Photo by Thinkstock
Photo by Thinkstock

POCUS catches on

Credentialing and training hospitalists to use handheld ultrasounds.

A young male patient who used IV drugs was admitted to the ED reporting pain and swelling in his scrotum. Following protocol, the attending physician initiated IV antibiotics and ordered a testicular ultrasound. With no evidence of an abscess, the patient was admitted with a diagnosis of scrotal cellulitis.

“When I arrived for my shift the next morning, this patient's pain had increased in severity, and on exam it really seemed consistent with fluid collection,” said Renee Dversdal, MD, FACP, assistant professor of medicine and director of point-of-care ultrasound (POCUS) at Oregon Health and Science University in Portland. Based on the patient's description of the pain, she performed a POCUS exam of the scrotum in the perineal area and discovered a large abscess.

“A formal testicular exam is a protocol-driven test, but it missed the area where the patient was reporting the most pain,” she said. “That's the power of ultrasound at the bedside—we're able to use our clinical reasoning based on what the patient is telling us, in addition to what a formal protocol dictates.”

It's one example of how hospitalists are employing POCUS to improve diagnostic accuracy, guide procedures, and reduce patient exposure to radiation. Ultrasound exams enhance the physical exam by enabling physicians to see, as well as listen, during a bedside evaluation, proponents say.

However, several barriers remain to implementing POCUS on a wider scale, including a lack of national standards and protocols to guide training and use. It is likely that standards will be forthcoming in the near future, given the potential benefits of POCUS, said Benji Mathews, MD, FACP, assistant professor of medicine at the University of Minnesota and director of POCUS and hospital medicine at HealthPartners and Regions Hospital in St. Paul.

“EHRs, online resources, and other technologies have often put providers in front of a screen and away from the patient,” he said. “POCUS is a powerful piece of technology that is bringing us back to the bedside.”

Uses for POCUS

Hospitalists are using POCUS in procedures, including paracentesis and central line placement, as well as diagnostically to assess the heart, lung, abdomen, and vasculature. Those who use it routinely say it often uncovers abnormalities that might not be apparent during a traditional physical exam.

“In contrast to the kind of comprehensive study done in radiology, hospitalists usually use ultrasound to answer targeted questions,” said Gordon Johnson, MD, a hospitalist at Legacy Health in Portland, Ore., and a champion of POCUS. “Is there a pericardial effusion present? Is the ejection fraction reduced? Is there a pleural effusion? These are questions that need to be answered immediately at the bedside.”

Gregg McCord, MD, a hospitalist at Portland Adventist Hospital in Oregon, said he uses POCUS daily to assist in making differential diagnoses. He may be able to rule out deep venous thrombosis by performing a vascular ultrasound at the bedside, for example, as opposed to calling in a specialist and sending the patient to radiology for testing.

POCUS also helps with monitoring patients, said Dr. Dversdal. For example, if she notices a spike in creatinine and blood urea nitrogen levels in a patient being aggressively diuresed, she can use POCUS to check the level of fluid in the lungs and inferior vena cava before deciding whether or not to slow diuresis.

“In the past, I might have given the patient a break on diuretics, which could mean an extra day in the hospital,” she said. “On the flip side, there's some suggestion that if we diurese until the signs of fluid are gone it may reduce readmissions. Being able to visualize the lungs helps in decision making about ongoing treatment and length of stay.”

At Froedtert Hospital in Milwaukee, hospitalists are trained to use POCUS for very specific purposes, said Ricardo Franco Sadud, MD, ACP Member, director of the bedside procedure service and associate professor of medicine at the Medical College of Wisconsin. Echocardiograms, for example, are used for visual assessment of left ventricular ejection fraction, presence of pericardial effusion, and contractility of the right ventricle.

“Whenever we suspect that shortness of breath might have a cardiac source or we want to do a volume check, we use POCUS because it helps us achieve a diagnosis,” he said. “If results are normal, we might not call a specialist, but if we think it's abnormal we'll obtain a formal exam to confirm our diagnosis.”

A typical case where POCUS aids in diagnosis might involve differentiating between hypovolemia and obstruction of the urinary outlet in a patient with decreased urine output, said Dr. Franco. The hospitalist would use POCUS to look at the size of the kidneys and assess for hydronephrosis, check the bladder for urine, and examine the inferior vena cava.

If the kidneys are normal, the bladder is empty with no urethral jets, and the inferior vena cava is flat and collapsed, the patient does not have an obstruction, he said. The physician can then administer fluid to treat hypovolemia while using POCUS to monitor the lungs for interstitial edema.

Although research confirms that POCUS has similar diagnostic accuracy as standard imaging for specific conditions, there are fewer studies on how it compares with the traditional physical exam, noted an article published in the December 2016 Mayo Clinic Proceedings.

There have been some studies suggesting that the use of POCUS reduces procedure-related complications as well as associated costs and lengths of stay, the authors noted. However, there is a paucity of data supporting the routine use of POCUS for diagnostic evaluations. As POCUS applications become incorporated into evidence-based guidelines, there is a growing need for larger, randomized studies on how POCUS affects health outcomes.

