Emergency Medicine

Barriers to point-of-care ultrasound utilization during cardiac arrest in the emergency department: a regional survey of emergency physicians

a b s t r a c t

Introduction: Though Point-of-care ultrasound is recognized as a useful diagnostic and prognostic inter- vention during cardiac arrest , critics advise caution. The purpose of this survey study was to determine the barriers to POCUS during CA in the Emergency Department (ED).

Methods: Two survey instruments were distributed to emergency medicine (EM) attending and resident physi- cians at three academic centers in the South Florida. The surveys assessed demographics, experience, proficiency, attitudes and barriers. Descriptive and inferential statistics along with Item Response Theory Logistic Model and the Friedman Test with Wilcoxon Signed Rank Tests were used to profile responses and rank barriers.

Results: 206 EM physicians were invited to participate in the survey, and 187 (91%) responded. 59% of attending physicians and 47% of resident physicians reported that POCUS is performed in all their cases of CA. 5% of attend- ing physicians and 0% of resident physicians reported never performing POCUS during CA. The top-ranked de- partmental barrier for attending physicians was “No structured curriculum to educate physicians on POCUS.” The top-ranked personal barriers were “I do not feel comfortable with my POCUS skills” and “I do not have suf- ficient time to dedicate to learning POCUS.” The top-ranked barriers for resident physicians were “Time to re- trieve and operate the machine” and “Chaotic milieu.” Conclusions: While our study demonstrates that most attending and resident physicians utilize POCUS in CA, bar- riers to high-quality implementation exist. Top attending physician barriers relate to POCUS education, while the top resident physician barriers relate to logistics and the machines. Interventions to overcome these barriers might lead to optimization of POCUS performance during CA in the ED.

(C) 2020

  1. Introduction

The utilization of Point-of-care ultrasound in the emergent management of Cardiac arrest in the emergency department (ED) is not without controversy. While advocates recognize POCUS as a pow- erful diagnostic and prognostic intervention, several critics advise cau- tion [1-3].

A consensus statement by the American Society of Echocardiogra- phy and the American College of Emergency Physicians states that

* Corresponding author.

E-mail addresses: [email protected] (M.R. Singh), [email protected] (J.S. Jackson), [email protected] (M.A. Newberry), [email protected] (C. Riopelle), [email protected] (V.H. Tran), [email protected] (L.L. PoSaw).

POCUS is a “fundamental tool to expedite the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment and triage decisions by the emergency physician” [4]. Research supports the role of POCUS in (a) the diagnosis of cardiac etiologies (myocardial infarction, cardiac tamponade, wall rupture, valvular dysfunction) [5-10] and non-cardiac etiologies (hypovolemia, Tension pneumothorax, aortic aneurysm and pulmonary embolism) [5] [11-21]; (b) the guidance of life-saving procedures [5]; (c) the identification of organized cardiac contractility, asystole, Pulseless electrical activity , or pseudo- PEA [22]; (d) the management after return of spontaneous circulation

[23]; and (e) prognostication [6] [24-32].

Despite the proposed benefits, there may also be potential harm. Two recent publications have demonstrated that POCUS performance leads to an increased duration of Pulse checks and delays to compres- sion, which may negatively affect outcomes in CA [33,34], and one

https://doi.org/10.1016/j.ajem.2020.12.040

0735-6757/(C) 2020

systematic review cautions against terminating resuscitation based solely on cardiac standstill [26]. Another study conducted at three aca- demic medical centers demonstrated that there is significant variability in physician interpretation of cardiac standstill, which crosses special- ties, self-reported training levels and self-reported ultrasonography ex- pertise [35]. To date, there is no study that unequivocally demonstrates that POCUS utilization in CA improves clinical outcomes.

Resuscitation events in the ED are complex, team-based events. Most are managed in designated resuscitation areas, and are affected by institutional, departmental, and operator dynamics. We hypothe- sized that emergency physicians face multiple challenges to the perfor- mance of high-quality POCUS in CA. We believed that a starting point for understanding these challenges would be to understand the barriers faced by the very physicians who manage these events.

Although several studies have profiled barriers to the general utiliza- tion of POCUS [36-46], our study is the first to investigate barriers spe- cific to CA. Our goal was to profile attending and resident emergency physicians at three academic centers, by directly asking them about their knowledge, attitude and barriers to POCUS performance during CA.

  1. Materials and methods
    1. Location

This study profiled POCUS utilization in CA in 3 academic programs belonging to the South Florida emergency medicine (EM) Consortium. EM attending and resident physicians were grouped according to their affiliation to Program A, B, or C, and to 4 training sites, Hospital A1, A2, B or C.

Program A is a 3-year EM residency program with 15 residents per class. This program utilizes two training hospital sites: Hospital A1 and A2. A1 is a 1550-bed non-profit, public hospital, level I trauma center, and comprehensive cardiac and stroke center. The A1 ED has 110,000 annual visits and 5 ultrasound machines. A2 is a 559-bed community hospital with a comprehensive cardiac and stroke center. The A2 ED av- erages 58,000 annual visits and has 2 ultrasound machines.

