Josiah Brown Poster Abstract

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Jonathan J. Morales
Alan Chiem, MD, MPH
Zach Achen, Elitz Alegria-Leal, Cyrus Nguyen, Carlos Basaure, MD, & Manpreet Singh, MD, MBE
Feasibility of Training Emergency Medicine Residents To Perform An Acute Heart Failure Ultrasound Protocol
STTP

Background: Acute Heart Failure affects greater than 5 million Americans with over 550,000 new patients diagnosed every year. The overall annual cost of AHF is over $33 billion, with an estimated $20 billion spent on HF hospitalizations. There are over 1 million hospitalizations per year and it is the number one Medicare discharge diagnosis that leads to re-admission within 60 days.[1-2] Studies have identified risk factors for increased mortality, the presence of phenotypes of AHF, and the efficacy of acute treatment and secondary prevention.[3]  In particular, there is a disconnect between the estimated 50% of patients that are identified from large heart failure registries like ADHERE as potentially dischargeable from the ED, and the current practice of admitting over 90% of acute heart failure patients.Studying AHF phenotype and severity in the ED allows for tailored treatment to the patient’s immediate physiologic derangements, and reassessment allows for identification of patients that improve and can be discharged from the ED.  The use of quantitative Doppler—in addition to focused assessment of systolic function, pulmonary edema, and systemic congestion—in this acute heart failure ultrasound protocol allows for rapid identification of the severity of acute heart failure as well as immediate response to treatment that potentially can facilitate disposition of the patient. Specifically, the use of E/e’ has been well validated in both acute and outpatient clinically settings. Objective: We propose that training emergency medicine residents in this acute heart failure ultrasound protocol is feasible. After training, EM residents will be able to perform this protocol as well as identify the various AHF phenotypes based on findings from the AHF US protocol. The proposed outcome is to demonstrate 80% success in image acquisition and correct interpretation after training.This study was approved by the Olive View-UCLA Institutional Review Board. Methods: We developed a training video explaining acute heart failure phenotypes, diastolic dysfunction severity, and how to obtain the following on ultrasound: parasternal long axis view for the assessment of systolic function; apical four chamber view for assessing diastolic function using pulse wave doppler and tissue doppler imaging; pulmonary ultrasound for assessing the presence of pulmonary edema; and IVC ultrasound for the assessment of systemic congestion.We developed a pre- & post-assessment skills checklist, pre-test & post-test quizzes for knowledge assessment, and a four-hour, hands-on training session.We recruited Emergency Medicine residents from both the combined UCLA-Olive View and the Harbor-UCLA programs. Currently, we have enrolled 28 of the total 100 emergency medicine residents from Olive View-UCLA Medical Center and Harbor-UCLA Medical Center. We have completed training and post-test assessment on 14 of these subjects. We will assess the average improvement in scores on the knowledge and skills assessment after training. We will calculate a Cohen’s D statistic to assess the effect size of our intervention. Results: Comparison of the pre-intervention assessment and the post-intervention assessment demonstrated improvement in residents learning the techniques to be used for the protocol. Post-test quiz results (score = 11.67) demonstrate an increase in the average score  when compared to the pre-test quiz (score = 10.44). Conclusion: Kirkpatrick Model of Teaching was used as the basis for this study. We successfully developed an educational module incorporating both online video podcast and skills training. Results suggest that EM residents are capable of learning these techniques and could utilize this protocol to assess for AHF and its phenotypes. Future studies should compare the application of this protocol by residents to assess for AHF and the standard method for AHF diagnosis.

Sources

  1. Gheorghiade M, Zannad F, Sopko G, et al. Acute Heart Failure Syndromes: Current State and Framework for Future Research. Circulation. 2005; 112:3958-3968.
  2. Peacock WF, Braunwald E, Abraham W, et al. National Heart, Lung, and Blood Institute Working Group on Emergency Department Management of Acute Heart Failure. JACC. 2010;56(5):343-351.
  3. Pang PS, Cleland JGF, Teerlink JR, et al. A proposal to standardize dyspnoea measurement in clinical trials of acute heart failure syndromes: the need for a uniform approach. Eur Heart J. 2008; 29:816-824.

 

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