Barriers to learning and using point-of-care ultrasound: a survey of practicing internists in six North American institutions

A National Survey on Point of Care Ultrasonography Use Among Veterans Affairs Clinicians in Home Care and Skilled Nursing Facilities

INTRODUCTION

Older adults who are homebound and those in skilled nursing facilities (SNFs) often have limited access to point of care imaging to inform clinical decision making. Point-of-care ultrasonography (POCUS) can help span this gap by augmenting the physical examination to aid in diagnosis and triaging. Although training in POCUS for medical trainees is becoming more common and may focus on settings such as the emergency department, intensive care unit, and inpatient care, little is known about POCUS training among practicing clinicians who work outside of these settings. We conducted a national needs assessment survey around experience with POCUS focused on practicing clinicians in the sub-acute, long-term, and home-based care settings in the Veterans Affairs (VA) health system.

METHODS

An electronic survey was developed and sent out to clinicians via Listservs for the VA long-term and sub-acute care facilities [Community Living Centers (CLCs)], Home Based Primary Care outpatient teams, and Hospital in Home teams to assess current attitudes, previous training, and skills related to POCUS.

RESULTS

Eighty-eight participants responded to the survey, for an overall response rate of 29% based on the number of emails on each Listserv, representing CLC, home-based primary care, and hospital in home. Sixty percent of clinicians reported no experience with POCUS, and 76% reported that POCUS and POCUS training would be useful to their practice. More than 50% cited lack of training and lack of equipment as 2 significant barriers to POCUS use.

DISCUSSION

This national needs assessment survey of VA clinicians reveals important opportunities for training in POCUS for clinicians working with older adults who are receiving home care homebound or living in SNFs.

Current perception and barriers to implementing lung ultrasound in Canadian neonatal intensive care units: a national survey

Despite the growing body of literature supporting the use of point-of-care lung ultrasound (POC-LU) in neonates, its adoption in Canadian neonatal intensive care units (NICUs) remains limited. This study aimed to identify healthcare providers' perceptions and barriers to implementing POC-LU in Canadian NICUs. We conducted an electronic survey targeting neonatologists, neonatal fellows, neonatal nurse practitioners, and registered respiratory therapists in 20 Canadian NICUs. The survey comprised a 28-item questionnaire divided into four sections: (1) participants' demographics and availability of POC-LU equipment, (2) experience and interest in POC-LU learning, (3) perception of POC-LU as a diagnostic tool, and (4) barriers to POC-LU implementation in NICUs. A total of 194 participants completed the survey, with neonatologists comprising the majority (45%). Nearly half of the participants (48%) reported prior experience with POC-LU. The most prevalent indications for POC-LU use were diagnosis of pleural effusion (90%), pneumothorax (87%), and respiratory distress syndrome (76%). Participants identified the primary barrier to POC-LU adoption as the lack of trained providers available for both training and clinical integration. Notably, most respondents (87%) expressed keen interest in learning neonatal POC-LU. A subgroup analysis based on the responses collected from NICU-directors of 12 institutions yielded results consistent with those of the overall participant pool.     Conclusion: This survey underscores the perceived importance of POC-LU among NICU healthcare providers. A Canadian consensus is required to facilitate the development of widespread training programs as well as standardized clinical practice guideline for its implementation. What is Known: • In recent years, point-of-care lung ultrasound (POC-LU) has emerged as an important tool in neonatology, revolutionizing the assessment and management of critically ill infants. However, its adoption in Canadian Neonatal Intensive Care Units remains limited. What is New: • Most Canadian healthcare providers showed high level of interest in learning POC-LU techniques. Additionally, POC-LU was perceived as a useful tool for diagnosis and guiding intervention in various neonatal respiratory diseases. Nonetheless, the lack of expertise emerged as the primary barrier to its adoption and practice across different groups of participants regardless of their clinical experience level.

Point of care ultrasonography as the new "Laennec Sthetoscope"

Point of care ultrasonography (POCUS) has evolved to become the fifth pillar of the conventional physical examination, and use of POCUS protocols have significantly decreased procedure complications and time to diagnose. However, lack of experience in POCUS by preceptors in medical schools and nephrology residency programs are significant barriers to implement a broader use. In rural and low-income areas POCUS may have a transformative effect on health care management.

Point-of-care ultrasound Usage and accuracy within a Canadian urology division

INTRODUCTION

This research evaluates the utility and precision of point-of-care ultrasound (POCUS) in urology, inspired by recent affirmations of its feasibility and value.1,2 Our study provides valuable insights for urologists about POCUS's practical usage.

METHODS

A prospective study assessed POCUS usage and accuracy in the University of Alberta's Division of Urology using data from April 4, 2022, to April 4, 2023. Data include POCUS indications, findings, and correlation with the final diagnosis/gold standard. Additionally, a qualitative survey was conducted among urologists and residents about POCUS's pros, cons, and barriers to integration.

RESULTS

Thirty-three patients underwent POCUS examinations, mainly for suspected hydronephrosis (27%, n=9). Other indications included urinary retention, testicular mass, torsion, cryptorchidism, renal mass, extended focused assessment with sonography in trauma (eFAST ) exams, nephrostomy tube placement confirmation, and scrotal hematomas. POCUS findings matched the final diagnosis in most cases, showing 86% sensitivity, with an average exam time of 1-5 minutes. POCUS showed potential for suprapubic tube insertions. Residents (60%, n=20) were the most frequent users, followed by staff (33%, n=10), and students (6%, n=2). The surveyed urologists and residents expressed comfort with POCUS but cited time, cost, and practicality as barriers.

CONCLUSIONS

POCUS proves accurate and beneficial in urology, particularly for hydronephrosis. Most findings align with the gold standard, and the average exam time is brief. Barriers include time and cost. Further research is necessary to evaluate cost-effectiveness and POCUS's impact on patient outcomes in routine urologic practice.

Change in economy of ultrasound probe motion among general medicine trainees

OBJECTIVES

To observe change in economy of 9 ultrasound probe movement metrics among internal medicine trainees during a 5-day training course in cardiac point of care ultrasound (POCUS).

METHODS

We used a novel probe tracking device to record nine features of ultrasound probe movement, while trainees and experts optimized ultrasound clips on the same volunteer patients. These features included translational movements, gyroscopic movements (titling, rocking, and rotation), smoothness, total path length, and scanning time. We determined the adjusted difference between each trainee's movements and the mean value of the experts' movements for each patient. We then used a mixed effects model to trend average the adjusted differences between trainees and experts throughout the 5 days of the course.

RESULTS

Fifteen trainees were enrolled. Three echocardiographer technicians and the course director served as experts. Across 16 unique patients, 294 ultrasound clips were acquired. For all 9 movements, the adjusted difference between trainees and experts narrowed day-to-day (p value < 0.05), suggesting ongoing improvement during training. By the last day of the course, there were no statistically significant differences between trainees and experts in translational movement, gyroscopic movement, smoothness, or total path length; yet on average trainees took 28 s (95% CI [14.7-40.3] seconds) more to acquire a clip.

CONCLUSIONS

We detected improved ultrasound probe motion economy among internal medicine trainees during a 5-day training course in cardiac POCUS using an inexpensive probe tracking device. Objectively quantifying probe motion economy may help assess a trainee's level of proficiency in this skill and individualize their POCUS training.

Normology: Is it Time to Rethink Point-of-Care Ultrasound Training?

