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Background: People experiencing homelessness (PEH) suffer from 60-70% higher rates of cardiovascular disease than housed counterparts. Heart Failure is modifiable, if detected early and treated appropriately. Point-of-care ultrasound (POCUS) offers an accessible tool for early HF detection in street medicine settings like UCLA Mobile Clinic Project (MCP), a student-run, street-side clinic supporting PEH in Hollywood. To our knowledge, there are no published reports using POCUS as a screening tool for HF in PEH. 

Objective: To assess physician readiness for and feasibility of implementing POCUS for Heart Failure screenings at a student-run street clinic.

Design: This study utilized a multi-phase implementation design for heart failure screenings utilizing POCUS among unhoused patients seeking care at MCP. In the training phase, providers (n=5) were surveyed on baseline POCUS competency and underwent standardized POCUS training, including asynchronous curricula and didactics. In the development phase, a retrospective chart review of 600 MCP patients informed the creation of a 3-tiered heart failure screening tool to assist physicians in identifying patients for POCUS. 6 focus groups were conducted to design robust referral and clinic protocols, education materials, and patient chart documentation. During the implementation phase, patients are systematically screened utilizing the symptom and risk factor tool. Those meeting criteria undergo pulmonary (B-lines) and internal jugular vein (IJV) ultrasound scans. Tailored referrals are made to ED or primary care clinics based on findings and barriers such as insurance status, assigned primary care provider (PCP), transportation, medical mistrust, etc. Evaluation includes iterative protocol refinement through routine feedback focus groups, post-training physician surveys, and prospective patient data collection. 

Impact: Pre-training surveys of POCUS competency showed physicians had low baseline confidence across POCUS skills (2.80 / 5 Likert scale), with comfort level averaging 1.8/10-point scale. Following standardized training, physician scores improved across all competency domains, with the largest confidence gains in IJV interpretation (2.80→ 4.75). By the second pilot month, 10 patients were identified for HF POCUS screening; however, only four patient scans have been completed with various client and clinic barriers limiting exam completion. Two of the four patient scans demonstrate evidence of pulmonary edema and volume overload. Patients were referred to primary care, barriers were identified and mitigated. Feedback focus groups guided screening and protocol modifications. Physicians identified trainee-to-faculty ratio as a critical limitation to increasing scanning capacity. Key obstacles faced in the early integration included patient volume and visit length; an operation modification was developed– at risk patient scans limited by time were given “return to clinic” cards for priority scanning at the start of subsequent clinics. Preliminary patient impact data is forthcoming and will guide ongoing analysis.

Summary/Lessons Learned: This first-of-its-kind program implementation highlights the possibility of decreasing HF morbidity and mortality amongst unsheltered patients with novel screening technology in a street-side clinic with 26 years of community rapport. A suspected etiology for the lack of adoption of POCUS within street medicine is the need for targeted physician training. Our study revealed multifactorial challenges: patient privacy, scanning criteria ambiguity, time limitations, care navigation barriers. Next steps encompass analysis of exam interference factors, changes in clinical management pre/post POCUS. Findings could inform other low-barrier street care delivery models that improve inequities in HF detection, diagnosis, & subsequent initiation of treatment.