The Ins and Outs of Point-of-Care Ultrasound Supervision

Implementation of a point-of-care ultrasound (POCUS) program could be complex when midlevel practitioners or resident physicians perform the scans. What, if any, supervision is required from the attending physician? What are the credentialing standards for non-physicians? In this post we will discuss how an effective curriculum, proper supervision, and adherence to local regulations allow for use of POCUS by a broad group of clinicians.

What are competency standards for midlevel practitioners?

Current ACEP guidelines recommend physician assistants (PAs) and nurse practitioners (NPs) to adhere to the same Ultrasound Guidelines that apply to emergency physicians.[1] Both, ACEP and SEMPA (Society of Emergency Medicine Physician Assistants), support credentialing of advanced practice providers (APPs) who demonstrate competency in ultrasound. [2] Developing credentialing guidelines can provide standardized training, with demonstrated competency in APPs.[3] Middleware and cloud technologies can enable providers to streamline image review. It should be noted however that POCUS is not currently required in PA or NP curriculums. A 2019 review of 218 PA programs showed 23% had integrated some POCUS training.[4] However, APPs may pursue additional training that may require up to 40 hours of bedside ultrasound experience, or even a year-long ultrasound fellowship, such as this one. [4] Given variability in POCUS education, it is imperative for to establish institutional guidelines to establish competency with appropriate department oversight.

What about overseeing resident physicians?

POCUS knowledge and residency curriculum implementation

The American Institute of Ultrasound Medicine (AIUM) lists over 200 medical schools that include POCUS in their curriculum.  Thus, many residents already had exposure to POCUS and potentially developed significant skills by the time they enter a training program. One retrospective analysis of POCUS in an academic hospital showed efficacy in implementation within an emergency medicine residency program, with documentation as a noted barrier to entry.[5] POCUS integration into four internal medicine residencies demonstrated the following initial roadblocks: faculty training, equipment purchasing, and quality assurance.[6] Another study of 5 Canadian internal medicine residency programs demonstrated high demand for POCUS applications in paracentesis, echocardiogram, central line insertion, and deep vein vascular studies.[7] ACEP guidelines integrate POCUS into emergency medicine training, but internal medicine has not yet adapted standardized residency training.[8] The American Academy of Family Practice (AAFP) has endorsed a curriculum, but it is not yet widely adopted.[9] It is important to understand the competency of each individual resident, as there is not yet a standardized training outlined by the Accreditation Council for Graduate Medical Education (ACGME) for all residents.[10]

Supervision of residents performing POCUS

Remember that residents provide medical care under the attending physician’s license with some exceptions. It is attending physician’s responsibility to review POCUS clips, interpretation, and documentation done by the residents.  Because residents need to achieve a high number of POCUS exams for graduation, they often perform “educational” scans that are not used for clinical decision making. It is important for residents to perform educational scans only if a confirmatory scan will be done or if you, a credentialed provider, are immediately available to review the exam. For example, do an “educational” echo only if there will be an echo performed on the same visit. You don’t want to end up in an unfortunate situation of your resident missing an abdominal aortic aneurysm that gets discovered during quality assurance session 1 week later after the patient has long left your care.

How can I safely implement a POCUS program?

Integrating POCUS into clinical practice requires an organizational system of oversight. Mid-level practitioners and residents may require an educational curriculum for specific applications of POCUS within a supervising physician’s scope of practice. Sample curriculums have been created with demonstrated efficacy. This curriculum should satisfy institutional and departmental credentialing requirements. Supervisors should understand the scope of training of providers practicing under a supervisor’s license. Competency for specific exams and procedural adjuncts should be specifically addressed, as POCUS remains a goal-directed tool.

Documentation becomes instrumental in running a POCUS program. In settings with technological resources, virtual quality assurance can expedite image review. Integrated workflows can seamlessly integrate POCUS into documentation. While initial training and setup may seem as barriers to entry, implementation of POCUS can be accomplished with efficient workflows.[5] Successful and safe POCUS programs will follow state and institutional policies, as well as your professional organization’s guidelines.

