Editorials

Point-of-Care Ultrasonography in Family Medicine

 

Am Fam Physician. 2018 Aug 15;98(4):200-202.

Point-of-care ultrasonography (POCUS) refers to limited ultrasound protocols performed at the patient's bedside by a clinician to assess for many conditions such as aortic aneurysm and pleural effusion. The protocols usually answer a specific question (Table 1) that helps guide treatment and can be performed after a relatively brief training period. This is in distinction to consultative, comprehensive, or formal ultrasound examinations that are performed by sonographers and interpreted by radiologists with years of training in reading ultrasound results. POCUS, on the other hand, is a tool of the generalist. Its use was first introduced by emergency medicine physicians, but with technological advances allowing for smaller, pocket-sized ultrasound machines at lower costs, POCUS is becoming more accessible to family physicians. A feasibility study of the use of POCUS by family medicine residents and faculty who were given a handheld ultrasound machine and 16 total hours of training revealed users found it was easy to learn to use and improved diagnostic efficiency and accuracy, and patients were satisfied.1 In the study, 86% of participants agreed or strongly agreed that they would continue to use POCUS in their daily practices.1

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TABLE 1.

Questions Answered by Point-of-Care Ultrasonography That Are Applicable to Family Medicine

UseYes/No Question

Abdominal aortic aneurysm screening

Is there an aneurysm?

Cardiac

Is there left ventricular systolic dysfunction?

Is there left ventricular hypertrophy?

Is there a pericardial effusion?

Does the patient still have fluid overload?

Deep venous thrombosis (for a video of this test, see https://youtu.be/M0JmjOOg10M)

Is there a deep venous thrombosis?

Hepatobiliary

Is there cholelithiasis?

Is there cholecystitis?

Is there hepatosplenomegaly?

Is there steatosis of the liver?

Is there ascites?

Musculoskeletal

Is there a fracture?

Is there ligament or tendon pathology?

Is there a joint effusion?

Is the median nerve enlarged, suggesting carpal tunnel syndrome?

Obstetric

Is there an intrauterine pregnancy?

What is the fetal presentation?

Is there a heartbeat?

What is the gestational age?

Ophthalmologic

Is there a retinal detachment?

Is there a vitreous hemorrhage?

Is the optic nerve enlarged, suggesting increased intracranial pressure?

Procedural guidance

Is the needle/catheter/endotracheal tube in the proper location?

Pulmonary (for a video of this test, see https://youtu.be/WOlz8-km6hE)

Is there a pneumothorax?

Is there evidence of pneumonia?

Is there a plural effusion?

Is there evidence of pulmonary edema?

Skin and soft tissue infections

Is there an abscess?

Thyroid

Is there a lesion on the thyroid?

Urologic

Is there hydronephrosis or evidence of nephrolithiasis?

What is the postvoid residual volume?


Note: This is not an exhaustive list, and studies continue to find new applications as the use of point-of-care ultrasonography increases.

TABLE 1.

Questions Answered by Point-of-Care Ultrasonography That Are Applicable to Family Medicine

UseYes/No Question

Abdominal aortic aneurysm screening

Is there an aneurysm?

Cardiac

Is there left ventricular systolic dysfunction?

Is there left ventricular hypertrophy?

Is there a pericardial effusion?

Does the patient still have fluid overload?

Deep venous thrombosis (for a video of this test, see https://youtu.be/M0JmjOOg10M)

Is there a deep venous thrombosis?

Hepatobiliary

Is there cholelithiasis?

Is there cholecystitis?

Is there hepatosplenomegaly?

Is there steatosis of the liver?

Is there ascites?

Musculoskeletal

Is there a fracture?

Is there ligament or tendon pathology?

Is there a joint effusion?

Is the median nerve enlarged, suggesting carpal tunnel syndrome?

Obstetric

Is there an intrauterine pregnancy?

What is the fetal presentation?

Is there a heartbeat?

What is the gestational age?

Ophthalmologic

Is there a retinal detachment?