Program B is a 3-year EM residency program with 7 residents per class. Hospital B is a 672-bed private, not-for-profit community hospital, cardiac and stroke center. The ED averages 75,000 annual visits and has 3 ultrasound machines.

Program C is a 3-year EM residency program with 10 residents per year. Hospital C is a 407-bed private for-profit, level II trauma center and comprehensive stroke center. The 42-bed ED averages 65,000 an- nual visits and has 2 ultrasound machines.

    1. Survey design

Two separate surveys were designed for attending and resident phy- sicians by the site investigators, all of whom have considerable expertise in ultrasound education. Item content, clarity and import (criterion va- lidity) were based on prior published studies on barriers to POCUS uti- lization [36-46], and the combined experience and practice (content validity) of the investigators. Surveys were carefully examined for con- struct validity. MN, HT, LP are emergency ultrasound (EUS) directors at their respective academic centers, and JJ has substantial expertise in EUS.

The attending physician survey contained 18 multiple-choice items (some with sub-items), and the resident physician survey contained 12 open-ended and multiple-choice items (some with sub-items). Both surveys contained questions pertaining to demographics, POCUS training, frequency of POCUS utilization during cardiac arrest, confi- dence in performance and supervision, and barriers to the performance of POCUS in CA. The site investigators prior to study implementation ap- proved a final version of the survey, available as supplemental file, S1.

Surveys also included a question on perceived level of POCUS proficiency, modeled on The Accreditation Council of Graduate Medical Education (ACGME) Emergency Medicine Patient Care PC12 milestone for “Goal-Directed Focused Ultrasound”, which uses behavioral anchors to evaluate EM resident’s competency levels on a scale from 1 to 5 (1 = entry level, 5 = expert) [45].

    1. Barriers

Attending physicians were surveyed for nine departmental barriers (“no structured curriculum”, “lack of funding”, “bedside space”, “insuffi- cient mentorship”, “machine availability”, “consultant pushback”, “de- partment resistance”, “machine size”, “POCUS priority/value”) and seven personal barriers (“comfort with POCUS skills”, “dedicated learn- ing time”, “on shift practice”, “POCUS value”, “negative impact on effi- ciency”, “negative impact on teamwork”, “negative impact on patient care”).

Resident physicians were surveyed for nine barriers (“time to re- trieve and operate ultrasound machine”, “chaotic milieu”, “machine availability”, “attending supervision”, “breakdown in teamwork”, “in- sufficient mentorship”, “personal POCUS knowledge/skills”, “belief in negative patient outcomes” and “consultant pushback”).

    1. Survey implementation

Site investigators were responsible for identifying and surveying el- igible participants. The same attending and resident survey was admin- istered at all participating sites. All eligible participants were assigned a number code to maintain anonymity. Survey distribution was con- ducted over 3 months in Spring 2019. Both surveys were administered in paper format during attending and resident physician conferences. Physicians who did not attend conference received an electronic survey on Google Forms. Four weekly reminder e-mails were sent to partici- pants who had not completed the survey. All surveys included a de- scription of the project and contact information of the study investigators. No incentives were offered for survey completion. The in- stitutional review board at the University of Miami approved this study.

    1. Data analysis

We performed data analysis on respondent demographics (training, experience, self-reported confidence and proficiency) by computing frequencies and percentages. Additionally, we performed inferential statistics (One-way ANOVA) to analyze attending and resident physi- cian sub-groups. Finally, we evaluated the barriers faced by attending and resident physicians using either the Friedman test with Wilcoxon Signed Rank tests or the Item Response Theory Logistic model, depend- ing upon the survey format.

Attending physician barriers were reported as Likert-style ordinal data from 1 to 5 (1 = strongly agree, 2 = disagree, 3 = neutral, 4 = dis- agree, 5 = strongly disagree). We performed a series of Friedman test with Wilcoxon Signed Rank tests, which are non-parametric. First, the tests produced mean ranks for each barrier, and next, each barrier was assessed for significant difference.

Resident physician barriers were reported as binary data, with the

presence of a barrier reported as 1, and the absence of a barrier reported as zero. The Rasch Item Response Theory Logistic model assessed the relative rank of barriers as a trade-off between respondent’s abilities and the difficulty of the barrier. The logit values from each Rasch model were sorted in order of relative difficulty. A large, negative logit represented a significant barrier, while a large positive logit represented an insignificant barrier.

Analyses were performed using IBM SPSS Statistics for Windows, Version 24.0, (IBM Corp., Armonk, NY) and with Stata Statistical Soft- ware: Release 15 (College Station, TX).

  1. Results

The eligible population at the three academic programs was 206 EM physicians of whom 110 were attending physicians and 96 were resi- dent physicians. At the time of this study, Program A had 46 residents, Program B had 21 residents, and Program C had 29 residents. The resi- dent physician response rate was 97% (93/96). The attending physician response rate was 85% (94/110).

