Background Point-of-care ultrasound (POCUS) improves patient care by expedited diagnosis and safer procedures. Despite POCUS benefits, some clinicians, including emergency physicians, do not readily use POCUS.Objectives The study objective identified barriers and facilitators to clinical POCUS use and performed an intervention to address these barriers.Methods A prospective cohort study at a single academic hospital included emergency department attendings, residents and advanced practice providers (APPs). Participants were surveyed on perceived POCUS use barriers and facilitators (primary outcome). A multifaceted intervention from December 2023 to January 2024 addressed identified barriers and involved: in-person POCUS education during shift by ultrasound faculty, clinical POCUS workflow demonstration during resident conference/faculty meetings and QR code reference files on machines.Results 42/99 participants (42.4%) responded to surveys preintervention and 28 postintervention (28.3%). 56 physicians and APPs participated in the in-person POCUS intervention (17 attendings, 34 residents, 5 APPs). Perceived POCUS barriers were time constraints on shift; internet/connectivity problems and losing saved images; forgetting to finish exam worksheets online; images not uploading into Butterfly cloud by the end of shift and residents performing ‘phantom scans’. Perceived POCUS facilitators included clear documentation protocols, hands-on teaching sessions and incentives for completing scans. Comfort in teaching diagnostic and procedural POCUS improved pre to postintervention but did not change for performing POCUS.Conclusion Identified barriers and facilitators were incorporated into a multifaceted intervention to improve clinical POCUS workflow processes. Future individualised interventions for low POCUS users and institutional initiatives with POCUS champions can be studied for improved patient care.

INTRODUCTION:Infective endocarditis (IE) is associated with high mortality (30%). Patients with structural cardiac disease or implanted hardware have higher risk for IE (23-47%). Diagnosis per the 2023 Duke-International Society for Cardiovascular Infectious Diseases criteria is by pathological confirmation or the major/minor criteria. Major criteria include ≥ 2 positive blood culture sets, echocardiography or computed tomography vegetation visualization, and surgical visualization. Septic emboli symptoms (which complicate 25% of IE cases) include neurological deficits or shortness of breath. Early intravenous antimicrobial therapy within one hour for patients who meet sepsis criteria is recommended per Infectious Diseases Society of America guidelines. CASE REPORT:A middle-aged male with recent IE and aortic valve prosthesis presented to the emergency department with altered mental status and hypoglycemia. He had right basilar lung rales but no heart murmur, leg swelling, or jugular venous distension. He met sepsis criteria with leukocytosis and hypothermia. Computed tomography head was performed due to his altered mental status and revealed a right parietal-occipital hypodense lesion concerning for an abscess with edema and mass effect. Given his history of IE and ill appearance, three blood culture sets were drawn and intravenous antibiotics initiated. The patient was admitted to the hospital with magnetic resonance imaging confirming brain abscess; and neurosurgery performed a craniotomy with brain abscess evacuation. Intravenous antibiotics were continued for four weeks for septic brain emboli from recent IE. CONCLUSION:Clinicians should keep a broad differential for altered mental status patients. Sepsis patients should have antimicrobials initiated within one hour. Expedited diagnosis with three sets of blood cultures, echocardiography, and surgical consult should be completed in patients with suspected infective endocarditis for improved patient outcomes. Finally, clinicians should evaluate for septic emboli symptoms such as neurological deficits or respiratory symptoms.

Over 350,000 patients experience out-of-hospital cardiac arrest annually in the United States. Patients presenting to the emergency department (ED) in cardiac arrest are critically ill and require emergent clinical decisions and treatment. Point-of-care ultrasound (POCUS) is useful as a rapid, bedside diagnostic imaging tool to help elucidate possible causes of cardiac arrest and guide management. Using a validated systematic approach such as the SHoC and CASA protocols, clinicians can safely perform POCUS with shortened pauses during pulse checks. POCUS is key in evaluating cardiac arrhythmias such as ventricular fibrillation (VF), which has higher survival rates with defibrillation, versus cardiac standstill, which has higher mortality per recent research studies. When performed by experienced users, POCUS also facilitates identification of reversible causes for improved cardiac arrest patient outcomes and can guide decisions in resuscitative efforts. In summary, this manuscript is a narrative review that illustrates identifiable POCUS findings and synthesizes them to guide potential emergent intervention in patients in cardiac arrest including: ventricular fibrillation, cardiac standstill, pericardial effusion, cardiac tamponade, right heart strain such as from acute pulmonary embolism, reduced cardiac function, wall motion abnormality, ruptured ventricular pseudoaneurysm, and aortic dissection.

