Pulmonary embolism is a serious condition requiring accurate diagnosis, management, and risk stratification to guide treatment and disposition. While outpatient management for pulmonary embolism may be safe for select patients, its application in the emergency department (ED) setting remains uncertain. This study aimed to evaluate the safety of outpatient management for patients presenting to the ED with pulmonary embolism. This was a health-record review of patients with confirmed pulmonary embolism in 2 large EDs of a tertiary care hospital. Stable patients were discharged by the ED physicians, usually without consultation and patients were seen in a specialized thrombosis clinic within 48 h. Anticoagulation follow-up was coordinated through the thrombosis clinic. We reviewed electronic hospital records using a standardized data collection form. The primary outcome was return to the ED within 5 days due to early clinical deterioration requiring escalation of treatment. Descriptive statistics are presented. Out of the 300 patients initially screened, 253 patients had confirmed pulmonary embolism and were evaluated in this review. Ten were excluded (3 admitted for another reason, 5 were discharged by the consulting service, 1 left against medical advice, 1 died in the ED). Of the 243 patients in the final analysis, 101 patients (41.6

BACKGROUND:Point-of-care ultrasound (PoCUS) is increasingly integrated into acute care for its diagnostic efficiency and accessibility. While prior studies associate PoCUS use with higher patient satisfaction, little is known about how patients themselves experience it as part of their care. OBJECTIVE:To explore how patients experience PoCUS during acute care encounters and how it shapes their overall perception of care. DESIGN:Qualitative study using semi-structured interviews and reflexive thematic analysis within a constructivist paradigm. PARTICIPANTS:Eighteen adult patients who underwent PoCUS during emergency department or inpatient general internal medicine assessments at a tertiary care academic hospital in Ottawa, Canada. APPROACH:Participants were recruited and interviewed at the bedside shortly after receiving PoCUS examinations. Transcripts were inductively coded and analyzed using Braun and Clarke's six-phase framework for reflexive thematic analysis. KEY RESULTS:Three interrelated themes captured how patients experienced PoCUS. First, PoCUS enhanced both emotional reassurance and physical convenience through real-time feedback and avoidance of transport to diagnostic areas. Second, patients perceived PoCUS as integrated within holistic, patient-centered care, where their impressions of PoCUS were intertwined with their impressions of the care they received overall. Third, patients' largely positive experiences were grounded in trust in their physicians despite and in the midst of limited technical understanding of PoCUS. CONCLUSIONS:Overall, patients had positive experience with PoCUS integration. With little technical knowledge of PoCUS, patients' positive views were shaped by trust and interaction with physicians. While supporting existing literature, our findings stress the need for clear communication and scope awareness. As PoCUS use increases in prevalence, it should be seen as both a diagnostic tool and a contributor to patient-centered care.

Delirium complicates 20% to 62% of the estimated 1.5 million hip fractures annually. Meta-analyses suggest that point-of-care ultrasound-guided regional anesthesia (POCUS-GRA) may reduce delirium, but uptake by emergency department (ED) physicians is highly variable. To measure the impact of a knowledge-to-practice intervention on uptake of POCUS-GRA by ED physicians, incidence and number of days of delirium, analgesic effectiveness, safety, and procedure time. This stepped-wedge cluster randomized clinical trial was conducted at 7 academic EDs from 4 provinces in Canada. The order in which ED physicians were trained at each site was randomized. ED physicians working at least 1 shift per week who did not regularly perform POCUS-GRA and patients aged 65 years and older with a hip fracture who were not delirious on arrival were included. Data were analyzed in August 2025. A 2-hour structured training session on fascia iliaca blocks was followed by competency assessment, with a procedure bundle and email reminders provided. Incidence of delirium within 7 days of ED presentation was measured using the Confusion Assessment Method, and duration of delirium was measured in days. A total of 208 of 213 ED physicians (97.7%) who assessed 694 eligible patients with hip fracture (median [IQR] age, 81.0 [74.0-88.0] years; 483 female [69.6%]) were trained. Among these patients, 248 individuals were analyzed prior to training per intention-to-treat analysis, including 6 with protocol violations (control group), and 446 individuals after training (intervention group). The intervention increased blocks from 6 of 264 patients (2.2%) to 236 of 446 patients (52.9%) after training, for a change of 51.7%. After adjustment for a priori confounders, time, and clustering by site, delirium risk in the intervention group was reduced (odds ratio, 0.72; 95% CI, 0.57-0.93). Mean days of delirium was not reduced. Among 186 nerve blocks with pain effectiveness data, most nerve blocks were effective (107 nerve blocks [57.5%]with ≥50% pain reduction), quick (median [IQR] time, 15 [12-20] minutes; 113 nerve blocks [90.0%] <25 minutes), and safe (1 minor hematoma). In this study, a knowledge-to-practice intervention improved nerve block uptake, and nerve blocks were quick, safe, and mostly effective. Despite suboptimal uptake, the study adds to the evidence that POCUS-GRA reduces delirium. ClinicalTrials.gov Identifier: NCT02892968