The demographic profile, self-rated proficiency and self-rated confi- dence levels in performing POCUS during CA for attending physicians are presented in Table 1 and for resident physicians are presented in Table 2.

Site-specific and combined data for attending and resident perfor- mance of POCUS during CA are presented in Tables 1 & 2. At all pro- grams, 74 (81%) EM attending physicians reported managing 1-5 cases of CA per month. 5 (5%) attending physicians never perform POCUS and 54 (59%) attending physicians perform POCUS in 100% of their CA cases. Only 8 (9%) of attending physicians report independently performing POCUS during CA, without resident involvement, and 13 (15%) report that only residents perform POCUS in all their cases. Across all programs, in a 4-week rotation, 42 (45%) residents reported manag- ing 1-5 cases of CA and 23 (25%) manage more than 11 cases. 44 (47%) perform POCUS in all cases of CA, while 0% of residents reported never using POCUS in CA.

Site-specific and combined data for departmental barriers and per- sonal barriers faced by attending physicians when performing POCUS in CA are ranked in descending order and presented in Table 3, and the barriers faced by resident physicians are presented in Table 4.

For attending physicians, the top ranked personal barriers were “I do not feel comfortable with my POCUS skills” and “I do not have sufficient time to dedicate to learning,” while the lowest ranked personal barrier was “Using POCUS in cardiac arrest negatively impacts patient out- comes.” The top ranked departmental barrier was “No structured curric- ulum,” while the least significant barrier was “Resistance from other departments.”

The top ranked barriers for resident physicians were “Time to re- trieve and operate the machine” and “Chaotic milieu.” The lowest ranked barriers were “Pushback from consultants” and “Belief in nega- tive impact.”

  1. Limitations

First, a major limitation of this study is that it is based at academic centers with EM residency programs, and has been conducted in a sin- gle, geographic region. Thus, our results may not be generalizable to centers without training programs or located outside our region. We also recognize that there are considerable variations between hospitals located within our region, and we only sampled four of many hospitals.

Table 1

Attending physician demographic profile, proficiency and Confidence levels in performing point-of-care ultrasound during cardiac arrest

Program/Hospital Training Sites

A1

A2

B

C

Total

N (%)

N (%)

N (%)

N (%)

N (%)

Total number of attending physicians

51 (46)

16 (15)

23 (21)

20 (18)

110

Number of surveys completed

41 (80)

16 (100)

22 (96)

15 (75)

94 (85)

Years of practice after residency

0-5

6 (15)

4 (25)

3 (14)

7 (47)

20 (22)

6-10

4 (10)

4 (25)

6 (29)

5 (33)

19 (21)

11-15

5 (13)

3 (19)

6 (29)

1 (7)

15 (16)

16 plus

POCUS training pathways*

24 (62)

5 (31)

6 (29)

2 (13)

37 (41)

No training

3 (5)

1 (5)

0 (0)

1 (6)

5 (5)

Bedside instruction on shift

14 (23)

7 (32)

7 (21)

2 (12)

30 (32)

Ultrasound in-class course

14 (23)

6 (27)

9 (26)

1 (6)

30 (32)

Primarily self-taught

14 (23)

0 (0)

1 (3)

2 (12)

17 (18)

Formal EUS training

16 (26)

8 (36)

17 (50)

11 (65)

52 (55)

Self-rated proficiency levels**

Level 1

12 (31)

1 (7)

1 (5)

1 (7)

15 (17)

Level 2

4 (10)

2 (13)

0 (0)

0 (0)

6 (7)

Level 3

10 (26)

2 (13)

7 (33)

1 (7)

20 (22)

Level 4

6 (15)

7 (47)

8 (38)

7 (47)

28 (31)

Level 5

7 (18)

3 (20)

5 (24)

6 (40)

21 (23)

Self-rated confidence levels in performing POCUS

1

2 (5)

0 (0)

0 (0)

0 (0)

2 (2)

2

6 (16)

1 (6)

0 (0)

1 (7)

8 (9)

3

4 (11)

4 (25)

3 (14)

0 (0)

11 (12)

4

14 (37)

6 (38)

7 (33)

3 (20)

30 (33)

5

12 (32)

5 (31)

11 (52)

11 (73)

39 (43)

Number of cardiac arrest cases managed per month

0

2 (5)

0 (0)

0 (0)

1 (6)

3 (3)

1-5

31 (79)

14 (88)

18 (86)

11 (73)

74 (81)

6-10

6 (15)

2 (12)

3 (14)

3 (20)

14 (15)

Percentage of cardiac arrest cases managed with POCUS

0%

3 (8)

1 (6)

0 (0)

1 (7)

5 (5)

25%

10 (26)

4 (25)

1 (5)

1 (7)

16 (18)

50%

3 (8)

1 (6)

1 (5)

0 (0)

5 (5)

75%

5 (13)

2 (13)

2 (10)

2 (13)

11 (12)

100%

18 (46)

8 (50)

17 (81)

11 (73)

54 (59)

POCUS performance by attending & resident physicians, expressed as a percentage of total cases

100% Attending

3 (8)

1 (6)

2 (10)

2 (13)

8 (9)

75% Attending & 25% Resident

1 (3)

2 (13)

1 (5)

1 (7)

5 (6)

50% Attending & 50% Resident

9 (24)

5 (33)

6 (29)

4 (27)

24 (27)

25% Attending & 75% Resident

19 (50)

5 (33)

11 (52)

4 (27)

39 (44)

100% Resident

6 (16)

2 (13)

1 (5)

4 (27)

13 (15)

POCUS: point-of-care ultrasound. * The total is >100% **Based on ACGME (Accreditation Council of Graduate Medical Education) competency Levels 1-5.

