Building a POCUS Powerhouse: Point-of-Care Ultrasound Workflow, Training and Innovation in Pulmonary Critical Care

Podcast Transcript

Raed Dweik, MD:

Hello, and welcome to the Respiratory Exchange Podcast. I'm Raed Dweik, Chief of the Integrated Hospital Care Institute at Cleveland Clinic. This podcast series of short digestible episodes is intended for healthcare providers, and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of lung health, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of your patients. I hope you enjoy today's episode.

Abhijit Duggal, MD:

Hello, everyone. Welcome to our latest episode of Respiratory Exchange. Today I have two of my colleagues with me. My name is Dr. Abhijit Duggal. I'm the Vice Chair for the Department of Critical Care at Cleveland Clinic, Vice Chair for Research for Pulmonary Critical Care and Infectious Diseases, and I'm also the Associate Professor at Cleveland Clinic Lerner College of Medicine.

Today I have with me Dr. Siddharth Dugar, who is the Director of the Point of Care Ultrasonography Program at the medical ICU at Cleveland Clinic. He's also an Assistant Professor of Medicine at the Cleveland Clinic Lerner College of Medicine. Dr. Dugar is a diplomate of the National Board of Echocardiographers and has been in practice for close to a decade. My other guest is Dr. Ajit Moghekar. He is the Quality Improvement Officer for the Medical ICU and has been a testament for the National Board of Echocardiographers and has been heavily involved in our Point of Care Ultrasonography Program for more than a decade now.

Welcome Dr. Moghekar, welcome Dr. Dugar. Dr. Moghekar, I'll be starting with you. Can you talk to me a little bit about point-of-care ultrasonography in the intensive care unit and how did you really develop this program for your practice?

Ajit Moghekar, MD:

Thank you, Dr. Duggal, for having us here, and hello everyone. It's a pleasure to be here to discuss our Point of Care Ultrasonography Program. So, you know, I was thinking about it, when was the first time I actually used point-of-care ultrasound, and it goes all the way back to 2007. I was in my fellowship. I was very fortunate to be trained at a place where they were at the cutting edge of using point-of-care ultrasound, for our patients. So, I was exposed to it back in New York in 2007, and I've been using point-of-care ultrasound in my practice since then. I was recruited to Cleveland Clinic in 2011, and the reason I was recruited, one of the main reasons I came here, was to establish point-of-care ultrasound.

When I first came here, we had one ultrasound machine for our medical ICU, which is about 64 beds and, you know, I've been very fortunate to be surrounded by like-minded people and colleagues who are interested in point-of-care ultrasound, and we really developed a very robust and complex program. Dr. Duggal was one of my fellows who trained with us at Cleveland Clinic, and he really took over the reins of the Point-of-Care Ultrasound Program around [unknown 03:33]. I mean, I couldn't be happier about where this program is heading and where we are right now. I'll let him describe how the program has grown since 2016 and tell you how successful we've been here at Cleveland Clinic.

Siddharth Dugar, MD (03:51):

Thank you so much for the invitation to talk about something that we are very passionate about point-of-care ultrasound in critically ill patients at critical care settings. And, as Dr. Moghekar, I was also fortunate to come to be trained at Cleveland Clinic where I had experienced how to use point-of-care ultrasound in our critically ill patients. I was trained by Dr. Moghekar who started the ultrasound program. As he alluded to, we had only one ultrasound system that was also not integrated to PACS and we had to do it manually. I used to help him out with uploading images, and I just look back and see how we have progressed. 2016 was when I took over as a director of point-of-care ultrasound. We moved at least from one to two ultrasound systems. Currently, we have close to 15 ultrasound systems in our ICU, so anybody coming to our ICU, needs a point-of-care ultrasound will have a point-of-care ultrasound machine available to be able to perform it without any difficulty.

In the last years during COVID, what we found was that we wanted to reduce exposure to all our healthcare providers, and that was a stimulus to significantly expand our point-of-care ultrasound program. Before that, we used to perform ultrasound examination once in a while, but during COVID, because we had such a robust program already in place and to reduce exposure to all our radiology and cardiology colleagues, we took over performing the whole-body ultrasound. As most of you are aware, most patients with COVID come with respiratory failure, they have ARDS, they have myocarditis, they develop PBTs and pulmonary embolism.