Point-of-care ultrasound (PoCUS) is increasingly being adopted by clinicians to augment their clinical examination and aid procedures. Evidence-based clinical practice guidelines now support many aspects of PoCUS practice. As a result, more and more medical schools are integrating PoCUS into their curricula, creating a significant demand for training resources. All training must ensure that trainees have the appropriate knowledge, skills and behaviour to enable the clinical integration of PoCUS. The transition from supervised to unsupervised practice is an important step in PoCUS, but should not be confused with expertise. At the start of clinical practice, confirming that something is not normal is probably enough, and trainees can subsequently improve their PoCUS diagnostic accuracy at the bedside during clinical rotations. Our hypothesis is that competency can be achieved without the need to scan patients suspected or suffering from the target pathology. This would enable most of the training to be carried out outside the clinical environment, using volunteers in planned sessions. These planned sessions will be able to accommodate a larger number of trainees and may facilitate collaboration between specialties. When patients are scanned in the clinical environment, trainees should have acquired a good level of competence beforehand. In summary, normology principles could help PoCUS trainees, at the start of their training, to acquire the knowledge, skills and behaviour necessary to achieve a level of competency allowing them to proceed to unsupervised practice. Initially confirming whether something is normal or not is enough. Nevertheless, further research should be conducted to support this concept, and its impact on PoCUS teaching in clinical practice.

Executive summary of the consensus document for the training and development of clinical ultrasound in Internal Medicine: Recommendations from the Clinical Ultrasound Working Group of the Spanish Society of Internal Medicine (GTECO-SEMI)

INTRODUCTION

Given the increasing adoption of clinical ultrasound in medicine, it is essential to standardize its application, training, and research.

OBJECTIVES AND METHODS

The purpose of this document is to provide consensus recommendations to address questions about the practice and operation of clinical ultrasound units. Nineteen experts and leaders from advanced clinical ultrasound units participated. A modified Delphi consensus method was used.

RESULTS

A total of 137 consensus statements, based on evidence and expert opinion, were considered. The statements were distributed across 10 areas, and 99 recommendations achieved consensus.

CONCLUSIONS

This consensus defines the most important aspects of clinical ultrasound in the field of Internal Medicine, with the aim of standardizing and promoting this healthcare advancement in its various aspects. The document has been prepared by the Clinical Ultrasound Working Group and endorsed by the Spanish Society of Internal Medicine.

Teaching point-of-care ultrasound using a serious game: a randomized controlled trial

BACKGROUND

Point-of-care ultrasound (POCUS) is an important diagnostic tool for internists. However, there are important barriers in learning POCUS, including lack of practice time and lack of experts for supervision. Alternative learning tools may assist in overcoming these barriers. A serious game is being developed specifically for teaching ultrasound. In this study, we assessed the use of a serious game in learning POCUS.

METHODS

Ultrasound-native medical students were randomly assigned to the intervention group (N = 27) or the control group (N = 26). Both groups performed a real ultrasound on a volunteer after a brief introduction, but the intervention group played a serious game in advance. The endpoints were the assessments of the videos by experts (scoring quality of the probe movements) and the research team (counting probe movements), and probe movements measured with an accelerometer.

RESULTS

The intervention group completed the exam faster (247 s vs. 347 s, p = 0.006 (95% CI: [30.20;168.80]) and lifted the probe less frequently from the model (0.54 vs. 3.79, p = 0.001 (95% CI: [1.39;5.11]). Also, we found an in-game learning effect between levels, showing a 48% decrease in total playing time (p < 0.001), 36% reduction in attempts per coin (p = 0.007), a 33% reduction in total probe distance (p = 0.002), and a 61% decrease in contact moments (p < 0.001). However, there was no significant difference in expert score between the two groups.

CONCLUSION

The serious game 'Underwater' is a fun and useful addition to traditional bedside ultrasound learning, which also may overcome one of the most important barriers in learning ultrasound: lack of supervised practice time. We show that the game improves real-practice probe handling with faster and more goal-oriented probe movements.

Physician Assistant Student Preceptors and Point-of-Care Ultrasound: Perceptions and Readiness to Teach

PURPOSE

Point-of-care ultrasound (POCUS) inclusion in medical education is increasing, and understanding of clinical educators' perceptions and use patterns is needed. The purpose of this research project was to explore current use, interest, knowledge, perceptions, and readiness to teach POCUS from the perspectives of clinical preceptors for physician assistant (PA) students.

METHODS

A survey research study was completed on previously identified preceptors. Descriptive statistics outlined the frequencies of responses. Bivariate analysis with Chi-Square or Fischer Exact Testing was used to identify statistically significant differences between groupings.

RESULTS

Most preceptors (87.1%) believe POCUS adds clinical value, but a minority received POCUS training (37%), are familiarity with its use (37.4%), and currently use POCUS (23.4%). Two-thirds (66.1%) of preceptors stated they would allow PA students to practice POCUS skills on clinical rotation; however, few (31%) felt comfortable with this and even fewer (22.6%) felt comfortable findings on POCUS into their clinical decision making.

CONCLUSIONS

Despite support of incorporation of POCUS into PA education, clinical preceptors' readiness to teach POCUS on clinical rotations is limited. This study shows that preceptors are neither comfortable with student use nor incorporating student findings into clinical decision making. A lack of sufficient clinical preceptors to support POCUS education has not been previously reported. PA programs attempting to incorporate POCUS into their curricula will need to be intentional providing opportunities to continue POCUS on clinical rotations.

Critical Care Ultrasound Competency of Fellows and Faculty in Pulmonary and Critical Care Medicine: A Nationwide Survey

Purpose: Competency assessment standards for Critical Care Ultrasonography (CCUS) for Graduate Medical Education (GME) trainees in pulmonary/critical care medicine (PCCM) fellowship programs are lacking. We sought to answer the following research questions: How are PCCM fellows and teaching faculty assessed for CCUS competency? Which CCUS teaching methods are perceived as most effective by program directors (PDs) and fellows. Methods: Cross-sectional, nationwide, electronic survey of PCCM PDs and fellows in accredited GME training programs. Results: PDs and fellows both reported the highest rates of fellow competence to use CCUS for invasive procedural guidance, but lower rates for assessment of deep vein thrombosis and abdominal organs. 54% and 90% of PDs reported never assessing fellows or teaching faculty for CCUS competency, respectively. PDs and fellows perceived hands-on workshops and directly supervised CCUS exams as more effective learning methods than unsupervised CCUS archival with subsequent review and self-directed learning. Conclusions: There is substantial variation in CCUS competency assessment among PCCM fellows and teaching faculty nationwide. The majority of training programs do not formally assess fellows or teaching faculty for CCUS competence. Guidelines are needed to formulate standardized competency assessment tools for PCCM fellowship programs.

Point-of-care ultrasonography-An essential skill for medical graduates?

The recent proliferation of point-of-care ultrasonography (POCUS) in the clinical practice of many medical specialties has exposed persistent barriers to education, training and standardisation. Specialist training curriculums are already overwhelming, having grossly insufficient time available for the specialist trainees and for the small number of available trainers alike to incorporate POCUS into postgraduate education. The logical solution to overcome these barriers could be to incorporate basic POCUS education and training into the undergraduate university curriculums, introducing longitudinal integration with other relevant medical sciences. The Australasian Society of Ultrasound in Medicine already has well-established educational programmes in POCUS with standardised assessment of competency, which could potentially offer the basis for symbiosis with the Australian and New Zealand medical schools.