To learn more about POCUS program implementation check out our previous post on implementation.

Supervising physicians should consider the following:

1. What is the midlevel provider’s or resident’s scope of practice in their state and what level of supervision is required?

2. Did APPs complete the credentialing process outlined by their institution and obtain privileges to perform POCUS?

3. How will you ensure continued competency?

An example of verifying scope of practice and supervision requirements in New York state.

For example, in New York, midlevel practitioners have the authority to perform certain procedures independently. Specific requirements for performing POCUS may be outlined in collaborative agreements with physicians or institutional policies. Up-to-date information and recommendations may be obtained from professional organizations, such as the New York State Department of Health, the New York State Medical Board, the New York State Board of Nursing, and/or the New York State Society of Physician Assistants.

Bottom Line

POCUS can be safely performed by a broad group of clinicians. The integration of POCUS education is growing in PA, nursing, and medical schools. Similarly, POCUS programs are now being effectively implemented in IM and FM residency programs. Given considerable variability in POCUS knowledge, it’s imperative for institutions to have vigorous credentialing and quality assurance processes. In addition, make sure to check your state requirements for supervision of APPs.

Authored by Jason Wang DO, MBS

Edited by Tatiana Havryliuk, MD

References 

[1]        “Advanced Practice Provider Point-of-Care Ultrasound Guidelines.” Accessed: Dec. 06, 2023. [Online]. Available: https://www.acep.org/patient-care/policy-statements/advanced-practice-provider-point-of-care-ultrasound-guidelines2

[2]        C. Huang et al., “Advanced practice providers proficiency‐based model of ultrasound training and practice in the ED,” J. Am. Coll. Emerg. Physicians Open, vol. 3, no. 1, p. e12645, Jan. 2022, doi: 10.1002/emp2.12645.

[3]        K. A. Rath, J. B. Bonomo, and K. Ballman, “Point-of-Care Ultrasonography for Advanced Practice Providers: A Training Initiative,” J. Nurse Pract., vol. 19, no. 2, p. 104435, Feb. 2023, doi: 10.1016/j.nurpra.2022.08.018.

[4]  D. Rizzolo and R. E. Krackov, “Integration of Ultrasound Into the Physician Assistant Curriculum,” J. Physician Assist. Educ. Off. J. Physician Assist. Educ. Assoc., vol. 30, no. 2, pp. 103–110, Jun. 2019, doi: 10.1097/JPA.0000000000000251.

[5]        M. Melton et al., “Description of the Use of Incentives and Penalties for Point-of-Care Ultrasound Documentation Compliance in an Academic Emergency Department,” Cureus, vol. 13, no. 7, p. e16199, doi: 10.7759/cureus.16199.

[6]        “A road map for point-of-care ultrasound training in internal medicine residency | The Ultrasound Journal | Full Text.” Accessed: Dec. 07, 2023. [Online]. Available: https://theultrasoundjournal.springeropen.com/articles/10.1186/s13089-019-0124-9

[7]        K. Watson et al., “Point of care ultrasound training for internal medicine: a Canadian multi-centre learner needs assessment study,” BMC Med. Educ., vol. 18, p. 217, Sep. 2018, doi: 10.1186/s12909-018-1326-8.

[8]        D. Ramgobin et al., “POCUS in Internal Medicine Curriculum: Quest for the Holy-Grail of Modern Medicine,” J. Community Hosp. Intern. Med. Perspect., vol. 12, no. 5, pp. 36–42, Sep. 2022, doi: 10.55729/2000-9666.1112.

[9]        J. Shen-Wagner and M. Deutchman, “Point-of-Care Ultrasound: A Practical Guide for Primary Care,” Fam. Pract. Manag., vol. 27, no. 6, pp. 33–40, Nov. 2020.

[10]      S. C. Biggerstaff, A. M. Silver, J. H. Donroe, and R. K. Dversdal, “The POCUS Imperative,” J. Grad. Med. Educ., vol. 15, no. 2, pp. 146–149, Apr. 2023, doi: 10.4300/JGME-D-22-00247.1.