Lung Ultrasound Prior to Discharge in Heart Failure Patients:: Assessing Internal Medicine Residents’ Attitudes on Barriers, Facilitators, Utility, and Comfort with POCUS as a Clinical Tool

From the 2023 HVPA National Conference

Alex Fultz MD (LUMC/Edward Hines Jr VA Hospital), Meghan O’Halloran MD

Intro: 
Heart Failure is a common reason for hospital admission and contributes greatly to health care costs. Accurate clinical assessment can be difficult in this population, however, it is key to determining readiness for discharge. Emerging data has demonstrated the utility of point of care lung ultrasound in the diagnosis of acute heart failure exacerbation and evaluation of heart failure patient’s prior to discharge correlating with improved readmission rates and mortality. Despite this data, few attending level providers or residents take advantage of this clinical assessment tool. Our study aimed to determine the major barriers and facilitators to diagnostic point of care ultrasound among internal medicine residents and improve the knowledge, understanding, and application of dedicated lung ultrasound in heart failure patients through monthly teaching sessions and protocolized assessment of inpatients.

Methodology:
General medicine residents rotating on the Inpatient Medicine Service at Edward Hines Jr VA Hospital from December to April participated in a survey about diagnostic point of care ultrasound assessing perceived barriers, facilitators, experience, and clinical utility. The residents were then provided with a one-time educational session that highlighted the data associated with the use of dedicated lung US prior to discharge in heart failure patients and outlined the inpatient protocol for evaluation of inpatients. Residents were then tasked with completing a dedicated 8-point lung US and IVC assessment in the 1-3 days prior to discharge of patients admitted to their respective general medicine teams for acute exacerbation of heart failure. After completion of the US assessment, residents completed a post-protocol survey to assess confidence, utility, and likelihood of incorporation of POCUS into their respective clinical practice. In addition to the above, pre-intervention survey data was expanded upon through the use of focus groups of residents adding to the qualitative data collection to help generate additional context with regards to cited barriers and facilitators of POCUS use.

Results:
During the 4-month study period, the most common barriers were found to be Pre: Time(31%), Competency(27%), and Access (16%) and Residency wide: Time 28%, Lack of Attending Bedside Teaching 21%, and Access to US 19% respectively. The Residency wide survey further demonstrated that the barrier of time was most associated with time limitations of pre-rounding tasks (38%) and clinical workflow that limits US performance after initial patient evaluation 23%. Finally, the survey found that the 3 biggest proposed facilitators of increased POCUS use were Pre: Near Peer Mentorship (32% ), Hands-on practice/US simulation (30%), and Attending Mentorship (23%) and Residency wide survey: Hands-on practice/US simulation (31%), Attending Bedside US Teaching (29%), and Near Peer Bedside US teaching (24%). The survey demonstrated residents felt Attending/Near Peer Bedside US teachingwould improve exam accuracy/competency 31%, Prompt use 24%, and Facilitate dedicated time 23%.

Conclusions:
The survey demonstrated some key points: residents want to learn and use POCUS, time limitations are a barrier to use of POCUS, the majority of residents fall below the number of exams correlated with proficiency in a given exam, and Attending/Near Peer teaching would facilitate US use and education through multiple mechanisms. By leveraging the knowledge gained about barriers, facilitators, and resident interest in both learning and utilizing POCUS in the clinical setting, it would be possible to design future  interventions for increased use and improved education of POCUS with the goal of generating improved patient outcomes.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog