Name: workflow and framework for collecting and implementing point-of-care ultrasound data in the management of heart failure patients
Uploaded: 2024-07-12T14:45:00.000+00:00
Duration: 3 min 47 s
Description: Management and prevention of acute decompensated heart failure remain highly prevalent and challenging medical conditions. Incorporation of Point-of-Care ...

Cedars-Sinai Hospital Honest Enterprise Research Broker (HERB) Committee, Los Angeles, California, USA.

The Institutional Review Board approval from Cedars-Sinai Medical Center in Los Angeles, California, USA was obtained prior to the collection of patient data and evaluation. Written informed consent was waived because the use of POCUS in patient care is a standard and routine clinical examination practice for patients seen within the included cohort. It was offered in addition to standard clinical practice and did not alter the minimal standard of care. Each patient care encounter included a POCUS exam alongside conventional medical history, physical exam, and review of clinical data. POCUS was not used as a substitute for standard clinical practice or in place of indicated testing or imaging. Data were collected from a cohort of hospitalized heart failure patients at Cedars-Sinai Hospital from January 1, 2016, through December 31, 2021. Patients were included in the cohort if they had a primary admitting diagnosis of heart failure or if heart failure was among the top five diagnosis codes on admission (ICD-10 I50*). The analysis included discrete data fields within a commercially purchased electronic health record, such as IVC measurements, presence of pleural effusion, length of stay, survival, and 30-day readmission. The details of the equipment used for this study are listed in the Table of Materials.
Inclusion/exclusion criteria: 
Patients included in the care cohort were those identified as being cared for by the cardiology consultative service at Cedars-Sinai Hospital, where POCUS devices were utilized. The inclusion criteria specified the use of a protocol for IVC measurement with POCUS and the inclusion of data within the discrete IVC data field in the electronic health record. The care was provided by a team consisting of 6 cardiologists and 2 nurse practitioners. Patients who were unable to undergo imaging with POCUS or who were not imaged with POCUS were excluded from the clinical experience.
1. Patient and equipment preparation
<ol>
	<li>Position the patient appropriately to expose the area of interest.</li>
	<li>Ensure the ultrasound machine (see Table of Materials) is set up and calibrated correctly for the type of scan needed.</li>
	<li>Select the probe and adjust the settings. Choose the appropriate ultrasound probe (linear, curved, phased array) based on the depth and type of tissue being imaged.</li>
	<li>Adjust the frequency and depth settings on the ultrasound machine to optimize image resolution.</li>
</ol>
2. Image acquisition (for inferior vena cava)
<ol>
	<li>Position the patient in the supine position for optimal POCUS image acquisition.</li>
	<li>Apply a sufficient amount of ultrasound gel to the skin surface to ensure good acoustic coupling and reduce air between the probe and the skin.</li>
	<li>Use a phased array ultrasound probe (2-5 MHz) (see Table of Materials) to obtain inferior vena cava (IVC) measurements at the level caudal to the insertion of the hepatic vein. 
	NOTE: Ultrasound wave frequency varies depending on the depth setting on the ultrasound device.</li>
	<li>Capture the IVC image with measurements displayed, including the anatomy and beam depth gauge, on the image display screen.</li>
	<li>Record the IVC measurement into a prebuilt discrete data field within the electronic health record flowsheet (Supplementary File 1).</li>
	<li>Include the prebuilt IVC measurement data field flowsheet, designed for and embedded within the electronic health record, and screen-captured images in the patient progress note. 
	NOTE: This ensures visualization of each patient&#39;s anatomy and IVC measurement for more reproducible and consistent measurement location over time (Figure 2). Patient images uploaded directly into the electronic health record flow into the patient&#39;s medical record and are not stored on personal mobile devices.</li>
</ol>
3. Image acquisition (for pleural spaces)
<ol>
	<li>Position the patient upright or in the lateral decubitus posture, alternating between right and left sides serially.</li>
	<li>Utilize a 2-5 MHz phased array probe to scan for echo-free space inferior to the lung pleural border and superior to the ipsilateral diaphragm during scanning.</li>
	<li>Document yes for the presence of pleural effusion, identified by increased echo-free space in the ipsilateral pleural space, or no for the absence of pleural effusion.</li>
	<li>Enter the response into the corresponding cell in the electronic health record flowsheet (Figure 3).</li>
</ol>
4. Cleaning of the equipment and disposing of the gel
<ol>
	<li>After completing the scan, clean the ultrasound probe and accompanying display screen or associated device/machine.</li>
	<li>Dispose of used ultrasound gel appropriately and ensure the patient is comfortable post-procedure.</li>
</ol>
5. Follow-up procedures
<ol>
	<li>Identify actionable findings that influence clinical care decision-making on a patient-by-patient basis.</li>
	<li>Identify IVC images consistent with physiology associated with elevated or reduced central venous pressure (CVP).</li>
	<li>Modify medical therapy (diuretics, vasodilators, volume expanders) as indicated, aiming to optimize clinical physiology by adjusting CVP levels (either lowering or raising).</li>
</ol>

POCUS Protocol for IVC Assessment in Management of Heart Failure

<ol>
	<li>Diaz-Gomez, J., Mayo, P. H., Koenig, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Point-of-care+ultrasonography.">Point-of-care ultrasonography.</a> N Engl J Med. 385, 1593-1602 (2021).</li><li>Zieleskiewicz, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bedside+POCUS+during+ward+emergencies+is+associated+with+improved+diagnosis+and+outcome:+An+observational,+prospective,+controlled+study.">Bedside POCUS during ward emergencies is associated with improved diagnosis and outcome: An observational, prospective, controlled study.</a> Crit Care. 25 (1), 34 (2021).</li><li>Al Deeb, M., Barbic, S., Featherstone, R., Dankoff, J., Barbic, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Point-of-care+ultrasonography+of+the+diagnosis+of+acute+cardiogenic+pulmonary+edema+in+patients+presenting+with+acute+dyspnea:+A+systematic+review+and+meta-analysis.">Point-of-care ultrasonography of the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: A systematic review and meta-analysis.</a> Acad Emerg Med. 21 (8), 843-852 (2014).</li><li>Spevack, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Serial+lung+and+IVC+ultrasound+in+the+assessment+of+congestive+heart+failure.">Serial lung and IVC ultrasound in the assessment of congestive heart failure.</a> Crit Ultrasound J. 9 (1), 7 (2017).</li><li>Ciozda, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+efficacy+of+sonographic+measurement+of+inferior+vena+cava+diameter+as+an+estimate+of+central+venous+pressure.">The efficacy of sonographic measurement of inferior vena cava diameter as an estimate of central venous pressure.</a> Cardiovascular Ultrasound. 14 (1), 33 (2015).</li><li>Kedan, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Decreasing+hospital+utilization+of+a+high+risk+heart+failure+population+in+a+large+urban+Accountable+Care+Organization:+The+use+of+a+clinical+pharmacist,+serial+biomarkers,+and+Point+of+Care+Ultrasound.">Decreasing hospital utilization of a high risk heart failure population in a large urban Accountable Care Organization: The use of a clinical pharmacist, serial biomarkers, and Point of Care Ultrasound.</a> J Am Coll Cardiol. 67, 1298 (2016).</li><li>Kehl, D., Zimmer, R., Sudan, M., Kedan, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Handheld+ultrasound+as+a+novel+predictive+tool+in+atrial+fibrillation:+Prediction+of+outcomes+following+electrical+cardioversion.">Handheld ultrasound as a novel predictive tool in atrial fibrillation: Prediction of outcomes following electrical cardioversion.</a> JMIR Cardio. 2 (1), e7 (2018).</li><li>Miller, W. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fluid+volume+homeostasis+in+heart+failure:+A+tale+of+2+circulations.">Fluid volume homeostasis in heart failure: A tale of 2 circulations.</a> J Am Heart Assoc. 11 (18), e026668 (2022).</li><li>Porter, T. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+the+use+of+echocardiography+as+a+monitor+for+therapeutic+intervention+in+adults:+A+report+from+the+American+Society+of+Echocardiography.">Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: A report from the American Society of Echocardiography.</a> J Am Soc Echocardiogr. 28 (1), 40-56 (2015).</li><li>Katz, S. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=In+search+of+euvolemia+in+heart+failure.">In search of euvolemia in heart failure.</a> J Am Cardiol HF. 2 (3), 306-307 (2014).</li><li>Bhoil, R., Ahluwalia, A., Chopra, R., Surya, M., Bhoil, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Signs+and+lines+in+lung+ultrasound.">Signs and lines in lung ultrasound.</a> J Ultrason. 21 (86), e225-e233 (2021).</li><li>Hacialiogullari, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+point-of-care+lung+and+inferior+vena+cava+ultrasound+in+clinical+decisions+for+patients+presenting+to+the+emergency+department+with+symptoms+of+acute+decompensated+heart+failure.">Role of point-of-care lung and inferior vena cava ultrasound in clinical decisions for patients presenting to the emergency department with symptoms of acute decompensated heart failure.</a> J Ultrasound Med. 40 (4), 751-761 (2021).</li><li>Gil-Rodriguez, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+findings+of+lung+ultrasonography+in+COVID-19:+A+systematic+review.">Ultrasound findings of lung ultrasonography in COVID-19: A systematic review.</a> Eur J Radiol. 148, 110156 (2022).</li><li>Li, S. J., Lee, J., Hall, J., Sutherland, T. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+inferior+vena+cava:+Anatomical+variants+and+acquired+pathologies.">The inferior vena cava: Anatomical variants and acquired pathologies.</a> Insights into Imaging. 12 (1), 123 (2021).</li><li>Lam, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accelerated+remote+consultation+tele-POCUS+in+cardiopulmonary+assessment+(ARCTICA).">Accelerated remote consultation tele-POCUS in cardiopulmonary assessment (ARCTICA).</a> POCUS J. 5 (2), 55-58 (2020).</li></ol>

The authors have nothing to disclose.

