Health System and Training Institution Administrators

The Role of Point-of-Care Ultrasound in Improving Healthcare Delivery

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The United States (US) Federal Government’s progressive need to reduce healthcare expenditures has triggered a broad range of quality improvement metrics and initiatives. The Center for Medicare Services (CMS) views “value-based purchasing” as a critical pathway to reforming how care and services are paid for, transitioning towards rewarding better value, outcomes, and innovations (pay-for-performance) rather than merely volume (pay-for-service). These changes directly affect hospitals, clinics, home health centers, and nursing homes.

According to CMS, “improvement in these evidence-based quality measures is expected to provide long-term savings, because of their demonstrated relationship to improved patient health, fewer complications and fewer hospital re-admissions.” (CMS) The CMS will implement a methodology for assessing the total performance of each facility based on performance standards, under which they will score each facility based on achievement and improvement ranges for each applicable measure. In addition, the CMS will compute a total score for each facility by combining the greater of the facility’s achievement or improvement points for each measure to determine a score for each domain, multiplying each domain score by a proposed weight (i.e., clinical process of care accounts for 70 percent, patient experience of care accounts for 30 percent), and adding together the weighted domain scores. Each facility’s total score will be converted into a value-based incentive payment.

Significant synergies exist between the benefits of widespread adoption of point-of-care ultrasonography and healthcare improvement trends (Table 1). Ultrasound is a well-documented method of decreasing surgical complications (including iatrogenic pneumothorax, death among surgical patients, accidental puncture or laceration), all of which are Agency for Healthcare Research and Quality (AHRQ) quality improvement measures. Adoption of point-of-care ultrasound by healthcare providers within a healthcare system is a proven method of improving patient care, decreasing complications, and improving efficiency (with resultant cost savings).

Hospital and health system-wide adoption of point-of-care ultrasound will enable facilities to improve their CMS performance standards (clinical process and patient experience) scores and optimize future value-based incentive payments. Despite the well-documented benefits of ultrasonography, as of 2009 it was only used in 34 percent of emergency departments (EDs) in California and in only 19 percent of nonacademic EDs in the United States. (Moore, Stein) The primary bottleneck to widespread adoption of ultrasound by careproviders is limited ultrasound training opportunities.

Clinical Case Studies

Case Study: Central Venous Catheter Placement

Ultrasound guidance is a documented method of decreasing central venous line placement complications by 78 percent. (AHRQ, NICE, Bansal, Miller) In addition, ultrasound decreases the number of needle stick attempts and reduces patient discomfort and anxiety, all of which are relevant to CMS patient experience reporting metrics. (AHRQ) Central venous catheter placement is unsuccessful in 20 percent of attempts with an associated 10 percent minor and major complication rate (e.g., arterial puncture, iatrogenic pneumothorax, hemothorax, air embolus, arrhythmias, catheter knotting, hemothorax, chylothorax, and brachial plexus injury). (AHRQ)

Medical provider analysis and review (MedPAR) data from the CMS indicates that iatrogenic pneumothorax was reported in 2.31 per 1,000 discharges in 2007. (MedPAR) Average length of stay is increased from four to seven days following iatrogenic pneumothorax and the cost per incident ranges from $17,000 to $45,000. (Zhan) The range of dollars paid resulting from claims related to iatrogenic injury related to central venous catheter placement from the American Society of Anesthesiology claims registry is a median payment of $105,500 per claim. (Domino) The costs associated with iatrogenic pneumothorax (based on these estimates) ranges from $510 million to $1.3 billion annually. Ultrasound-guided thoracentesis was found to decrease pneumothorax complications from 10.3 to 4.9 percent (48 percent relative risk reduction), thus saving lives and between $245 and $624 million annually. (Barnes 2005) 

Case Study: Iatrogenic Hospital-Acquired Urinary Tract Infection

Urinary tract infections are the most common type of hospital-acquired infection, accounting for greater than 30 percent of infections reported by acute care hospitals. (Klevens) The catheter-related urinary tract infection rate is 3.1 to 7.5 infections per 1000 hospital catheter days. An estimated 15 to 25 percent of patients get catheters. (Warren, Weinstein 1999)  Catheter-associated urinary tract infections are the most common source of secondary nosocomial bloodstream infections. Seventeen percent of hospital-acquired bacteremias are from a urinary source, with a mortality rate of 10 percent. (Weinstein 1997) Approximately 17 to 69 percent of catheter-associated urinary tract infections are preventable with recommended infection control measures, which means 380,000 infections and 9,000 deaths related to catheter-associated infections per year could be avoided. (Umscheid) Bladder ultrasonography with subsequent selective bladder catheterization has decreased the incidence of nosocomial urinary tract infections by 30 to 50 percent. A recent meta-analysis documented that selective bladder catheterization based on bladder ultrasonography resulted in an OR of .27 in favor of reducing nosocomial urinary tract infection rates. (Palese)

