The ED is swamped with new patient arrivals. As a result, the 20-year-old who told the triage nurse he is having difficulty breathing waits an hour before his turn in the triage room. The ED technician hands me the ECG — sinus tachycardia — and takes the vitals.
Me: “What brings you to the emergency department today?”
Him: “I feel like I cannot breathe. It started all of a sudden at work.”
As I scroll through the chart, I see no relevant medical history. He looks anxious. No accessory muscle use. No wheeze. Heart quick and regular.
ED technician: “Chest X-ray and back to the waiting room, doc?”
Me: “Hold just one minute.”
I grab the ultrasound and place the probe on the right chest and see lung sliding. I place the probe on the left chest and see no sliding. Up a rib space, down a rib space: Anteriorly. Laterally. No lung sliding. Parasternal area: no fluid.
Me: “No waiting room. This patient is going back now. Concern for spontaneous pneumothorax.”
It’s a perfect storm of risk factors for adverse outcomes: EDs are busy. Physicians are navigating high volumes, crowded waiting rooms, sick patients, and boarding. Patients are encountering prolonged waiting room times, with alarming rates of leaving without being seen. And the ultimate feared event for everyone, i.e., the patient dying in the waiting room, weighs heavily.
Across the U.S., the ED provider in triage (PIT) model is a mitigating measure to differentiate the sickest patients, to address long wait times, and to manage limited physical spaces for evaluation and treatment.
A nurse assesses the patient with a few focused questions allowing the quick “sick” versus “not sick” determination. The technician records vital signs, and conducts other complaint point-of-care tests, such as an ECG. With this information, an emergency severity index (ESI) from 1 to 5 — most to least emergent — is assigned. When the baton is passed to the physician, they obtain a brief history, review the EHR, and perform an abbreviated examination to drive decision-making for placing labs and ordering imaging.
As a human-centered design solution, the physician PIT model makes sense. Patients with time-sensitive or life-threatening conditions can be identified sooner. However, one important diagnostic imaging tool has not been integrated into the conversation: the ultrasound. Point-of-care ultrasound (POCUS) is well-established as safe, quick to perform, and efficient for diagnostic patient care. The time is now for PIT physicians to use POCUS for better, safer care. Here is why:
POCUS answers a yes/no question and gives actionable information. Emergency physicians can synthesize chief complaints and vital signs to answer yes/no questions. In the vignette above, no lung sliding on the left chest gave the physician immediate definitive data leading to a time-sensitive diagnosis. This highlights the importance of history, abbreviated physical examination, and point-of-care testing including POCUS.
POCUS in triage helps risk stratify effectively. Not every patient coming to the ED is acutely ill. The ESI score assists with risk determination, and POCUS improves its accuracy. For example, we evaluated a pregnant patient with normal vital signs and lower abdominal pain: ESI 3. While in triage, the abdominal POCUS showed a moderate amount of free fluid pooling around the uterus and bladder. The urine pregnancy test was positive, her vital signs became unstable and the ESI was reassigned a 2. She emergently went to resuscitation, ob/gyn consultation, and to the OR with a ruptured ectopic pregnancy.
POCUS in triage is the same workflow. A POCUS performed in triage helps the PIT team make the next diagnostic, consultation, and disposition decision. This is not “phantom scanning,” or imaging without archiving and writing a note. So, images are captured, saved, and available for review via the EHR. Thus, any consulting physician can view the POCUS examination. It’s the same workflow throughout the ED.
POCUS is time efficient. In the patient from the vignette above, the POCUS examination took less than two minutes. With adequate adoption of POCUS triage protocols that are tailored to specific chief complaints, the overall workflow changes and time investments are minimal. The POCUS examination has the potential to improve outcomes through less downstream imaging, more comprehensive workups, and more immediate diagnoses.
No new education or workflow is required. Emergency physicians who complete an accredited emergency medicine residency are highly trained to perform POCUS and integrate interpretations into patient care. Moreover, AI features, including image acquisition guidance and generative interpretation software, will decrease time at the bedside and increase specificity for complicated diagnoses.
POCUS is in every area of the ED. Why not triage? A handheld unit or cart-based unit easily works in the triage space. If we are willing to take the time and steps to obtain an EKG in triage, why are we not willing to do the same for POCUS? It occupies less space and evaluates many parts of the body. POCUS is a mainstay to evaluate patients in the ED, critical care, trauma, and resuscitation rooms. Why not in triage?
We realize that naysayers may believe that POCUS in triage is not worth the effort. ED leaders may seek the business justification for POCUS in triage; this could be an article in itself. Although our perspective highlights safer and improved patient care, we believe the business argument can be substantiated. POCUS is a codable, billable procedure. The current procedural terminology codes for POCUS exist and bring revenue to EDs.
POCUS helps us make diagnoses at the time of patient presentation in the triage area. The technology and workflows allow the physician PIT to identify acutely ill patients quickly and efficiently. We believe patients will suffer worse outcomes — and preventable deaths will be missed — if practices do not adapt.
The time is now for POCUS leaders to partner with ED operations, medical directors, nursing staff, technicians, and leaders in biomedical engineering and hospital information technology to refresh the design of triage spaces. The time is now for PIT evaluations to include POCUS.
What other tools do you want to see in triage, or EM more broadly? Share in the comments.
Courtney M. Smalley, MD is an associate professor of emergency medicine at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. She is the vice chair of education and the director of emergency ultrasound.
Resa E. Lewiss, MD is an adjunct professor of emergency medicine at the Warren Alpert Medical School of Brown University. She is an emergency medicine and lifestyle medicine physician. She is co-author of "MicroSkills: Small Actions, Big Impact" and host of "The Visible Voices Podcast." Disclosure: Dr Lewiss is a volunteer consultant for Medecins San Frontiere, a consultant for GE Healthcare, and has received travel and device support from Butterfly Network.
Previously published on KevinMD.
Image by Peakstock / Shutterstock