A valuable contribution of this publication lies in presenting a scalable clinical workflow that incorporates bedside-acquired dynamic anatomical measurements (the IVC), which correlate with and respond to physiological changes. Changes in CVP are correlated with alterations in IVC measurements. These anatomical changes occur in response to treatment and often correlate with symptoms in patients diagnosed with heart failure5,7,8. Guidelines describing IVC diameter measurements and the corresponding right atrial pressure values in mmHg are outlined in a standards publication from the American Society of Echocardiography9.
Optimizing care for hospitalized heart failure patients is guided by treatment aimed at achieving euvolemia10. POCUS serves as a clinical tool providing a validated assessment of CVP, which dynamically changes with alterations in volume status5. The use of POCUS in clinical management of heart failure patients aims to assist in guiding optimal medical therapy, with the goal of directing patient care toward achieving and maintaining clinical euvolemia. Furthermore, longitudinal care of heart failure patients guided by POCUS can help keep patients closer to or within a narrower therapeutic window, aiming for long-term sustained euvolemia (Figure 4).
Creating workflows to standardize, personalize, and optimize the acquisition and use of POCUS as a clinical tool in managing CHF has broad and impactful implications for how patients receive care. The clinical team has developed a scalable workflow that can be implemented by various members of the clinical care team, including nurses, sonographers, clinical pharmacists, advanced practice providers, and physicians (Figure 5). This POCUS-guided protocol for managing heart failure offers practitioners using the standardized workflow opportunities for iterative improvement in POCUS acquisition skills, which can translate to an enhanced ability to acquire images of other anatomical regions. This streamlined and scalable workflow may serve as a pathway to broader utilization of POCUS in other clinical areas and foster the development of innovative applications in both acute and chronic disease management.
Lung POCUS is an emerging and, in some settings, a common method for assessing lung water and, by association, lung congestion. B-lines, also known as comet tails, are reverberation artifacts originating from the lung pleural interface11. In acute decompensated heart failure patients, B-lines may be observed in the emergency department12. Challenges associated with lung ultrasound include the necessity for multiple anatomical assessments on each patient (4-8 lung imaging windows per lung POCUS exam), the time required to acquire these multiple lung POCUS images, the subjectivity and variability of imaging influenced by clinician operators and patient positioning, and the difficulty in longitudinally comparing and assessing treatment responses. Furthermore, there is a lack of empirical physiological measurements correlating with the presence, absence, or density of lung B-lines. Additionally, while POCUS-identified B-lines are indicative of pulmonary congestion, they are not specific to this condition and can also be observed in COVID-19 pneumonia and various acute and chronic pulmonary infectious and inflammatory conditions13.
There are still limitations to the proposed workflow. Participants need to develop proficiency in POCUS imaging of the IVC and adhere to a standardized protocol for the location and timing of IVC measurements during the respiratory cycle. The clinical practice proposed aims to identify the maximal IVC diameter during end expiration, specifically caudal to the middle hepatic vein. However, a challenge lies in the variability of this anatomy among patients14. To address this variability, the workflow includes an image capture and measurement protocol that enables serial comparison of IVC measurements within each patient over time. This approach facilitates monitoring and may mitigate the impact of anatomical differences between individuals.
The expansion of a POCUS protocol in the management of heart failure patients beyond traditional healthcare settings holds promise for delivering more precise and personalized care. Implementing standardized POCUS workflows for heart failure management not only allows for more thorough patient evaluation but also benefits individuals who face barriers to accessing conventional healthcare settings. This includes patients residing in remote areas, those with limited mobility or transportation options, and individuals with constrained resources for healthcare services15. Moreover, integrating clinical tools like POCUS presents opportunities for closely monitoring symptomatic CHF patients in ambulatory settings, potentially reducing reliance on inpatient hospital resources. This model not only enhances patient care but also optimizes resource allocation in healthcare delivery.
Potential future research could involve a prospective observational cohort study to accurately assess the value of POCUS in managing heart failure patients. Such a study could involve matching a POCUS-directed heart failure management group with a standard care heart failure treatment group to evaluate outcomes comprehensively. Given the expanding use of POCUS in clinical settings, a prospective evaluation of its efficacy and impact is crucial.
Furthermore, addressing inter-user variability in the acquisition and interpretation of IVC diameter and collapsibility with POCUS is essential. Variability in both congenital and acquired anatomical features of the IVC can pose challenges in accurately assessing its borders and dimensions, as well as its collapsibility14. These challenges may complicate the standardized assessment and longitudinal measurement of the IVC in clinical practice. Research aimed at understanding and mitigating these challenges could enhance the reliability and utility of POCUS measurements as a standardized clinical tool in heart failure management.
As POCUS becomes increasingly integrated into the clinical care of heart failure patients, workflows and protocols for personalized application will evolve and expand. The study group's demonstration of collecting and utilizing large volumes of POCUS data in daily clinical practice shows promise for further expansion and refinement. Future research will be crucial for refining methods of acquiring POCUS data and optimizing its use in managing heart failure patients, particularly in achieving tighter control of volume status. Longitudinal management and assessing transitions of care-from hospitalization to ambulatory settings-carry significant implications at a population level. Understanding how POCUS data can support these processes will be essential for enhancing patient outcomes and optimizing healthcare resource utilization.

