The Need for POCUS Safeguards
Point-of-care ultrasound (POCUS) imaging refers to the use of medical ultrasound by the treating clinician at the bedside—as opposed to referring the patient to an imaging specialist—when an ultrasound exam is indicated. POCUS is also routinely used in resuscitation (e.g., for cardiac arrest), in trauma settings, and for assessing dyspnea and hypotension. It is used to guide interventional procedures such as vascular access; nerve blocks; fluid aspirations such as paracentesis, thoracentesis, and pericardiocentesis; and lumbar punctures. POCUS is also beneficial to monitor fluid volume status and cardiac function, and to guide therapeutic injection of medications.
A wide range of ultrasound scanners are available that have been designed for POCUS applications, and the majority are highly portable, comparatively inexpensive, battery-operated, and easy to use. As a result of the advances in POCUS technologies and the recognized clinical benefits of using POCUS, the number and types of users have rapidly increased and continue to expand throughout acute care facilities as well as in emergency patient transport settings (e.g., ambulances, helicopters), at disaster sites, and at major sporting events.
The main benefit of POCUS is that it allows clinicians to quickly determine whether an abnormality is present so that they can expedite patient management decisions. POCUS provides clinically relevant information and is complementary to a physical examination. Because outpatients don't need to be referred to imaging specialists, they don't need to make an additional appointment for the imaging exam and wait for the diagnosis to be provided to their treating physician. The result is more time-efficient care and enhanced patient satisfaction. POCUS has been proven to enhance diagnoses in complicated cases and to reduce complications during interventional procedures.(1)
However, optimal utilization of POCUS can be hampered by inefficient and inconsistent application of the technology and a lack of universal guidelines and recommendations pertaining to POCUS use, training, licensure/credentialing, or competency testing. Consider the following:
- Currently, POCUS training guidelines and competency expectations are specialty-specific. Comprehensive ultrasound training is mandatory in some residencies, such as for emergency medicine and OB/GYN, and is included in some residency programs for other disciplines, such as internal medicine, family practice, and anesthesia. Ultrasound training is also part of some fellowships, but again the training can vary between disciplines or educational institutions. The inclusion of POCUS education is growing in medical school curricula, but the amount of training varies between institutions, and many users have not received any formal POCUS training.
- Although some healthcare systems have created POCUS policies and procedures, those may not be applied consistently between users and disciplines within the facility or healthcare system. The lack of sufficient oversight, policies, and procedures increases the potential that patients will be adversely affected by problems associated with use of the technology, such as a healthcare-associated infection (HAI) from a probe that is not properly disinfected. And suboptimal administrative policies have the potential to place providers and facilities in danger of legal actions if POCUS is indicated but not performed, or to reduce revenue if POCUS studies are not properly billed.
The rapid adoption of POCUS brings with it a need to establish safeguards to ensure appropriate, effective, and safe use of this valuable advance in healthcare. Herein, we provide our recommendations regarding the essential aspects of a successful POCUS service. The basics of POCUS are described in our report
Point-of-Care Ultrasound Scanners: An Introduction, and links to additional ECRI publications, including the results from our Evaluations of more than 25 POCUS scanners, are listed under the Supplementary Materials tab.
Left: POCUS guidance for an invasive procedure. Right: POCUS using a probe wired to a smartphone for obstetric assessment. (Images courtesy of Mindray [left] and Butterfly Network [right].)
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ECRI Recommendations
There are several key aspects of a successful POCUS service, including proper oversight, technology management, integration, administration, training, and credentialing, as described below. Our recommendations address issues that affect all POCUS users within a facility, as well as the responsibilities of individual departments that employ POCUS.
Facility-wide Oversight
Healthcare facilities should establish a multidisciplinary POCUS committee tasked to provide oversight, with the goal of standardizing the use of the technology throughout the facility or healthcare system while encouraging adoption, education, and innovation. A multidisciplinary approach allows the facility to capitalize on existing internal expertise and minimize redundancy, while standardizing processes.
The POCUS committee should include relevant stakeholders, clinicians and administrators from departments that use POCUS, a health technology management representative, and hospital administration. It may be beneficial to include ultrasound professionals, such as sonographers or radiologists, and educational program leaders. The variety of settings where POCUS is used within a facility will influence the committee's size and the types of individuals who should be on it. For example, large facilities that have many disciplines using POCUS likely will require input from several clinicians, representatives from risk management, and the facility's IT department, whereas a freestanding clinic may be able to operate effectively with a single POCUS director or small team to coordinate activities.
The primary objective of a POCUS committee is to establish policies and procedures that address the areas listed below. We recognize that implementing and carrying out these policies and procedures system-wide, especially in larger institutions with multiple POCUS users, will require sufficient time, capital investments, and personnel resources.
