Neonatal Cardiac POCUS - A Survey of Academic Neonatal Centers in the United States

doi:10.21203/rs.3.rs-4716930/v1

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Neonatal Cardiac POCUS - A Survey of Academic Neonatal Centers in the United States

https://doi.org/10.21203/rs.3.rs-4716930/v1

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Journal Publication

published 09 Sep, 2024

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Objective

To investigate the current state of clinical practice and training regarding the use of cardiac point of care ultrasound (cPOCUS) in neonatal intensive care units.

Study Design:

An online survey was disseminated through the Association of Academic Directors of Neonatology to appraise clinical usage, infrastructure, and training for cPOCUS. A single response per center was obtained.

Results

Overall survey response rate was 51% (48/94). Of respondents [40/48 (83%)] who reported having a POCUS program, 19/40 (47%) reported performing cPOCUS. In 74% of centers, < 10 cPOCUS studies are performed monthly. Only 16% (3/19) of centers had standardized imaging protocols. The most common indication for cPOCUS was central line evaluation. Only 9 (19%) programs reported cPOCUS training, of whom 4 had a formalized process of ongoing competency assessment.

Conclusion

Although use of cPOCUS is increasing, program infrastructure and governance, training, and evaluation vary markedly between institutions and are missing in many. There is an urgent need to develop consensus standards regarding clinical practice and training.

neonatology

point-of-care ultrasound

targeted neonatal echocardiography

echocardiogram

Point-of-care ultrasound (POCUS) is an efficient, non-invasive imaging tool that may enhance bedside clinical decision-making and procedural support. Unlike trends in adult medicine, the clinical integration of POCUS in the neonatal population is relatively novel (1, 2). The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) published guidelines on common indications for POCUS in the pediatric (PICU) and neonatal (NICU) intensive care units, including specific cardiac (cPOCUS) recommendations(3). These recommendations were based on the consensus of international POCUS experts, but with the recognition that evidence in the neonatal population was low-grade. Many of the indications for neonatal cPOCUS are drawn from PICU experience, as its use in the NICU is less well defined (4).

On the contrary, the scope and clinical indications for neonatal hemodynamics-based cardiovascular evaluation are well established through the recently published updated guidelines for targeted neonatal echocardiography (TnECHO) in the American Society of Echocardiography (ASE) (5). These also provide some guidance on use of cPOCUS and how the specific indications and scope of practice differ from TnECHO. In addition, the differences in the training required for neonatal hemodynamics with comprehensive training in cardiovascular physiology, image acquisition, and study interpretation are outlined. In contrast, neonatal cPOCUS is a basic and focused assessment that can be performed by generalist neonatal providers. As with general POCUS assessment, the goal of cPOCUS is to answer straightforward and potentially clinically emergent questions relevant to the cardiopulmonary system.

A recent technical report by the American Academy of Pediatrics (AAP) provides some guidance around the use of neonatal cPOCUS and highlights its role in conducting time-sensitive assessments of the symptomatic patient and the immediate identification of pathologic processes including pericardial effusions, catheter malpositioning and subjective myocardial dysfunction (6). Various protocols have also been designed that incorporate cPOCUS in the rapid evaluation of clinically unstable patients (7, 8). There is relative absence of literature regarding the training required to achieve the necessary skills, maintain competency, and the infrastructure needed; therefore, it has become challenging to achieve standardization and quality assurance in clinical practice. Unless this is achieved, the impact of neonatal cPOCUS on patient outcomes will remain uncertain. With the availability of portable ultrasound machines, use of cPOCUS within daily NICU practice is growing; however, the prevalence and quality of neonatal cPOCUS in the United States has not been determined. The primary aim of this study is to investigate current perspectives, training standards, and local governance regarding the use of neonatal cPOCUS.

This was a cross-sectional survey designed to appraise the use of neonatal cPOCUS at academic neonatal programs across the United States.

