Point-of-Care Ultrasonography by Pediatric Emergency Medicine Physicians

Point-of-care ultrasonography is a focused ultrasonography performed and interpreted at the patient’s bedside by a health care provider in conjunction with his or her clinical examination. Point-of-care ultrasonography can expedite clinical decision-making, direct follow-up diagnostic imaging, aid in procedural guidance, and improve patient satisfaction.^1,–6 Point-of-care ultrasonography is designed to answer specific yes or no questions in real time. The point-of-care ultrasonography examination has important qualities as an imaging modality. There is no need to transport a patient outside of the emergency department (ED), examinations can be performed at all hours, examinations may be repeated, and there is no ionizing radiation exposure. Moreover, it may help direct further evaluation so as to avoid unnecessary and costly testing.

Clinician-performed ultrasonography has been used and accepted since the 1960s, when obstetricians and cardiologists first adopted the technology. The use of ultrasonography by those specialists is endorsed by various professional radiology organizations.^7,8 At present, nonphysician providers, such as nurses and prehospital care workers, are also using point-of-care ultrasonography as a part of their practice.^9,–17 

One of the appealing aspects of ultrasonography is its inherent safety. It relies on sound waves and not x-rays to generate images. In many instances, computed tomography (CT) imaging or radiography are the optimal diagnostic modalities in the evaluation of the pediatric patient; however, there is an increasingly large body of literature emphasizing and delineating the risks of ionizing radiation, particularly from CT.^18,–31 Pediatric patients are particularly sensitive to ionizing radiation, given the larger organ-specific dosing they receive with each study, the increased susceptibility of these organs to radiation-induced cancer, and the increased life span over which children may develop radiation-induced cancers.²¹ In response to this risk, several national campaigns have been initiated to reduce the use of unnecessary CT imaging in pediatric patients. These include efforts by the Society for Pediatric Radiology,³² the National Council on Radiation Protection and Measurements,³³ the Food and Drug Administration,³⁴ and the National Cancer Institute.³⁵ In summary, when imaging is indicated, practitioners should attempt to optimize the use of nonradiating diagnostic modalities, such as ultrasonography.

PEM physicians can use point-of-care ultrasonography as a diagnostic or procedural adjunct in the evaluation of patients in the ED.³⁶  Diagnostic applications are those that assist in diagnosis and inform medical decision-making. Procedural applications may be “ultrasonography-assisted” or “static” or “ultrasonography-guided,” also referred to as “dynamic.” Static ultrasonography is defined as using ultrasonography before the procedure, identifying anatomic structures, and determining the ideal circumstances for the procedure to be performed. The procedure itself is performed without the use of ultrasonography. In contrast, in dynamic ultrasonography, the ultrasonography and procedure are performed simultaneously.

Clinical applications will be practice-specific and based on the patient population, incidence of disease, and the availability of resources, such as 24-hour attending radiologist coverage, availability of ultrasonography technicians, and distance/transfer times to facilities that can provide ultrasonography imaging. ED leaders should determine which point-of-care ultrasonography examinations will be most useful to their practice environments. Physicians would then apply for institutional privileges in those specific areas. There will be a natural transition period for physicians who did not receive point-of-care ultrasonography education as part of their graduate medical training. Therefore, the indications for which clinicians use point-of-care ultrasonography will evolve over time as the education is disseminated throughout the PEM community. Finally, clinicians should be aware that point-of-care ultrasonography is better used as a “rule in” and not a “rule out” diagnostic modality. The absence of an abnormal finding should not indicate a normal examination. For example, nonvisualization of an intussusception with high clinical concern must prompt further evaluation. Likewise, when findings other than those sought to “rule in” a diagnosis are encountered, a more complete imaging evaluation is warranted.

Before implementing a program in the ED, departmental leaders should identify a core group of individuals with expertise in point-of-care ultrasonography. This group is responsible for educating faculty and trainees as well as managing administrative tasks, such as outlining credentialing pathways and performing quality assurance image reviews. Standardized and universally accepted criteria for what designates a point-of-care expert are likely to evolve over time as advanced training programs are established. In departments or divisions without point-of care ultrasonography–trained individuals, departmental leadership should consider sending an individual or group of individuals with interest to receive additional training in point-of-care ultrasonography. Alternatively, an expert from another department (eg, general emergency medicine, radiology) may assume these responsibilities and work collaboratively with ED leaders.