Development of a national point-of-care ultrasound training course for physicians in Japan: A 3-year evaluation

Purpose: Point-of-care ultrasound (POCUS) allows bedside clinicians to acquire, interpret, and integrate ultrasound images into patient care. Although the availability of POCUS training courses has increased, the educational effectiveness of these courses is unclear. Methods: From 2017 to 2019, we investigated the educational effectiveness of a standardized 2-day hands-on POCUS training course and changes in pre- and post-course exam scores in relationship to participants' (n = 571) clinical rank, years of POCUS experience, and frequency of POCUS use in clinical practice. Results: The mean pre- and post-course examination scores were 67.2 (standard deviation [SD] 12.3) and 79.7 (SD 9.7), respectively. Higher pre-course examination scores were associated with higher clinical rank, more years of POCUS experience, and more frequent POCUS use (p < 0.05). All participants showed significant changes in pre- to post-course exam scores. Though pre-course scores differed by clinical rank, POCUS experience, and frequency of POCUS use, differences in post-course scores according to participant baseline differences were non-significant. Conclusion: A standardized hands-on POCUS training course is effective for improving POCUS knowledge regardless of baseline differences in clinical rank, POCUS experience, or frequency of POCUS use. Future studies shall evaluate changes in POCUS use in clinical practice after POCUS training.

2D/3D ultrasound diagnosis of pediatric distal radius fractures by human readers vs artificial intelligence

Wrist trauma is common in children and generally requires radiography for exclusion of fractures, subjecting children to radiation and long wait times in the emergency department. Ultrasound (US) has potential to be a safer, faster diagnostic tool. This study aimed to determine how reliably US could detect distal radius fractures in children, to contrast the accuracy of 2DUS to 3DUS, and to assess the utility of artificial intelligence for image interpretation. 127 children were scanned with 2DUS and 3DUS on the affected wrist. US scans were then read by 7 blinded human readers and an AI model. With radiographs used as the gold standard, expert human readers obtained a mean sensitivity of 0.97 and 0.98 for 2DUS and 3DUS respectively. The AI model sensitivity was 0.91 and 1.00 for 2DUS and 3DUS respectively. Study data suggests that 2DUS is comparable to 3DUS and AI diagnosis is comparable to human experts.

Training of Non-expert Users Using Remotely Delivered, Point-of-Care Tele-Ultrasound: A Proof-of-Concept Study in 2 Canadian Communities

ABSTRACT

Many physicians, particularly those practicing in remote regions, lack training opportunities to develop point-of-care ultrasound (POCUS) skills. This pretest-posttest study quantified the skill improvement of learners after participating in a virtual training program that used real-time, remotely delivered point-of-care tele-ultrasound (tele-POCUS) for teaching and learner feedback provision. Ten physicians practicing in an urban tertiary (Kingston, Ontario, Canada, n = 6) or remote care center (Moose Factory, Ontario, Canada, n = 4) completed a 3-week educational program that consisted of e-learning module review, independent image acquisition practice, and expert-guided tele-POCUS consultations. Pretraining and posttraining assessments were performed to evaluate skill enhancement in image acquisition, image quality, and image interpretation for cardiac and lung/pleura POCUS using a 5-point Likert scale. A total of 76 tele-POCUS consultations were performed during the study period. Significant improvements in image quality were noted following remotely delivered mentorship and guidance (all P < 0.01). In cardiac POCUS, pretraining and posttraining comparisons noted significant improvements in image acquisition (means, 2.69-4.33; P < 0.02), quality (means, 2.40-4.03; P < 0.01), and interpretation (means, 2.50-4.40; P < 0.02). In lung/pleura POCUS, significant improvements in image acquisition (means, 3.00-4.43; P < 0.01), quality (means, 3.23-4.37; P < 0.01), and interpretation (means, 3.00-4.40; P < 0.01) were demonstrated. Introductory ultrasound can be taught to novice users using a virtual, live-streamed training format with tele-POCUS while demonstrating significant enhancement in imaging skills.

Minutes matter: Time it takes to perform point-of-care ultrasound

Background

While point-of-care ultrasound (PoCUS) is a safe, versatile tool that can improve patient care, the perceived time investment needed to incorporate PoCUS into clinical care is cited as a barrier to performance. We sought to determine the time it takes to perform a PoCUS examination and whether this time was influenced by training level and prior ultrasound experience.

Methods

This was a retrospective study looking at time stamps of all emergency medicine (EM) provider-performed PoCUS examinations during clinical shifts from August 10, 2019, to June 7, 2022, at a suburban academic emergency department that is the site for a 3-year EM residency. Our workflow is order-based; when PoCUS is ordered, that patient's information populates the ultrasound machine worklist. Selecting the patient's name from the worklist generates a time-stamped patient information page (PIP). We defined the PIP time stamp as the start of the PoCUS examination. The duration of one PoCUS examination was defined as the time of the last image acquired minus the time of the PIP. General estimating equations were used to estimate differences between training level and between prior scan status using an exchangeable correlation and Tukey adjusted pairwise comparisons. A two-tailed chi-square analysis was used for comparing accuracy according to training level.

Results

Of 4187 PoCUS examinations abstracted, 2144 met study criteria. The median (IQR) time spent per examination was 6.0 (3-9) min. First-year residents took the longest to perform PoCUS among all providers (p < 0.0001). Residents with fewer than 250 prior scans took longer than residents with 501-800 (p = 0.0002) and >800 (p = 0.0013). Resident accuracy was not significantly different according to training level.

Conclusions

Overall median time to perform PoCUS was 6.0 min. EM residents became more efficient in performing PoCUS as they advanced from first- to third-year, without compromising accuracy.

Point-of-Care Ultrasonography in Internal Medicine: Limitations and Pitfalls for Novice Users

Point-of-care ultrasound (POCUS) is increasingly being adopted in the field of internal medicine, leading to the development of POCUS curricula in undergraduate and postgraduate medical education programs. Prominent internal medicine societies and organizations worldwide recognize the expanding utilization of POCUS by internal medicine physicians, emphasizing the need for practitioners to be aware of both its benefits and limitations. Despite the growing enthusiasm for POCUS, clinicians, particularly those with limited clinical experience, must be cautious regarding its inherent limitations and the potential impact on their clinical practice. This review aims to outline the limitations and potential drawbacks of POCUS for medical students, residents, and internists who wish to stay abreast of the escalating use of POCUS in internal medicine and have a desire, or have already commenced, to incorporate POCUS into their practice. Additionally, it provides recommendations for enhancing POCUS proficiency to mitigate these limitations.

Barriers and Facilitators to Point-of-Care Ultrasound Use in Rural Australia

This study explores the barriers and facilitators to point-of-care ultrasound (POCUS) use and adoption in rural healthcare since POCUS is a useful resource for rural clinicians to overcome the challenges associated with limited on-site clinical support, such as limited diagnostic imaging services and infrastructure. A qualitative descriptive study was employed, interviews with ten rural clinicians were conducted, and the data were analysed using the Walt and Gilson health policy framework to guide interpretation. Barriers include a lack of standardised training requirements, the cost of the devices and challenges recouping the costs of purchase and training, difficulty with the maintenance of skills, and a lack of an effective method to achieve quality assurance. Coupling POCUS with telemedicine could address the issues of the maintenance of skills and quality assurance to facilitate increased POCUS use, leading to positive patient safety and social and economic implications.

