title: Can emergency physicians diagnose and correctly classify diastolic dysfunction using bedside echocardiography?
abstract: OBJECTIVE
  The goal of this study was to determine if emergency physicians (EPs) can correctly perform a bedside diastology examination (DE) and correctly grade the level of diastolic function with minimal additional training in echocardiography beyond what is learned in residency. We hypothesize that EPs will be accurate at detecting and grading diastolic dysfunction (DD) when compared to a criterion standard interpretation by a cardiologist.
  
  
  METHODS
  We conducted a prospective, observational study on a convenience sample of adult patients who presented to an urban emergency department with a chief concern of dyspnea. All patients had a bedside echocardiogram, including a DE, performed by an EP-sonographer who had 3 hours of didactic and hands-on echocardiography training with a cardiologist. The DE was interpreted as normal, grade 1 to 3 if DD was present, or indeterminate, all based on predefined criteria. This interpretation was compared to that of a cardiologist who was blinded to the EPs' interpretations.
  
  
  RESULTS
  We enrolled 62 patients; 52% had DD. Using the cardiology interpretation as the criterion standard, the sensitivity and specificity of the EP-performed DE to identify clinically significant diastolic function were 92% (95% confidence interval [CI], 60-100) and 69% (95% CI, 50-83), respectively. Agreement between EPs and cardiology on grade of DD was assessed using κ and weighted κ: κ = 0.44 (95% CI, 0.29-0.59) and weighted κ = 0.52 (95% CI, 0.38-0.67). Overall, EPs rated 27% of DEs as indeterminate, compared with only 15% by cardiology. For DEs where both EPs and cardiology attempted an interpretation (indeterminates excluded) κ = 0.45 (95% CI, 0.26 to 0.65) and weighted κ = 0.54 (95% CI, 0.36-0.72).
  
  
  CONCLUSIONS
  After limited diastology-specific training, EPs are able to accurately identify clinically significant DD. However, correct grading of DD, when compared to a cardiologist, was only moderate, at best. Our results suggest that further training is necessary for EPs to achieve expertise in grading DD.
authors.affiliation: Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St Antoine, Suite 3R, Detroit, MI 48201. Electronic address: robehrman@gmail.com.
authors.forename: Robert R
authors.initials: RR
authors.lastname: Ehrman
authors.affiliation: Department of Emergency Medicine, The John H. Stroger, Jr. Hospital of Cook County, Rush University School of Medicine, 1969 W Ogden Ave, Chicago, IL, 60612; Department of Emergency Medicine Indiana University School of Medicine 1701 N. Senate Blvd, B401 Indianapolis, IN 46202. Electronic address: frussell27@gmail.com.
authors.forename: Frances M
authors.initials: FM
authors.lastname: Russell
authors.affiliation: Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Chicago, IL 60611. Electronic address: ansari01@gmail.com.
authors.forename: Asimul H
authors.initials: AH
authors.lastname: Ansari
authors.affiliation: Department of Medicine, Division of Cardiology, The John H. Stroger, Jr. Hospital of Cook County, Rush University School of Medicine 1969 W Ogden Ave, Chicago, IL, 60612. Electronic address: bosko_margeta@hotmail.com.
authors.forename: Bosko
authors.initials: B
authors.lastname: Margeta
authors.affiliation: Department of Medicine, Division of Cardiology, Indiana University School of Medicine, 545 Barnhill Dr EH 317, Indianapolis, IN 46202. Electronic address: jmclary@iu.edu.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Clary
authors.affiliation: Department of Emergency Medicine, The John H. Stroger, Jr. Hospital of Cook County, Rush University School of Medicine, 1969 W Ogden Ave, Chicago, IL, 60612. Electronic address: echristian@cookcountyhhs.org.
authors.forename: Errick
authors.initials: E
authors.lastname: Christian
authors.affiliation: Department of Emergency Medicine, The John H. Stroger, Jr. Hospital of Cook County, Rush University School of Medicine, 1969 W Ogden Ave, Chicago, IL, 60612. Electronic address: kcosby40@gmail.com.
authors.forename: Karen S
authors.initials: KS
authors.lastname: Cosby
authors.affiliation: Department of Emergency Medicine, The John H. Stroger, Jr. Hospital of Cook County, Rush University School of Medicine, 1969 W Ogden Ave, Chicago, IL, 60612. Electronic address: jbailitz@cookcountyhhs.org.
authors.forename: John
authors.initials: J
authors.lastname: Bailitz
mesh_terms: D002309:Cardiology; D002983:Clinical Competence; D003971:Diastole; D004417:Dyspnea / Q000209:etiology; D004635:Emergency Medicine / Q000592:standards*; D004636:Emergency Service, Hospital / Q000592:standards; D005260:Female; D006333:Heart Failure / Q000145:classification* / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D000067716:Point-of-Care Testing; D011446:Prospective Studies; D014463:Ultrasonography