And what we were able to do was on day one, as soon as they came to the ICU, we performed ultrasound exam in the heart, the lung and the venous system to make sure that the treatment that is provided to our patients did not get compromised, yet they're able to reduce the exposure to healthcare providers. In addition, we realized the potential of point-of-care ultrasound, and we have expanded it to all our regional hospitals. So, all our regional hospitals now have a robust ultrasound program so that care is provided as a part of any other institution in the world.

Abhijit Duggal, MD (06:16):

Thank you so much, Dr. Moghekar and Dr. Dugar. It seems like you both have really taken this program and then established a very well-run point-of-care ultrasound taking care of our patients. So I would like to ask you, what is the most common application of point-of-care ultrasound in your practice? Dr. Dugar, I'll start with you.

Siddharth Dugar, MD:

So we both work in the medical intensive care unit, so most of our patients who come to the intensive care unit do have respiratory failure or shock. Hence, we use point-of-care ultrasound mostly to look at the heart and the lung and the venous RTL system. Currently we perform over 1,400 cardiac ultrasounds and over 600 lung ultrasounds, and those are just diagnostic ultrasounds. We perform over 2,000 to 3,000 vascular ultrasounds to make sure all the procedures that are done in the ICU are done at the safest and most efficient rate. I'm very, very proud to say that when we did a study to look at what is our median time from admission to ICU to performance of our ultrasounds, we found it was 5.5 hours, which is exceptional. So we perform a lot of cardiac lung DVD ultrasound, and we perform it as soon as we can to provide the best care to our patients.

Abhijit Duggal, MD:

Thank you so much. Dr. Moghekar, would you like to add anything in terms of the usual application of point-of-care ultrasound in your practice?

Ajit Moghekar, MD:

Yeah, I want to add that we do perform a lot of cardiac ultrasounds, lung ultrasounds and vascular ultrasounds, but what I'm most excited about is where the field is going in terms of doing advanced ultrasound studies and doing transesophageal echocardiography studies to understand the diaphragm function for patients. Those are some of the studies that we are increasing in our numbers now. We see a lot more of the studies coming up than we did before.

Abhijit Duggal, MD:

Thank you so much. As point-of-care ultrasound has become more and more common in clinical practice, we hear a lot of challenges that many programs face in terms of both the optimization of their program, and then how they basically characterize their imaging techniques and how they move forward with things. I think it’s' a good time for us to really discuss how your workflow for your point-of-care ultrasound program works.

Siddharth Dugar, MD (09:00):

So we have certain pillars that we keep in mind when we talk about our focus workflow. As we alluded to, this focus is performed by the physicians who have a lot of responsibilities, so we wanted to make it as efficient and seamless as possible yet not compromise on the safety and quality of those ultrasounds. With those pillars, we have worked on our workflow to make sure all of those are optimized as much as possible. The first thing is the order set. We have all our ultrasounds integrated into Epic, so if somebody is going into the room to perform an ultrasound, they will be able to put an order in using their cell phone or using the computers, and it will immediately show up on the ultrasound system So all the images that are acquired are linked to the patient-appropriate chat.

In addition, for all our ultrasounds, we have tried to integrate the protocols that we want them to follow to acquire certain images, so we don't misdiagnose things and there are also charts that are put on the computers. We have the protocols available to all our trainees and performers, so every meeting we do stress the importance of adhering to the protocol. Once you pull the order set from the patient, you can perform the ultrasound, and as soon you hit N, all the studies are immediately transferred to our PACS system, which is available to be viewed by anybody who has access to the medical chart of the patient. So that way, we are not only able to have the clinician look at it very quickly, but also with our collaboration with the cardiology and radiology departments, they're able to access the images so in case of emergency, we can have a multidisciplinary discussion and make decisions very quickly. We also know how much time it takes to document notes; hence we moved to NoteWriter last year, which has made the documentation part standardized and seamless, and we have gotten very great reviews about it.

Ajit Moghekar, MD:

Yeah, that's great. Thank you, Dr. Dugar. I think any successful point-of-care ultrasound is dependent on an efficient workflow, and I think the workflow that we have established here speaks volumes. I think having the standardized way to document the study, the standardized way to capture images, and having a standardized way to store images is really important. You don't want to be in a situation where all these images are being performed on the patients, but nothing is being stored or nothing is being captured and nothing is being documented in the patient chart.

