD, MS

Luis F. Reyes, MD

Ana Rodríguez‐Almodóvar, MD

Juan Manuel Fernández‐Alonso, MD

Rosa González‐Davia, MD

José Manuel Casas‐Rojo, MD

Marcos I. Restrepo, MD, MS

Gonzalo García de Casasola, PhD

Author(s)

Pilar Cubo‐Romano, MD

Juan Torres‐Macho, PhD

Nilam J. Soni, MD, MS

Luis F. Reyes, MD

Ana Rodríguez‐Almodóvar, MD

Juan Manuel Fernández‐Alonso, MD

Rosa González‐Davia, MD

José Manuel Casas‐Rojo, MD

Marcos I. Restrepo, MD, MS

Gonzalo García de Casasola, PhD

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METHODS

Study Design

IVC Measurement

Statistical Analysis

RESULTS

Patient Characteristics

Table 1.Baseline Characteristics of the Study Population
	Total Cohort, n = 80	Nonsurvivors, n = 11	Survivors, n = 69	P Value
NOTE: Abbreviations: ACE, angiotensin‐converting enzyme; ARB, angiotensin receptor blocker; COPD, chronic obstructive pulmonary disease; eGFR, estimate glomerular filtration rate; IVC, inferior vena cava; IVCCI, IVC collapsibility index; LA, left atrium; LVEF, left ventricular ejection fraction; NYHA: New York Heart Association; NT‐proBNP, N‐terminal pro‐brain natriuretic peptide; PASP, Pulmonary artery systolic pressure; RVDD, right ventricular diastolic diameter; SBP, systolic blood pressure; TAPSE, tricuspid annular plane systolic excursion. *Mean standard derivation. Barthel Index (0100); higher scores correspond with greater independence in performing activities of daily living;
Demographics
Age, y*	78 (13)	86 (7)	76 (14)	0.02
Men, n (%)	34 (42)	3 (27)	26 (38)	0.3
Vital signs*
Heart rate, beats/min	94 (23)	99 (26)	95 (23)	0.5
SBP, mm Hg	141 (27)	127 (22)	147 (25)	0.01
Comorbidities, n (%)
Hypertension	72 (90)	10 (91)	54 (78)	0.3
Diabetes mellitus	35 (44)	3 (27)	26 (38)	0.3
Atrial fibrillation	48 (60)	10 (90)	38 (55)	0.008
COPD	22 (27)	3 (27)	16 (23)	0.5
Etiology of heart failure
Ischemic	20 (25)	1 (9)	16 (23)	0.1
Hypertensive	22 (27)	2 (18)	18 (26)	0.4
Valvulopathy	29 (36)	7 (64)	19 (27)	0.07
Other	18 (22)	1 (9)	16 (23)	0.09
NYHA IIIIV	38 (47)	8 (72)	23 (33)	0.016
Charlson score*	7.5 (2)	9.0 (3)	7.1 (2)	0.02
Barthel index*	76 (31)	58 (37)	81.9 (28)	0.01
Medications
‐blocker	44 (55)	2 (18)	41 (59)	0.01
ACE inhibitor/ARB	48 (60)	3 (27)	35 (51)	0.1
Loop diuretic	78 (97)	10 (91)	67 (97)	0.9
Aldosterone antagonist	31 (39)	4 (36)	21 (30)	0.4
Lab results*
Sodium, mmol/L	137 (4.8)	138 (6)	139 (4)	0.6
Creatinine, umol/L	1.24 (0.4)	1.40 (0.5)	1.17 (0.4)	0.1
eGFR, mL/min	57.8 (20)	51.2 (20)	60.2 (19)	0.1
Albumin, g/L	3.4 (0.4)	3.3 (0.38)	3.5 (0.41)	0.1
Hemoglobin, g/dL	12.0 (2)	10.9 (1.8)	12.5 (2.0)	0.01
Echo parameters*
LVEF, %	52.1 (15)	51.9 (17)	51.6 (15)	0.9
LA diameter, mm	50.1 (10)	54 (11)	49 (11)	0.04
RVDD, mm	32.0 (11)	34 (10)	31 (11)	0.2
TAPSE, mm	18.5 (7)	17.4 (4)	18.8 (7)	0.6
PASP, mm Hg	51.2 (16)	53.9 (17)	50.2 (17)	0.2
Admission*
NT‐proBNP, pg/mL	8,816 (14,260)	9,413 (5,703)	8,762 (15,368)	0.81
Log NT‐proBNP	3.66 (0.50)	3.88 (0.31	3.62 (0.52)	0.11
IVC_max, cm	2.12 (0.59)	2.39 (0.37)	2.06 (0.59)	0.02
IVC_min, cm	1.63 (0.69)	1.82 (0.66)	1.56 (0.67)	0.25
IVCCI, %	25.7 (0.16)	25.9 (17.0)	26.2 (16.0)	0.95
Discharge*
NT‐proBNP, pg/mL	3,132 (3,093)	4,693 (4,383)	2,909 (2,847)	0.08
Log NT‐proBNP	3.27 (0.49)	3.51 (0.37)	3.23 (0.50)	0.08
IVC_max, cm	1.87 (0.68)	1.97 (0.54)	1.81 (0.66)	0.45
IVC_min, cm	1.33 (0.75)	1.40 (0.65)	1.27 (0.71)	0.56
IVCCI, %	33.1 (0.20)	32.0 (21.0)	34.2 (19.0)	0.74