Survey Design

The content of the survey was based on a review of current literature regarding cPOCUS use (in adult and pediatric medicine) as well as TnECHO training and guidelines. Surveys performed to understand POCUS and TnECHO practices were used as models to guide the structure of this survey instrument(1, 9). A 43-step instrument was evaluated by four independent neonatologists (3 within the division of Neonatology at the University of Iowa and 1 outside the division) with neonatal POCUS and hemodynamics expertise to assess readability and content validity. An online pilot survey was then sent to two neonatal fellows to determine ease of completion and suggestions were incorporated prior to formalizing the questionnaire. The online link to the survey was made available in the body of the invitation email through the University of Iowa Clinical and Translational Science Institute’s Research Electronic Data Capture (REDCap) secure web-based application (10, 11). The study was approved by the University of Iowa’s Institutional Review Board and waiver of consent was obtained.

Study Dissemination

The Association of Academic Division Directors of Neonatology (AANDD) is an independent national collaboration of leaders at academic centers and membership is defined by the presence of a neonatal fellowship or residency program(12). The survey was disseminated to the AANDD listserv which includes the email addresses of all neonatology division directors. The online letter of invitation specifically requested to have a single response per program completed by the cPOCUS program lead or most knowledgeable representative. The initial recruitment email was sent in June 2023. Follow up reminders to complete they survey were sent every 3 weeks for 2 months to maximize response rate.

Survey Content: The survey was divided into three domains (Appendix 1): (i) unit characteristics and access to different services for cardiac evaluation, (ii) cPOCUS infrastructure, if applicable and (iii) current training and competency evaluation. The survey included following definitions for the respondents to refer to while filling the survey:

Targeted neonatal echocardiogram: advanced hemodynamic evaluation performed by a neonatologist who has completed a formal fellowship (usually 1 year) in neonatal hemodynamics according to the ASE guidelines (5).

Point-of-care ultrasound: ultrasonography performed at the bedside by practitioners with varying imaging skills (have not completed a formal 1 year fellowship, certification for proficiency may differ between centers) (6).

Pediatric cardiology echocardiogram: echocardiogram performed by a trained pediatric cardiologist/sonographer.

Analysis

Our goal was to achieve at least 50% response rate (47 respondents) as a representative sample. The frequency of utilizing cPOCUS for various indications as reported in the literature were recorded using a Likert scale. Descriptive summary statistics were used to analyze the data.

Survey Respondents: The overall survey response rate was 51% (48/94). The survey was most commonly completed by the division director (39.6%), POCUS program director (29.2%) or a neonatologist with POCUS expertise (29.2%). Neonatologist experience ranges were equally distributed [n = 16/ (0–48), 33.3%] across the following time intervals: less than 10 years, 10 to 20 years, and greater than 20 years. Most centers served both inborn and outborn neonates (n = 54, 58%) and an average range of deliveries annually between 2000 and 6000. Of the 48 centers that responded, 40 (83.3%) reported having access to POCUS evaluation. In the subgroup of centers with access to POCUS, almost half reported performing limited cardiac assessment (n = 19, 47.5%) as part of their POCUS exam. Most assessments were completed within 15 min (58.1%).

cPOCUS Use

The most common indication for general POCUS evaluation was central line placement/tip assessment (80%) and as a procedural aid [e.g., for vascular access, lumbar puncture, fluid drainage (82.5%)]. The most common indications for cPOCUS evaluation were qualitative assessment of cardiac function, evaluating response to inotropes, central line tip position, or presence of pericardial effusion, and evaluating sudden cardiorespiratory deterioration (Fig. 1).

Program Infrastructure

24/7 cPOCUS was available at 47.3% (9/19) of POCUS sites while the remaining 10 programs provided weekday coverage only. Table 1 shows access to other services for cardiac evaluation at these sites. Most programs were developed within the last 5 years [11/19, (58%)]. cPOCUS exams were most commonly performed by neonatal faculty [17/19, (89%)] and fellows [11/19, (58%)]. Factors that have contributed towards and against cPOCUS implementation are identified in Table 2. Of the centers identifying ‘other’ factors that influenced usage, the most common theme was that “cPOCUS was more readily available than other echocardiography services”.

