Matthew Kelleher, MD, MEd

The coronavirus disease of 2019 (COVID-19) pandemic has strained the healthcare system by rapidly depleting multiple resources including hospital space, medications, ventilators, personal protective equipment (PPE), clinical revenue, and morale. One of the most essential at-risk resources is healthcare providers. Healthcare providers have been overwhelmed as hospital systems have experienced local surges in COVID-19 patients. Compounding this is the fact that providers are more likely to contract COVID-19, which could sideline portions of an already taxed workforce.

Multiple “surge” interventions have been planned or implemented to mitigate a current or anticipated dearth of physicians. Some institutions are reallocating subspecialists and surgeons to general ward and intensive care unit (ICU) roles, often with support from hospitalists and ICU physicians.¹ Others have used telemedicine to reduce personnel exposure and conserve PPE.² A novel and perhaps paradigm-shifting solution arose in March 2020 when several medical schools around the world announced they would graduate final year students early to allow them to join the workforce during the COVID-19 surge.^3-7 In the United States, fourth-year medical students at multiple institutions in cities such as New York, Boston, Phoenix, Tucson, Newark, Portland, and Bethesda were offered the opportunity to graduate in April rather than in May or June. The Liaison Committee on Medical Education stated that for students to graduate early, they must have already met all curricular requirements and be deemed ready by an evaluations and promotions committee.⁸ What these early graduates do with their “gap time” before residency is neither standardized nor prescribed. The Accreditation Council for Graduate Medical Education has discouraged individuals from joining their newly matched residency programs early.⁹ Some early graduates who wish to bolster the workforce have signed temporary training agreements with local healthcare systems to work for a 1- to 2-month period before moving on to their matched residency program. Some institutions have already been working with local and state officials to rapidly grant provisional temporary licenses for this purpose.¹⁰

Early medical school graduation in times of international crisis is not without precedent. When faced with physician shortages during World War II, the United States federal government urged medical colleges to graduate trainees in 3 years.¹¹ The national medical education milieu was different then, with standardized medical school training still crystalizing merely 30 years following the Flexner report. However, there was pressure from the federal government during World War II, whereas decisions around early graduation today are driven by institutional and local officials. While a few accelerated programs persist today, there has not been an urgent, unplanned early release of graduates to meet a public health need on such a large scale in recent history. The seasonal timing of the pandemic surge in the United States may have been a key factor in deciding to graduate students early. With a late winter and early spring peak, final year students are graduating only 2 to 3 months early. But what if another peak occurs in late summer or early fall, and some students are graduated even earlier? With which aspects of patient care would hospitalists trust these graduates, and with what level of supervision? Whether now or with a future COVID-19 peak, we describe how trust develops with learners and provide hospitalists with a framework for deliberate entrustment if and when they are asked to integrate early medical school graduates into their workforce.

The degree of supervision that is provided to a learner is linked to how much a supervisor trusts the learner, as well as the specific context. Trust has many forms, often depending on what type of information informs it. Presumptive trust is trust based on credentials, without any actual interaction with the learner.¹² Healthcare systems typically assume that medical school graduates are ready to perform intern-level tasks based on their medical degree. This presumptive trust may be bolstered by the assumption that a residency program director has vetted a learner’s credentials during the match process. On meeting a learner, we develop initial trust, which is based on first impressions and snap-judgment. Over time, presumptive and initial trust can be replaced by grounded trust, or trust based on demonstrated performance after prolonged experience with a learner. Under normal circumstances, supervisors use observations of learner performance in the clinical environment to develop grounded trust. With early graduates, especially those who sign temporary work agreements, the usual progression of trust may be compressed. Hospitalists may have less presumptive trust because these students graduated early and little time to develop grounded trust before integrating new graduates into patient care. How should hospitalists navigate supervision in this setting?

Missing a few months at the end of medical school likely does not significantly affect competence and, therefore, should not affect presumptive trust. The value of the fourth year of medical school has been questioned because, after fulfilling graduation requirements, students often spend significant amounts of time interviewing, traveling, taking electives with lighter workloads, or exploring nonclinical interests late in the year.¹³ More intense “subintern” rotations, which are important for the residency application process, occur earlier in the academic year. It is therefore reasonable to presume that most students graduating in April are not less prepared than those graduating in June.