Point-of-care ultrasound (POCUS) is an emerging technology that can be used in day-to-day clinical settings. Although commercially available hand-carried ultrasound devices have been marketed for over 13 years, regular use outside of bedside procedures has been limited1. POCUS offers an intuitive application in the acute care setting for the diagnosis of specific disease states like cardiac arrest, congestive heart failure, identification of pneumothorax, assessment of pericardial effusion, and detection of free intra-abdominal fluid in trauma or surgery patients2. POCUS is well established as an evidence-based tool in assessing patients for the diagnosis of heart failure3. However, the implementation of POCUS using serial assessment in response to therapy is less well-established4.
POCUS-guided heart failure management includes the visual assessment of central venous pressure (CVP) and right atrial pressure by observing the diameter and collapsibility of the inferior vena cava (IVC). Additionally, POCUS can be used to observe the presence of pleural effusions and anatomical changes that correlate with physiological changes during treatment, including biventricular cardiac function, heart rate, contractility, mitral valve regurgitation, and acute changes in clinical status not self-evident with physical examination5.
In 2011, the clinical practice group began incorporating POCUS into the routine physical examination for all face-to-face inpatient and outpatient encounters (approximately 40,000). Anecdotal observations of anatomical changes visualized by POCUS often seemed to correspond with clinical events and biomarker measurements6 (Figure 1).
In the study institution, beginning in 2015, a discrete data field was built within the electronic health record to track the diameter and compressibility of the inferior vena cava (IVC). A binary data field was also created to document the presence or absence of pleural effusions identified with POCUS. In over seven years of patient care with the incorporation of POCUS in the clinical management of hospitalized heart failure patients, the acquisition and incorporation of POCUS data and IVC measurements have been recorded for more than 6,000 encounters. From an experiential perspective, the clinical practice group found the use of POCUS valuable in assisting with optimizing medical management and refining guideline-directed medical therapy, thereby personalizing the care of heart failure patients.
In this study, a POCUS exam was conducted using a phased-array hand-carried ultrasound device with a digital display screen. Images of the inferior vena cava (IVC) were obtained by scanning the patient through the subcostal acoustic window7 (Figure 2). The IVC images were acquired and measured on the digital display, specifically at a level caudal to the middle hepatic vein. Live images were paused, and a frame-by-frame image scroll on the device was utilized to identify and measure the maximal IVC diameter during the cardiac and respiratory cycle. The measurement was recorded in a data flowsheet within the patient&#39;s electronic medical record, and a screenshot of the measured image was uploaded into the patient chart to document the location and angle of measurement acquisition. Subsequently, the measurement flowsheet and uploaded image were added to the patient&#39;s progress note.

<table><tbody><tr><td>Aquasonic Ultrasound Gel 100</td><td>Parker</td><td>ECO #20-0299</td><td>The company and the catalog number is one example</td></tr><tr><td>Epic Electronic Health Record</td><td>Epic</td><td></td><td>The company and the catalog number is one example</td></tr><tr><td>GE Vscan Extend</td><td>General Electric</td><td>5721203-100 Rev.13</td><td>Broad-bandwidth linear array: 3.3-8.0 MHz</td></tr><tr><td>Haiku</td><td>Epic</td><td>10.3</td><td>The company and the catalog number is one example</td></tr></tbody></table>

workflow and framework for collecting and implementing point-of-care ultrasound data in the management of heart failure patients

Management and prevention of acute decompensated heart failure remain highly prevalent and challenging medical conditions. Incorporation of Point-of-Care Ultrasound (POCUS) as an adjunctive tool for assessing volume status and treatment response has shown significant promise. POCUS can be used for imaging internal anatomic structures serially and capturing these images for comparison and measurement over time. This protocol describes a scalable and standardized methodology for the serial assessment of the inferior vena cava (IVC). The methodology includes serial image collection, measurement, and presentation in the electronic medical record. A workflow for POCUS-acquired images of the IVC was created to capture the images and measure the diameter in a discrete data field for direct comparison over time and in response to clinical management. The protocol also includes the assessment of the presence or absence of pleural effusion as discrete data in the standardized workflow. By integrating POCUS into heart failure management, clinicians can improve patient outcomes through more precise and timely adjustments in treatment.

