Time to establish pillars in point-of-care ultrasound

Recommendations for developing a comprehensive point-of-care ultrasound (POCUS) program in the emergency department: an Emergency Medicine Ultrasound Group advocacy statement

OBJECTIVES

Point-of-care ultrasound (POCUS) use is widespread in EDs and throughout those practising medicine. Between institutions and specialities, there is widespread variety and training. With this comes the risk of patient harm and backlash to a clinically useful modality. Our objective is to form a statement that encompasses current published and unpublished guidance for creating and maintaining robust POCUS programs in EDs.

METHODS

Emergency Medicine Ultrasound Group (EMUG) identified this gap and volunteers from the group undertook a literature search of current best practice and institution guidelines relating to POCUS programs. They contacted colleagues from other specialities to find and get access to other countries and colleges' POCUS guidelines. EMUGs regularly run discussion forums (Collab-labs) and points from these were considered. Recommendations were then formed from these and recurrent unpublished obstacles the group had encountered. The result was reviewed by clinical leaders in ultrasound and POCUS users in Australasia.

RESULTS

The recommendations were organised under five pillars: Infrastructure, Governance, Administration, Education and Quality.

CONCLUSION

These recommendations complement existing guidelines and are not intended to replace them; however, we hope to promote discussion and provide reference support for those developing POCUS programs. Implementing a comprehensive and robust ED POCUS program will ensure safe, effective and standardised high-quality POCUS use, with the aim of improving patient care across Australia and New Zealand. Patient safety will be enhanced through effective risk management and quality assurance and there will be consistency in POCUS education, training and credentialing across institutions.

Optimising POCUS programs: A summary of EMUG's recommendations for the development and maintenance of ED POCUS programs

OBJECTIVES

Point-of-care ultrasound (POCUS) use is widespread in EDs and throughout those practising medicine. Between institutions and specialities, there is widespread variety and training. With this comes risk of patient harm and backlash to a clinically useful modality. Our objective is to form a statement that encompasses current published and unpublished guidance for creating and maintaining robust POCUS programs in EDs.

METHODS

Emergency Medicine Ultrasound Group (EMUG) identified this gap and volunteers from the group undertook a literature search of current best practice and institution guidelines relating to POCUS programs. They contacted colleagues from other specialities to find and get access to other countries and colleges' POCUS guidelines. EMUGs regularly run discussion forums (Collab-labs) and points from these were considered. Recommendations were then formed from these and recurrent unpublished obstacles the group had encountered. The result was reviewed by Clinical Leads in Ultrasound and POCUS users in Australasia.

RESULTS

The recommendations were organised under five pillars: Infrastructure, Governance, Administration, Education and Quality.

CONCLUSION

These recommendations complement existing guidelines and are not intended to replace them; however, we hope to promote discussion and provide reference support for those developing POCUS programs. Implementing a comprehensive and robust ED POCUS program will ensure safe, effective, and standardised high-quality POCUS use, with the aim of improving patient care across Australia and New Zealand. Patient safety will be enhanced through effective risk management and quality assurance and there will be consistency in POCUS education, training and credentialing across institutions.

A Modern Diagnostic Procedure-The Introduction of Point-of-Care Ultrasound in Romanian Emergency Physicians' Daily Routine

BACKGROUND

Emergency medicine in Romania has developed fast since inception. The need for faster diagnostic capabilities due to the high workload pre- and in-hospital made point-of-care ultrasound (POCUS) a logical next step. The advantages of POCUS are well known, but implementation presents challenges. Our goal was to study how a straightforward method of implementation would work locally.

METHODS

Two prospective observational studies were conducted at 6 months (prehospital) and 4 months (in-hospital). The protocol used was extended focused assessment sonography in trauma (eFAST), and the shock index (SI) was used to stratify patients. Voluntary sampling was conducted by emergency physicians. The primary outcomes were patient numbers, type of case use, results, and accuracy.

RESULTS

The prehospital study registered 34 patients: 41% traumas, 35% cardiac arrest, 18% shock, and 6% acute respiratory distress. The in-hospital study patients were 78: 36% traumas, 6% cardiac arrests, 41% shock, and 17% acute respiratory distress. A total of 88.5% of the cases were confirmed with definitive imagistic findings.

CONCLUSION

The studies mark an increase in POCUS usage and use in complicated cases. Providing supervision and feedback into clinical practice resulted in a further increase in POCUS usage, the second study having an 88.5% accuracy when compared to the final diagnostic proving the increased efficiency of a longitudinal training approach.