In 74% of the centers, less than 10 cardiac POCUS studies were performed every month (Table 3). All POCUS centers reported having a dedicated ultrasound machine. Urgent cPOCUS evaluations were most commonly reported within an hour (86.7%) and non-urgent evaluations reported within 12 hours (93.3%). Very few (less than 20%) of the programs report cPOCUS according to a standardized template. Many centers [9/19, (47%)] reported that cPOCUS studies are not permanently archived. In addition, cPOCUS studies were either not reported (37%) or were verbally reported (42%). Most cPOCUS imaging was followed by a pediatric cardiology echocardiogram; however, 3 centers reported either infrequent or lack of follow up formal imaging.

Training

Only nine (9%) of cPOCUS centers reported availability of structured training. Multiple modalities were used for learning as depicted in Table 4. The duration of training was typically greater than 6 months and most commonly offered to neonatology fellows. Most learners received < 2 hours of training per week (66.7%). Teaching was most often performed by neonatologist with formal POCUS training (66.7%); however, the degree of “formality” was not defined. More than half of respondents with a cPOCUS program reported utilizing a simulator for training. Three sites reported requiring a total number of observed and completed assessments for the completion of the training. The number of these studies ranged from 10 to 25.

Evaluation

Of the centers that provided cPOCUS training, 2/3rd reported not having a formal assessment process at the end of the training. The evaluation methods utilized are outlined in Table 3. The total number of studies needed for review of performance were between 25–50. In more than 50% of centers, there is no formal process for assessment of ongoing competency. The most common methods used to adjudicate ongoing competency included observation of performance (75%) and logbook review (50%). For ongoing competency, typically 10–25 exams were reviewed per year (75%).

These data re-affirm the overall growth in utilization of cPOCUS in neonatology programs across the United States; however, there is marked variance in clinical implementation, program infrastructure, and standardized training is lacking. It is noteworthy that one of the most common factors reported as justification for implementation of cPOCUS is the published literature regarding its use; however, there is lack of literature on the impact of cPOCUS in neonates specifically. This may relate to the lack of appreciation of differences in scope of TnECHO as compared to cPOCUS in recent sentinel publications. For example, the recent American Academy of Pediatrics statement on POCUS in the NICU cites publications on the efficacy of TnECHO as justification for cPOCUS use. While there is growing evidence that advanced hemodynamic care, based on comprehensive evaluation from TnECHO, has a positive impact on patient outcomes(13), there are currently no such data available regarding neonatal cPOCUS use.

Several studies highlight a positive clinical impact of cPOCUS in other medical settings. In a randomized controlled trial, an immediate focused cardiac POCUS performed on patients with undifferentiated shock in an emergency department (ED) improved the rate of correct diagnosis at 15 minutes from 50% (95% CI 40–60%) to 80% (95% CI 70–87%)(14). Another observational study demonstrated that utilization of cPOCUS in undifferentiated hypotension in the ED altered the treatment plan and the imaging strategy in a quarter and a third of patients, respectively (15).Similarly, the use of cPOCUS in adult intensive care and anesthesia led to an important change in clinical management in 41–51% and 43–82% of cases as noted in a systemic review(16). Recently, a retrospective analysis done in a pediatric intensive care unit showed that implementation of a cPOCUS protocol had a positive impact on patient management in 2/3rd of the cases(17). Although these data are promising, the clinical impact of routine neonatal cPOCUS have not been investigated. One contributing factor may be that the introduction of POCUS, and specifically cPOCUS, is relatively new as most of the programs (58%) have developed the necessary infrastructure within the last 5 years. As the availability of skilled personnel is relatively rare, volumes of cPOCUS are therefore low (< 10 studies/month in 74% centers). This is likely to change as more practitioners acquire the skill of cPOCUS.