INTRODUCTION:Point-of-care ultrasound (POCUS) can expedite patient diagnoses and improve procedural safety in emergency department (ED) patients. Nevertheless, clinical POCUS use lags in many ED sites nationwide, with only 40% of community physicians using POCUS according to a study from 2019-2021. We studied the impact of a multifaceted clinical POCUS intervention to address barriers and increase clinical POCUS use. METHODS:We conducted a prospective cohort study at a single academic hospital that included ED attendings, residents, and advance practice clinicians (APC). A multifaceted four-week intervention for emergency clinicians from December 2023-January 2024 addressed barriers to POCUS use identified on a pre- and post-intervention survey. The intervention included POCUS education during clinical shifts by ultrasound faculty, clinical POCUS workflow demonstration during resident conference/faculty meetings, and QR code reference files on machines for a total of two hours of additional training per clinician. The primary outcome was the number of clinical ED POCUS performed during the 18 months pre-intervention and 12 months post-intervention. Secondary outcomes were POCUS workflow knowledge exam scores and POCUS revenue. We analyzed clinical POCUS numbers from July 2022-December 2024 using an interrupted time series model. RESULTS:Forty-two of 99 emergency clinicians (42.4%) responded to surveys pre-intervention and 28 post-intervention (28.3%). Fifty-six physicians/APCs (56.6%) participated in the in-person POCUS intervention (17 attendings, 34 residents, 5 APCs). The unadjusted number of POCUS exams performed increased from 6,708 pre-intervention (18 months) to 11,600 post-intervention (12 months). After controlling for the underlying secular trend, we saw no effect of the intervention with no significant increase in overall number of POCUS exams performed per 100 ED patients after the intervention (mean level change = -0.81, 95% CI, -2.43 to 0.82; P = .33). Neither was there an increase in the slope of the secular trend post-intervention (difference in slope, β = 0.00, 95% CI, -0.10 to 0.10; P = .98 for post-intervention, β = 0.02, 95% CI, -0.08 to 0.12 for sustainability period). Monthly POCUS revenue increased ~$55,000 in total billed and $10,000 reimbursed (~16% reimbursement). This was the professional component only that was billed by the physician and not the technical component covering equipment and maintenance. Post-intervention mean knowledge scores were 88% correct (standard deviation 12.0) with 16/22 participants (72.7%) passing the assessment (score > 90%). CONCLUSION:A multifaceted intervention was not shown to improve clinical point-of-care ultrasound use and revenue when accounting for an underlying sustained secular upward trend in number of POCUS exams performed per 100 emergency department patients throughout the study period. Future interventions directed toward low POCUS users and identification of clinical POCUS champions may improve clinical POCUS use.

Patients presenting with abdominal pain require expedited diagnosis and treatment. Computed tomography (CT) scans, which are frequently ordered in the inpatient and emergency departments, have high diagnostic sensitivity and specificity. However, CTs are costly, have radiation exposure, can create hospital workflow inefficiencies, and create a potential safety risk with patient transport. Point-of-care ultrasound (POCUS) use is growing as an efficient, safe, and bedside assessment tool for diagnosing and treating gastrointestinal (GI) pathologies. This manuscript synthesizes key sonographic findings and techniques for a series of important GI pathologies that physicians should recognize: diverticulitis, hernia, appendicitis, intussusception, and intra-abdominal mass.

