Current Use, Training, and Barriers to Point-of-Care Ultrasound Use in ICUs in the Department of Veterans Affairs

BackgroundPoint-of-care ultrasound (POCUS) has become an integral part of critical care medicine for procedural guidance, bedside diagnostics, and assessing response to treatment. Multiple critical care societies recommend POCUS use, and POCUS training has been a requirement for critical care fellowship since 2012. Yet, current practice patterns of POCUS use in ICUs are not well known.Research QuestionThis study aimed to characterize current POCUS use, training needs, and barriers to use among intensivists.Study Design and MethodsA prospective observational study of all Veterans Affairs (VA) medical centers was conducted between June 2019 and March 2020 using a web-based survey of all chiefs of staff and ICU chiefs. These data were compared with those from a similar survey conducted in 2015.ResultsChiefs of staff and ICU chiefs from 130 VA medical centers were surveyed with 100% and 94% response rates, respectively. At least one physician currently uses POCUS in 93% of ICUs, and 62% of individual physicians were estimated to be using POCUS. The most common POCUS applications were procedural guidance (59%), cardiac ultrasound (55%), and thoracic ultrasound (56%) . Most chiefs (80%) reported teaching POCUS to trainees in their ICU. The most frequently reported barriers to POCUS use were lack of trained providers (48%), lack of funding for training (45%), lack of training opportunities (37%), and lack of image archiving (34%). From 2015 through 2020, POCUS use increased across most applications and an increase in desire for training was seen.InterpretationPOCUS use increased across VA ICUs between 2015 and 2020, but significant gaps remain. Without a deliberate investment in POCUS training and infrastructure for physicians in practice, institutions are unlikely to benefit fully from standardized POCUS use in ICUs. Point-of-care ultrasound (POCUS) has become an integral part of critical care medicine for procedural guidance, bedside diagnostics, and assessing response to treatment. Multiple critical care societies recommend POCUS use, and POCUS training has been a requirement for critical care fellowship since 2012. Yet, current practice patterns of POCUS use in ICUs are not well known. This study aimed to characterize current POCUS use, training needs, and barriers to use among intensivists. A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between June 2019 and March 2020 using a web-based survey of all chiefs of staff and ICU chiefs. These data were compared with those from a similar survey conducted in 2015. Chiefs of staff and ICU chiefs from 130 VA medical centers were surveyed with 100% and 94% response rates, respectively. At least one physician currently uses POCUS in 93% of ICUs, and 62% of individual physicians were estimated to be using POCUS. The most common POCUS applications were procedural guidance (59%), cardiac ultrasound (55%), and thoracic ultrasound (56%) . Most chiefs (80%) reported teaching POCUS to trainees in their ICU. The most frequently reported barriers to POCUS use were lack of trained providers (48%), lack of funding for training (45%), lack of training opportunities (37%), and lack of image archiving (34%). From 2015 through 2020, POCUS use increased across most applications and an increase in desire for training was seen. POCUS use increased across VA ICUs between 2015 and 2020, but significant gaps remain. Without a deliberate investment in POCUS training and infrastructure for physicians in practice, institutions are unlikely to benefit fully from standardized POCUS use in ICUs. Take-home PointsStudy Question: How do critical care physicians in practice currently use point-of-care ultrasound (POCUS), which POCUS applications are most desired for training, and what barriers exist to POCUS use in clinical practice in ICUs?Results: A national survey of ICUs demonstrated that most critical care physicians (62%) currently use ultrasound for procedural guidance, cardiac, and lung exams and that training is most desired in the same applications because lack of training is the greatest barrier to POCUS use.Interpretation: