Journal of Hospital MedicineEarly View PROGRESS NOTES Clinical progress note: 5 Essential point-of-care ultrasound skills for hospitalists Ariadna Perez-Sanchez MD, Corresponding Author Ariadna Perez-Sanchez MD [email protected] orcid.org/0009-0009-4615-2812 @PerezSanchezMD Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA Correspondence Ariadna Perez-Sanchez, MD, Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Dr, MC 7982, San Antonio, TX 78229, USA. Email: [email protected]; Twitter: @PerezSanchezMDSearch for more papers by this authorTrevor P. Jensen MD, MS, Trevor P. Jensen MD, MS Department of Medicine, Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USASearch for more papers by this authorNilam J. Soni MD, MS, Nilam J. Soni MD, MS orcid.org/0000-0002-8460-0323 Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA Medicine Service, Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA Department of Medicine, Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USASearch for more papers by this author Ariadna Perez-Sanchez MD, Corresponding Author Ariadna Perez-Sanchez MD [email protected] orcid.org/0009-0009-4615-2812 @PerezSanchezMD Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA Correspondence Ariadna Perez-Sanchez, MD, Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Dr, MC 7982, San Antonio, TX 78229, USA. Email: [email protected]; Twitter: @PerezSanchezMDSearch for more papers by this authorTrevor P. Jensen MD, MS, Trevor P. Jensen MD, MS Department of Medicine, Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USASearch for more papers by this authorNilam J. Soni MD, MS, Nilam J. Soni MD, MS orcid.org/0000-0002-8460-0323 Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA Medicine Service, Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA Department of Medicine, Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USASearch for more papers by this author First published: 17 January 2024 https://doi.org/10.1002/jhm.13276Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat CONFLICT OF INTEREST STATEMENT The authors declare no conflict of interest. Supporting Information Filename Description jhm13276-sup-0001-Video_1.mp41.6 MB Video 1 Normal parasternal long-axis view. Left ventricular systolic function is normal based on qualitative assessment of endocardial excursion and myocardial thickening of the septal and inferior walls, and approximation of the anterior mitral valve leaflet tip within 1 cm of the septum. jhm13276-sup-0002-Video_2.mp41.3 MB Video 2 Severely reduced left ventricular systolic function from a parasternal long-axis view. Left ventricular systolic function is severely reduced based on poor endocardial excursion and myocardial thickening of the septal and inferior walls (septal > inferior wall). The anterior mitral valve leaflet tip does not come within 1 cm of the septum when maximally open, and the left ventricular cavity is dilated. jhm13276-sup-0003-Video_3.mp41.6 MB Video 3 Normal parasternal short-axis view. This parasternal short-axis view at the level of the papillary muscles (mid-ventricular level) demonstrates normal left ventricular systolic function. Note the symmetrical endocardial excursion toward the center of the chamber and equal myocardial thickening of the anterior, lateral, inferior, and septal walls. jhm13276-sup-0004-Video_4.mp41.2 MB Video 4 Severely reduced left ventricular systolic function from a parasternal short-axis view. This parasternal short-axis view at the level of the papillary muscles (mid-ventricular level) demonstrates severely reduced left ventricular systolic function. Note the reduced endocardial excursion and myocardial thickening of all walls with the inferior and lateral walls contracting slightly more than the septal and anterior walls. jhm13276-sup-0005-Video_5.mp41.3 MB Video 5 Normal subcostal 4-chamber view. This normal subcostal 4-chamber view shows the right atrium, right ventricle, and tricuspid valve in the near field, and left atrium, left ventricle, and mitral valve in the far field. The left ventricular systolic function is normal, and no pericardial fluid is seen in between the right heart and liver in the near field or circumferentially around the heart. jhm13276-sup-0006-Video_6.mp41.5 MB Video 6 Small pericardial effusion from a subcostal 4-chamber view. A small pericardial effusion is seen as an anechoic stripe in the near field between the right heart and liver. jhm13276-sup-0007-Video_7.mp41 MB Video 7 Cardiac tamponade from a subcostal 4-chamber view. A large pericardial effusion is seen in the near field that is causing right ventricular diastolic collapse, one of the echocardiographic signs of cardiac tamponade. Note the serpentine-like motion of the right ventricular free wall which is due to chamber collapse. jhm13276-sup-0008-Video_8.mp41.7 MB Video 8 Pericardial effusion from a parasternal long-axis view. A moderate-size, circumferential pericardial effusion most pronounced posteriorly is seen from a parasternal long-axis view. Note the severely reduced left ventricular systolic function. jhm13276-sup-0009-Video_9.mp42.4 MB Video 9 Normal right costophrenic recess. The absence of an anechoic space and lack of visualization of the spine above diaphragm rules out a pleural effusion in this right costophrenic recess. jhm13276-sup-0010-Video_10.mp43 MB Video 10 Simple pleural effusion with spine sign. A small, simple pleural effusion is seen in the right costophrenic recess. Note the visualization of the spine above the level of the diaphragm (positive spine sign). jhm13276-sup-0011-Video_11.mp43.6 MB Video 11 Complex pleural effusion with septations. A large, complex pleural effusion with dense septations is seen in the left costophrenic recess. Note the visualization of the spine above the level of the diaphragm in the far field (positive spine sign) as well as ascites around the spleen below the diaphragm. jhm13276-sup-0012-Video_12.mp41.9 MB Video 12 Moderate-to-large volume ascites in right lower quadrant. Ascites is seen in the right lower quadrant with floating loops of small bowel tethered posteriorly. jhm13276-sup-0013-Video_13.mp41.1 MB Video 13 Small-volume ascites in right upper quadrant. A small amount of perihepatic ascites is detected for diagnostic purposes in the right upper quadrant of a cirrhotic patient. jhm13276-sup-0014-Video_14.mp42.2 MB Video 14 Normal compression of lower extremity veins. Normal venous compression is demonstrated with wall-to-wall touching at the right common femoral vein–greater saphenous vein junction. jhm13276-sup-0015-Video_15.mp41.6 MB Video 15 Lower extremity deep venous thrombosis. Partial or incomplete venous compression signifying presence of an intraluminal thrombus is seen at the right common femoral vein–greater saphenous vein junction. At the point of maximal compression, the thrombus is faintly visible in the lumen. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. REFERENCES 1Thomas MK, Conner SM, Maw A, Soni NJ. Point-counterpoint: should point-of-care ultrasound be a required skill of hospitalists? J Hosp Med. 2023; 18: 1150-1155. doi:10.1002/jhm.13208 10.1002/jhm.13208 PubMedWeb of Science®Google Scholar 2Soni NJ, Schnobrich D, Mathews BK, et al. 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Comparison of hand-carried ultrasound assessment of the inferior vena cava and N-terminal pro-brain natriuretic peptide for predicting readmission after hospitalization for acute decompensated heart failure. JACC: Cardiovasc Imaging. 2008; 1(5): 595-601. doi:10.1016/j.jcmg.2008.06.005 10.1016/j.jcmg.2008.06.005 PubMedWeb of Science®Google Scholar 12Rivas-Lasarte M, Álvarez-García J, Fernández-Martínez J, et al. Lung ultrasound-guided treatment in ambulatory patients with heart failure: a randomized controlled clinical trial (LUS-HF study). Eur J Heart Fail. 2019; 21(12): 1605-1613. doi:10.1002/ejhf.1604 10.1002/ejhf.1604 CASPubMedWeb of Science®Google Scholar 13Araiza-Garaygordobil D, Gopar-Nieto R, Martinez-Amezcua P, et al. A randomized controlled trial of lung ultrasound-guided therapy in heart failure (CLUSTER-HF study). Am Heart J. 2020; 227: 31-39. doi:10.1016/j.ahj.2020.06.003 10.1016/j.ahj.2020.06.003 PubMedWeb of Science®Google Scholar 14Marini C, Fragasso G, Italia L, et al. 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The use of cardiac point-of-care ultrasound (POCUS) is now widespread in clinics, emergency departments, and all areas of the hospital. Users include medical trainees, advanced practice practitioners, and attending physicians in many specialties and sub-specialties. Opportunities to learn cardiac POCUS and requirements for training vary across specialties, as does the scope of the cardiac POCUS examination. In this review, we describe both a brief history of how cardiac POCUS emerged from echocardiography and the state of the art across a variety of medical fields.