Is there a vitreous hemorrhage?

Is the optic nerve enlarged, suggesting increased intracranial pressure?

Procedural guidance

Is the needle/catheter/endotracheal tube in the proper location?

Pulmonary (for a video of this test, see https://youtu.be/WOlz8-km6hE)

Is there a pneumothorax?

Is there evidence of pneumonia?

Is there a plural effusion?

Is there evidence of pulmonary edema?

Skin and soft tissue infections

Is there an abscess?

Thyroid

Is there a lesion on the thyroid?

Urologic

Is there hydronephrosis or evidence of nephrolithiasis?

What is the postvoid residual volume?


Note: This is not an exhaustive list, and studies continue to find new applications as the use of point-of-care ultrasonography increases.

There is mounting evidence that POCUS can help decrease the costs of care while improving patient access to care and safety. POCUS may reduce direct health care costs by serving as an initial triage tool to determine which patients may need more advanced imaging, thus decreasing the use of more expensive studies. A study comparing ultrasonography and computed tomography scans for evaluation of suspected nephrolithiasis in the emergency department found that initial testing with POCUS decreased the number of computed tomography scans by 59% without any change in outcomes.2 A 2008 study of Medicare data for musculoskeletal magnetic resonance imaging indicated that 45% of primary diagnoses could have been made with ultrasonography.3

Downstream costs from complications are a consideration as well. Ultrasonography has no radiation and no known direct adverse effects. Also, when used as an adjunct to help guide common procedures, such as venous access, thoracentesis, and arthrocentesis, ultrasonography has been shown to decrease rates of complications.46

In addition to being more cost-effective, POCUS is better than physical examination or plain radiography in many settings. When using POCUS, generalists are as accurate as cardiologists in assessing left ventricular systolic function, and even medical students are able to increase their diagnostic accuracy from 50% to 75%.7,8 POCUS is better than a physical examination in differentiating an abscess from cellulitis, changing management in 14% to 56% of cases.9 POCUS is superior to physical examination or chest radiography for making many lung diagnoses, including pleural effusion, pulmonary edema, pneumonia, and pneumothorax.1015

Another benefit of POCUS in primary care is its ability to expedite and increase access to imaging. For example, abdominal aortic aneurysm screening using POCUS has a sensitivity of 99% to 100%, compared with screening in the radiology setting, and takes less than four minutes to complete.16,17 POCUS evaluation of the lower extremities for deep venous thrombosis has a sensitivity of 95% and specificity of 96%, compared with screening in the radiology setting, and can also be completed in less than four minutes.18,19

Given the benefits of different POCUS applications, interest in its use in the family physician's office is increasing. A 2014 survey of program directors found that only 2% of residency programs had a formal POCUS curriculum, but 29% indicated they had started one in the previous year and 11% were in the process of starting one.20 In 2016, the American Academy of Family Physicians (AAFP) Congress of Delegates passed a resolution encouraging all family medicine residency programs to include POCUS as part of their training and for the AAFP to increase continuing medical education offerings that incorporate POCUS training.21 The AAFP has since created a curriculum guideline for POCUS in graduate medical education.22  Resources for additional information on POCUS education and implementation are included in Table 2.

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TABLE 2.

Resources for Point-of-Care Ultrasonography Education and Implementation

Resource

American Academy of Family Physicians

Member interest group

https://www.aafp.org/membership/involve/mig/ultrasound.html

Curriculum guideline

https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint290D_POCUS.pdf

American College of Emergency Physicians

Information on program development, educational guidelines, and coding, as well as additional resources

https://www.acep.org/by-medical-focus/ultrasound

TABLE 2.