Site-specific resident physician self-rated proficiency and confidence levels in performing point-of-care ultrasound during cardiac arrest

Program Training Sites

A

B

C

Total

Number of residents

N (%)

46 (48)

N (%)

21 (22)

N (%)

29 (30)

N (%)

96

Number of surveys completed

43 (93)

21 (100)

29 (100)

93 (97)

PGY1

15 (35)

7 (33)

10 (34)

32 (34)

PGY2

15 (35)

7 (33)

10 (34)

32 (34)

PGY3

Self-rated proficiency levels*

13 (30)

7 (33)

9 (31)

29 (31)

Level 1

0 (0)

0 (0)

0 (0)

0 (0)

Level 2

2 (5)

0 (0)

2 (7)

4 (4)

Level 3

6 (14)

6 (29)

6 (21)

18 (20)

Level 4

32 (76)

15 (71)

17 (59)

64 (70)

Level 5

2 (5)

0 (0)

4 (14)

6 (7)

Self-rated confidence levels

1

0 (0)

0 (0)

0 (0)

0 (0)

2

2 (5)

1 (5)

0 (0)

3 (3)

3

3 (7)

5 (24)

8 (28)

16 (17)

4

21 (49)

12 (41)

12 (41)

45 (48)

5

17 (40)

3 (14)

9 (31)

29 (31)

Number of cardiac arrest cases managed per 4-week rotation

0

0 (0)

0 (0)

1 (3)

1 (1)

1-5

15 (35)

12 (57)

15 (52)

42 (45)

6-10

15 (35)

6 (29)

6 (21)

27 (29)

11+

Percentage of cardiac arrest cases managed with POCUS

13 (30)

3 (14)

7 (24)

23 (25)

0%

0 (0)

0 (0)

0 (0)

0 (0)

25%

0 (0)

0 (0)

2 (7)

2 (2)

50%

6 (14)

0 (0)

7 (24)

13 (14)

75%

13 (30)

10 (47)

11 (38)

34 (37)

100%

24 (56)

11 (52)

9 (31)

44 (47)

*Based on Accreditation Council of Graduate Medical Education competency Levels 1-5.

Second, our surveys had a list of preselected barriers, and it is possible that we may have underestimated certain influences, and not included them as barriers. We did not perform an external validation of the sur- vey. We had closed-ended questions, which might have led to response bias. Third, the survey was only piloted with the site directors involved in this study, and not with a representative respondent sample. Fourth, our surveys relied on physician reporting of self-assessed competency, confidence levels, which may differ from actual practice. There may have been an overestimation of the frequency of POCUS utilization.

Surveys are known to be associated with over-reporting of socially de- sirable behaviors, and our cohort might suffer from the same bias.

  1. Discussion

The goal of our study was to profile POCUS performance at three ac- ademic centers, so as to better understand the challenges faced by at- tending and resident physicians to high quality POCUS performance during CA in the ED. We hoped that recognizing these challenges

Table 3

Attending physician ranked personal and departmental barriers to performing point-of-care ultrasound during cardiac arrest, by individual and combined sites. Friedman Test with Wilcoxon Signed Rank tests was used to profile responses and rank barriers

Personal Barriers

Combined

A1

A2

B

C

(N = 90)

(N = 38)

(N = 16)

(N = 21)

(N = 15)

I do not feel comfortable with my ultrasound skills to make Clinical decisions with POCUS

1

2

1

1

4

I do not have sufficient time to dedicate to learning POCUS in cardiac arrest

2

1

2

2

1

I do not work enough clinical shifts to effectively practice my POCUS skills

3

4

5

3

2

I do not place significant value to using POCUS in cardiac arrest

4

3

3

4

3

I feel that using POCUS in cardiac arrest negatively impacts efficiency

5

5

4

5

5

I feel that using POCUS in cardiac arrest negatively impacts teamwork

6

6

6

6

6

I feel that using POCUS in cardiac arrest negatively impacts patient outcomes

7

7

7

7

7

Departmental Barriers

There is no structured curriculum to educate physicians on POCUS in cardiac arrest

Combined (N = 90)

1

A1

(N = 38)

1

A2

(N = 16)

1

B

(N = 21)

4

C

(N = 15)

7

There is lack of funding to further training in POCUS in cardiac arrest

2

3

7

2

4

There is not enough space at the bedside

3

6

2

7

1

There is not sufficient mentorship in POCUS in cardiac arrest

4

2

3

3

9

The machine is being used elsewhere

5

7

5

5

2

My consultants would not use POCUS findings for medical decision-making

6

5

6

1

5

The machine is too bulky

7

4

4

8

3

POCUS in cardiac arrest is not a priority in my department

8

8

8

9

8

There is resistance from other departments to POCUS in cardiac arrest

9

9

9

6

5

POCUS: point-of-care ultrasound. A1, A2, B, C: Program/Hospital Training Sites.