Is gallbladder PoCUS diagnostic accuracy accessible to medical students after PoCUS training exclusively on healthy volunteers? A pilot randomized control trial

BACKGROUND

Point-of-care ultrasound (PoCUS) is increasingly used in clinical practice and is now included in many undergraduate curricula. Here, we aimed to determine whether medical students who participated in a PoCUS teaching program with several practical training sessions involving healthy volunteers could achieve a good level of diagnostic accuracy in identifying gallbladder pathologies. The intervention group (IG) was trained exclusively on volunteers with a healthy gallbladder, whereas the control group (CG) had access to volunteers with a pathological gallbladder as recommended in most PoCUS curricula.

MATERIALS AND METHODS

Twenty medical students were randomly assigned to the IG and CG. After completing the training program over 2 months, students were evaluated by three independent examiners. Students and examiners were blind to group allocation and study outcome. Sensitivity and specificity of students' PoCUS gallstone diagnosis were assessed. Secondary outcomes were students' confidence, image quality, acquisition time, and PoCUS skills.

RESULTS

Sensitivity and specificity for gallstone diagnosis were, respectively, 0.85 and 0.97 in the IG and 0.80 and 0.83 in the CG. Areas under the curve (AUC) based on the receiver operating characteristic curve analysis were 0.91 and 0.82 in the IG and CG, respectively, with no significant difference (p = 0.271) and an AUC difference of -0.092. No significant between-group difference was found for the secondary outcomes.

CONCLUSIONS

Our pilot study showed that medical students can develop PoCUS diagnostic accuracy after training on healthy volunteers. If these findings are confirmed in a larger sample, this could favor the delivery of large practical teaching sessions without the need to include patients with pathology, thus facilitating PoCUS training for students.

Evaluation of Point-of-Care Ultrasound Training for Family Physicians Using Teleultrasound

BACKGROUND AND OBJECTIVES

The goal of this study was to assess family physicians' change in knowledge and ability to perform abdominal aorta ultrasound after implementation of a novel teleultrasound curriculum.

METHODS

This was a prospective, observational study conducted at a single academic institution. Family physicians completed a preassessment, test, and objective structured clinical evaluation (OSCE). Physicians then individually completed a standard curriculum consisting of online content and an hour-long, hands-on training session on abdominal aorta ultrasound using teleultrasound technology. Physicians then performed a minimum of 10 independent examinations over a period of 8 weeks. After physicians completed the training curriculum and 10 independent scans, we administered a postassessment, test, and OSCE. We analyzed differences between pre- and postcurriculum responses using Fisher exact and Wilcoxon signed rank tests.

RESULTS

Thirteen family physicians completed the curriculum. Comparing pre- to postcurriculum responses, we found significant reductions in barriers to using aorta POCUS and improved confidence in using, obtaining, and interpreting aorta POCUS (P<0.01). Knowledge improved from a median score of 70% to 90% (P<0.01), and OSCE scores improved from a median of 80% to 100% (P=0.012). Overall, 211 aorta ultrasound examinations were independently acquired with a median image quality of 4 (scale 1 to 4).

CONCLUSIONS

After an 8-week teleultrasound curriculum, family physicians with minimal experience with POCUS showed improved knowledge and psychomotor skill in abdominal aorta POCUS.

Start spreading the news: a deliberate approach to POCUS program development and implementation

While there is an expanding body of literature on Point-of-Care Ultrasound (POCUS) pedagogy, administrative elements that are necessary for the widespread adoption of POCUS in the clinical environment have received little attention. In this short communication, we seek to address this gap by sharing our institutional experience with POCUS program development and implementation. The five pillars of our program, selected to tackle local barriers to POCUS uptake, are education, workflow, patient safety, research, and sustainability. Our program logic model outlines the inputs, activities, and outputs of our program. Finally, key indicators for the monitoring of program implementation efforts are presented. Though designed for our local context, this approach may readily be adapted toward other clinical environments. We encourage others leading the integration of POCUS at their centers to adopt this approach not only to achieve sustainable change but also to ensure that quality safeguards are in place.

Utility of hand-held ultrasound for image acquisition and interpretation by trained Kenyan providers

BACKGROUND

Point-of-care ultrasound (POCUS) plays a prominent role in the timely recognition and management of multiple medical, surgical, and obstetric conditions. A POCUS training program for primary healthcare providers in rural Kenya was developed in 2013. A significant challenge to this program is the acquisition of reasonably priced ultrasound machines with adequate image quality and the ability to transmit images for remote review. The goal of this study is to compare the utility of a smartphone-connected, hand-held ultrasound with a traditional ultrasound device for image acquisition and interpretation by trained healthcare providers in Kenya.

METHODS

This study took place during a routine re-training and testing session for healthcare providers who had already received POCUS training. The testing session involved a locally validated Observed Structured Clinical Exam (OSCE) that assessed trainees' skills in performing the Extended Focused Assessment with Sonography for Trauma (E-FAST) and focused obstetric exams. Each trainee performed the OSCE twice, once using a smartphone-connected hand-held ultrasound and once using their notebook ultrasound model.

RESULTS

Five trainees obtained a total of 120 images and were scored on image quality and interpretation. Overall E-FAST imaging quality scores were significantly higher for the notebook ultrasound compared to the hand-held ultrasound but there was no significant difference in image interpretation. Overall focused obstetric image quality and image interpretation scores were the same for both ultrasound systems. When separated into individual E-FAST and focused obstetric views, there were no statistically significant differences in the image quality or image interpretation scores between the two ultrasound systems. Images obtained using the hand-held ultrasound were uploaded to the associated cloud storage using a local 3G-cell phone network. Upload times were 2-3 min.

CONCLUSION

Among POCUS trainees in rural Kenya, the hand-held ultrasound was found to be non-inferior to the traditional notebook ultrasound for focused obstetric image quality, focused obstetric image interpretation, and E-FAST image interpretation. However, hand-held ultrasound use was found to be inferior for E-FAST image quality. These differences were not observed when evaluating each E-FAST and focused obstetric views separately. The hand-held ultrasound allowed for rapid image transmission for remote review.

The assessment of point-of-care-ultrasound (POCUS) in acute care settings is benefitted by early medical school integration and fellowship training

CONTEXT

Point-of-care ultrasound (POCUS) has widespread utilization in multiple clinical settings. It has been shown to positively influence clinician confidence in diagnosis and can help appropriately manage patients in acute care settings. There has been a growing trend of increased emphasis on incorporating POCUS training in the first 2 years of the medical school curriculum.

OBJECTIVES

This article aims to analyze the clinical use of POCUS in acute settings and how training early in medical school may strengthen clinician confidence and utilization.

METHODS

An anonymous 10-question survey on POCUS use was conducted via a secure online platform and distributed to board-certified practicing physicians (MDs and DOs) with educational agreements with Midwestern University (MWU) across acute care specialties. This included preceptors within the MWU graduate medical education clinical consortium. Survey questions were aimed at assessing frequency of use, machine type, reasons for utilizing POCUS, initial ultrasound training, confidence in performing/interpreting POCUS, and perceived impact on patient outcomes. Surveys less than 50% complete were excluded. All surveys returned were more than 50% complete and thus included in the study. Statistical analyses were conducted utilizing the statistical software R version 4.0.