Implementation of a point-of-care ultrasound archiving system and governance framework in a UK physician-paramedic staffed helicopter emergency medical service

INTRODUCTION

There has been a rapid expansion in the use of point-of-care ultrasonography (POCUS) by emergency medical services (EMS). However, less than a third of UK EMS utilise imaging archiving for POCUS, and fewer review saved images as part of a clinical governance structure. This paper describes the implementation of a novel image archiving system and a robust clinical governance framework in our UK physician-paramedic staffed helicopter emergency medical service (HEMS).

METHODS

A retrospective database review was conducted of all patients attended by East Anglian Air Ambulance (EAAA) between the introduction of a new POCUS device and image archiving system on 1 December 2020 to 31 January 2024. All patients with recorded POCUS examinations were included. Images from POCUS examinations at EAAA are archived on a cloud-based server, and retrospectively reviewed within 24 h by an EAAA POCUS supervisor. Image quality is graded using a 5-point Likert-type scale, agreement between reviewer and clinician is recorded and feedback is provided on scanning technique. T-tests were used to assess the difference in image quality between physicians and paramedics. Inter-rater reliability between reviewers and clinicians was assessed using Cohen's kappa (κ).

RESULTS

During the study period, 5913 patients were attended by EAAA. Of these, 1097 patients had POCUS images recorded. The prevalence of POCUS during the study period was 18.6%. 1061 patient examinations underwent quality assurance (96.7%). The most common POCUS examination was echocardiography (60%), predominantly during cardiac arrest. The primary scanning clinician was a paramedic in 25.4% of POCUS examinations. Across all examination types; image quality was not significantly different between physicians and paramedics and agreement between reviewers and clinicians was strong (κ > 0.85).

CONCLUSIONS

In this service evaluation study, we have described outcomes following the introduction of a new POCUS device, image archiving system and governance framework in our HEMS. Paramedics were the primary scanning clinician in a quarter of scans, with image quality comparable to physicians. Almost all scans underwent quality assurance and inter-rater reliability was strong between clinicians and reviewers. Further research is required to investigate the diagnostic accuracy of POCUS and to demonstrate the effect of utilising prehospital POCUS to refine diagnosis on clinical outcomes.

Identifying commonalities in definition and governance of point-of-care ultrasound within statements from medical organizations in the United States: A scoping review for a shared understanding

This scoping review analyzed statements from 22 medical organizations in the United States to identify commonalities in the definition and governance of point-of-care ultrasound (POCUS). A total of 41 statements were included. The review found that the most commonly used elements in defining POCUS were "focused," "bedside," and "patient care." In terms of governance, consistent requirements included specific training programs, documentation in medical records, continuous quality assurance, and standards for credentialing and privileging. These findings suggest the existence of essential commonalities that could facilitate communication and the development of standardized POCUS programs in the future.

CORONA (COre ultRasOund of covid in iNtensive care and Acute medicine) study: National service evaluation of lung and heart ultrasound in intensive care patients with suspected or proven COVID-19

BACKGROUND

Combined Lung Ultrasound (LUS) and Focused UltraSound for Intensive Care heart (FUSIC Heart - formerly Focused Intensive Care Echocardiography, FICE) can aid diagnosis, risk stratification and management in COVID-19. However, data on its application and results are limited to small studies in varying countries and hospitals. This United Kingdom (UK) national service evaluation study assessed how combined LUS and FUSIC Heart were used in COVID-19 Intensive Care Unit (ICU) patients during the first wave of the pandemic.

METHOD

Twelve trusts across the UK registered for this prospective study. LUS and FUSIC Heart data were obtained, using a standardised data set including scoring of abnormalities, between 1st February 2020 to 30th July 2020. The scans were performed by intensivists with FUSIC Lung and Heart competency as a minimum standard. Data was anonymised locally prior to transfer to a central database.

RESULTS

372 studies were performed on 265 patients. There was a small but significant relationship between LUS score >8 and 30-day mortality (OR 1.8). Progression of score was associated with an increase in 30-day mortality (OR 1.2). 30-day mortality was increased in patients with right ventricular (RV) dysfunction (49.4% vs 29.2%). Severity of LUS score correlated with RV dysfunction (p < 0.05). Change in management occurred in 65% of patients following a combined scan.

CONCLUSIONS

In COVID-19 patients, there is an association between lung ultrasound score severity, RV dysfunction and mortality identifiable by combined LUS and FUSIC Heart. The use of 12-point LUS scanning resulted in similar risk score to 6-point imaging in the majority of cases. Our findings suggest that serial combined LUS and FUSIC Heart on COVID-19 ICU patients may aid in clinical decision making and prognostication.