Table 4

Site-specific and combined ranks of resident physician barriers to performing point-of-care ultrasound during cardiac arrest. Item Response Theory Logistic Model was used to profile re- sponses and rank barriers

Combined

A1

A2

B

C

Barriers

(N = 130)

(N = 42)?

(N = 40)?

(N = 19)?

(N = 29)

Time to retrieve and operate machine

1

1

1

2

2

(-0.555, 0.006)

(-0.833, 0.015)

(-0.311, 0.300)

(0.481, 0.665)

(-1.155, 0.089)

Chaotic milieu

2

2

3

1

3

(-0.339, 0.081)

(-0.686, 0.039)

(-0.005, 0.988)

(0.234, 0.820)

(-0.718, 0.227)

Availability of functional machine

3

3

2

5

1

(-0.243, 0.199)

(-0.245, 0.417)

(-0.008, 0.978)

(2.093, 0.282)

(-1.773, 0.029)

Faculty supervision

4

5

4

4

??

(0.735, 0.001)

(0.425,

(0.013, 0.966)

(1.915, 0.301)

0.227)

Breakdown in teamwork

5

4

6

7

6

(0.754, 0.001)

(0.047,

(0.352, 0.278)

(4.527, 0.232)

(2.429, 0.030)

0.883)

Insufficient mentorship in POCUS in cardiac arrest

6

6

5

6

5

(0.788, 0.001)

(0.474,

(0.173, 0.571)

(3.515, 0.238)

(2.429, 0.030)

0.175)

Personal POCUS knowledge/skills

7

7

7

3

4

(0.818, 0.000)

(0.851,

(0.483, 0.150)

(1.892, 0.309)

(1.329, 0.083)

0.025)

Belief in negative impact on efficacy and patient outcomes

8

8

8

9

??

(1.583, 0.000)

(1.017,

(0.733, 0.055)

(6.135, 0.236)

0.015)

Pushback from consultants

9

9

9

8

7

(2.514, 0.000)

(2.804,

(1.867, 0.003)

(6.046, 0.234)

(2.995, 0.027)

0.002)

POCUS: point-of-care ultrasound. A1, A2, B, C: Program/Hospital Training Sites.

Data presentation: Rank in bold font, (Rasch Logit, P > [z]), ?? Lack of variation in sample.

* Number of residents who answered part, but not the barrier section, of the survey, A1 = 1, A2 = 2, B = 2.

would move us one step closer to addressing concerns of potential pa- tient harm through sub-optimal POCUS performance.

Published barriers to general POCUS utilization in the ED can be di- vided into several broad categories: lack of funding [38], equipment [37-40], training and skill maintenance [37,38,40,41,44], quality assur- ance [38,41,44], time to perform POCUS, [38,40], unclear documentation and reimbursement guidelines [39,41], and lack of institutional support [37]. Our study is the first to examine departmental and personal bar- riers specific to POCUS performance in CA.

At all 3 studied programs, attending physicians believed that POCUS

performance does not negatively impact efficiency, teamwork or pa- tient outcomes. However, even though POCUS is reported as a depart- ment priority, most attending physicians report not having a structured curriculum or dedicated time to learn POCUS.

Resident physicians from all programs identified their top barriers as the time to retrieve and operate an ultrasound machine and chaotic re- suscitation logistics. Neither the value of POCUS utilization in CA nor consultant pushback was reported as significant barriers. Other barriers, like breakdown in teamwork and POCUS knowledge and skills varied between programs and are best appreciated at the individual site level. Institutions have differences in culture, physical footprint, financial allocations, clinical operations, and political differences, leading to site-specific departmental barriers. However, it is not surprising that personal barriers are more generalizable across cohorts of attending

physicians.

The recognition of barriers has led to real progress. Schnittke et al.

[36] recently published an observational study that surprisingly identi- fied the lack of a uniform documenting protocol as the most important barrier to resident on-shift POCUS performance. They reported the im- plementation of a stream lined documentation protocol, which led to an increase in POCUS performance by residents.

Our study generated discussion among administrators and policy makers at all 3 academic programs, and has promoted change. The next step would be to measure success with outcome data.

At Program C, this survey identified the single largest resident and attending physician barrier as issues with the machine. At the time, the program had two outdated machines and experienced frequent cord damage and broken probes that took several weeks to fix. Validation of this barrier to hospital administration led to the procurement of 4 technologically advanced machines and im- proved access. The data gained from the survey lead to an in- creased awareness of the potential for improper use. As a result, current controversies and best practices have been increasingly discussed with residents in training.