Table 2.Admission and Discharge BNP and IVC Characteristics of Nonsurvivors (n = 11) and Survivors (n = 69)
	Admission			Discharge			Difference (DischargeAdmission)
	Nonsurvivors	Survivors	P Value	Nonsurvivors	Survivors	P Value	Nonsurvivors	Survivors	P Value
NOTE: Abbreviations: BNP, brain natriuretic peptide; NT‐proBNP, N‐terminal pro‐brain natriuretic peptide; IVC, inferior vena cava; IVCCI, inferior vena cava collapsibility index.
NT‐proBNP, pg/mL	9,413 (5,703)	8,762 (15,368)	0.81	4,693 (4,383)	2,909 (2,847)	0.08	3,717 5,043	5,026 11,507	0.7
Log NT‐proBNP	3.88 0.31	3.62 0.52	0.11	3.51 0.37	3.23 0.50	0.08	0.29 0.36	0.38 0.37	0.4
IVC_max, cm	2.39 0.37	2.06 0.59	0.02	1.97 0.54	1.81 0.66	0.45	0.39 0.56	0.25 0.51	0.4
IVC_min, cm	1.82 0.66	1.56 0.67	0.25	1.40 0.65	1.27 0.71	0.56	0.37 0.52	0.30 0.64	0.7
IVCCI, %	25.9 17.0	26.2 16.0	0.95	32.0 21.0	34.2 19.0	0.74	3.7 7.9	8.3 22	0.5

Outcomes

Table 3.Cox Proportional Hazards Regression Analysis
Endpoint	Variable	HR (95% CI)	P Value
NOTE: Abbreviations: CI, confidence interval; HR, hazard ratio; IVC, inferior vena cava; NT‐proBNP, N‐terminal pro‐brain natriuretic protein.
90‐day mortality	Age	1.14 (1.031.26)	0.009
	IVC diameter at admission	5.88 (1.2128.1)	0.025
	Log NT‐proBNP at admission	1.00 (1.001.00)	0.910
90‐day readmission	Age	1.06 (1.001.12)	0.025
	IVC diameter at admission	3.20 (1.248.21)	0.016
	Log NT‐proBNP at discharge	1.00 (1.001.00)	0.910
180‐day mortality	Age	1.12 (1.031.22)	0.007
	IVC diameter at admission	4.77 (1.2118.7)	0.025
	Log NT‐proBNP at admission	1.00 (1.001.00)	0.610
180‐day readmission	Age	1.06 (1.011.11)	0.009
	IVC diameter at admission	2.56 (1.145.74)	0.022
	Log NT‐proBNP at discharge	1.00 (1.001.00)	0.610