Background Loin pain hematuria syndrome (LPHS) is an uncommon disease but has debilitating symptoms. Patients can present with recurrent flank pain, nausea, vomiting, and hematuria and present over a minimum duration of six months. The disease is more prevalent in women between the ages of 10 to 60 years old. As LPHS is a diagnosis of exclusion, it is important for emergency medicine physicians to evaluate for emergent illnesses presenting with similar symptoms such as nephrolithiasis, pyelonephritis, ruptured abdominal aortic aneurysm, aortic dissection, renal artery occlusion or other pathology. Case report Our patient was a young female who was status post renal autotransplant who presented to the emergency department (ED) with fever, severe flank pain, vomiting, and hematuria. Her laboratory tests revealed a creatinine of 1.3 milligrams per deciliter and her urinalysis had positive red blood cells. An ultrasound of her renal transplant did not show hydronephrosis or increased renal indices. She was treated with intravenous opioids and eventually admitted to internal medicine for further pain management. Her presentation was deemed secondary to LPHS.Why should an emergency medicine physician be aware of this? LPHS is defined by severe flank pain, vomiting, and hematuria and is difficult to diagnose. It often requires continued investigation and management beyond the ED but should be considered in patients without elucidated etiology, continued unrelenting pain, and recurrent presentations. Physicians should focus on improving patient-centered outcomes with early pain management, adequate evaluation for life-threatening conditions, and care coordination between healthcare teams.

Objectives Blood cultures obtained in the emergency department (ED) may become positive after discharge. Healthcare professionals must determine if these results represent true infection or a likely contaminant. An institutional algorithm was developed to assist with healthcare professional response to positive blood cultures for S. aureus and coagulase-negative staphylococci (CoNS) in these situations. Methods We conducted a single system, multisite cohort study comparing before and after implementation of an ED decision-making algorithm from November 2022 to December 2023. Adults were included if they were discharged from the ED before blood cultures became positive for Staphylococcus species. The primary outcome was the difference in rates of patients called back to the ED pre- and postalgorithm implementation. Secondary endpoints evaluated algorithm adherence and safety. Results A total of 253 patients, 188 pre- and 65 postimplementation, were enrolled. There was a 7.3% reduction in patients called back to the ED after algorithm implementation (95% CI [−21.1 to 6.3], P = .3). Algorithm adherence after implementation was 84.6% with a difference in actual and algorithm-based callback rates of 4.6%. After algorithm implementation, no patients deemed to have a contaminant experienced an infectious-related safety event. Conclusions This time-saving algorithm was well received by our ED professionals and served as a helpful tool in safely and effectively triaging patients who had positive blood cultures for Staphylococcus species after discharge to determine who should be called back for further evaluation. There was a nonstatistically significant but clinically meaningful reduction in callback rates. Postimplementation algorithm adherence was high, and the majority of callback decisions were appropriate.

STUDY OBJECTIVES:Ventricular fibrillation (VF) is traditionally identified on ECG but echocardiography can visualize myocardial fibrillation. The prevalence and importance of occult VF defined as a nonshockable ECG rhythm but VF by echocardiography is unknown. METHODS:In this multicenter, prospective study, emergency department patients presenting following out-of-hospital cardiac arrest were eligible for inclusion if echocardiography and ECG were performed simultaneously. Recorded echocardiography and ECG were interpreted separately by physicians blinded to all patient and resuscitation information. The primary outcome was percentage of occult VF. The secondary outcomes included survival to hospital discharge, termination of defibrillated VF, and return of spontaneous circulation (ROSC). Termination of VF is described as a postdefibrillation change in ECG rhythm to a nonshockable rhythm. Multivariate modeling accounted for confounding variables. RESULTS:Of 811 patients enrolled, 5.3% (95% confidence interval [CI] 3.9 to 7.1) demonstrated occult VF. An additional 24.9% (95% CI 22.1 to 28.0) demonstrated ECG VF. Of the patients with occult VF, 81.4% demonstrated ECG pulseless electrical activity (PEA) and 18.6% demonstrated ECG asystole. Occult VF was less likely to be defibrillated compared with ECG VF. Defibrillation was not significantly more likely to terminate occult VF (75.0% vs 55.6%; odds ratio [OR], 2.3; 95% CI 0.42 to 15.24). ROSC was not statistically different for occult VF compared with ECG VF (39.5% vs 24.8%; OR, 2.26; 95% CI 0.87 to 5.9). Survival to hospital discharge was no different for patients with occult VF compared with ECG VF (7.0% vs 5.4%; OR, 3.6; 95% CI 0.63 to 19.2) despite fewer defibrillation attempts for patients with occult VF. CONCLUSION:Occult VF was seen in 5.3% of patients following out-of-hospital cardiac arrest. Recognizing and treating occult VF who otherwise would have been treated as PEA or asystole led to survival outcomes indistinguishable to traditionally recognized VF.

