Title: Acceptability and Feasibility of Interprofessional Scheduled Whole-Body Point-of-Care Ultrasound in the Intensive Care Unit
Funder: Health Education England

Abstract: Background Routine point-of-care ultrasound (PoCUS) benefits patient care and outcomes including reductions in ICU stay, duration of mechanical ventilation, utilisation of other imaging modalities, radiation exposure and ultimately treatment costs. However, low doctor-to-patient ratios limits application of PoCUS in routine clinical care. Advanced critical care practitioners (ACCPs), ICU nurses, and physiotherapists can perform PoCUS with comparable accuracy to doctors. Although application of PoCUS by these groups would increase the availability to ICU patients, no studies have investigated the implementation of scheduled interprofessional whole-body PoCUS in the ICU. Aim To evaluate the acceptability and feasibility of implementing an interprofessional-led whole-body (heart, lung bases, bladder and 6 major central veins) PoCUS scan (INSIGHT scan) to inform an adequately powered randomised controlled trial (RCT). Objectives Study 1 To assess barriers and facilitators to performing and utilising the INSIGHT scan. To refine the INSIGHT intervention so that it is acceptable to key stakeholdersStudy 2 To evaluate the feasibility of the INSIGHT intervention in a RCT design measured by the number of complete INSIGHT scan reports on days 1, 3 and 7 of ICU admission.Methods Study 1: A single-centre, mixed-methods study conducted in year 1, across two adult ICUs. Twenty adult patients will be recruited to receive the INSIGHT scan using consecutive sampling. Scans will be performed by nurses, ACCPs, doctors and physiotherapists trained prior to study commencement. Data will be collected from go-along interviews with INSIGHT-trained staff, focus groups with both INSIGHT trained and untrained staff, observations to evaluate how the INSIGHT scan is accessed and utilised during ward round, and acceptability questionnaires. Interviews will be guided by the theoretical framework of acceptability and the theoretical domains framework. Study 2 protocol refinement will take place with key stakeholders to address barriers and facilitators identified during Study 1. Study 2: An 18-month, single-centre, open, parallel arm feasibility RCT in 60 ICU patients. Participants will be randomised to receive either INSIGHT scans (ICU days 1,3,7) or usual care. Feasibility outcomes including recruitment rate of eligible patients and number of complete INSIGHT scans will be assessed. A priori progression criteria (% scan completion and % patients consented and randomised) will determine whether further refinements to the protocol are required before progressing to an RCT. Twenty staff involved in the INSIGHT intervention will be interviewed to address any common behaviours affecting progression criteria. Exploratory clinical outcomes will be evaluated (number of other diagnostic imaging requests, radiation exposure, number, and type of incidental findings due to the INSIGHT scan). These data will inform primary outcome sample size calculations for an adequately powered RCT. Anticipated Impact This research will facilitate effective implementation of interprofessional whole-body PoCUS using the INSIGHT intervention across ICUs nationwide. Combined with ever decreasing costs of equipment, interprofessional PoCUS could dramatically increase the availability of this intervention, with the potential to significantly improve patient outcomes and reduce NHS treatment costs. Key findings will be disseminated to patients, stakeholders, and clinicians, locally, nationally and internationally.

Lay abstract: Ultrasound is a medical test that produces live pictures of the inside of the body, by placing a small probe on the surface of the skin. It can be used at the patient's bedside to rapidly diagnose and treat problems. Use at the bedside is known as point-of-care ultrasound (PoCUS). When used routinely in the intensive care unit (ICU), PoCUS can identify problems earlier in the patient's care which can result in quicker delivery of vital treatments such as kidney dialysis and life-saving medications. PoCUS may therefore prevent patient deterioration, as well as reduce the time spent on breathing support and the number of days in ICU. Research indicates PoCUS is as accurate as X-ray and CT scans, and could reduce the need for other imaging, therefore reducing exposure to radiation. PoCUS is performed mostly by doctors, yet there are not enough doctors in ICU to perform PoCUS routinely. Evidence from recent studies suggests other healthcare professionals such as advanced critical care practitioners (ACCPs), ICU nurses, and physiotherapists can perform PoCUS scans as accurately as doctors. Training these healthcare professionals to use PoCUS will increase the number of trained staff available to perform routine PoCUS in the ICU. I have designed a simple PoCUS scan of the whole body (the INSIGHT scan) that ACCPs, ICU nurses, physiotherapists, and ICU doctors can perform on ICU patients at set days during their ICU stay. However, we do not currently know how easy it will be for staff to perform the INSIGHT scan in ICU as part of routine care, or whether the scan could benefit patients. My two studies aim to answer the following questions: (1) What are the barriers to performing and using the INSIGHT Scan in ICU? (2) Using standard care as the benchmark, how easily can the INSIGHT scan be carried out and used by staff in ICU ? Study 1 I will carry out face-to-face interviews, observe staff performing the INSIGHT scan observe and doctors using the scan during ward rounds. My study asks: (1) are there any issues preventing staff from carrying out scans (for example, is a trained member of staff available or is the patient too sick?); (2) can the INSIGHT scan be performed as a regular part of patient assessment?; (3) Do doctors regularly access the INSIGHT scans during ward rounds?; and (4) Do INSIGHT scans identify key problems with the patient and speed up treatment times? Answers from these questions will be discussed with a group of ICU staff members, ICU survivors and my supervisory team. Before commencing Study 2, we will decide jointly on any necessary changes concerning how the INSIGHT scan is carried out and used. Study 2 Sixty ICU patients from the same hospital will be randomly allocated to one of two groups. In group 1, 30 patients will receive standard ICU care. In group 2, 30 patients will receive standard care plus the INSIGHT scan on days 1,3 and 7 of their ICU admission. Data will be collected for each group, including how quickly and easily we recruit patients to participate in the study, and the frequency and types of other diagnostic scans (e.g. X-Rays). I will also interview staff to understand if they are experiencing any problems with the INSIGHT scan. This research and lay summary were designed with the help of former ICU patients, carers, and members of the public (Critical Care Pathfinders Group - CCPG). I will share findings with all ICU healthcare professionals and the CCPG and will also present study results at conferences nationally and internationally to improve awareness of routine interprofessional PoCUS.

Research activity codes: 4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health categories: GENERIC HEALTH RELEVANCE