EMERGENCY ULTRASOUND SECTION
Addressing POCUS Workflow in the ED Joshua Guttman, MD FRCPC FAAEM
I
ntroduction
Consider a patient with a history of congestive heart failure (CHF) presenting with leg swelling and mild shortness of breath on exertion. The patient has been compliant with medication but recently increased salt intake due to a holiday barbecue. Despite the symptoms, the patient is still ambulatory, and the vital signs are unremarkable. While the legs are moderately swollen, the lung exam doesn’t reveal significant findings. Triage labs and ECG show a mild increase in BNP over baseline, but CBC, CMP, troponin, and ECG remain at their baseline levels. As a physician, you understand that if the patient has minimal pulmonary edema, you could increase the furosemide dosage and schedule a follow-up with a cardiologist next week. However, if significant pulmonary edema is present, more aggressive overnight diuresis in the observation unit would be necessary. Point-of-care ultrasound (POCUS) is known to be more effective at detecting pulmonary edema compared to Chest X-Ray (CXR), which often underestimates its severity. Performing a POCUS would provide immediate relevant information, allowing you to make prompt decisions about the patient’s care. However, hesitations arise: y “I have so many patients to evaluate.” y “The machine is often turned off and takes forever to turn on.” y “If I’m going to act on my findings, I need to save images and write a report.” Consequently, the decision is made: “I’ll just get the CXR.” Sound familiar? This scenario illustrates how poor POCUS workflow can hinder excellent patient care. Defining POCUS Workflow
POCUS workflow can be defined as “a systematic step-by-step process designed to integrate the use of ultrasound imaging at the bedside in clinical settings.” This workflow begins when a physician considers performing a POCUS exam and continues through the examination process until submission for reimbursement. Each step must be optimized to create a streamlined workflow. Improving the Workflow
In the initial scenario, the physician hesitated to perform a POCUS exam for several reasons. Let’s break down these concerns and suggest improvements to the workflow. “I have so many patients to evaluate.” This is a machine readiness issue.
Increasing the number of machines and ensuring convenient placement, or providing handheld ultrasounds for easy access, will improve efficiency. >>
Investing in a robust POCUS workflow is an investment in the future of POCUS and emergency medicine.”
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COMMON SENSE SEPTEMBER/OCTOBER 2024
Key Elements of POCUS Workflow in the ED
y Machine Readiness - Technical Aspects ◦ Are the machines frequently broken? ◦ Are the machines user-friendly for all staff in the ED? ◦ Is it cumbersome to change probes or initiate scanning? y Machine Readiness - Location ◦ Are ultrasound machines conveniently located? ◦ Are they placed near power outlets? ◦ Are tracking devices available to locate machines left in rooms? y POCUS Order Entry ◦ Are POCUS orders automated (known as encounter based order entry) or included in nursing order sets for likely indications? y IT Readiness ◦ Is the machine’s WIFI reliable for accessing patient information? ◦ Is it easy and quick to add patient information to the scan from the worklist? y Imaging Archival ◦ Does the ultrasound machine seamlessly connect to PACS or archival software? ◦ Are images available for immediate review? ◦ Can other clinicians access the images via the same EMR? y POCUS Documentation ◦ Can POCUS procedure notes be easily documented within the EMR, similar to other procedures? ◦ If a separate archival system is used, is it easily accessible from the EMR? ◦ Is the separate archival system intuitive? ◦ Is report generation from EMR templates straightforward? ◦ Are reports readily available for review, ideally with easy access to images? y POCUS Billing ◦ Is billing integrated within the EMR or does it require additional steps? ◦ Are coders accurately billing the POCUS exam? ◦ Are payers reimbursing POCUS exams?