ObjectivesWe aimed to decrease barriers to acquiring Point‐of‐Care Ultrasound (POCUS) knowledge among attending physicians and improve the safety of trainee POCUS use through a novel flexible and cognitive based curriculum.MethodsWe developed three educational pathways using varied approaches to educational delivery: a novel and asynchronous cognitive curriculum to allow Educational Supervision, a hands‐on pathway for Limited Practice, and a more robust pathway for Independent Practice and credentialing.ResultsFrom November 2018 through June 2021, 102 of 116 hospitalists engaged in some portion of the curriculum. Twenty‐four completed the Educational Supervision pathway, 31 completed the Limited Practice pathway, and 17 enrolled in the Independent Practice pathway with three achieving independent practice. Faculty who completed the Educational Supervision pathway had improved scores on a comprehensive POCUS knowledge assessment, 43.5% [95% Confidence Interval (CI) 38.2–48.8] versus 72.0% [95% CI 65.2–78.8], P < .001. Junior faculty were more likely to engage in the supervision pathway and senior faculty were more likely to complete an intensive course to complete the Limited Practice pathway.ConclusionsA flexible, cognitive focused POCUS curriculum was effective in creating high levels of engagement, and a cognitive only curriculum resulted in significant improvement in hospitalists' POCUS knowledge without hands on training. Finally, we found that hospitalist engagement in the curriculum did not follow the lowest barrier to entry or time commitment and engagement varied by time in practice. Training faculty to independent practice remains a substantial challenge.

Point of Care Ultrasound (POCUS) has the potential to rapidly aide in diagnostic algorithms at the bedside, however POCUS users are often faced with the dilemma of appropriate management of incidental findings [1]. Incidental findings in POCUS are defined as any indeterminate, benign, or potentially concerning finding found unexpectedly that is not related to the patient’s chief complaint [2]. Increased use of POCUS has driven the increased discovery of incidental findings, with a reported frequency between 1.6% to 26% depending on the institution, frequency of documentation, and level of experience [1,2]. While many incidental findings are benign, some are not and benefit from follow-up. This raises important concerns regarding the need for systematic, evidence-based guidelines to ensure necessary follow-up while avoiding unnecessary additional imaging, patient anxiety and increased healthcare costs [1,3].

Lung ultrasound (LUS) has received considerable interest in the clinical evaluation of patients with COVID‐19. Previously described LUS manifestations for COVID‐19 include B‐lines, consolidations, and pleural thickening. The interrater reliability (IRR) of these findings for COVID‐19 is unknown.

Introduction: Point-of-care ultrasound (POCUS) can detect the cardiopulmonary manifestations of COVID-19 and may predict patient outcomes in an expedient and cost-effective manner.Methods: We conducted a prospective cohort study at four medical centers from 3/2020 to 9/2020 to evaluate the relationship between POCUS findings and clinical outcomes with COVID-19. Our inclusion criteria included adult patients hospitalized for COVID-19 who received lung ultrasound (LUS) examinations at the bedside with a 12-zone protocol. All images were interpreted by at least two reviewers who were blinded to clinical outcomes.Results: N=99 patients met inclusion criteria. The median time from ED triage to LUS was 0.9 days (IQR: 0.1-2.9). LUS was rarely normal (11% of patients), with B-lines (90%) and subpleural consolidations (62%) representing the most prevalent findings. Findings associated with ICU admission included anterior B-lines (OR: 3.1 [95% CI: 1.2-9.7]), anterior consolidations (OR: 3.1 [95% CI: 1.1-9.9]) and lateral consolidations (OR: 4.1 [95% CI: 1.3-15.5]), while a normal scan was strongly protective against ICU admission (OR 0.08 [95% CI: 0.00-0.68]). LUS findings remained stable over a period of 28 days from symptom onset.Discussion: Anterior and/or lateral lung involvement on POCUS may portend a three to four-fold risk of critical illness among COVID-19 patients. The location, rather than the absolute appearance of POCUS findings, may be important harbingers of severe disease. POCUS findings did not change over a 28-day scanning period, suggesting that their detection at any time point may be clinically important.Funding Statement: None to declareDeclaration of Interests: None to declare. Ethics Approval Statement: This study was approved by the Institutional Review Boards of Stanford University and the University of California, San Francisco. A waiver of consent was obtained by both institutions.