As more specialties have begun to use Point-of-Care Ultrasound (POCUS) in patient care, hospitals and healthcare systems have been investing increasing resources in POCUS infrastructure (training, equipment, and administration). Since each specialty uses different POCUS applications, healthcare systems seek to identify commonalities and differences between specialties to make thoughtful investments in POCUS infrastructure to support each specialty’s use of POCUS while minimizing redundancies. Historically, past studies have focused on POCUS use in individual specialties, primarily emergency medicine and critical care, but comparative studies of different specialties are needed to guide investment in POCUS infrastructure and bolster POCUS implementation across healthcare systems. We conducted a cross-sectional survey of all Veterans Affairs (VA) medical centers in the United States and compared data from 5 different specialties on current usage, training needs, and barriers to POCUS implementation. Data were collected from facility chiefs of staff (n = 130; 100

Integrating point-of-care ultrasound (POCUS) into patient care requires a multifaceted culture change using a multi-pronged approach. A standardized implementation method is lacking for POCUS program sustainability. We developed a standardized training curriculum and clinical POCUS documentation, archival, and image review process at a single Veterans Affairs Emergency Department (ED). We hypothesized that co-designed development and implementation of the multifaceted POCUS intervention would maximize ED provider uptake and sustainability. Using Participatory Action Research (PAR) and adapted Experience-Based Co-design (EBCD) methods, stakeholders collaboratively co-designed our POCUS intervention to optimize implementation. Using the PRODUCES framework, 12 stakeholder participants (co-creators including study researchers, ultrasound faculty, ED leadership, and ED providers (POCUS end-users)) met in four monthly co-design meetings from July to October 2021 to brainstorm, discuss, refine, and finalize the POCUS intervention and implementation plan. Throughout the co-design process, stakeholders reviewed findings from prior meetings, reflected on successes and failures, and held open discussions on refining and finalizing the proposed POCUS educational and clinical program. By involving stakeholders as co-creators throughout the co-design process, we maximized end-user POCUS enthusiasm, program uptake, and sustained use. This simple, streamlined, and generalizable user-centered co-design method serves as a framework for future POCUS implementation and dissemination plans.

Introduction: Point-of-care ultrasound (POCUS) is a rapid bedside tool, particularly in undifferentiated emergency department patients. Point-of-care ultrasound can investigate potential intra-abdominal infections in febrile patients, especially in the elderly, who often present atypically without abdominal pain or localizing symptoms. Case Report: We highlight the important POCUS findings of cholecystoduodenal fistula and staghorn calculus in a febrile, elderly patient with dementia. Conclusion: Early recognition of cholecystoduodenal fistula and staghorn calculus using POCUS can expedite appropriate antibiotic and interventional treatment for improved patient outcomes.