At Program B, the EUS director was surprised to find that the at- tending physicians were not comfortable with their POCUS skills, and felt that time, funding and training opportunities were lacking. Program B is currently working towards promoting available train- ing resources, including free local conferences and access to the ED scanning shift schedule. To overcome the resident physician barrier of disorganized logistics, teamwork and leadership training with simulation is planned.

The identification of barriers prompted Program A to make the following changes: (a) access to a functional, resuscitation-specific machine placed in the resuscitation room, cleaned, charged and ready to use at short notice; (b) development of a single applica- tion credentialing curriculum and mentorship for attending physi- cians; (c) adoption of a resuscitation POCUS protocol that emphasizes team training and leadership. Protocols with desig- nated POCUS providers to conduct and interpret images at specific times have been published [47] and have been shown to be mean- ingful when incorporated by the resuscitation team [48]. Practice

[49] may increase operator confidence and change the perception of barriers.

Other suggestions might be to establish best practice protocols, for- mal Quality improvement projects, access to continuing education pro- grams, and to establish a financial stipend for continued medical education.

  1. Conclusions

At three academic centers in South Florida, emergency physicians support POCUS in CA and report routine utilization of POCUS in resusci- tations. Attending physician self-rated proficiency and confidence in POCUS performance correlates to years of clinical practice and type of EUS training. Both attending and resident physicians report multiple barriers to performing POCUS in CA. Recognition of these barriers and targeted interventions might lead to the optimization of POCUS perfor- mance during CA in the ED.

Author contributions

  1. MRS: Study concept and design, Acquisition of the data, Analysis and interpretation of the data, Drafting of the Manuscript, Critical revi- sion of the manuscript for important intellectual content.
  2. JSJ: Acquisition of the data, Critical revision of the manuscript for im- portant intellectual content
  3. MAN: Acquisition of the data, Drafting of the Manuscript, Critical re- vision of the manuscript for important intellectual content
  4. CR: Analysis and interpretation of the data, Statistical expertise
  5. VHT: Acquisition of the data, Drafting of the Manuscript, Critical revi- sion of the manuscript for important intellectual content
  6. LLP: Study concept and design, Acquisition of the data, Analysis and interpretation of the data, Drafting of the manuscript, Critical revi- sion of the manuscript for important intellectual content, Faculty Mentor

Credit Author Statement

  1. Mallika Singh: Study concept and design, Acquisition of the data, Analysis and interpretation of the data, Drafting of the Manuscript, Critical revision of the manuscript for important intellectual content, Statistical expertise.
  2. Jennifer Jackson: Acquisition of the data, Drafting of the Manuscript, Critical revision of the manuscript for important intellectual content.
  3. Mark Newberry: Acquisition of the data, Drafting of the Manuscript, Critical revision of the manuscript for important intellectual content.
  4. Cameron Riopelle: Analysis and interpretation of the data, Statistical expertise
  5. Vu Huy Tran: Acquisition of the data, Drafting of the Manuscript, Crit- ical revision of the manuscript for important intellectual content.
  6. Leila PoSaw: Study concept and design, Acquisition of the data, Anal- ysis and interpretation of the data, Drafting of the manuscript, Critical revision of the manuscript for important intellectual content, Statis- tical expertise.

Declaration of Competing Interest

None.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2020.12.040.

References

  1. Gottlieb M, Alerhand S. Ultrasonography: a useful adjunct in cardiac arrest. Ann Emerg Med. 2020;75(4):514-5. https://doi.org/10.1016/j.annemergmed.2019.07. 025.
  2. Long B, April M, et al. Ultrasound should not be routinely used during cardiopulmo- nary resuscitation for Shockable rhythms. Ann Emerg Med. 2020;75(4):515-7. https://doi.org/10.1016/j.annemergmed.2019.07.027.
  3. Sonmez E, Gulen B. Ultrasound is useful in cardiac arrest, but we still have concerns. Resuscitation. 2020;146:147-8. https://doi.org/10.1016/j.resuscitation.2019.09.039.
  4. Labovitz AJ, Noble VE, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American

College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23(12):1225-30. https://doi.org/10.1016/j.echo.2010.10.005.

