Point‐of‐care ultrasound‐first for the evaluation of small bowel obstruction: National cost savings, length of stay reduction, and preventable radiation exposure

Abstract

Objectives Computed tomography (CT) has long been the gold standard in diagnosing patients with suspected small bowel obstruction (SBO). Recently, point‐of‐care ultrasound (POCUS) has demonstrated comparable test characteristics to CT imaging for the diagnosis of SBO. Our primary objective was to estimate the annual national cost saving impact of a POCUS‐first approach for the evaluation of SBO. Our secondary objectives were to estimate the reduction in radiation exposure and emergency department (ED) length of stay (LOS). Methods We created and ran 1000 trials of a Monte Carlo simulation. The study population included all patients presenting to the ED with abdominal pain who were diagnosed with SBO. Using this simulation, we modeled the national annual cost savings in averted advanced imaging from a POCUS‐first approach for SBO. The model assumes that all patients who require surgery or have non‐diagnostic POCUS exams undergo CT imaging. The model also conservatively assumes that a subset of patients with diagnostic POCUS exams undergo additional confirmatory CT imaging. We used the same Monte Carlo model to estimate the reduction in radiation exposure and total ED bed hours saved. Results A POCUS‐first approach for diagnosing SBO was estimated to save a mean (±SD) of $30.1 million (±8.9 million) by avoiding 143,000 (±31,000) CT scans. This resulted in a national cumulative decrease of 507,000 bed hours (±268,000) in ED LOS. The reduction in radiation exposure to patients could potentially prevent 195 (±56) excess annual cancer cases and 98 (±28) excess annual cancer deaths. Conclusions If adopted widely and used consistently, a POCUS‐first algorithm for SBO could yield substantial national cost savings by averting advanced imaging, decreasing ED LOS, and reducing unnecessary radiation exposure in patients. Clinical decision tools are needed to better identify which patients would most benefit from CT imaging for SBO in the ED.

Diagnostic accuracy of transthoracic echocardiography for the identification of proximal aortic dissection: a systematic review and meta-analysis

“…Within minutes, TTE can identify sonographic findings consistent with aortic dissection, warranting expedited advanced aortic imaging or transfer to specialized centers 13 . Furthermore, exposure to radiation and contrast load are eliminated 24 , and is therefore suitable for a broader subset of patients in which CTA may present complications. Its serial use is also advantageous for identification of delayed complications secondary to aortic dissection such as the development of pericardial tamponade requiring emergent drainage.…”

Time to FOCUS - ‘Palliative Medicine Point-of-Care Ultrasound’

“…[60,61] 'POCUS first' diagnostic strategies aim to reduce hospital visits and improve the quality of life in a patient who is already mobility constrained. [62] It provides flexibility in planning for future hospital visits if needed, by providing a baseline assessment. The greatest utility of ultrasound is in avoiding patient shifting and administering contrast injections in palliative care patients.…”

“…POCUS should become the first-line testing, following which a contrast-based computed tomography could be considered if needed on initial POCUS evaluation, rather than initiating it in an already decompensated patient. [1,62,63] This is especially true in the case of inoperable metastatic peritoneal tumours, wherein POCUS provides just enough pragmatic information clinically at the bedside, rather than subjecting to repeated patient shifting for higher imaging requisites. Whereas in a patient, with no previous established malignancy, presenting with pain abdomen, suggestive of an acute or subacute intestinal obstruction, POCUS should be the starting point of the diagnostic evaluation pathway in an outpatient setting.…”

“…‘POCUS first’ diagnostic strategies aim to reduce hospital visits and improve the quality of life in a patient who is already mobility constrained. [ 62 ] It provides flexibility in planning for future hospital visits if needed, by providing a baseline assessment.…”

“…POCUS should become the first-line testing, following which a contrast-based computed tomography could be considered if needed on initial POCUS evaluation, rather than initiating it in an already decompensated patient. [ 1 , 62 , 63 ]…”