IntroductionPoint-of-care ultrasound (POCUS) has the potential to transform healthcare delivery in the era of COVID-19 with its diagnostic and therapeutic expediency. It can be performed by clinicians already at the bedside, which permits an immediate and augmented assessment of a patient. Although lung ultrasound can be used to accurately diagnose a variety of disease states such as pneumothorax, pleural effusions, pneumonia and interstitial lung disease2, there are limited reports on the sonographic manifestations of COVID-19. There is an urgent need to identify alternative diagnostic modalities that can be immediately employed at the bedside of COVID-19 patients.MethodsThis study was conducted at two medical centers in the United States from 3/21/2020-6/01/2020. Any adult who was hospitalized with COVID-19 (based on symptomatology and a confirmatory RT-PCR for SARS-CoV-2) and received a pulmonary POCUS examination was included. Providers were instructed to use a 12-zone scanning protocol for pulmonary views and save 6 second clips of each lung zone. This study utilized several POCUS devices, including Butterfly IQ, Vave, Lumify, and Sonosite. The collected images were interpreted by the study researchers based on a consensus document developed by the study authors and previously accepted definitions of lung POCUS findings.ResultsA total of 22 eligible patients who received 36 lung scans were included in our study. Eleven (50%) patients experienced clinical deterioration (defined as either ICU admission, invasive mechanical ventilation, or death within 28 days from the initial symptom onset). Among the 36 lung scans collected, only 3 (8%) were classified as normal. The remaining scans had the following abnormalities: presence of B-lines (n=32, 89%), consolidations (n=20, 56%), pleural thickening (n=17, 47%), and pleural effusion (n=4, 11%). Out of 20 scans with consolidations, 14 (70%) were subpleural and 5 (25%) were translobar. A-lines were present in 26 (72%) of patients, although they were only observed in the majority of the collected lung zones in 5 (14%) of patients. Ultrasound findings were stratified by time from symptom onset to the scan based on the following time periods: early (0-6 days), middle (7-13 days), and late (14-28 days). B-lines appeared early after symptom onset and persisted well into the late disease course. In contrast, pleural thickening increased in frequency over time (early: 25%, middle: 47%, late: 67%). Subpleural consolidations also appeared in higher frequency later in the disease course (early: 13%, middle 42%, late: 56%).Discussioncertain lung ultrasound findings may be common in Covid-19, while others may appear later in the disease course or only occur in patients who experience clinical deterioration. Future efforts should investigate the predictive utility of consolidations, pleural thickening and B-lines for clinical deterioration and compare them to traditional radiological studies such as X-rays or CTs.

Introduction Point-of-care ultrasound (POCUS) may detect the cardiopulmonary manifestations of COVID-19 and expediently predict patient outcomes. Methods We conducted a prospective cohort study at four medical centers from 3/2020-1/2021 to evaluate POCUS findings and clinical outcomes with COVID-19. Our inclusion criteria included adult patients hospitalized for COVID-19 who received cardiac or lung POCUS with a 12-zone protocol. Images were interpreted by two reviewers blinded to clinical outcomes. Our primary outcome was ICU admission incidence. Secondary outcomes included intubation and supplemental oxygen usage. Results N=160 patients (N=201 scans) were included. Scans were collected a median 23 hours (IQR:7-80) from emergency department triage. Triage POCUS findings associated with ICU admission included B-lines (OR 4.41 [95% CI:1.71-14.30]; p<0.01) or consolidation (OR 2.49 [95% CI:1.35-4.86]; p<0.01). B-lines were associated with intubation (OR 3.10 [95% CI:1.15-10.27]; p=0.02) and supplemental oxygen usage (OR 3.74 [95% CI:1.63-8.63; p<0.01). Consolidations present on triage were associated with the need for oxygen at discharge (OR 2.16 [95% CI: 1.01-4.70]; p=0.047). A normal lung triage scan was protective for ICU admission (OR 0.28 [95% CI:0.09-0.75; p<0.01) or need for supplemental oxygen during the hospitalization (OR 0.26 [95% CI:0.11-0.61]; p<0.01). Triage cardiac POCUS scans were not associated with any outcomes. Discussion Lung POCUS findings detected early in the hospitalization may provide expedient risk stratification for important COVID-19 clinical outcomes, including ICU admission, intubation, or need for oxygen on discharge. A normal admission scan appears protective against adverse outcomes, which may aid in triage decisions of patients.