Additionally, there is significant interlearner variability in rates of competence attainment.¹⁴ This means that there is no magic point in time at which students are fully ready for resident-­level responsibilities. Some students are likely competent to be interns without a fourth year at all, while others are still facing challenges in their development at the end of medical school. As Englander and Carraccio wrote, “The notion that every medical student across the nation has somehow achieved all the competencies necessary to start residency training on July 1 of their graduation year is magical thinking.”¹⁵ Since there is no universal, time-based finish line for competence, we should not be thrown by a slight change in the arbitrary line currently drawn in June. Whether students graduate in April or June, it remains true that some will be more ready than others.

With compressed timelines, hospitalists may default to initial trust, relying heavily on first impressions to determine how much supervision an early graduate requires. For example, a graduate who is extroverted, assertive, and articulate may give off an air of confidence, which could entice a supervising hospitalist to give a “longer leash” with higher-risk patient care tasks. It is easy to fall prey to the “confidence equals competence” heuristic, but this has been shown to be unreliable.¹⁶ Initial trust is influenced by both social biases (eg, gender, race, age) and cognitive biases (eg, halo effect) that have little or nothing to do with the actual abilities of learners. While initial trust and accompanying biases often develop unconsciously, it is important to reflect on how unfounded first impressions can influence trust and supervision decisions.

Hospitalists must be deliberate with entrustment decisions, especially in a pandemic environment. There are useful guides for making these decisions that can be used in a point-of-care manner.¹⁷ First, it is important to acknowledge that entrustment is based in part on the perceived trustworthiness of a person. Kennedy and colleagues have described four components of trustworthiness, all of which can be assessed by hospitalists in the moment of care delivery: (1) knowledge and skill (Does the trainee possess the requisite knowledge and skill to perform the task?), (2) conscientiousness (Does the trainee follow through on tasks? Are they thorough and dependable?), (3) discernment (Does the trainee recognize personal limitations and seek help when needed?), and (4) truthfulness (Does the trainee tell the truth?).¹⁷

Entrustment decisions also depend on the specific task being observed (eg, high risk vs low risk) and context (eg, severity of illness of the patient, acuity of the setting).¹⁸ Trust is linked with perceived risk and benefits.¹⁹ More entrustment (less supervision) may be given when perceived risk is low, such as prescribing acetaminophen on a stable patient or taking an initial history. Less entrustment (more supervision) may be given when perceived risk is high, such as with managing septic shock or inserting a central venous catheter. However, the duress of the COVID-19 pandemic may tilt the risk/benefit balance toward less-than-usual supervision if an early graduate is the only provider available for some higher-risk tasks. This underscores the importance of direct observation leading to grounded trust with progressively higher-risk tasks as dictated by the local pandemic environment.

As much as possible, trust should be determined based on direct observation, not fallible first impressions or inference. Supervisors often use inference when assuming that performance on one task reflects performance on others. For example, if learners are observed to be competent when interpreting electrocardiograms, one might infer they also know how to manage tachyarrhythmias. If they can manage tachyarrhythmias, one might infer they also know how to manage acute coronary syndrome. These inferences are not the way to build grounded trust because competence is task and context dependent.

Direct observation can include watching patient interactions, being present for procedures, think-alouds during didactics, cognitive autopsies, reviewing notes, and informal conversations. Being deliberate with direct observation and entrustment decision-making can be challenging because of the high cognitive load of caring for sick and complex patients, maintaining proper PPE practices, and simultaneously assessing an early graduate’s performance. However, maintaining a level of supervision that is appropriate for trainee competence is paramount for patient safety. It may be valuable to identify tasks needing to be performed by early graduates and using focused simulation to generate a significant number of observations over a short period of time. Trust should be gained once competence is observed, not inferred or assumed. Instead of “trust, but verify,” we should “observe, then trust.”

There is a moral obligation to patients to avoid placing trainees in situations for which they are ill prepared based on their current abilities. We must balance the risk that exists both in leaving early graduates on the sidelines (overprotecting them as learners) and in asking them to perform tasks for which they are not prepared (overextending them as a workforce). Focusing on grounded trust derived from direct observation of performance while also balancing the risks and benefits inherent in the local pandemic context can help hospitalists calibrate supervision to a level that helps extend the workforce in a time of crisis while maintaining patient safety.

