SCGH ED Ultrasound Service audit results

Emergency Ultrasound

James Rippey & the Sonoboys

An audit of 1750

sequential DDU ED Cases

7 months

Background

• The Vision

– Ultrasound is user dependent

– DDU vs CCPU

– The Roster

• Why the audit?

– Financial accountability

– Hospital Politics

Background• Method

– Only DDU scans counted

– Relied on the Sonoboys to enter the cases

Date DDU

UMRN

Study Description

Indication Diagnostic Impact Managementimpact

Disposition Actual diagnosis

Quality

Abdominal- upper

pain- lower pain- rif pain- flank pain- hernia- other

Echo- arrest- SOB- hypoten.- chest pain

…..

Resus

Classic

Procedural

Equivocal

Confirmed suspicion

Excluded suspicion

Alternative diagnosis

Incidental finding

Not useful

Major

Minor

No impact

Impeded Mx

Assisted admission

Assisted discharge

No effect

(obstructed adm)

(obstructed disc)

Free text 1-5

TOTAL 1750

• Trauma Ultrasound 130 7%

• AAA 34 2%

• Abdominal ultrasound 554 32%

• Gynaecological ultrasound 104 6%

• Renal ultrasound 119 7%

• Vascular ultrasound (exc AAA) 183 10%

• Echocardiography 181 10%

• Testes 36 9%

• Ocular 16 1%

• Musculoskeletal 153 9%

• Procedural ultrasound 193 11%

Trauma - Major

Trauma 130 = 7% of workload

EFAST normal 109 (84%)

Free fluid 5

Free air 2

Splenic rupture & free fluid 1 (indication actually LUQ pain)

Renal injury 1

Sternal or rib fracture 9

Pneumothorax 2

Haemothorax 2

Retroperitoneal haemorrhage 1

Abdominal Aorta

Total scans 35 = 2% of workload

Normal scans 25 (71%)

Ruptured AAA 1

Ruptured iliac aneurysm 1

Aortic Dissection 1

AAA (not ruptured) new diagnosis 2

AAA (known – not bigger) 2

Repaired AAA 2

Inadequate images 1 (3%)

Echo - Indication

Total 181 = 10% of workload

Cardiac arrest 26

Chest pain 45

SOB 36

Hypotension 20

Sepsis & shock 32

Other (e.g. collapse, endocarditis,murmur)

22

Normal 61

Echo - Arrest

Total 26 (11 ROSC)

No reversible cause evident 19

PE 1 (saddle, heparinised)

Dissection and then Tamponade 1 (died)

RWMA 5 (to cath lab)

Chest pain Total 45

Tamponade 2

Type A dissection 2

Pericarditis with effusion 2

Pleural effusion 1

Acute MI 1 pericarditis vs RWMA (young pt)1 Takutsubo vs RWMA (young pt)1 inferior STEMI

Shoulder haemarthrosis (new LBBB) 1

HOCM, SAM, severe MR 1

Myopericarditis 1 (impaired LV young pt, trop 3000)

Pericarditis (pericardial thickening) 1

Normal 32 (71%)12 ?PE; 12 ?pericarditis; 3 ?tamponadepost procedure, ?dissection, ?HOCM; AbnECG; abn CXR

Short of Breath

Total 36

APO 11

Pulmonary embolism 3

Pneumonia 1

Pleural effusion 2

Pericardial effusion 2 tamponade1 no tamponade

Normal 16 (44%)1 later shown to have endocarditis1 had multiple bilateral PE on CTPA

Hypotension

Total 21

Biventricular failure 2

Pulmonary embolism 1

Hypovolaemia 4 (3 blood loss, 1 gastroenteritis)

Sepsis relatively underfilled 4 (given fluids)

Hypotension despite adequate filling 7 5 Sepsis, 1 DKA, 1 OD (given inotropes)

Other 1 moderate to severe MS1 moderate to severe AS

Normal 1 (5%)

Sepsis & Shock

Total 32

Underfilled 12

Reasonably filled 20 (1 rapid AF)

Source / other pathology 1 Pneumonia2 Infected obstructed kidney1 Trauma, pancreatitis, free fluid2 Bowel obstruction1 Cholecystitis, choledocholithiasis1 Pyelonephritis & bladder debris2 Pleural effusions1 Huge liver cyst1 AAA