RESULTS

Surveys were sent out to 187 participants with 68 responses (36.4% response rate). The survey results demonstrated a relationship between learning POCUS earlier in one's medical career (medical school, residency, or fellowship) to increased use in acute settings when compared to learning POCUS during clinical practice. Of the 68 respondents, 65 (95.6%) indicated that they agree or strongly agree that POCUS use improves patient care, and 64 (94.1%) indicated that they agree or strongly agree that the use of POCUS can improve patient outcomes.

CONCLUSIONS

Our survey of acute care physicians indicated that most respondents utilize POCUS daily or weekly (90.8%), and this was related to fewer years of practice (under 10 years from medical school graduation, 94.6%). Moreover, POCUS was utilized primarily in acute care settings for procedures (25%, n=17/68 respondents). These survey results indicate that early integration of POCUS education in osteopathic medical school curricula and throughout fellowship training could likely enhance POCUS utilization in acute care settings.

Stakeholder perspectives on current determinants of ultrasound-guided thoracentesis in resource limited settings: a qualitative study

OBJECTIVE

Preprocedure pleural fluid localization using bedside ultrasound has been shown to reduce complications related to thoracentesis and is now considered the standard of care. However, ultrasound-guided thoracentesis (USGT) has not been broadly adopted in many low-resource settings. With increasing affordability and portability of ultrasound equipment, barriers to USGT are changing. The aim of this multisite qualitative study is to understand the current barriers to USGT in two resource-limited settings.

SETTING

We studied two geographically diverse settings, Harare, Zimbabwe, and Kathmandu, Nepal.

PARTICIPANTS

19 multilevel stakeholders including clinical trainees, attendings, clinical educators and hospital administrators were interviewed. There were no exclusion criteria.

PRIMARY OUTCOME

To understand the current determinants of USGT adoption in these settings.

RESULTS

Three main themes emerged from these interviews: (1) stakeholders perceived multiple advantages of USGT, (2) access to equipment and training were perceived as limited and (3) while an online training approach is feasible, stakeholders expressed scepticism that this was an appropriate modality for procedural training.

CONCLUSION

Our data suggests that USGT implementation is desired by local stakeholders and that the development of an educational intervention, cocreated with local stakeholders, should be explored to ensure optimal contextual fit.

Bedside Point-of-Care Ultrasonography in Anesthesiology and Pain Management: A New Trend in Iran: A Narrative Review

: Since the emergence of ultrasonography, many specialists, including anesthesiologists, have become interested in its practices. Technological innovations in portable ultrasonography devices and their quality enable anesthesiologists to use ultrasonography in various medical conditions and improve their diagnostic and therapeutic interventions. This article clarifies the significance of point-of-care ultra-sonography (POCUS) and highlights the challenges ahead. POCUS can help regional anesthesiologists and pain physicians in vascular access, airway management, focused cardiac ultra-sound (FoCUS), lung ultrasound, gastric ultrasound, focus assessment with sonography in trauma (FAST), regional and neuraxial nerve blocks, and acute and chronic pain management. However, similar to any new clinical method, there are challenges to POCUS, especially in developing countries like Iran. These challenges include the need for more budget allocation for medical equipment and portable devices, developing a comprehensive local curriculum and transparent framework to train residents and postgraduates, creating and/or revising university policies, clinical coordination with healthcare networks, and collaboration with healthcare providers. This article expresses the importance and effectiveness of point-of-care sonography performed by anesthesiologists and pain specialists in Iran and highlights the challenges ahead.

Visual Rounds Based on Multiorgan Point-of-Care Ultrasound in the ICU

Point-of-care ultrasonography (POCUS) is performed by a treating clinician at the patient's bedside, provides a acquisition, interpretation, and immediate clinical integration based on ultrasonographic imaging. The use of POCUS is not limited to one specialty, protocol, or organ system. POCUS provides the treating clinician with real-time diagnostic and monitoring information. Visual rounds based on multiorgan POCUS act as an initiative to improve clinical practice in the Intensive Care Unit and are urgently needed as part of routine clinical practice.

Agreement in measurements of ultrasonography-derived periodontal diagnostic parameters among multiple raters: A diagnostic accuracy study

OBJECTIVE

The aim of this study was to investigate the reproducibility of measurements of ultrasound-derived periodontal diagnostic parameters (PDPs) among raters.

STUDY DESIGN

Periodontists with various degrees of ultrasound experience were invited to measure 3 PDPs: soft tissue height (STH), soft tissue thickness (STT), and crestal bone thickness (CBT) on 37 human periodontal ultrasound scans acquired at the midfacial site of non-molar maxillary teeth. After an online training session and a 2-week calibration exercise, intraclass correlation coefficients (ICCs) were estimated with mixed linear regression models. The interrater mean absolute differences (MADs) were calculated among the raters and between the raters and a reference standard examiner.

RESULTS

Thirteen raters participated in the study. MADs among the 13 raters were 0.18 mm (STH), 0.16 mm (STT), and 0.12 mm (CBT). ICC values for STH, STT, and CBT were 0.83, 0.77, and 0.76, respectively. The MADs between the raters and the reference standard were 0.23 mm (STH), 0.19 mm (STT), and 0.14 mm (CBT). Survey results showed that ultrasound has diagnostic value and is generally easy to learn.

CONCLUSIONS

Within the limitations of this study, good agreement was observed among ultrasound learners with various degrees of experience when measuring ultrasound-derived PDPs.

Motivations, barriers, and professional engagement: a multisite qualitative study of internal medicine faculty's experiences learning and teaching point-of-care ultrasound

BACKGROUND

Point-of-care ultrasound (POCUS) graduate medical education is expanding across many specialties, but a lack of trained faculty is a common barrier. Even well-designed faculty development programs struggle with retention, yet little is known about the experiences of practicing physicians learning POCUS. Our objective is to explore the experiences of clinician-educators as they integrate POCUS into their clinical and teaching practices to help inform curriculum design.

METHODS

Qualitative study using instrumental case study design to analyze interview data from 18 internal medicine clinician-educators at 3 academic health centers. Interviewees were recruited by program directors at each site to include participants with a range of POCUS use patterns. Interviews took place from July-August 2019.

RESULTS

Analysis yielded 6 themes: teaching performance, patient care, curriculum needs, workflow and access, administrative support, and professional engagement. Participants felt POCUS enhanced their teaching skills, clinical decision making, and engagement with patients. The themes highlighted the importance of longitudinal supervision and feedback, streamlined integration of POCUS into clinical workflow, and administrative support of time and resources. Interviewees reported learning and teaching POCUS helped combat burn-out and enhance their sense of professional engagement.

CONCLUSIONS

Learning POCUS as a practicing clinician-educator is a complicated endeavor that must take into account mastery of psychomotor skills, existing practice habits, and local institutional concerns. Based upon the themes generated from this study, we make recommendations to help guide POCUS faculty development curriculum design. Although this study focused on internists, the findings are likely generalizable to other specialties with growing interest in POCUS education.