Resources for Point-of-Care Ultrasonography Education and Implementation

Resource

American Academy of Family Physicians

Member interest group

https://www.aafp.org/membership/involve/mig/ultrasound.html

Curriculum guideline

https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint290D_POCUS.pdf

American College of Emergency Physicians

Information on program development, educational guidelines, and coding, as well as additional resources

https://www.acep.org/by-medical-focus/ultrasound

Address correspondence to Paul Bornemann, MD, at Paul.Bornemann@uscmed.sc.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Bornemann P, Bornemann G. Military family physicians' perceptions of a pocket point-of-care ultrasound device in clinical practice. Mil Med. 2014;179(12):1474–1477....

2. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014;371(12):1100–1110.

3. Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal imaging: Medicare use, costs, and potential for cost substitution. J Am Coll Radiol. 2008;5(3):182–188.

4. Calvert N, Hind D, McWilliams RG, Thomas SM, Beverley C, Davidson A. The effectiveness and cost-effectiveness of ultrasound locating devices for central venous access: a systematic review and economic evaluation. Health Technol Assess. 2003;7(12):1–84.

5. Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med. 2010;170(4):332–339.

6. Sibbitt WL Jr, Band PA, Kettwich LG, Chavez-Chiang NR, Delea SL, Bankhurst AD. A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol. 2011;17(8):409–415.

7. Panoulas VF, Daigeler AL, Malaweera AS, et al. Pocket-size hand-held cardiac ultrasound as an adjunct to clinical examination in the hands of medical students and junior doctors. Eur Heart J Cardiovasc Imaging. 2013;14(4):323–330.

8. Mjølstad OC, Snare SR, Folkvord L, et al. Assessment of left ventricular function by GPs using pocket-sized ultrasound. Fam Pract. 2012;29(5):534–540.

9. Barbic D, Chenkin J, Cho DD, Jelic T, Scheuermeyer FX. In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis [published correction appears in BMJ Open. 2017;7(9):e013688corr1]. BMJ Open. 2017;7(1):e013688.

10. Yousefifard M, Baikpour M, Ghelichkhani P, et al. Screening performance characteristic of ultrasonography and radiography in detection of pleural effusion: a meta-analysis. Emerg (Tehran). 2016;4(1):1–10.

11. Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics. 2015;135(4):714–722.

12. Xia Y, Ying Y, Wang S, Li W, Shen H. Effectiveness of lung ultrasonography for diagnosis of pneumonia in adults: a systematic review and meta-analysis. J Thorac Dis. 2016;8(10):2822–2831.

13. Filopei J, Siedenburg H, Rattner P, Fukaya E, Kory P. Impact of pocket ultrasound use by internal medicine housestaff in the diagnosis of dyspnea. J Hosp Med. 2014;9(9):594–597.

14. Martindale JL, Wakai A, Collins SP, et al. Diagnosing acute heart failure in the emergency department: a systematic review and meta-analysis. Acad Emerg Med. 2016;23(3):223–242.

15. Noble VE. Think ultrasound when evaluating for pneumothorax. J Ultrasound Med. 2012;31(3):501–504.

16. Blois B. Office-based ultrasound screening for abdominal aortic aneurysm. Can Fam Physician. 2012;58(3):e172–e178.

17. Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013;20(2):128–138.

18. Blaivas M, Lambert MJ, Harwood RA, Wood JP, Konicki J. Lower-extremity Doppler for deep venous thrombosis—can emergency physicians be accurate and fast? Acad Emerg Med. 2000;7(2):120–126.

19. Burnside PR, Brown MD, Kline JA. Systematic review of emergency physician-performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med. 2008;15(6):493–498.

20. Hall JW, Holman H, Bornemann P, et al. Point of care ultrasound in family medicine residency programs: a CERA study. Fam Med. 2015;47(9):706–711.

21. American Academy of Family Physicians. Resolution no. 602 (New York E) - increase point of care ultrasound (POCUS) education in family medicine. https://www.aafp.org/about/governance/congress-delegates/2016/resolutions/newyork-e.mem.html. Accessed September 29, 2017.

22. American Academy of Family Physicians. Family medicine residency curriculum guidelines. Point of care ultrasound. https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint290D_POCUS.pdf. Accessed January 22, 2018.

 

 

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