Back to the Bedside: Internal Medicine Bedside Ultrasound Program

BACK TO THE BEDSIDEThe Internal Medicine Bedside UltraSound Program

!!!

IMBUS#David Tierney, MD FACP

Abbott Northwestern Hospital - Dept.Director - IMBUS Program

Assoc.

POINT OF CARE ULTRASOUND: POCUS

Clinician: Focused Question in Focused Timing/Situation

POCUS

Clinician: Obtain images to answer that question

POCUS

Clinician: Interpretation of Adequate Image

POCUS

Clinician: Integration of interpretation into the rest of the clinical picture IN REAL TIME

POCUS

Clinician: Come back and check again after a treatment/intervention

• A few cases

• Why did we start it?

• What does it take?• Training & Resources

• What do we get out of it• AKA “Why are we still doing it”

• What don’t we know yet?

BACK TO THE BEDSIDE

• CASE #1: 78 yo female

•ANGMA at Center for Outpatient Care

•“I have a sinus infection and need some antibiotics”

1

2

3

BACK TO THE BEDSIDE


•ANGMA resident clinic

•New patient establishing care post cholecystectomy

•Doing well, but some sob increasing since prior to surgery, getting much worse now. Legs a little swollen.

•Pulse 110, BP 92/70

ANGMA Resident Clinic

BACK TO THE BEDSIDE


•ANGMA resident clinic

•bit by a bug while camping last week, got Augmentin without improvement in cellulitis

BACK TO THE BEDSIDE

• CASE #4: 82 yo male

• In hospital with acute on chronic renal insufficiency. Minimal urine output and abdominal pain. Foley draining some urine but tapering off last 48hrs. Bladder scanner = 60cc

BACK TO THE BEDSIDE• CASE #5: 59 yo male, establishing care at ANGMA COC clinic

•no medical problems

•“sick as a dog” for 3mo

•fevers off/on, sweats, exhausted

•multiple urgent care and allergist visits

•extensive lab w/u, trials empiric abx

•allergist concerned for possible lymphoma

•BP 92/50, pluse 80, temp 99.4F

•systolic murmur throughout

BACK TO THE BEDSIDE


•HD# 16: Sepsis, ARDS, On/Off Ventilator

•2:15AM in ICU:

•Acute Hypotension, hypoxia

BACK TO THE BEDSIDE


•HD# 16: Sepsis, ARDS, On/Off Ventilator

•2:15AM in ICU:

•Acute Hypotension, hypoxia

• PEA Arrest

Hypovolemia Hypoxia

Hydrogen ion (acidosis) Hypoglycemia Hypo/Hyperkalemia Hypothermia Tension Ptx Tamponade Toxins

Thrombosis

PEA

ObstructionVolume Pump

Ptx Tamponade PE

BACK TO THE BEDSIDE30”

30”

15”

BACK TO THE BEDSIDE

• Case #s 7-182: Short of Breath Patient

“B-LINES”

PNEUMONIA

• A few cases





WHY DID IT START HERE?one of the national leaders in IM POCUS

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IMBUS#

WHY HERE, WHY NOW?

• Procedural Safety & Standard of Care

• Medical Students, Residents, Fellows

• Global Health & Limited Resource Locations

• Patient Communication, Understanding & Satisfaction

• Better Patient Care

Central lines Less complica,ons OR 0.43 (0.22-‐0.87) Less failed inser,ons OR 0.14 (0.06-‐0.33) AHRQ 1 of 12 most highly rated pa,ent safety prac,ces to reduce medical errors

Thoracentesis Ptx: 4% vs. 9% (OR 0.3 [0.2-‐0.7]) Training ins,tu,on ptx rates

(10% vs. 5%) & (18% vs. 3%) 10% underlying solid organ with clinically selected site Easily obtained ultrasound skill by house staff and intensivists 1hr training session

Paracentesis Success rate 95% vs. 65% (P = .0003)

Emerg Med Residents & Staff <1% bleed or bowel perf complica,on rate with blind & ultrasound

Lumbar Puncture Successful LP: OR 1.32 US vs. Tradi,onal landmark Iden,fica,on of landmarks in obese pts. BMI>30 = 75%

BMI >30: OR 2.3 US vs. Tradi,onal landmark

Hind, et al. BMJ. 2003; 327(7411): 361-‐368. Agency for Healthcare Research and Quality. (AHRQ publica,on no. 01-‐E058.)

Gordon, et al. Arch Intern Med. 2010; 170 (4): 332-‐339. Daniels, C, Ryu, J. Current Opinion in Pulmonary Medicine 2011, 17:000–000.

Diacon AH, et al. Chest 2003; 123:436–441. Mayo, et al. Chest 2004;125;1059-‐1062.