Background Lack of training is currently the most common barrier to implementation of point-of-care ultrasound (POCUS) use in clinical practice, and in-person POCUS continuing medical education (CME) courses have been paramount in improving this training gap. Due to travel restrictions and physical distancing requirements during the COVID-19 pandemic, most in-person POCUS training courses were cancelled. Though tele-ultrasound technology has existed for several years, use of tele-ultrasound technology to deliver hands-on training during a POCUS CME course has not been previously described. Methods We conducted a retrospective observational study comparing educational outcomes, course evaluations, and learner and faculty feedback from in-person versus tele-ultrasound POCUS courses. The same POCUS educational curriculum was delivered to learners by the two course formats. Data from the most recent pre-pandemic in-person course were compared to tele-ultrasound courses during the COVID-19 pandemic. Results Pre- and post-course knowledge test scores of learners from the in-person ( n = 88) and tele-ultrasound course ( n = 52) were compared. Though mean pre-course knowledge test scores were higher among learners of the tele-ultrasound versus in-person course (78% vs. 71%; p = 0.001), there was no significant difference in the post-course test scores between learners of the two course formats (89% vs. 87%; p = 0.069). Both learners and faculty rated the tele-ultrasound course highly (4.6–5.0 on a 5-point scale) for effectiveness of virtual lectures, tele-ultrasound hands-on scanning sessions, and course administration. Faculty generally expressed less satisfaction with their ability to engage with learners, troubleshoot image acquisition, and provide feedback during the tele-ultrasound course but felt learners completed the tele-ultrasound course with a better basic POCUS skillset. Conclusions Compared to a traditional in-person course, tele-ultrasound POCUS CME courses appeared to be as effective for improving POCUS knowledge post-course and fulfilling learning objectives. Our findings can serve as a roadmap for educators seeking guidance on development of a tele-ultrasound POCUS training course whose demand will likely persist beyond the COVID-19 pandemic.

ObjectivesPoint‐of‐care ultrasound (POCUS) detects the pulmonary manifestations of COVID‐19 and may predict patient outcomes.MethodsWe conducted a prospective cohort study at four hospitals from March 2020 to January 2021 to evaluate lung POCUS and clinical outcomes of COVID‐19. Inclusion criteria included adult patients hospitalized for COVID‐19 who received lung POCUS with a 12‐zone protocol.Each image was interpreted by two reviewers blinded to clinical outcomes. Our primary outcome was the need for intensive care unit (ICU) admission versus no ICU admission. Secondary outcomes included intubation and supplemental oxygen usage.ResultsN = 160 patients were included. Among critically ill patients, B‐lines (94 vs 76%;P < .01) and consolidations (70 vs 46%;P < .01) were more common. For scans collected within 24 hours of admission (N = 101 patients), early B‐lines (odds ratio [OR] 4.41 [95% confidence interval, CI: 1.71–14.30];P < .01) or consolidations (OR 2.49 [95% CI: 1.35–4.86];P < .01) were predictive of ICU admission. Early consolidations were associated with oxygen usage after discharge (OR 2.16 [95% CI: 1.01–4.70];P = .047). Patients with a normal scan within 24 hours of admission were less likely to require ICU admission (OR 0.28 [95% CI: 0.09–0.75];P < .01) or supplemental oxygen (OR 0.26 [95% CI: 0.11–0.61];P < .01). Ultrasound findings did not dynamically change over a 28‐day scanning window after symptom onset.ConclusionsLung POCUS findings detected within 24 hours of admission may provide expedient risk stratification for important COVID‐19 clinical outcomes, including future ICU admission or need for supplemental oxygen. Conversely, a normal scan within 24 hours of admission appears protective. POCUS findings appeared stable over a 28‐day scanning window, suggesting that these findings, regardless of their timing, may have clinical implications.

Point-of-care ultrasonography (POCUS) has the potential to transform healthcare delivery through its diagnostic expediency. Trainee competency with POCUS is now mandated for emergency medicine through the Accreditation Council for Graduate Medical Education (ACGME), and its use is expanding into other medical specialties, including internal medicine. However, a key question remains: how does one define "competency" with this emerging technology? As our trainees become more acquainted with POCUS, it is vital to develop validated methodology for defining and measuring competency amongst inexperienced users. As a framework, the assessment of competency should include evaluations that assess the acquisition and application of POCUS-related knowledge, demonstration of technical skill (e.g., proper probe selection, positioning, and image optimization), and effective integration into routine clinical practice. These assessments can be performed across a variety of settings, including web-based applications, simulators, standardized patients, and real clinical encounters. Several validated assessments regarding POCUS competency have recently been developed, including the Rapid Assessment of Competency in Echocardiography (RACE) or the Assessment of Competency in Thoracic Sonography (ACTS). However, these assessments focus mainly on technical skill and do not expand upon other areas of this framework, which represents a growing need. In this review, we explore the different methodologies for evaluating competency with POCUS as well as discuss current progress in the field of measuring trainee knowledge and technical skill.

