title: Interrater reliability of cardiac output measurements by transcutaneous Doppler ultrasound: implications for noninvasive hemodynamic monitoring in the ED.
abstract: BACKGROUND
  Hemodynamic monitoring is an important aspect of caring for the critically ill patients boarding in the emergency department (ED). The purpose of this study is to investigate the interrater agreement of noninvasive cardiac output measurements using transcutaneous Doppler ultrasound technique.
  
  
  METHODS
  This is a prospective observational cohort study performed in a 32-bed adult ED of an academic tertiary center with approximately 65000 annual patient visits. Patients were enrolled after verbal consent over a 7-month period. The raters were ED personnel involved in patient care. Paired measurements of cardiac index (CI) and stroke volume index (SVI) were obtained from a transcutaneous Doppler ultrasound cardiac output monitor.
  
  
  RESULTS
  A convenience sample of 107 (50 women and 57 men) patients with a median age of 49 (32, 62) years was enrolled. One hundred two paired measurements were performed in 91 patients in whom adequate Doppler ultrasound signals were obtainable. The raters included 35 emergency medicine attending physicians, 31 emergency medicine residents, 80 medical students, 47 nurses, and 11 emergency medical technicians. Cardiac index range was 0.6 to 5.3 L/min per square meter, and SVI range was 7.7 to 63.0 mL/m(2). The correlation of CI measurements between 2 raters was good (r(2) = 0.87; 95% confidence interval, 0.86-1.00; P < .001). Likewise, SVI measurements between 2 raters also showed acceptable correlation (r(2) = 0.84; 95% confidence interval, 0.81-0.96; P < .001). Interrater reliability was strong for CI (kappa = 0.83 with 92.2% agreement) and SVI measurements (kappa = 0.72 with 88.2% agreement). Most patients had an interrater difference below 10% in CI and SVI measurements.
  
  
  CONCLUSIONS
  Emergency department personnel, regardless of their role in patient care, are able to obtain reliable cardiac output measurements in ED patients over a wide range of CI and SVI. Transcutaneous Doppler ultrasound technique may be an alternative to traditional invasive hemodynamic monitoring of critically ill patients presenting to the ED.
authors.affiliation: Department of Emergency Medicine, Loma Linda University Medical Center, Loma Linda, CA 92354, USA. hbnguyen@ahs.llumc.edu
authors.forename: H Bryant
authors.initials: HB
authors.lastname: Nguyen
authors.forename: Theodore
authors.initials: T
authors.lastname: Losey
authors.forename: Janet
authors.initials: J
authors.lastname: Rasmussen
authors.forename: Rebecca
authors.initials: R
authors.lastname: Oliver
authors.forename: Mindi
authors.initials: M
authors.lastname: Guptill
authors.forename: William A
authors.initials: WA
authors.lastname: Wittlake
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Corbett
mesh_terms: D000328:Adult; D002302:Cardiac Output / Q000502:physiology*; D002983:Clinical Competence; D015331:Cohort Studies; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D015203:Reproducibility of Results; D014159:Transducers; D018608:Ultrasonography, Doppler / Q000379:methods*