An Increased Focus on Developing Local POCUS Programs to Augment Care

Point-of-care ultrasonography (POCUS) is an invaluable bedside tool widely recognized for improving diagnostic accuracy and supporting management decisions in many areas of medicine, including pediatrics.1 Moreover, integration of POCUS has resulted in tangible benefits, including improved clinical outcomes,2,3 reduced delays in care,2,4,5 decreased exposure to ionizing radiation,6,7 shorter hospital stays,4,6,8 increased patient satisfaction,9–11 and enhanced revenue generation for both providers and divisions.4,6,12 In this issue, Fennell et al outline the effectiveness of POCUS at improving clinical outcomes in pediatric hospitalizations at a single hospital in their registry study.3 Although their findings are limited by being an observational rather than prospective study, the authors found that approximately half of diagnostic and management changes were effectuated by POCUS, half of lumbar puncture (LP) attempts were salvaged by POCUS, and the vast majority of vascular cases avoided central venous access. This adds to a growing body of evidence that supports the utility and value of POCUS in pediatric hospital medicine (PHM).Despite these advantages, recent national data show that only 17% of PHM divisions report having a formal POCUS program, highlighting the slower adoption relative to other specialties.13 So what barriers exactly hinder broader implementation of POCUS into PHM and how can these be overcome? Major obstacles include the need for organized training, education, financial investment, and administrative buy-in, which can ensure availability of resources needed to successfully implement a POCUS program. This includes readily accessible ultrasonography machines, integration of imaging databases, and faculty who have time dedicated to run the POCUS program and perform quality assurance.It is essential that pediatric residency and PHM fellowship training more consistently incorporate POCUS education. Recent surveys estimate that only 12% to 17% of pediatric residency programs offer formalized POCUS curricula, leaving new graduates with limited experience and confidence in using the technology.14,15 This training gap will further be widened by changes in the Accreditation Council for Graduate Medical Education pediatric residency requirements that increase ambulatory care time while reducing inpatient time. Presumably, this may reduce pediatric trainees’ exposure to inpatient procedural skills and ultrasonography techniques. Local program development can facilitate increased exposure to POCUS in pediatrics by regularly incorporating it into pediatric hospital medicine training at both the graduate and continuing medical education levels.Programs adapted to meet local needs may have better frameworks to teach learners at all levels from undergraduate to graduate to faculty. This will result in consistency in knowledge base, shared cases, and faculty availability, which in turn may result in improved outcomes with more steadfast integration of POCUS. Longitudinal, hands-on curricula that start with high-yield applications in PHM—such as lung ultrasonography and LP guidance—have proven effective for integrating a new program. This allows for incremental adoption as faculty proficiency increases.13,14,16Collaboration between local divisions with already established POCUS expertise, such as pediatric emergency medicine, critical care, or other departments such as family practice or internal medicine, is an effective approach for bringing mentorship and shared curriculum resources to PHM.16 Shared collaborative efforts can also streamline care and foster improved interdepartmental relations and teamwork, allowing for further growth, steering strategies, and potential academic output.Engaging with national professional organizations (eg, American Academy of Pediatrics, Society of Hospital Medicine) and listservs (POCUS in Pediatrics) can expand professional networks and allow faculty pursuit of certificates and continuing medical education, which provide resources for sustaining growth and building a community of practice. Additionally, if local institutional expertise is lacking, inter-institutional collaboration can be fostered through these professional networks to support program development. National template designs, such as the CHEST and SHM Certificate of Completion, can be used directly or can be modified and instituted locally for initial training.Establishing a program locally can provide opportunities for faculty development and further academic missions of medical centers. Given that the usual rate-limiting step of programs is having faculty with POCUS knowledge and teaching ability, institutions can invest in faculty training and provide funded time for select faculty. Use and integration of POCUS can lend itself to a plethora of quality improvement and research projects. Novel methods of diagnosis and management can be considered by employing new care paradigms including POCUS. Local champions can grow skillsets to become national experts, by building faculty portfolios and increasing academic output. These faculty can then help programs flourish, improve sustainability, and promote faculty academic advancement, which in turn can lead to reduced faculty turnover and associated costs.It is crucial that pediatric hospitalists advocate and highlight to administrative leaders within their institutions the clinical utility and cost-effectiveness of POCUS. Administrative perceptions and concerns about cost is a barrier for POCUS adoption, particularly in divisions lacking internal champions or dedicated experts.13 PHM divisions commonly report a lack of local mentorship, insufficient administrative buy-in, and poorly defined credentialing pathways as primary impediments when attempting to grow or sustain a POCUS program.17 To address these issues, PHM divisions should seek to identify internal champions who can advocate for resources and help develop credentialing pathways in their institutions.Program development requires financial investment. Many of these costs are one-time capital investments for establishing infrastructure, but long-term benefits of POCUS programs can help recoup these costs and improve long term financial productivity in addition to academic advancement. Initial costs of supporting a POCUS program include the purchasing of ultrasonography equipment, establishing image archiving systems, and investing in faculty credentialing and continued training.13,17 Direct billing may increase relative value unit generation.18,19 The American College of Emergency Physicians has published POCUS billing guidelines that have become the gold standard for all POCUS-practicing providers.20 Some specialties have tailored this guideline for their disciplines: family medicine,21 neonatology,22 adult critical care,23 and anesthesiology.24 Additional financial benefits may include improved hospital throughput4,6,8; enhanced clinical outcomes2–5; and greater patient satisfaction.9–11 Costs may be mitigated through initial intra-institutional department cost sharing or device lending from other departments that employ POCUS. Securing sustainable financial support—whether through hospital foundations, institutional grants, or targeted funding for technology and patient safety—often determines long-term program success.25 These resources can be secured by providing a compelling value proposition emphasizing improved patient care, revenue generation, and alignment with national evidence-based recommendations.1,13Although POCUS is an emerging tool within PHM, there is precedent of its use and clear demonstration of its benefit among other specialties. Ongoing collaboration, curriculum innovation, and persistent advocacy from local champions are leading to broader implementation. These efforts, further supported by national organizations, are transforming pediatric hospital care and promoting substantial improvements in diagnostic efficiency, procedural safety, and outcomes for children.1,3,13 Pediatric hospitals should invest in opportunities to develop local programs to improve uptake, increase faculty development, further research, and provide high-value care.