Does nurse-led point-of-care ultrasound (POCUS) improve the triage of elderly community patients with suspected heart failure? A feasibility study
Authors: Moosavi S , Ionescu A , Griffiths E , Adenwalla F , Davies A , Rees E 
Published: July 2023

Abstract

Funding Acknowledgements
Type of funding sources: Public Institution(s). Main funding source(s): Research and Development of Swansea Bay University Health Board (Pathway to Portfolio)

Background/Introduction
In elderly people, the early diagnosis of heart failure (HF) in community settings can be challenging. The presence of multiple chronic conditions in this age group often limits the diagnostic accuracy of both the clinical examination and point-of-care tests such as electrocardiogram (ECG) and brain natriuretic peptide (BNP) blood test; low diagnostic confidence can negatively impact management and outcomes. There is evidence that point-of-care ultrasound (POCUS), used as an extension to the clinical examination, can improve diagnostic decision-making. However, it is unclear whether adding POCUS to the existing HF pathway for older people is feasible and where it offers improved accuracy compared with the ECG and BNP.

Objectives
This small feasibility study assessed whether:
1) community nurses could add POCUS to their current clinical assessment of patients with suspected HF in residential settings,
2) nurses could accurately and reliably detect left ventricular systolic dysfunction (LVSD),
3) adding POCUS to the pathway could improve the time to diagnosis and effectiveness of management decisions.

Methods
Single-arm, single-centre, prospective feasibility study in patients aged over 60yrs referred to a community-based acute clinical team with suspected HF. Four nurses completed a dedicated POCUS training programme prior to patient enrolment. Nurses completed the existing clinical pathway, recording working diagnosis and management plan before adding POCUS (focused heart and lung protocol), and recording whether the findings would hypothetically alter their diagnosis and plan. All images were reviewed and reported by an accredited specialist, blind to nurse results (reference test).

Results
N=32 (mean age 81 ± 9yrs). POCUS was performed in 100% and LVSD could be evaluated in 94%. Nurses could accurately and reliably detect LVSD (sensitivity 0.94, specificity 0.88, reliability 0.81 [Cohen’s kappa]). The standard care pathway (including ECG and BNP) provided confirmation of LVSD in 0% and exclusion of LVSD in 19% within 24hrs. Specialist echocardiography referral was requested in 81% (38% inappropriate). In contrast, POCUS allowed nurses to confirm or exclude LVSD at the bedside in 94% of patients. POCUS would have impacted the medication decision in 38% and led to referral for specialist echocardiography in 53% (12% inappropriate).

Conclusion
Adding POCUS to the current diagnostic community pathway appears to be feasible and reliable, leading to shorter time-to-diagnosis (and therefore initiation of treatment), and more effective triage. These preliminary data need to be confirmed in a larger effectiveness-implementation study which we have designed and which we will recruit to in 2023.