Title: Using Point‐of‐Care Ultrasound on Home Visits: The Home‐Oriented Ultrasound Examination (HOUSE)
Abstract: Journal of the American Geriatrics SocietyVolume 67, Issue 12 p. 2662-2663 Letter to the EditorFree Access Using Point-of-Care Ultrasound on Home Visits: The Home-Oriented Ultrasound Examination (HOUSE) Alexander R. Bonnel MD, Corresponding Author Alexander R. Bonnel MD [email protected] @alexbonnelMD orcid.org/0000-0002-0640-6330 Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PennsylvaniaAddress correspondence to Alexander R. Bonnel, MD, 3400 Spruce St, Ground Admin Suite Philadelphia, PA 19146. E-mail: [email protected], Twitter: @alexbonnelMDSearch for more papers by this authorCameron M. Baston MD, Cameron M. Baston MD @Cameron_baston Department of Medicine, University of Pennsylvania, Philadelphia, PennsylvaniaSearch for more papers by this authorPaul Wallace MD, Paul Wallace MD Department of Medicine, University of Pennsylvania, Philadelphia, PennsylvaniaSearch for more papers by this authorNova Panebianco MD, Nova Panebianco MD Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PennsylvaniaSearch for more papers by this authorBruce Kinosian MD, Bruce Kinosian MD orcid.org/0000-0003-2098-6340 Department of Medicine, University of Pennsylvania, Philadelphia, PennsylvaniaSearch for more papers by this author Alexander R. Bonnel MD, Corresponding Author Alexander R. Bonnel MD [email protected] @alexbonnelMD orcid.org/0000-0002-0640-6330 Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PennsylvaniaAddress correspondence to Alexander R. Bonnel, MD, 3400 Spruce St, Ground Admin Suite Philadelphia, PA 19146. E-mail: [email protected], Twitter: @alexbonnelMDSearch for more papers by this authorCameron M. Baston MD, Cameron M. Baston MD @Cameron_baston Department of Medicine, University of Pennsylvania, Philadelphia, PennsylvaniaSearch for more papers by this authorPaul Wallace MD, Paul Wallace MD Department of Medicine, University of Pennsylvania, Philadelphia, PennsylvaniaSearch for more papers by this authorNova Panebianco MD, Nova Panebianco MD Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PennsylvaniaSearch for more papers by this authorBruce Kinosian MD, Bruce Kinosian MD orcid.org/0000-0003-2098-6340 Department of Medicine, University of Pennsylvania, Philadelphia, PennsylvaniaSearch for more papers by this author First published: 06 October 2019 https://doi.org/10.1111/jgs.16188Citations: 11 Twitter handle for co-author: @Cameron_baston AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat To the Editor: Primary care physicians often refer patients to a radiology department for an ultrasound examination, a considerable hurdle for homebound patients. Several handheld ultrasound (HHUS) devices have entered the market and are becoming accessible to providers.1 Use of this technology by general practitioners remains limited but will likely increase as more medical schools and residency programs incorporate ultrasound education.2-4 We report the use of HHUS during home visits and developed a protocolized ultrasound examination based on our experience. To our knowledge, this is the first report on the use of this technology with the home visit population. METHODS A geriatrician with an established home visit practice in a large US city and an internal medicine physician participating in a dedicated point-of-care ultrasound (POCUS) fellowship5 identified visits that would be ideal for this pilot. All patients were home limited and unable to be transported easily for outpatient appointments. Before the visit, the patient's case was reviewed and assessed for ultrasound utility. The team traveled to the patient's home and provided care including the ultrasound. All images were acquired on a Lumify (Philips, Inc, Bothwell, WA) or iQ (Butterfly, Inc, Guilford, CT) and were interpreted in real time by the fellow. Limited patient history, clinical, and imaging findings were stored in a secure database/server (RedCap Consortium, Nashville, TN) for asynchronous review. A change in management was defined as a circumstance in which the geriatrician stated that their clinical decision was affected by the HHUS results. RESULTS Over a 7-month period, 16 patients were evaluated during 22 visits. Mean age was 79 years. We performed 68 HHUS examinations. The most common images were cardiac (n = 19), lung (n = 18), inferior vena cava (IVC) (n = 17), and bladder (n = 6). Common indications were assessment of intravascular volume status (n = 17), dyspnea/hypoxia (n = 4), and urinary retention (n = 4). In 14 of 22 (64%) visits, the patient's management was changed as a result of the ultrasound findings. Changes included adjustments in diuretic regimen (n = 8), deferring additional