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Emergency Department Ultrasound at Auckland Hospital

Emergency Department Ultrasound at Auckland Hospital. FAST and AAA: The first year. Objectives. The role of FAST History of ED ultrasound at Auckland Hospital The ultrasound credentialling process How we performed in the first year How we compare to the rest of the world

Thomas
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Emergency Department Ultrasound at Auckland Hospital

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  1. Emergency Department Ultrasound at Auckland Hospital FAST and AAA: The first year

  2. Objectives • The role of FAST • History of ED ultrasound at Auckland Hospital • The ultrasound credentialling process • How we performed in the first year • How we compare to the rest of the world • Where we go from here

  3. FAST • Focused • Assessment • Sonography • Trauma

  4. FAST • Integral part of initial trauma workup • Proven • Quick • Safe • Reliable • Reproducible • Repeatable

  5. FAST • Pitfalls • Poor sonographer • Poor scan • Air • Obesity • Negative FAST doesn’t exclude injury! • Failure to serially examine the patient

  6. History • 1998 Purchased portable ultrasound machine • 1998 First Australasian FAST course • 1999-2001 Sporadic use of ultrasound • Dec 2000 Formal Emergency Ultrasound credentialling program • Feb 2001 1st credentialled ED sonographers

  7. The Credentialling Process - Background Radiologist Clinician Radiologist Clinician

  8. The Credentialling Process - Background • Much debate in literature last 10 years • Consensus meeting • Each department decide own credentialling process • 200 scans and ongoing audit • Subsequent literature • Shackford 1999 4 yr experience • 50 scans • Suggests acceptable error rates

  9. The Credentialling Process - Background • Workshop beneficial • Rozycki 1996 • Exit exam • Sisley 1999

  10. The Credentialling Process - Background • American College of Emergency Physicians 2001 • 8 workshop hours • 25 scans in each of 6 areas • Can be partially credentialled • Only 1/76 departments met criteria • Boulanger 2000

  11. The Credentialling Process - Background • Australasian College for Emergency Medicine • 16 workshop hours • 25 Accurate scans for FAST • 15 Accurate scans for AAA • >50% clinically indicated • Proctored by credentialled/ultrasound qualified person • Exit exam

  12. Auckland ED • Adopted ACEM guideline December 2000 • 4 sonographers • Satisfied workshop requirement • Scans should not alter management • All measured against ‘gold standard’ • Proctored by radiologist • Standardised form • Monthly/bimonthly • Modified criteria for scans • 100% clinically indicated • Exit examination February 2001

  13. Results FAST • 1 ED registrar ‘credentialled’ by June 2001 • 79% Indicated scans • 2/3 ED Specialists credentialled by Feb 2002 • All scans clinically indicated

  14. Results FAST • For Detection Any Free Fluid • 113 scans in 102 patients over 13 months • 9 scanned by 2 sonographers • 1 scanned by 3 sonographers

  15. TP 20 TN 83 FP 3 FN 7 Sn 74.1% Sp 96.5% PPV 87% NPV 92% Accuracy 91.2% Results FAST(Any Free Fluid) n=113

  16. TP 11 TN 89 FP 5 FN 2 Sn 84.6% Sp 94.7% PPV 68.8% NPV 97.8% Accuracy 93.5% Results FAST(Laparotomy or Extra Investigation) n=107

  17. Results FAST Existing literature • vs gold standard, novice sonographers • 3 studies • Sn 69-79% • Sp 96-98% • vs clinical observation and experienced sonographers • Sn 80-98% • Sp >90%

  18. Errors FAST • 7 FN • 5/7 Trivial fluid, conservative management • 1 penetrating trauma with minor injury • 1 blunt trauma bladder injury, stable • All views adequate and correct interpretation according to radiologist

  19. Errors FAST • 3 FP • 1 “ascites” • 1 “?pericardial effusion” • 1 Retroperitoneal and abdominal wall haematomas • Adequate views but incorrect interpretation

  20. Result of errors FAST • 1 CT scan thorax for “?Pericardial effusion”

  21. Emergency Department Ultrasound for AAA • 2 Case series in literature

  22. Results AAA • 66 Scans in 58 Patients in 12 months • 5 Scanned by 2 sonographers • 1 Scanned by all 4 • 3/4 sufficient scans to meet requirement

  23. TP 26 TN 39 FN 1 FP 0 Sn 96.3% SP 100% PPV 96.3% NPV 97.5% Accuracy 98.3% Results AAAn=66

  24. “Error” AAA • Free air obscured 6cm AAA • Free fluid detected in Morison’s and Splenorenal recesses • Found to have perforated DU

  25. Shuman 1998 n=60 Sn 97% Sp 100% Kuhn 2000 n=68 Sn 100% Sp 95% AAA Existing Literature

  26. Time Taken to Scan • FAST median 5min (1-20) • AAA median 3.5 (1-16) • Similar to literature published

  27. FAST Learning Curve • Debate about this • Shackford only author to look at initial experience • Suggests 10 scans before proficient • Showed ‘Institutional learning curve’ • 12 Individuals = wide variation in error rates • Only 4/12 had >25 scans in 4 years

  28. FASTLearning Curve

  29. FAST Learning Curve • Error rate <10% • Most ‘errors’ clinically insignificant • Individual variation

  30. Potential Bias • Patients not consecutive • Opportunity for pre-selection of patients • Individual sonographers could discard unsatisfactory scans prior to proctoring

  31. Summary • Emergency Department Ultrasound is established in Auckland Hospital • Accuracy mirrors existing literature • Pitfalls exist and should be considered

  32. The future • Credentialling continues • Credentialled sonographers record in notes • Clinical management may alter • Ongoing audit • Expanded indications • Unstable patient with abdominal pain • Is there free fluid?

  33. Case 1 • 37f • 4hr Abdominal pain • Collapse and seizure • Shock • Arrives ED 1755 • SLOH 1806

  34. Case 1 • OT 1815

  35. Case 2 • 28f • 1/2 hr Abdominal pain • HR 84, SBP 90, RR 16 • Arrives ED 0910 • S/B registrar 1000 • SLOH 1018

  36. Case 2 • Urine pregnancy test 1025, positive

  37. Case 2 • OT 1055

  38. Case 3 • 19m • Fall from tree • Collapse at home • Fighting en route • Arrives ED 1635 • FAST 1645

  39. Case 3 • OT for thoracotomy

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