Perspectives on Safety—Point-of-Care Ultrasound: Safety and Utility

This month's interview features Richard Hoppmann, MD, the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Director of the Ultrasound Institute of the University of South Carolina School of Medicine. He founded and served as the first President of the Society of Ultrasound in Medical Education. We talked to him about safety and usability of point-of-care ultrasound.

In an accompanying commentary, Chris Moore, MD, of Yale School of Medicine, highlights how point-of-care ultrasound can improve and expedite diagnosis and advocates for having an individual responsible for overseeing point-of-care ultrasound use within a health care delivery organization.

Perspectives on Safety
Published June 2018

Safety Considerations in Building a Point-of-Care Ultrasound Program

by Chris Moore, MD

Perspective

At the American College of Emergency Physicians Scientific Assembly in Washington, DC, a device was unveiled that claims to provide "Whole body imaging. Under $2K."(1) The booth was mobbed, with thousands of attendees signing up to buy an ultrasound probe that connects to an iPhone and allows ultrasound to be done anytime, anywhere. While this form factor and price arguably brings disruption to a new level, it represents just the latest technological advance facilitating the spread of point-of-care ultrasound (POCUS)—ultrasound performed by the examining and treating clinician at the bedside.(2)

A 2001 survey of physicians on the relative importance of 30 medical innovations ranked ultrasound as Number 11 (CT and MRI shared the Number 1 spot).(3) AHRQ has listed the "use of real-time ultrasound guidance during central line insertions" as one of the top 11 safety practices to reduce medical errors.(4) Used properly, POCUS has vast potential to improve patient safety through efficient and accurate diagnosis and procedural guidance.(2,5) However, as with any diagnostic technique, the potential benefits must be balanced against overuse and misuse—avoiding both wasted resources and potential morbidity from false positive and false negative diagnoses. Prioritizing patient safety in building and implementing a POCUS program involves careful attention and judgment.

Stethoscope or Diagnostic Imaging?

Nearly 30 years ago, an editorial in Radiology lamented that "As we look at the proliferation of US [ultrasound] instruments into the hands of untrained physicians, we can only come to the unfortunate realization that diagnostic sonography truly is the next stethoscope: used by many, understood by few."(6) While unlocking the full potential of ultrasound may require substantial training, even novices with POCUS outperform experienced providers who are using the classic skills of auscultation and physical examination.(7,8) POCUS is also far more versatile. As an experienced POCUS user, my only current use for the stethoscope is in the detection of wheezing on pulmonary exam. For virtually every other finding involving the heart, lungs, abdomen, and vasculature, POCUS is superior.

Defining a paradigm for POCUS—is it an extension of the physical examination or a focused diagnostic test?—has implications for safety, quality, and reimbursement. It is possible that POCUS may be viewed simply as an extension of the physical examination, like the stethoscope, in which someone might use it informally, not record images, and simply document basic findings in the medical record, much as they do with a classic physical examination. However, it is the recording of images and detailed documentation of findings that provides the information needed for training, assessment of competency, and a quality assurance feedback loop that will ensure patient safety. Although images could be recorded without reimbursement, both the requirement for image retention and the resources that reimbursement provides may help drive true quality in POCUS use. Defining appropriate reimbursement for POCUS, which may be different than that provided for imaging performed by imaging specialists, remains challenging.(9) While exactly how to reimburse is debatable, relegating a tool as powerful and complex as POCUS to a nonreimbursable physical exam-like status would adversely affect quality and safety. Training in POCUS—starting in medical school and including competency assessments as practitioners advance—is certainly paramount. However, the tool is complex and diverse enough that unlike the stethoscope, image, capture, and review are essential to ensuring quality. Appropriate reimbursement also helps to provide resources needed to ensure quality oversight, both equipment and personnel. Without both the carrot and the stick of reimbursing only exams with appropriate documentation and image capture, quality of POCUS will undoubtedly suffer, resulting in poorer patient outcomes.

Defining Scope of Practice: Who, Where, For What, With What Training and Competency

In 2005, Tom Cruise bought an ultrasound machine so that he and Katie Holmes could view their growing fetus from the comfort of their own home, prompting a press release from the American Institute of Ultrasound in Medicine stating this was "both inappropriate and in violation of FDA rules."(10) While the widespread use of POCUS by laypersons may not be imminent, there is a large pool of potential health care users of POCUS, including medical students, emergency medical services providers, nurses, physician assistants, and physicians from diverse medical specialties. Even within a given type of user, there also exist multiple potential uses. For example, emergency physicians may use POCUS for examinations ranging from trauma and pregnancy to focused echocardiography.(11) Within focused echocardiography, it may be reasonable to assess for pericardial effusion, but out of scope to make determinations regarding valvular pathology.(9,11) Defining and implementing scope of practice for POCUS requires judgment and will differ depending on the provider and practice environment.

