This study describes the potential utility of a small hand held ultrasound device during consultation rounds in the evaluation of patients in non-cardiac departments with suspected cardiac disease. In 84 patients (78.5%) the PUI provided the physician with efficient instant information indicating that further examination with SED could have been avoided. In patients in whom a complete echocardiographic study was considered necessary, it was due mostly to the need for haemodynamic assessment by Doppler. With the addition of this feature in the next generation PUIs the need for SED for patients seen during consultation rounds may be reduced even further.
Prior studies using limited imaging protocols have provided evidence that a limited imaging study is feasible for both the diagnosis and evaluation of most of the important cardiac pathologies (hypertrophic cardiomyopathy,7
left ventricular hypertrophy,8–11
mitral valve prolapse,12
and abdominal aortic aneurysm).13,14
Such a limited echocardiographic strategy can be effectively implemented with a small hand held ultrasound device.
Today, small hand held ultrasound devices aim to couple the physical examination and echocardiography at the point of care. By being ultraportable and easy to use they are practical for carrying while undertaking consultation rounds. Our group showed in a recent previous study the efficacy and high accuracy of this small imaging device in assessing pathomorphology and the function of the heart, thus enhancing and extending the physical examination and allowing goal oriented examination.4,5
The current study further confirmed these results.
Cost effectiveness of PUI during consultation rounds
Like all technological breakthroughs, the PUI has to be evaluated in financial terms, as well as for its clinical effectiveness, to gain wide acceptance. The capital investment in such a device is economic (about one 12th of the cost of an SED) and the maintenance costs are low.
In our hospital 1125 inpatients from non-cardiac departments were referred for an echocardiographic examination during 2001. Thus, for the year 2001, the total cost for the 1125 consultation visits that required an echocardiographic examination with the SED was €148 500. According to our study the cost can be reduced to €98 901 (66.6% of the initial amount) with the use of the PUI.
Eighty five per cent of the patients in our study were preoperative patients. In fact, in our hospital the majority of inpatients referred for cardiac consultation are preoperative patients. The usual request from anaesthesiologists and surgeons is to evaluate the systolic left ventricular function or a murmur, which can reliably be answered by an echocardiographic examination. Thus, the standard approach for these patients is to request an echocardiographic study further to the physical examination. The instant answer to a request can prevent potential delay in a patient who is planned for surgery and can therefore lead to cost savings. But this is only a hypothesis that has to be investigated.
Recently, Kimura and colleagues15
reported that the consequence of the presence of an abnormal initial limited echocardiographic examination in the emergency department was that patients had a significant length of hospital stay (that is more than two days). Furthermore, their study showed that, in the setting of the emergency department, a limited echocardiographic examination has better diagnostic accuracy than a physical examination in identifying cardiac abnormalities.
The present study was performed by cardiologists with experience in echocardiography. Immediate decision making diagnosis based on the echocardiographic examination with a PUI during consultation rounds requires level II or III training in echocardiography.16
Kimura and colleagues15
proved that it is feasible to train health care providers to obtain a parasternal long axis view and to interpret significant abnormalities. However, training and licensing non-cardiologists to use these devices will become an important issue in the future.
In the present study we did not specifically address the impact of the use of the PUI on hospitalisation stay. This may form the basis for future studies.
The PUI that was used for this study had no Doppler modalities to obtain haemodynamic data. Spectral Doppler and colour Doppler are now integrated in the new generation of PUIs.
During consultation rounds, a PUI can help to make an instant diagnosis at the bedside, leading to a shortened time to diagnosis with efficacy equal to that of an SED and with lower cost.