So, POCUS and program administration, more versus less. Point-of-care ultrasound programs vary in the degree of hospital, system, and department or division oversight. Variation in credentialing, the need for archiving, definitions of basic versus advanced critical care POCUS, and best practices for documentation will be reviewed. POCUS is widely used with a wide variety of program maintenance, potentially putting clinicians at medical legal risk. So, as I mentioned, I'm Bryce Milligan, nurse practitioner at the VA Pittsburgh Healthcare System. I have a doctorate of nursing practice from the University of Pittsburgh, and my clinical specialties include point-of-care ultrasound and cardiogenic shock. I have no conflicts of interest or financial relationships to disclose. So, I'll be presenting the perspective that it is the wild, wild west in ultrasound. It's like a stethoscope. There should be a little caveat there that I'm not a true cowboy, as they say, of ultrasound, and that I do believe that there should be regulations. That's been pretty supported by organizations in emergency medicine and in critical care medicine. So, the core elements needed for a CCM POCUS exam should be simple. A POCUS program should not be onerous for advanced practice providers or physicians to complete. So, I'm gonna provide the background and a practical approach to keeping ultrasound programs simple and easy to use. The traditional physical exam includes observation, palpation, percussion, auscultation, and it has a high degree of inter-provider variability. So, I think the question we all ask is, should we add incination? The stethoscope is an icon in medicine. It's a virtual representation of expertise in education. So, Dr. Linek is credited with its invention in 1816. He apparently didn't think it was appropriate to do direct auscultation to the chest of a young woman, so he rolled up a piece of paper to indirectly listen to her chest. And fortunately, technology has evolved since then, and we have new devices to optimize our physical exam. Now, in those new devices, I'm talking about the ultrasound, but I think this quote from a textbook on history and physical exam was pertinent. It says, the single most useful device for optimal performance of the physical exam is an inquisitive and sensitive mind. I think it doesn't matter what device you're using, whether it be a rolled up piece of paper, a stethoscope, or an ultrasound probe. The most important thing is the critical thinking ability of the provider using that device and their ability to synthesize that information. So, ultrasound is, can be, and should be an extension of the stethoscope. According to Miriam Webster, the word stethoscope has Greek and French origins. Stethos meaning chest and scope to look at. And so, even the word stethoscope itself is begging for an ultrasound counterpart because we all know you can't look at the chest with a stethoscope. So, how accurate is the stethoscope? Well, with mercury sphygmomanometry, it is the gold standard for blood pressure measurement against which all new technologies are compared. However, in other aspects of the physical exam, the stethoscope does not prove to fare so well. Meta-analysis in 2020 showed, I think it was 34 articles, showed that lung auscultation has a sensitivity of 37% and a specificity of 89% in acute pulmonary pathologies. The authors actually concluded that when a better diagnostic modality is available, it should be used instead of auscultation. In cardiac disease, the literature is a bit less robust, but in mild valvular heart disease and significant valvular heart disease, you can see the sensitivities of 32% and 42% respectively and a specificity of 67% and 69% respectively. So, lung auscultation versus POCUS. There have been many meta-analyses and systematic reviews that show that lung ultrasound has a high sensitivity and specificity for pulmonary pathologies. However, there's a poor agreement between lung auscultation and lung ultrasound. There was a study of 1,000 patients who, and 300 of them were shown to have pulmonary edema on lung ultrasound, but over half had normal auscultation. And then, as you can imagine, residents were significantly better at diagnosing lung pathologies with ultrasound than with physical exam. And then in cardiac disease, ultrasound provides a more accurate diagnosis than physical exam. It identifies abnormal findings, and that can be performed by experts and novice providers alike. Of note in those, you can see all of those references there, I think most interesting is cardiologists were able to identify abnormal cases in 40 to 50% of the time with auscultation, and with ultrasound, both cardiologists and novice ultrasound users were able to identify abnormal pathologies in 70 to 80% of cases. So POCUS, in addition to the physical exam, gives improved detection of pathologies and improved diagnostic accuracy. The COVID-19 pandemic also provided a unique opportunity for point-of-care ultrasound. It addressed barriers to safe, timely, and resource-efficient care. There was shown to be a similar prevalence of microbial surface contamination between ultrasound and stethoscopes, so they do need to be decontaminated, but there's not a higher risk with ultrasound machines. And use was with triage, diagnosis, and medical management. They provide a