Hocus POCUS?
By Beth W. Orenstein
Radiology Today
Vol. 21 No. 3 P. 16

Is point-of-care ultrasound being overused?

Is point-of-care ultrasound (POCUS) the new stethoscope? Over the past 20 years or so, ultrasound systems have become more portable, lighter, and easier to use. As a result, they have been rapidly adopted throughout medicine. Emergency care physicians were the first to utilize POCUS technology, “and now it’s spreading to many other specialties,” says Eitan Dickman, MD, FAIUM, FACEP, an emergency physician at Maimonides Medical Center in New York and a member of the American Institute of Ultrasound in Medicine (AIUM) board of governors. Today, he says, “you would be hard pressed to find many specialties not utilizing point-of-care ultrasound for whatever specific area they find they need it.”

Srikar Adhikari, MD, MS, FAIUM, a professor of emergency medicine at the University of Arizona in Tucson and chair of the AIUM’s Point-of-Care Ultrasound Community, agrees. “We have seen POCUS become a powerful tool for diagnosis and for guiding interventional procedures in many clinical environments,” he says. As emergency department physicians, Dickman and Adhikari see this rapid rise of POCUS as overall beneficial to patient care, especially in their field, where time to diagnosis can often mean the difference between life and death.

Overuse or Overblown?
However, POCUS made the top of the most recent annual list of medical technology hazards by the ECRI Institute in Plymouth Meeting, Pennsylvania, an independent nonprofit organization with a mission of promoting medical practices and products that provide the safest, most cost-effective care. POCUS was number two on the list, behind surgical staplers. In its executive summary, ECRI says POCUS’s speedy implementation has “outpaced policies and practices that could prevent [its] misuse or [lead to a] misdiagnosis.” The report also says that physicians may be relying on POCUS too much and not ordering more comprehensive exams by imaging specialists as indicated.

Daniel Merton, BS, RDMS, diagnostic ultrasound specialist and principal project officer at ECRI, says the institute’s conclusion is based on a more than eight-year investigation of POCUS technologies. “Our evaluations included more than 30 different models from no fewer than 10 different vendors,” Merton says. The evaluations included surveys that asked users how they utilize the devices and how well they perform for their applications. “We also asked about the users’ POCUS training, experience using the modality, as well as their comfort level employing the technology and confidence in their findings and diagnoses,” Merton says.

Additionally, the evaluation process included discussions with POCUS vendors and expert clinicians. “We have also discussed issues related to POCUS with clinicians and educators at academic centers that are incorporating POCUS training in medical school curricula, specifically to prepare future physicians to utilize POCUS and to avoid some of the issues we describe,” Merton says. He emphasizes the fact that in the institute’s top hazards report, “ECRI never says to not do POCUS,” but rather that it “needs proper oversight.”

Some physician users take issue with some of the ECRI report’s conclusions about POCUS. Adhikari says he’s not aware of any evidence, eg, published studies, showing that utilization of POCUS is associated with poor outcomes. That’s not to say physicians don’t make mistakes “here and there,” he says. “But it is no different from anything else or any other technology. Those misses exist everywhere and in every specialty. I’m not saying it doesn’t happen with POCUS, but not to the degree that ECRI is suggesting in this report.”

Arun Nagdev, MD, director of emergency ultrasound for the Alameda Health System and an associate clinical professor at the University of California, San Francisco School of Medicine, says POCUS is often a big part of a physician’s diagnosis today, but it is never the only test or study. “Most clinicians are risk averse, and when they see something, they often call a colleague over and ask, ‘What do you think? Can you confirm? Do you think I need another study to confirm my findings?’” Nagdev says. “There are other times, especially in critically ill patients, clinicians must use POCUS in conjunction with clinical findings to make important decisions to help resuscitate the patient.” Nagdev has faith in clinicians using common sense when using POCUS to make a diagnosis and thinks ECRI calling it a potential hazard due to overuse is significantly overblown.

Dickman agrees with the part of the ECRI report that says POCUS users need to be properly trained, but he believes that, for the most part, they are. “We need to ensure that people who are using it do have the appropriate training, and that occurs through multiple levels,” Dickman says. Because POCUS has become one of the most common procedures residents in emergency medicine perform, it is now a mandatory component of their training. “There are 23 different milestones that each emergency medicine resident in the country is evaluated on, and one of them is POCUS,” he says. “The residents are assessed for their abilities using ultrasound on a regular basis and with specific guidelines.”

First Alert
The physicians also argue that POCUS is different from comprehensive ultrasound examinations performed by imaging specialists elsewhere in patient care. In the emergency department, POCUS is most used to answer yes-or-no clinical questions, Dickman says. Does a patient have condition X? That’s a different ultrasound compared with a sonogram performed by a sonographer when a patient is sent to an imaging facility or department. The ultrasound at bedside is designed to answer focused questions, whereas comprehensive ultrasound examinations evaluate all organs in an anatomical region, he says. For example, an abdominal POCUS exam may be performed to evaluate for presence or absence of intraperitoneal free fluid, whereas a comprehensive examination done as a follow-up would look at the right upper quadrant and evaluate the region including the liver, gallbladder, and biliary ducts.

