Best Practices for Point of Care Ultrasound: An Interdisciplinary Expert Consensus

Despite the growing use of point of care ultrasound (POCUS) in contemporary medical practice and the existence of clinical guidelines addressing its specific applications, there remains a lack of standardization and agreement on optimal practices for several areas of POCUS use. The Society of Point of Care Ultrasound (SPOCUS) formed a working group in 2022 to establish a set of recommended best practices for POCUS, applicable to clinicians regardless of their training, specialty, resource setting, or scope of practice. Using a three-round modified Delphi process, a multi-disciplinary panel of 22 POCUS experts based in the United States reached consensus on 57 statements in domains including: (1) The definition and clinical role of POCUS; (2) Training pathways; (3) Credentialing; (4) Cleaning and maintenance of POCUS devices; (5) Consent and education; (6) Security, storage, and sharing of POCUS studies; (7) Uploading, archiving, and reviewing POCUS studies; and (8) Documenting POCUS studies. The consensus statements are provided here. While not intended to establish a standard of care or supersede more targeted guidelines, this document may serve as a useful baseline to guide clinicians, leaders, and systems considering initiation or enhancement of POCUS programs.

International consensus conference recommendations on ultrasound education for undergraduate medical students

OBJECTIVES

The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students.

METHODS

64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting.

RESULTS

A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care.

CONCLUSIONS

The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice.

Point-of-Care Ultrasound in Family Medicine Residencies 5-Year Update: A CERA Study

BACKGROUND AND OBJECTIVES

In 2014, family medicine residency programs began to integrate point-of-care ultrasound (POCUS) into training, although very few had an established POCUS curriculum. This study aimed to evaluate the resources, barriers, and scope of POCUS training in family medicine residencies 5 years after its inception.

METHODS

Questions regarding current training and use of POCUS were included in the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors, and results compared to similar questions on the 2014 CERA survey.

RESULTS

POCUS is becoming a core component of family medicine training programs, with 53% of program directors reporting establishing or an established core curriculum. Only 11% of program directors have no current plans to add POCUS training to their program, compared to 41% in 2014. Despite this increase in training, the reported clinical use of POCUS remains uncommon. Only 27% of programs use six of the eight surveyed POCUS modalities more than once per year. The top three barriers to including POCUS in residency training in 2019 have not changed since 2014, and are (1) a lack of trained faculty, (2) limited access to equipment, and (3) discomfort with interpreting images without radiologist review.

CONCLUSIONS

Training in POCUS has increased in family medicine residencies over the last 5 years, although practical use of this technology in the clinical setting may be lagging behind. Further research should explore how POCUS can improve outcomes and reduce costs in the primary care setting to better inform training for this technology.

Prevalence of Abnormal Ultrasound Findings in Asymptomatic Posterior Tibial Tendons

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) is a pathological condition that can cause failure of the posterior tibial tendon (PTT). Initially, patients with PTTD are often asymptomatic, making early identification and treatment challenging. Certain ultrasound (US) characteristics have been implicated in the presence of tendinopathy, but their frequency has yet to be assessed in the PTT. The purpose of this study was to identify and report on the frequency of incidental, or potentially early subclinical, tendinopathic US characteristics in asymptomatic PTTs.

METHODS

Following institutional review board approval, 150 participants underwent a bilateral-comprehensive US assessment. The resulting images were reviewed and assessed to identify the presence of abnormalities demonstrated to represent tendinopathy.

RESULTS

Overall, 266 tendons were assessed and 128 (48.1%) were determined to have at least one tendinopathic trait. Specifically, 51 (19.2%) had circumferential fluid, 69 (25.9%) had noncircumferential fluid, 22 (8.3%) had thickening, 31 (11.7%) had heterogenicity, 19 (7.1%) had hyperemia, and 2 (0.8%) had calcification. Additionally, Caucasian participants were found to be nearly 3 times more likely to have tendinopathic findings when compared with African American participants.

CONCLUSION

Sixty-seven percent of participants and 48.1% of PTTs evaluated had at least one tendinopathic feature identified on US. The prevalence rates of these findings, observed in participants, were as follows: noncircumferential fluid, circumferential fluid, heterogenicity, and thickening. Knowing the frequency of these traits may help clinicians to identify subclinical tendinopathy in the PTT before it progresses to PTTD.

LEVEL OF EVIDENCE

Level IV, case series.

Point-of-care ultrasound: Coming soon to primary care?

Point-of-care ultrasound (POCUS) has been gaining greater traction in recent years as a way to quickly (and cost-effectively) assess for conditions including systolic dysfunction, pleural effusion, abdominal aortic aneurysms (AAA), and deep vein thrombosis (DVT). It involves limited and specific ultrasound protocols performed at the bedside by the health care provider who is trying to answer a specific question and, thus, help guide treatment of the patient. In this article, we will review the evidence for the use of POCUS in 4 areas: the cardiovascular exam, the lung exam, the screening exam for AAAs, and the evaluation for DVT. For all of these applications, POCUS is safe, accurate, and beneficial and can be performed with a relatively small amount of training by non-radiology specialists, including family physicians.