A proposed framework for point of care musculoskeletal ultrasound and ultrasound image-guided interventions by physiotherapists: scope of practice, education and governance

BACKGROUND

The use of point of care ultrasound (PoCUS) in the management of musculoskeletal (MSK) disorders is a diverse area of PoCUS practice. Its use by clinicians, such as physiotherapists, can occur across a wide range of roles and care pathway configurations; however, professional, educational and regulatory uncertainties can leave clinicians, managers and patients at risk.

MAIN BODY

A PoCUS framework approach (previously applied to support PoCUS consolidation and expansion) is used to frame these proposals. Central to this is the defining of (clinical and sonographic) scope of practice (ScoP). A number of indicative ScoPs are described to both (i) illustrate application of the principles and (ii) provide templates for ScoP derivations for individual services or clinicians. Image-guided MSK interventions are increasingly an aspect of MSK physiotherapy PoCUS. Given the utility of physiotherapists drawing upon their imaging to fully inform the selection (and performance) of such techniques, we present a rationale for competency in undertaking sonographic differentials as a pre-cursor to performing ultrasound image-guided MSK interventions. Alignment of ScoP with the relevant education and formal competency assessments are a cornerstone of the PoCUS framework approach; as such, key aspects of MSK PoCUS education and competency assessment are outlined. Strategies for addressing such requirements in healthcare settings where formal provision is not accessible, are also presented. Governance considerations are aligned with the regulatory environment, including those pertaining to professional guidance and insurance considerations. In addition, generic quality assurance elements are emphasised, as core aspects of high-quality service provision. Whilst the paper clarifies the situation for MSK physiotherapists using PoCUS in the UK, prompts are provided to support other professional groups working in MSK services in the United Kingdom (UK) and MSK physiotherapists/physical therapists in other countries-to facilitate their application of the principles.

CONCLUSION

Acknowledging the breadth of MSK physiotherapy PoCUS practice, this paper draws upon a framework approach to provide integrated ScoP, education/competency and governance solutions, along with mechanisms for other professions working with MSK PoCUS-and physiotherapists/physical therapists outside of the UK-to consolidate and expand their practice.

A proposed framework for point of care lung ultrasound by respiratory physiotherapists: scope of practice, education and governance

Background

Point of care ultrasound (PoCUS) has the potential to provide a step change in the management of patients across a range of healthcare settings. Increasingly, healthcare practitioners who are not medical doctors are incorporating PoCUS into their clinical practice. However, the professional, educational and regulatory environment in which this occurs is poorly developed, leaving clinicians, managers and patients at risk.

Main body

Drawing upon existing medical and non-medical literature, the authors present a proposed framework for the use of PoCUS. Throughout, mechanisms for applying the principles to other professionals and healthcare settings are signposted. Application of the framework is illustrated via one such group of healthcare practitioners and in a particular healthcare setting: respiratory physiotherapists in the UK.

In defining the point of care LUS scope of practice we detail what structures are imaged, differentials reported upon and clinical decisions informed by their imaging. This is used to outline the educational and competency requirements for respiratory physiotherapists to safely and effectively use the modality. Together, these are aligned with the regulatory (professional, legal and insurance) arrangements for this professional group in the UK.

In so doing, a comprehensive approach for respiratory physiotherapists to consolidate and expand their use of point of care LUS is presented. This provides clarity for clinicians as to the boundaries of their practice and how to train in the modality; it supports educators with the design of courses and alignment of competency assessments; it supports managers with the staffing of existing and new care pathways. Ultimately it provides greater accessibility for patients to safe and effective point of care lung ultrasound.

For clinicians who are not respiratory physiotherapists and/or are not based in the UK, the framework can be adapted to other professional groups using point of care LUS as well as other point of care ultrasound (PoCUS) applications, thereby providing a comprehensive and sustainable foundation for PoCUS consolidation and expansion.

Conclusion

This paper presents a comprehensive framework to support the use of point of care LUS by respiratory physiotherapists in the UK. Mechanisms to adapt the model to support a wide range of other PoCUS users are outlined.

Point of care ultrasound in pelvic health: scope of practice, education and governance for physiotherapists

Pelvic health and pelvic floor dysfunction have wide-reaching implications across a range of patient groups. Placing ultrasound imaging into the hands of assessing and treating clinicians (i.e. point of care ultrasound, PoCUS) can provide a step change in clinical effectiveness and efficiency. Pelvic floor dysfunction is managed by one or more members of a multi-disciplinary team that includes physiotherapists. Physiotherapists' involvement includes diagnosis, patient education, identifying shared treatment goals, using rehabilitative strategies and empowering patients through self-management. Drawing upon existing publications in this area and applying framework principles, the authors propose a clinical and sonographic scope of practice for physiotherapists as part of supporting the consolidation and expansion of pelvic health PoCUS. Education and governance considerations are detailed to ensure the robust and safe use of this modality. Alongside empowering the use of ultrasound imaging by clinicians such as physiotherapists in the UK and internationally, we provide clarity to other members of the care pathway and ultrasound imaging professionals.

