Emily Fu, PGY-1
Title: Randomized Controlled Clinical Trial of Point-of-Care, Limited Ultrasonography for Trauma in the Emergency Department: The First Sonography Outcomes Assessment Program Trial
Melniker, L. A., Leibner, E., McKenney, M.G., Lopez, P., Briggs, W.M., Mancuso, C.A. (2006). Annals of Emergency Medicine, 48(3), 227-234.
Idea: While prior studies have shown that point-of-care ultrasonography is sensitive and specific for free peritoneal and pleural fluid, there is less information on whether FAST improves clinical outcomes for trauma patients. This study examines how the use of FAST as a rapid screening tool affects door-to-operative care times and other measures of clinical and societal effectiveness.
Study: This was a randomized, concealed, and controlled clinical trial that took place at two Level I trauma centers (one supervised solely by trauma surgeons and the other by ED physicians and trauma surgeons). Inclusion criteria were all adult and pediatric blunt and penetrating traumas who presented with mechanism, symptomatology, or physical findings concerning for torso trauma. Patients who were unable to consent or required immediate transfer to the OR were excluded. The primary objective was to evaluate the effects of point of care limited ultrasonography (PLUS) screening on door-to-operative time, CT use, hospital length of stay and charges for care. The PLUS used in this study was a 4-view assessment of the pericardial sac, RUQ, LUQ and pelvis.
Results: A total of 525 patients were assessed for eligibility, and ultimately 262 patients were enrolled and randomized for a result of 135 PLUS patients and 127 controls.
No bluntly traumatized patient with a negative PLUS required operative care. Time from ED arrival to OR for PLUS patients averaged 57 mins as opposed to 166 mins for control patients. PLUS patients were also significantly less likely to require CT, with an odds ratio of 0.16 (confidence interval 0.07,0.31) compared to control patients. On average PLUS patients length of stay was 4 days shorter and they were charged $15,000 less than control patients.
Takeaway: This study showed reduction in length of stay, CT use, and charges in PLUS-evaluated patients in both operatively and non-operatively treated groups. This suggests that focused ultrasound assessment in trauma allows for expedited decision-making on whether patients require operative care, which in turn facilitates other care (e.g. neurosurgery) in certain patients, leading to shorter lengths of stay and reduced charges. Therefore when used as a screening tool, FAST is not only clinically accurate, but also societally effective in improving hospital resource utilization, patient quality of life, and cost-effectiveness.