Assessment of a Novel Point-of-Care Ultrasound Curriculum's Effect on Competency Measures in Family Medicine Graduate Medical Education

OBJECTIVES

Point-of-care ultrasound has been shown to decrease the use of expensive diagnostic studies and improve quality outcome measures. Currently, there is a large desire for training in family medicine residencies, but very few programs have established curricula. We sought to develop a family medicine residency curriculum and evaluate it with tools we developed. We wanted our curriculum to be easy to adopt by other residency programs, even if they did not have many well-trained ultrasound faculty.

METHODS

We developed a curriculum in the form of a 4-week rotation in a family medicine residency program. It consisted of self-study videos, hands-on training, and image review. We followed residents in postgraduate years 1 to 3 over a 12-month period. We developed tools, including a knowledge exam, to test image interpretation and clinical decision making, an observed structured clinical exam to assess scanning skills, and a survey to assess perceptions of point-of-care ultrasound in family medicine. The assessments were administered before and after each resident's rotation.

RESULTS

Seventeen residents completed the rotation. The average knowledge test score improved significantly, from 62 to 84%. The average observed structured clinical exam scores also improved significantly, from 41 to 85%. The average perception survey scores improved slightly from 4.4 to 4.6.

CONCLUSIONS

We developed a point-of-care ultrasound curriculum for family medicine residency programs that improves measures of resident attitude, skills, and knowledge. This curriculum can be adopted by residency programs with few faculty members who are experienced in ultrasound.

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Military family physicians' perceptions of a pocket point-of-care ultrasound device in clinical practice

Point-of-care ultrasonography with a pocket ultrasound device, General Electric Medical Systems Vscan (Milwaukee, Wisconsin), has been shown to be effective and easy to learn. However, no studies to date have evaluated its use in the military primary care setting where its portability and value in bedside diagnosis would be especially beneficial. We tested the feasibility of the Vscan in the day-to-day care of patients by family physicians in their clinic, inpatient wards, and its potential for use in the military-deployed setting. Participants were trained and credentialed in the use of the point-of-care ultrasonography. Then, participants were provided with a pocket ultrasound device to use in their normal day-to-day practice. Additionally, participants completed surveys and provided ratings on their perceptions regarding the use of the device. According to the survey analysis, participants found the devices to be easy to use, valuable in discerning a diagnosis, and were not prohibitively time consuming. Moreover, patients were perceived by the participants to have been satisfied with the use of the device. Overall, participants had high satisfaction with the Vscan and perceived that the device would be highly valuable in the military-deployed setting.

Point of Care Ultrasound in Family Medicine Residency Programs: A CERA Study

BACKGROUND AND OBJECTIVES

Point-of-care (POC) ultrasound is increasingly used by clinicians across multiple medical specialties. Current perceptions and prevalence of POC ultrasound practice and training in family medicine residency programs has not been described.

METHODS

Questions were included in the 2014 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency directors. The survey included questions regarding current use and current curricula regarding POC ultrasound. It also asked rank order questions of perceived benefits and perceived barriers to expanding such training.

RESULTS

Fifty percent (n=224) of residency program directors completed the 2014 CERA survey. Few programs (2.2%) reported an established ultrasound curriculum. However, 29% indicated they have started a program within the past year, and 11.2% reported starting the process of establishing such training. Ultrasound assistance for procedural guidance was the most commonly reported (44%) use out of seven POC examples. The three leading perceived benefits of POC ultrasound were: making a more rapid diagnosis, the potential to save health care costs, and the potential to improve patient outcomes. The three leading barriers to expanding training were a lack of appropriately trained faculty, limited access to ultrasound equipment, and a lack of comfort in interpreting images without radiologist review.

CONCLUSIONS

A small, but rapidly growing, number of family medicine residencies currently use POC ultrasound. Further research is needed to explore how POC ultrasound can improve patient outcomes in the ambulatory setting and to develop appropriate training methods for this technology.

Endoscopic features of intestinal smooth muscle tumor in a child with AIDS

Intestinal leiomyosarcomas are exceedingly rare in immunologically intact children, except during infancy. While leiomyosarcomas account for less than 2% of all soft tissue tumors in childhood, they are the second most frequent malignancy in children with the acquired immunodeficiency syndrome (AIDS). In this cohort they are often located in unusual sites for primary soft tissue tumors. This report describes a young girl with advanced AIDS, referred for evaluation of abdominal pain, hematochezia, and wasting syndrome. Colonoscopy revealed two 1- to 2-cm submucosal nodules with central umbilication. Repeat colonoscopy 18 months later revealed no changes in these lesions. Biopsy revealed a submucosal spindle-cell lesion, with necrosis and cellular atypia. Initially it was characterized as a partially excised low-grade leiomyosarcoma. However, the final consensus diagnosis was smooth muscle tumor of uncertain malignant potential. Because of her advanced AIDS, there was no attempt at surgical resection or chemotherapy. Thirty-six months after initial referral, she remains alive without radiographic or clinical evidence of local extension or metastases. Additional data are required to determine the long-term outcome of these indolent submucosal tumors in the digestive tracts of children with AIDS.

[Epidermolysis bullosa atrophicans gravis. Report of a therapeutic trial with dapsone]

A case of junctional epidermolysis bullosa (Herlitz) is reported. The patient has been treated with high doses of Dapson. The result is encouraging.