STUDY DESCRIPTION - ABDOMINAL 786/1750 = 45% of workload

AbdoUpper abdo painLower abdo painRIF painFlank painHerniaOther

563 (72%)256 (33%)128 (16%)92 (12%)53 (7%)6 (1%)28 (4%)

Gynae1st trimesterPelvic painOther (mainly 2nd and 3rd)

104 (13%)523715

RenalFailureColicHaematuriaInfectionOther

119 (15%)2339 7437

ABDOMINAL RESULTS SUMMARY

Total 786

Relevant pathology 419 (53%)

Incidental findingsCavernous haemangiomaDermoid (ovarian)Horseshoe kidney

20 (2%)

No useful images 4 (0.5%)

Normal scans 353 (45%)

BILIARY PATHOLOGY

Cholelithiasis alone 40

Cholecystitis2 perforated GB; one tract to skin8 stones in GB neck; 1 acalculous

34

Cholangitis 2

CBD dilation5 tumours (4 pancreatic, 1 cholangiocarcinoma); 5 stones; 2 pneumobilia

22

GB polyps 1

HEPATIC PATHOLOGY

Hepatitis 2

Metastases 3

Abscess 2

Fatty liver 6

Cirrhosis 1

Hepatic adenoma 1

Cavernous haemangioma 3

Simple cysts 2

Portal vein thrombosis 2

OTHER ABDOMINAL PATHOLOGY

Pancreatic mass 5

Pancreatic cyst 1

Ascites 5

Free fluid with debris 6

Splenic rupture with free fluid 1

Adrenal adenoma (known) 1

RENAL PATHOLOGY

Hydronephrosis 14

Infected obstructed 4

Intrarenal calculi 2

PUJ stone 4

Mid ureteric stone 3

VUJ stone 18

Pyelonephritis 7 (many more with no USS abn)

Ureteric reimplantation 2 (1 obstructed; 1 pyelonephritis)

Nephritis 1

AML 1

Nephrocalcinosis 1

Polycystic kidneys 1

Duplex collecting system 1

Horseshoe kidney 1

JJ stents 3

Nephrostomy tube pulled back too far 1

CRF kidneys 4

BLADDER AND PROSTATE PATHOLOGY

Urinary retention and outflow obstruction 9

Full bladder 1

Bladder calculi 3

Bladder tumour 4 (2 with ureteric obstruction)

Large clot 3

Bladder diverticuli 1

IDC in prostate 1

Prostatic abscess 1

GYNACOLOGY - UTERUS

Ruptured ectopic 3

PUL 5

Very early pregnancy 2

SLIUP – first trimester 40

2nd and 3rd trimester 17

Miscarriage 7

Post partum empty uterus 1

Adenomyosis 2

Haematometra and cervical stenosis 1

PID 5 (one with bilateral pyosalpinx)

Uterine perforation 1

GYNACOLOGY - OVARIES

Simple cyst 8

Haemorrhagic cyst / cyst rupture 15

Ovarian tumour 3 (one advanced, 2 dermoids)

Ovarian torsion 2

Ovarian hyperstimulation 1

ABDOMINAL WALL AND OTHER PATHOLOGY

Inguinal hernia 2

Femoral hernia 1

Incisional hernia 1

Umbilical hernia 2

Sister Mary Joseph nodule 1

Rib fracture 1

Abdominal wall abscess 3

Retroperitoneal haematoma 1

AAA 3

Post op collection 3

BOWEL PATHOLOGY

Bowel pathology 2

Perforated viscus (DU) 2

Diffusely thickened bowel (enteritis) 7

Bowel obstruction 8 (2 tumours seen; 1 gall stone ileus)

Thickened bowel wall 5 (2 lymphoma, crohns, 2 ca bowel)

Appendicitis 43 (3 in pregnant women, 1 appendicealmass, 2 with rupture and abscess)

Diverticulitis 10

Inflammatory bowel mass 2

GI bleed (blood in intestine) 1

Faecal loading 2

OTHER STUFF FOUND WHIST SCANNING THE ABDOMEN

Pleural effusion 4

Pulmonary embolism 1

Hypovolaemia 1

VASCULAR SCANS 218 (12%)

Aorta 35

DVT 158

Other arteries 25

DVT scans 158 (9% of workload)

Upper limb 12 (8%)

Normal 6 (6/12 = 50%)

DVT 6 (5 subclavian; 1 basilic) (6/12 = 50%)

Lower limb 146 (146/158 = 92%)

Normal 64 (64/146 = 44%)