Case Study: Infant Fever Evaluation

The presentation of a febrile infant to an emergency department (ED) is a frequent occurrence. Given the frequency of a urinary tract infection as a cause of an infant’s fever, urinalysis and culture is a critical part of the patient’s evaluation. Suprapubic bladder aspiration has been replaced by urethral catheterization as the preferred method of obtaining a urine sample. Voided urine samples are considered suboptimal due to contamination risks and length of time required for obtaining a sample. A very frequent occurrence is a “dry catheterization”. A nurse often attempts a urethral catheterization; however, the infant has recently voided or may be dehydrated and no urine is obtained. Parents frequently refuse subsequent attempts due to the perceived and real discomfort associated with the procedure by the patients. This results in inefficient, prolonged, and suboptimal care. Careproviders are forced to either keep the patient in the ED and await a voided urine sample (increased length of stay and potentially contaminated urine sample), empirically treat with antibiotics, or the patient and family leave the ED without an adequate evaluation that excludes a life-threatening gram-negative urinary tract infection.

Suboptimal care could be avoided by simply having nurses screen patients for a full bladder prior to attempted urethral catheterization, which would negate “dry catheterizations”. (Baumann 2007 & 2008, Chen 2004 & 2005) First-attempt success rates are improved from 67 to 92 percent with ultrasound assistance. (Baumann 2008) In addition, both careproviders and caregivers of young children expressed greater satisfaction following the use of ultrasound to determine bladder volume prior to urethral catheterization. (Baumann 2007)

References

Barnes TW, Morgenthaler TI, Olson EJ, et al. Sonographically guided thoracentesis and rate of pneumothorax. J Clin Ultrasound 2005 Dec;33(9):442-446.

Baumann B, McCans K, Stahmer S, et al. Volumetric bladder ultrasound performed by trained nurses increases catheterization success in pediatric patients. Am J Emerg Med 2008 Jan;26(1):18-23.

Baumann BM, McCans K, Stahmer SA, et al.  Caregiver and health care provider satisfaction with volumetric bladder ultrasound. Acad Emerg Med 2007 Oct;14(10):903-907.

Centers for Medicare and Medicaid Services (CMS). Hospital Quality Initiatives: Inpatient Measures. [cited 2011 April 4]. Available from:  URL: https://www.cms.gov/HospitalQualityInits/16_InpatientMeasures.asp#

Chen L, Hsiao A, Moore C, Santucci K. Utility of bedside bladder ultrasound prior to urethral catheterization in infants. Acad Emerg Med 2004 May;11(5):598 Abstract.

Chen L, Hsiao AL, Moore CL, et al. Utility of bedside ultrasound before urethral catherization in young children. Pediatrics 2005 Jan;115(1):108-111.

Domino KB, Bowdle TA, Posner KL, et al. Injuries and liability related to central vascular catheters–a closed claims analysis. Anesthesiology 2004 Jun;100(6):1411-1418.

Frost and Sullivan. Unites States Ultrasound Markets Strategic Report. [cited 2011 Apr 4].  Available from: URL: http://www.frost.com/prod/servlet/report-brochure.pag?id=A675-01-00-00-00#report-overview

Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med 2007 May;35(5 Suppl):S126-S130.

Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007 Mar-Apr;122(2):160-166.

Miller AH, Roth BA, Mills TJ, et al. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med 2002 Aug;9(8):800-805.

Moore CL, Gregg S, Lambert M. Performance, training, quality assurance, and reimbursement of emergency physician-performed ultrasonography at academic medical centers. J Ultrasound Med 2004 Apr;23(4):459-466.

Moore CL, Molina AA, Lin H. Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography.  Ann Emerg Med 2006; 47:147-153.

National Institute for Health and Clinical Excellence (NICE).  Central venous catheters – ultrasound-locating devices, 2002.  [cited 2011 Apr 5]  Available from:  URL: http://guidance.nice.org.uk/TA49

Palese A, Buchini S, Deroma L, et al. The effectiveness of the ultrasound bladder scanner in reducing urinary tract infections. a meta-analysis. J Clin Nurs 2010 Nov;19(21-22):2970-2979.

Stein JC, River G, Kalika I, et al.  A Survey of Bedside Ultrasound Use by Emergency Physicians in California. J Ultrasound Med 2009; 28:757-763.

Umscheid C, Mitchell M, Agarwal R, Williams K, Brennan P. Mortality from reasonably-preventable hospital acquired infections. included in written testimony by the society of healthcare epidemiology of america for the committee on oversight and government reform hearing on healthcare-associated infections: A preventable epidemic, chaired by henry A. waxman, april 16, 2008, washington, DC. [congressional testimony].

Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents 2001 Apr;17(4):299-303.

Weinstein MP, Towns ML, Quartey SM, et al. The clinical significance of positive blood cultures in the 1990s: a prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults. Clin Infect Dis 1997 Apr;24(4):584-602.

Weinstein JW, Mazon D, Pantelick E, et al. A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol 1999 Aug;20(8):543-548.

Zhan C, M Smith, D Stryer. Incidences, outcomes and factors associated with iatrogenic pneumothorax in hospitalized patients. [cited 2011 March 31].  Available from:  URL: http://www.academyhealth.org/files/2004/abstracts/quality.pdf