The Rise of Point-of-Care Ultrasound in Advanced Practice Providers’ Education
Point-of-care ultrasound (POCUS) has become increasingly implemented throughout all practices of medicine in the United States. Beyond the hospital, paramedics and military medics are being trained, given the relatively simple training and utilization as an adjunct in emergent settings. Advanced practice providers (APPs) are also being trained in POCUS, but there are currently no widely implemented POCUS curricula in graduate training for nurse practitioners (NPs) and physician assistants (PAs). What training can be expected from them? How can POCUS be implemented into clinical practice with APPs?
POCUS Education for Nurse Practitioners
NP students have demonstrated POCUS proficiency after the implementation of POCUS curriculum. [1] Organizations, such as the American Association of Nurse Practitioners (AANP), have created curricula and POCUS training programs specifically for NPs. [2] However, this has not been implemented into every NP curriculum. Without structured training protocols, ultrasound skills will vary. Given this lack of integration into educational curricula, alternative training pathways may be required. Post-graduate training programs, such as an ultrasound or emergency medicine fellowship, may offer more comprehensive training and hands-on practice. NPs, similar to physicians without formal POCUS training, may undergo practice-based training designed within an institution. Competency checklists have been developed, with demonstrated improvement after short courses and a variety of didactics and hands-on experience. [3]
Emerging Physician Assistant Postgraduate Programs
Approximately 29% of PA programs have incorporated ultrasound into their curricula, compared to over 60% of medical schools. [4] Beyond graduate training, there exist postgraduate training opportunities for PAs. For example, the POCUS PA Fellowship at Brooke Army Medical Center offers 1-year training. Some POCUS fellowships for physicians also accept APPs. In addition, PAs have the unique opportunity of pursuing new emergency medicine “residencies” or “fellowships” created in the past 10 years. There are approximately 40 programs, according to the Society of Emergency Medicine Physician Assistants (SEMPA). [5] These programs are not ACGME accredited like physician programs are, and thus curricula may vary from program to program. Curricula seem on average to be approximately 12–18 months, and most include bedside ultrasound training. For example, the Albany Medical Center program offers 2 weeks of dedicated ultrasound, and Staten Island University Hospital offers 3 weeks. However, New York University, Cornell, and Upstate Medical University do not specify a dedicated curriculum for ultrasound. Thus, PAs may have some experience with ultrasound as students. Those with residency or fellowship training may have additional dedicated hours and greater competency. However, this varies based on school and postgraduate training.
Competency Guidelines
The American College of Emergency Physicians (ACEP) has generalized recommendations for ultrasound competency, including understanding the mechanics of ultrasound, the applications of ultrasound, and institutional capabilities. [6] ACEP emphasizes the availability of free open-access medical (FOAM) education to meet standardized competency. Additionally, quality assurance (QA) is required to document proficiency with appropriate supervision, such as QA teaching sessions, exam feedback, standardized knowledge assessments, or one-on-one standardized direct observation tools (SDOTs). A benchmark of 25–50 quality-reviewed exams for a specific application is recommended to demonstrate proficiency; overall, ACEP recommends 150–300 total POCUS exams. The Association for Medical Ultrasound (AIUM) recommends similar guidelines of at least 300 total ultrasound examinations within the previous 3 years. [7] A review of images can be performed with appropriate clinical supervision, such as the POCUS-trained medical director or chair of the department. In addition, week-long courses have been implemented successfully and may be beneficial for practitioners with fewer institutional resources. [8]
POCUS Proficiency Considerations
Proficiency in POCUS hinges on education and preceptorship, as POCUS is still an emerging technology. As new applications and studies become validated, providers must seek additional opportunities to continue honing their skills, such as online courses, POCUS simulation tools, and hands-on POCUS workshops. Independent third-party organizations, such as the Point-of-Care Ultrasound Certification Academy, have created certification programs for various POCUS applications for providers with any level of training expertise. [8, 9] Other certifications of varying quality and scope exist. Although having a POCUS certificate might ensure a certain standard among providers, it does not guarantee competency. ACEP and AIUM, do not endorse such certifications. Preceptorship and clip review with feedback on clip/image quality and interpretation accuracy are essential. Beyond licensing requirements and society guidelines, institutions can implement their own credentialing and ongoing education. Additionally, a robust quality assurance infrastructure is key for timely review of POCUS exams. As specialty guidelines evolve and educational milestones increase, additional changes to institutional policies may be necessary.
