Point-of-Care Ultrasound: A Practical Guide for Primary Care

 

Ultrasound has head-to-toe applications for primary care, and the newest machines are portable and affordable enough to fit into almost any practice.

Fam Pract Manag. 2020 Nov-Dec;27(6):33-40.

Author disclosures: Dr. Deutchman is on the medical advisory board of EchoNous, a point-of-care ultrasound device manufacturer. It is an unpaid position. He also owns stock in the company. No other relevant financial affiliations disclosed.

Related article from American Family Physician: "Point-of-Care Ultrasonography."

Family physicians can order a wide range of imaging services for patients. But barriers such as time, money, and physical distance sometimes prevent patients from accessing those services, causing gaps in care. Incorporating point-of-care ultrasound (POCUS) into clinical practice is one way to bridge those gaps.

Technological advancements have allowed more physicians to bring ultrasound services to the office visit or bedside, and to make POCUS an integral part of practice. I [Dr. Deutchman] was an early adopter, adding ultrasound to my rural practice in 1980 after delivering a surprise set of twins in the wee hours of the morning. I have never since been surprised by twins, nor missed an ectopic pregnancy. In addition, I [Dr. Shen-Wagner] first used POCUS during residency in 2011, after a patient complained that it felt like her intrauterine device (IUD) had moved. Everything looked normal on the pelvic exam, but a hand-me-down ultrasound machine from the clinic's obstetrics department revealed the unmistakable flutter of a tiny heartbeat. The patient was pregnant, despite having an IUD for three years.

These are just two examples of the many ways POCUS can benefit doctors and patients. There is robust evidence that POCUS improves care in critically ill patients and improves the efficiency and safety of many invasive ambulatory surgeries that are otherwise performed blindly or by anatomic landmarks.1 There is also preliminary but growing evidence that POCUS can improve diagnostic capabilities, expedite patient care, and inform bedside treatment and management.2,3 Most recently, POCUS has proven to be a valuable tool for confirming COVID-19 diagnoses, as well as monitoring some symptoms of the disease.4

The hands-on, “showing while telling” nature of POCUS advances physical diagnosis skills, fosters doctor-patient communication, and increases patient satisfaction.5 This article outlines some common uses for POCUS and explains how to add it to a practice.

KEY POINTS

  • Advances in technology have made ultrasound machines more portable and affordable, increasing their accessibility for primary care clinicians.

  • Point-of-care ultrasound beginners should start with impactful procedures that are easy to perform, simple to interpret, and relatively low liability for both patient and physician. Move on to more complex uses only after those are learned.

  • Pocket-sized ultrasound machines cost $2,000 to $10,000, plus the costs of gel, probe covers, and cleaning supplies. But several high-yield ultrasound codes can help recoup those expenses.

ABOUT THE AUTHORS

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Dr. Shen-Wagner is the family medicine point-of-care ultrasound director at Prisma Health-Upstate in Greenville, S.C. She is also the family medicine clerkship director at the University of South Carolina School of Medicine-Greenville and core faculty for the school's family medicine residency program....

Dr. Deutchman is professor of family medicine, associate dean for rural health, and director of the rural medicine track at the University of Colorado School of Medicine.

Author disclosures: Dr. Deutchman is on the medical advisory board of EchoNous, a point-of-care ultrasound device manufacturer. It is an unpaid position. He also owns stock in the company. No other relevant financial affiliations disclosed.

References

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1. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev. 2015;1(1):CD006962....

2. Wagner M, Shen-Wagner J, Zhang KX, Flynn T, Bergman K. Point-of-care ultrasound applications in the outpatient clinic. South Med J. 2018;111(7):404–410.

3. Arnold MJ, Jonas CE, Carter RE. Point-of-care ultrasonography. Am Fam Physician. 2020;101(5):275–285.

4. Mathews BK, Koenig S, Kurian L, et al. Clinical progress note: point-of-care ultrasound applications in COVID-19. J Hosp Med. 2020;15(6):353–355.

5. Howard ZD, Noble VE, Marill KA, et al. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014;46(1):46–53.

6. Bornemann P, Jayasekera N, Bergman K, Ramos M, Gerhart J. Point-of-care ultrasound: Coming soon to primary care?. J Fam Pract. 2018;67(2):70–80.

7. Bonnel AR, Baston CM, Wallace P, Panebianco N, Kinosian B. Using point-of-care ultrasound on home visits: the home-oriented ultrasound examination (HOUSE). Letter. J Am Geriatr Soc. 2019;67(12):2662–2663.

8. Adhikari S, Blaivas M. Sonography first for subcutaneous abscess and cellulitis evaluation. J Ultrasound Med. 2012;31(10):1509–1512.

9. Mantuani D, Frazee BW, Fahimi J, Nagdev A. Point-of-care multi-organ ultrasound improves diagnostic accuracy in adults presenting to the emergency department with acute dyspnea. West J Emerg Med. 2016;17(1):46–53.

10. Privileging for ultrasound imaging H-230.960. American Medical Association Council on Medical Service. 2020. Accessed Sept. 3, 2020. https://policyse-arch.ama-assn.org/policyfinder/detail/Ultrasound%20imaging?uri=%2FAMADoc%2FHOD.xml-0-1591.xml

11. Recommended curriculum guidelines for family medicine residents: point of care ultrasound (AAFP reprint No. 290D). American Academy of Family Physicians. Accessed Sept. 3, 2020. https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint290D_POCUS.pdf

12. American Institute of Ultrasound in Medicine. AIUM practice parameter for documentation of an ultrasound examination J Ultrasound Med. 2020;39(1):E1–E4.

13. Standard reporting guidelines: ultrasound for procedure guidance. American College of Emergency Physicians. May 2015. Accessed Sept. 3, 2020. https://www.acep.org/globalassets/uploads/uploaded-files/acep/by-medical-focus/ultrasound/eus-srg-proc-guidmay2015_final.pdf

14. Liu RB, Blaivas M, Moore C, et al. Emergency ultrasound standard reporting guidelines. American College of Emergency Physicians. June 2018. Accessed Sept. 3, 2020. https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/policy-statements/information-papers/emergency-ultrasound-standard-reporting-guidelines---2018.pdf

15. Digest of council actions 2019–2020 (appendix E). American College of Radiology. Accessed Sept. 3, 2020. https://www.acr.org/-/media/ACR/Files/Governance/Digest-of-Council-Actions.pdf

16. A rational approach to disinfection and sterilization. Centers for Disease Control and Prevention. Sept. 18, 2016. Accessed Sept. 3, 2020. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/rational-approach.html

17. Guidelines for cleaning and preparing external- and internal-use ultrasound transducers and equipment between patients as well as safe handling and use of ultrasound coupling gel. American Institute of Ultrasound in Medicine. March 27, 2020. Accessed Sept. 3, 2020. https://www.aium.org/officialStatements/57

18. List N: disinfectants for Coronavirus (COVID-19). United States Environmental Protection Agency. Updated Oct.5, 2020. Accessed Oct. 8, 2020. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2

19. Akkus Z, Cai J, Boonrod A, et al. A survey of deep-learning applications in ultrasound: Artificial intelligence-powered ultrasound for improving clinical workflow. J Am Coll Radiol. 2019:16(9 Pt B):1318–1328.

 
 

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