Abstract Background Blood culture (BCx) diagnostic stewardship aids in accurately identifying microbial pathogens and guiding appropriate antibiotic therapy. We compared effects of a BCx algorithm (Fig 1) on BCx rates (BCx/100 ED visits) in the emergency department (ED) using two implementation approaches: 1) an intensive approach including weekly, individualized BCx appropriateness data feedback and modifications to electronic health record order sets, and 2) a passive approach with group-level, BCx appropriateness data feedback of a random BCx sample.Figure 1:ED Blood culture algorithmAlgorithm used by emergency department providers to determine if blood cultures are necessary Methods We performed a quasi-experimental pre-/post-intervention study from 12/1/2020 to 2/29/2024 using data from 3 academic-affiliated EDs. The BCx algorithm was introduced in 12/2022 in ED1. 7 ED providers reviewed BCxs ordered each week for appropriateness of BCx indication according to the algorithm and provided weekly, individualized feedback to colleagues regarding their performance in. In addition, BCx were removed from order sets for low-risk clinical scenarios, such as simple cystitis or community-acquired pneumonia. The algorithm was introduced to ED2 in 7/2023. In ED2, a pharmacist reviewed 5 BCx per week for appropriateness and one ED physician provided a secondary review when the clinical scenario was unclear. Feedback was provided to ED leadership every 2 months regarding appropriateness and BCx utilization. ED3 served as control and did not have the algorithm introduced. BCx rates were analyzed using interrupted time series models evaluating each ED separately. Incidence rate ratios (IRR) compared BCx rates before the intervention to BCx rates after the intervention.Figure 2.Monthly blood culture event rate (per 100 ED admissions) for the emergency department before (12/2020-11/2022) and after (12/2022-2/2024) the blood culture algorithm introduction. Intensive chart reviews occurred during 12/2022 to 5/2023. After that time only the algorithm was used without audit and feedback.β1= -0.004 (95% CI -0.0057, -0.0014, p-value <0.01)]. At the time of the intervention there was an acute drop measured by the β2 coefficient -0.16(95% CI -0.38, -0.01, p-value 0.04), followed by a slow increase in slope (β3= 0.007, 95% CI -0.003, 0.010,p-value 0.06). Results A total of 105,975 BCxs over 572,776 ED visits were included in the analysis. ED1 saw a 25% decrease in BCx rate with IRR 0.80 (95% CI 0.74, 0.86, p-value 0.01). (Fig 2) ED2 experienced a 4% decrease in BCx rate with IRR 0.72 (95% CI 0.54, 0.95, p-value 0.02). (Fig 3) ED3 did not experience any change (Fig 4).Figure 3.Monthly blood culture event rate (per 100 ED admissions) for emergency department 2 before (12/2020-6/2023) and after (7/2023-2/2024) the blood culture algorithm introduction. Random, small sampling of chart reviews occurred during 7/2023 to 2/2024.β1= -0.044 (95% CI -0.0059, -0.0028, p-value <0.01)]. At the time of the intervention there was an acute drop measured by the β2 coefficient -0.43(95% CI -0.83, -0.03, p-value 0.03), followed by an increase in slope (β3= 0.014, 95% CI 0.002, 0.025,p-value 0.02). Conclusion The BCx rate was most significantly impacted in ED1 by combining audit and feedback with modifications to the electronic medical record. However, both EDs saw drift back towards prior BCx utilization rates after the intervention. Sustainability can likely be improved by implementing computerized clinical decision support systems.Figure 4.Monthly blood culture event rate (per 100 ED admissions) for the emergency department from 12/2020 to 2/2024. No algorithm was used in this emergency department.β1= -0.004 (95% CI -0.0027, 0.0019, p-value 0.74)]. At the time of the intervention there was no significant change measured by the β2 coefficient 0.13 (95% CI -0.0241, 0.279, p-value 0.99), followed by stable slope (β3= -0.004, 95% CI -0.009, 0.002,p-value 0.17). Disclosures Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties Jessica Seidelman, MD, MPH, 3M: Expert Testimony