Nazeer Am J Emer Med 2005; 23(3):363 -‐367. McGibbon. Dig Dis Sci 2007; 52:3307–3315.

Wong, et al. JAMA. 2008; 299(10):1166-‐1178. Nomura J, et al. J Ultrasound Med 2007;26;1341-‐8.

It is easily learned, evidence-‐based, and “best prac<ce”


• Medical Students, Residents, Fellows….A.K.A “the future”



• Better Patient Care

WHY HERE, WHY NOW?

MEDICAL SCHOOL PUSH





• Improved Diagnostic Ability as Internists

WHY HERE, WHY NOW?

The Physician-Patient RelationshipIMBUS#





• Improved Diagnostic Ability as Internists = Better, more efficient patient care

WHY HERE, WHY NOW?

Physical Finding ExamSens% (LR-) Spec% (LR+)

AAA 22-68 (0.6) 75-99 (7.6)Ascites Flank Dullness 80-94 (0.3) 29-69 (NS) Shifting Dullness 60-87 (0.4) 56-90 (2.3) Fluid Wave 50-80 (0.5) 82-92 (5.0)Splenomegaly 18-69 (0.6) 89-99 (9.6)Hepatomegaly 50-71 (0.5) 56-77 (1.7)Hypovolemia Dry Axilla 50 (NS) 82 (2.8) Dry MM 85 (0.3) 58 (NS)Volume overload 3rd Heart Sound 13 (0.8) 99 (11) JVD 39 (0.6) 92 (5.1) Abd Jugular Reflux

24 (0.8) 96 (6.4) (*CT Scan as Gold Standard) Lichtenstein. Anesthesiology 2004; 100:9 –15

• A few cases


• What does it take?

• Training & Resources



THE NUTS & BOLTS!!!

IMBUS#

IMBUS SPECTRUM OF CARE

Basics of Ultrasound Physics, Ar,facts, Bio effects Portable ultrasound machine mechanics and knobology Bedside ultrasound mechanics in a pa,ent room Pa,ent discussion & consent Draping of male/female pa,ents Image annota,on Integra,ve approach to clinical decision making at the bedside

Pulmonary Ultrasound Pleural ultrasound – A-‐Lines, lung sliding, Pneumothorax, pleural effusion Inters,,al syndromes – B-‐Lines Alveolar syndromes – consolida,on, atelectasis

Cardiovascular Ultrasound Windows: Parasternal long/short Axis, Apical 4/5, LA & 2 chamber, Subxyphoid 4-‐chamber and short axis

Pericardial assessment Assessment of LV and RV func,on Semi-‐quan,ta,ve assessment of clinically significant valvular dysfunc,on Assessment of diastology & dysfunc,on* Qualita,ve assessment of chamber size and overload Semi-‐quan,ta,ve assessment of volume status and fluid responsiveness -‐ E/e’, Cardiac Output, Passive Leg Raise, etc.

Assessment of aorta for aneurysm * Vascular 2-‐point DVT screening *

Abdominal Ultrasound Urinary

Renal evalua,on for hydronephrosis Kidney findings in chronic kidney disease Bladder assessment

Hepatobiliary Assessment for hepatomegaly Findings in cirrhosis Assessment of the gallbladder and CBD *

Assessment for splenomegaly Peritoneal free fluid evalua,on Bowel

Assessment for ileus and small bowel obstruc,on Assessment of inflammatory bowel states *

SoC Tissue Ultrasound Lymphadenopathy * Celluli,s and Abscess

HEENT Ultrasound Thyroid ultrasound * Ocular ultrasound * Sinus ultrasound ICP assessment with op,c nerve sheath * Real-‐,me intuba,on guidance and confirma,on

Musculoskeletal Ultrasound Assessment of the symptoma,c joint, bursa, tendon/ligament *

Procedural Ultrasound Central and peripheral venous and arterial line placement Thoracentesis Lumbar puncture Paracentesis Abscess I&D Endotracheal tube placement verifica,on Central venous line placement verifica,on Joint, sos ,ssue, and bursa injec,ons

IMBUS TRAINING

1 12 13 16 16 12 11 10

Core Faculty

Resident G1/2s

Resident G1/3s Staff Physicians Hospitalists

ClinicIntensivists

ED

2011 2012 2012 20132006

Resident G1s and staff

2013 2014

Resident G1s Intensivists

Telecardiology NPs

2014

2

1

2013

Outpatient IM Staff

CLINICAL WORKFLOW

!!!

IMBUS#

ANW Center for Outpatient Care

ANGMA Resident Clinic

Pulmonary Cardiac & Fluid Abdominal MSKL Soft Tissue HEENT Vasc

!!!

