Background Lung ultrasound (LUS) has received considerable interest in the clinical evaluation of patients with COVID‐19. Previously described LUS manifestations for COVID‐19 include B‐lines, consolidations, and pleural thickening. The interrater reliability (IRR) of these findings for COVID‐19 is unknown. Methods This study was conducted between March and June 2020. Nine physicians (hospitalists: n = 4; emergency medicine: n = 5) from 3 medical centers independently evaluated n = 20 LUS scans ( n = 180 independent observations) collected from patients with COVID‐19, diagnosed via RT‐PCR. These studies were randomly selected from an image database consisting of COVID‐19 patients evaluated in the emergency department with portable ultrasound devices. Physicians were blinded to any patient information or previous LUS interpretation. Kappa values ( κ ) were used to calculate IRR. Results There was substantial IRR on the following items: normal LUS scan ( κ = 0.79 [95% CI: 0.72–0.87]), presence of B‐lines ( κ = 0.79 [95% CI: 0.72–0.87]), ≥3 B‐lines observed ( κ = 0.72 [95% CI: 0.64–0.79]). Moderate IRR was observed for the presence of any consolidation ( κ = 0.57 [95% CI: 0.50–0.64]), subpleural consolidation ( κ = 0.49 [95% CI: 0.42–0.56]), and presence of effusion ( κ = 0.49 [95% CI: 0.41–0.56]). Fair IRR was observed for pleural thickening ( κ = 0.23 [95% CI: 0.15–0.30]). Discussion Many LUS manifestations for COVID‐19 appear to have moderate to substantial IRR across providers from multiple specialties utilizing differing portable devices. The most reliable LUS findings with COVID‐19 may include the presence/count of B‐lines or determining if a scan is normal. Clinical protocols for LUS with COVID‐19 may require additional observers for the confirmation of less reliable findings such as consolidations.

Objectives Lung ultrasound (LUS) can accurately diagnose several pulmonary diseases, including pneumothorax, effusion, and pneumonia. LUS may be useful in the diagnosis and management of COVID‐19. Methods This study was conducted at two United States hospitals from 3/21/2020 to 6/01/2020. Our inclusion criteria included hospitalized adults with COVID‐19 (based on symptomatology and a confirmatory RT‐PCR for SARS‐CoV‐2) who received a LUS. Providers used a 12‐zone LUS scanning protocol. The images were interpreted by the researchers based on a pre‐developed consensus document. Patients were stratified by clinical deterioration (defined as either ICU admission, invasive mechanical ventilation, or death within 28 days from the initial symptom onset) and time from symptom onset to their scan. Results N = 22 patients (N = 36 scans) were included. Eleven (50%) patients experienced clinical deterioration. Among N = 36 scans, only 3 (8%) were classified as normal. The remaining scans demonstrated B‐lines (89%), consolidations (56%), pleural thickening (47%), and pleural effusion (11%). Scans from patients with clinical deterioration demonstrated higher percentages of bilateral consolidations (50 versus 15%; P = .033), anterior consolidations (47 versus 11%; P = .047), lateral consolidations (71 versus 29%; P = .030), pleural thickening (69 versus 30%; P = .045), but not B‐lines (100 versus 80%; P = .11). Abnormal findings had similar prevalences between scans collected 0–6 days and 14–28 days from symptom onset. Discussion Certain LUS findings may be common in hospitalized COVID‐19 patients, especially for those that experience clinical deterioration. These findings may occur anytime throughout the first 28 days of illness. Future efforts should investigate the predictive utility of these findings on clinical outcomes.

a novel coronavirus disease (COVID-19) emerged in Wuhan, China, and spread globally, resulting in the first World Health Organization (WHO)-classified pandemic in over a decade. 1 As of April 2020, the United States has the most confirmed COVID-19 cases worldwide, but public health interventions and testing availability have varied across the country. 2Santa Clara County, California, has a population density of approximately 1,400 people per square mile and a high median household income ($116,178/year) and is part of the San Francisco Bay Area. 3 It was one of the first counties where COVID-19 was detected in the United States, with its first case (on January 31, 2020) being the seventh case nationwide. 4 The San Francisco Bay Area was also the first region in the United States to implement "shelter in place" orders on March 16, 2020, which consisted of widespread school and business closures and social distancing measures including prohibition of all nonessential travel and gatherings. 4 The objective of this study was to describe the demographics, clinical characteristics, and outcomes of emergency department (ED) patients who tested positive for COVID-19 at a medical center in Santa Clara County with the aim of identifying clinical patterns and assessing possible effects of local public health measures.This was an observational, cross-sectional study of ED patients with a laboratory-confirmed diagnosis of COVID-19 at a single academic hospital (Stanford Health Care). Our ED is a tertiary care, Level I trauma center that treated approximately 56,000 adults and 23,000 children in 2019. The hospital has 86 intensive care unit (ICU) beds.A novel polymerase chain reaction (PCR) laboratory test to diagnose COVID-19 was developed at the Stanford Clinical Virology Laboratory and approved for clinical use by the Food and Drug Administration (FDA). It utilizes a nasopharyngeal swab specimen that is collected by a health care provider, preserved in viral transport medium, and tested via reverse-transcriptase-PCR (RT-PCR). The test screens for the presence of RNA encoding an envelope protein of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative virus of COVID-19, and is followed by a confirmatory test for the SARS-CoV-2 RNA polymerase. 5

ProblemThe COVID-19 pandemic significantly disrupted point-of-care ultrasound (POCUS) education. Medical schools and residency programs placed restrictions on bedside teaching and clinical scanning as part of risk mitigation. In response, POCUS faculty from 15 institutions nationwide collaborated on an alternative model of ultrasound education, A Distance-learning Approach to POCUS Training (ADAPT). ApproachADAPT was repeated monthly from April 1 through June 30, 2020. It accommodated 70 learners, who included 1-to 4-week rotators and asynchronous learners. The curriculum included assigned prework and learning objectives covering 20 core