INTRODUCTION:Ultrasound-guided regional anaesthesia enhances pain control, patient outcomes and lowers healthcare costs. However, teaching this skill effectively presents challenges with current training methods. Simulation-based medical education offers advantages over traditional methods. However, the use of instructional design features in ultrasound-guided regional anaesthesia simulation training has not been defined. This systematic review aimed to identify and evaluate the prevalence of various instructional design features in ultrasound-guided regional anaesthesia simulation training and their correlation with learning outcomes using a modified Kirkpatrick model. METHODS:A comprehensive literature search was conducted including studies from inception to August 2024. Eligibility criteria included randomised controlled trials; controlled before-and-after studies; and other experimental designs focusing on ultrasound-guided regional anaesthesia simulation training. Data extraction included study characteristics; simulation modalities; instructional design features; and outcomes. RESULTS:Of the 2023 articles identified, 62 met inclusion criteria. Common simulation modalities included live-model scanning and gel phantom models. Instructional design features such as the presence of expert instructors, repetitive practice and multiple learning strategies were prevalent, showing significant improvements across multiple outcome levels. However, fewer studies assessed behaviour (Kirkpatrick level 3) and patient outcomes (Kirkpatrick level 4). DISCUSSION:Ultrasound-guided regional anaesthesia simulation training incorporating specific instructional design features enhances educational outcome; this was particularly evident at lower Kirkpatrick levels. Optimal combinations of instructional design features for higher-level outcomes (Kirkpatrick levels 3 and 4) remain unclear. Future research should standardise outcome measurements and isolate individual instructional design features to better understand their impact on clinical practice and patient safety.

Importance:Delirium complicates 20% to 62% of the estimated 1.5 million hip fractures annually. Meta-analyses suggest that point-of-care ultrasound-guided regional anesthesia (POCUS-GRA) may reduce delirium, but uptake by emergency department (ED) physicians is highly variable. Objectives:To measure the impact of a knowledge-to-practice intervention on uptake of POCUS-GRA by ED physicians, incidence and number of days of delirium, analgesic effectiveness, safety, and procedure time. Design, Setting, and Participants:This stepped-wedge cluster randomized clinical trial was conducted at 7 academic EDs from 4 provinces in Canada. The order in which ED physicians were trained at each site was randomized. ED physicians working at least 1 shift per week who did not regularly perform POCUS-GRA and patients aged 65 years and older with a hip fracture who were not delirious on arrival were included. Data were analyzed in August 2025. Intervention:A 2-hour structured training session on fascia iliaca blocks was followed by competency assessment, with a procedure bundle and email reminders provided. Main Outcome and Measures:Incidence of delirium within 7 days of ED presentation was measured using the Confusion Assessment Method, and duration of delirium was measured in days. Results:A total of 208 of 213 ED physicians (97.7%) who assessed 694 eligible patients with hip fracture (median [IQR] age, 81.0 [74.0-88.0] years; 483 female [69.6%]) were trained. Among these patients, 248 individuals were analyzed prior to training per intention-to-treat analysis, including 6 with protocol violations (control group), and 446 individuals after training (intervention group). The intervention increased blocks from 6 of 264 patients (2.2%) to 236 of 446 patients (52.9%) after training, for a change of 51.7%. After adjustment for a priori confounders, time, and clustering by site, delirium risk in the intervention group was reduced (odds ratio, 0.72; 95% CI, 0.57-0.93). Mean days of delirium was not reduced. Among 186 nerve blocks with pain effectiveness data, most nerve blocks were effective (107 nerve blocks [57.5%]with ≥50% pain reduction), quick (median [IQR] time, 15 [12-20] minutes; 113 nerve blocks [90.0%] <25 minutes), and safe (1 minor hematoma). Conclusion and Relevance:In this study, a knowledge-to-practice intervention improved nerve block uptake, and nerve blocks were quick, safe, and mostly effective. Despite suboptimal uptake, the study adds to the evidence that POCUS-GRA reduces delirium. Trial Registration:ClinicalTrials.gov Identifier: NCT02892968.