Although POCUS use reportedly increased in ICUs from 2015 through 2020, important gaps in POCUS adoption remain, including use of some POCUS applications that are now considered standard of care, and a deliberate investment in POCUS training and infrastructure is needed to overcome the most common barriers to POCUS implementation. Study Question: How do critical care physicians in practice currently use point-of-care ultrasound (POCUS), which POCUS applications are most desired for training, and what barriers exist to POCUS use in clinical practice in ICUs? Results: A national survey of ICUs demonstrated that most critical care physicians (62%) currently use ultrasound for procedural guidance, cardiac, and lung exams and that training is most desired in the same applications because lack of training is the greatest barrier to POCUS use. Interpretation: Although POCUS use reportedly increased in ICUs from 2015 through 2020, important gaps in POCUS adoption remain, including use of some POCUS applications that are now considered standard of care, and a deliberate investment in POCUS training and infrastructure is needed to overcome the most common barriers to POCUS implementation. Over the last 2 decades, point-of-care ultrasound (POCUS) has become an integral part of critical care medicine. In ICUs, POCUS can rapidly diagnose life-threatening conditions, aid in urgent decision-making, and guide invasive bedside procedures.1Volpicelli G. Elbarbary M. Blaivas M. et al.International evidence-based recommendations for point-of-care lung ultrasound.Intensive Care Med. 2012; 38: 577-591Google Scholar, 2Díaz-Gómez J.L. Mayo P.H. Koenig S.J. Point-of-care ultrasonography.N Engl J Med. 2021; 385: 1593-1602Google Scholar, 3Lau Y.H. See K.C. Point-of-care ultrasound for critically-ill patients: a mini-review of key diagnostic features and protocols.World J Crit Care Med. 2022; 11: 70-84Google Scholar Numerous critical care societies and professional organizations have endorsed POCUS use in critically ill patients.4Mayo P.H. Beaulieu Y. Doelken P. et al.American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography.Chest. 2009; 135: 1050-1060Google Scholar, 5Frankel H.L. Kirkpatrick A.W. Elbarbary M. et al.Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part I: general ultrasonography.Crit Care Med. 2015; 43: 2479-2502Google Scholar, 6Levitov A. Frankel H.L. Blaivas M. et al.Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II: cardiac ultrasonography.Crit Care Med. 2016; 44: 1206-1227Google Scholar, 7Expert Round Table on Echocardiography in ICUInternational consensus statement on training standards for advanced critical care echocardiography.Intensive Care Med. 2014; 40: 654-666Google Scholar, 8Arntfield R. Millington S. Ainsworth C. et al.Canadian recommendations for critical care ultrasound training and competency.Can Respir J. 2014; 21: 341-345Google Scholar, 9Abboud P.A. Kendall J.L. Ultrasound guidance for vascular access.Emerg Med Clin North Am. 2004; 22: 749-773Google Scholar, 10Expert Round Table on Ultrasound in ICUInternational expert statement on training standards for critical care ultrasonography.Intensive Care Med. 2011; 37: 1077-1083Google Scholar To ensure appropriate use, training and competence in critical care POCUS are essential, especially for common applications like echocardiography and lung ultrasound. The Accreditation Council for Graduate Medical Education has emphasized competence in both diagnostic and procedural POCUS and made POCUS training an Accreditation Council for Graduate Medical Education requirement for pulmonary and critical care fellowship in 2012.11Accreditation Council for Graduate Medical Education, ACGME program requirements for graduate medical education in pulmonary and critical care medicine, Accreditation Council for Graduate Medical Education website. Accessed 23 January 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/156_pccm_2022_tcc.pdf.Google Scholar Despite these recommendations, important gaps in POCUS implementation remain, especially inconsistencies and heterogeneity in POCUS training.12Stowell J.R. Kessler R. Lewiss R.E. et al.Critical care ultrasound: a national survey across specialties.J Clin Ultrasound. 