Cardiology, Improving Outcomes, Improving Throughput

The Lean ED in the Obs Unit

The “lean ED” has been embraced in multiple ways – keep your vertical patients vertical, a disposition area where patients await paperwork & final signatures, bedside sono, the list goes on.

It would stand to reason that lean principles would trickle down the halls and up the elevator to other departments as well.  Along these lines, I’ve started to see ultrasound trickle into the hands of internal medicine residents with good results:

This study (, after just 9 hours of training, focused cardiac ultrasound allowed for “substantial” agreement between trainee and tutor for identification of pericardial effusion (k=0.71) and global cardiac systolic function (k= 0.77), “moderate” for marked right and left ventricular enlargement (k= 0.56-0.64).  After an additional 9 hours of training, residents were only proficient in obtaining adequate images in the parasternal window without mastering the apical and subcostal views.

While here (, ten internal medicine attending physicians performed focused cardiac ultrasound on178 inpatients and compared to formal echo interpreted by cardiologists.  Sensitivity and specificity for any degree of left ventricular systolic function was 91% and 88% respectively.  The interrater agreement between the internist and cardiologist was “good/substantial” with K = 0.77.

These principles can and should be applied to observation units, where many chest pain rule outs and CHF exacerbations will be placed – and along with them, orders for an echo (I’ll leave the discussion of whether or not they all need an echo for another day).  I’ve waited until the next day for an echo to be done and read in an observation unit so I can dispo a patient.  If you are working in observation regularly, and chest pain and CHF is your bread and butter, I see no reason why echo competency can not be obtained rather quickly.  By learning bedside cardiac sono as an observation unit provider, you’ll make yourself an invaluable team member and likely decrease length of stay without harming patients.


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