BACKGROUND:The etiology of acute kidney injury (AKI) can be divided into pre-renal, renal, and post-renal causes. Ultrasound is the test of choice to identify post-renal AKI. While ultrasound is routinely used in the assessment of AKI, obstructive AKI is rare, leading to concerns of potential test overutilization. OBJECTIVE:Our primary aim is to describe patterns of use of imaging in patients admitted to hospital with AKI and to determine whether imaging patterns reflect risk of obstruction. Our secondary aim is to identify the role of point-of-care ultrasound (POCUS) when assessing patients with AKI. DESIGN:This is a retrospective cohort study. PARTICIPANTS:Patients admitted to internal medicine with AKI over a 12-month period at a large tertiary care academic center. MAIN MEASURES:Our outcome variables were radiology-performed ultrasound, computed tomography (CT), or point-of-care ultrasound (POCUS), presence or absence of hydronephrosis and urological intervention. KEY RESULTS:The proportion of patients with imaging was highest among those with a high-risk score and lowest in patients with a low-risk score (66.0% versus 52.2%). For radiology ultrasound specifically, the rate was 19.5% in low-risk patients and 17.7% in high-risk patients. The prevalence of hydronephrosis among patients at low, moderate and high risk for hydronephrosis was 7.1%, 8.5% and 19.7%, respectively and the rate of urological intervention was 1.4%, 1.2% and 3.8%, respectively. In moderate to high-risk patients, POCUS had a sensitivity of 86.7% and specificity of 90.0% for the identification of hydronephrosis. CONCLUSIONS:In our cohort, nearly 20% of radiology ultrasounds are ordered in patients with a low risk of obstructive uropathy, despite low rates of hydronephrosis and hydronephrosis requiring intervention in this group. With a sensitivity of 86.7% and specificity of 90.0% in patients at moderate to high risk of obstruction, POCUS may support clinical decision making in patients with AKI.

As point-of-care ultrasound (POCUS) applications expand in the emergency department (ED), its utilization within the management of patients presenting with rapid atrial fibrillation (AF) or flutter (AFL) is unclear. The co-morbidity of heart failure and AF/AFL complicates the rate/rhythm control and disposition of this population. ED physicians diagnose heart failure by integrating POCUS left ventricular function assessment, but studies have not focused on the rapid AF/AFL population. Our survey aimed to explore the use, integration, and perceived barriers of POCUS left ventricular function assessment in AF/AFL patients. Canadian ED physicians and residents who are members of the Canadian Association of Emergency Physicians (CAEP) completed an online survey through email between February and March 2024. We received 91 responses. For patients presenting with rapid AF/AFL with no prior imaging in the last 12 months, 51