imaging (n = 4), and discontinuation of a Foley catheter after a voiding trial (n = 1). In conclusion, this case series demonstrates the feasibility and potential impact of HHUS in the home care setting. Most patients in our series experienced a change in clinical management attributable to the ultrasound findings. We propose a home-oriented ultrasound examination (HOUSE) that incorporates the most frequently used ultrasound examinations in a home care program.6, 7 Pillars of HOUSE were the internal jugular vein for jugular venous pressure (JVP) estimate, lung ultrasound, cardiac ultrasound, bladder volume, and a deep venous thrombosis (DVT) assessment (Figure 1). These examinations were selected by weighing the value of information they added against their difficulty of image acquisition. Figure 1Open in figure viewerPowerPoint Components of the Home-Oriented Ultrasound Exam (HOUSE). The examination begins with A, identification of the meniscus of the internal jugular vein for a jugular venous pressure (JVP) estimate and then moves to B, the apical and lateral lung views to identify A- or B-line artifacts. C, A gross ejection fraction estimate is made using at least two of the four standard cardiac views. D, Inferior vena cava (IVC) assessment is attempted to corroborate JVP findings for a central venous pressure estimate. Bladder examination in E, transverse view, and F, longitudinal view, for bladder volume estimation (volume = length × width × height × 0.52).8 Given the frequency of leg edema in this population, a deep venous thrombosis (DVT) examination can be incorporated if indicated. The least challenging studies to perform were seen with JVP assessment, lung ultrasound for A- or B-line artifacts, and bladder volume. The most difficult images to obtain in our patients were cardiac views, IVC, and DVT evaluation. We attempted all four standard cardiac views (parasternal long axis, parasternal short, apical four-chamber, subxiphoid) but often could only acquire the parasternal images due to patient body habitus or positioning challenges. None of our patients were evaluated for DVT, but given the frequency of leg edema in this population, we felt that including DVT examination in the HOUSE protocol was important, albeit challenging, in patients with limited mobility. The home visit setting and devices themselves introduced limitations to acquiring images. The habitus and mobility limitations of patients impaired patient and sonologist positioning that led to nondiagnostic studies. Patients were often examined on their couches, recliners, or wheelchairs. The variable lighting of each scanning location often led to excessive gain of images when later reviewed during data analysis. Difference in screen size of our devices also affected image quality. Gross ejection fraction estimate and lung artifact assessment (ie, number of B-lines) were easier when the device probe was connected to a tablet rather than a smartphone. Other technical challenges included battery life and overheating of the ultrasound probe with prolonged use. In conclusion, HHUS is both feasible and valuable in home visits. By delivering real-time clinical information at the time of patient contact, HHUS can bridge the delays between physical assessment, data acquisition, and clinical decision making for patients enrolled in home care programs. However, HHUS is operator dependent, and diagnostic performance will depend on the training of the clinician. There is no current standard for formal training to adopt this technology into home care practice, but we hope that a protocol such as HOUSE will help to guide training efforts. ACKNOWLEDGMENTS Conflict of Interest The authors have declared no conflicts of interest for this article. Author Contributions All authors contributed to the design of the series. Alexander R. Bonnel and Bruce Kinosian enrolled patients during home visits. Alexander R. Bonnel analyzed the data and prepared the manuscript. Cameron M. Baston and Nova Panebianco provided significant edits that resulted in the finalized manuscript. Sponsor's Role There was no sponsor for this research. REFERENCES 1Chamsi-Pasha MA, Sengupta PP, Zoghbi WA. Handheld echocardiography: current state and future perspectives. Circulation. 2017; 136(22): 2178- 2188. 2Mengel-Jørgensen T, Jensen MB. Variation in the use of point-of-care ultrasound in general practice in various European countries. Results of a survey among experts. 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Measurements of urinary bladder volume: comparison of five ultrasound calculation methods in volunteers. Arch Ital di Urol Androl. 2005; 77(1): 60- 62. Citing Literature Volume67, Issue12December 2019Pages 2662-2663 FiguresReferencesRelatedInformation