Australasian emergency ultrasound: A survey on the current status

OBJECTIVE

Emergency ultrasound (EUS) has become an integral part of emergency medicine, and the core pillars of governance, infrastructure, administration, education and quality assurance (QA) are vital for its quality and continued growth. We aimed to assess the status of these vital pillars among Australasian EDs.

METHODS

A survey among the clinical leads in ultrasound (CLUS) in Australasian EDs from November 2020 to April 2021.

RESULTS

We analysed a total of 98 responses from CLUS representing 98 EDs. Most CLUS (85%) held EUS qualifications (CCPU 57%, DDU 18%, other 9%) but 15% had none. Only 66% of CLUS had dedicated clinical support time, and a mere 5% had administrative personnel support. Up to three ultrasound machines in 62% of EDs, but only 26% of EDs had secured image archiving facilities. In-house credentialing and the Australasian College for Emergency Medicine (ACEM) trainee special skills placement were available in 50% and 32% of EDs, respectively. Only 11% of EDs had regular EUS training for FACEMs, and only 66% of EDs had regular EUS education for emergency medicine trainees. Only 20 EDs had sonographer educators. Regarding EUS QA, only 33% of EDs provided formal EUS report, 23% of EDs conducted regular image reviews and 37% of EDs audited EUS performance. Only 35% of EDs had high-level disinfection equipment, and 56% of EDs had formal transducer disinfection protocols.

CONCLUSION

Despite ACEM recommendations for the practice of EUS, Australasian EDs still lack vital governance, administrative support, infrastructure, education and QA processes. Prompt actions such as ACEM mandating these recommendations are required to improve resource allocation by health services.

Implementing a quality framework for storing emergency department point-of-care ultrasound examinations on a picture archiving and communication system

INTRODUCTION

There is a lack of a quality framework in most emergency departments despite the set national standards for storing point-of-care ultrasound (PoCUS) examinations. To explore and address this problem, a quality improvement project was undertaken in an emergency department.Methods and interventions: A consecutive sample of the most recent PoCUS examinations in a district general hospital emergency department in the United Kingdom was audited. None was handled and stored on the picture archiving and communication system (PACS). Quality improvement project tools, such as plan, do, study, act (PDSA) cycles, were utilised to analyse and improve practice. The PoCUS machine was connected to the local area network to allow transfer of images to PACS. For requesting and booking the examinations, specific requests on the integrated clinical environment were created akin to the computerised radiology information system codes. Other interventions were introduced such as a reporting proforma. The success of the quality improvement project depended partly on key stakeholders such as emergency department consultants, radiology staff and PACS teams. The number of stored examinations on PACS was the main process measure, but others were also considered, for example reporting and documentation.

RESULTS

Over a 10-month period (September 2018-July 2019), there were three PDSA cycles, which included a total of 195 performed emergency department PoCUS examinations. The implemented quality framework led to 90% of examinations stored to PACS, with a mean of 63%. No negative impacts were reported, and feedback was positive.

CONCLUSION

Implementing a quality framework for storing emergency department PoCUS examinations on PACS is feasible and significantly improves practice. Further work is required to sustain and improve the process.

Point-of-care lung ultrasound in patients with COVID-19 - a narrative review

Ultrasound imaging of the lung and associated tissues may play an important role in the management of patients with COVID-19-associated lung injury. Compared with other monitoring modalities, such as auscultation or radiographic imaging, we argue lung ultrasound has high diagnostic accuracy, is ergonomically favourable and has fewer infection control implications. By informing the initiation, escalation, titration and weaning of respiratory support, lung ultrasound can be integrated into COVID-19 care pathways for patients with respiratory failure. Given the unprecedented pressure on healthcare services currently, supporting and educating clinicians is a key enabler of the wider implementation of lung ultrasound. This narrative review provides a summary of evidence and clinical guidance for the use and interpretation of lung ultrasound for patients with moderate, severe and critical COVID-19-associated lung injury. Mechanisms by which the potential lung ultrasound workforce can be deployed are explored, including a pragmatic approach to training, governance, imaging, interpretation of images and implementation of lung ultrasound into routine clinical practice.