Background: TEE is increasingly recognized as a valuable imaging modality during cardiac arrest (CA) resuscitation, particularly for assessing the area of maximal compression (AMC) during CPR. Small single center studies have shown that compression of the left ventricular outflow tract or the aortic root (AMC-LVOT/Ao) is common during CPR, and that when CPR is performed with the AMC over the LV, this results in higher ETCO2, and ROSC. This study aimed to investigate the AMC and its relationship to ETCO2, and ROSC, hypothesizing that patients experiencing AMC-LVOT/Ao have lower ETCO2 and are less likely to achieve ROSC. Methods: A prospective, multicenter cohort study of patients with out-of-hospital and in-hospital CA (OHCA/IHCA) in whom TEE was performed during CPR comparing AMC over the LV (AMC-LV) vs AMC-LVOT/Ao. The study was conducted through the Resuscitative TEE Collaborative Registry, an ongoing multicenter research network involving 37 hospitals (NCT04972526). Collected data included patient and procedure characteristics, hemodynamics, and outcomes according to Utstein-style guidelines. Primary outcome was ROSC, and the secondary outcome was ETCO2 at the time of AMC determination. We performed univariate analysis and multivariate regression evaluating variables known to impact resuscitation outcomes. Results: 271 patients including 205 OHCA and 66 IHCA were included. Only 133 (49%) of the total cohort had AMC-LV, with AMC-LVOT/Ao in 47% of OHCA and 42.1% of IHCA. There was no significant difference in the location of the AMC when analyzed by demographic characteristics, height, weight, or comorbidities between patients who received manual vs mechanical CPR. In OHCA, there was no difference in ROSC between AMC-LV and AMC-LVOT/Ao, however the group of patients with AMC-LVOT/Ao had on average 10 units lower ETCO2 compared to AMC-LV (Beta -10; 95% CI -19 - 1.5; p = 0.023). In IHCA, after controlling for factors known to impact outcomes, patients with AMC-LVOT/Ao had significantly lower probability of ROSC (OR 0.25, 95% CI 0.06-0.88; p=0.038). Conclusion: Obstruction of the LVOT/Ao during CPR is a common finding in CA patients evaluated with TEE. This multicenter study extends previous animal and smaller clinical studies suggesting the mechanistic association between the AMC during CPR, with ETCO2 and ROSC, and the potential of TEE-guided resuscitation to improve the effectiveness of CPR.

Background Acute kidney injury is a common disorder that is associated with significant morbidity and mortality. Point-of-care ultrasonography (PoCUS) is an imaging modality performed at the bedside and is used to assess for obstructive causes of acute kidney injury. Little is known about the test characteristics of PoCUS in patients with acute kidney injury. Objective Our primary objective was to describe the test characteristics of PoCUS for the detection of hydronephrosis in patients presenting with acute kidney injury at our centre. Our secondary objective was to describe the current rate of use of PoCUS for this indication. Results In total, 7873 patients were identified between June 1, 2019 and April 30, 2021, with 4611 meeting inclusion criteria. Of these, 94 patients (2%) underwent PoCUS, and 65 patients underwent both PoCUS and reference standard, for a total of 124 kidneys included in our diagnostic accuracy analysis. The prevalence of hydronephrosis in our cohort was 33% (95% CI 25–41%). PoCUS had a sensitivity of 85% (95% CI 71–94%) and specificity of 78% (95% CI 68–87%) for the detection of hydronephrosis. Conclusion We describe the test characteristics of PoCUS for the detection of hydronephrosis in a cohort of patients with acute kidney injury. The low uptake of this test presents an opportunity for quality improvement work to increase its use for this indication.

