RESUMO

In the outpatient setting, ambulatory electrocardiography is the most frequently used diagnostic modality for the evaluation of patients in whom cardiac arrhythmias or conduction abnormalities are suspected. Proper selection of the device type and monitoring duration is critical for optimizing diagnostic yield and cost-effective resource utilization. However, despite guidance from major professional societies, the lack of systematic guidance for proper test selection in many institutions results in the need for repeat testing, which leads to not only increased resource utilization and cost of care, but also suboptimal patient care. To address this unmet need at our own institution, we formed a multidisciplinary panel to develop a concise, yet comprehensive algorithm, incorporating the most common indications for ambulatory electrocardiography, to efficiently guide clinicians to the most appropriate test option for a given clinical scenario, with the goal of maximizing diagnostic yield and optimizing resource utilization. The algorithm was designed as a single-page, color-coded flowchart to be utilized both as a rapid reference guide in printed form, and a decision support tool embedded within the electronic medical records system at the point of order entry. We believe that systematic adoption of this algorithm will optimize diagnostic efficiency, resource utilization, and importantly, patient care and satisfaction.

Assuntos

Eletrocardiografia Ambulatorial , Sistemas Automatizados de Assistência Junto ao Leito , Algoritmos , Análise Custo-Benefício , Eletrocardiografia , Humanos , Pacientes Ambulatoriais

RESUMO

Background: Many internal medicine residency programs have incorporated ultrasonography into their curriculum; however, its integration with physical examination skills teaching at a graduate medical level is scarce. The program's aim is to create a reproducible elective that combines physical exam and bedside ultrasound as a method for augmenting residents' knowledge and competence in these techniques with the ultimate goal of improving patient care. Methods: We designed and implemented a two-week elective rotation for senior internal medicine residents, combining evidence-based physical examination with diagnostic bedside ultrasonography. The rotation took place in an inpatient setting at Denver Health Hospital. Program evaluation data was collected data between February 2016 to March 2019. IRB approval was waived. Results: Since its inception in 2016, 19 residents completed the rotation. Residents performed a pre-test and a post-test under direct observation by course faculty. Each resident was measured on the ability to perform pre-determined physical exam and point-of-care ultrasound (POCUS) skills. In the pre-test, participants correctly performed an average of 40% of expected physical exam maneuvers and 32% of expected POCUS skills. At elective conclusion, all participants were effectively able to demonstrate the highest yield physical exam and ultrasound maneuvers. Discussion and Conclusion: An elective designed specifically to integrate POCUS and physical exam modalities improves the ability of resident physicians to utilize both diagnostic modalities.