Diku Mandavia, MD, senior vice president and CMO for SonoSite Inc, agrees that a POCUS exam in an emergency department setting is far different from a comprehensive ultrasound a physician might order when caring for a patient’s condition. “A POCUS done in real time by the clinician at bedside could lead to a comprehensive diagnostic ultrasound or CT imaging exam later, but it helps put what’s needed in context,” Mandavia says. Another difference, he notes, is that POCUS is performed and interpreted by the provider in real time, whereas a comprehensive sonogram is likely performed by a sonographer and interpreted by a radiologist afterward.

Physicians also see several advantages to having POCUS in the emergency department and elsewhere. Adhikari says a significant advantage to using ultrasound at bedside in the trauma center is that physicians can get answers quickly and, in the emergency department, minutes can matter. “If the patient’s situation is life threatening, you can intervene based on the ultrasound findings in the first 15 to 20 minutes and, for some conditions, that can make a huge difference,” he says. In the past, Adhikari says, emergency physicians often had to perform invasive procedures to diagnose conditions such as bleeding in the abdomen and, not only were the invasive procedures riskier but they also took much longer.

POCUS is also highly valuable should a patient need an IV catheter placed, Mandavia says. The use of ultrasound-guided IV improves successful cannulation and decreases complications, he says. “Top-performing hospitals empower nurses to use POCUS for difficult IV patients,” Mandavia explains. “[Otherwise, the] patient arrives at the emergency department, and the nurse tries for five to 10 minutes and can’t get the catheter in. The patient has multiple needlesticks, and treatment can be delayed by 30 to 40 minutes. With POCUS, the nurse can see the vein and have nearly 100% success on the first try. That’s another example of POCUS improving patient care.”

Mandavia also sees POCUS as a cost saver. As the technology has improved and the images are clearer, using POCUS “could help break the upward cost curve in the health care system,” he says. “Instead of going for the high-cost CT, you could use POCUS first and save the patient not only money but also ionizing radiation, in many cases.”

Oversight and Training
Merton says that more oversight could help to eliminate concerns expressed in his organization’s report about POCUS. “We offer a broad set of recommendations for facilitywide oversight as well as department-level responsibilities,” he says. “At the highest level, we recommend that hospitals consider establishing a multidisciplinary POCUS committee to provide oversight, with the goal of standardizing the use of the technology throughout the facility or health care system.”

A number of societies have written and adopted position statements on the credentialing of physicians who utilize POCUS. One of the first groups was the American College of Emergency Physicians (ACEP), which in 1990 published a position statement supporting the use of ultrasound by appropriately trained emergency physicians. The following year, the Society for Academic Emergency Medicine endorsed the ACEP’s statement and called for a training curriculum that was published in 1994. Two years later, that published curriculum included POCUS for residency graduates.

In 1999, the American Medical Association passed Resolution 802 and policy H-230.960, which recommended that hospital privileging committees recognize specialty-specific guidelines for ultrasound credentialing decisions. That gave each specialty, including emergency physicians, full responsibility for developing guidelines for their field, Dickman says. In 2001, the Accreditation Council for Graduate Medical Education required that all emergency medicine residents attain competency in the use of POCUS. The ACEP also published its first emergency ultrasound guidelines that year. ACEP published updates to those original guidelines in 2008 and 2016. The updates were more comprehensive and specialty oriented. Dickman believes that specialty-specific guidelines make the most sense and that emergency medicine shouldn’t dictate to other specialties what their guidelines should be.

Dickman also agrees with ECRI that “we need to ensure that providers who are utilizing ultrasound have appropriate training,” but, he says, “that occurs through multiple levels.” Every facility should require those performing POCUS at their sites to demonstrate competency with the ultrasound system and transducer, he says.

Adhikari points out that ACEP has a quality and accreditation organization, the Clinical Ultrasound Accreditation Program (CUAP), which was created in 2015 to promote quality, oversight, and safety for POCUS. The programs meeting CUAP criteria must have a POCUS director, credentialing documentation, reporting, safety maintenance, and oversight standards. “Most of the concerns about POCUS in the ECRI report and other recent articles are addressed by the efforts of this organization,” Adhikari says.

Nagdev teaches ultrasound courses around the country and online. His students have included novice providers and seasoned practitioners. He believes all have a genuine interest in learning how and when to use POCUS appropriately and, when they do, he has no doubt that they will use the technology to make the correct calls. “Most physicians do a really great job with what they’ve learned about POCUS,” he says.

“What has evolved is a technology, point-of-care ultrasound, that, when placed in the right provider’s hands—doctor, nurse, paramedic, etc—can affect patient care for the better,” Mandavia says. “It’s a great first test to use and can help discover a diagnosis immediately.”

— Beth W. Orenstein of Northampton, Pennsylvania, is a freelance medical writer and regular contributor to Radiology Today.