IMBUS#

TimeCompensation Models

Politics & Turf

All vs. Core Group

Bottom Up

Trainer Bottleneck

!!!

IMBUS#

Personal Skill & Motivation

Machines

• A few cases



• What do we get out of it

• AKA “Why are we still doing it”


TEACHING PHYSICAL EXAM

!!!

IMBUS#

S1

LA

LV

Ao

S1 S2 S1Systole

A2,P2M1,T1 M1,T1

Diastole

S2

PATIENT SATISFACTION & UNDERSTANDING

BIG IMPACTS

LITTLE IMPACTS

change management confirm management avoid additional resources

!!!

IMBUS#

BETTER INTERNISTS & SUBSPECIALISTS

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IMBUS#

RECRUITING & CAREERS

• A few cases





Advanced Cardiac:

EF, Diastology, Cardiac arrest

IMBUS RESEARCH

Outpatient IMInpatient IM

ICU US Integrated IM Physical Exam

Fluid Responsiveness

Anti-Hypertensive

Mgmt

Central Line Position

Sinusitis

Acute Resp

Faiure

Systems

!!!

IMBUS#

Education & Competency

Remote Training

Certification

Advanced Cardiac:


IMBUS RESEARCH

Inpatient IM

ICU


Anti-Hypertensive

Mgmt


Sinusitis

Acute Resp

Faiure

Systems

!!!

IMBUS#


Remote Training

CertificationOutpatient IM

US Integrated IM Physical Exam

HYBRID PRIMARY CARE PHYSICAL EXAM

ANW Center for Outpatient CareANGMA Resident Clinic

Advanced Cardiac:


IMBUS RESEARCH




Anti-Hypertensive

Mgmt


Sinusitis

Acute Resp

Faiure

Systems

!!!

IMBUS#


Remote Training

Certification

Advanced Cardiac:


IMBUS RESEARCH

Outpatient IM

US Integrated IM Physical Exam


Anti-Hypertensive

Mgmt


Sinusitis

Acute Resp

Faiure

!!!

IMBUS#


Remote Training

Certification

ICU

Inpatient IMSystems

Terry Rosborough, MD FACP!David Tierney, MD FACP!

!Department of Medical Education!Abbott Northwestern Hospital!

!

The IMBUS-PCI Study:!Internal Medicine Bedside UltraSound !

Patient Care Improvement Study!

To#be#Top#10%…#

Cost#Reduc2on#

Length#of#stay#&#ICU#days#

Diagnos2c#Efficiency#

Reduc2on#in#costly#imaging#

Reduc2on#in#unnecessary#

medica2on#use#

Pa2ent#Care#

Safety#

Time#to#Dx/Tx#

Length#of#stay#

Less#Radia2on#(XJray/CT#Scan)#

Pa2ent#Experience#

Physician#Communica2on#

Pt.#Understanding#

Pt/Physician#Rela2onship#

Leader#

Recruit#

Top#Decile#

To#be#Top#10%…#

Cost#Reduc2on#





medica2on#use#

Pa2ent#Care#

Safety#

Time#to#Dx/Tx#

Length#of#stay#


Pa2ent#Experience#


Pt.#Understanding#


Leader#

Recruit#

Top#Decile#

To#be#Top#10%…#

Cost#Reduc2on#





medica2on#use#

Pa2ent#Care#

Safety#

Time#to#Dx/Tx#

Length#of#stay#


Pa2ent#Experience#


Pt.#Understanding#


Leader#

Recruit#

Top#Decile#

13,000 Patients

Advanced Cardiac:


IMBUS RESEARCH




Anti-Hypertensive

Mgmt


Sinusitis

Acute Resp

Faiure

Systems

!!!

IMBUS#


Remote Training

Certification

EDUCATION & COMPETENCY

Advanced Cardiac:


IMBUS RESEARCH




Anti-Hypertensive

Mgmt


Sinusitis

Acute Resp

Faiure

Systems

!!!

IMBUS#


Remote Training

Certification

As internists, we orchestrate some of medicine’s most complex hunts.

The tools we search with are one half of the equation.

The ability to recognize & integrate what we find is the other half.

However, neither gets us anywhere without a patient relationship.

!!!

IMBUS#

Thank you

David Tierney, MD FACPAbbott Northwestern Hospital - Dept of Med Ed

Director - IMBUS ProgramAssoc. Prog. Dir. - IM Residency Program

Email: [email protected]

!!!

IMBUS#

mailto:[email protected]

Back to the Bedside: Internal Medicine Bedside Ultrasound Program

Health & Medicine

Transcript of Back to the Bedside: Internal Medicine Bedside Ultrasound Program