Original contribution
Goal-directed abdominal ultrasonography: impact on real-time decision making in the Emergency Department

Poster Presentation at SAEM Western Regional Research Forum, Newport Beach, California, May 2001.
https://doi.org/10.1016/S0736-4679(03)00032-5Get rights and content

Abstract

The impact of “goal-directed” abdominal ultrasound (US) on real-time decision making in the Emergency Department (ED) was studied, with specific emphasis on the certainty of diagnosis, treatment, and disposition plans. A prospective, interventional study enrolled 212 patients at a county teaching hospital ED, who underwent bedside US by experienced ED sonographers. A study questionnaire was completed documenting the US indication, working diagnosis, treatment, and disposition plan. The physicians assigned pre-test and post-test levels of certainty for the diagnosis, treatment plan, and disposition on an integral scale from 1 to 10. Scores for diagnosis were further categorized into low (1–3), moderate (4–7) and high certainty of disease. Absolute mean changes in level of certainty for diagnosis, treatment, and disposition were 3.2 (95% CI 3.1–3.3), 2.0 (95% CI 1.9–2.1), and 1.9 (95% CI 1.8–2.0), respectively. The direction of change after US for certainty of diagnosis was evenly split, with 47% increasing and 47% decreasing. The majority of patients categorized as either high or low certainty of disease had US results concordant with the physician’s initial assessment. However, 16% moved from either high to low or from low to high certainty categories after US. Patients with moderate certainty moved evenly to either the low or high post-test category in 97% of cases. Treatment and disposition decisions were less impacted by US, with the majority of cases increasing in certainty irrespective of the US results. Bedside ultrasonography in the ED has an important impact on real-time decision-making, particularly in terms of the certainty of diagnosis.

Introduction

An essential component in the success of ultrasonography (US) in the Emergency Department (ED) has been its portability and easy integration into the clinical process. The term “goal-directed” ultrasonography describes the manner in which images are obtained at the bedside and then incorporated real-time into an overall clinical assessment of the patient. This has led some to describe US as the stethoscope of the new millennium; a more clinical tool than pure imaging modality. With most studies focusing on either feasibility or diagnostic accuracy, it remains unclear to what extent ED US may influence key clinical elements of the decision-making process such as diagnostic certainty, treatment, and disposition 1, 2, 3, 4, 5, 6, 7. The ultimate value of any diagnostic test must be judged in part by its impact on physician behavior and management decisions. Information on the accuracy and sensitivity of ED ultrasound, described in previous studies, offers little insight into how emergency physicians incorporate their own bedside images into overall patient care 1, 2, 3, 4, 5, 6, 7.

We sought to evaluate the impact of “goal-directed” abdominal ultrasonography on real-time decision making in the ED with specific emphasis on physicians’ certainty of diagnosis, treatment, and disposition.

Section snippets

Materials and methods

Ultrasonography was performed and interpreted by one of five credentialed sonographers using an Aloka 650 CL or Medison SA-6000 ultrasound machine. The Department of Emergency Medicine, together with the hospital’s credentialing committee, implemented credentialing guidelines for the use of ultrasound in the ED. These guidelines were modeled on those proposed by Mateer et al. in the 1994 SAEM guidelines and include a 16-h didactic course, 17 training examinations, and 155 practice examinations

Results

A total of 212 patients were enrolled in our study. Twelve patients (6%) were excluded from the data analysis due to incomplete forms. The median number of examinations performed by the five study physicians was 32 (range 20–65). Table 1 lists the distribution and percentages of presenting chief complaints and corresponding suspected disease processes of the remaining 200 patients. The two most common indications for ED US were the evaluation of biliary tract disease (38%) and complications of

Discussion

The results of this study suggest that among experienced ED sonographers at our institution, goal-directed abdominal US significantly impacts diagnostic, treatment, and disposition certainty. This impact seems to be greater for diagnostic certainty than for either treatment or disposition decisions.

In patients with either a high or low pretest probability of disease, a confirmatory test usually allows the physician to either rule in or rule out the disease process. In this study, 92 patients

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