Point-of-care ultrasonography training varies depending on the practitioner’s previous education and practice environment. Until now, most PEM physicians have received little or no point-of-care ultrasonography instruction as part of their training. It is important that PEM fellowship programs provide adequate training, including measurements of competency for trainees. Point-of-care ultrasonography education is now an American Board of Pediatrics requirement for PEM fellowship programs.³⁷ Consensus education guidelines and a model curriculum were recently published.³⁸ There are 2 training pathways for physicians: a “training-based” pathway for current trainees and a “practice-based” pathway for faculty without previous experience. The details of such pathways are outlined in the accompanying technical report.³⁹ 

Before performing a point-of-care ultrasonography examination for medical decision-making, PEM physicians must demonstrate application-specific competency. During this “training” phase, the point-of-care ultrasonography expert should review all ultrasonography examinations in a timely manner. Practitioners can receive relevant feedback regarding their examinations. In addition, novice practitioners should be supervised at the bedside to ensure that the examinations are being performed correctly. Examination reviews and bedside supervision may be performed by a department or division “expert” or by another physician already credentialed to perform ultrasonography for that indication. These educational scans should not be used for medical decision-making or billing purposes, and this should be clearly communicated to patients and their families.

Given that a point-of-care ultrasonography examination is intended to be a focused examination, training requirements necessarily differ from those set forth by other specialty organizations, such as the American College of Radiology and others. A similar distinction was made in the 2002 training guidelines adopted by the American Society of Echocardiography, which outlined basic training requirements for anesthesiologists performing perioperative echocardiography, which differed from the more rigorous training needed for more consultative echocardiography performed by cardiologists.⁴⁰ Competency and subsequent credentialing within a division or department may be achieved after performing a specified number, or range, of accurately performed and interpreted point-of-care ultrasonography examinations. With the lack of robust data supporting a specified number of examinations per indication, some guidelines suggest 25 to 50 examinations needed to achieve competency.⁴¹ However, physicians should not interpret this recommendation as a “one-size-fits-all” approach, because examinations vary in difficulty and therefore may require more experience to establish competency. In addition, the number of examinations performed may not always best define competency. Because point-of-care ultrasonography incorporates both cognitive and psychomotor components, individual physicians may gain competency at varying rates that may be independent of a predetermined numerical goal and better assessed through simulation, observed structured clinical examinations, or direct observation during clinical shifts.

Hospital privileging committees should provide an opportunity for privileging in specific pediatric point-of-care ultrasonography examinations. Written requirements for privileging should be delineated. Building on the recommendations set forth by the American College of Emergency Physicians, when a physician applies for appointment or reappointment to the medical staff and for clinical privileges, the process should include assessment of current competency by the point-of-care ultrasonography director.⁴¹ Because point-of-care ultrasonography is a relatively new technology for PEM physicians, some specialists and hospital privileging committees may not be familiar with the precedent already set forth for point-of-care ultrasonography and the benefits to patient care. Therefore, PEM physicians should educate those who are unfamiliar with its use, citing the established literature attesting to emergency physicians’ ability to accurately perform and interpret point-of-care ultrasonography examinations.^5,42,–105 In addition, PEM physicians should consider collaboration with radiologists and expert sonographers when implementing point-of-care ultrasonography into their ED.

Once PEM physicians are credentialed to perform point-of-care ultrasonography for a particular application, they can integrate the point-of-care ultrasonography examination into patient care. Details of the point-of-care ultrasonography examination must be documented at the time of performance in the medical record. Specifically, documentation should include the indication for the examination, structures/organs identified, and the interpretation.¹⁰⁶ If the study is inadequate, this finding should also be noted. Images should be archived, ideally electronically, and entered as part of the electronic health record for ease of retrieval and review.

1. PEM physicians should be familiar with the definition and application of point-of-care ultrasonography and the utility for patients in the ED.

2. Pediatric emergency physicians who integrate point-of-care ultrasonography in their patient care should be competent in point-of-care examinations that are specific and relevant to their clinical environment.

3. For EDs with a PEM point-of-care ultrasonography program, there must be a process in place for educating and assessing practitioner skill, maintaining quality assurance, implementing quality improvement activities, and acquiring and maintaining hospital privileges.

4. PEM fellowship programs should have a structured point-of-care ultrasonography education curriculum and competency assessment for fellows in training.

5. Standardized, universally accepted criteria for what defines point-of-care ultrasonography expertise should be developed in the near future by national organizations such as the American Academy of Pediatrics, the Society for Academic Emergency Medicine, and/or the American College of Emergency Physicians.

There is an increasing demand for PEM physicians to become adept in point-of-care ultrasonography. Mounting evidence supports the benefits to pediatric patients. This policy statement and accompanying technical report have been developed to define a structured and safe program for the integration and implementation of point-of-care ultrasonography by PEM physicians.