Teaching point-of-care ultrasonography (PoCUS) to medical students is resource intensive. Peer-assisted learning, where the teacher can be a medical student, may be a feasible alternative to expert-led learning. The objective of this systematic review and meta-analysis was to compare the PoCUS performance assessments of medical students receiving peer-assisted vs expert-led learning. This study was submitted to PROSPERO (CRD42023383915) and reported with PRISMA guidelines. MEDLINE, Embase, ERIC, Education Source, Scopus, and Web of Science were searched from inception to November 2022. Inclusion criteria were studies comparing peer-assisted vs expert-led PoCUS teaching for undergraduate medical students. The primary outcome was performance assessment of PoCUS skills. Two reviewers independently screened citations and extracted data. The Cochrane risk-of-bias tool for randomized trials was used to assess study quality. Studies were included in the meta-analysis if mean performance assessment scores with standard deviations and sample sizes were available. A random-effects meta-analysis was conducted to estimate the accuracy score of practical knowledge test for each group. A meta-regression evaluated difference in mean scores. The search yielded 2890 citations; 1417 unique citations remained after removing duplicates. Nine randomized-controlled studies conducted in Germany, USA, and Israel, with 593 participants, were included in the meta-analysis. The included studies assessed teaching of abdominal, cardiac, thoracic, musculoskeletal, and ocular PoCUS skills. Most studies had some risk-of-bias concerns. The estimate accuracy score after weighting is 0.56 (95

Study objective To evaluate the clinical effect, safety, and clinical outcomes of focused transesophageal echocardiography (TEE) in the evaluation of critically ill patients in the emergency department (ED) and ICUs. Methods We established a prospective, multicenter, observational registry involving adult critically ill patients in whom focused TEE was performed for evaluation of out-of-hospital cardiac arrest (OHCA), inhospital cardiac arrest, evaluation of undifferentiated shock, hemodynamic monitoring, and/or procedural guidance in the ED, ICU, or operating room setting. The primary objective of the current investigation was to evaluate the clinical influence and safety of focused, point-of-care TEE in critically ill patients. Data elements included patient and procedure characteristics, laboratory values, timing of interventions, clinical outcomes, and TEE video images. Results A total of 1,045 focused TEE studies were collected among 916 patients from 28 hospitals, including 585 (64%) intraarrest and postarrest OHCA and inhospital cardiac arrest, 267 (29%) initial evaluation of undifferentiated shock, 101 (11%) procedural guidance, and 92 (10%) hemodynamic monitoring. TEE changed management in 85% of patients with undifferentiated shock, 71% of patients with inhospital cardiac arrest, and 62% of patients with OHCA. There were no reported esophageal perforations or oropharyngeal injuries, and other procedural complications were rare. Conclusions A prospective, multicenter, and multidisciplinary TEE registry was successfully implemented, and demonstrated that focused TEE is safe and clinically impactful across multiple critical care applications. Further studies from this research network will accelerate the development of outcome-oriented research and knowledge translation on the use of TEE in emergency and critical care settings.

Background Point-of-Care-Ultrasound (POCUS) curricula have rapidly expanded in undergraduate medical education (UME). However, the assessments used in UME remain variable without national standards. This scoping review characterizes and categorizes current assessment methods using Miller’s pyramid for skills, performance, and competence of POCUS in UME. A structured protocol was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). A literature search of MEDLINE was performed from January 1, 2010, to June 15, 2021. Two independent reviewers screened all titles and abstracts for articles that met inclusion criteria. The authors included all POCUS UME publications in which POCUS-related knowledge, skills, or competence were taught and objectively assessed. Articles were excluded if there were no assessment methods used, if they exclusively used self-assessment of learned skills, were duplicate articles, or were summaries of other literature. Full text analysis and data extraction of included articles were performed by two independent reviewers. A consensus-based approach was used to categorize data and a thematic analysis was performed. Results A total of 643 articles were retrieved and 157 articles met inclusion criteria for full review. Most articles ( n = 132; 84%) used technical skill assessments including objective structured clinical examinations ( n = 27; 17%), and/or other technical skill-based formats including image acquisition ( n = 107; 68%). Retention was assessed in n = 98 (62%) studies. One or more levels of Miller’s pyramid were included in 72 (46%) articles. A total of four articles (2.5%) assessed for students’ integration of the skill into medical decision making and daily practice. Conclusions Our findings demonstrate a lack of clinical assessment in UME POCUS that focus on integration of skills in daily clinical practice of medical students corresponding to the highest level of Miller’s Pyramid. There exists opportunities to develop and integrate assessment that evaluate higher level competencies of POCUS skills of medical students. A mixture of assessment methods that correspond to multiple levels of Miller’s pyramid should be used to best assess POCUS competence in UME.

