Original Article
Changes in the availability of bedside ultrasound practice in emergency rooms and prehospital settings in France

https://doi.org/10.1016/j.accpm.2017.06.008Get rights and content

Abstract

Objective

Ensuring the availability of ultrasound devices is the initial step in implementing clinical ultrasound (CUS) in emergency services. In France in 2011, 52% of emergency departments (EDs) and only 9% of mobile intensive care stations (MICS) were equipped with ultrasound devices. The main goal of this study was to determine the movement of these rates since 2011.

Methods

We conducted a cross-sectional, descriptive, multicentre study in the form of a questionnaire. To estimate the numbers of EDs and MICS equipped with at least one ultrasound system with a confidence level of 95% and margin of error of 5%, 170 responding EDs and 145 MICS were required. Each service was solicited three times by secure online questionnaire and then by phone.

Results

Three hundred and twenty-eight (84%) services responded to the questionnaire: 179 (86%) EDs and 149 (82%) MICS. At least one ultrasound machine was available in 127 (71%, 95% CI [64; 78]) EDs vs. 52% in 2011 (P < 0.01). 42 (28%, 95% CI [21; 35]) MICS were equipped vs. 9% in 2011 (P < 0.01). In 97 (76%) EDs and 24 (55%) MICS, less than a half of physicians were trained. CUS was used at least three times a day in 52 (41%) EDs and in 8 (19%) MICS.

Conclusion

Our study demonstrates improved access to ultrasound devices in French EDs and MICS. Almost three-quarters of EDs and nearly one-third of MICS are now equipped with at least one ultrasound device. However, the rate of physicians trained per service remains insufficient.

Introduction

Clinical ultrasonography (CUS) is now integrated into the diagnostic tool-kits of many medical specialties [1]. The American College of Emergency Physicians (ACEP) defined ‘clinical ultrasound’ as follows: “CUS is a diagnostic tool, providing clinical information that would not have been obtained by the inspection, palpation, auscultation or any other component of patient's physical examination. This is a separate diagnostic tool, not a component or extension of the physical examination” [2]. Since validation of the FAST protocol (Focused Assessment with Sonography for Trauma) [3], many applications were described and/or recommended, e.g. lung ultrasound [4], [5], focused cardiac ultrasound [6], diagnosis of intrauterine pregnancy [7], [8], of abdominal aortic aneurysm, of deep venous thrombosis [9], of hepatobiliary and urinary tract pathologies [10], transcranial Doppler [11], [12] and others. The French Society of Emergency Medicine (SFMU) has recently issued its first national guidelines on emergency CUS [13].

Several studies suggest that CUS enables therapy optimisation in prehospital settings during the evaluation of traumatic injuries [12], [14]. Other studies suggest prehospital usefulness of CUS in evaluation of dyspnoea, chest pain, abdominal trauma and in invasive procedures guidance [15], [16], [17]. International recommendations now include CUS in cardiopulmonary resuscitation algorithms [18]. Several randomised controlled studies are underway to evaluate the real contribution of CUS in prehospital settings [19], [20], [21].

A first study conducted in 2011 in France showed an availability rate of ultrasound devices of 52% in emergency departments (EDs) and only 9% in mobile intensive care stations (MICS) (22). We decided to check those rates after five years, at the time when the French recommendations were published. The main objective of our study was to determine the evolution of availability rates between 2011 and 2016 in France for both in-hospital and prehospital emergency settings. Secondary objectives were to determine the number of ultrasound devices available in each ward, type and number of practitioners trained in CUS and, finally, main clinical applications.

Section snippets

Objectives of the study

We conducted a cross-sectional, descriptive, multicentre study in the form of a questionnaire. The centres surveyed in this study were all EDs in public and private hospitals as well as all MICS in mainland France and overseas territories.

The primary objective of our study was to determine the numbers of EDs and MICS equipped with ultrasound devices after five years. The primary endpoint was availability or not of one or more ultrasound device in each service.

Secondary objectives were to

Results

Three hundred twenty-eight (84%) services answered the questionnaire: 179 (86%) EDs and 149 (82%) MICS. Characteristics of responding services are described in Table 1.

Among the 179 ED that responded, at least one ultrasound machine was available in 127 EDs (71%, 95% CI [64; 78]) vs. 52% in 2011 (P < 0.01). Among the 142 responding MICS, at least one ultrasound machine was available in 42 (28%, 95% CI [21; 35]) vs. 9% in 2011 (P < 0.01). Results are summarised in Fig. 1. In unequipped services,

Main results

Results of our study are showing that from 2011 to 2016, the number of French emergency services equipped with ultrasound increased in both EDs (52% vs. 71%; P < 0.001) and MICS (9% vs. 28%; P < 0.001) [22]. Although few studies are available on access to clinical ultrasound in emergency services, our study lies in the intermediate position in international literature. In a study gathering data from five American states and published in 2015, the presence of an ultrasound machine was of 113 EDs

Conclusion

Our study shows a clear 5-year increase (2011–2016) in the number of French EDs and MICS with access to ultrasound equipment for EPs. Almost three-quarters of EDs and nearly one-third of MICS are now equipped. This is clearly a positive sign for improving patient management. Moreover, it is in line with the latest recommendations published in this field by both French and international scientific societies.

Nevertheless, the rate of trained physicians per service remains inadequate as the number

Disclosure of interest

Xavier Bobbia declares a competing interest as an ultrasound teacher for GE (GE MEDICAL SYSTEMS ULTRASOUND) customers. The other authors declare that they have no competing interest..

Ethical statement

This observational study was approved by the institutional review board (IRB) (Nîmes, France, 16/01-04).

Acknowledgements

The authors acknowledge all the EPs who responded to our survey.

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