DISCUSSION

CONCLUSIONS

Disclosures

METHODS

Study Design

IVC Measurement

Statistical Analysis

RESULTS

Patient Characteristics

Table 1.Baseline Characteristics of the Study Population
	Total Cohort, n = 80	Nonsurvivors, n = 11	Survivors, n = 69	P Value
NOTE: Abbreviations: ACE, angiotensin‐converting enzyme; ARB, angiotensin receptor blocker; COPD, chronic obstructive pulmonary disease; eGFR, estimate glomerular filtration rate; IVC, inferior vena cava; IVCCI, IVC collapsibility index; LA, left atrium; LVEF, left ventricular ejection fraction; NYHA: New York Heart Association; NT‐proBNP, N‐terminal pro‐brain natriuretic peptide; PASP, Pulmonary artery systolic pressure; RVDD, right ventricular diastolic diameter; SBP, systolic blood pressure; TAPSE, tricuspid annular plane systolic excursion. *Mean standard derivation. Barthel Index (0100); higher scores correspond with greater independence in performing activities of daily living;
Demographics
Age, y*	78 (13)	86 (7)	76 (14)	0.02
Men, n (%)	34 (42)	3 (27)	26 (38)	0.3
Vital signs*
Heart rate, beats/min	94 (23)	99 (26)	95 (23)	0.5
SBP, mm Hg	141 (27)	127 (22)	147 (25)	0.01
Comorbidities, n (%)
Hypertension	72 (90)	10 (91)	54 (78)	0.3
Diabetes mellitus	35 (44)	3 (27)	26 (38)	0.3
Atrial fibrillation	48 (60)	10 (90)	38 (55)	0.008
COPD	22 (27)	3 (27)	16 (23)	0.5
Etiology of heart failure
Ischemic	20 (25)	1 (9)	16 (23)	0.1
Hypertensive	22 (27)	2 (18)	18 (26)	0.4
Valvulopathy	29 (36)	7 (64)	19 (27)	0.07
Other	18 (22)	1 (9)	16 (23)	0.09
NYHA IIIIV	38 (47)	8 (72)	23 (33)	0.016
Charlson score*	7.5 (2)	9.0 (3)	7.1 (2)	0.02
Barthel index*	76 (31)	58 (37)	81.9 (28)	0.01
Medications
‐blocker	44 (55)	2 (18)	41 (59)	0.01
ACE inhibitor/ARB	48 (60)	3 (27)	35 (51)	0.1
Loop diuretic	78 (97)	10 (91)	67 (97)	0.9
Aldosterone antagonist	31 (39)	4 (36)	21 (30)	0.4
Lab results*
Sodium, mmol/L	137 (4.8)	138 (6)	139 (4)	0.6
Creatinine, umol/L	1.24 (0.4)	1.40 (0.5)	1.17 (0.4)	0.1
eGFR, mL/min	57.8 (20)	51.2 (20)	60.2 (19)	0.1
Albumin, g/L	3.4 (0.4)	3.3 (0.38)	3.5 (0.41)	0.1
Hemoglobin, g/dL	12.0 (2)	10.9 (1.8)	12.5 (2.0)	0.01
Echo parameters*
LVEF, %	52.1 (15)	51.9 (17)	51.6 (15)	0.9
LA diameter, mm	50.1 (10)	54 (11)	49 (11)	0.04
RVDD, mm	32.0 (11)	34 (10)	31 (11)	0.2
TAPSE, mm	18.5 (7)	17.4 (4)	18.8 (7)	0.6
PASP, mm Hg	51.2 (16)	53.9 (17)	50.2 (17)	0.2
Admission*
NT‐proBNP, pg/mL	8,816 (14,260)	9,413 (5,703)	8,762 (15,368)	0.81
Log NT‐proBNP	3.66 (0.50)	3.88 (0.31	3.62 (0.52)	0.11
IVC_max, cm	2.12 (0.59)	2.39 (0.37)	2.06 (0.59)	0.02
IVC_min, cm	1.63 (0.69)	1.82 (0.66)	1.56 (0.67)	0.25
IVCCI, %	25.7 (0.16)	25.9 (17.0)	26.2 (16.0)	0.95
Discharge*
NT‐proBNP, pg/mL	3,132 (3,093)	4,693 (4,383)	2,909 (2,847)	0.08
Log NT‐proBNP	3.27 (0.49)	3.51 (0.37)	3.23 (0.50)	0.08
IVC_max, cm	1.87 (0.68)	1.97 (0.54)	1.81 (0.66)	0.45
IVC_min, cm	1.33 (0.75)	1.40 (0.65)	1.27 (0.71)	0.56
IVCCI, %	33.1 (0.20)	32.0 (21.0)	34.2 (19.0)	0.74