Acute cholecystitis accounts for up to 9% of hospital admissions for acute abdominal pain, and best practice entails early surgical management. Ultrasound is the standard modality used to confirm diagnosis. Our objective was to perform a systematic review and meta-analysis to determine the diagnostic accuracy of emergency physician-performed point-of-care ultrasound for the diagnosis of acute cholecystitis when compared with a reference standard of final diagnosis (informed by available surgical pathology, discharge diagnosis, and radiology-performed ultrasound). We completed a systematic review and meta-analysis, registered in PROSPERO, in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched 7 databases as well as gray literature in the form of select conference abstracts from inception to February 8, 2023. Two independent reviewers completed study selection, data extraction, and risk of bias (QUADAS-2) assessment. Disagreements were resolved by consensus with a third reviewer. Data were extracted from eligible studies to create 2 × 2 tables for diagnostic accuracy meta-analysis. Hierarchical Summary Receiver Operating Characteristic models were constructed. Of 1855 titles/abstracts, 40 were selected for full-text review. Ten studies (n=2356) were included. Emergency physician-performed point-of-care ultrasound with final diagnosis as the reference standard (7 studies, n=1,772) had a pooled sensitivity of 70.9% (95% confidence interval [CI] 62.3 to 78.2), specificity of 94.4% (95% CI 88.2 to 97.5), positive likelihood ratio of 12.7 (5.8 to 27.5), and negative likelihood ratio of 0.31 (0.23 to 0.41) for the diagnosis of acute cholecystitis. Emergency physician-performed point-of-care ultrasound has high specificity and moderate sensitivity for the diagnosis of acute cholecystitis in patients with clinical suspicion. This review supports the use of emergency physician-performed point-of-care ultrasound to rule in a diagnosis of acute cholecystitis in the emergency department, which may help expedite definitive management.

Abstract Aims  To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS). Methods  We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of “strongly agree” and “agree” on the Likert scale responses. Findings and Recommendations  One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3–5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6–8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). Conclusion  These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.

While there is an expanding body of literature on Point-of-Care Ultrasound (POCUS) pedagogy, administrative elements that are necessary for the widespread adoption of POCUS in the clinical environment have received little attention. In this short communication, we seek to address this gap by sharing our institutional experience with POCUS program development and implementation. The five pillars of our program, selected to tackle local barriers to POCUS uptake, are education, workflow, patient safety, research, and sustainability. Our program logic model outlines the inputs, activities, and outputs of our program. Finally, key indicators for the monitoring of program implementation efforts are presented. Though designed for our local context, this approach may readily be adapted toward other clinical environments. We encourage others leading the integration of POCUS at their centers to adopt this approach not only to achieve sustainable change but also to ensure that quality safeguards are in place.

Point of care ultrasound (POCUS) in Canadian undergraduate medical education (UGME) is limited. To address this paucity, the inaugural Seguin Canadian POCUS Education Conference hosted 14 of the 17 Canadian medical schools to develop a list of recommendations for POCUS education in Canadian UGME. Attending schools were divided into delegations consisting of a pre-clerkship student, a clerkship student and a staff physician. Recommendations were developed via a modified consensus development panel. Delegations submitted school-specific POCUS education summary documents for roundtable discussions, which yielded an initial set of recommendations. These were then summarized in a large group setting and voted upon for adoption with an a priori agreement threshold of 80%. Conference attendees developed 14 recommendations which 87% of participants agreed to adopt. Conference recommendations reflect the opinions of Canadian trainees and POCUS education experts thus serving as a framework for UGME POCUS education in Canada.