Point-of-care ultrasound (POCUS) has been a mainstay of clinical decision-making in the intensive care unit and emergency department for more than a decade, but adoption into hospital medicine has lagged behind. Recently, internal medicine residency programs have started to develop POCUS curricula for trainees, though concurrent hospitalist training programs have been limited to date, with little consensus on what hospitalist-oriented curricula should entail. As such, there is wide variability amongst hospitalists with respect to utilization of, training in, and proficiency in POCUS. We conducted a two-part survey of internal medicine hospitalists at our institution: (1) needs assessment that focused on prior training, attitudes and perspectives, current practices, desired use, and barriers to clinical integration; and (2) knowledge test of exam indications, image interpretation, medical decision-making, and understanding of limitations. Our results demonstrate that a majority of hospitalists felt that POCUS was important for diagnostic purposes and that they would benefit from POCUS-specific education. Inadequate training was the most cited barrier to POCUS use. Hospitalist knowledge was lacking in all domains, particularly image interpretation and clinical integration. As a result, we created a three-tiered training program meant to engage: (1) All hospitalists in basic knowledge and appropriate use of POCUS, (2) Some hospitalists in hands-on skill acquisition and image interpretation, and (3) Few hospitalists in mastery of POCUS with resultant formal credentialing. A tiered approach to POCUS training for hospitalists ensures a fundamental cognitive understanding of POCUS for all, but also facilitates hands-on training for those who are committed to further skillset development.

Point-of-care ultrasound (POCUS) is defined as ultrasound used at the bedside by the provider to answer directed clinical questions and guide clinical care. While POCUS first gained popularity in emergency medicine, its application is rapidly expanding in the field of internal medicine.1 This method of ultrasound can conceptually be split into 2 groups: procedural and diagnostic. Procedural POCUS (ultrasound-guidance of common bedside procedures) improves patient safety and is now standard of care for many procedures.

Many hospitalists incorporate point-of-care ultrasound (POCUS) into their daily practice to answer specific diagnostic questions or to guide performance of invasive bedside procedures. However, standards for hospitalists in POCUS training and assessment are not yet established. Most internal medicine residency training programs, the major pipeline for incoming hospitalists, have only recently begun to incorporate POCUS in their curricula. The purpose of this document is to inform a broad audience on what POCUS is and how hospitalists are using it. This document is intended to provide guidance for the hospitalists who use POCUS and administrators who oversee its use. We discuss POCUS 1) applications, 2) training, 3) assessments, and 4) program management. Practicing hospitalists must continue to collaborate with their local credentialing bodies to outline requirements for POCUS use. Hospitalists should be integrally involved in decision-making processes surrounding POCUS program management.

Point-of-care ultrasonography (POCUS) has the potential to transform healthcare delivery through its diagnostic expediency. Trainee competency with POCUS is now mandated for emergency medicine through the Accreditation Council for Graduate Medical Education (ACGME), and its use is expanding into other medical specialties, including internal medicine. However, a key question remains: how does one define “competency” with this emerging technology? As our trainees become more acquainted with POCUS, it is vital to develop validated methodology for defining and measuring competency amongst inexperienced users. As a framework, the assessment of competency should include evaluations that assess the acquisition and application of POCUS-related knowledge, demonstration of technical skill (e.g., proper probe selection, positioning, and image optimization), and effective integration into routine clinical practice. These assessments can be performed across a variety of settings, including web-based applications, simulators, standardized patients, and real clinical encounters. Several validated assessments regarding POCUS competency have recently been developed, including the Rapid Assessment of Competency in Echocardiography (RACE) or the Assessment of Competency in Thoracic Sonography (ACTS). However, these assessments focus mainly on technical skill and do not expand upon other areas of this framework, which represents a growing need. In this review, we explore the different methodologies for evaluating competency with POCUS as well as discuss current progress in the field of measuring trainee knowledge and technical skill.