The coronavirus disease of 2019 (COVID-19) pandemic has strained the healthcare system by rapidly depleting multiple resources including hospital space, medications, ventilators, personal protective equipment (PPE), clinical revenue, and morale. One of the most essential at-risk resources is healthcare providers. Healthcare providers have been overwhelmed as hospital systems have experienced local surges in COVID-19 patients. Compounding this is the fact that providers are more likely to contract COVID-19, which could sideline portions of an already taxed workforce.

Multiple “surge” interventions have been planned or implemented to mitigate a current or anticipated dearth of physicians. Some institutions are reallocating subspecialists and surgeons to general ward and intensive care unit (ICU) roles, often with support from hospitalists and ICU physicians.¹ Others have used telemedicine to reduce personnel exposure and conserve PPE.² A novel and perhaps paradigm-shifting solution arose in March 2020 when several medical schools around the world announced they would graduate final year students early to allow them to join the workforce during the COVID-19 surge.^3-7 In the United States, fourth-year medical students at multiple institutions in cities such as New York, Boston, Phoenix, Tucson, Newark, Portland, and Bethesda were offered the opportunity to graduate in April rather than in May or June. The Liaison Committee on Medical Education stated that for students to graduate early, they must have already met all curricular requirements and be deemed ready by an evaluations and promotions committee.⁸ What these early graduates do with their “gap time” before residency is neither standardized nor prescribed. The Accreditation Council for Graduate Medical Education has discouraged individuals from joining their newly matched residency programs early.⁹ Some early graduates who wish to bolster the workforce have signed temporary training agreements with local healthcare systems to work for a 1- to 2-month period before moving on to their matched residency program. Some institutions have already been working with local and state officials to rapidly grant provisional temporary licenses for this purpose.¹⁰

Early medical school graduation in times of international crisis is not without precedent. When faced with physician shortages during World War II, the United States federal government urged medical colleges to graduate trainees in 3 years.¹¹ The national medical education milieu was different then, with standardized medical school training still crystalizing merely 30 years following the Flexner report. However, there was pressure from the federal government during World War II, whereas decisions around early graduation today are driven by institutional and local officials. While a few accelerated programs persist today, there has not been an urgent, unplanned early release of graduates to meet a public health need on such a large scale in recent history. The seasonal timing of the pandemic surge in the United States may have been a key factor in deciding to graduate students early. With a late winter and early spring peak, final year students are graduating only 2 to 3 months early. But what if another peak occurs in late summer or early fall, and some students are graduated even earlier? With which aspects of patient care would hospitalists trust these graduates, and with what level of supervision? Whether now or with a future COVID-19 peak, we describe how trust develops with learners and provide hospitalists with a framework for deliberate entrustment if and when they are asked to integrate early medical school graduates into their workforce.

The degree of supervision that is provided to a learner is linked to how much a supervisor trusts the learner, as well as the specific context. Trust has many forms, often depending on what type of information informs it. Presumptive trust is trust based on credentials, without any actual interaction with the learner.¹² Healthcare systems typically assume that medical school graduates are ready to perform intern-level tasks based on their medical degree. This presumptive trust may be bolstered by the assumption that a residency program director has vetted a learner’s credentials during the match process. On meeting a learner, we develop initial trust, which is based on first impressions and snap-judgment. Over time, presumptive and initial trust can be replaced by grounded trust, or trust based on demonstrated performance after prolonged experience with a learner. Under normal circumstances, supervisors use observations of learner performance in the clinical environment to develop grounded trust. With early graduates, especially those who sign temporary work agreements, the usual progression of trust may be compressed. Hospitalists may have less presumptive trust because these students graduated early and little time to develop grounded trust before integrating new graduates into patient care. How should hospitalists navigate supervision in this setting?

Missing a few months at the end of medical school likely does not significantly affect competence and, therefore, should not affect presumptive trust. The value of the fourth year of medical school has been questioned because, after fulfilling graduation requirements, students often spend significant amounts of time interviewing, traveling, taking electives with lighter workloads, or exploring nonclinical interests late in the year.¹³ More intense “subintern” rotations, which are important for the residency application process, occur earlier in the academic year. It is therefore reasonable to presume that most students graduating in April are not less prepared than those graduating in June.

