Randomized clinical trial of bedside ultrasound among patients with abdominal pain in the emergency department: impact on patient satisfaction and health care consumption

Background\ud \ud Previous research shows that surgeon-performed ultrasound for patients presenting with abdominal pain in the emergency department leads both to higher diagnostic accuracy and to other benefits. We have evaluated the level of patient satisfaction, health condition and further health care consumption after discharge from the emergency department.\ud Methods\ud \ud A total of 800 patients who attended the emergency department for abdominal pain were randomized to surgeon-performed ultrasound or not as a complement to standard examination. All patients were interviewed by telephone six weeks after the visit to the emergency department using a structured questionnaire including information about health condition, satisfaction and medical examinations. A regional health register was used to check health care consumption over two years and mortality was checked for in the personal data register.\ud Results\ud \ud We found a higher self-rated patient satisfaction in the ultrasound group when leaving the emergency department. After six weeks the figures were equal. There were fewer patients in the ultrasound group with completed or planned complementary examinations after six weeks (31.1%) compared with the control group (41.4%), p = 0.004. There was no difference found in the two-year health care consumption or mortality between the groups.\ud Conclusion\ud \ud For patients with acute abdominal pain, bedside ultrasound examination is related to higher satisfaction and decreased short-term health care consumption. No major effects were revealed when evaluating effects on a long-term basis, including mortality. The previously proven benefit together with the lack of adverse effects from the method makes ultrasound well worth considering for implementation in emergency departments

The role of surgeon-performed ultrasound in the management of the acute abdomen

The overall objective of this thesis was to evaluate the effects of bedside surgeon-performed ultrasound on the diagnostic accuracy and management of the patient admitted to the emergency department for abdominal pain. Methods We randomized 800 patients who attended the emergency department at Stockholm South General Hospital, Sweden, for abdominal pain, to either receive or not receive surgeon-performed ultrasound as a complement to routine management. The patients were followed up by a telephone interview after six weeks and by a registry follow-up after two years. Outcome measures included proportion of correct diagnoses, the number of complementary investigations, admission rate, time for surgery if required, time consumption at the emergency department and at hospital if admitted, self-rated patient satisfaction at the Emergency Department and at follow-up, health condition at follow-up, health consumption and mortality at six week and two year follow-up. Diagnostic accuracy and need of further examinations and admissions were measured in specific subgroups as well as timing of surgery among patients with peritonitis. Results Several benefits were seen in the group receiving US. Diagnostic accuracy was significantly higher in the group examined with ultrasound (65% versus 57%, p=0.027). The number of ordered complementary US examinations was considerably higher in the group who did not receive bedside US (9% versus 28%, p < 0.001). The admission rate was lower in the ultrasound group (43% versus 50%, p = 0.04) and the proportion of patients requiring surgery submitted for surgery directly from the emergency department was higher in the ultrasound group (34% versus 16%, p = 0.01). Self-rated patient satisfaction was slightly higher in the ultrasound group when leaving the emergency department but equal after six weeks. There was no difference found in the two-year health consumption or mortality between the groups. Regarding sub group analyses increased diagnostic accuracy of bedside US was seen in the patients with Body Mass Index>25(67% versus 54%, p=0.02), elevated C-reactive protein (63% versus 52%,p=0.047), peritonitis (74% versus 54%, age 30-59 years(68% versus 58%, p=0.042) and/or upper abdominal pain(72% versus 52%, p=0.045). Other benefits such as decreased need of further examinations and/or fewer admissions were seen in all groups except the patients with a first diagnosis of appendicitis where the outcomes were equal between the intervention groups. Among patients with peritonitis admitted for surgery the decision about surgery was taken while still at the emergency department for 61 % in the ultrasound group and 19 % in the control group, p= 0.003. Conclusion The results we have shown in our large randomized study, following up patients on a short- and long-term basis, is that US performed bedside by the surgeon on duty when a patient seeks care for abdominal pain, can increase diagnostic accuracy, decrease the need of further examinations, decrease admission frequency and increase self-rated patient satisfaction. There are benefits of different kinds in nearly all subgroups and the health consumption and mortality on a long term basis are equal. The method is well worth recommending for implementation as a routine for evaluation of the acute abdomen in the ED

Surgeon-Performed Ultrasound in Diagnosing Acute Cholecystitis and Appendicitis

Abstract Background The use of ultrasound (US) outside the radiology department has increased the last decades, but large studies assessing the quality of bedside US are still lacking. This study evaluates surgeon-performed US (SPUS) and radiologist-performed US (RPUS) with respect to biliary disease and appendicitis. Methods Between October 2011 and November 2012, 300 adult patients, with a referral for an abdominal US, were prospectively enrolled in the study and examined by a radiologist as well as a surgeon. The surgeons had undergone a 4-week-long US education. US findings of the surgeon and of the radiologist were compared to final diagnosis, set by an independent external observer going through each patient’s chart. Results Among 183 patients with suspected biliary disease, 74 had gallstones and 21 had acute cholecystitis. SPUS and RPUS diagnosed gallstones with a sensitivity of 87.1 versus 97.3%. Specificity was 96.0 versus 98.9%, and the accuracy 92.3 versus 98.2%. The sensitivity, specificity and accuracy for acute cholecystitis by SPUS and RPUS were: 60.0 versus 80.0%, 98.6 versus 97.8% and 93.9 versus 95.6%, respectively. Among 58 patients with suspected appendicitis, 15 had the disease. The sensitivity, specificity and accuracy for appendicitis by SPUS and RPUS were: 53.3 versus 73.3%, 89.7 versus 93.3% and 77.3 versus 86.7%, respectively. Conclusion SPUS is reliable in diagnosing gallstones. Diagnosing cholecystitis and appendicitis with US is more challenging for both surgeons and radiologists. Trial registration number The study was registered at clinicaltrials.gov. Registration number: NCT02469935. </jats:sec