EM POCUS Fellowships in Canada

It’s coming up on 10 years since we started our POCUS fellowship in Sudbury. Dr Andrew Skinner was our first fellow who we conned accepted into the fellowship 🙂 Andrew went onto start the fellowship at St Paul’s in Vancouver. Since then, the number of Canadian EM POCUS has grown significantly. Among them are fellowships started by EDE Book authors: Dr Joel Turner at McGill (www.mcgill.ca/emergency/programs/ultrasound-fellowship), Dr Michael Woo in Ottawa (www.ultrasound.emottawa.ca/eng/index.html), and Dr Jordan Chenkin in Toronto (www.pocustoronto.com/fellowship.html). EDE 2 instructors Dr Danny Peterson in Calgary and Dr Frank Myslik in London also run fellowships. All Canadian EM POCUS fellowships and more info can be found at www.pocus.ca. Application deadlines are just around the corner so get your applications in!

Avoid the poor man’s TURP with a Foley by using POCUS

Nurses are really good at putting in Foley catheters. They do it all the time and most of them are really easy to place. Most of them…

When they aren’t, who do they ask for help? You bet ya! The emergency physician. If you are like Dr Lloyd Gordon, the first thing that you do is pick up your probe, and rightly so! Here is a case from Lloyd…

A colleague had a concern with a Foley catheter. The catheter had drained the bladder but there was a question with the balloon placement. I looked at the bladder which was only 2-3 cm wide, no balloon in sight. I asked him to deflate the balloon and insert the Foley a bit further. The bladder completely collapsed with nothing to see.. Some urine had come out of the Foley. He injected the Foley with water and it filled again to 2-3 cm. When the balloon was filled, I could see the balloon. However it was in the prostate.

Deflate the balloon, insert a bit further and the tip of the Foley appeared in the bladder. This time when the balloon was inflated it was clearly surrounded by bladder. The morale: always use POCUS for any problematic Foley insertions.

I am not looking forward to the day when I need a Foley catheter. But if I do need one, you can bet that I will asking asking that the location of the catheter tip before the balloon is inflated 🙂

By the way, similar to how nurses have been shown to be able to use POCUS for placing peripheral IVs, Bladder EDE would be really easy for nurses to learn.

Hope to see a bunch of you this weekend at WCUME 2017 in Montreal!

Rhein Man and POCUS-guided IVs

Stéphane Rhein who works at Hôpital Charles LeMoyne in Longueuil (just south of Montréal) recently sent us this article summary of some research that he and his colleagues published on POCUS-guided IVs by RNs in Québec. We thought we would share 🙂

Hi Guys,

Since I doubt any of you spend any time reading nursing literature I thought I would bring your attention to this article which came out last month in the Journal of Nursing Management titled: Cost-effectiveness of introducing a nursing-based program of ultrasound-guided peripheral venous access in a regional hospital. Click here for the Pub Med link.

Background

I know we all have seen the wonders of POCUS for patients who have a difficult venous access.  The literature is quite clear: for the select patients, ultrasound-guidance decreases pain and time to access the vein. Not only that, we also know that nurses, appropriately trained, are as good as we are at doing this… ok let’s be honest here they are much better than us are at doing this! Not only do they have much better technical skills when it comes to the cannulation of a plastic tubes in tiny vessels, but their experience for everything else around the procedure is invaluable.

This is why about 8 years ago, we started going around the province of Québec teaching nurses in various setting to do this (Emerg, ICU, peds, dialysis departments, etc.). Nurses who took the UPVA course were outstanding, MDs were free to take care of their packed waiting room, and patients loved simply loved it. However, we quickly faced a wall in trying to push this further. You know how hard it is convincing hospital administration to invest the little money they have in their budget for nurses to get trained!  We therefore set out to investigate if doing this was cost effective?

Methodology

What we did was compare the direct cost of the 3 years preceding, and the 3 years following, the creation of a nurse-based program of ultrasound-guided venous access in our hospital CHUS (Centre Hospitalier Universitaire de Sherbrooke, QC, Canada). The program, started in 2012, focused exclusively on treating all the requests that had been made for 1) difficult access 2) long term IV antibiotics, or 3) IV hyperalimentation. The variables were the number of catheters placed, the types of catheters (short peripheral, mid-lines, or PICC lines), the types of professional inserting it (nurse, radiologist, or anesthesiologists), and finally where they were inserted (bedside, radiology suite, or operating room).

Results

Since this program’ creation, the number of PICC lines decreased dramatically (811 the first year to 54 the sixth).

Indeed nurses, who by the way cost slightly less than radiologists 😉, were much more likely to follow the directional algorithm for choosing the most appropriate access for patients. Not only less costly catheters were inserted, but they were now done at the bedside rather in the radiology suite, which decreased cost even more.

In the first 3 years following creation of the program, reductions amounted to $675,641.91. If the cost of the training and of the machines is deducted, the net amount of saving is $609,236.91 or over $200,000 each year! Imagine this throughout Canada and even worldwide?

This cost reduction did not seem to be at the expense of patient care and safety.  And even though further studies need to be done to look at this specifically, it seemed that they were also non-monetary benefits to this program such as rigorous patient monitoring post-IV placement and overall patient satisfaction.

Conclusion:

Well all this just makes sense, doesn’t it? It is not rocket science to figure out that letting nurses use an ultrasound for difficult access cost less than putting patients on a waiting list for a PICC by a radiologist and staying in a costly bed in the hospital in the mean time.  Unfortunately, not all government and hospital administrations have thought of this and are willing to invest to make the change. I know many of you who have faced the same challenges to see this happen in their hospitals, in many ways we are not that far from the time we had to fight with our radiologist colleagues to bring ultrasound to our department! Remember 😉?

Hopefully this article will be a tool in your hands to make this breakthrough throughout Canada and become standard of care for our patient with difficult access!

More than welcome to hear your comments and answer your questions

Stephane Rhein MD CCFP-EM
Associate Professor of Emergency Medicine
University of Sherbrooke
CPoCUS Quebec Representative
UPVA Course Director