Hello everyone and thank you for being here today. I'm going to be discussing barriers to point-of-care ultrasound in the ICU. My name is Mark Foster. I'm an emergency medicine critical care physician at UTHealth in San Antonio. I work in the emergency department, the surgery trauma ICU there, as well as our cardiothoracic and transplant ICU where we house our ECMO patients. And I also function as the fellowship director for the emergency clinical ultrasound fellowships. No disclosures. So I'm going to kind of tell a story today discussing adversity to point-of-care ultrasound in the ICU. Kind of discussing leaving fellowship and going to a new hospital and working in a unit as the only non-surgeon there. And then we'll talk about some review of literature on barriers to point-of-care ultrasound as well as discussing overcoming those barriers. So as I said, I left fellowship and I'm in a new unit in a new state and I have training in ultrasound. I have training in critical care and I show up and I want to use these two things but I get to a unit where they have a 15 year old ultrasound machine. It's not plugged in either. And so I, you know, say this is something that we can work on. Let's work together and and change that. And this is me saying, hey look, look what we can do. And now we've always done it this way. I have a thin patient. I can feel a pulse here. I don't need an ultrasound to put a line into that. And I said, okay, well about this time we were also heading the budget to buy a new machine. So we buy a new ultrasound machine. Nobody's really utilizing it. But I saw this as a chance to kind of lead by example. And so this is a long axis view of a needle going into a vessel. So I use ultrasound for all vascular access. A lot of the society guidelines recommend that for safety reasons. It is a true patient safety issue. And then I became the person, the go-to person. Hey, this this person we can get a line on or, you know, this is a difficult whatever. Let's ask the ultrasound guy. Here's a positive fast. This is a left upper quadrant. You see free fluid makes those nice sharp angles in there. We had a patient come up from the trauma bay. High-grade spleen injury. CT scan had no free fluid. They become unstable. I grabbed the ultrasound machine because why wouldn't you? You have an unstable patient. Wow, look at all this free fluid, which is going to be blood. And that patient, you know, went expeditiously to the operating room. So this is a nice example of a subdiphoid cardiac view. And you see those kind of bubbles floating through the right side of the heart. So if I put a central line in, I'll take some agitated saline, flush that and watch it and go into the right heart. So I know that it happens quickly so I can confirm my line. During COVID, it would take two hours or more to get an x-ray. You have three pressers running through someone's thumb and like we need a line. And so I started saying we don't need an x-ray right now to use this line. We can put it through here. And that kind of started to raise some eyebrows and but there were no complications associated with that. And then getting a little more complex, we had a soft tissue, so non-trauma patient there in the trauma ICU for necrotizing soft tissue infection. They had tamponade. They were peri-arrest. And I have an unstable patient. I grabbed the ultrasound machine and we drained a pericardial effusion to get ROSC on that patient. So at this point, starting to get a lot of interest. Here's Larry David saying, my interest is peaked. So we always did it this way as started to change. And now I have faculty saying, can you come up to the ICU to examine this patient with, you know, do a ultrasound assessment. All of our fellows are requesting education at this point. All the trainees are saying, what is this POCUS? I hear about it. Can we learn this? But there was definite barriers to that. So let's do a little literature review. Top barriers to point-of-care ultrasound. So this is in CHEST, a recent study. This was Neelam Soni, one of my colleagues in San Antonio. He's a VA hospitalist and helps cover the point-of-care ultrasound in the ICU. So he surveyed 130 centers. And the reason that they were not doing ultrasound in the ICU was lack of trained providers in point-of-care ultrasound. Also in 2023, this is a survey of low middle income countries trying to assess their barriers to ultrasound. 241 respondents, 62 countries. So low and middle income countries, there was lack of an ultrasound. So it's going to be hard to use it. But the number two barrier was lack of training. This is Neelam Soni again in the American Journal of Medicine. He's doing surveys of 105 primary care centers. What is their top barrier to ultrasound to point-of-care ultrasound? Lack of trained providers. And Ultrasound Journal 2020, again, survey 170 internal medicine participants responded. Their number one barrier to point-of-care ultrasound was lack of training. And this coincides, a few of us on this panel published that nice sub-xiphoid view of bubbles going through the heart on confirming your central lines using that. And the number one respondent, why people aren't doing that is they don't have training. So what is the solution here? It should be pretty obvious at this point. We need to train people in point-of-care ultrasound. So that is a obvious solution, but it's not easy. So what we did, I know, so I'll talk about that picture in a second. I'll just do it now. I was teaching a point-of-care course in San Antonio. They hired a professional photographer. They were taking all sorts of nice fancy pictures, and this is the one that they took. I was like, why would I not put this in a national lecture? So the solution is education, right? It's obvious. All of these studies say there's lack of education why we're not doing it. So at our institution, what I proposed to our ICU, my colleagues there, is let's do a very intimate ultrasound session. It's going to be just myself, one other ultrasound faculty, and we can ask all of the questions just open freely and go through kind of basic point-of-care ultrasound. And then we started doing a fellow boot camp, similar to what Ann was saying at shock trauma. And this is a, it was initially internal medicine, home critical care fellows only. I advocated for our surgery critical care fellows to do that as well as neuro critical care, anesthesia critical care. So true multidisciplinary group. Every year we do essentially ICU point-of-care training, and then there's point-of-care courses all over the country now. And some of these big critical care societies sponsor those. And there's tons of online education as well. So what I noticed after doing these education sessions, there was a noticeable difference. The machines plugged on, plugged in, turned on, clean, ready to go. The number of fast exams being done skyrocketed. Number of DPLs being done, right, plummeted. I was teaching the course this week and I said that same line of DPLs plummeted. They're like, what's a DPL? It's like, exactly. There's a need for them, but, and so it was an obvious transformation. Additional benefits to implementing point-of-care ultrasound in your units. I would say make it easy to make good decisions. So we created a workflow to make it easy. Meaning I can go into the electronic medical record. I can order a point-of-care study. I can then go to the machine that that order shows up there. I do my study, I hit end, and it saves automatically and through Wi-Fi sends it to our PACS. And then I go back to the EMR and write my procedure note, and it attaches those images to my procedure note, and then that gets sent to our billing department. And so now you're generating revenue off of this as well. So it's a, you know, patient's safety issue, it's an education issue, and now you're generating revenue, so billing. The last thing before I go through all the summary here, you know, the American College of Surgeons Committee on Trauma recommends that you have this workflow. Save images of your trauma patients with FAST exams. So that was another thing that we were able to implement at our center as well, because they were not saving images before. So again, the number one barrier to ultrasound is So again, the number one barrier to ultrasound is lack of training. So show utility to get buy-in from your colleagues, patient safety, education, billing, and then provide and encourage ultrasound education through courses, however you would like to do that. Thank you.

POCUS

ICU

training

patient care

workflow