  1. Long B, Alerhand S, et al. Echocardiography in cardiac arrest: an emergency medi- cine review. Am J Emerg Med. 2018;36(3):488-93. https://doi.org/10.1016/j.ajem. 2017.12.031.
  2. Breitkreutz R, Price S, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. 2010;81 (11):1527-33. https://doi.org/10.1016/j.resuscitation.2010.07.013.
  3. Tayal VS, Kline JA. Emergency echocardiography to detect pericardial effusion in pa- tients in PEA and near-PEA states. Resuscitation. 2003;59(3):315-8. https://doi.org/ 10.1016/s0300-9572(03)00245-4.
  4. Niendorff DF, Rassias AJ, et al. Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers. Resuscitation. 2005;67(1):81-7. https://doi.org/10.1016/j.resuscitation.2005.04.007.
  5. Mandavia DP, Hoffner RJ, et al. Bedside echocardiography by emergency physicians. Ann Emerg Med. 2001;38(4):377-82. https://doi.org/10.1067/mem.2001.118224.
  6. Nagdev A, Stone MB. Point-of-care ultrasound evaluation of pericardial effusions: does this patient have cardiac tamponade? Resuscitation. 2011;82(6):671-3. https://doi.org/10.1016/j.resuscitation.2011.02.004.
  7. Price S, Uddin S, et al. Echocardiography in cardiac arrest. Curr Opin Crit Care. 2010; 16(3):211-5. https://doi.org/10.1097/MCC.0b013e3283399d4c.
  8. MacCarthy P, Worrall A, et al. The use of transthoracic echocardiography to guide thrombolytic therapy during cardiac arrest due to massive pulmonary embolism. Emerg Med J doi:https://doi.org/10.1136/emj.19.2.178.
  9. Lyon M, Blaivas M, et al. sonographic measurement of the inferior vena cava as a marker of blood loss. Am J Emerg Med. 2005;23(1):45-50. https://doi.org/10. 1016/j.ajem.2004.01.004.
  10. Nagdev AD, Merchant RC, et al. Emergency department bedside ultrasonographic measurement of the Caval index for noninvasive determination of low central ve- nous pressure. Ann Emerg Med. 2010;55(3):290-5. https://doi.org/10.1016/j. annemergmed.2009.04.021.
  11. Weekes AJ, Tassone HM, et al. Comparison of serial Qualitative and quantitative as- sessments of caval index and left ventricular systolic function during early fluid re- suscitation of hypotensive emergency department patients. Acad Emerg Med. 2011; 18(9):912-21. https://doi.org/10.1111/j.1553-2712.2011.01157.x.
  12. Wallace DJ, Allison M, et al. Inferior vena cava percentage collapse during respiration is affected by the sampling location: an ultrasound study in healthy volunteers. Acad Emerg Med. 2010;17(1):96-9. https://doi.org/10.1111/j.1553-2712.2009.00627.x.
  13. Muller L, Bobbia X, et al. Respiratory variations of inferior vena cava diameter to pre- dict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use. Crit Care. 2012;16(5):R188 Published 2012 Oct 8 https://doi.org/10.1186/cc11672.
  14. Tovar EA, Borsari A, et al. Diagnosis of fulminant pulmonary embolism by transtho- racic echocardiography. Tex Heart Inst J. 1997;24(1):68-70.
  15. Dulchavsky SA, Schwarz KL, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma. 2001;50(2):201-5. https://doi.org/10. 1097/00005373-200102000-00003.
  16. Husain LF, Hagopian L, et al. Sonographic diagnosis of pneumothorax. J Emerg Trauma Shock. 2012;5(1):76-81. https://doi.org/10.4103/0974-2700.93116.
  17. Borloz MP, Frohna WJ, et al. Emergency department focused bedside echocardiogra- phy in massive pulmonary embolism. J Emerg Med. 2011;41(6):658-60. https://doi. org/10.1016/j.jemermed.2011.05.044.
  18. Zengin S, Gumusboga H, et al. Comparison of manual pulse palpation, cardiac ultra- sonography and Doppler ultrasonography to check the pulse in cardiopulmonary ar- rest patients. Resuscitation. 2018;133:59-64. https://doi.org/10.1016/j.resuscitation. 2018.09.018.
  19. Elfwen L, Hildebrand K, et al. Focused cardiac ultrasound after return of spontaneous circulation in cardiac-arrest patients. Resuscitation. 2019;142:16-22. https://doi. org/10.1016/j.resuscitation.2019.06.282.
  20. Tsou PY, Kurbedin J, et al. Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: a systematic review and meta-analysis. Resuscitation. 2017;114:92-9. https://doi.org/10.1016/j.resusci- tation.2017.02.021.
  21. Salen P, Melniker L, et al. Does the presence or absence of sonographically identified Cardiac activity predict resuscitation outcomes of cardiac arrest patients. Am J Emerg Med. 2005;23(4):459-62. https://doi.org/10.1016/j.ajem.2004.11.007.
  22. Gaspari R, Weekes A, et al. Emergency department point-of-care ultra- sound in out- of-hospital and in-ED cardiac arrest. Resuscitation. 2016;109:33-9. https://doi.org/ 10.1016/j.resuscitation.2016.09.018.
  23. Salen P, O’Connor R, et al. Can cardiac sonography and capnography be used inde- pendently and in combination to predict resuscitation outcomes? Acad Emerg Med. 2001;8:610-5. https://doi.org/10.1111/j.1553-2712.2001.tb00172.x.