“For known POCUS applications that are not yet the standard of care, such as evaluation of acute dyspnea with POCUS, additional clinical outcomes and health services research will likely be needed to confirm benefit and assess the effect on health care costs, length of stay, and patient experience,” the study concluded. “For other newer, novel POCUS applications, such as elastography and 3-dimensional ultrasound imaging, diagnostic accuracy studies are needed to establish their role in clinical medicine.”

Training pathways

Currently, there are no internal medicine-specific guidelines on how POCUS should be used or the basic skill set needed for competency. That's led some hospitalists to pursue certifications offered by other specialty groups, such as the American College of Chest Physicians. In addition, some hospitals are developing and establishing their own training programs and credentialing pathways.

HealthPartners, for example, implemented the Comprehensive Hospitalist Assessment and Mentorship with Portfolios Ultrasound (CHAMP US) program in 2014, said Dr. Mathews. To ensure ongoing quality, 10% of point-of-care images are randomly selected and reviewed by a multidisciplinary committee (including emergency medicine, radiology, critical care, and cardiology) whose members then provide feedback to trainees.

“Our comprehensive training program, including competency assessments, significantly improved ultrasound acquisition skills with hospitalists,” said Dr. Mathews, who implemented a quality assurance process to track effectiveness of the training program. Those attending monthly scanning sessions and participating in the portfolio completion, as well as a one-day refresher course, retained or augmented skills significantly more than those who had not done either.

At Portland Adventist, hospitalists must take 20 hours of continuing medical education in order to earn POCUS privileges, said Dr. McCord. Currently, three out of the 21 hospitalists on staff have met those criteria.

“I believe all hospitalists should have some training, even if they are near the end of their careers,” said Dr. Dversdal. “Even if you aren't actually performing POCUS clinically, it's important to be able to understand the terminology and significance of findings that colleagues and learners will be reporting to you on an increasing basis.”

Studies have found that the usefulness of POCUS is highly dependent on the training and skill of the operator. Multiple skills are required, and research has indicated that insufficient faculty training can be a barrier to POCUS adoption.

At Froedtert, a six-week training course is required of hospitalists to gain basic POCUS privileges. During that time, hospitalists attend an introductory workshop, then obtain a minimum of five images per organ area under supervision of a trained faculty member. Participants receive continuous feedback so they can improve as they progress through the course.

For basic training, it's important to impose a specific scope of practice, said Dr. Franco. For example, successful completion of initial training at his institution qualifies hospitalists to assess the abdomen only for certain indications, including presence or absence of normal aorta, fluid around the kidneys, hydronephrosis, and normal gallbladder.

“That's all that's included in our training—we don't want them to look at the common bile duct or anything else that they haven't been taught,” he said. “In the absence of formal guidelines, we think this training defines the scope of practice pretty well.”

When approaching POCUS for the first time, it helps to think of training in phases, said Dr. Johnson. Relatively simple exams, such as assessing fluids in the abdomen, can be learned in a few hours, whereas more complicated ones, such as advanced cardiac care, can take much longer.

“Most hospitalists want to learn POCUS, but some are wary of the time involved,” said Dr. Johnson. “It's a lifelong learning process to become an expert, but you can start with focused exams and build skills gradually over time.”

Future directions

While basic competency in POCUS may be useful for all hospitalists, requiring everyone to travel and take courses at their own expense would be impractical, noted Dr. Dversdal. However, most experts say there is a need for minimum standards so that competency can be assessed across institutions.

“For now, POCUS is a skill set that individual providers are acquiring on their own,” said Nilam Soni, MD, MSc, FACP, a hospitalist at the University of Texas Health System in San Antonio and leader of several national and regional POCUS training workshops. “It would be helpful to have nationally recognized certification courses that lay out a standard curriculum for hospitalists to follow.”

One possible solution would be to establish regional centers of excellence that offer courses approved by national professional societies, such as ACP or the Society of Hospital Medicine, said Dr. Dversdal. Each center could develop its own certification pathway or program, but all would have to meet a set of universal standards specific to internal medicine. Ideally, there would be a formalized path for both basic and advanced training, said Dr. Franco.

There may be less need to test and certify competency of future hospitalists, as POCUS is increasingly being integrated into medical school and residency training, said Dr. Soni.

For example, UT Health San Antonio's School of Medicine houses the Center for Clinical Ultrasound Education, which offers hands-on training with live and simulation models throughout all four years of the medical school curriculum. Eventually, hospitalists will start practice with a basic set of skills that they can build on throughout their careers, Dr. Soni said.

He noted that POCUS is not meeting the same resistance as some new technologies and modes of practice, judging by the enthusiasm he's seen at various professional conferences and meetings. He is gathering data for long-term study on the implementation and benefits of POCUS in the VA health care system.

“Often people resist change, but many physicians have embraced the use of POCUS because it hits at the core of what we do every day—examination and evaluation of sick people,” he said. “If we have better technology on the front end at the bedside, we can reduce unnecessary testing and ultimately improve patient care on the back end.”