2018; 46: 167-177Google Scholar Specifically, the most frequently cited barrier to POCUS education from the perspective of trainees is a lack of trained faculty.13Yorkgitis B.K. Bryant E.A. Brat G.A. Kelly E. Askari R. Ra J.H. Ultrasonography training and utilization in surgical critical care fellowships: a program director’s survey.J Surg Res. 2017; 218: 292-297Google Scholar, 14Carver T.W. Ultrasound training in surgical critical care fellowship: a survey of program directors.J Surg Educ. 2018; 75: 1250-1255Google Scholar, 15Brady A.K. Spitzer C.R. Kelm D. Brosnahan S.B. Latifi M. Burkart K.M. Pulmonary critical care fellows’ use of and self-reported barriers to learning bedside ultrasound during training: results of a national survey.Chest. 2021; 160: 231-237Google Scholar, 16Cheng J. Arntfield R. Training strategies for point of care ultrasound in the ICU.Curr Opin Anaesthesiol. 2021; 34: 654-658Google Scholar, 17Jarwan W. Alshamrani A.A. Alghamdi A. et al.Point-of-care ultrasound training: an assessment of interns’ needs and barriers to training.Cureus. 2020; 12e11209Google Scholar, 18Galarza L. Wong A. Malbrain M. The state of critical care ultrasound training in Europe: a survey of trainers and a comparison of available accreditation programmes.Anaesthesiol Intensive Ther. 2017; 49: 382-386Google Scholar A survey of pulmonary and critical care fellowship programs in 2017 revealed that 46% of programs lacked a formal POCUS curriculum.15Brady A.K. Spitzer C.R. Kelm D. Brosnahan S.B. Latifi M. Burkart K.M. Pulmonary critical care fellows’ use of and self-reported barriers to learning bedside ultrasound during training: results of a national survey.Chest. 2021; 160: 231-237Google Scholar POCUS training during surgical residencies has been identified as an area of concern, where 58% of surveyed programs had a POCUS curriculum despite reported efficacy of such curricula.13Yorkgitis B.K. Bryant E.A. Brat G.A. Kelly E. Askari R. Ra J.H. Ultrasonography training and utilization in surgical critical care fellowships: a program director’s survey.J Surg Res. 2017; 218: 292-297Google Scholar,19Tripu R. Lauerman M.H. Haase D. et al.Graduating surgical residents lack competence in critical care ultrasound.J Surg Educ. 2018; 75: 582-588Google Scholar,20Townsend N.T. Kendall J. Barnett C. Robinson T. An effective curriculum for focused assessment diagnostic echocardiography: establishing the learning curve in surgical residents.J Surg Educ. 2016; 73: 190-196Google Scholar Beyond Accreditation Council for Graduate Medical Education training requirements, physicians in practice have limited opportunities to learn POCUS through continuing medical education courses or programs.21Greenstein Y.Y. Littauer R. Narasimhan M. Mayo P.H. Koenig S.J. Effectiveness of a critical care ultrasonography course.Chest. 2017; 151: 34-40Google Scholar, 22Mosier J.M. Malo J. Stolz L.A. et al.Critical care ultrasound training: a survey of US fellowship directors.J Crit Care. 2014; 29: 645-649Google Scholar, 23Wong A. Galarza L. Duska F. Critical care ultrasound: a systematic review of international training competencies and program.Crit Care Med. 2019; 47: e256-e262Google Scholar, 24Schott C.K. LoPresti C.M. Boyd J.S. et al.Retention of point-of-care ultrasound skills among practicing physicians: findings of the VA National POCUS Training Program.Am J Med. 2021; 134: 391-399.e398Google Scholar These courses have been shown to be effective for clinicians in practice to acquire and retain the novel cognitive and psychomotor skills required for POCUS.24Schott C.K. LoPresti C.M. Boyd J.S. et al.Retention of point-of-care ultrasound skills among practicing physicians: findings of the VA National POCUS Training Program.Am J Med. 2021; 134: 391-399.e398Google Scholar, 25Soni N.J. Boyd J.S. Mints G. et al.Comparison of in-person versus tele-ultrasound point-of-care ultrasound training during the COVID-19 pandemic.Ultrasound J. 2021; 13: 39Google Scholar, 26Yamada T. Minami T. Soni N.J. et al.Skills acquisition for novice learners after a point-of-care ultrasound course: does clinical rank matter?.BMC Med Educ. 2018; 18: 202Google Scholar However, lack of physician training remains the most commonly cited barrier to POCUS implementation in multiple specialties.16Cheng J. Arntfield R. Training strategies for point of care ultrasound in the ICU.Curr Opin Anaesthesiol. 