  24. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001;8 (6):616-21. https://doi.org/10.1111/j.1553-2712.2001.tb00174.x.
  25. Cebicci H, Salt O, et al. Benefit of cardiac sonography for estimating the early term survival of the cardiopulmonary arrest patients. Hippokratia. 2014;18(2):125-9.
  26. Blyth L, Atkinson P, et al. Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review [published correction appears in Acad Emerg med. 2015 Jul;22(7):892]. Acad Emerg Med. 2012;19(10):1119-26. https:// doi.org/10.1111/j.1553-2712.2012.01456.x.
  27. Cohn B. Does the absence of cardiac activity on ultrasonography predict failed resus- citation in cardiac arrest? Ann Emerg Med. 2013;62(2):180-1. https://doi.org/10. 1016/j.annemergmed.2013.03.031.
  28. Kedan I, Ciozda W, et al. Prognostic value of point-of-care ultrasound during cardiac arrest: a systematic review. Cardiovasc Ultrasound. 2020;18(1):1 Published 2020 Jan 13 https://doi.org/10.1186/s12947-020-0185-8.
  29. Huis In’t Veld MA, Allison MG, et al. Ultrasound use during cardiopulmonary resus- citation is associated with delays in chest compressions. Resuscitation. 2017;119: 95-8. https://doi.org/10.1016/j.resuscitation.2017.07.021.
  30. Clattenburg EJ, Wroe P, et al. Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: a prospective cohort study. Resuscitation. 2018;122:65-8. https://doi.org/10.1016/j.resuscita- tion2017.11.056.
  31. Hu K, Gupta N, et al. Variability in interpretation of cardiac standstill among physi- cian sonographers. Ann Emerg Med. 2018;71(2):193-8. https://doi.org/10.1016/j. annemergmed.2017.07.476.
  32. Schnittke N, Damewood S. Identifying and overcoming barriers to resident use of point-of-care ultrasound. West J Emerg Med. 2019;20(6):918-25. https://doi.org/ 10.5811/westjem.2019.8.43967.
  33. Sanders JL, Noble VE, et al. Access to and use of point-of-care ultrasound in the emer- gency department. West J Emerg Med. 2015;16(5):747-52. https://doi.org/10.5811/ westjem.2015.7.27216.
  34. Micks T, Sue K, et al. Barriers to point-of-care ultrasound use in rural emergency de- partments. CJEM. 2016;18(6):475-9. https://doi.org/10.1017/cem.2016.337.
  35. Herbst MK, Camargo Jr CA, et al. Use of point-of-care ultrasound in Connecticut emergency departments. J Emerg Med. 2015;48(2). https://doi.org/10.1016/j. jemermed.2014.09.017 191-196.e2.
  36. Leschyna M, Hatam E, et al. Current State of Point-of-care Ultrasound Usage in Cana- dian Emergency Departments. Cureus. 2019;11(3). https://doi.org/10.7759/cureus. 4246 e4246. Published 2019 Mar 13.
  37. Amini R, Wyman MT, et al. Use of emergency ultrasound in Arizona community emergency departments. J Ultrasound Med. 2017;36(5):913-21. https://doi.org/ 10.7863/ultra.16.05064.
  38. Leger P, Fleet R, et al. A majority of rural emergency departments in the province of Quebec use point-of-care ultrasound: a cross-sectional survey. BMC Emerg Med. 2015;15:36 Published 2015 Dec 11 https://doi.org/10.1186/s12873-015-0063-0.
  39. Boyd JS, LoPresti CM, et al. Current use and Training needs of point-of-care ultra- sound in emergency departments: a national survey of VA hospitals. Am J Emerg Med. 2019;37(9):1794-7. https://doi.org/10.1016/j.ajem.2019.02.043.
  40. Stein JC, River G, et al. A survey of bedside ultrasound use by emergency physicians in California. J Ultrasound Med. 2009;28(6):757-63. https://doi.org/10.7863/jum. 2009.28.6.757.
  41. Graglia S, Huang C, et al. Faculty opinions concerning ultrasound utilization in the emergency department. Am J Emerg Med. 2019;37(7):1372-4. https://doi.org/10. 1016/j.ajem.2018.12.021.
  42. McLaughlin RE, Lee A, et al. Survey of attitudes of Senior emergency physicians to- wards the introduction of emergency department ultrasound. Emerg Med J. 2005; 22(8):553-5. https://doi.org/10.1136/emj.2004.018713.
  43. Clattenburg EJ, Wroe PC, et al. Implementation of the cardiac arrest Sonographic as- sessment (CASA) protocol for patients with cardiac arrest is associated with shorter CPR pulse checks. Resuscitation. 2018;131:69-73. https://doi.org/10.1016/j.resusci- tation.2018.07.030.
  44. Rolston DM, Li T, et al. Mechanical, team-focused, video-reviewed cardiopulmonary resuscitation improves return of spontaneous circulation after emergency depart- ment implementation. J Am Heart Assoc. 2020;9(6):e014420. https://doi.org/10. 1161/JAHA.119.014420.
  45. Greenstein YY, Martin TJ, Rolnitzky L, Felner K, Kaufman B. Goal-directed transtho- racic echocardiography during advanced cardiac life support: a pilot study using simulation to assess ability. Simul Healthc. 2015;10(4):193-201. https://doi.org/ 10.1097/SIH.0000000000000088.

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