Additionally, there is significant interlearner variability in rates of competence attainment.¹⁴ This means that there is no magic point in time at which students are fully ready for resident-­level responsibilities. Some students are likely competent to be interns without a fourth year at all, while others are still facing challenges in their development at the end of medical school. As Englander and Carraccio wrote, “The notion that every medical student across the nation has somehow achieved all the competencies necessary to start residency training on July 1 of their graduation year is magical thinking.”¹⁵ Since there is no universal, time-based finish line for competence, we should not be thrown by a slight change in the arbitrary line currently drawn in June. Whether students graduate in April or June, it remains true that some will be more ready than others.

With compressed timelines, hospitalists may default to initial trust, relying heavily on first impressions to determine how much supervision an early graduate requires. For example, a graduate who is extroverted, assertive, and articulate may give off an air of confidence, which could entice a supervising hospitalist to give a “longer leash” with higher-risk patient care tasks. It is easy to fall prey to the “confidence equals competence” heuristic, but this has been shown to be unreliable.¹⁶ Initial trust is influenced by both social biases (eg, gender, race, age) and cognitive biases (eg, halo effect) that have little or nothing to do with the actual abilities of learners. While initial trust and accompanying biases often develop unconsciously, it is important to reflect on how unfounded first impressions can influence trust and supervision decisions.

Hospitalists must be deliberate with entrustment decisions, especially in a pandemic environment. There are useful guides for making these decisions that can be used in a point-of-care manner.¹⁷ First, it is important to acknowledge that entrustment is based in part on the perceived trustworthiness of a person. Kennedy and colleagues have described four components of trustworthiness, all of which can be assessed by hospitalists in the moment of care delivery: (1) knowledge and skill (Does the trainee possess the requisite knowledge and skill to perform the task?), (2) conscientiousness (Does the trainee follow through on tasks? Are they thorough and dependable?), (3) discernment (Does the trainee recognize personal limitations and seek help when needed?), and (4) truthfulness (Does the trainee tell the truth?).¹⁷

Entrustment decisions also depend on the specific task being observed (eg, high risk vs low risk) and context (eg, severity of illness of the patient, acuity of the setting).¹⁸ Trust is linked with perceived risk and benefits.¹⁹ More entrustment (less supervision) may be given when perceived risk is low, such as prescribing acetaminophen on a stable patient or taking an initial history. Less entrustment (more supervision) may be given when perceived risk is high, such as with managing septic shock or inserting a central venous catheter. However, the duress of the COVID-19 pandemic may tilt the risk/benefit balance toward less-than-usual supervision if an early graduate is the only provider available for some higher-risk tasks. This underscores the importance of direct observation leading to grounded trust with progressively higher-risk tasks as dictated by the local pandemic environment.

As much as possible, trust should be determined based on direct observation, not fallible first impressions or inference. Supervisors often use inference when assuming that performance on one task reflects performance on others. For example, if learners are observed to be competent when interpreting electrocardiograms, one might infer they also know how to manage tachyarrhythmias. If they can manage tachyarrhythmias, one might infer they also know how to manage acute coronary syndrome. These inferences are not the way to build grounded trust because competence is task and context dependent.

Direct observation can include watching patient interactions, being present for procedures, think-alouds during didactics, cognitive autopsies, reviewing notes, and informal conversations. Being deliberate with direct observation and entrustment decision-making can be challenging because of the high cognitive load of caring for sick and complex patients, maintaining proper PPE practices, and simultaneously assessing an early graduate’s performance. However, maintaining a level of supervision that is appropriate for trainee competence is paramount for patient safety. It may be valuable to identify tasks needing to be performed by early graduates and using focused simulation to generate a significant number of observations over a short period of time. Trust should be gained once competence is observed, not inferred or assumed. Instead of “trust, but verify,” we should “observe, then trust.”

There is a moral obligation to patients to avoid placing trainees in situations for which they are ill prepared based on their current abilities. We must balance the risk that exists both in leaving early graduates on the sidelines (overprotecting them as learners) and in asking them to perform tasks for which they are not prepared (overextending them as a workforce). Focusing on grounded trust derived from direct observation of performance while also balancing the risks and benefits inherent in the local pandemic context can help hospitalists calibrate supervision to a level that helps extend the workforce in a time of crisis while maintaining patient safety.