OBJECTIVES:Internal medicine (IM) residency point-of-care ultrasound (POCUS) curricula are being developed but often are limited in scope or components. In this article, we discuss the demonstration of a need for POCUS training in our large academic IM residency program; the development of a longitudinal curriculum; and the impact of the curriculum on POCUS knowledge, use, and confidence.METHODS:In 2014, we designed a cross-sectional POCUS survey and knowledge test for all IM residents at the University of California, San Francisco. The results of this assessment drove the design of a longitudinal POCUS curriculum that included a 2-hour workshop for all IM interns and a 1-month elective offered to all IM residents. Residents were tested on their POCUS knowledge and image interpretation before the elective and were given the same test 6 months after the elective. The posttest included a survey of self-reported POCUS use and confidence.RESULTS:In the needs assessment, residents scored a mean of 27% on the knowledge test, and across all applications the percentage of residents reporting confidence in their POCUS skills was lower than the percentage reporting use of the application in clinical practice. Residents scored a mean of 37% on the elective pretest and 74% on the posttest, an increase of 37% (95% confidence interval 31.6-42.8, P < 0.001), with improvements seen across all applications. After the elective, self-reported use of POCUS and confidence in POCUS skills were increased for the applications, using the needs assessment as an approximate baseline. For core cardiac and pulmonary applications, 76% to 95% of residents, depending on application, reported "high" or "very high" use and 79% to 100% reported "high" or "very high" confidence in their POCUS skills.CONCLUSIONS:We used a needs assessment to guide the development of a longitudinal, multidisciplinary POCUS curriculum. Residents who completed all components showed substantial long-term gains in knowledge in all major applications and high use of and confidence in cardiac and pulmonary applications.

Ultrasound guidance is used increasingly to perform the following 6 bedside procedures that are core competencies of hospitalists: abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis. Yet most hospitalists have not been certified to perform these procedures, whether using ultrasound guidance or not, by specialty boards or other institutions extramural to their own hospitals. Instead, hospital privileging committees often ask hospitalist group leaders to make ad hoc intramural certification assessments as part of credentialing. Given variation in training and experience, such assessments are not straightforward “sign offs.” We thus convened a panel of experts to conduct a systematic review to provide recommendations for credentialing hospitalist physicians in ultrasound guidance of these 6 bedside procedures. Pathways for initial and ongoing credentialing are proposed. A guiding principle of both is that certification assessments for basic competence are best made through direct observation of performance on actual patients.

Journal of Hospital MedicineVolume 12, Issue 9 p. 775-776 Editorial Certification of Point-of-Care Ultrasound Competency Nilam J. Soni MD, MS, Corresponding Author Nilam J. Soni MD, MS [email protected] Division of General & Hospital Medicine, The University of Texas School of Medicine at San Antonio, San Antonio, Texas Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, TexasAddress for correspondence and reprint requests: Nilam J. Soni, MD, MS, 7703 Floyd Curl Drive, MC 7982, San Antonio, TX 78229; Telephone: 210-743-6030; Fax: 210-358-0647; E-mail: [email protected]Search for more papers by this authorDavid M. Tierney MD, David M. Tierney MD Abbott Northwestern Hospital, Department of Medical Education, Minneapolis, MinnesotaSearch for more papers by this authorTrevor P. Jensen MD, MS, Trevor P. Jensen MD, MS Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CaliforniaSearch for more papers by this authorBrian P. Lucas MD, MS, Brian P. Lucas MD, MS Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont Geisel School of Medicine at Dartmouth College, Hanover, New HampshireSearch for more papers by this author Nilam J. Soni MD, MS, Corresponding Author Nilam J. Soni MD, MS [email protected] Division of General & Hospital Medicine, The University of Texas School of Medicine at San Antonio, San Antonio, Texas Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, TexasAddress for correspondence and reprint requests: Nilam J. Soni, MD, MS, 7703 Floyd Curl Drive, MC 7982, San Antonio, TX 78229; Telephone: 210-743-6030; Fax: 210-358-0647; E-mail: [email protected]Search for more papers by this authorDavid M. Tierney MD, David M. Tierney MD Abbott Northwestern Hospital, Department of Medical Education, Minneapolis, MinnesotaSearch for more papers by this authorTrevor P. Jensen MD, MS, Trevor P. Jensen MD, MS Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CaliforniaSearch for more papers by this authorBrian P. Lucas MD, MS, Brian P. Lucas MD, MS Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont Geisel School of Medicine at Dartmouth College, Hanover, New HampshireSearch for more papers by this author First published: 01 September 2017 https://doi.org/10.12788/jhm.2812Citations: 7Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume12, Issue9September 2017Pages 775-776 RelatedInformation

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