key: cord-0796690-q2cect47 authors: Yuriditsky, Eugene; Saric, Muhamed; Horowitz, James M. title: Point‐of‐care ultrasound during the COVID‐19 pandemic: A multidisciplinary approach between intensivists and echocardiographers date: 2021-02-15 journal: Echocardiography DOI: 10.1111/echo.14996 sha: 2d425282d92e392fef4de91d636b400073b7ee9e doc_id: 796690 cord_uid: q2cect47 PURPOSE: The coronavirus disease‐2019 (COVID‐19) led to a large influx of critically ill patients and altered echocardiography laboratory workflow. We developed a point‐of‐care ultrasound (POCUS) first approach to patients requiring echocardiography and describe our workflow and findings. METHODS: We performed a single‐center retrospective analysis of all POCUS studies performed on critically ill patients with COVID‐19. Sonography was performed by intensivists, uploaded and archived, and rapidly reviewed by echocardiographers. We evaluated each study based on the number of views obtained. Additionally, we provide a description of the workflow during the COVID‐19 surge at a tertiary care hospital in New York City. RESULTS: Fifty patients had POCUS studies performed by intensivists and reviewed by echocardiographers obviating the need for sonographer‐performed studies. Of the 48 cardiac POCUS studies, 17% of patients had 4 of 4 standard views available while 53% had 3 of 4 standard views. The parasternal long‐axis view was obtained on 81%, subxiphoid view on 79%, apical 4‐chamber view on 71%, and parasternal short‐axis view on 63% of patients. CONCLUSIONS: Our POCUS workflow allowed intensivists to perform cardiac sonography for rapid bedside diagnosis of pathology with immediate interpretation performed by echocardiographers. At least 3 views were obtained in the majority of cases. At our institution, POCUS was the first-line ultrasound imaging technique in our ICU during the COVID-19 pandemic. Ultrasound studies were performed by intensivists using the Phillips Lumify ultrasound system using either an S4-1 broadband phase array transducer for cardiac and lung imaging and/or the L12-4 broadband linear array transducer for vascular and pleural imaging (Koninklijke Phillips, NV). Transducers were attached to Samsung Galaxy tablets (SAMSUNG) equipped with the Phillips Lumify application. Commonly, tablets were set on Nova Pro mounts (Tryten Technologies, Inc) equipped with transducer and ultrasound gel bottle holders. The touchscreen technology and minimal accessories allowed for easy and thorough disinfection. Devices were kept on the COVID units and designated solely for COVID-19 patients. All studies were performed in patient rooms either in the ICU or the ward. Ultrasound studies were ordered by the care team in our electronic health record system (Epic ©, Epic Systems Corporation, Milky Way, Verona, WI), and the patient was automatically added to the worklist in the Phillips Lumify application. After completion of the examination, images were uploaded to our ultrasound PACS system (Syngo ® Dynamics workplace (version: VA20E_20.0.0.2645_HF02 Build 2645). A board-certified echocardiographer would read the study and provide a report in Epic. This collaboration afforded teaching opportunity for the intensivist and a means to have their image interpretation evaluated. Archived images provided an option to compare POCUS studies to prior echocardiograms. During the initial phases of the pandemic at our institution, echocardiographers would review transthoracic echocardiogram (TTE) orders and in discussion with intensivists, often change the studies to POCUS to limit formal TTEs when deemed appropriate. Intensivists performing POCUS entering the room of a mechanically ventilated patient required an N-95 mask, facie shield, gown, and 2 sets of gloves. Worklists on the Phillips Lumify application were updated, and the patient was selected prior to entering the room. After performing a POCUS examination, one layer of gloves was removed and the tablet and transducer were thoroughly cleaned with germicidal disposable wipes. Rolling stands housing the tablets stored on the unit obviated the need to place tablets on clean surfaces. No equipment was used on COVID negative patients to further mitigate potential spread. In total, 9/48 patients (19%) had significant pathology on cardiac POCUS that was thought to explain the cause of the patients' decompensation; 2 patients had significant RV dysfunction, and 7 patients had significant LV dysfunction. As studies were not performed in a systematic way, we are unable to comment on the true frequency of cardiac pathology among critically ill patients with COVID-19. Likely, some POCUS studies were performed during instances of acute deterioration and were not transmitted for review therefore limiting the numbers in this report. As such, we are unable to comment on the utility of those studies in regard to answering the question posed. As POCUS interpretation is often binary, more advanced cardiac assessment, such as evaluation of valvular dysfunction, is usually not performed by intensivists and requires advanced skills. A formal approach integrating a strict POCUS protocol, and more advanced training and simulations for intensivists may improve both study quality and interpretation. To limit exposure of sonographers to SARS-CoV-2 and conserve PPE, we established a system at our institution that allowed for intensivistperformed POCUS to be immediately interpreted by echocardiographers with images stored for future access. Of the patients that underwent cardiac POCUS, the majority of patients had at least 3 views available for interpretation. In each instance, it was felt that the study was sufficient to urgently answer the question and understand the pathophysiology of respiratory failure and shock. Whether this approach will prove useful in post-pandemic times is worth exploring. None. 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