Introduction/Purpose:Point-of-care ultrasound (POCUS) is an important diagnostic bedside tool, yet a gap remains between Emergency Department (ED) POCUS programme implementation and achieving sustained POCUS use and retention. We performed an impact evaluation of a co-designed POCUS programme implementation intervention and assessed programme acceptability, effectiveness and feasibility. Methods:Our mixed-methods cohort study implemented a co-designed, multifaceted intervention using the consolidated framework for implementation research at a single Veterans Affairs ED (November 2021-October 2022) to enhance POCUS usability and sustainability, including provider education, image review and archival. Primary ED providers (20/25) participated in hands-on POCUS training sessions between February and May 2022. We assessed POCUS program acceptability, appropriateness, and feasibility via provider pre/post-course surveys, interviews, and health record data using a validated tool (AIM-IAM-FIM; assessing ED POCUS, radiology ultrasound orders, and ED metrics). Results:ED POCUS significantly increased (from 72 to 267 scans, p < 0.001) 6 months post-intervention, with no significant change in radiology ultrasounds ordered (from 355 to 361, p = 0.417) or ED length-of-stay (from 6.7 to 7.5 h, p = 0.0849). Cardiac, deep vein thrombosis (DVT), soft tissue, musculoskeletal, and biliary ED POCUS were most common; and radiology studies were DVT, biliary and scrotal ultrasound. The pre/post-intervention surveys showed provider comfort with performing and teaching diagnostic and procedural POCUS changed minimally. All respondents approved of POCUS use and education (acceptability), endorsed clinical tool applicability (appropriateness) and stated the course/training was doable (feasibility). Discussion/Conclusions:POCUS use increased post-program implementation. Future studies should evaluate program sustainability, incorporate methods to reduce radiology ultrasound and improve patient-centered outcomes.

Background Two-dimensional ultrasound (2DUS) is first-line imaging for pediatric appendicitis but is often nondiagnostic. Computed tomography (CT) is expensive with ionizing radiation. Three-dimensional ultrasound (3DUS) can capture multiplanar images using volume acquisition without radiation exposure. Objective We hypothesized that bedside-performed 3DUS would be feasible, with rapid image acquisition times, and good image quality comparable to 2DUS and CT. Methods We performed a cross-sectional pilot study on emergency department patients being evaluated for appendicitis. An emergency physician captured 3DUS images using a Sonosite M-Turbo machine equipped with an inertial measurement unit and customized software. Our primary outcome was 3DUS acquisition times compared to 2DUS and CT. Secondary outcomes were 3DUS image quality, with visual demonstrations of appendicitis findings compared to clinical imaging. Results 20 subjects underwent an experimental 3DUS between October 2015 and March 2017. Mean age was 11.6 years (4.6-30.4 years). Five patients (25%) had clinical appendicitis (2 by 2DUS and 3 by CT). Mean 3DUS acquisition and reconstruction times were 10.3 and 14.5 seconds, compared to 2DUS (41 minutes) and CT (22 minutes). Mean 3DUS pixels were 320.5 PPI depth, 388 PPI width, mean total frame number 344, and field of view 78.8 degrees. Finally, we demonstrated two appendicitis complications on 3DUS: abscess and a dilated noncompressible appendix with appendicoliths. Conclusion Our study suggests 3DUS is fast with good image quality. We presented 3DUS images of acute appendicitis comparable to 2DUS and CT as visual demonstrations of feasibility. Future studies with larger cohorts are needed to assess diagnostic accuracy.

BACKGROUND:Blood culture (BCx) diagnostic stewardship is essential for reducing unnecessary treatments, minimizing false-positive results, and improving patient outcomes and hospital resource utilization. The objective of this study was to compare the effectiveness of diagnostic stewardship interventions on BCx utilization in three emergency departments (ED). METHODS:We used a quasi-experimental pre-/post-intervention study to compare BCx rates (BCx/100 ED visits) between December 1, 2020, and February 29, 2024 before and after the implementation of a BCx algorithm and electronic health record (EHR) modifications at one large academic ED and level 1 trauma center, and two EDs at academic-affiliated community hospitals. A sample of visits with a BCx order were audited in one academic ED and one academic-affiliated ED, and summary data on indication appropriateness were provided to respective leadership. In the academic ED, there was weekly provider led audit and feedback on 3478 ED visits. In one academic-affiliated ED, one pharmacist reviewed five visits weekly (100 total) for appropriateness. The second academic-affiliated ED served as a control and did not receive any feedback on BCx utilization. Each ED's BCx rates were analyzed using interrupted time series models. Incidence rate ratios (IRR) compared BCx rates before and after the interventions. RESULTS:A total of 211,950 BCxs over 572,776 ED visits were included in the analysis. The academic ED saw a 25 % decrease in BCx rate with IRR 0.80 (95 % CI 0.74, 0.86, p-value 0.01). The first academic-affiliated ED experienced a 0.8 % decrease in BCx rate with IRR 1.1 (95 % CI 1.01, 1.19, p-value 0.02). No change was observed in the second academic-affiliated ED. CONCLUSIONS:Decreased BCx rates occurred only after direct audit and feedback and EHR modifications. Both the academic ED and first academic-affiliated ED saw a drift back towards pre-intervention BCx rates after the intervention.