more accurate initial diagnosis of hypoxemia in the setting of COVID pneumonia, and benefits are that it is immediately available, it's repeatable, it's cost and resource saving, and of course there is a reduction in radiation exposure. So who can accurately perform POCUS exams? Attendings, APPs, medical students, Tom Cruise, wait. I found this article in People from 2005 where Tom Cruise said that he bought an ultrasound machine for Katie Holmes when they were pregnant with their first daughter, and obviously that was hit with a slew of backlash. The American College of Radiology and the FDA, the AIUM, and then even the state of California passed a bill prohibiting the sale of diagnostic ultrasound to anyone except for appropriately licensed clinicians. So I think we can both agree, or all agree, that celebrities and those without training should not be performing POCUS exams, but who, according to the literature, can accurately perform a POCUS exam. So I've shared some of this in some of the prior studies, but novice learners have shown to have successful image acquisition and interpretation. And novice learners can be medical students or providers with minimal ultrasound training. Sometimes this is just a few hours of ultrasound classes, sometimes it's a few weeks of ultrasound classes. But there is agreement between novice and expert ultrasound providers in detecting many pathologies. I thought this one study was interesting. It showed agreement in simulation between ultrasound naive paramedics and emergency physicians in detecting free fluid on FAST exam. Now of course that was simulation, but it just sort of is an interesting thinking for the future. So what should the CCM POCUS exam look like? Well, I think it has to be different depending on every provider. So based on your patient population and your needs in that moment, that is where the CCM POCUS exam should start. I think when you're just starting out, there needs to be a focus on it being simple and basic and yeah, cutting down things. Because I think it would be just absolutely ineffective to learn all of the different ultrasound scans, basic, advanced cardiology, all of the other body systems, and expect to be able to just go out and use it. So start in one place. If you're in a medical ICU, it might be with thoracic ultrasound, it might be with specific cardiac view, it might be with FAST exam if you're practicing in the ER. But start with one place and whatever diagnostic questions you have, that'll guide what exam you're starting with. So all POCUS should be answering a specific diagnostic or management question. Shouldn't just go and ultrasound everything. That would be a huge waste of time and it would just be overuse misdiagnosis for their downstream testing. But whatever questions you're asking your practice, that's where you start with your ultrasound exam. Here are some examples of clinical questions. I mean, the point of this is just to show you that these are specific questions. I am concerned about this hemodynamically unstable patient. Is there a pericardial effusion? Does this patient have a DVT? Is there pulmonary edema? Is there a lung consolidation? Whatever the specific question is, that's where you start. Another important component of CCM POCUS exams is the ability to do serial exams. Whether you're following pulmonary congestion through looking at B-lines or the IVC or doing repeat FAST exams, you can always, I think it's really nice to get a baseline exam and then you can get repeat exams with a change in clinical condition. Image archiving. So this needs to be simple and I know that that's easier said than done, those of you who have POCUS programs. But I think that this is more just a plug at what you should be arguing for from your administration or ultrasound program directors. Ideally, you can transmit directly from the ultrasound device or the handheld device into a medical image archiving system. But I think just however it is, it needs to be something that providers, you don't have, you know, not a ton of steps in the way. Documentation, again, needs to be simple. I know we personally have a template and I can do the dropdown boxes on the template note for point of care ultrasound faster than I can type out my interpretations in my progress note. So automated workflow and emphasizing documentation early on leads to an increase in compliance. And we all know that, unfortunately, I mean, billing is a thing. So documentation leads to billing, leads to revenue to be able to continue your POCUS program. Barriers to ultrasound use. Our training competency credentialing is by far and away seems to be the highest listed barrier, although this is not super, super well studied. But other things are access to machines, supervision, quality assurance. And then another study I found talked about faculty discomfort. There was, I believe it was 343 providers who were interviewed and trainees actually rated themselves as more comfortable with the majority of exams than the faculty had rated themselves. Now that is difficult to interpret. It could be that the trainees don't know what they don't know, or it could be that the faculty have limited training compared to the trainees. But I think the biggest thing is we need to address the barriers, make it simple for people to just get their education, get their