Impact of Insurance Benefits and Education on Point-of-Care Ultrasound Use in a Single Emergency Department: An Interrupted Time Series Analysis

Background and Objectives: Point-of-care ultrasound (POCUS) is a useful tool that helps clinicians properly treat patients in emergency department (ED). This study aimed to evaluate the impact of specific interventions on the use of POCUS in the ED. Materials and Methods: This retrospective study used an interrupted time series analysis to assess how interventions changed the use of POCUS in the emergency department of a tertiary medical institute in South Korea from October 2016 to February 2021. We chose two main interventions—expansion of benefit coverage of the National Health Insurance (NHI) for emergency ultrasound (EUS) and annual ultrasound educational workshops. The primary variable was the EUS rate, defined as the number of EUS scans per 1000 eligible patients per month. We compared the level and slope of EUS rates before and after interventions. Results: A total of 5188 scanned records were included. Before interventions, the EUS rate had increased gradually. After interventions, except for the first workshop, the EUS rate immediately increased significantly (p < 0.05). The difference in the EUS rate according to the expansion of the NHI was estimated to be the largest (p < 0.001). However, the change in slope significantly decreased after the third workshop during the coronavirus disease 2019 pandemic (p = 0.004). The EUS rate increased significantly in the presence of physicians participating in intensive POCUS training (p < 0.001). Conclusion: This study found that expansion of insurance coverage for EUS and ultrasound education led to a significant and immediate increase in the use of POCUS, suggesting that POCUS use can be increased by improving education and insurance benefits.

The unmet demand for point-of-care ultrasound among general pediatricians: a cross-sectional survey

BACKGROUND

Point-of-care ultrasound (POCUS) is a noninvasive bedside tool with many pediatric applications but is not currently a formal part of pediatric training and practice. Formal surveys of general pediatricians regarding POCUS training are lacking. We aimed to quantify the baseline ultrasound experience and training needs of general pediatricians and pediatric residents across different practice settings.

METHODS

In 2020, we sent an online survey to 485 current faculty, residents, and graduates from an urban pediatric academic medical center in Northern California. Pediatric subspecialists were excluded. Survey questions about baseline experience, comfort, and perceived usefulness of 20 common POCUS applications were developed by two POCUS experts using existing literature. Chi-squared analysis was used to compare residents versus attendings and to compare attendings practicing in inpatient versus outpatient versus mixed settings.

RESULTS

Response rate was 20% (98/485). Compared to attendings (n = 73), residents (n = 25) endorsed more exposure to POCUS in medical school (32% vs 5%, p = 0.003) and residency (12% vs 5%, p = 0.003). Respondents endorsed low comfort with POCUS (mean 1.3 out of 5 on Likert scale). Of 20 procedural and diagnostic applications, respondents identified abscess drainage, bladder catheterization, soft tissue, neck, advanced abdominal, and constipation as most useful. Overall, 50% of pediatricians (and 70% of pediatric residents) responded that there were opportunities to use POCUS multiple times a week or more in their clinical practice.

CONCLUSIONS

There is an unmet demand for POCUS training among general pediatricians and trainees in our study. Although the majority of respondents were not POCUS users, our results could guide future efforts to study the role of POCUS in general pediatrics and develop pediatric curricula.

Training medical students in physical examination and point-of-care ultrasound: An assessment of the needs and barriers to acquiring skills in point-of-care ultrasound

BACKGROUND:

With growth of the use of point of care ultrasound (PoCUS) around the world, some medical schools have incorporated this skill into their undergraduate curricula. However, because of epidemiology of disease and regional differences in approaches to patient care, global application of PoCUS might not be possible. Before creating a PoCUS teaching course, it is critical to perform a needs analysis and recognize the training obstacles.

MATERIALS AND METHODS:

A validated online questionnaire was given to final-year medical students at our institution to evaluate their perceptions of the applicability of specific clinical findings, and their own capability to detect these signs clinically and with PoCUS. The skill insufficiency was assessed by deducting the self-reported clinical and ultrasound skill level from the perceived usefulness of each clinical finding.

RESULTS:

The levels of expertise and knowledge in the 229 students who participated were not up to the expected standard. The applicability of detection of abdominal aortic aneurysm (AAA) (3.9 ± standard deviation [SD] 1.4) was the highest. However, detection of interstitial syndrome (3.0 ± SD 1.1) was perceived as the least applicable. The deficit was highest in the detection of AAA (mean 0.95 ± SD 2.4) and lowest for hepatomegaly (mean 0.57 ± SD 2.3). Although the majority agreed that training of preclinical and clinical medical students would be beneficial, 52 (22.7%) showed no interest, and 60% (n = 136) reported that they did not have the time to develop the skill.

CONCLUSION:

Although medical students in Saudi Arabia claim that PoCUS is an important skill, there are significant gaps in their skill, indicating the need for PoCUS training. However, a number of obstacles must be overcome in the process.

Automation of Lung Ultrasound Interpretation via Deep Learning for the Classification of Normal versus Abnormal Lung Parenchyma: A Multicenter Study

Lung ultrasound (LUS) is an accurate thoracic imaging technique distinguished by its handheld size, low-cost, and lack of radiation. User dependence and poor access to training have limited the impact and dissemination of LUS outside of acute care hospital environments. Automated interpretation of LUS using deep learning can overcome these barriers by increasing accuracy while allowing point-of-care use by non-experts. In this multicenter study, we seek to automate the clinically vital distinction between A line (normal parenchyma) and B line (abnormal parenchyma) on LUS by training a customized neural network using 272,891 labelled LUS images. After external validation on 23,393 frames, pragmatic clinical application at the clip level was performed on 1162 videos. The trained classifier demonstrated an area under the receiver operating curve (AUC) of 0.96 (±0.02) through 10-fold cross-validation on local frames and an AUC of 0.93 on the external validation dataset. Clip-level inference yielded sensitivities and specificities of 90% and 92% (local) and 83% and 82% (external), respectively, for detecting the B line pattern. This study demonstrates accurate deep-learning-enabled LUS interpretation between normal and abnormal lung parenchyma on ultrasound frames while rendering diagnostically important sensitivity and specificity at the video clip level.

Development and Remodeling of Point-of-Care Ultrasound Education for Emergency Medicine Residents in Resource Limited Countries during the COVID-19 Pandemic

The administration of an accurate and effective POCUS course is a crucial tool in improving health education and thus the health care system in low- to middle-income countries. The development of the ultrasound curriculum in these countries during the pandemic era is a major challenge for medical educators. Therefore, this study aims to survey the learner experience after implementing the POCUS curriculum for first-year emergency medicine residents. All learners responded to the survey. Our results demonstrated that the ultrasound rotation and our ultra-sound learning materials were useful tools which showed a positive impact on POCUS knowledge for our learners. However, some obstacles of POCUS learning were identified to assist in closing faculty development gaps, including the availability of handheld devices, as well as the re-modeling of the ultrasound rotation course, which should be managed according to the feedback we received. This study demonstrated a clear need for constant updates in higher education, medical program development, accuracy of local learning materials, and the explosion of virtual and online learning platforms during this decade.

Diagnostic Challenges in Sepsis

Purpose of Review

Sepsis is a leading cause of death worldwide. Groundbreaking international collaborative efforts have culminated in the widely accepted surviving sepsis guidelines, with iterative improvements in management strategies and definitions providing important advances in care for patients. Key to the diagnosis of sepsis is identification of infection, and whilst the diagnostic criteria for sepsis is now clear, the diagnosis of infection remains a challenge and there is often discordance between clinician assessments for infection.

Recent Findings

We review the utility of common biochemical, microbiological and radiological tools employed by clinicians to diagnose infection and explore the difficulty of making a diagnosis of infection in severe inflammatory states through illustrative case reports. Finally, we discuss some of the novel and emerging approaches in diagnosis of infection and sepsis.

