title: Real-time point of care microcirculatory assessment of shock: design, rationale and application of the point of care microcirculation (POEM) tool.
abstract: BACKGROUND
  Despite over a decade of research and technological advances, sublingual microcirculatory monitoring has not yet reached clinical utility. Offline analysis is time consuming and occurs away from the patient. A system to assess the microcirculation at the point of care is desirable. We present a novel 5-point grading system (the point of care microcirculation (POEM) scoring system) that can be used at the point of care during non-invasive sublingual microcirculatory monitoring.
  
  
  METHODS
  The POEM score is an ordinal scale from 1 (worst) to 5 (best), based on a composite assessment of flow and heterogeneity of four individual sublingual video-microscopy clips. Thirty-two healthcare professionals were trained in how to assign POEM scores. Following training they assigned scores to five test sequences (each consisting of four video clips). They were blinded to clinical status. Inter-user consistency and agreement were assessed using intra-class correlation coefficient (ICC) analysis. In addition, blinded expert scores for 68 video clips were compared to offline computer analysis using traditional microcirculatory parameters including total vessel density (TVD), perfused vessel density (PVD), proportion of perfused vessels (PPV), microcirculatory flow index (MFI) and microcirculatory heterogeneity index (MHI). The time taken to assign each was recorded.
  
  
  RESULTS
  Participants showed good inter-rater consistency (ICC 0.83, 95 % CI 0.626, 0.976) and agreement (ICC 0.815, 95 % CI 0.602, 0.974) for assigned POEM scores. Expert scoring of videos correlated with offline values for PVD (R2= 0.39; p < 0.05), PPV (R2= 0.71; p < 0.001), MFI (R2= 0.75; p < 0.001), and MHI (R2= 0.68; p < 0.001). POEM scores took less time to assign than conventional offline computer analysis (2 minutes versus 44 minutes).
  
  
  CONCLUSIONS
  We present for the first time a novel 5-point ordinal scale of microcirculatory flow and heterogeneity that can be used at the point of care. It has minimal inter-user variability amongst healthcare professionals after just 1 hour of training. POEM scores take a short time to assign, and correspond well to traditional offline computer-analyzed parameters.
authors.affiliation: NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, B152TH, UK. david.naumann@nhs.net.
authors.forename: David N
authors.initials: DN
authors.lastname: Naumann
authors.affiliation: Kings College Hospital, Denmark Hill, London, UK.
authors.forename: Clare
authors.initials: C
authors.lastname: Mellis
authors.affiliation: Heartfelt Technologies Ltd, Fen House Fen Road, Cambridge, UK.
authors.forename: Shamus L G
authors.initials: SL
authors.lastname: Husheer
authors.affiliation: Kings College Hospital, Denmark Hill, London, UK.
authors.forename: Philip
authors.initials: P
authors.lastname: Hopkins
authors.affiliation: NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, B152TH, UK.
authors.forename: Jon
authors.initials: J
authors.lastname: Bishop
authors.affiliation: NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, B152TH, UK.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Midwinter
authors.affiliation: Kings College Hospital, Denmark Hill, London, UK.
authors.forename: Sam D
authors.initials: SD
authors.lastname: Hutchings
mesh_terms: D001783:Blood Flow Velocity / Q000502:physiology; D003199:Computer Systems / Q000592:standards*; D006282:Health Personnel / Q000592:standards; D006801:Humans; D008833:Microcirculation / Q000502:physiology*; D018715:Microscopy, Video / Q000379:methods / Q000592:standards*; D019095:Point-of-Care Systems / Q000592:standards*; D011897:Random Allocation; D012720:Severity of Illness Index; D012769:Shock / Q000175:diagnosis* / Q000503:physiopathology; D016037:Single-Blind Method
keywords: Circulation; Hemorrhage; Microcirculation; Point-of-care; Sepsis; Shock