2021; 34: 654-658Google Scholar,27Wong J. Montague S. Wallace P. et al.Barriers to learning and using point-of-care ultrasound: a survey of practicing internists in six North American institutions.Ultrasound J. 2020; 12: 19Google Scholar, 28Williams J.P. Nathanson R. LoPresti C.M. et al.Current use, training, and barriers in point-of-care ultrasound in hospital medicine: a national survey of VA hospitals.J Hosp Med. 2022; 17: 601-608Google Scholar, 29Resop D.M. Basrai Z. Boyd J.S. et al.Current use, training, and barriers in point-of-care ultrasound in emergency departments in 2020: a national survey of VA hospitals.Am J Emerg Med. 2023; 63: 142-146Google Scholar Currently, it is not well known how intensivists are using POCUS and what barriers exist in ICUs in the United States. An observational study of 142 ICUs across Europe found that 55% of POCUS examinations were performed on 36% of patients. Thus, two-thirds of critically ill patients were never evaluated with POCUS.30Zieleskiewicz L. Muller L. Lakhal K. et al.Point-of-care ultrasound in intensive care units: assessment of 1073 procedures in a multicentric, prospective, observational study.Intensive Care Med. 2015; 41: 1638-1647Google Scholar Another study demonstrated that echocardiography was used in only 2% of patients to guide fluid management in ICUs.31Cecconi M. Hofer C. Teboul J.L. et al.Fluid challenges in intensive care: the FENICE study: A global inception cohort study.Intensive Care Med. 2015; 41: 1529-1537Google Scholar These studies suggest substantial heterogeneity in both the number of intensivists trained in POCUS as well as frequency of use. To better understand current use, training needs, and barriers to POCUS use in ICUs in the United States, we conducted a national survey of all ICUs at medical centers in the Veterans Affairs (VA) health care system. A prospective observational study of all VA medical centers was conducted between June 2019 and March 2020 using a web-based survey. A multidisciplinary POCUS Technical Advisory Group with physicians from emergency medicine, internal medicine, hospital medicine, pulmonary medicine, and critical care collaborated with the VA’s Healthcare Analysis and Information Group to develop and disseminate a web-based survey system wide (Verint Systems, Inc.). This study was reviewed by the institutional review board of the University of Texas Health Science Center San Antonio and was deemed to be nonresearch (Identifier: HSC20210630NRR). The web-based survey included questions on current use, barriers to use, institutional support, equipment, and training needs of POCUS. Question types were multiple choice, forced choice (yes or no), open-ended with numerical or free-text entry, and free-text boxes when “other” was selected. For questions of prevalence, respondents were provided the option to answer as few (1%-25%), some (26%-50%), many (51%-75%), most (76%-99%), or all (100%). Some questions included conditional skip or display logic. The survey was deployed in two phases. First, a survey was distributed to all chiefs of staff (n = 130) of VA medical centers nationwide between August and October 2019. The chief-of-staff survey included 10 questions about facility-level POCUS use, training, competency, and policies, as well as contact information for all chiefs of medical and surgical ICUs (e-Appendix 1). Second, a follow-up survey with 25 questions was sent to all ICU chiefs at each facility to obtain service-level data on diagnostic and procedural POCUS use, training needs, workflows, and equipment availability (e-Appendix 2). ICU chiefs reported on POCUS use on behalf of their service and specialty at their respective VA medical center. The survey period for ICU chiefs started in December 2019 but ended early in March 2020 because of the COVID-19 pandemic. In 2015, we conducted a similar prospective observational study of all VA medical centers. Instead of querying all ICU chiefs, the chiefs of staff forwarded the survey to all specialty service chiefs who the chiefs of staff