Through an iterative process over the course of months, a workflow for incorporating POCUS data, specifically IVC measurements, was formulated and standardized. It involves capturing a photographed image of the IVC and entering corresponding measurements into a chronological, discrete data field flowsheet (Supplementary File 1). The collection of patient data and its incorporation into a live clinical patient electronic health record demonstrates the development of a novel POCUS discrete data collection strategy. These data can augment clinical care and serve as a trackable clinical data field for both clinical and scientific purposes (Figure 3, Figure 4, and Figure 5).
The results illustrate a workflow for the clinical care team to measure POCUS-acquired IVC diameter dynamically and serially over time. These images can be longitudinally compared to prior and future measurements, potentially influencing clinical care decision-support.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/67040/67040fig01.jpg" /> 
Figure 1: Patient examples. Plotted Inferior Vena Cava (IVC) diameters in two different heart failure patients before and after treatment. The top panel illustrates the IVC flowsheet with decreasing numerical values, corresponding to decreasing B-type natriuretic peptide levels. Graphs depict IVC diameter (y-axis, in centimeters) over time (x-axis, in days). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67040/67040fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/67040/67040fig02.jpg" /> 
Figure 2: Representative example of inferior vena cava (IVC) workflow. (A) An image of the IVC is acquired using POCUS. (B) The maximal IVC diameter is measured (typically end-expiratory max measurement). (C) The image is uploaded to the patient chart using the electronic health record mobile application. (D) The measured IVC max diameter is entered into the IVC flowsheet. The image from the image selector tool and the corresponding flowsheet link are included in the electronic health record (refreshable data field) in the patient progress note. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67040/67040fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/67040/67040fig03.jpg" /> 
Figure 3: Representative example of pleural effusion and resolution with treatment in heart failure. Using POCUS to identify and assess treatment effects on pleural effusion in a hospitalized heart failure patient. (A) depicts Day 0 with a large pleural effusion. (B) depicts Day 5 with a small pleural effusion. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67040/67040fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/67040/67040fig04.jpg" /> 
Figure 4: Goal of maintaining euvolemia with ultrasound-guided management of heart failure. Utilizing point-of-care ultrasound (POCUS) to guide patient management and achieve precise euvolemia maintenance over time in heart failure patients. The x-axis represents time in days, and the y-axis represents volume status in cm H2O. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67040/67040fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/67040/67040fig05.jpg" /> 
Figure 5: Point-of-Care Ultrasound (POCUS) acquired in various settings. POCUS (Point-of-care ultrasound) can be acquired in diverse settings such as hospitals, outpatient clinics, homes, various remote locations, nursing facilities, and field environments. Acquisition of POCUS is performed by physicians, advanced practice providers, sonographers, nurses, clinical pharmacists, first responders, trained caregivers, and family members. Image interpretation can be conducted by those acquiring the images, remote third-party reviewers, and through automated digital assessment and artificial intelligence. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67040/67040fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
Supplementary File 1: Example of image capture of inferior vena cava (IVC) flowsheet embedded into the electronic health record. This data demonstrates the integration of an IVC flowsheet into the electronic health record, illustrating how it can be mapped to the patient chart and progress notes. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67040/Supplementary File 1.zip" target="_blank">Please click here to download this File.</a>

Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients

This protocol presents a scalable workflow for the use of point-of-care ultrasound in the management of hospitalized and outpatient heart failure patients.

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients

Management and prevention of acute decompensated heart failure remain highly prevalent and challenging medical conditions. Incorporation of Point-of-Care ...

workflow-framework-for-collecting-implementing-point-care-ultrasound

Nanyang Technological University

Research

JoVE Journal

Medicine

691 Views.  Smidt Heart Institute. This protocol presents a scalable workflow for the use of point-of-care ultrasound in the management of hospitalized and outpatient heart failure patients.

Video: Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients

In Silico Clinical Trials for Cardiovascular Disease

The SILICOFCM project mainly aims to develop a computational platform for in silico clinical trials of familial cardiomyopathies (FCMs). The unique characteristic of the platform is the integration of patient-specific biological, genetic, and clinical imaging data. The platform allows the testing and optimization of medical treatment to maximize positive therapeutic outcomes. Thus, adverse effects and drug interactions can be avoided, sudden cardiac death can be prevented, and the time between the commencement of drug treatment and the desired result can be shortened. This article presents a parametric model of the left ventricle automatically generated from patient-specific ultrasound images by applying an electromechanical model of the heart. Drug effects were prescribed through specific boundary conditions for inlet and outlet flow, ECG measurements, and calcium function for heart muscle properties. Genetic data from patients were incorporated through the material property of the ventricle wall. Apical view analysis involves segmenting the left ventricle using a previously trained U-net framework and calculating the bordering rectangle based on the length of the left ventricle in the diastolic and systolic cycle. M-mode view analysis includes bordering of the characteristic areas of the left ventricle in the M-mode view. After extracting the dimensions of the left ventricle, a finite elements mesh was generated based on mesh options, and a finite element analysis simulation was run with user-provided inlet and outlet velocities. Users can directly visualize on the platform various simulation results such as pressure-volume, pressure-strain, and myocardial work-time diagrams, as well as animations of different fields such as displacements, pressures, velocity, and shear stresses.

