Surgeon attitudes toward point of care ultrasound for biliary disease: a nationwide Canadian survey G allstone disease affects more than 20 million Americans yearly. 1 In Ontario, 260 elective cholecystectomies per 100 000 patients are performed each year. 2 Point of care ultrasound (PoCUS) has a growing role in the diagnosis of gallstone disease. 3 Results of PoCUS are similarly accurate compared with formal radiology-performed ultrasounds. 4 Emergency physicians who use biliary PoCUS improve emergency department (ED) throughput and reduce length of stay in the ED. 3 However, surgeons still depend on formal radiology-performed imaging for the management of biliary disease. 5 We surveyed surgeons about their opinions of biliary PoCUS. Our objectives were to quantify surgeon confidence in biliary PoCUS and elucidate possible barriers to use in order to improve surgeon utilization. Our apprOach A cross-sectional survey was emailed to general surgery program directors from the 14 primarily English-speaking academic programs in Canada. They were asked to distribute the survey to all general surgery residents, fellows and staff associated with their centre and to provide us with the number of survey recipients so we could determine the overall response rate. To explore the factors associated with confidence in biliary PoCUS, we dichotomized confidence by considering everyone who answered "slightly confident" to "extremely confident" as having some confidence with PoCUS and those who answered "unconfident" as being unconfident with PoCUS. All other variables were dichotomized as seen in Box 1. We also distilled 5 potential barriers to applying the results of biliary PoCUS in clinical practice: perceived poor test characteristics, user-dependent nature of the technology, poor documentation of results, lack of personal ability to replicate the test, and lack of detailed imaging findings. We analyzed the response data to model the relationships between the survey respondents'

Introduction: Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making many emergency medicine physicians have pursued specialized training to perform point of care biliary ultrasound in the emergency department (BUSED). The purpose of this study was to determine the usefulness of BUSED in predicting the need for surgical consultation and intervention for biliary disease. Methods: A retrospective study of 283 consecutive patients visiting the emergency department who received a BUSED scan from December 1, 2016 to July 16, 2017. Physician interpretations of the BUSED scans were collected from the electronic image storage and interpretation system. Additional data was collected from the electronic health record including lab values, the subsequent use of diagnostic imaging, and outcomes data including disposition, surgical consultation or intervention, and 28 day follow up for representation or complication. Descriptive statistics and logistic regression were performed. Results: Of the patients who received a biliary POCUS scan, 29% were referred to general surgery, and 43% of those referred proceeded to eventual cholecystectomy. Factors found to be independently predictive of surgical intervention on point of care BUSED scans included presence of gall stones (OR 13.01, 95%CI 5.02 to 27.1) and increased gallbladder wall thickness (OR 6.01, 95%CI 1.7 to 11.1). A total of 30% of patients receiving BUSED required at least one additional, radiology based imaging test (CT or diagnostic US). Average emergency department length of stay was substantially longer for those who required additional imaging as compared to those who were able to be diagnosed by BUSED alone (16.1 versus 5.2 hours, 10.9 hours 95%CI 10.6 11.2, p<0.05) . Conclusion: Point of care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gall stones and increased gall bladder wall thickness are highly predictive of the need for surgical intervention. Future, prospective studies are warranted to determine if point of care sonography is sufficient to proceed to surgery in select cases of uncomplicated biliary disease.