I mean, just from a qualitative standpoint, we want to ensure that some of the images are acquired appropriately and interpreted appropriately, and so the workflow really is the backbone of all the quality assurance work that we are doing in our program, and it helps our trainees go through this in a very standardized way. All the new staff that come in really like the workflow that we have established, and when new staff come from other institutes, not a lot of businesses have the kind of workflow that we have established here, following the program. So we’re fortunate to have support from our information technology colleagues to help us establish this.

Abhijit Duggal, MD (12:26):

Thank you so much. Seems like we hear a lot about the use of ultrasonography for both the guidance procedures and diagnostic evaluation, but not a lot of programs have spent the time that you guys have spent in terms of both quality assurance and other factors in terms of maintaining patient safety. I think one of the things that a lot of our listeners would be very interested in hearing about is what are the advanced techniques that are coming into the literature in terms of point-of-care ultrasonography in a modern ICU? The use of procedural support with ultrasonography and early diagnostic interventions has been going on for almost a decade and a half-to two decades now, but what are the things that you guys think are most interesting as we move forward from here?

Siddharth Dugar, MD:

That's a great question. I personally love how the field of point-of-care ultrasound has expanded. There are certain things I'm super excited about. One I've done is the use of TEE, of transesophageal echocardiography in cardiac cases. There are multiple studies that are coming out and there is a multi-center study going on right now looking at TEE at the point the patient has a cardiac arrest to be able to determine the cause of cardiac arrest, to be able to determine, to prognosticate their outcomes. Not only that, but we also have studies that are being done that is looking at TEE to determine the best location for chest compression, and those are something that I'm very excited about. We all know cardiac arrest has a very poor prognosis, and the only thing that we can do to make sure that they survive and have a good healthy life is to be able to supply blood to the brain, and I think TEE has a lot of potential there.

The other thing that excites me a lot is the use of lung ultrasound in respiratory failure. There is so much literature coming out about the ability of the lung ultrasound being better than chest X-ray, not only to diagnose ARDS, but also phenotype ARDS and determine the best treatment possible in terms of antiviral management, fluid resuscitation, you know, recruitment that can be guided with lung ultrasound, some of the things that excite me a lot. My personal area of interest is using cardiac focus to be able to phenotype in sepsis, and that is such a cool field right now where before we used to say that somebody has a weak heart or not a weak heart, but now we are going into which part of the heart is weak, why is it weak, what are the things that we can do to optimize those, and though that field may, I believe has the potential to change how we manage [inaudible 00:15:27].

Ajit Moghekar, MD:

Yeah. I do want to add that diagnostic ultrasound definitely is an exciting field for TEEs and phenotype in sepsis ultrasounds, but also from the procedural standpoint, I mean, we're increasingly using ultrasound to access subterranean veins. So I think we published a paper on how to use [unknown 15:48] to access subterranean veins. I think it is good for patient care, it helps keep our infections under control by using the subterranean access, reduces complications associated with subterranean veins. So, you know, even from a procedural standpoint, I think there are more advances as we move forward using this technology. Thanks.

Abhijit Duggal, MD (16:13):

Thank you so much. As you have developed such a well-rounded program, I think a question that a lot of our listeners might be wondering is, are there any downsides to the use of point-of-care ultrasonography?

Ajit Moghekar, MD:

Like any new modality that we start using, there are always going to be challenges and downsides from using it. As you can imagine any ultrasound study that you do in the ICU is operated [unknown 00:16:40], and so we want to ensure that our operators are adequately trained, that they're skilled to perform ultrasound. There's a steep learning curve, so having a really robust training program for new operators is key. As you can imagine, if your operator is not adequately trained, it opens up doors for mistakes and errors, and that can be key. So there is literature out there which looks into patient harm in hospital point-of-care ultrasound, and this is something that we are very mindful of in our ICU. And so we ensure that all our operators meet some minimum standards before they are able to perform point-of-care ultrasounds independently of the ICU.