This survey also highlights the lack of standardization in the current infrastructure regarding neonatal cPOCUS use. Currently very few programs utilize a standardized imaging protocol to ensure consistency in the acquisition of reliable information. This may also explain, at least in part, the wide variety of reported indications for cPOCUS use in the survey. Of particular concern was the reported usage of cPOCUS to evaluate hemodynamic significance of a patent ductus arteriosus, pulmonary hypertension, or response to vasoactive medications which represent conditions that frequently require a more meticulous and systematic approach, that is beyond the scope of a cPOCUS evaluation, as outlined in the recent ASE guidelines(5)^,(18). While the enthusiasm for POCUS in the NICU setting is admirable and should be encouraged, these patterns highlight the gaps in appreciation of the clinical scope of cPOCUS vs TnECHO and importance of educating Neonatology program leaders about the needs for standard operating procedures and consistency in practice. While most centers utilize a dedicated ultrasound machine, study reporting and storage methods are highly inconsistent and absent in some places. This could potentially impact quality assurance and consequently affect clinical decisions, training, and research. Our data also reveals that a follow up comprehensive TnECHO or cardiology echocardiogram after a cPOCUS evaluation is not obtained in most centers. These findings highlight the need for standardization on when cPOCUS evaluation should be followed and by what modality, as cPOCUS is a limited exam.

The need for a standardized framework for neonatal POCUS training, maintenance of competency and quality assurance has been recognized by experts in the field (6). Our data demonstrate significant variation in current training practices related to neonatal cPOCUS use. Most centers did not report a minimum requirement for completion of cPOCUS studies for the training. The three sites that did report having this requirement indicated a variable range of studies to be completed and reviewed to be skilled in neonatal cPOCUS. In addition, justification for these numbers is based on expert opinion rather than objective evidence, which represents an educational gap(19). The reported range of 25 to 50 studies may be hard for trainees to achieve in centers with low cPOCUS volumes. The development of a standard framework with clarity around indications for use may help increase volumes. While simulation models are commonly utilized for training, they are expensive and may not be as readily accessible across all centers, which could result in variations in the training and educational curriculum and limitation of widespread adoption of neonatal cPOCUS. In addition, the methods utilized for evaluation at the end of the training and assessing competency are inconsistent across the centers. There is a paucity of literature regarding long term retention of these skills which makes assessment of competency particularly challenging.

Limitations

These data were self-reported and as such are subject to respondent biases. In particular, centers without a cPOCUS program may have been less likely to respond which creates additional biases and potential overestimation of the frequency of cPOCUS use. In addition, the data is applicable to academic programs across the United States only. Finally, there may still be confusion regarding neonatal hemodynamics versus POCUS that influenced responses.

As neonatal cardiac POCUS is becoming more widespread, there is a need for standardization of clinical practices, training methods, and evaluation of competency. The establishment of the national POCUS collaborative in the United States represents a positive step forward.

Conflict of Interest: The authors declare they have no competing interests.

Ethics approval and consent to participate: The study was approved by the University of Iowa’s Institutional Review Board and waiver of consent was obtained.

Consent for publication: Not applicable

Availability of data and materials: Attached Appendix 1.

Funding: No funding was received for conducting this study.

Author Contributions NA –design, data collection, analysis, writing first draft, approving final draft; JLR, BT, REG, JW, AS, RH – design, approval of final draft; PJM – design, data collection, analysis, approval of final draft.

Acknowledgments: J Lauren Ruoss², MD, Brady Thomas, MD¹, Regan E. Giesinger, MD, BScH, FRCPC¹, Patrick J. McNamara, MB, BCH, BAO, DCH, MSc (Paeds), MRCP, MRCPCH FASE¹

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Table 1 to 4 are available in the Supplementary Files section.

There is NO conflict of interest to disclose.

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Journal Publication

published 09 Sep, 2024

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Editorial decision: revise
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Review #1 received at journal
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Reviewer #1 agreed at journal
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Submission checks completed at journal
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Neonatal Cardiac POCUS - A Survey of Academic Neonatal Centers in the United States

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