training, and start doing it because the technology is here. And speaking of that, handheld devices. They make this an even more pertinent issue. They're here and they're not going anywhere, and they are cheap. So strengths of these devices are that they're portable, they're cheaper than traditional machines, and there's an increased utility in a variety of clinical settings, and that includes resource-poor settings. Weaknesses are the small screen, dexterity of holding both the screen and the probe, and then limited options for fine-tuning image quality. There are concerns, depending on the device too, I won't go deep into it, but depending on the device, concerns for privacy and how things are transmitted over a cloud for image storage and everything like that. But these are just the sort of more grounded pros and cons. So here's a quick case study. This was from a few weeks ago. We had an 80-year-old patient with a history of hypertension, diabetes, CKD, and osteomyelitis. There was a rapid response called overnight for witnessed syncope. When our team arrived, this patient was awake, alert, hemodynamically stable, you can see the vital signs, 82 heart rate and blood pressure of 118 over 68, but the most concerning thing was that this patient said, call my family, I'm going to die tonight. He had a repeat syncoble episode while our team was there, and he was transferred to the ICU. POCUS in the ICU revealed this apical four-chamber view, which I think you can see the sort of obvious elephant in the room there, but there's a clearly dilated RV. There's McConnell's sign, which is the RV free wall decreased contractility with spared apical contractility, and then a clot in transit. So this patient had a PE. He was still awake and alert, totally hemodynamically stable, was able to consent to getting TPA, but unfortunately, shortly thereafter, did have a PEA arrest, and serial POCUS revealed this image. Clearly you can see that clot is no longer there in the right side of the heart. They did get ROSC after ACLS, and this patient did receive TPA. Unfortunately, it was not a great outcome. His family came in, and he had had multiple PEA arrests, and was very unstable. He wasn't able to get a thrombectomy, so the family chose to not escalate care any further. But I think the biggest point of this for me is, I was not there this night, but two of my colleagues were, and especially when a patient is awake and alert and telling you these things, just sort of the moral distress you have as a provider in these situations, and I think the greatest take-home from this is that our providers on gave this patient the best chance of survival. They saw this clot immediately. They didn't wait to react to things. They went with their gut. He was fine. He could have stayed on the floor, and they could have waited till then an arrest was called, and they responded to that, but they escalated as they felt needed, and then they were able to use POCUS to diagnose this, and to follow up when there was a change in clinical status. So key points are that POCUS improves diagnosis. It can be performed by experts and novice providers, and it should be used to answer a specific clinical question. It should always be correlated and synthesized with other clinical findings. But in conclusion, the ideal world doesn't exist. I wish that everyone who was in practice now had ultrasound training during their education, whether it be in med school or nurse practitioners or PAs during our training, but that's not the case. So I kind of imagine there was a similar concern before the uses of the stethoscope became widespread. Concerns regarding training, expectations for use, diagnostic accuracy, and quality assurance. They could all be argued for the stethoscope at that time, as they are with point-of-care ultrasound, but the stethoscope has found its way into standard of care. So I think that it's just more of a paradigm shift. We need to make it simple for the providers, especially the providers who are already in practice to get the education they need, get the training they need, and start using this device, because it's everywhere. I mean, I've listened to presentations this week talking about how med students are just getting them in med school, and we need to be able to get on top of it. And I think that the biggest thing is empowering providers to embrace this evolving technology. So what's next? I just kind of touched on this, but the growth of point-of-care ultrasound technology is outpacing regulation. So we just talked about that, but I think that the really cool thing is embracing the future potential uses of POCUS for critical care daily rounds, resuscitation, emergencies, even other disciplines, pre-hospital. There's increased access, there will be, and are starting to be increased accessibility and better access to high-quality care, especially for people in more resource-poor areas. So is ultrasound like a stethoscope? Well, as a diagnostic tool, I hope not, because the stethoscope has not shown to do very well. But from a cultural standpoint, I hope so, because I think that ultrasound needs to be the standard of care, as the stethoscope has been able to be. These are my many, many, many references, and that's it.

point-of-care ultrasound

POCUS

critical care medicine

standardized POCUS programs

diagnostic accuracy