Table 2.Admission and Discharge BNP and IVC Characteristics of Nonsurvivors (n = 11) and Survivors (n = 69)
	Admission			Discharge			Difference (DischargeAdmission)
	Nonsurvivors	Survivors	P Value	Nonsurvivors	Survivors	P Value	Nonsurvivors	Survivors	P Value
NOTE: Abbreviations: BNP, brain natriuretic peptide; NT‐proBNP, N‐terminal pro‐brain natriuretic peptide; IVC, inferior vena cava; IVCCI, inferior vena cava collapsibility index.
NT‐proBNP, pg/mL	9,413 (5,703)	8,762 (15,368)	0.81	4,693 (4,383)	2,909 (2,847)	0.08	3,717 5,043	5,026 11,507	0.7
Log NT‐proBNP	3.88 0.31	3.62 0.52	0.11	3.51 0.37	3.23 0.50	0.08	0.29 0.36	0.38 0.37	0.4
IVC_max, cm	2.39 0.37	2.06 0.59	0.02	1.97 0.54	1.81 0.66	0.45	0.39 0.56	0.25 0.51	0.4
IVC_min, cm	1.82 0.66	1.56 0.67	0.25	1.40 0.65	1.27 0.71	0.56	0.37 0.52	0.30 0.64	0.7
IVCCI, %	25.9 17.0	26.2 16.0	0.95	32.0 21.0	34.2 19.0	0.74	3.7 7.9	8.3 22	0.5

Outcomes

Table 3.Cox Proportional Hazards Regression Analysis
Endpoint	Variable	HR (95% CI)	P Value
NOTE: Abbreviations: CI, confidence interval; HR, hazard ratio; IVC, inferior vena cava; NT‐proBNP, N‐terminal pro‐brain natriuretic protein.
90‐day mortality	Age	1.14 (1.031.26)	0.009
	IVC diameter at admission	5.88 (1.2128.1)	0.025
	Log NT‐proBNP at admission	1.00 (1.001.00)	0.910
90‐day readmission	Age	1.06 (1.001.12)	0.025
	IVC diameter at admission	3.20 (1.248.21)	0.016
	Log NT‐proBNP at discharge	1.00 (1.001.00)	0.910
180‐day mortality	Age	1.12 (1.031.22)	0.007
	IVC diameter at admission	4.77 (1.2118.7)	0.025
	Log NT‐proBNP at admission	1.00 (1.001.00)	0.610
180‐day readmission	Age	1.06 (1.011.11)	0.009
	IVC diameter at admission	2.56 (1.145.74)	0.022
	Log NT‐proBNP at discharge	1.00 (1.001.00)	0.610