Summary

While prompt diagnosis and treatment of sepsis is essential to improve outcomes in sepsis, there remains no single tool to reliably identify or exclude infection. This contributes to unnecessary antimicrobial use that is harmful to individuals and populations. There is therefore a pressing need for novel solutions. Machine learning approaches using multiple diagnostic and clinical inputs may offer a potential solution but as yet these approaches remain experimental.

Teaching Seasoned Doctors New Technology: An Intervention to Reduce Barriers and Improve Comfort With Clinical Ultrasound

Introduction Although clinical ultrasound (CUS) is a core skill that is a requirement for emergency medicine (EM) residency graduation, only a fraction of EM practitioners who trained prior to this requirement are certified in CUS. The objective of the study was to implement a CUS workshop for practicing EM physicians, identify barriers to utilization, and assess comfort with the machine, obtaining and interpreting images, and incorporating CUS into clinical practice. Methods This was a prospective descriptive cohort study of EM physician faculty who participated in an interactive 5-hour CUS workshop intervention that introduced four core CUS modalities via didactics and hands-on scanning stations. Pre- and post-surveys were administered to identify barriers to utilization and assess perceived comfort with CUS using a 5-point Likert scale. Results were analyzed using Fisher's exact and paired t-tests. Results Thirty-five EM physicians participated with a 100% survey response rate. Only five of the physicians were ultrasound certified at the time of the workshop. On average, physicians were 16 years post-residency. Prior to the workshop, 29% had minimal ultrasound experience and 43% had not performed more than 50 ultrasounds. In the pre-course survey, every physician expressed at least one barrier to CUS utilization. Post-workshop, physicians felt significantly more comfortable using the ultrasound machine (p=0.0008), obtaining and interpreting images (p=0.0009 and p=0.0004), and incorporating CUS into clinical practice (p=0.002). Conclusion This workshop is an effective tool to expose practicing physicians to core concepts of CUS, improve their comfort level, and reduce barriers to ultrasound utilization.

First year internal medicine residents' self-report point-of-care ultrasound knowledge and skills: what (Little) difference three years make

BACKGROUND

With increasing availability of point-of-care ultrasound (POCUS) education in medical schools, it is unclear whether or not learning needs of junior medical residents have evolved over time.

METHODS

We invited all postgraduate year (PGY)-1 residents at three Canadian internal medicine residency training programs in 2019 to complete a survey previously completed by 47 Canadian Internal Medicine PGY-1 s in 2016. Using a five-point Likert scale, participants rated perceived applicability of POCUS to the practice of internal medicine and self-reported skills in 15 diagnostic POCUS applications and 9 procedures.

RESULTS

Of the 97 invited residents, 58 (60 %) completed the survey in 2019. Participants reported high applicability but low skills across all POCUS applications and procedures. The 2019 cohort reported higher skills in assessing pulmonary B lines than the 2016 cohort (2.3 ± SD 1.0 vs. 1.5 ± SD 0.7, adjusted p-value = 0.01). No other differences were noted.

CONCLUSIONS

POCUS educational needs continue to be high in Canadian internal medicine learners. The results of this needs assessment study support ongoing inclusion of basic POCUS elements in the current internal medicine residency curriculum.

Comparison of in-person versus tele-ultrasound point-of-care ultrasound training during the COVID-19 pandemic

Background

Lack of training is currently the most common barrier to implementation of point-of-care ultrasound (POCUS) use in clinical practice, and in-person POCUS continuing medical education (CME) courses have been paramount in improving this training gap. Due to travel restrictions and physical distancing requirements during the COVID-19 pandemic, most in-person POCUS training courses were cancelled. Though tele-ultrasound technology has existed for several years, use of tele-ultrasound technology to deliver hands-on training during a POCUS CME course has not been previously described.

Methods

We conducted a retrospective observational study comparing educational outcomes, course evaluations, and learner and faculty feedback from in-person versus tele-ultrasound POCUS courses. The same POCUS educational curriculum was delivered to learners by the two course formats. Data from the most recent pre-pandemic in-person course were compared to tele-ultrasound courses during the COVID-19 pandemic.

Results

Pre- and post-course knowledge test scores of learners from the in-person (n = 88) and tele-ultrasound course (n = 52) were compared. Though mean pre-course knowledge test scores were higher among learners of the tele-ultrasound versus in-person course (78% vs. 71%; p = 0.001), there was no significant difference in the post-course test scores between learners of the two course formats (89% vs. 87%; p = 0.069). Both learners and faculty rated the tele-ultrasound course highly (4.6–5.0 on a 5-point scale) for effectiveness of virtual lectures, tele-ultrasound hands-on scanning sessions, and course administration. Faculty generally expressed less satisfaction with their ability to engage with learners, troubleshoot image acquisition, and provide feedback during the tele-ultrasound course but felt learners completed the tele-ultrasound course with a better basic POCUS skillset.

Conclusions

Compared to a traditional in-person course, tele-ultrasound POCUS CME courses appeared to be as effective for improving POCUS knowledge post-course and fulfilling learning objectives. Our findings can serve as a roadmap for educators seeking guidance on development of a tele-ultrasound POCUS training course whose demand will likely persist beyond the COVID-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-021-00242-6.

Canadian Internal Medicine Ultrasound (CIMUS) Expert Consensus Statement on the Use of Lung Ultrasound for the Assessment of Medical Inpatients With Known or Suspected Coronavirus Disease 2019

OBJECTIVES

To develop a consensus statement on the use of lung ultrasound (LUS) in the assessment of symptomatic general medical inpatients with known or suspected coronavirus disease 2019 (COVID-19).

METHODS

Our LUS expert panel consisted of 14 multidisciplinary international experts. Experts voted in 3 rounds on the strength of 26 recommendations as "strong," "weak," or "do not recommend." For recommendations that reached consensus for do not recommend, a fourth round was conducted to determine the strength of those recommendations, with 2 additional recommendations considered.

RESULTS

Of the 26 recommendations, experts reached consensus on 6 in the first round, 13 in the second, and 7 in the third. Four recommendations were removed because of redundancy. In the fourth round, experts considered 4 recommendations that reached consensus for do not recommend and 2 additional scenarios; consensus was reached for 4 of these. Our final recommendations consist of 24 consensus statements; for 2 of these, the strength of the recommendations did not reach consensus.

CONCLUSIONS

In symptomatic medical inpatients with known or suspected COVID-19, we recommend the use of LUS to: (1) support the diagnosis of pneumonitis but not diagnose COVID-19, (2) rule out concerning ultrasound features, (3) monitor patients with a change in the clinical status, and (4) avoid unnecessary additional imaging for patients whose pretest probability of an alternative or superimposed diagnosis is low. We do not recommend the use of LUS to guide admission and discharge decisions. We do not recommend routine serial LUS in patients without a change in their clinical condition.