Ultrasound is undoubtedly one of the most user-dependent diagnostic technologies that exists. While some very basic uses of ultrasound can be picked up quickly, substantial skill is needed to both acquire and interpret appropriate information.(5) Ultrasound has begun to diffuse into undergraduate medical education, and it is likely that, eventually, all physicians will receive training that provides them a basic understanding of POCUS and the ability to incorporate it appropriately into their practice.(12) However, there is and likely will persist a wide range of training and competency levels, even within relatively well-circumscribed practice environments. When it comes to procedural education, medical education is moving toward a system based on competency evaluation, rather than on simply the number of procedures performed.(5,9,12) POCUS education and competency assessment benefit from the availability of online resources for asynchronous teaching and evaluation, but curation and monitoring of these resources requires attention. Certification—the attestation by a third party that an individual practitioner has attained competency in ultrasound—may be available, though more organic competency assessment by those most familiar with the practice environment may prove to be more effective. For those practitioners working within a hospital system, there often will be institutional privileging involved. Some hospitals have adopted application-specific privileging (i.e., privileging for POCUS assessment of volume status), but in general it is preferable to have basic overall POCUS privileges, with specific scope defined at the departmental level.(11)

Quality Assurance

A program of quality assurance is essential to optimizing patient safety. Ultrasound is particularly amenable to the capture of images (ideally actual videos or cineloops) that allow for true quality assurance and feedback to the operator. Like ultrasound itself, the technology to store and move images has become increasingly accessible and affordable, although appropriate image capture and retention must be balanced against what information is truly needed and how it will be used. Ideally, at least a portion of POCUS examinations will be overread by an expert who can ensure quality and provide feedback. The potential for remote quality assurance in areas that lack local expertise can now be realized using the Internet, even across international borders.(13)

The POCUS Point Person

Given the variability and complexity of issues above, probably the most important factor in safely building and maintaining a POCUS program is the identification and support of a person who has the responsibility for overseeing POCUS implementation and use within a defined realm. This person will be responsible for determining who within their realm can and should do what; how training will be provided and competency assessed; what should be documented and whether and how images can be captured; and what level of quality assurance is needed, as well as interfacing with patients, providers, and the health care system regarding the use of POCUS in their realm and beyond.

For example, I serve as the Chief of the Emergency Ultrasound Section within the Department of Emergency Medicine. As such, I ultimately oversee the performance of about 12,000 POCUS examinations per year, a figure that includes diagnostic, procedural, and educational examinations by practitioners. These practitioners include medical students, midlevel providers, resident physicians, fellows, and board-certified emergency physicians. I have also led the formation of the Yale Point-of-care Ultrasound Council: a multispecialty group that meets every 2 months and involves specialists within our institution who use both POCUS and more traditional ultrasound.

To do this correctly of course requires some resources—to ensure that the person providing oversight is properly trained and that he or she has sufficient time to provide the needed oversight. The training, identification, and realm of oversight for this individual will vary depending on the environment. However, investing in and supporting this person is probably the single most important factor in safely developing and implementing POCUS.

Summary

POCUS can be a powerful tool to enhance patient safety through improved and expedited diagnosis and procedural guidance. Building a POCUS program that optimizes patient safety and patient-centered outcomes requires judgment and oversight of this powerful tool. Provision of appropriate resources including robust training and competency assessment, capture and documentation of images, appropriate reimbursement to ensure quality, and defining and empowering an appropriate point person will ensure best outcomes.

Chris Moore, MD
Associate Professor, Department of Emergency Medicine
Yale University School of Medicine

References

1. Butterfly iQ. Butterfly Network, Inc. [Available at]

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4. Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E058. [Available at]

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6. Filly RA. Ultrasound: the stethoscope of the future, alas. Radiology. 1988;167:400. [go to PubMed]

7. Mouratev G, Howe D, Hoppmann R, et al. Teaching medical students ultrasound to measure liver size: comparison with experienced clinicians using physical examination alone. Teach Learn Med. 2013;25:84-88. [go to PubMed]

8. Kobal SL, Trento L, Baharami S, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005;96:1002-1006. [go to PubMed]

9. Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26:567-581. [go to PubMed]

10. AIUM discourages the sale and use of ultrasound equipment for personal use in the home. Laurel, MD: American Institute of Ultrasound in Medicine; 2005. [Available at]

11. Ultrasound guidelines: emergency, point-of-care, and clinical ultrasound guidelines in medicine. Ann Emerg Med. 2017;69:e27-e54. [go to PubMed]

12. Dinh VA, Fu JY, Lu S, Chiem A, Fox JC, Blaivas M. Integration of ultrasound in medical education at United States medical schools. J Ultrasound Med. 2016;35:413-419. [go to PubMed]

13. Swanson JO, Plotner D, Franklin HL, et al. Web-based quality assurance process drives improvements in obstetric ultrasound in 5 low- and middle-income countries. Glob Health Sci Pract. 2016;4:675-683. [go to PubMed]