believed were using POCUS. To account for this difference in data collection, a subgroup analysis of 39 ICU services that answered both the 2015 and 2020 surveys was conducted to assess trends in POCUS use. We used the paired t test to compare trends between survey years of the percentage of facilities using POCUS and facilities desiring POCUS training across categories of POCUS applications. Current POCUS use and training desired were averaged across all applications or procedures when reported by body system or category. We used the McNemar test to compare facility changes in processes or resources. A P value of < .05 was considered statistically significant. Data are presented as percent change from 2015 to 2020. All chiefs of staff (n = 130) of VA medical centers completed 10 questions regarding facility-level POCUS use, training, competency, and policies (100% response rate). Chiefs of ICUs (n = 122) completed 25 questions (94% response rate) on service-level POCUS use, training needs, workflows, and equipment availability. Among the responding ICUs, 48 were medical ICUs, 34 were surgical ICUs, and 40 were medical-surgical ICUs. Six ICUs identified as medical-cardiac ICUs were analyzed as medical ICUs because the patients primarily had medical conditions based on survey responses (Table 1, Table 2). Most ICUs (86%) were at VA medical centers categorized as “high complexity,” with 53% having level 1 ICUs. VA ICUs are designated as levels 1 though 4 based on medical complexity, and level 1 indicates the highest degree of complexity. Geographically, most ICUs were in urban areas (94%), and most responses were received from the southern region (40%). The ICUs reported a median of nine attendings per ICU with five board certified in critical care medicine.Table 1Characteristics of VA Medical Centers and ICUs SurveyedCharacteristicAll FacilitiesMICUaFacilities that identified as MICU/cardiac care unit were counted as MICU, based on their responses and the patient characteristics.SICUMed-Surg ICUNo. of facilities93473440Internal medicine plus surgery beds < 10060 (65)22 (47)11 (32)35 (88) ≥ 10033 (35)25 (53)23 (68)5 (12)Internal medicine beds < 7563 (68)23 (49)14 (41)36 (90) ≥ 7530 (32)24 (51)20 (59)4 (10)Surgery beds < 2549 (53)18 (38)7 (21)28 (70) ≥ 2544 (47)29 (62)27 (79)12 (30)VHA facility complexity levelbHigh-complexity facilities have high levels of patient volume, patient risk, specialists, teaching, and research. Low-complexity facilities have medium to low levels of patient volume and patient risk, and some to little teaching or research. High80 (86)44 (94)34 (100)30 (75) Low13 (14)3 (6)0 (0)10 (25)VHA ICU levelbHigh-complexity facilities have high levels of patient volume, patient risk, specialists, teaching, and research. Low-complexity facilities have medium to low levels of patient volume and patient risk, and some to little teaching or research. 149 (53)32 (68)30 (88)14 (35) 215 (16)7 (15)2 (6)7 (18) 322 (24)5 (11)2 (6)15 (38) 44 (4)2 (4)0 (0)2 (5) Not available3 (3)1 (2)0 (0)2 (5)Region Northeast16 (17)7 (15)5 (15)7 (18) Midwest23 (25)12 (26)8 (24)11 (28) South37 (40)20 (43)16 (47)13 (33) West17 (18)8 (17)5 (15)9 (23)Location Urban87 (94)46 (98)33 (97)36 (90)Data are presented as No. (%), unless otherwise indicated. Med-Surg ICU = medical-surgical ICU; MICU = medical ICU; SICU = surgical ICU; VA = Veterans Affairs; VHA = Veterans Health Administration.a Facilities that identified as MICU/cardiac care unit were counted as MICU, based on their responses and the patient characteristics.b High-complexity facilities have high levels of patient volume, patient risk, specialists, teaching, and research. Low-complexity facilities have medium to low levels of patient volume and patient risk, and some to little teaching or research. Open table in a new tab Table 2Characteristics of Intensivists, Current POCUS Use, and Training in POCUS in ICUs SurveyedVariableAll ICUs (n = 122)MICUaFacilities that identified as MICU/cardiac care unit were counted as MICU, based on their responses and the patient characteristics. (n = 48)SICU (n = 34)Med-Surg ICU (n = 40)Characteristics of intensivists No. of attending physicians in ICUbNo. of physicians working in CCM as