Hospitalist Perceptions of Barriers to Lung Ultrasound Adoption in Diverse Hospital Environments

Despite the many advantages of lung ultrasound (LUS) in the diagnosis and management of patients with dyspnea, its adoption among hospitalists has been slow. We performed semi-structured interviews of hospitals from four diverse health systems in the United States to understand determinants of adoption within a range of clinical settings. We used the diffusion of innovation theory to guide a framework analysis of the data. Of the 27 hospitalists invited, we performed 22 interviews from four hospitals of diverse types. Median years post-residency of interviewees was 10.5 [IQR:5-15]. Four main themes emerged: (1) There are important clinical advantages to LUS despite operator dependence, (2) LUS enhances patient and clinician experience, (3) Investment of clinician time to learn and perform LUS is a barrier to adoption but yields improved efficiency for the health system and (4) Mandated training and use may be necessary to achieve broad adoption as monetary incentives are less effective. Despite the perceived benefits of LUS for patients, clinicians and health systems, a significant barrier to broad LUS adoption is the experience of time scarcity by hospitalists. Future implementation strategies should focus on changes to the clinical environment that address clinician barriers to learning and adoption of new skills.

Multi-Level Stakeholder Perspectives on Determinants of Point of Care Ultrasound Implementation in a US Academic Medical Center

There is growing interest from multiple specialties, including internal medicine, to incorporate diagnostic point of care ultrasound (POCUS) into standard clinical care. However, few internists currently use POCUS. The objective of this study was to understand the current determinants of POCUS adoption at both the health system and clinician level at a U.S. academic medical center from the perspective of multi-level stakeholders. We performed semi-structured interviews of multi-level stakeholders including hospitalists, subspecialists, and hospital leaders at an academic medical center in the U.S. Questions regarding the determinants of POCUS adoption were asked of study participants. Using the framework method, team-based analysis of interview transcripts were guided by the contextual domains of the Practical Robust Implementation and Sustainability Model (PRISM). Thirty-one stakeholders with diverse roles in POCUS adoption were interviewed. Analysis of interviews revealed three overarching themes that stakeholders considered important to adoption by clinicians and health systems: clinical impact, efficiency and cost. Subthemes included two that were deemed essential to high-fidelity implementation: the development of credentialing policies and robust quality assurance processes. These findings identify potential determinants of system and clinician level adoption that may be leveraged to achieve high-fidelity implementation of POCUS applications that result in improved patient outcomes.

Current Use, Perceived Barriers, and Learning Preference of Point of Care Ultrasound (POCUS) in the Emergency Medicine in Qatar - A Mixed Design

Introduction

Point of care ultrasound (POCUS) has been a part of emergency medicine (EM) training for almost two decades. EM training program has a very broad and rigorous POCUS curricula which, in several cases, does not translate to routine application in clinical settings. This study therefore sought to compare the indications, utilization, barriers, and preferred POCUS educational method in a large Middle Eastern academic EM.

Methodology

A validated questionnaire was emailed to 50 EM faculties between April and May 2019. Volunteer faculty members partook in a semi-structured interview to better understand the indications, current use, barriers, and preferred learning method. Responses were anonymous, and data were analyzed with descriptive statistics.

Results

This was a mixed design study. 30/50 (60%) of faculty responded to the survey, with a mean age of 39.2 years and a mean number of years in practice, 13.1. 55% (n=28) completed POCUS training in less than five years, while 45% completed more than five years ago and 5% never completed it. Forty percent of EM physicians were trained in Africa, while 55% were qualified in Asia and 5% completed their training in Europe. The indications and frequently performed procedures were consistent with the previous research. The common barrier reported was lack of time, lack of credentialing, lack of quality assurance, and national guidelines. The majority of the faculty preferred a blended learning approach for POCUS.

Conclusion

POCUS perceived barriers to its full use include time constraints, lack of national guidelines, and credentialing (awarding POCUS qualifications) of the faculty. Blended learning appears to be the preferred approach towards acquiring the knowledge and skills of POCUS.

Building and Maintaining an Ultrasound Program: It Takes a Village

Building and maintaining a successful point-of-care ultrasound program is a complex process that involves establishing an ecosystem between three unique but overlapping domains: ultrasound equipment, ultrasound users, and the health care system. By highlighting the different areas of focus and each of the key stakeholders and components, a group can ensure adequate attention is paid to all aspects of point-of-care ultrasound program development in nephrology.

A survey demonstrating that the procedural experience of residents in internal medicine, critical care and emergency medicine is poor: training in ultrasound is required to rectify this

BACKGROUND

Training in procedural skills is often suboptimal. The aim of this study was to quantify the needs of residents in internal medicine (IM), critical care (CC), and emergency medicine (EM) for instruction in ultrasound-guided procedures.

METHODS

All IM, EM and CC residents (n = 200) at King Abdulaziz Medical City, Riyadh, Saudi Arabia, were invited to participate in a questionnaire-based survey to identify skill and experience gaps. The contribution of procedural skills to patient care (i.e. applicability) and proficiency in the sterile technique required to perform ultrasound-guided procedures were rated on Likert scales. Data on training, accreditation, and experience with and without ultrasound were collected.

RESULTS

The overall response rate was 72% (IM 91%, CC 100%, EM 40%). Although the sample reported that procedural skills were very applicable, 19% (IM n = 25, EM n = 2) had not performed any procedures. However, five residents were accredited in point-of-care ultrasound, 61% of the sample had performed ultrasound-guided procedures and 65% had used landmark techniques. Whilst more internists had performed procedures using landmark techniques, CC and EM residents had performed more ultrasound-guided procedures. Whilst CC residents had not missed any opportunities to perform procedures because supervisors were less available, EM (6) and IM (89) residents had. Whilst skill gaps were only identified in the IM residency programme, experience gaps were present in all three residency programmes. The IM residency programme had larger experience gaps than the CC and EM programmes for all procedural skills.

DISCUSSION

Residents in IM, CC and EM perceive that ultrasound-guided procedures are relevant to their practice. However, the IM residents performed fewer procedures than CC residents and EM residents at least partly because internists also lack skills in ultrasound. Training in ultrasound-guided procedures may reduce the use of landmark techniques and improve patient safety. Residents in IM, CC and EM therefore require training in ultrasound-guided procedures.

Design and evaluation of the I-SCAN faculty POCUS program

BACKGROUND

Point-of-care ultrasound (POCUS) is becoming widely adopted with increasing accessibility of courses. Little is known about the optimal design of the introductory course or longitudinal training programs targeting hospitalists that are critical to success.

METHODS

Hospitalists at four academic sites participated in a two-day introductory course and a longitudinal phase comprising clinical POCUS practice, clip uploading with online feedback, hands-on teaching, and monthly ultrasound conferences. Assessments were performed immediately before and after the two-day course and after 1 year.

RESULTS

Knowledge increased from baseline to post two-day course (median score 58 and 85%, respectively, p < 0.001) and decreased slightly at 1 year (median score 81%, p = 0.012). After the two-day introductory course, the median score for hands-on image acquisition skills, the principal metric of participant success, was 75%. After 1 year, scores were similar (median score 74%). Confidence increased from baseline to post two-day course (1.5 to 3.1 on a 4 point Likert scale from Not at all confident (1) to Very confident (4), p < 0.001), and remained unchanged after 1 year (2.73). Course elements correlating with a passing score on the final hands-on test included number of clip uploads (r = 0.85, p,0.001), attendance at hands-on sessions (r = 0.7, p = 0.001), and attendance at monthly conferences (r = 0.50, p = 0.03).

CONCLUSIONS

The I-ScaN POCUS training program increased hospitalist knowledge, skill and confidence with maintained skill and confidence after 1 year. Uploading clips and attending hands-on teaching sessions were most correlative with participant success.