The coronavirus disease of 2019 (COVID-19) pandemic has strained the healthcare system by rapidly depleting multiple resources including hospital space, medications, ventilators, personal protective equipment (PPE), clinical revenue, and morale. One of the most essential at-risk resources is healthcare providers. Healthcare providers have been overwhelmed as hospital systems have experienced local surges in COVID-19 patients. Compounding this is the fact that providers are more likely to contract COVID-19, which could sideline portions of an already taxed workforce.

Multiple “surge” interventions have been planned or implemented to mitigate a current or anticipated dearth of physicians. Some institutions are reallocating subspecialists and surgeons to general ward and intensive care unit (ICU) roles, often with support from hospitalists and ICU physicians.¹ Others have used telemedicine to reduce personnel exposure and conserve PPE.² A novel and perhaps paradigm-shifting solution arose in March 2020 when several medical schools around the world announced they would graduate final year students early to allow them to join the workforce during the COVID-19 surge.^3-7 In the United States, fourth-year medical students at multiple institutions in cities such as New York, Boston, Phoenix, Tucson, Newark, Portland, and Bethesda were offered the opportunity to graduate in April rather than in May or June. The Liaison Committee on Medical Education stated that for students to graduate early, they must have already met all curricular requirements and be deemed ready by an evaluations and promotions committee.⁸ What these early graduates do with their “gap time” before residency is neither standardized nor prescribed. The Accreditation Council for Graduate Medical Education has discouraged individuals from joining their newly matched residency programs early.⁹ Some early graduates who wish to bolster the workforce have signed temporary training agreements with local healthcare systems to work for a 1- to 2-month period before moving on to their matched residency program. Some institutions have already been working with local and state officials to rapidly grant provisional temporary licenses for this purpose.¹⁰

Early medical school graduation in times of international crisis is not without precedent. When faced with physician shortages during World War II, the United States federal government urged medical colleges to graduate trainees in 3 years.¹¹ The national medical education milieu was different then, with standardized medical school training still crystalizing merely 30 years following the Flexner report. However, there was pressure from the federal government during World War II, whereas decisions around early graduation today are driven by institutional and local officials. While a few accelerated programs persist today, there has not been an urgent, unplanned early release of graduates to meet a public health need on such a large scale in recent history. The seasonal timing of the pandemic surge in the United States may have been a key factor in deciding to graduate students early. With a late winter and early spring peak, final year students are graduating only 2 to 3 months early. But what if another peak occurs in late summer or early fall, and some students are graduated even earlier? With which aspects of patient care would hospitalists trust these graduates, and with what level of supervision? Whether now or with a future COVID-19 peak, we describe how trust develops with learners and provide hospitalists with a framework for deliberate entrustment if and when they are asked to integrate early medical school graduates into their workforce.

The degree of supervision that is provided to a learner is linked to how much a supervisor trusts the learner, as well as the specific context. Trust has many forms, often depending on what type of information informs it. Presumptive trust is trust based on credentials, without any actual interaction with the learner.¹² Healthcare systems typically assume that medical school graduates are ready to perform intern-level tasks based on their medical degree. This presumptive trust may be bolstered by the assumption that a residency program director has vetted a learner’s credentials during the match process. On meeting a learner, we develop initial trust, which is based on first impressions and snap-judgment. Over time, presumptive and initial trust can be replaced by grounded trust, or trust based on demonstrated performance after prolonged experience with a learner. Under normal circumstances, supervisors use observations of learner performance in the clinical environment to develop grounded trust. With early graduates, especially those who sign temporary work agreements, the usual progression of trust may be compressed. Hospitalists may have less presumptive trust because these students graduated early and little time to develop grounded trust before integrating new graduates into patient care. How should hospitalists navigate supervision in this setting?

Missing a few months at the end of medical school likely does not significantly affect competence and, therefore, should not affect presumptive trust. The value of the fourth year of medical school has been questioned because, after fulfilling graduation requirements, students often spend significant amounts of time interviewing, traveling, taking electives with lighter workloads, or exploring nonclinical interests late in the year.¹³ More intense “subintern” rotations, which are important for the residency application process, occur earlier in the academic year. It is therefore reasonable to presume that most students graduating in April are not less prepared than those graduating in June.

