Studies Show POCUS Saves Time for Pregnant Patients

July 10, 2019

In a March 2019 meta-analysis of eight studies published in the American Journal of Emergency Medicine, data shows that the use of pelvic point-of-care ultrasound (PPOCUS) can lead to pregnant patients spending less time in the Emergency Department. These decreased lengths of stay can help EDs and hospitals reduce crowding and enhance their quality of care1.

When examining a pregnant patient, emergency physicians must make a choice of performing either PPOCUS or a comprehensive ultrasound (CUS) through the radiology or gynecology departments. Access to CUS, however, varies widely by location and the time of day, and CUS will often increase a patient’s time in the ED. Increased lengths of stay can lead to crowding in the ED and adversely affect the quality of care3. For this reason, The Institute of Medicine has called for EDs and hospitals to identify ways to reduce crowding and lengths of stay4.

With PPOCUS, emergency clinicians can avoid the need for CUS to diagnose early symptomatic pregnancies1. For example, PPOCUS is 99% sensitive for ectopic pregnancy with the visualization of intrauterine pregnancy (IUP)1-2. PPOCUS is a time-saving method of identifying this serious condition.

A review of the literature was performed to conform to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement5. While the meta-analysis showed a strong association between the use of PPOCUS and decreased lengths of stay when compared to the use of CUS, this association was likely affected significantly by the subgroup of patients who have an IUP. Decreased lengths of stay were more likely observed at night and with use of transvaginal ultrasound. In addition, several of the studies excluded either patients without an IUP or patients receiving both PPOCUS and CUS7-9.

The overall trend of decreased lengths of stay strongly favors the PPOCUS group across all the studies. The studies that did include patients without an IUP, as well as patients receiving follow-up CUS in the study group6, 10-12 showed decreased lengths of stay with PPOCUS. Even if the time-saving association with PPOCUS is only seen in patients with an IUP, an estimated 50–70% of patients with symptomatic early pregnancy will have an IUP identified with PPOCUS6, 8, 13-15. In the case that this meta-analysis overstated the decreased lengths of stay with PPOCUS, the data still suggests that the majority of patients with symptomatic early pregnancy will spend less time in the ED when examined with PPOCUS.

The authors of this review believe PPOCUS for evaluation of symptomatic early pregnancy is likely to lead to decreased lengths of stay in the ED. Bear in mind, however, that this effect is expected to be driven by the subgroup of patients with an IUP. The study’s conclusion must be considered in the context of the availability of CUS and emergency physician experience at a given clinical location.

Learn More about Ultrasound in Women's Health

POCUS Profile: Dr. Farah Chaudhry

I’m Not Sure I Could Do That – Women’s Health, SonoSite Ultrasound (video)

Floating Doctors: Remembering a Fetal Ultrasound from Years Ago

References

1McRae A, Edmonds M, Murray H. Diagnostic accuracy and clinical utility of emergency department targeted ultrasonography in the evaluation of first-trimester pelvic pain and bleeding: a systematic review. CJEM: Canadian Journal of Emergency Medicine 2009; 11(4):355.

2Stein JC, Wang R, AdlerN, et al. Obstetrics and gynecology/original research: emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Annals of Emergency Medicine 2010; 56(6):674–83.

3Bernstein SL, Aronsky D, Duseja R, et al. The effect of emergency department crowding on clinically oriented outcomes. Academic Emergency Medicine 2009; 16 (1):1–10.

4Chang AM, Lin A, Fu R, McConnell KJ, Sun B. Associations of emergency department length of stay with publicly reported quality-of-care measures. Academic Emergency Medicine 2017; 24(2): 246–50.

5Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLOS Medicine 2009; 6 (7): e1000097.

6Panebianco NL, Shofer F, Fields JM, et al. Original contribution: the utility of transvaginal ultrasound in the ED evaluation of complications of first trimester pregnancy. American Journal of Emergency Medicine 2015; 33 (6):743–8.

7Shih CH. Effect of emergency physician-performed pelvic sonography on length of stay in the emergency department. Annals of Emergency Medicine 1997; 29 (3):348–51 [discussion 352].

8Blaivas M, Sierzenski P, Plecque D, Lambert M. Do emergency physicians save time when locating a live intrauterine pregnancy with bedside ultrasonography? Academic Emergency Medicine 2000; 7(9):988–93.

9Thamburaj R, Sivitz A. Does the use of bedside pelvic ultrasound decrease length of stay in the emergency department? Pediatric Emergency Care 2013; 29 (1):67–70.

10Burgher SW. T, y TK, DawdyMR. Transvaginal ultrasonography by emergency physicians decreases patient time in the emergency department. Academic Emergency Medicine 1998; 5 (8):802–7.

11Morgan BB, Kao A, Trent SA, et al. Effect of emergency physician-performed point-of-care ultrasound and radiology department-performed ultrasound examinations on the emergency department length of stay among pregnant women at less than 20 weeks' gestation. Journal of Ultrasound in Medicine 2018; 37(11):2497–505.

12Wilson SP, Connolly K, LahhamS, et al. Point-of-care ultrasound versus radiology department pelvic ultrasound on emergency department length of stay. World Journal of Emergency Medicine 2016; 7(3):178.

13Wang R, Reynolds TA, West HH, et al. Use of a beta-hCG discriminatory zone with bedside pelvic ultrasonography. Annals of Emergency Medicine 2011; 58(1):12–20.

14Tayal VS, Cohen H, Norton HJ. Outcome of patients with an indeterminate emergency department first-trimester pelvic ultrasound to rule out ectopic pregnancy. Academic Emergency Medicine: Official journal of the Society for Academic Emergency Medicine 2004; 11(9):912–7.

15Mateer JR, Valley VT, Aiman EJ, Phelan MB, Thoma ME, Kefer MP. Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Annals of Emergency Medicine 1996; 27(3):283–9.

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