In Silico Clinical Trials for Cardiovascular Disease

This protocol demonstrates the workflow of the SILICOFCM platform for automatically generating a parametric model of the left ventricle from patient-specific ultrasound images by applying a multi-scale electromechanical model of the heart. This platform enables in silico clinical trials intended to reduce real clinical trials and maximize positive therapeutic outcomes.

The SILICOFCM project mainly aims to develop a computational platform for in silico clinical trials of familial cardiomyopathies (FCMs). The unique ...

Bioengineering

Hydra, a Computer-Based Platform for Aiding Clinicians in Cardiovascular Analysis and Diagnosis

Cardiovascular diseases (CVDs) are the leading cause of death throughout the world. The total risk of developing CVD is determined by the combined effect of different cardiovascular risk factors (e.g., diabetes, raised blood pressure, unhealthy diet, tobacco use, stress, etc.) that commonly coexist and act multiplicatively. Most CVDs can be prevented by an early identification of the highest risk factors and an appropriate treatment. The stratification of cardiovascular risk factors involves a wide range of parameters and tests that specialists use in their clinical practice. In addition to cardiovascular (CV) risk stratification, ambulatory blood pressure monitoring (ABPM) also provides relevant information for diagnostic and treatment purposes. This work presents a list of protocols based on the Hydra platform, a web-based system for clinical decision support which incorporates a set of functionalities and services that are required for complete cardiovascular analysis, risk assessment, early diagnosis, treatment and monitoring of patients over time. The program includes tools for inputting and managing comprehensive patient data, organized into different checkups to track the evolution over time. It also has a risk stratification tool to compute a CV risk factor based upon several risk stratification tables of reference. Additionally, the program includes a tool that incorporates ABPM analysis and allows the extraction of valuable information by monitoring blood pressure over a specific period of time. Finally, the reporting service summarizes the most relevant information in a set of reports that aid clinicians in their clinical decision-making process.

This article presents a protocol based on Hydra &#8212; a web-based system for clinical decision support that integrates a full and detailed set of functionalities and services required by physicians for complete cardiovascular analysis, risk assessment, early diagnosis, treatment, and monitoring over time.

Cardiovascular diseases (CVDs) are the leading cause of death throughout the world. The total risk of developing CVD is determined by the combined effect ...

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Longitudinal evaluations of critically ill patients by combinations of clinical examination, biochemical analysis and critical care ultrasonography (CCUS) may detect adverse events of interventions such as fluid overload at an early stage. The Simple Intensive Care Studies (SICS) is a research line that focuses on the prognostic and diagnostic value of combinations of clinical variables.
The SICS-I specifically focused on the use of clinical variables obtained within 24 h of acute admission for prediction of cardiac output (CO) and mortality. Its sequel, SICS-II, focuses on repeated evaluations during ICU admission. The first clinical examination by trained researchers is performed within 3 h after admission consisting of physical examination and educated guessing. The second clinical examination is performed within 24 h after admission and includes physical examination and educated guessing, biochemical analysis and CCUS assessments of heart, lungs, inferior vena cava (IVC) and kidney. This evaluation is repeated at days 3 and 5 after admission. CCUS images are validated by an independent expert, and all data is registered in an online secured database. Follow-up at 90 days includes registration of complications and survival status according to patient&#39;s medical charts and the municipal person registry. The primary focus of SICS-II is the association between venous congestion and organ dysfunction.
The purpose of publishing this protocol is to provide details on the structure and methods of this on-going prospective observational cohort study allowing answering multiple research questions. The design of the data collection of combined clinical examination and CCUS assessments in critically ill patients are explicated. The SICS-II is open for other centers to participate and is open for other research questions that can be answered with our data.

Structured protocols are necessary to provide answers on research questions in critically ill patients. The Simple Intensive Care Studies (SICS) provides an infrastructure for repeated measurements in critically ill patients including clinical examination, biochemical analysis and ultrasonography. SICS projects have specific focus but the structure is flexible to other investigations.

Longitudinal evaluations of critically ill patients by combinations of clinical examination, biochemical analysis and critical care ultrasonography (CCUS) ...

Protocol and Guidelines for Point-of-Care Lung Ultrasound in Diagnosing Neonatal Pulmonary Diseases Based on International Expert Consensus

Ultrasound is a safe bedside imaging tool that obviates the use of ionizing radiation diagnostic procedures. Due to its convenience, the lung ultrasound has received increasing attention from neonatal physicians. Nevertheless, clear reference standards and guideline limits are needed for accurate application of this diagnostic modality. This document aims to summarize expert opinions and to provide precise guidance to help facilitate the use of the lung ultrasound in the diagnosis of neonatal lung diseases.

Lung ultrasound is a noninvasive and valuable tool for bedside evaluation of neonatal lung diseases. However, a relative lack of reference standards, protocols and guidelines may limit its application. Here, we aim to develop a standardized neonatal lung ultrasound diagnostic protocol to be used in clinical decision-making.

