Our secondary objective was to assess the accuracy of PEM fellows’ interpretive skills of both FOCUS and complete echocardiograms in a remote classroom setting.
Our primary objective was to assess PEM fellows’ accuracy in assessing cardiac function and the presence of pericardial effusions while performing FOCUS exams with limited training. However, there are limited data on competency assessment of PEM fellows with routine training in POCUS during their PEM fellowships. PEM providers who have completed a dedicated extra year of POCUS fellowship training can diagnose pericardial effusion and abnormalities of function with high sensitivity and specificity. An expert panel of PEM physicians trained in POCUS, included FOCUS as one of the core ultrasound exams for this curriculum. They recommend a structured POCUS curriculum and competency assessment for PEM fellows. Subsequently, the American Academy of Pediatrics and the American College of Emergency Physicians have released policy statements stressing the importance of training for pediatric emergency medicine (PEM) fellows in point of care ultrasound (POCUS). In 2010, the American Society of Echocardiography and the American College of Emergency Physicians released a consensus statement on the importance of focused cardiac ultrasound (FOCUS) on patient care and treatment in an emergency setting. However, they made real-time interpretation errors and likely need further training to incorporate real-time image acquisition and interpretation into their practice. Novice PEM fellow sonologists (a physician who performs and interprets ultrasound) in the majority of instances were able to acquire and remotely interpret FOCUS images with limited training. Interrater reliability for interpretation of remote images (kappa) was 0.66 (95% CI 0.59–0.73) for effusion and 0.31 (95% CI 0.24–0.38) for function among the fellows. There were no differences in sensitivity and specificity of PEM fellows’ interpretation of FOCUS studies compared to their interpretation of cardiology echocardiograms. When PEM fellows remotely interpreted 15 echocardiograms, the sensitivity was 81.3% (95% CI 70.7–88.8) and specificity 75% (95% CI 67.0–81.0) for detecting diminished function, and sensitivity of 76.3% (95% CI 65.0–85.0) and specificity 94.4% (95% CI 89.0–97.0) for detecting pericardial effusion.
PEM fellow FOCUS had a sensitivity of 50.0% (95% CI 9.19–90.8) and specificity of 100.0% (95% CI 91.1–100.0) for detecting diminished function, and sensitivity of 50.0% (95% CI 2.67–97.33) and specificity of 98.1% (95% CI 88.42–99.9) for detecting pericardial effusions. ResultsĮight PEM fellows performed 54 FOCUS exams, of which two had pericardial effusion and four had diminished function. Subsequently, eight different PEM fellows remotely interpreted a subset of the PEM-acquired and cardiology-acquired echocardiograms.
PEM fellows performed and interpreted FOCUS on patients who also received cardiology service echocardiograms, the reference standard. The objectives of this study were (1) to evaluate test characteristics of PEM-fellow-performed FOCUS for pericardial effusion and diminished cardiac function and (2) to assess image interpretation independent of image acquisition. Focused cardiac ultrasound (FOCUS) is a core competency for pediatric emergency medicine (PEM) fellows.
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