Clinical Pearls & Morning Reports
Point-of-care ultrasonography (POCUS) is defined as the acquisition, interpretation, and immediate clinical integration of ultrasonographic imaging performed by a treating clinician at the patient’s bedside rather than by a radiologist or cardiologist. Read the NEJM Review Article here.
Q: Name a concern associated with the use of handheld ultrasound systems.
A: Low-cost handheld ultrasound systems that connect to a smartphone or tablet by means of sophisticated wireless technology, the Internet, and a cloud-based system have become readily available to the frontline clinician. Careless use of handheld ultrasound systems could lead to violations of the Health Insurance Portability and Accountability Act (HIPAA) in the United States (or similar regulations in other countries). Clinicians who use these systems should anticipate concern on the part of their information technology colleagues about Internet connectivity and the need for technical solutions to prevent HIPAA violations.
Q: What are some of the uses and benefits of POCUS?
A: Clinicians who become proficient in POCUS can use it to track clinical conditions that may progress rapidly — for example, acute respiratory failure, intracranial hypertension, and hemodynamic failure and resuscitation from traumatic shock. POCUS can be useful as a monitoring tool during the performance of cardiopulmonary resuscitation. POCUS is effective as a screening tool for the identification of certain disorders, such as abdominal aortic aneurysm. Several studies indicate that POCUS is more cost-effective and time-efficient than traditional ultrasonography in obtaining data that may decrease the length of stay in the emergency department (for evaluation of nephrolithiasis, uncomplicated biliary disease, early intrauterine pregnancy, and soft-tissue infection). Implementation of POCUS for a broad range of clinical conditions in general medical practice has led to a measurable reduction in planned referrals.
A: Use of ultrasonography to guide procedures requires that the clinician be competent in its use for specialty-specific functions. Clinicians can develop technical competence with task trainers (simulators that integrate ultrasonography with the physical aspects of a specific procedure and allow repeated practice before an encounter with a patient). On the basis of expert consensus, 25 to 50 examinations are required to ensure basic competence in performing most diagnostic ultrasonographic procedures. The acquisition of competence in ultrasonography for guidance during procedures appears to have a shorter learning curve (10 procedures). However, a numerical standard alone cannot be used to determine competence in POCUS-driven procedures, given the level of the data. At present, there is no widely accepted method of determining competence in the performance of ultrasonography to guide procedures.
A: Clinicians who have not been adequately trained may harm patients by making an inaccurate diagnosis or using POCUS inappropriately. In 2020, the Joint Commission on Accreditation of Healthcare Organizations and the Emergency Care Research Institute identified the adoption of POCUS without necessary safeguards as a major health technology hazard. With the widespread availability of lower-cost handheld ultrasound systems, training large numbers of clinicians to become competent in POCUS poses a challenge. At the medical school level, 35% of 222 medical schools in the United States have implemented a focused ultrasound training program. Specialty-specific training in POCUS and methods that test for competence are important for postgraduate medical training. The Accreditation Council for Graduate Medical Education defines requirements for ultrasonographic training in emergency medicine and anesthesiology residencies. In the United States and Canada, training standards have been formulated for specialty-specific POCUS, but national-level postgraduate certification is generally not available for the many applications of POCUS.