Ultrasound is a safe bedside imaging tool that obviates the use of ionizing radiation diagnostic procedures. Due to its convenience, the lung ultrasound ...

Integration of Brain Tissue Saturation Monitoring in Cardiopulmonary Exercise Testing in Patients with Heart Failure

Cerebral hypo-oxygenation during rest or exercise negatively impacts the exercise capacity of patients with heart failure with reduced ejection fraction (HF). However, in clinical cardiopulmonary exercise testing (CPET), cerebral hemodynamics is not assessed. NIRS is used to measure cerebral tissue oxygen saturation (SctO2) in the frontal lobe. This method is reliable and valid and has been utilized in several studies. SctO2 is lower during both rest and peak exercise in patients with HF than in healthy controls (66.3 &#177; 13.3% and 63.4 &#177; 13.8% vs. 73.1 &#177; 2.8% and 72 &#177; 3.2%). SctO2 at rest is significantly linearly correlated with peak VO2 (r = 0.602), oxygen uptake efficiency slope (r = 0.501), and brain natriuretic peptide (r = -0.492), all of which are recognized prognostic and disease severity markers, indicating its potential prognostic value. SctO2 is determined mainly by end-tidal CO2 pressure, mean arterial pressure, and hemoglobin in the HF population. This article demonstrates a protocol that integrates SctO2 using NIRS into incremental CPET on a calibrated bicycle ergometer.

This protocol integrated near-infrared spectroscopy into conventional cardiopulmonary exercise testing to identify the involvement of the cerebral hemodynamic response in exercise intolerance in patients with heart failure.

Cerebral hypo-oxygenation during rest or exercise negatively impacts the exercise capacity of patients with heart failure with reduced ejection fraction ...

Troubleshooting FoCUS Image Acquisition: Patient Positioning, Transducer Manipulation, and Image Optimization

Focused cardiac ultrasound (FoCUS) is a limited, clinician-performed application of echocardiography to add real-time information to patient care. These bedside exams are problem oriented, rapidly and repeatedly performed, and largely qualitative in nature. Competency in FoCUS includes mastery of the stereotactic and psychomotor skills required for transducer manipulation and image acquisition. Competency also requires the ability to optimize the setup, troubleshoot image acquisition, and understand the sonographic limitations because of complex clinical environments and patient pathology. This article presents concepts for successful, high-quality two-dimensional (B-mode) image acquisition in FoCUS.
Concepts of high-quality image acquisition can be applied to all established sonographic windows of the FoCUS exam: the parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical four chamber (A4C), subcostal fourchamber (SC4C), and the inferior vena cava (IVC). The apical five-chamber (A5C) and subcostal short-axis (SCSA) views are mentioned, but are not discussed in-depth. A pragmatic figure illustrating the movements of the phased array transducer is also provided to serve as a cognitive aid during FoCUS image acquisition.

Here, we present a protocol to allow providers to perform focused cardiac ultrasound (FoCUS) in the clinical environment. We describe methods of transducer manipulation, review common pitfalls of transducer movements, and suggest tips to optimize phased array transducer use.

Focused cardiac ultrasound (FoCUS) is a limited, clinician-performed application of echocardiography to add real-time information to patient care. These ...

Point-of-Care Lung Ultrasound in Adults: Image Acquisition

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally prevents direct visualization of the lung parenchyma. When showing the lung parenchyma, ultrasound typically generates a number of non-anatomic artifacts. However, over the past several decades, these artifacts have been studied by diagnostic point-of-care ultrasound (POCUS) practitioners, who have identified findings that have value in narrowing the differential diagnoses of cardiopulmonary dysfunction. For instance, in patients presenting with dyspnea, lung POCUS is superior to chest radiography (CXR) for the diagnosis of pneumothorax, pulmonary edema, lung consolidations, and pleural effusions. Despite its known diagnostic value, the utilization of lung POCUS in clinical medicine remains variable, in part because training in this modality across hospitals remains inconsistent. To address this educational gap, this narrative review describes lung POCUS image acquisition in adults, including patient positioning, transducer selection, probe placement, acquisition sequence, and image optimization.

Point-of-care ultrasound (POCUS) of the lungs provides quick answers in rapidly changing clinical scenarios. We present an efficient and informative protocol for image acquisition for use in acute care settings.

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally ...

Ultrasound Protocol for Perioperative Frailty Assessment

Identifying Frailty Using Point-of-Care Ultrasonography: Image Acquisition and Assessment

Frailty is a significant predictor of a range of adverse outcomes in surgical patients, including increased mechanical ventilation time, longer hospital stays, unplanned readmissions, stroke, delirium, and death. However, accessible tools for screening in clinical settings are limited. Computed tomography of the psoas muscle is the current standard imaging device for measuring frailty, but it is expensive, time-consuming, and exposes the patient to ionizing radiation. Recently, the use of point-of-care ultrasound (POCUS) has emerged as a potential tool to determine the presence of frailty and has been shown to accurately predict frailty and postoperative outcomes. In this article, we will describe the image acquisition of the quadriceps muscles and explain how they can be used to determine frailty and predict postoperative adverse events. We will present information on probe selection, patient positioning, and troubleshooting. Images from a demonstration will be used to present the POCUS technique and example results. The article will culminate in a discussion of the use of these images in medical decision-making and potential limitations.

