key: cord-0721848-ve21e9t7 authors: McPhail, Eleanor; Jahagirdar, Nishat; Walker, Nicola; Harris, Scott; Monaghan, Mark; Papachristidis, Alexandros title: The role of expert focus echocardiography during the COVID‐19 pandemic date: 2022-04-17 journal: Echocardiography DOI: 10.1111/echo.15351 sha: 48c9491e715f698fffde8645231e794dc198af36 doc_id: 721848 cord_uid: ve21e9t7 BACKGROUND: Focus Echocardiography has routinely been used to offer quick diagnosis in critical care environments, predominantly by clinicians with limited training. During the COVID‐19 pandemic, international guidance recommended all echocardiography scans were performed as focus studies to limit operator viral exposure in both inpatient and outpatient settings. The aim of this study was to assess the effectiveness of eFoCUS, a focus scan performed by fully trained echocardiographers following a minimum dataset plus full interrogation of any pathology found. METHODS: All diagnostic echocardiograms, performed by fully trained echocardiographers during an 8‐week period during the first UK COVID‐19 wave, were included. The number of images acquired was compared in the following categories: admission status, COVID status, image quality, indication, invasive ventilation, pathology found, echocardiographer experience, and whether eFoCUS was deemed adequate to answer the clinical question. RESULTS: In 87.4% of the 698 scans included, the operator considered that the eFOCUS echo protocol, with additional images when needed, was sufficient to answer the clinical question on the request. Echocardiographer experience did not affect the number of images acquired. Less images were acquired in COVID‐19 positive patients compared to negative/asymptomatic (38 ± 12 vs. 42 ± 12, p = .001), and more images were required when a valve pathology was identified. CONCLUSION: eFoCUS echocardiography is an effective protocol for use during the COVID‐19 pandemic. It provides sufficient diagnostic information to answer the clinical question but differs from standard focus/limited protocols by enabling the identification and interrogation of significant pathology and incidental findings, preventing unnecessary repeat scans and viral exposure of operators. Problem-oriented focus cardiac ultrasound examination (FoCUS) or Point of Care echocardiography is widely recognized as a useful method of assessing cardiac function to support the clinical presentation of a patient in an emergency care setting. 1, 2 There are several FoCUS echocardiography protocols developed by professional bodies, however these are usually performed by nonechocardiography specialists such as intensive care physicians, anesthetists, and other non-cardiologists who undergo a condensed training programme. 1, 3, 4 FoCUS scans tend to be performed bedside in critically ill patients who are generally technically challenging with ultrasound machines limited to two-dimensional (2D) assessment. All these factors carry a risk of overlooking significant abnormalities and misinterpretation 2,5 and should not replace comprehensive echocardiography. Comprehensive echocardiography is a full study performed by a highly specialized, suitably trained and accredited sonographer or Cardiologist. The operator follows a minimum dataset 6, 7 to produce a detailed and thorough examination of cardiac structure and function. If an abnormality is detected, the sonographer will need to have the skill and expertise to investigate further, using additional views, measurements, and advanced techniques such as three-dimensional (3D) and myocardial strain (GLS) assessment. The COVID-19 pandemic prompted a change in the provision of the echocardiography service worldwide. The American Society of Echocardiography (ASE) as well as the European Association of Cardiovascular Imaging (EACVI) and the British Society of Echocardiography 8-10 released relevant guidance. The recommendation was for all scans to be performed as goal-directed FoCUS scans performed by specialist sonographers. A restricted protocol was thought to reduce the viral exposure time of the sonographer whilst providing the necessary echocardiographic information to facilitate clinical decision-making. Our department's policy expanded on this to create an expert FoCUS (eFoCUS) protocol, defined as a minimum dataset with full interrogation of an identified pathology aiming to reduce requests for repeat scans seeking additional diagnostic information. An expert was defined as an echocardiographer with full BSE TTE accreditation or an equivalent internationally recognized accreditation. The aim of this study was to assess the effectiveness of eFOCUS echocardiography use in a pandemic, as its role as a replacement for comprehensive echocardiography remains unclear. We conducted a prospective, observational study evaluating the results of eFoCUS in a large tertiary hospital during the peak of the COVID-19 Pandemic. All patients who underwent transthoracic echocardiography (TTE) during an 8-week period between March 18 and May 13 2020 were included. Scans performed by professionals who did not have a rec-ognized full transthoracic echocardiography accreditation and all nondiagnostic scans due to suboptimal image quality were excluded. Studies which followed a specified protocol such as research and patients under private care were also excluded. Therefore, the included studies were those performed for clinical purposes, were of interpretable image quality, and performed by expert professionals defined as accredited individuals in adult transthoracic echocardiography who had completed the local departmental competency