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EP.006
The accuracy of hand-held echocardiography performed by non-cardiologists with limited echocardiography training

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ACCURACY OF HAND-HELD BEDSIDE ECHOCARDIOGRAPHY PERFORMED BY NON-CARDIOLOGISTS WITH LIMITED ECHOCARDIOGRAPHY TRAINING

INTRODUCTION

Echocardiography is becoming a core skill in critical care, with a demand for real time results to guide treatment decisions

Hand-held echocardiography (HHE) is reported to produce similar image quality + diagnostic accuracy when compared with standard transthoracic echocardiography (TTE)1,2 in some conditions

HHE is rapid, convenient, and lends well to a ‘focused’ echo examination

To date, most studies of HHE have analysed performance in the hands of experienced cardiologists with formal echocardiography qualifications

We aimed to explore the accuracy and clinical utility of HHE in acutely presenting and critically unwell patients, performed by non-cardiologists after a defined, limited period of echocardiography training

METHODS

Prospective, cross-sectional study of consecutive patients referred for TTE in the period of Jan 2017 → Jan 2018

Patients first underwent bedside HHE with a Vscan™ (GE Healthcare) prior to a control, full departmental TTE  for comparison

Bedside HHE was performed by two assessors with no prior experience (both core trainees) who were given 30 hours of hands-on training by an accredited BSE trainer before the study; the control TTEs were performed by BSE accredited scanners

Each HHE study assessed 4 specific areas, broadly based on the Focused Intensive Care Echo (FICE) minimum dataset (table 1), with addition of 2D and colour flow doppler valvular assessment

Referrals were considered for HHE if within these domains, but otherwise excluded, particularly if the use of spectral doppler was obviously indicated

After HHE, the assessor specified whether they would recommend departmental TTE because of suspected pathology or inadequate images

RESULTS

Paired HHE and TTE were performed on N=42 acute medical and intensive care patients (21 per assessor)

Assessment for LV systolic dysfunction and pericardial effusion was consistently accurate with HHE (table 2)

Although RV dysfunction and valvular regurgitation were occasionally underestimated, full departmental scan had been recommended in each case

In all cases of significant discrepancy between HHE and TTE, the scanner had recommended departmental TTE (table 3)

No cases of severe LVSD, severe valve disease or pericardial effusion were missed by HHE

CONCLUSIONS

Diagnostic accuracy of HHE was comparable to full TTE in an inpatient population, within the 4 stated domains 

Assessment of LV dysfunction and pericardial effusion was consistently accurate; mild RV dysfunction was  described as normal on 2 occasions

Assessment of valvular disease was less reliable, perhaps because valvular regurgitation assessment by colour flow doppler alone is subjective, and assessment of stenosis relies heavily on doppler ultrasound

Additionally, these results were achieved by 2 relatively inexperienced scanners, following a short but formal and focused training period

We suggest that focused training in HHE in the acute medical and critical care setting can help guide real-time clinical decision-making, reduce demand for full TTE in the ICU, and complement the FICE accreditation process

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