The policies and procedures should cover:
1. Technology selection, acquisition, and management: The purchase of POCUS scanners should follow established facility procurement procedures. Scanners under consideration should be evaluated by end users to ensure that the devices have the capabilities and support the transducers necessary to meet clinical demands. Standardization of vendors and models can yield cost savings, as well as benefits associated with staff training, device integration, routine maintenance, and other technology management requirements. POCUS scanner types vary, from cart-based to hand-carried to pocket-size models, with options for mounting on portable carts or poles.
2. Service and maintenance: Scanners and accessories must be maintained and serviced as recommended by the vendor, including software and cybersecurity updates. The physical locations of scanners must be tracked and recorded; the use of a radio-frequency identification (RFID) system can facilitate asset management. Inventory—including probes, which are frequently damaged—must be maintained in good repair and in sufficient quantities to meet clinical demands.
3. Reprocessing: Cleaning and disinfection procedures for POCUS scanners, probes, and accessories that are based on published guidelines should be specified.(2,3,4) The facility's infection preventionist may need to be consulted, and products and processes used must be validated and approved by the POCUS equipment vendor. When not in use, scanners and probes must be properly stored. For more information, refer to ECRI's
recommendations for reprocessing ultrasound scanners and transducers.
4. Integration: Integration of POCUS technologies with a hospital network is essential for data archiving and to allow timely access to findings for effective patient management. Digital Imaging and Communications in Medicine (DICOM) data transfer and archiving is recommended, and Wi-Fi capability enhances workflow. Local area network (LAN) access ports and cables must be available as a backup for Wi-Fi. Ultrasound workflow software can be used to facilitate archiving of images, and some packages offer editing, labeling, and measuring capabilities that can be used to create a report of the POCUS exam findings. This software can also provide departmental or institutional ability to perform quality assurance and collate examinations for credentialing.
5. Cybersecurity: Appropriate cybersecurity measures must be employed at the network and device levels and updated as necessary to prevent unauthorized intrusions and system compromise by hackers, which can result in viruses, removal or corruption of data, ransomware attacks, or patient identity theft.
Some handheld ultrasound probes require a smartphone or tablet to display data and serve as the user interface. These devices can pose additional cybersecurity vulnerabilities. Policies should address the use of both personal electronic devices, including clinician-purchased smartphones and tablets, and POCUS probes. Any of these small devices can easily be misplaced or stolen, so device security and Health Insurance Portability and Accountability Act (HIPAA) concerns must be considered. Dedicated POCUS tablets provided by the facility are recommended when using these probes to ensure interoperability and adherence to facility IT policies. The display device can be secured to a wheeled stand to enhance transportability, use at the bedside, and security.
Cybersecurity best practices should be implemented as appropriate for the care setting. These may include:
a) Enabling a POCUS scanner's automatic sleep mode or automatic log-off features, if available
b) The use of user-specific passwords to access the POCUS scanner and data archive, and automated processes that require users to regularly change their passwords
c) A system user access log that automatically records when and by whom the scanner is used
6. Image documentation and archiving: Image documentation is required for reimbursement and medicolegal purposes. Procedures should be established that describe documentation requirements and methods. Exam data—including images, preliminary findings, and final reports—should be archived in a timely manner and available for review as needed. Exam documentation should include the name of the clinician performing the study, the indication for the exam, a description of relevant anatomy assessed, and a diagnostic interpretation.
Digital data archiving is recommended over hard copies. Options include a picture archiving and communication system (PACS), either dedicated for POCUS or used for both conventional and POCUS studies, the latter having the potential to improve archiving and retrieval of exams and reports from throughout the enterprise. Other storage options include a commercially available ultrasound management system, vendor-neutral archive (VNA), cloud storage, or local storage. Additionally, it may be possible to archive data on a radiology or cardiology PACS.
Appropriate data security measures must be practiced as defined by local regulations or facility policies. Data storage on the ultrasound scanner should be used only temporarily until the data can be properly archived, preferably in a location where it can be accessed by other clinicians. Some cloud services provide workflow enhancements such as automated calculation packages and report templates. For more information about cloud storage, see our report
Choosing Cloud Services for Point-of-Care Ultrasound: What You Need to Consider.
7. Communication: Policies and procedures should describe who is responsible for communicating results, how results are communicated, and when and how results are to be incorporated into the electronic health record (EHR). Policies and procedures should also address how to respond when a POCUS exam is equivocal or the findings are of uncertain significance. The circumstance might, for example, warrant consultation with an appropriate specialist, such as a cardiologist or obstetrician.
