Point-of-care Ultrasound in Finland
Point-of-care Ultrasound in Finland
This study has two aims.

 1. Deep venous thrombosis (DVT) is a common suspected medical condition. If it cannot be
 excluded clinically and using D-dimer, ultrasound examination is required. An option for
 traditional radiologist-performed ultrasound is a 2-point compression ultrasound
 (2-CUS). The safety of this technique is proven. However there does not exist any data
 on costs comparing traditional and 2-CUS pathways in primary health care. This study
 will evaluate the total cost of both pathways by conducting a cost-minimization
 analysis. It will also study the effect of a simple ultrasound education on the
 referrals to hospital due to suspected DVT.

 Hypothesis 1: Short education in ultrasound will reduce significantly referrals to
 hospital and save resources.

 2. Length of stay (LOS) in emergency department (ED) is related to increased mortality,
 morbidity, prolonged hospital stay and probably patient satisfaction. LOS of patients
 with a point-of-care ultrasound (POCUS) performed by an emergency physician (EP) will be
 compared to those that have a radiology performed ultrasound examination. Further
 examination and accuracy of POCUS will be noted.

 Hypothesis 2: POCUS can shorten LOS significantly in selected clinical conditions
This study has two aims.

 1. Deep venous thrombosis is a common suspected medical condition. If it cannot be excluded
 clinically and using D-dimer, ultrasound examination is required. An option for
 traditional radiologist-performed ultrasound is a 2-point compression ultrasound
 (2-CUS). The safety of this technique is proven. However there does not exist any data
 on costs comparing traditional and 2-CUS pathways in primary health care. This study
 will evaluate the total cost of both pathways by conducting a cost-minimization
 analysis. It will also study the effect of a simple ultrasound education on the
 referrals to hospital due to suspected DVT. T

 he study is performed in Saarikka Primary Care Public Utility, Saarijärvi, Finland.
 There are 15 general practitioners (GP) working. During year 2014, 2 of them were
 performing 2-CUS. 9 of the other GPs were trained during years 2015-2016 to perform a
 2-CUS and hence 11 of 15 GPs are able to do 2-CUS in 2017.

 This is a register study. Referrals to hospital in 2014 (pre-training) and 2017
 (post-training) are examined and the difference is assumed to be because of training and
 new pathway. Based on population the expected number of referrals due to a suspected DVT
 should be approximately 100 annually and the expected number after intervention is 30.
 According to power analysis a reduction from 100 to 76 is statistically significant
 (p<0.05).

 Hypothesis 1: Short education in ultrasound will reduce significantly referrals to
 hospital and save resources.

 2. Length of stay (LOS) in emergency department (ED) is related to increased mortality,
 morbidity, prolonged hospital stay and probably patient satisfaction. LOS of patients
 with a point-of-care ultrasound (POCUS) performed by an emergency physician (EP) will be
 compared to those that have a radiology performed ultrasound examination.

 This part started in Central Finland Central Hospital and Kuopio University Hospital 10/2017.
 Tampere university hospital will start at 5/2018.

 An average LOS in Central Finland Central hospital ED is approximately 150 minutes. In a
 randomly selected monday in January, 2017, the average time from a referral to radiologist to
 a finished radiologist statement was 86 minutes. The times in Kuopio university hospital are
 much longer.

 When an EP decides to perform a POCUS exam, they will recruit the patient in the study and
 fill a simple structured form. It is up to the EP treating the patient to decide if the
 patients needs POCUS. No additional examination because of this study is made on the patient.

 The detailed time stamps for the patient to register in the ED, first doctor visit and
 finished from the doctor are retrieved from the files. In a follow-up of 6 months it is noted
 if the patient had a further examination by radiologist and if it was an ultrasound, CT, or
 some other examination. The results from POCUS will be compared to the radiologist
 examination, surgery or autopsy results where available and appropriate.

 The control group is found from picture archive system (PACS) system with going through
 ultrasound examinations on the same days as POCUS examinations are made, with a referral
 question that a POCUS could answer, and referring unit being emergency department, and the
 same time points will be recorded.

 There exists plenty of research on a focused ultrasound examination performed mostly by
 emergency physicians. In certain clinical questions such as abdominal aorta aneurysm or
 gallbladder stones, the accuracy of POCUS is excellent.

 There also exists some research on POCUS effect on LOS compared to a standard ultrasound
 examination performed mostly by a radiologist. The reduction in LOS has been huge.

 There is no data on regarding the Finnish health care system in this field. Also this study
 aims to evaluate multiple POCUS indications in a single real life setting which is not
 published before.

 Hypothesis 2: POCUS can shorten LOS significantly in selected clinical conditions

 Quality assurance plan: non-existent Data checks: non-existent Source data verification: EP
 filling the research form fills in only the finding in POCUS. It cannot reliably be verified
 in any way. All other data comes from medical records.

 Data dictionary: Non-existent for now Standard operation procedures: Non-existent

 Sample size assesment:

 Part 1: a whole year prior and after intervention is evaluated. According to power analysis,
 change from 100 to 76 would be statistically significant. A reduction of 100 to 30 is
 expected.

 Part 2: According to expected LOS reduction of at least 86 minutes, the study should need
 only approximately 10 patients + control group to show statistical significance. However a
 group of 400 patients will be recruited. The purpose of this is to be able to perform quality
 sub-group analysis based on indication of POCUS but also the experience level of EP
 performing the POCUS examination.

 Plan for missing data: The study form in part 2 is the only reliable source for the POCUS
 results and if this is missing, the patient must be excluded. All other data is derived from
 the medical files statistics and should reliable.

 Statistical analysis: A cost-minimization analysis will be performed in part 1. Other
 statistical analysis methods will be decided later.
Inclusion Criteria:

 -  Emergency department patient

 -  A suspected medical condition, that can be confirmed or excluded by basic POCUS exam,
 including: free fluid in pleura, pericardium or intraperitoneal space, abdominal aorta
 aneurysm, gallbladder stones, urine retention, deep venous thrombosis in lower limb,
 pneumothorax, early pregnancy with non-specified location (confirming intrauterine
 pregnancy), hydronephrosis.

 -  Emergency medicine specialist or resident decides to perform a POCUS exam

 Exclusion Criteria:

 -  age under 18

 -  not able to give informed consent in Finnish