Background Perinephric hematomas are defined by hemorrhage originating from the kidney parenchyma into the subcapsular and perirenal spaces. Spontaneous perinephric hematomas are rare and usually occur due to an underlying renal mass, vascular abnormality, coagulation disorder, or inflammatory disorder. The classic clinical presentation includes acute flank pain, hemorrhagic shock, and detection of a renal mass. Diagnosis is by computed tomography (CT), ultrasound, or angiography. Case report A 74-year-old male with coronary artery disease, severe heart failure, and atrial fibrillation/flutter on apixaban presented to the emergency department (ED) with left-sided abdominal and back pain for two weeks. He denied urinary symptoms, fever, or vomiting. The patient was hypotensive with low hemoglobin (8.9g/dL), thus he received blood transfusions and apixaban reversal for hemorrhagic shock. CT scan diagnosed a 10x9 cm perinephric hematoma, and he was transferred to our hospital’s ED. Point-of-care ultrasound demonstrated a left perinephric hematoma and clotted blood in the splenorenal recess. Urology and interventional radiology (IR) were consulted, with emergent transport to IR for angiogram and left coil embolization then intensive care unit admission.Why should an emergency medicine physician be aware of this?This case describes important diagnostic testing and bedside ultrasound utility in expediting care for patients with renal pathology. It describes a case of spontaneous renal hemorrhage and management steps including IR embolization, urology involvement, and evaluation for surgical intervention. Finally, we emphasize potential serious complications including chronic renal failure, pyelonephritis, renal obstruction, and permanent kidney distortion if disease is not recognized and treated early.

Consistent point-of-care ultrasound (POCUS) use and retention is difficult to achieve, with prior studies citing a lack of provider training, credentialed ultrasound users, and image review as contributing factors. We aimed to assess user feedback on a POCUS implementation intervention by identifying and characterizing the perceived barriers and facilitators at a single Veterans Affairs (VA) hospital using the consolidated framework for implementation research (CFIR). We implemented a co-designed multifaceted training intervention at a VA emergency department (ED) to enhance POCUS usability and sustainability from November 2021-October 2022. We performed semi-structured interviews with 13 attending physicians and 1 Advanced Practice Provider (average of 15 years of clinical practice) in August-October 2022. Interviews were audio-recorded, transcribed, and double-coded using inductive content analysis and mapped to the CFIR, using deductive coding strategies. Through inductive analysis, five major themes emerged: 1) POCUS workflow convenience and efficiency, 2) ED environment and resources, 3) perceptions of high clinical utility of POCUS, 4) perceptions of high educational utility of POCUS, and 5) peer influences, feedback, and teaching. Within these major themes, POCUS facilitator subthemes include: machine availability, use in resident teaching, use in ED procedures, hands-on group training, colleagues’ contagiousness and enthusiasm, and support from ultrasound faculty, ED, and hospital leadership. POCUS barrier subthemes were: time constraints, alternative radiology imaging availability, cumbersome steps for image acquisition and documentation/storage, and limited POCUS knowledge and skills comfort. Additional needs identified through CFIR mapping (archiving software, image review process, and faculty credentialing), require development locally to strengthen provider skills and reduce duplicated radiology studies. Our model is a reproducible clinical tool to evaluate barriers and facilitators to POCUS program implementation at any site. Future work should tailor POCUS education to individuals, use momentum from positive peer feedback including “ED clinical champions”, and integrate ED/hospital leadership support for program sustainability.