Author Spotlight: Assessing Surgical Frailty with Point-of-Care Ultrasound of Quadriceps Muscles

Here, we present a protocol to assess frailty in the perioperative setting using point-of-care ultrasound to measure quadriceps thickness. This method offers a practical, non-invasive alternative to traditional assessment methods, potentially enhancing perioperative care by quickly identifying frail patients.

Frailty is a significant predictor of a range of adverse outcomes in surgical patients, including increased mechanical ventilation time, longer hospital ...

Training Novices in POCUS for Vascular Cannulation Using Simulation Models

Using Simulation Models to Train Clinicians in the Use of Point-of-Care Ultrasound

The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide critical elements of visual and measurable information that proves to be useful in the context of vascular access cannulation, in combination with the practical skill of the clinician performing the cannulation. However, the use of POCUS in this context is to practically train and enable individuals who are novices in using this technique to become proficient in performing this task subsequently on patients in a careful and successful way. The simulation of these vascular conditions may be useful to help healthcare professionals learn, understand, apply, and establish such practical skills for vascular cannulation safely to achieve the desired outcomes. This project intended, through the attendance of a half-day workshop, to establish skills to use POCUS in connection with simulation models and perform specific tasks to enable clinicians to use this method in their clinical practice for vascular access cannulation in patients. A mixed-methods longitudinal study design was used to evaluate the effect of a point-of-care ultrasound workshop for peripheral intravenous cannula insertion, including specific tasks for the participants to be performed on simulation models. A total of 81 individuals participated in 11 half-day workshops through 2021 and 2022. Offering a workshop that uses simulation models in combination with various POCUS devices is useful in establishing this newly learned skill in clinicians, such as measurements of depth, caliper, and direction of a vein with POCUS prior to cannulation providing essential anatomical facts to the operator, which increases the likelihood of first-time success in cannulation.

Author Spotlight: Evaluating Clinicians' Adoption of Ultrasound-Guided Vascular Cannulation Through Simulation Training

The present protocol describes an ideal solution to train novices in the use of point-of-care ultrasound devices for the practical clinical skill of visually assessing distinct individual anatomical vascular conditions prior to and during an intended venous vascular cannulation using point-of-care ultrasound in a patient.

The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide ...

Point-of-Care Ultrasound for Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Without Left Ventricular Venting

Over the past several decades, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has become a critical tool in the management of patients with severe cardiogenic shock and cardiopulmonary failure. Due to the inherent instability of these patients, their transport away from intensive care units is fraught with risk. As a result, bedside diagnostic tools are essential for their daily care. One such tool is point-of-care ultrasound (POCUS) of the heart, which can non-invasively assess several parameters: left ventricular (LV) performance (size, systolic function, stroke volume, aortic valve opening), right ventricular (RV) performance (size, systolic function), and the presence of intracardiac thrombus. Additionally, POCUS can assist in evaluating readiness for V-A ECMO weaning and eventual decannulation. Despite its potential, the use of POCUS in the context of V-A ECMO remains inconsistent due to variability in provider training. This study aims to address this gap by detailing POCUS image acquisition in V-A ECMO, particularly in the absence of LV venting. It covers key aspects such as patient positioning, transducer selection, probe placement, acquisition sequence, and image optimization.

This protocol outlines the use of point-of-care ultrasound (POCUS) to monitor patients on peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) without left ventricular venting. It evaluates left ventricular distension, intracardiac or aortic root thrombus, and identifies useful cardiac POCUS parameters for weaning from V-A ECMO.

Over the past several decades, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has become a critical tool in the management of patients with ...

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients

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Chapters in this video

In Silico Clinical Trials for Cardiovascular Disease

Hydra, a Computer-Based Platform for Aiding Clinicians in Cardiovascular Analysis and Diagnosis

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Protocol and Guidelines for Point-of-Care Lung Ultrasound in Diagnosing Neonatal Pulmonary Diseases Based on International Expert Consensus

Integration of Brain Tissue Saturation Monitoring in Cardiopulmonary Exercise Testing in Patients with Heart Failure

Troubleshooting FoCUS Image Acquisition: Patient Positioning, Transducer Manipulation, and Image Optimization

Point-of-Care Lung Ultrasound in Adults: Image Acquisition

Identifying Frailty Using Point-of-Care Ultrasonography: Image Acquisition and Assessment

Using Simulation Models to Train Clinicians in the Use of Point-of-Care Ultrasound

Point-of-Care Ultrasound for Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Without Left Ventricular Venting