Implementing POCUS into a Practice with APPs
Given the lack of standardized education in APP curricula, it is essential to build a POCUS program for the specific scope of practice. This begins with understanding how POCUS will be used in practice and developing clinical pathways based on this information. Consider provider competency, specialty practice, patient population, and institutional resources. Acknowledging varying levels of training, the POCUS credentialing process and tangible minimum benchmarks must be standardized within an institution based on existing guidelines from professional organizations. In addition to baseline training, providers should be allowed the opportunity to learn new skills and to continue to improve their technique. Continued education may be organizational, through a third party, or within periodic reviews. Reassessment of POCUS proficiency can be achieved through continuous quality assurance. Given that POCUS is mostly used as an adjunct to diagnosis, POCUS studies can oftentimes be compared to gold standard modalities. A successful POCUS program relies on a focused scope of practice, competency assessment, continued training, and QA.
In Summary
The advancement of POCUS in APP education underscores the need for structured training, competency benchmarks, and an adaptable approach to build POCUS programs that include APPs into training opportunities and credentialing protocols. In addition, given high variability of POCUS knowledge among APPs, a robust and timely QA process is essential.
Authored by Jason Wang DO, MBS
Edited by Tatiana Havryliuk, MD
References
[1] S. Ventura et al., “Implementation of Point-of-Care Ultrasound Training Into Nurse Practitioner Student Education: A Cohort Study,” The Journal for Nurse Practitioners, vol. 19, no. 9, p. 104732, Oct. 2023, doi: 10.1016/j.nurpra.2023.104732.
[2] “Experience Hands-On Training With State-of-the-Art Equipment,” American Association of Nurse Practitioners. Accessed: Feb. 05, 2024. [Online]. Available: https://www.aanp.org/news-feed/experience-hands-on-training-with-state-of-the-art-equipment
[3] L. Chen, D. Zuma, S. Gouker, and C. Tennyson, “Letter to the Editor: Implementation of Point-of-Care Ultrasound Training Into Nurse Practitioner Student Education: A Cohort Study,” The Journal for Nurse Practitioners, vol. 20, no. 1, Jan. 2024, doi: 10.1016/j.nurpra.2023.104811.
[4] D. S. M. CAQ-EM MS, PA-C., “Is Point-of-Care Ultrasound Training Feasible During PA Programs?,” Clinical Advisor. Accessed: Feb. 05, 2024. [Online]. Available: https://www.clinicaladvisor.com/home/my-practice/physician-assistant-career-resources/point-of-care-ultrasound-training-for-pas/
[5] “Postgraduate Programs – SEMPA.” Accessed: Feb. 05, 2024. [Online]. Available: https://sempa.org/postgraduate-programs/
[6] “Ultrasound Guidelines: Emergency, Point-of -care, and Clinical Ultrasound Guidelines in Medicine.” Accessed: Nov. 11, 2023. [Online]. Available: https://www.acep.org/patient-care/policy-statements/ultrasound-guidelines-emergency-point-of--care-and-clinical-ultrasound-guidelines-in-medicine
[7] “Training Guidelines for Licensed Medical Providers (PA, NP, CNM/CM, DPT, and DC) Who Perform and/or Interpret Diagnostic Ultrasound Examinations,” www.aium.org. Accessed: Feb. 05, 2024. [Online]. Available: https://www.aium.org/resources/training-guidelines/view/training-guidelines-for-licensed-medical-providers-(pa-np-nmw-dpt-and-dc)-who-evaluate-and-interpret-diagnostic-ultrasound-examinations
[8] “Point-of-Care Ultrasound (POCUS) Certification Academy | POCUS.org,” Point-of-Care Ultrasound Certification Academy. Accessed: Feb. 05, 2024. [Online]. Available: https://www.pocus.org/
[9] “ARDMS | American Registry for Diagnostic Medical Sonography.” Accessed: Feb. 05, 2024. [Online]. Available: https://www.ardms.org/