The other downside that I can think of is that point-of-care ultrasound is a very limited ultrasound study. You're just trying to answer one or two questions, such as “why is my patient in shock,” and you want to look at what the cardiac functions are, is the cardiac function normal, is it low, is it high. So we are very limited in terms of the questions that we ask and the answers we get. Whereas when cardiology comes and does an [unknown 17:51] patient support comprehensive study, then they look at a lot more things than what we would be interested in. So, you know, this is something that we are always mindful of and we are always appreciative of cardiology colleagues coming in these studies. I think the key part is recognizing the [unknown 18:08]. I think point-of-care ultrasound is great, I think it helps patient outcomes, it speeds up things, it gets the right treatment to the patient sooner, but you always have to know things that are not within your scope of practice and involves experts like cardiologists and radiologists quickly at the bedside.

And we are very fortunate; we believe that they're very open to our suggestions and recommendations. I can pick up a phone, call a cardiologist and tell them what my findings are, tell them that maybe I see a pericardial effusion, "I think this patient [inaudible 00:18:42]. Can you come and please evaluate?" And they're usually very receptive and they trust our skills and they will come to the bedside to [unknown 18:52]. So making sure our trainees are adequately trained and making sure that our exams meet certain standards is a key part of our progress. I'll let Dr. Dugar talk a little bit about some of the other challenges that we face, especially related to, you know, using ultrasound in really complex patients and some of the limitations of it.

Siddharth Dugar, MD (19:19):

That was excellent, Dr. Moghekar. Thank you so much. One thing I keep saying is that ultrasound doesn't have a brain, you have to use a bone, and that I think is a very important point to be raised is when we ... Our trainees with all the robust ultrasound training programs that we have today a bootcamp for all our fellows who are joining in, we have regular scheduled bi-weekly ultrasound rounds where we discuss about cutting-edge ultrasound news where we invite local and national experts, we also have focus interest group where we discuss all the interesting cases, but that is still not enough to be able to make sure that the ultrasound is performed at the most optimal level.

You have to know what is the indication, what is the question that you're asking, and how you are going to integrate the images, and that's where the complex patient comes in. For example, a patient who may have a shock and we just look at the heart and we miss performing a venous ultrasound, that may be a case where the heart was weak, but that was the baseline of the patient, and we missed a DVT. So it's always very, very important to use ultrasound to fit your clinical picture.

Abhijit Duggal, MD:

Thank you so much. I think that's such an important point for us to really think about: that ultrasound in the end is a tool that we need to use it as a composite part of our full assessment of these patients. I would like to quickly talk a little bit about how you have developed your ultrasound program in terms of both training and education, and any competency assessments that you provide for your trainees and your staff physicians.

Siddharth Dugar, MD:

That’s a great question. Now, this is where the size of your program really matters. If you have a certain number of trainees, I will highly recommend that we do peer mentorship where an expert kind of walks around with the trainee and performs point-of-care ultrasound and give them the nuances, but as you, as the program becomes bigger, you have to allow some of that to a more standardized protocol, and that's what we did. We realized we have a very, very large program, and that's why we invested in an ultrasound mentor - where we have them complete the curriculum, which usually takes 10 hours, and at the end they have a test that they have to pass before they can perform any ultrasound on the patient.

In addition, we also have badges that we provide to all our trainees and the badges are earned based on the competency that they have demonstrated to the staff physician that the ultrasounds that are being performed are at par with the expertise of the trainee. We have realized that it's very common to perform a point-of-care ultrasound to look at chambers, and we have published a study where we showed that we do a pretty good job when it comes to ventricular size and functions, or we still have a lot to learn about pulse, and that's where I think the collaboration of us with cardiology, and knowing your limitation, plays a very important part in being able to say and provide appropriate care to your patients.

Abhijit Duggal, MD (22:33):

Thank you so much. I guess given that you have such an established program at Cleveland Clinic, is point-of-care ultrasonography only a clinical intervention, or are there other factors that you and your program are invested in? Is there ongoing research? Are there ongoing factors that your team is involved in for the betterment of care for your patients?

Siddharth Dugar, MD:

Yeah. So that is something that, again, excites me a lot is that we are not only providing the best care to our patients, but we are also at the forefront of pushing the boundaries of point-of-care ultrasound. We are part of multi-center studies looking at the application of point-of-care ultrasound Clovers, which was one of the biggest studies to look at fluid resuscitation and sepsis, and an arm that looked at echocardiography and changes, and we were very proud to be part of that.