DVT (including muscular) 31 (31/146 = 21%)

Other cause found 52 (52/146 = 36%)

Lower limb 146

Normal 64

DVT 31

Iliofemoral 5 (1 pregnant)

Common femoral vein 1

Femoral vein 6 (1 new diagnosis ALL)

Popliteal vein 3

Posterior tibial vein 4

Fibular vein 2

Gastrocnemius muscle v 5

Soleus muscle vein 3

Chronic DVT with collaterals 1

Lower limb 146

Normal 64

DVT 31

Other case found 52

Varicose vein thrombus 2

Superficial thrombophlebitis 5

Prepatellar bursitis 2

Baker’s cyst 10

Oedema 4

Groin nodes - malignant 4 (lymphoma, SCC, sarcoma, new)

Cellulitis 15

Knee effusion 2 (haemarthrosis, gout)

Haematoma 2

Gastrocnemius tear 8

Myositis 1

OTHER ARTERIES

AV fistula thrombus 3

Bilateral CFA occlusion 1

Brachial artery occlusion 2

Femoral artery occlusion 3 (1 site of previous stent)

Popliteal artery occlusion 2

Post procedural review (?complication) 6 (haematoma / seroma)

PVD chronic worsening 3

Varicose veins 1

SCROTAL AND PENILE ULTRASOUND

Normal 8

Epididimitis 6

Epididymo-orchitis 11

Orchitis 1

Torsion 1

Atrophic testes 2

Traumatic rupture of testis 1 (haematoma only)

Torted Hydatid of Morgagni 1

Fluid in scrotum - CAPD 1

Fourniers gangrene with gas 1

Penile fracture 1

Dorsal penile vein thrombosis 1

PROCEDURAL ULTRASOUND 194 (11% OF WORKLOAD)

Arterial lines 24

Peripheral IV lines 67 (20% in IVDU); (14% >3 prior fails)

Central venous lines 21

Pleural aspiration / Seldinger / ICC 7

Ascites tap / drainage 7

Abscess drainage 6

Foreign body detection & removal 20

Joint aspiration / injection 18 (knee, ankle, elbow, shoulder) / 2

Femoral nerve block / catheter 17

Other nerve blocks 7

Fracture reduction 7 (6 distal radial, 1 femoral)

Urinary catheterisation 5

Lap band port aspiration 3

Blood tests 2

OCULAR ULTRASOUND 16

Vitreous detachment 7

Vitreous haemorrhage 4

Retinal detachment 1

Normal 4 (1 IOL)

MUSCULOSKELETAL 153 (9% of workload)

Injury 26

Mass 30

Joint Effusion ? 25

Abscess ? 44

Other 28

MSK INJURY 26

Achilles rupture 7

Gastrocnemius tear 2

Lipohaemarthrosis 1

Biceps rupture 2

Muscle haematoma 3

Quads rupture 1

Medial collateral of knee rupture 1

Laceration of Palmaris longus 1

Fracture - rib 1

Supraspinatus tear 1

Normal 6

MSK ? MASS 30

Haematoma (limb) 7

Rectus sheath haematoma 1

Lymph nodes (1 avascular) 3

Collection post op 5

Baker’s cyst with haemorrhage 1

Lipoma 1

Abscess 2

Parotitis 3

Carpal tunnel syndrome 1

Normal 7

MSK ?EFFUSION 25

Knee 7 (5 effusions, 2 of these lipohaemarthroses, 1 Baker’s cyst)

Ankle 6 (no effusions – 1 tenosynovitis; 2 cellulitis)

Hip 5 (2 effusion; 1 fracture; 1 psoas haematoma)

Shoulder 6 (5 effusions, 1 haemarthrosis drained acutely)

Wrist 1 (no effusion)

MSK ?ABSCESS 44

Cellulitis 15

Bursitis 5 (3 prepatellar; 2 olecranon)

Abscess 20

Tenosynovitis 1

Thrombophlebitis 1

Tonsillitis 2

MSK OTHER 28

Dislocation - shoulder 3

FB detection 6

Post op collection 5

Flexor tendon sheath infection 1

Spina bifida, dermoid, leaking 1

Tenosynovitis 2

Plantar fasciitis 1

Lymph node 1

Baker’s cyst 1

Normal 4

The Future

• Who knows?

• What do you want as a potential patient?

• Conveyor belt medicine

• Clinical Emergency Sonologist should be part of that conveyor belt