Point-of-Care Ultrasound: Potential and Limitations

Ultrasound was not widely used outside the radiology suite or echocardiography laboratory 20 years
ago. More recently, ultrasound has become common in emergency departments (EDs), perioperative
care units, acute care floors in the hospital and in clinics. It is routinely used by physicians and
advanced practice providers with variable training for diagnostic purposes and procedural guidance,
often with little to no oversight by radiologists.

"It will be impossible to watch over every ultrasound examination performed at the point of care,
which exacerbates the potential for patient harm with inadequately trained providers," says Amy E.
Morris, MD, Division of Pulmonary and Critical Care Medicine, University of Washington. "It is therefore
crucial that radiologists and POC ultrasound users work together to recognise its potential and its
limitations, teach current and future care providers how to use it responsibly, and create an
infrastructure that maximises quality of care while minimising patient risk."

This report by Dr. Morris, published in Current Problems in Diagnostic Radiology , provides a brief
overview of key issues related to the increasing practice of point-of-care (POC) ultrasound: how it
differs from complete ultrasound examinations, its potential to affect patient care, and issues of
training, competency assessment, and ongoing quality assurance.

What POC Ultrasound Is, and What It Is Not

In any broad discussion of POC ultrasound, it is important to remember that it is a modality, not a
specific application. The scope of practice differs by specialty. POC ultrasound examinations differ
from complete studies in that they are:

Limited in scope, designed to achieve specific procedural aims (eg, direct the needle to the
correct location) or answer focused questions (eg, does my patient have ascites?).
Performed by the same care provider who will be using the information to direct immediate
patient care management at the bedside.

Factors Driving the Increasing Use of POC Ultrasound

Smaller ultrasound machines, acceptance of ultrasound procedural guidance, and increasing

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Machines capable of rendering high-quality images are smaller and less expensive, making it feasible
for hospitals and clinics to purchase more units, and for providers to fit the machines into their
inpatient and clinic rooms.

There is a well-established safety benefit of ultrasound guidance for several common invasive
procedures such as thoracentesis and central venous catheter placement. In keeping with
professional organisation guidelines and the Agency for Healthcare Research and Quality
recommendations, in most institutions, it is considered the standard of care to place internal jugular
venous catheters using real-time ultrasound needle guidance.

Recognising that POC ultrasound has the potential to be an important tool for diagnosis and clinical
management, some medical schools have embraced the technology to augment anatomy lessons,
and as an adjunct to the physical examination. In clinical clerkships, students at these and other
medical schools are increasingly exposed to ultrasound at the POC, either as a planned part of their
training or incidentally in clinical practice. In graduate medical education, ultrasound training is
required and fairly standardised in emergency medicine residencies in the United States.

Utility of POC Ultrasound

POC ultrasound cannot supplant all aspects of the physical examination. However, if used
appropriately, it is an extension of the physical examination, which can provide more rapid and
accurate assessments.

One may question the ability of practitioners who are not radiologists, trained sonographers or
cardiologists to accurately obtain and interpret ultrasound images. Review of the literature suggests
that in appropriately narrow investigations, this is in fact the case. For example, internists with
relatively brief transthoracic echocardiography training can obtain and interpret focused cardiac
images to estimate left ventricular function with good accuracy, and focused ultrasound examinations
performed by emergency medicine physicians have excellent sensitivity and specificity for detecting
deep venous thrombosis and subcutaneous abscesses.

Less clear is how well these improved individual diagnostic findings translate into measurably more
efficient clinical decision making and improved patient outcomes. These are more difficult end points
to measure, and the evidence is far less robust, but there are some examples: the use of the
focused assessment with sonography for trauma examination in the ED, which in patients with blunt
trauma is associated with fewer CT scans, shorter hospital length of stay, and lower hospital bills.

Competency Assessment and Ongoing Quality Assurance

For physicians in practice, several national and international organisations offer training and
certification in various aspects of POC ultrasound. The content and quality of educational offerings is
not held to any universal standard, in part because the scope of practice varies by specialty. Outside
emergency medicine, general consensus is emerging as to what should be included in the POC
ultrasound skill set for providers in several areas of medicine, notably critical care.

In addition, prominent professional organisations have released consensus statements for certain
examination types such as the focused assessment with sonography for trauma examination and
focused transthoracic echocardiography, which helps to standardise educational content.

Establishing scope of practice and developing curricula are only the first steps toward assuring
provider competence. Standards of assessment that encompass both examination performance and
interpretation should be developed to ensure that providers are using POC ultrasound appropriately.

Both competence and ongoing quality assessment are hampered by the fact that unlike chest
radiographs and CT scans, which have standard protocols such that they can be interpreted widely by
providers who did not perform the examination themselves, POC ultrasound is by its nature
individualised and brief. There are traditional cardiac views, and some anatomical structures are
readily identified by their sonographic appearance, but some images will be difficult to interpret by
someone who was not present at the time of the examination.

The essential advantage to POC ultrasound is that it is rapid, and in the urgent setting, it will not be
practical to label every image in detail. Despite this limitation, for most common POC ultrasound
examinations, it is possible to elucidate key required views, and users should be able to record their
examinations for other providers to review and verify.

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Summary

As ultrasound machines become smaller, indeed reduced to the size of mobile phone applications,
medical students in the not-too-distant future may carry transducers next to the stethoscopes in
their pockets. It would be impossible to disallow use of this technology altogether, and indeed
inappropriate to do so, in light of the growing body of literature documenting its benefit.

As more providers use ultrasound at the POC, radiologists can take a leadership role in ensuring its
effective use by collaborating to help shape standards of training and quality assurance.

Image Credit: Wikimedia Commons

Published on : Mon, 16 Feb 2015

© For pers onal and private us e only. Reproduction mus t be permitted by the copyright holder. Email to
[email protected].