8. User training: Didactic and practical user training should include ultrasound physics and instrumentation, specialty-specific clinical utilization, scanning techniques, and exam interpretation. Use of online modules can allow trainees to complete independent education and maximize scanning time during practical scanning sessions. In addition to a defined curriculum, requirements include experienced staff who have dedicated teaching time, sufficient availability of ultrasound scanners, physical space with appropriate exam tables, and administrative support to ensure effective and consistent training. In some circumstances there may be a need to supplement internal staff with outside educational consultants or instructors. Training should comply with guidelines and recommendations published by specialty societies.
9. Credentialing, competency, and privileging: The quality of ultrasound imaging is highly user-dependent; both education and experience are required to become proficient. Documented credentialing and privileging policies and records are necessary for maintaining compliance with local, state, federal, and third-party requirements. Policies should be established that address credentialing, competency assessment, and privileging processes for POCUS users. Credentialing typically requires verification of a clinician's qualifications obtained through education and training combined with POCUS experience. Competency may be demonstrated using formal testing instruments and/or demonstration of scanning and interpretation skills. Examples of specialty-specific POCUS training and use guidelines and position statements are listed in the table below. Some published guidelines recommend the specific number of exams a user must perform to be considered competent in diagnostic POCUS applications and interventional procedure guidance. Competency assessments developed internally can be tailored to meet the specific requirements of users and the clinical applications practiced. Privileging, granted to staff who have met credentialing and competency requirements, ensures that each clinician is appropriately and effectively using POCUS.
In addition to the skills needed to perform POCUS assessments, the qualifications required to interpret POCUS data and provide formal reports should be defined. Interpretation competency may be demonstrated using case reviews, observation of interpretations by others, and supervised interpretations. Policies should also describe recredentialing and continued privileging, and/or maintenance of competency (MOC) requirements, which should be consistent with accepted standards for the discipline.
10. Quality assurance: The quality of POCUS exams should be assessed and tracked using case reviews, clinical audits, and feedback mechanisms. Maintaining a log of POCUS exams can be helpful to allow review of studies for teaching, or to have a record of unusual cases for reference. A variety of POCUS software programs are available to enhance management of POCUS services, including tracking exam performance for training, quality assurance, formal reporting, and billing.
11. Billing and reimbursement: Billing policies and procedures should be standardized to facilitate reimbursement for POCUS procedures. Local coverage determinations, Medicare policies, and third-party payer policies should be considered. The complexities of billing and reimbursement are beyond the scope of this report. The appropriate billing representatives in a facility should be consulted to establish policies for appropriate billing practices. One potential issue can occur when a patient undergoes two ultrasound studies performed by different departments for the same indication. For example, a patient may undergo a "limited" cardiac POCUS study in the emergency department, followed by a comprehensive ("complete") echocardiography exam in the cardiology department. In these cases, both studies may be billed, but only if the limited POCUS exam was equivocal or indicated the need for a complete exam. Otherwise, the complete study is reimbursable and the limited study is usually denied.
Department-Level Recommendations
Individual departments, clinics, and other settings where POCUS is used should establish policies and procedures that comply with those of the facility, as described above, and available specialty-specific guidelines. Departments in disciplines that do not have established guidelines should work with the POCUS committee to modify existing guidelines for their specialty.
Departments should establish their own POCUS subcommittee or identify a POCUS director to provide guidance and administration of POCUS activities at the department level. The subcommittee or director should collaborate with other departments that use POCUS and with the facility's POCUS committee. The policies and procedures developed within the department should address practical aspects of providing POCUS services, including:
1. Scope of practice: Define the specific clinical POCUS assessments that may be performed, including the clinical indications for the exam.
2. Clinical availability: Establish requirements to ensure that a scanner and a competent user are available when POCUS is indicated.
3. Scanning protocols: Describe anatomy/body regions to be assessed, required images, and indications for additional modes such as M-mode and Doppler.
Other Departmental Responsibilities
American Medical Association (AMA) policy indicates that privileging to perform ultrasound imaging procedures should be a function of hospital medical staff and should be specifically delineated on the department's Delineation of Privileges form. The AMA policy further states that "each hospital medical staff should review and approve criteria for granting ultrasound privileges based upon background and training for the use of ultrasound technology and [AMA] strongly recommends that these criteria are in accordance with recommended training and education standards developed by each physician's respective specialty."(5)
Each department should perform a thorough inventory of all its POCUS scanners, including the type of scanner, its age, and performance capabilities. This information should be provided to the POCUS committee so that the entire facility's POCUS inventory can be assessed and compared. Additional departmental responsibilities include the development of report templates to facilitate exam interpretation and data entry into the EHR, identifying POCUS users who can serve as instructors or mentors to junior staff, and keeping abreast of the latest POCUS developments relative to their specialty.