Abstract Background Blood cultures (BCx) are commonly ordered for patients at low risk of bacteremia. Liberal ordering can increase false-positive results due to contamination, along with increasing length of stay, excess antibiotics, and unnecessary diagnostic procedures. We implemented an algorithm for appropriate blood culture obtainment (Figure 1) in an academic tertiary care emergency department (ED) and assessed the intervention’s impact on various operational, clinical, and safety metrics.Figure 1:ED Blood culture algorithm Methods We performed a prospective cohort study in the Duke University Hospital ED from 12/2022 to 3/2023 using historical controls from 12/2020-11/2022. The BCx algorithm was disseminated in-person, electronically, and accessible online. Weekly chart review of all eligible patients for algorithm adherence was completed by 7 ED clinicians with monthly feedback provided to all ED providers. We defined a BCx event as 1 or more BCx sets within 24 hours. We excluded patients < 18 years, absolute neutrophil count < 500 109/L, and heart and lung transplant recipients. We measured BCx order volume, indication, algorithm adherence, BCx positivity rate, antibiotic days of therapy (DOT), and 30-day hospital readmission. Results Average monthly BCx volume was 1387 pre-intervention compared to 1226 post-intervention (p= 0.046). An increase in culture positivity was see post-intervention with a rate of 13.9% compared to 11.23% in the pre-intervention group (Figure 2, p< 0.001). The majority of the 2168 BCx adhered to the algorithm. (Figure 3). The most common reasons for non-adherence were isolated fever or leukocytosis (29%), non-severe community-acquired pneumonia or healthcare-associated pneumonia (6.9%) and non-severe cellulitis (4%). No change in DOT (786 vs. 783 days of therapy per 1000 patient days, p-value 0.85) (Figure 4) or monthly 30-day hospital readmission (21.1% vs 19.6%, p-value 0.30) was observed.Figure 2:Blood cultures drawn per month and % appropriate pre/post-intervention (N=2168)Figure 3:Algorithm Adherent vs. Algorithm Non-Adherent blood cultures per month (N=2168)Figure 4:Emergency Department anti-bacterial days of antibiotic therapy per 1000 patient days Conclusion Introduction of a BCx algorithm in an academic tertiary care ED, resulted in a decrease in BCx volume, increase in BCx positivity rate, and no increase in DOT or readmission was observed. (Table 1)Table 1:Blood culture volume, positivity rate, days of antibiotic therapy, and 30-day readmission Disclosures Jessica Seidelman, MD, MPH, Uptodate: content editor for pelvic osteomyelitis page

Introduction/Purpose:Teleultrasound connects expert point-of-care ultrasound (POCUS) users with remote community and rural sites. Evolving technologies including handheld devices, upgraded image quality, and the ability to transmit over low bandwidth connections increase POCUS education, accessibility, and clinical integration. Potential teleultrasound venues include low-resource settings, prehospital care, and austere environments (high altitudes, microgravity, conflict zones, etc.). This scoping review assesses current teleultrasound uses and identifies implementation enablers and barriers. Methods:Using the PRISMA-ScR checklist, PubMed, Embase, and Cochrane were searched on 16 August 2024 for teleultrasound studies. Two reviewers independently screened results and abstracted data using a data collection table. 165 articles met the following inclusion criteria: research studies describing teleultrasound, involving humans, including healthcare workers, with remote point-of-care or medical ultrasound use, in any setting, and in English. Results:Teleultrasound studies were reported in most specialties and across all continents. Most were prospective (100 studies), review articles (27), or case studies (14). Study quality was variable, with 28 high quality, 77 moderate, 54 low, and 6 very low (GRADE assessment tool). Common themes that emerged include (1) type of image transmission method utilised, (2) remote provider training and curriculum development, (3) feedback methods between expert and novice users, (4) technologies and devices used, and (5) enablers and barriers to guide future teleultrasound implementation and training strategies. Conclusion:Overall, the teleultrasound literature is heterogeneous in setting, design, and quality outcomes. As teleultrasound technology evolves and the use expands, future studies should standardise protocols and ensure image quality fidelity to optimise remote patient care.

Author(s): Theophanous, Rebecca G.; Tupetz, Anna; Ragsdale, Luna; Krishnan, Padmaja; Vigue, Raelynn; Herman, Carson E.; White, Jaran; Peethumnongsin, Erica; Staton, Catherine A.; Gordee, Alexander; Kuchibhatla, Maragatha; Eucker, Stephanie