Background Point-of-care ultrasound (POCUS) is an important clinical tool for a growing number of medical specialties. The current American College of Emergency Physicians (ACEP) Ultrasound Guidelines recommend that trainees perform 150–300 ultrasound scans as part of POCUS training. We sought to assess the relationship between ultrasound scan numbers and performance on an ultrasound-focused observed structured clinical examination (OSCE). Methods This was a cross-sectional cohort study in which the number of ultrasound scans residents had previously performed were obtained from a prospective database and compared with their total score on an ultrasound OSCE. Ultrasound fellowship trained emergency physicians administered a previously published OSCE that consisted of standardized questions testing image acquisition and interpretation, ultrasound machine mechanics, patient positioning, and troubleshooting. Residents were observed while performing core applications including aorta, biliary, cardiac, deep vein thrombosis, Focused Assessment with Sonography in Trauma (FAST), pelvic, and thoracic ultrasound imaging. Results Twenty-nine postgraduate year (PGY)-3 and PGY-4 emergency medicine (EM) residents participated in the OSCE. The median OSCE score was 354 [interquartile range (IQR) 343–361] out of a total possible score of 370. Trainees had previously performed a median of 341 [IQR 289–409] total scans. Residents with more than 300 ultrasound scans had a median OSCE score of 355 [IQR 351–360], which was slightly higher than the median OSCE score of 342 [IQR 326–361] in the group with less than 300 total scans ( p = 0.04). Overall, a LOWESS curve demonstrated a positive association between scan numbers and OSCE scores with graphical review of the data suggesting a plateau effect. Conclusion The results of this small single residency program study suggest a pattern of improvement in OSCE performance as scan numbers increased, with the appearance of a plateau effect around 300 scans. Further investigation of this correlation in diverse practice environments and within individual ultrasound modalities will be necessary to create generalizable recommendations for scan requirements as part of overall POCUS proficiency assessment.

Background: Lung ultrasound (LUS) may be used in the diagnostic evaluation of patients with COVID-19. An abnormal LUS is associated with increased risk for ICU admission in COVID-19. Previously described LUS manifestations for COVID-19 include B-lines, consolidations, and pleural thickening. The interrater reliability (IRR) of these findings for COVID-19 is unknown. Research Question: What is the interrater reliability of lung ultrasound findings in patients with RT-PCR confirmed COVID-19? Study Design and Methods: This study was conducted at conducted at two academic medical centers between 03/2020-06/2020. Nine physicians (hospitalists: n=4; emergency medicine: n=5) independently evaluated n=20 LUS scans (n=180 independent observations) collected from RT-PCR confirmed COVID-19 patients. These studies were randomly selected from an image database consisting of COVID-19 patients evaluated in the emergency department with portable ultrasound devices. Physicians were blinded to any patient information or previous LUS interpretation. Kappa values were used to calculate IRR. Results: There was substantial IRR on the following items: normal LUS scan (K=0.79 [95% CI: 0.72-0.87]), presence of B-lines (K=0.79 [95% CI: 0.72-0.87]), >=3 B-lines observed (K=0.72 [95% CI: 0.64-0.79]). Moderate IRR was observed for the presence of any consolidation (K=0.57 [95% CI: 0.50-0.64]), subpleural consolidation (K=0.49 [95% CI: 0.42-0.56]), and presence of effusion (K=0.49 [95% CI: 0.41-0.56]). Fair IRR was observed for pleural thickening (K=0.23 [95% CI: 0.15-0.30]). Interpretation: Many LUS manifestations for COVID-19 appear to have moderate to substantial IRR across providers from multiple specialties utilizing differing portable devices. The most reliable LUS findings with COVID-19 may include the presence/count of B-lines or determining if a scan is normal. Clinical protocols for LUS with COVID-19 may require additional observers for the confirmation of less reliable findings such as consolidations.

Objectives The aim of this study was to evaluate the accuracy and timeliness of resident‐performed point‐of‐care lung ultrasound (LUS) examinations for the follow‐up of pneumothorax (PTX) after tube thoracostomy. Methods After brief training, Rwandan surgical residents blinded to chest radiography (CXR) performed and interpreted LUS examinations for PTX in participants undergoing CXR for PTX follow‐up. Treating clinicians interpreted CXR for the presence of PTX for therapeutic decisions. Lung ultrasound was later reviewed by ultrasound experts, and CXR was reviewed by a radiologist. We defined expert LUS interpretation as the reference standard. The sensitivity and specificity of resident‐performed LUS examinations for diagnosing PTX were calculated. We assessed agreement between trained resident versus expert LUS and clinician versus radiology CXR using the Cohen κ coefficient. We compared the time to results between LUS and CXR. Results Over an 8‐month period, 51 participants were enrolled. Compared to expert LUS interpretation, the sensitivity and specificity (95% confidence intervals) of resident LUS were 100% (85%–100%) and 96% (82%–100%), respectively, whereas the sensitivity and specificity of clinician‐interpreted CXR were 48% (27%–69%) and 100% (88%–100%). The agreement between resident and expert LUS was excellent (κ = 0.96), whereas the agreement between clinician and radiologist CXR was only moderate (κ = 0.60). The time to results was significantly longer for CXR than LUS (mean, 1335 versus 396 minutes; P = .0001). Conclusions A resident‐performed LUS examination was a quicker imaging modality with superior sensitivity compared to clinician‐interpreted CXR for PTX follow‐up after tube thoracostomy in this Rwandan study. Lung ultrasound can be a valuable imaging tool for PTX follow‐up, especially in resource‐limited settings.

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