Jennifer R. Marin, MD, MSc

Resa E. Lewiss, MD

Dr Lewiss has no financial disclosures or potential conflicts of interest. Dr Marin receives support from third Rock Ultrasound, LLC for serving as teaching faculty and received support from the Agency for Healthcare Quality and Research (R13HS023498) related to a conference on diagnostic imaging and from the National Institutes of Health (K12HL109068).

Jennifer R. Marin, MD, MSc, Chairperson

Resa E. Lewiss, MD

Alyssa M. Abo, MD

Stephanie J. Doniger, MD, RDMS

Jason W. Fischer, MD, MSc

David O. Kessler, MD, MSc, RDMS

Jason A. Levy, MD, RDMS

Vicki E. Noble, MD, RDMS

Adam B. Sivitz, MD

James W. Tsung, MD, MPH

Rebecca L. Vieira, MD, RDMS

Joan E. Shook, MD, MBA, FAAP, Chairperson

Alice D. Ackerman, MD, MBA, FAAP

Thomas H. Chun, MD, MPH, FAAP

Gregory P. Conners, MD, MPH, MBA, FAAP

Nanette C. Dudley, MD, FAAP

Susan M. Fuchs, MD, FAAP

Marc H. Gorelick, MD, MSCE, FAAP

Natalie E. Lane, MD, FAAP

Brian R. Moore, MD, FAAP

Joseph L. Wright, MD, MPH, FAAP

Lee Benjamin, MD – American College of Emergency Physicians

Kim Bullock, MD – American Academy of Family Physicians

Elizabeth L. Robbins, MD, FAAP – AAP Section on Hospital Medicine

Toni K. Gross, MD, MPH, FAAP – National Association of EMS Physicians

Elizabeth Edgerton, MD, MPH, FAAP – Maternal and Child Health Bureau

Tamar Magarik Haro – AAP Department of Federal Affairs

Angela Mickalide, PhD, MCHES – EMSC National Resource Center

Cynthia Wright, MSN, RNC – National Association of State EMS Officials

Lou E. Romig, MD, FAAP – National Association of Emergency Medical Technicians

Sally K. Snow, RN, BSN, CPEN, FAEN – Emergency Nurses Association

David W. Tuggle, MD, FAAP – American College of Surgeons

Sue Tellez

Steven B. Bird, MD

Andra L. Blomkalns, MD

Kristin Carmody, MD

Kathleen J. Clem, MD, FACEP

D. Mark Courtney, MD

Deborah B. Diercks, MD, MSc

Matthew Fields, MD

Robert S. Hockberger, MD

James F. Holmes, Jr, MD, MPH

Lauren Hudak, MD

Alan E. Jones, MD

Amy H. Kaji, MD, PhD

Ian B. K. Martin, MD

Christopher Moore, MD, RDMS, RCMS

Nova Panebianco, MD, MPH

Lee S. Benjamin, MD, FACEP, Chairperson

Isabel A. Barata, MD, FACEP, FAAP

Kiyetta Alade, MD

Joseph Arms, MD

Jahn T. Avarello, MD, FACEP

Steven Baldwin, MD

Kathleen Brown, MD, FACEP

Richard M. Cantor, MD, FACEP

Ariel Cohen, MD

Ann Marie Dietrich, MD, FACEP

Paul J. Eakin, MD

Marianne Gausche-Hill, MD, FACEP, FAAP

Michael Gerardi, MD, FACEP, FAAP

Charles J. Graham, MD, FACEP

Doug K. Holtzman, MD, FACEP

Jeffrey Hom, MD, FACEP

Paul Ishimine, MD, FACEP

Hasmig Jinivizian, MD

Madeline Joseph, MD, FACEP

Sanjay Mehta, MD, Med, FACEP

Aderonke Ojo, MD, MBBS

Audrey Z. Paul, MD, PhD

Denis R. Pauze, MD, FACEP

Nadia M. Pearson, DO

Brett Rosen, MD

W. Scott Russell, MD, FACEP

Mohsen Saidinejad, MD

Harold A. Sloas, DO

Gerald R. Schwartz, MD, FACEP

Orel Swenson, MD

Jonathan H. Valente, MD, FACEP

Muhammad Waseem, MD, MS

Paula J. Whiteman, MD, FACEP

Dale Woolridge, MD, PhD, FACEP

Carrie DeMoor, MD

James M. Dy, MD

Sean Fox, MD

Robert J. Hoffman, MD, FACEP

Mark Hostetler, MD, FACEP

David Markenson, MD, MBA, FACEP

Annalise Sorrentino, MD, FACEP

Michael Witt, MD, MPH, FACEP

Dan Sullivan

Stephanie Wauson

Vicki Noble, MD

Enrico Storti, MD

Jim Tsung, MD

Giovanni Volpicelli, MD

Jennifer Marin, MD, FAAP

Sue Tellez