reported by service chief.Median (IQR)9 (5-12)9 (6-12)5 (4-11)10 (5-13)Mean ± SD12.8 ± 21.411.4 ± 11.618.0 ± 37.610.1 ± 5.4 Board certified in CCMcNo. of CCM board-certified physicians as reported by service chief.Median (IQR)5 (2-9)7 (4-10)4 (2-5)3 (1-6)Mean ± SD5.7 ± 5.07.6 ± 5.34.2 ± 3.24.6 ± 5.1Current POCUS use by intensivists Intensivists using POCUS, %, weighted mean ± SD62 ± 3479 ± 2545 ± 3164 ± 36 ICUs with ≥ 1 physician using POCUS113 (93)46 (96)31 (91)36 (90) Intensivists using POCUS for resuscitation, %None42 (34)9 (19)12 (35)21 (53)Some (1%-50%)52 (43)25 (52)10 (30)17 (42)Most (> 50%)28 (23)14 (29)12 (35)2 (5) ICUs with intensivists who perform TEE9 (7)1 (2)6 (18)2 (5)POCUS training ICU physicians with POCUS training, %Via CMENone27 (22)6 (13)12 (35)9 (23)Some (1%-50%)63 (52)26 (54)13 (39)24 (60)Most (> 50%)32 (26)16 (33)9 (26)7 (18) Via residency or fellowshipNone26 (21)10 (21)8 (24)8 (20)Some (1%-50%)61 (50)25 (52)10 (30)26 (65)Most (> 50%)35 (29)13 (27)16 (47)6 (15) ICUs with desire for POCUS training97 (80)41 (85)24 (71)32 (80) ICUs with process to obtain POCUS training45 (37)22 (46)11 (32)12 (30) Residents or fellows trained in POCUS in ICU69 (57)36 (75)16 (47)17 (43) Intensivists confident supervising fellowsBedside proceduresNone21 (17)5 (10)5 (15)11 (27)Some (1%-50%)28 (23)5 (10)8 (24)15 (38)Most (> 50%)73 (60)38 (79)21 (62)14 (35)DiagnosticsNone22 (18)5 (10)5 (15)12 (30)Some (1%-50%)41 (34)13 (27)12 (35)16 (40)Most (> 50%)59 (48)30 (63)17 (50)12 (30)Data are presented as No. (%), unless otherwise indicated. CCM = critical care medicine; CME = continuing medical education; IQR = interquartile range; Med-Surg ICU = medical-surgical ICU; MICU = medical ICU; POCUS = point-of-care ultrasound; SICU = surgical ICU; TEE = transesophageal echocardiography.a Facilities that identified as MICU/cardiac care unit were counted as MICU, based on their responses and the patient characteristics.b No. of physicians working in CCM as reported by service chief.c No. of CCM board-certified physicians as reported by service chief. Open table in a new tab Data are presented as No. (%), unless otherwise indicated. Med-Surg ICU = medical-surgical ICU; MICU = medical ICU; SICU = surgical ICU; VA = Veterans Affairs; VHA = Veterans Health Administration. Data are presented as No. (%), unless otherwise indicated. CCM = critical care medicine; CME = continuing medical education; IQR = interquartile range; Med-Surg ICU = medical-surgical ICU; MICU = medical ICU; POCUS = point-of-care ultrasound; SICU = surgical ICU; TEE = transesophageal echocardiography. Among all responding ICUs, 93% reported having at least one physician currently using POCUS for either diagnostic or procedural purposes. An average of 62% of individual ICU physicians used POCUS (79% in medical ICUs, 45% in surgical ICUs, 64% in medical-surgical ICUs). Although 23% of all ICUs reported using POCUS for most resuscitations, a notable difference was seen between medical-surgical ICUs (5% used in > 50% of resuscitations) compared with medical (29%) or surgical (35%) ICUs (Table 2). The most frequently used POCUS applications were procedural guidance (59%) followed by cardiac (55%), thoracic (56%), abdominal (37%), and vascular (30%) ultrasound (Fig 1). POCUS is reported to be used by > 50% of ICUs for central line placement, arterial line placement, peripheral IV placement, paracentesis, thoracentesis, and chest tube insertion (e-Appendix 3, e-Fig 1). Among diagnostic cardiac POCUS applications, > 50% of ICUs used POCUS for evaluation of pericardial effusions, left ventricular systolic function, and volume status, whereas advanced hemodynamic applications were used by < 50% of ICUs (e-Appendix 3, e-Fig 2). Only 7% report using transesophageal echocardiography (Table 2). Only 59% of ICUs reported using procedural POCUS when averaged across different applications. Among the specific procedural applications that are considered standard of care, 85% of ICUs reported using POCUS for central line placement, 73% for thoracentesis, 61% for paracentesis, and 54% for chest tube placement. Common cardiac and pulmonary POCUS applications were reported to be used by 70% of ICUs for assessment of volume status, 62% for