DISCUSSION

CONCLUSIONS

Disclosures

References

Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29–e322.
Hall MJ, Levant S, DeFrances CJ. Hospitalization for congestive heart failure: United States, 2000–2010. NCHS Data Brief. 2012(108):1–8.
Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation. 2012;126(4):501–506.
Kociol RD, Hammill BG, Fonarow GC, et al. Generalizability and longitudinal outcomes of a national heart failure clinical registry: Comparison of Acute Decompensated Heart Failure National Registry (ADHERE) and non‐ADHERE Medicare beneficiaries. Am Heart J. 2010;160(5):885–892.
Cohen‐Solal A, Laribi S, Ishihara S, et al. Prognostic markers of acute decompensated heart failure: the emerging roles of cardiac biomarkers and prognostic scores. Arch Cardiovasc Dis. 2015;108(1):64–74.
Goonewardena SN, Gemignani A, Ronan A, et al. Comparison of hand‐carried ultrasound assessment of the inferior vena cava and N‐terminal pro‐brain natriuretic peptide for predicting readmission after hospitalization for acute decompensated heart failure. JACC Cardiovasc Imaging. 2008;1(5):595–601.
Papadimitriou L, Georgiopoulou VV, Kort S, Butler J, Kalogeropoulos AP. Echocardiography in acute heart failure: current perspectives. J Card Fail. 2016;22(1):82–94.
Kimura BJ, Amundson SA, Willis CL, Gilpin EA, DeMaria AN. Usefulness of a hand‐held ultrasound device for bedside examination of left ventricular function. Am J Cardiol. 2002;90(9):1038–1039.
Alexander JH, Peterson ED, Chen AY, Harding TM, Adams DB, Kisslo JA. Feasibility of point‐of‐care echocardiography by internal medicine house staff. Am Heart J. 2004;147(3):476–481.
DeCara JM, Lang RM, Koch R, Bala R, Penzotti J, Spencer KT. The use of small personal ultrasound devices by internists without formal training in echocardiography. Eur J Echocardiogr. 2003;4(2):141–147.
Lucas BP, Candotti C, Margeta B, et al. Diagnostic accuracy of hospitalist‐performed hand‐carried ultrasound echocardiography after a brief training program. J Hosp Med. 2009;4(6):340–349.
Mantuani D, Frazee BW, Fahimi J, Nagdev A. Point‐of‐care multi‐organ ultrasound improves diagnostic accuracy in adults presenting to the emergency department with acute dyspnea. West J Emerg Med. 2016;17(1):46–53.
Ferre RM, Chioncel O, Pang PS, Lang RM, Gheorghiade M, Collins SP. Acute heart failure: the role of focused emergency cardiopulmonary ultrasound in identification and early management. Eur J Heart Fail. 2015;17(12):1223–1227.
Lucas BP, Candotti C, Margeta B, et al. Hand‐carried echocardiography by hospitalists: a randomized trial. Am J Med. 2011;124(8):766–774.
Dickstein K, Cohen‐Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail. 2008;10(10):933–989.
Kucukdeveci AA, Yavuzer G, Tennant A, Suldur N, Sonel B, Arasil T. Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey. Scand J Rehabil Med. 2000;32(2):87–92.
Roos LL, Stranc L, James RC, Li J. Complications, comorbidities, and mortality: improving classification and prediction. Health Serv Res. 1997;32(2):229–238; discussion 239–242.
Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685–713; quiz 786–688.
Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18(12):1440–1463.
Delgado Parada E, Suarez Garcia FM, Lopez Gaona V, Gutierrez Vara S, Solano Jaurrieta JJ. Mortality and functional evolution at one year after hospital admission due to heart failure (HF) in elderly patients. Arch Gerontol Geriatr. 2012;54(1):261–265.
Curtis LH, Greiner MA, Hammill BG, et al. Early and long‐term outcomes of heart failure in elderly persons, 2001–2005. Arch Intern Med. 2008;168(22):2481–2488.
Pellicori P, Carubelli V, Zhang J, et al. IVC diameter in patients with chronic heart failure: relationships and prognostic significance. JACC Cardiovasc Imaging. 2013;6(1):16–28.
Lee HF, Hsu LA, Chang CJ, et al. Prognostic significance of dilated inferior vena cava in advanced decompensated heart failure. Int J Cardiovasc Imaging. 2014;30(7):1289–1295.
Nath J, Vacek JL, Heidenreich PA. A dilated inferior vena cava is a marker of poor survival. Am Heart J. 2006;151(3):730–735.
Logeart D, Thabut G, Jourdain P, et al. Predischarge B‐type natriuretic peptide assay for identifying patients at high risk of re‐admission after decompensated heart failure. J Am Coll Cardiol. 2004;43(4):635–641.
Cheng V, Kazanagra R, Garcia A, et al. A rapid bedside test for B‐type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: a pilot study. J Am Coll Cardiol. 2001;37(2):386–391.
Bettencourt P, Azevedo A, Pimenta J, Frioes F, Ferreira S, Ferreira A. N‐terminal‐pro‐brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients. Circulation. 2004;110(15):2168–2174.
Cohen‐Solal A, Logeart D, Huang B, Cai D, Nieminen MS, Mebazaa A. Lowered B‐type natriuretic peptide in response to levosimendan or dobutamine treatment is associated with improved survival in patients with severe acutely decompensated heart failure. J Am Coll Cardiol. 2009;53(25):2343–2348.
Schou M, Gustafsson F, Kjaer A, Hildebrandt PR. Long‐term clinical variation of NT‐proBNP in stable chronic heart failure patients. Eur Heart J. 2007;28(2):177–182.
Sallach JA, Tang WH, Borowski AG, et al. Right atrial volume index in chronic systolic heart failure and prognosis. JACC Cardiovasc Imaging. 2009;2(5):527–534.
Bursi F, McNallan SM, Redfield MM, et al. Pulmonary pressures and death in heart failure: a community study. J Am Coll Cardiol. 2012;59(3):222–231.
Brennan JM, Blair JE, Goonewardena S, et al. A comparison by medicine residents of physical examination versus hand‐carried ultrasound for estimation of right atrial pressure. Am J Cardiol. 2007;99(11):1614–1616.
Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol. 1990;66(4):493–496.
Drazner MH, Hamilton MA, Fonarow G, Creaser J, Flavell C, Stevenson LW. Relationship between right and left‐sided filling pressures in 1000 patients with advanced heart failure. J Heart Lung Transplant. 1999;18(11):1126–1132.
Fonarow GC, Peacock WF, Phillips CO, et al. Admission B‐type natriuretic peptide levels and in‐hospital mortality in acute decompensated heart failure. J Am Coll Cardiol. 2007;49(19):1943–1950.
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References

Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29–e322.
Hall MJ, Levant S, DeFrances CJ. Hospitalization for congestive heart failure: United States, 2000–2010. NCHS Data Brief. 2012(108):1–8.
Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation. 2012;126(4):501–506.
Kociol RD, Hammill BG, Fonarow GC, et al. Generalizability and longitudinal outcomes of a national heart failure clinical registry: Comparison of Acute Decompensated Heart Failure National Registry (ADHERE) and non‐ADHERE Medicare beneficiaries. Am Heart J. 2010;160(5):885–892.
Cohen‐Solal A, Laribi S, Ishihara S, et al. Prognostic markers of acute decompensated heart failure: the emerging roles of cardiac biomarkers and prognostic scores. Arch Cardiovasc Dis. 2015;108(1):64–74.
Goonewardena SN, Gemignani A, Ronan A, et al. Comparison of hand‐carried ultrasound assessment of the inferior vena cava and N‐terminal pro‐brain natriuretic peptide for predicting readmission after hospitalization for acute decompensated heart failure. JACC Cardiovasc Imaging. 2008;1(5):595–601.
Papadimitriou L, Georgiopoulou VV, Kort S, Butler J, Kalogeropoulos AP. Echocardiography in acute heart failure: current perspectives. J Card Fail. 2016;22(1):82–94.
Kimura BJ, Amundson SA, Willis CL, Gilpin EA, DeMaria AN. Usefulness of a hand‐held ultrasound device for bedside examination of left ventricular function. Am J Cardiol. 2002;90(9):1038–1039.
Alexander JH, Peterson ED, Chen AY, Harding TM, Adams DB, Kisslo JA. Feasibility of point‐of‐care echocardiography by internal medicine house staff. Am Heart J. 2004;147(3):476–481.
DeCara JM, Lang RM, Koch R, Bala R, Penzotti J, Spencer KT. The use of small personal ultrasound devices by internists without formal training in echocardiography. Eur J Echocardiogr. 2003;4(2):141–147.
Lucas BP, Candotti C, Margeta B, et al. Diagnostic accuracy of hospitalist‐performed hand‐carried ultrasound echocardiography after a brief training program. J Hosp Med. 2009;4(6):340–349.
Mantuani D, Frazee BW, Fahimi J, Nagdev A. Point‐of‐care multi‐organ ultrasound improves diagnostic accuracy in adults presenting to the emergency department with acute dyspnea. West J Emerg Med. 2016;17(1):46–53.
Ferre RM, Chioncel O, Pang PS, Lang RM, Gheorghiade M, Collins SP. Acute heart failure: the role of focused emergency cardiopulmonary ultrasound in identification and early management. Eur J Heart Fail. 2015;17(12):1223–1227.
Lucas BP, Candotti C, Margeta B, et al. Hand‐carried echocardiography by hospitalists: a randomized trial. Am J Med. 2011;124(8):766–774.
Dickstein K, Cohen‐Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail. 2008;10(10):933–989.
Kucukdeveci AA, Yavuzer G, Tennant A, Suldur N, Sonel B, Arasil T. Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey. Scand J Rehabil Med. 2000;32(2):87–92.
Roos LL, Stranc L, James RC, Li J. Complications, comorbidities, and mortality: improving classification and prediction. Health Serv Res. 1997;32(2):229–238; discussion 239–242.
Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685–713; quiz 786–688.
Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18(12):1440–1463.
Delgado Parada E, Suarez Garcia FM, Lopez Gaona V, Gutierrez Vara S, Solano Jaurrieta JJ. Mortality and functional evolution at one year after hospital admission due to heart failure (HF) in elderly patients. Arch Gerontol Geriatr. 2012;54(1):261–265.
Curtis LH, Greiner MA, Hammill BG, et al. Early and long‐term outcomes of heart failure in elderly persons, 2001–2005. Arch Intern Med. 2008;168(22):2481–2488.
Pellicori P, Carubelli V, Zhang J, et al. IVC diameter in patients with chronic heart failure: relationships and prognostic significance. JACC Cardiovasc Imaging. 2013;6(1):16–28.
Lee HF, Hsu LA, Chang CJ, et al. Prognostic significance of dilated inferior vena cava in advanced decompensated heart failure. Int J Cardiovasc Imaging. 2014;30(7):1289–1295.
Nath J, Vacek JL, Heidenreich PA. A dilated inferior vena cava is a marker of poor survival. Am Heart J. 2006;151(3):730–735.
Logeart D, Thabut G, Jourdain P, et al. Predischarge B‐type natriuretic peptide assay for identifying patients at high risk of re‐admission after decompensated heart failure. J Am Coll Cardiol. 2004;43(4):635–641.
Cheng V, Kazanagra R, Garcia A, et al. A rapid bedside test for B‐type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: a pilot study. J Am Coll Cardiol. 2001;37(2):386–391.
Bettencourt P, Azevedo A, Pimenta J, Frioes F, Ferreira S, Ferreira A. N‐terminal‐pro‐brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients. Circulation. 2004;110(15):2168–2174.
Cohen‐Solal A, Logeart D, Huang B, Cai D, Nieminen MS, Mebazaa A. Lowered B‐type natriuretic peptide in response to levosimendan or dobutamine treatment is associated with improved survival in patients with severe acutely decompensated heart failure. J Am Coll Cardiol. 2009;53(25):2343–2348.
Schou M, Gustafsson F, Kjaer A, Hildebrandt PR. Long‐term clinical variation of NT‐proBNP in stable chronic heart failure patients. Eur Heart J. 2007;28(2):177–182.
Sallach JA, Tang WH, Borowski AG, et al. Right atrial volume index in chronic systolic heart failure and prognosis. JACC Cardiovasc Imaging. 2009;2(5):527–534.
Bursi F, McNallan SM, Redfield MM, et al. Pulmonary pressures and death in heart failure: a community study. J Am Coll Cardiol. 2012;59(3):222–231.
Brennan JM, Blair JE, Goonewardena S, et al. A comparison by medicine residents of physical examination versus hand‐carried ultrasound for estimation of right atrial pressure. Am J Cardiol. 2007;99(11):1614–1616.
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Issue

