Abstract
Background: The number of patients requiring home-based medical care will increase given global ageing. One challenge in homecare is the lack of radiological tools to aid with clinical assessment. Ultrasound devices have become increasingly portable. This allows doctors to perform point-of-care ultrasound examinations (POCUS) and enhance their patient assessment in homecare.
We are an established homecare team called Community Health Team (CHT) in Tan Tock Seng Hospital, Singapore, with >700 annual home visits. We augmented our patient assessment using POCUS and collaborations with ultrasound-accredited doctors in the hospital.
Point-of-care ultrasound examinations can transform the care of home-bound patients, by bringing a valuable radiological assessment tool to the home setting, thereby enhancing physician assessment and patient care.
Approach: Two doctors in CHT obtained training in POCUS. A handheld ultrasound device was borrowed from the Intensive Care Unit. We worked with ultrasound-accredited clinicians and the hospital quality team to come up with a workflow for image acquisition, transmission, and interpretation.
We performed a prospective study to assess the utility of POCUS in aiding diagnosis for CHT patients. A doctor acquired and analyzed the ultrasound images, with image interpretation reaffirmed through a secure telemedicine platform by an ultrasound-accredited clinician.
Results: From January 2022 to April 2022, 39 POCUS examinations were performed for 21 patients. POCUS helped determine fluid status by dynamic measurements of inferior vena cava diameter (21 examinations, 53.8%). Lung ultrasound allowed assessment for pulmonary edema, pneumonia, or pleural effusion (13 examinations, 33.3%). Bladder ultrasound in 3 examinations (7.7%) enabled residual urine volume assessment or confirmation of urine catheter placement. 2-point lower limb ultrasound excluded deep vein thromboses in 2 cases (5.1%).
33 of 39 POCUS examinations (84.6%) influenced clinical decisions and treatment. 5 of 39 POCUS examinations (12.8%) did not influence clinical decision making but aided confirmation of physical findings. In 1 case (2.6%) with early aspiration pneumonia, POCUS did not detect consolidation. In 4 out of 21 cases (19.0%), POCUS examination helped in avoiding a hospital attendance for further radiological assessment.
In conclusion, we found that POCUS enables patient-centred care at home by:
(a)Real-time delivery of clinical information
(b)Improving confidence of clinical decision making, with telemedicine allowing support in the image interpretation
(c)Enabling potential cost-savings and reduction in need to travel for dedicated radiological imaging
Implications: From clinicians’ perspective, POCUS in homecare aids with patient assessment and management. From patients’ and family’s perspective, POCUS in homecare reduces the hassle of travelling for radiological imaging, especially for those who are bed-bound. From a systems point of view, POCUS in homecare reduces preventable hospital attendance and leads to potential cost savings.
The next steps are to develop this program further by looking at the three pillars of workflow, education and patient safety. Within workflow, the scope of practice for POCUS in homecare settings should be defined and accompanying clinical pathways and standard documentations norms established. Within education, curriculum should be developed for training of homecare doctors in POCUS. For patient safety, guidelines for quality assurance and governance should be formulated.