Since we perform so much point-of-care ultrasound, we have also realized there are certain topics that have not been given due justice that we notice on our patients. For example, systolic anterior motion sepsis is a very under-recognized condition that we are working on, trying to see if we can shed some light on how to identify it and what are the best strategies to manage it. I cannot say enough about our lung ultrasound study that has been published where we showed how lung ultrasound may be better than [unknown 24:12] pressure when it comes to estimation of left ventricular and diastolic volume and pressure. Dr. Moghekar has led so many amazing projects including lung ultrasound in lung transplant patients, which I think is the first study which has used lung ultrasound to diagnose rejection in patients with lung transplant.

Ajit Moghekar, MD:

Thank you, Dr. Dugar. We've really been at the forefront of using ultrasound to expand, see and think. We started using lung ultrasound when I first came here and we started recruiting patients right from the get-go. We were really interested to see how lung ultrasound could be used to look at extravascular. And as Dr. Dugar mentioned, we also looked at how lung ultrasound could potentially help us look at lung transplant patients and look at them to see if we could pick up early signs of lung transplant rejection. Those were very promising studies that we did, and we pushed the boundaries of lung ultrasound. We also looked at echocardiographies and looked at how echocardiography phenotypes come along with patients with a pulmonary embolism, some very good population data on that, and there are multiple ongoing investigative and administrative studies our fellows are involved in looking at point-of-car4e4 ultrasound.

Abhijit Duggal, MD (25:41):

That's great. As you talk, this is exciting; we are seeing a lot that has changed in the last decade or so. Tell me a little bit about where ultrasonography and critically ill patients is going. With all the technological advances that we are seeing, where do you both see this technology going over the next few years, Dr. Dugar?

Siddharth Dugar, MD:

Well, I think the best analogy that comes to my mind is the DSLR camera and the point-and-shoot camera. Right now, ultrasound is at the DSLR phase, so it's very training dependent. You have to make sure you change your aperture, you make sure that the light is good, but with the integration of AI and a lot of software coming out, I'm pretty sure that, not too far in the future, we will be seeing where you just basically put an ultrasound on the patient and it will be able to optimize and acquire the best image possible and also interpret the images for you, and your job at this will be to make sure that interpretation is accurate and how best to apply that information provided to your patient care.

Again, another thing is, as Dr. Moghekar previously mentioned, was miniaturization of the chip. As chips are getting smaller and smaller, we are getting ultrasound data also smaller. We are not far away from having ultrasound stickers being placed on the patient that can provide a continuous assessment of a vessel, of the cardiac function, or just being placed in the heart will give us accurate pressure monitoring so we can be very precise when it comes to management of our patients.

Abhijit Duggal, MD:

Thank you so much. Dr. Moghekar?

Ajit Moghekar, MD:

I think if I can add, I think the ultrasound is in stethoscope stage, if you ask me (laughs). Medical schools are heavily investing in they're treating, they're teaching our medical students use of ultrasound right from the first year of grade school. There are some medical schools that hand out point-of-care ultrasounds to medical students. So I think our point-of-care ultrasound is here to stay. It is going to be used at the school to be able to see a lot of applications, not only in the ICU but outside the ICU, and with the help of artificial intelligence and technology, I think it's going to be easy.

 I can easily see a day where patients have ultrasounds with them at home and they're monitoring their own health using point-of-care ultrasound, and we as physicians are totally looking at those images and give them guidance. I think the one area where I think point-of-care ultrasound can [unknown 28:26] resources, areas where medical facilities are not available. Point-of-care ultrasound can fill the void there and then [unknown 28:36]. So, I'm really excited to see how far we can take this field and artificial intelligence and smaller chips coming along. I think the sky is the limit. Thank you.

Abhijit Duggal, MD (28:49):

Thank you both. This was fascinating. I think it's very interesting listening to both of you as experts in this field in terms of how you have developed such a robust program, and perhaps more exciting is the exciting future directions that point-of-care ultrasonography is moving towards. I think you highlighted some very important factors both in terms of patient care, but also as we develop and use point-of-care ultrasonography, the need for and importance of quality improvement and assessment for our patients so that we provide them with the best care possible. I appreciate both of you giving me your time. Thank you so much for joining us for this episode of Respiratory Exchange.

Raed Dweik, MD:

Thank you for listening to this episode of the Respiratory Exchange Podcast. You can find additional podcast episodes on our website clevelandclinic.org/podcasts, or wherever you get your podcasts.