Journal of Hospital Medicine - 11(11)

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Journal of Hospital Medicine - 11(11)

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778-784

Page Number

778-784

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Journal of Hospital Medicine

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Journal of Hospital Medicine

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Admission inferior vena cava measurements are associated with mortality after hospitalization for acute decompensated heart failure

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Admission inferior vena cava measurements are associated with mortality after hospitalization for acute decompensated heart failure

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Nilam J. Soni, MD, MS

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Address for correspondence and reprint requests: Nilam J. Soni, MD, 7703 Floyd Curl Drive, MC 7982, San Antonio, TX 78229; Telephone: 210‐567‐4815; Fax: 210‐358‐0647; E‐mail: [email protected]

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Point-of-Care Ultrasound for Hospitalists: A Position Statement of the Society of Hospital Medicine

APPLICATIONS

TRAINING

Basic Knowledge

Image Acquisition

Image Interpretation

Clinical Integration

Pathways

ASSESSMENTS

Basic Knowledge

Image Acquisition

Image Interpretation

Clinical Integration

General Assessment

CERTIFICATES AND CERTIFICATION

External Certificate

Internal Certificate

Credentialing and Privileging

Maintenance of Skills

PROGRAM MANAGEMENT

Equipment and Image Archiving

Documentation and Billing

Quality Assurance

CONCLUSIONS

Acknowledgments

APPLICATIONS

TRAINING

Basic Knowledge

Image Acquisition

Image Interpretation

Clinical Integration

Pathways

ASSESSMENTS

Basic Knowledge

Image Acquisition

Image Interpretation

Clinical Integration

General Assessment

CERTIFICATES AND CERTIFICATION

External Certificate

Internal Certificate

Credentialing and Privileging

Maintenance of Skills

PROGRAM MANAGEMENT

Equipment and Image Archiving

Documentation and Billing

Quality Assurance

CONCLUSIONS

Acknowledgments

APPLICATIONS

TRAINING

Basic Knowledge

Image Acquisition

Image Interpretation

Clinical Integration

Pathways

ASSESSMENTS

Basic Knowledge

Image Acquisition

Image Interpretation

Clinical Integration

General Assessment

CERTIFICATES AND CERTIFICATION

External Certificate

Internal Certificate

Credentialing and Privileging

Maintenance of Skills

PROGRAM MANAGEMENT

Equipment and Image Archiving

Documentation and Billing

Quality Assurance

CONCLUSIONS

Acknowledgments

Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine

METHODS

RESULTS

Literature search

RECOMMENDATIONS

Terminology