Robert R Ehrman1, Frances M Russell2, Asimul H Ansari3, Bosko Margeta4, Julie M Clary5, Errick Christian6, Karen S Cosby7, John Bailitz8. 1. Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St Antoine, Suite 3R, Detroit, MI 48201. Electronic address: robehrman@gmail.com. 2. Department of Emergency Medicine, The John H. Stroger, Jr. Hospital of Cook County, Rush University School of Medicine, 1969 W Ogden Ave, Chicago, IL, 60612; Department of Emergency Medicine Indiana University School of Medicine 1701 N. Senate Blvd, B401 Indianapolis, IN 46202. Electronic address: frussell27@gmail.com. 3. Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Chicago, IL 60611. Electronic address: ansari01@gmail.com. 4. Department of Medicine, Division of Cardiology, The John H. Stroger, Jr. Hospital of Cook County, Rush University School of Medicine 1969 W Ogden Ave, Chicago, IL, 60612. Electronic address: bosko_margeta@hotmail.com. 5. Department of Medicine, Division of Cardiology, Indiana University School of Medicine, 545 Barnhill Dr EH 317, Indianapolis, IN 46202. Electronic address: jmclary@iu.edu. 6. Department of Emergency Medicine, The John H. Stroger, Jr. Hospital of Cook County, Rush University School of Medicine, 1969 W Ogden Ave, Chicago, IL, 60612. Electronic address: echristian@cookcountyhhs.org. 7. Department of Emergency Medicine, The John H. Stroger, Jr. Hospital of Cook County, Rush University School of Medicine, 1969 W Ogden Ave, Chicago, IL, 60612. Electronic address: kcosby40@gmail.com. 8. Department of Emergency Medicine, The John H. Stroger, Jr. Hospital of Cook County, Rush University School of Medicine, 1969 W Ogden Ave, Chicago, IL, 60612. Electronic address: jbailitz@cookcountyhhs.org.
Abstract
OBJECTIVES: The goal of this study was to determine if emergency physicians (EPs) can correctly perform a bedside diastology examination (DE) and correctly grade the level of diastolic function with minimal additional training in echocardiography beyond what is learned in residency. We hypothesize that EPs will be accurate at detecting and grading diastolic dysfunction (DD) when compared to a criterion standard interpretation by a cardiologist. METHODS: We conducted a prospective, observational study on a convenience sample of adult patients who presented to an urban emergency department with a chief concern of dyspnea. All patients had a bedside echocardiogram, including a DE, performed by an EP-sonographer who had 3 hours of didactic and hands-on echocardiography training with a cardiologist. The DE was interpreted as normal, grade 1 to 3 if DD was present, or indeterminate, all based on predefined criteria. This interpretation was compared to that of a cardiologist who was blinded to the EPs' interpretations. RESULTS: We enrolled 62 patients; 52% had DD. Using the cardiology interpretation as the criterion standard, the sensitivity and specificity of the EP-performed DE to identify clinically significant diastolic function were 92% (95% confidence interval [CI], 60-100) and 69% (95% CI, 50-83), respectively. Agreement between EPs and cardiology on grade of DD was assessed using κ and weighted κ: κ = 0.44 (95% CI, 0.29-0.59) and weighted κ = 0.52 (95% CI, 0.38-0.67). Overall, EPs rated 27% of DEs as indeterminate, compared with only 15% by cardiology. For DEs where both EPs and cardiology attempted an interpretation (indeterminates excluded) κ = 0.45 (95% CI, 0.26 to 0.65) and weighted κ = 0.54 (95% CI, 0.36-0.72). CONCLUSION: After limited diastology-specific training, EPs are able to accurately identify clinically significant DD. However, correct grading of DD, when compared to a cardiologist, was only moderate, at best. Our results suggest that further training is necessary for EPs to achieve expertise in grading DD.
OBJECTIVES: The goal of this study was to determine if emergency physicians (EPs) can correctly perform a bedside diastology examination (DE) and correctly grade the level of diastolic function with minimal additional training in echocardiography beyond what is learned in residency. We hypothesize that EPs will be accurate at detecting and grading diastolic dysfunction (DD) when compared to a criterion standard interpretation by a cardiologist. METHODS: We conducted a prospective, observational study on a convenience sample of adult patients who presented to an urban emergency department with a chief concern of dyspnea. All patients had a bedside echocardiogram, including a DE, performed by an EP-sonographer who had 3 hours of didactic and hands-on echocardiography training with a cardiologist. The DE was interpreted as normal, grade 1 to 3 if DD was present, or indeterminate, all based on predefined criteria. This interpretation was compared to that of a cardiologist who was blinded to the EPs' interpretations. RESULTS: We enrolled 62 patients; 52% had DD. Using the cardiology interpretation as the criterion standard, the sensitivity and specificity of the EP-performed DE to identify clinically significant diastolic function were 92% (95% confidence interval [CI], 60-100) and 69% (95% CI, 50-83), respectively. Agreement between EPs and cardiology on grade of DD was assessed using κ and weighted κ: κ = 0.44 (95% CI, 0.29-0.59) and weighted κ = 0.52 (95% CI, 0.38-0.67). Overall, EPs rated 27% of DEs as indeterminate, compared with only 15% by cardiology. For DEs where both EPs and cardiology attempted an interpretation (indeterminates excluded) κ = 0.45 (95% CI, 0.26 to 0.65) and weighted κ = 0.54 (95% CI, 0.36-0.72). CONCLUSION: After limited diastology-specific training, EPs are able to accurately identify clinically significant DD. However, correct grading of DD, when compared to a cardiologist, was only moderate, at best. Our results suggest that further training is necessary for EPs to achieve expertise in grading DD.
Authors: Zachary W Binder; Sharon E O'Brien; Tehnaz P Boyle; Howard J Cabral; Sepehr Sekhavat; Joseph R Pare Journal: West J Emerg Med Date: 2020-06-24