sign off to independently scan and report. eFOCUS scans were conducted following a departmental protocol, created from the BSE Level 1 protocol, 4 Valve stenosis and regurgitation were assessed as per ASE guidelines or by visual assessment. In order to investigate a learning curve effect on the number of acquired images per echocardiographic study, the time in days from the first scan to each subsequent scan was calculated for each operator. In addition, to assess possible correlation between the level of experience of the operators and the number of images acquired in their scans, the sonographers were divided in two groups based on the time since their accreditation: low experience: 1-5 years, and high experience: >5 years since accreditation (inclusive of 4 and 10 sonographers, respectively). In total, 879 TTEs were performed within the study period, out of which 181 scans were excluded, as were not performed by a fully accredited echocardiographer (n = 169), had technical issues (n = 5), performed on private patients (n = 4), followed research protocols (n = 2), or were undiagnostic due to inadequate image quality (n = 2). Hence, 698 echocardiograms were included in this study. The baseline characteristics are shown in Figure 2 . As a validation test, five echocardiograms from each sonographer were randomly selected and they were reviewed by an experienced sonographer (>5 years since accreditation) blinded to the initial report. A variety of pathologies, including chamber and valve pathologies, were identified in 46 scans, whereas 24 scans were normal. The agreement in interpretation between the initial operator and the blinded reviewer was 100%. The number of images taken were higher in outpatients and asymptomatic inpatients, however the incidence of pathology was higher in the symptomatic/awaiting results and the COVID-19 positive groups. The lower number of images in symptomatic/awaiting results and F I G U R E 2 Pathology detected COVID positive groups, could be due to lack of confidence in the PPE issued and a concern over viral load. The ASE and BSE 8,9 both released statements suggesting the risk of healthcare workers, especially echocardiographers contracting COVID-19 was high, due to the close face to face nature of their work, however there is limited data on this. Usage of full PPE for COVID-positive patients is time consum-ing and uncomfortable which could have also affected the number of images taken on these patients. 12 The number of images taken on ventilated patients were less than non-ventilated patients. This could have been due to the difficulty in obtaining images when the patients are in supine position and also be directly related to poorer image quality in ventilated patients. This is a single centre study with the inherent limitations and bias. There is a thorough sing off process in our department and all operators in this study were fully accredited in TTE. Therefore, our results may not apply to less experienced operators such FICE operators. This was not a controlled study, hence no comparisons were made to full protocol echocardiograms. The time taken for the eFOCUS examinations was not assessed and therefore not quantified, though it is expected to be reflected by the number of images acquired. Finally, data regarding diastolic function were not recorded systematically as diastology did not fall into the scope of the focused protocol. However, this is something to be considered in future studies. In this study, an eFOCUS echocardiography protocol was applied by fully accredited operators and its efficiency was evaluated in 698 patients during the COVID-19 pandemic. The protocol was found to provide sufficient diagnostic information to answer the clinical question but differs from standard focus/limited protocols by enabling the identification and interrogation of significant pathology and incidental findings, preventing unnecessary repeat scans and viral exposure to operators. A change in practice was identified by the number of images taken in negative/asymptomatic group versus symptomatic/awaiting results and covid-19 positive patients, as operators acquired less images when the risk of exposure was higher. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography Focus cardiac ultrasound: the European Association of Cardiovascular Imaging viewpoint Resuscitation Council UK. FEEL -Focused Echocardiography in Emergency Life Support course A minimum dataset for a Level 1 echocardiogram: a guideline protocol from the British Society of Echocardiography The impact of focused echocardiography using the Focused Intensive Care Echo protocol on the management of critically ill patients, and comparison with full echocardiographic studies by BSE-accredited sonographers Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography A minimum dataset for a standard adult transthoracic echocardiogram: a guideline protocol from the British Society of Echocardiography COVID-19 clinical guidance ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak COVID-19 pandemic and cardiac imaging: EACVI recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel Impact of focused echocardiography on scan time and diagnostic quality in Patients with COVID-19 Bedside focused cardiac ultrasound in COVID-19 from the Wuhan epicenter: the role of cardiac point-of-care ultrasound, limited transthoracic echocardiography, and critical care echocardiography -Journal of the American Society of Echocardiography (doi.org) Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice The authors would like to thank the Echocardiography team at King's