left ventricular function, 55% for pericardial effusion, 80% for pleural effusion, 64% for pneumothorax, and 46% for pulmonary edema (e-Appendix 3, e-Figs 2, 3). Only 7% of ICUs reported not having an ultrasound machine available. Among the 113 ICUs reporting current POCUS use, a total of 353 ultrasound machines or devices were available for use, with an average of three machines per ICU. A vast majority of these ICUs (84%) reported having at least one dedicated cart-based ultrasound machine (ie, not shared with another service). A total of 174 ultrasound machines were reported as dedicated for ICU use and 127 cart-based ultrasound machines were shared between the ICU and other services. A total of 39 handheld ultrasound devices were provided by the VA facility in 16 ICUs, and 13 handheld ultrasound devices were provided personally by an attending physician in eight ICUs (e-Appendix 3, e-Table 1). Only 14% of ICUs reported saving or archiving POCUS images. ICU chiefs reported a desire for training mostly in cardiac and pulmonary POCUS applications (63% and 56%, respectively), with less desire for training in procedural guidance and abdominal and vascular diagnostic applications (Fig 1). An even distribution of ways attending physicians had received POCUS training was reported (ie, continuing medical education or during residency or fellowship training) (Table 2). In contrast, some ICU chiefs reported that none of their physicians had received POCUS training either through continuing medical education courses (22%) or residency training (21%). A training gap, defined by greater desire for training than current use, was seen for some diagnostic POCUS applications (cardiac, 8%; vascular, 8%; abdominal, 3%). Only 37% of ICU chiefs reporting having a process to obtain POCUS training for their physicians. Current POCUS use and desire for training for specific applications are provided in e-Appendix 3 (e-Figs 1-4). Regarding POCUS education of trainees, 80% of ICU chiefs reported training residents or fellows in their ICUs (Table 2). Further details of POCUS training provided to fellows, residents, medical students, nurse practitioner students, physician assistant students, and nursing students is shown in e-Appendix 3 (e-Table 2). Most ICUs (57%) reported providing POCUS education to trainees, with 43% reporting that POCUS examinations performed during the ICU rotation counted toward graduation requirements. Most respondents (60%) reported that > 50% of their ICU attending physicians felt confident supervising trainees’ POCUS use for bedside procedures and 48% felt confident supervising trainees’ diagnostic POCUS use. When separated by ICU type, more attending physicians in medical and surgical ICUs reported feeling confident in supervising POCUS use compared with those in medical-surgical ICUs (Table 2). Most ICUs reported one or more barrier to POCUS use, and only 17% did not report any barriers to POCUS use. Lack of training and training-related barriers were reported by 67% of ICUs, along with barriers related to POCUS infrastructure (59%) and ultrasound equipment availability (35%). Specific barriers reported by more than one-third of ICUs were lack of trained providers (48%), lack of funding for training (45%), lack of training opportunities (37%), and lack of image archiving (34%) (Table 3).Table 3Barriers to POCUS Use in ICUsBarrierNo. of ICUs Reporting Barrier (n = 122)Training Lack of trained providers59 (48) Lack of funding for training55 (45) Lack of training opportunities45 (37) Lack of funding for travel40 (33) At least one of the training barriers listed above82 (67)Infrastructure Lack of image archiving42 (34) No clinician champion33 (27) Lack of funding for support staff32 (26) Lack of standard reporting form25 (20) Lack of funding for simulation space25 (20) Lack of privileging criteria22 (18) Lack of facility leadership support16 (13) At least one of the infrastructure barriers listed above72 (59)Equipment Lack of ultrasound equipment36 (30) Lack of funding for POCUS equipment25 (20) At least one of the equipment barriers listed above43 (35)Other No barriers identified21 (17) No perceived benefit10 (8)POCUS = point-of-care ultrasound. Open table in a