The ED is swamped with new affected person arrivals. Because of this, the 20-year-old who instructed the triage nurse he’s having issue respiration waits an hour earlier than his flip within the triage room. The emergency division technician palms me the ECG—sinus tachycardia—and takes the vitals.
Me: “What brings you to the emergency division as we speak?”
Him: “I really feel like I can’t breathe. It began swiftly at work.”
As I scroll via the chart, I see no related medical historical past. He seems to be anxious. No accent muscle use. No wheeze. Coronary heart fast and common.
ED technician: “Chest x-ray and again to the ready room, doc?”
Me: “Maintain only one minute.”
I seize the ultrasound and place the probe on the proper chest and see lung sliding. I place the probe on the left chest and see no sliding. Up a rib house, down a rib house: Anteriorly. Laterally. No lung sliding. Parasternal space: No fluid.
Me: “No ready room. This affected person goes again now. Concern for spontaneous pneumothorax.”
It’s an ideal storm of threat elements for antagonistic outcomes: Emergency departments (EDs) are busy. Physicians are navigating excessive volumes, crowded ready rooms, sick sufferers, and boarding. Sufferers are encountering extended ready room occasions, with alarming charges of leaving with out being seen. And the final word feared occasion for everybody, i.e., the affected person dying within the ready room, weighs closely.
Throughout the US, the ED supplier in triage (PIT) mannequin is a mitigating measure to distinguish the sickest sufferers, to deal with lengthy wait occasions, and to handle restricted bodily areas for analysis and remedy.
A nurse assesses the affected person with a number of targeted questions permitting the short sick vs. not sick willpower. The technician information important indicators and different criticism point-of-care assessments, similar to an ECG. With this info, an emergency severity index (ESI) from 1 to five—most to least emergent—is assigned. When the baton is handed to the doctor, they get hold of a quick historical past, evaluate the digital well being report (EHR), and carry out an abbreviated examination to drive decision-making for putting labs and ordering imaging.
As a human-centered design resolution, the doctor PIT mannequin is smart. Sufferers with time-sensitive or life-threatening situations will be recognized sooner. Nonetheless, one necessary diagnostic imaging device has not been built-in into the dialog: Ultrasound. Level-of-care ultrasound (POCUS) is properly established as protected, fast to carry out, and environment friendly for diagnostic affected person care. The time is now for PIT physicians to make use of POCUS for higher, safer care. Right here is why:
POCUS solutions a sure/no query and offers actionable info. EPs can synthesize chief complaints and important indicators to reply sure/no questions. Within the vignette above, no lung sliding on the left chest gave the EP rapid definitive knowledge resulting in a time-sensitive prognosis. This highlights the significance of historical past, abbreviated bodily examination, and point-of-care testing together with POCUS.
POCUS in triage helps threat stratify successfully. Not each affected person coming to the ED is acutely ailing. The ESI rating assists with threat willpower, and POCUS improves its accuracy. For instance, we evaluated a pregnant affected person with regular important indicators and decrease belly ache: ESI 3. Whereas in triage, the belly POCUS confirmed a reasonable quantity of free fluid pooling across the uterus and bladder. The urine being pregnant take a look at was optimistic, her important indicators grew to become unstable, and the ESI was reassigned a 2. She emergently went to resuscitation, OB/GYN session, and to the working room with a ruptured ectopic being pregnant.
POCUS in triage is identical workflow. A POCUS carried out in triage helps the PIT staff make the subsequent diagnostic, session, and disposition resolution. This isn’t “phantom scanning” or imaging with out archiving and writing a word. So, pictures are captured, saved, and out there for evaluate by way of the EHR. Thus, any consulting doctor can view the POCUS examination. It’s the identical workflow all through the ED.
POCUS is time environment friendly. Within the affected person from the vignette above, the POCUS examination took lower than 2 minutes. With sufficient adoption of POCUS triage protocols which are tailor-made to particular chief complaints, the general workflow modifications and time investments are minimal. The POCUS examination has the potential to enhance outcomes via much less downstream imaging, extra complete workups, and extra rapid diagnoses.
No new schooling or workflow is required. Emergency physicians who full an accredited emergency medication residency are extremely educated to carry out POCUS and combine interpretations into affected person care. Furthermore, AI options, together with picture acquisition steering and generative interpretation software program, will lower time on the bedside and enhance specificity for sophisticated diagnoses.
POCUS is in each space of the ED. Why not triage? A handheld unit or cart-based unit simply works within the triage house. If we’re prepared to take the time and steps to acquire an EKG in triage, then why are we not prepared to do the identical for POCUS? It occupies much less house and evaluates many components of the physique. POCUS is a mainstay to judge sufferers within the ED, important care, trauma, and resuscitation rooms. Why not in triage?
We notice that naysayers might imagine that POCUS in triage just isn’t definitely worth the effort. ED leaders might search the enterprise justification for POCUS in triage: This may very well be an article in itself. Though our perspective highlights safer and improved affected person care, we imagine the enterprise argument will be substantiated. POCUS is a codable, billable process. The present procedural terminology (CPT) codes for POCUS exist and produce income to EDs.
POCUS helps us make diagnoses on the time of affected person presentation within the triage space. The know-how and workflows enable the doctor PIT to determine acutely ailing sufferers shortly and effectively. We imagine sufferers will undergo worse outcomes—and preventable deaths might be missed—if practices don’t adapt.
The time is now for POCUS leaders to companion with ED operations, medical administrators, nursing workers, technicians, biomedical engineering, and hospital info know-how leaders to refresh the design of triage areas. The time is now for PIT evaluations to incorporate POCUS.
Resa E. Lewiss and Courtney M. Smalley are emergency physicians.
