How Point‐of‐Care Ultrasound May Improve At-Home Hospital Care

Throughout the COVID-19 pandemic, hospitals have been under severe stress and seen unprecedented strain placed on providers as well as the health care system overall. One way to mitigate this issue is hospital at home (HAH) programs, which facilitate care in eligible patients’ homes rather than the hospital. An article published in the Journal of Hospital Medicine explored the potential of point‐of‐care ultrasound (POCUS) to supplement care in HAH settings.

The number of HAH programs in the United States has grown to include 192 hospitals in 34 states with programs differing from hospital to hospital as well as patient needs. Overall, HAH programs have garnered positive patient and caregiver feedback and have not demonstrated negative effects on mortality or readmission thus far.

“As the house call's next iteration, HAH programs provide an exciting opportunity for hospitalists to enter our patients’ homes and lives,” the authors wrote. “Additional skills will be necessary for the competent home hospitalist—an expansion of purview without sacrificing the quality of care provided.”

POCUS, which is done at the bedside by health care professionals, has also become increasingly common in recent years. It provides a portable alternative to consultative imaging, and a recent survey conducted at large urban medical centers found that 93% of hospitalists considered POCUS a tool that can serve an important diagnostic purpose. In particular, the authors note that POCUS can assist with cardiopulmonary examination and diagnosis, which is commonly needed for HAH patients, in a relatively cost-effective way.

Working as a home hospitalist comes with unique challenges and requires skills to deal with the limitations of home care versus in-hospital care, and POCUS proficiency could be a very useful special skill in this setting. Advanced practice providers and nurses can perform POCUS exams, and the authors suggest that even patients may be capable of performing simple POCUS exams on themselves in the context of virtual HAH programs. One study cited in the article found that patients had a high success rate performing basic 4-zone lung ultrasounds on themselves in the context of titrating diuretic therapy—175 total lung zones were scanned, and 150 were interpretable with nearly 90% expert agreement.

Worsening heart failure is a common reason for home hospitalization, and POCUS can supplement examinations of patients presenting with dyspnea that is potentially related to heart failure. Lung ultrasound for diuretic effectiveness, inferior vena cava examination, and estimated jugular vena cava pulse validation are all strategies that providers proficient in POCUS could use to assist diagnosis in HAH settings. Nurses or patients could also be trained to perform relevant scans if an HAH program is largely virtual.

For post-surgical patients or those with inflammatory conditions, POCUS can help identify venous thrombosis and embolism. Detecting superficial thrombophlebitis in HAH settings via POCUS can spare patients with malfunctioning venous catheters visits to the hospital for the diagnostic ultrasound or line troubleshooting that a vascular access team would do within the institution. Kidney and bladder assessment with POCUS has been shown effective in identifying urinary retention and hydronephrosis, which elderly patients in HAH programs can be prone to.

“POCUS improves diagnostic accuracy over standard evaluation in the assessment of the acutely decompensating patient. This can crucially expedite management in resource‐limited settings where typical decision‐making supplements like blood tests and radiographs are not as readily available,” the authors wrote. “It may even allow the provider to identify a readily reversible cause that would have otherwise prompted transfer back to a brick‐and‐mortar institution.”

The authors concluded that POCUS can play an important role in HAH care and help providers assess, diagnose, and monitor a range of conditions with relatively little additional training. This could help minimize transfers to in-hospital care and maintain patient health and satisfaction within HAH programs. Additional research is warranted to quantify the effects of POCUS implementation on the rate of transfer to in-hospital care, the length of hospital stays, and costs.

Reference

Biggerstaff S, Restrepo D, Thompson R. POCUS at home: Point‐of‐care ultrasound for the home hospitalist. J Hosp Med. Published online August 28, 2022. doi:10.1002/jhm.12949