Additionally, there is significant interlearner variability in rates of competence attainment.¹⁴ This means that there is no magic point in time at which students are fully ready for resident-­level responsibilities. Some students are likely competent to be interns without a fourth year at all, while others are still facing challenges in their development at the end of medical school. As Englander and Carraccio wrote, “The notion that every medical student across the nation has somehow achieved all the competencies necessary to start residency training on July 1 of their graduation year is magical thinking.”¹⁵ Since there is no universal, time-based finish line for competence, we should not be thrown by a slight change in the arbitrary line currently drawn in June. Whether students graduate in April or June, it remains true that some will be more ready than others.

With compressed timelines, hospitalists may default to initial trust, relying heavily on first impressions to determine how much supervision an early graduate requires. For example, a graduate who is extroverted, assertive, and articulate may give off an air of confidence, which could entice a supervising hospitalist to give a “longer leash” with higher-risk patient care tasks. It is easy to fall prey to the “confidence equals competence” heuristic, but this has been shown to be unreliable.¹⁶ Initial trust is influenced by both social biases (eg, gender, race, age) and cognitive biases (eg, halo effect) that have little or nothing to do with the actual abilities of learners. While initial trust and accompanying biases often develop unconsciously, it is important to reflect on how unfounded first impressions can influence trust and supervision decisions.

Hospitalists must be deliberate with entrustment decisions, especially in a pandemic environment. There are useful guides for making these decisions that can be used in a point-of-care manner.¹⁷ First, it is important to acknowledge that entrustment is based in part on the perceived trustworthiness of a person. Kennedy and colleagues have described four components of trustworthiness, all of which can be assessed by hospitalists in the moment of care delivery: (1) knowledge and skill (Does the trainee possess the requisite knowledge and skill to perform the task?), (2) conscientiousness (Does the trainee follow through on tasks? Are they thorough and dependable?), (3) discernment (Does the trainee recognize personal limitations and seek help when needed?), and (4) truthfulness (Does the trainee tell the truth?).¹⁷

Entrustment decisions also depend on the specific task being observed (eg, high risk vs low risk) and context (eg, severity of illness of the patient, acuity of the setting).¹⁸ Trust is linked with perceived risk and benefits.¹⁹ More entrustment (less supervision) may be given when perceived risk is low, such as prescribing acetaminophen on a stable patient or taking an initial history. Less entrustment (more supervision) may be given when perceived risk is high, such as with managing septic shock or inserting a central venous catheter. However, the duress of the COVID-19 pandemic may tilt the risk/benefit balance toward less-than-usual supervision if an early graduate is the only provider available for some higher-risk tasks. This underscores the importance of direct observation leading to grounded trust with progressively higher-risk tasks as dictated by the local pandemic environment.

As much as possible, trust should be determined based on direct observation, not fallible first impressions or inference. Supervisors often use inference when assuming that performance on one task reflects performance on others. For example, if learners are observed to be competent when interpreting electrocardiograms, one might infer they also know how to manage tachyarrhythmias. If they can manage tachyarrhythmias, one might infer they also know how to manage acute coronary syndrome. These inferences are not the way to build grounded trust because competence is task and context dependent.

Direct observation can include watching patient interactions, being present for procedures, think-alouds during didactics, cognitive autopsies, reviewing notes, and informal conversations. Being deliberate with direct observation and entrustment decision-making can be challenging because of the high cognitive load of caring for sick and complex patients, maintaining proper PPE practices, and simultaneously assessing an early graduate’s performance. However, maintaining a level of supervision that is appropriate for trainee competence is paramount for patient safety. It may be valuable to identify tasks needing to be performed by early graduates and using focused simulation to generate a significant number of observations over a short period of time. Trust should be gained once competence is observed, not inferred or assumed. Instead of “trust, but verify,” we should “observe, then trust.”

There is a moral obligation to patients to avoid placing trainees in situations for which they are ill prepared based on their current abilities. We must balance the risk that exists both in leaving early graduates on the sidelines (overprotecting them as learners) and in asking them to perform tasks for which they are not prepared (overextending them as a workforce). Focusing on grounded trust derived from direct observation of performance while also balancing the risks and benefits inherent in the local pandemic context can help hospitalists calibrate supervision to a level that helps extend the workforce in a time of crisis while maintaining patient safety.

Point-of-care ultrasound (POCUS) continues to gain traction in contemporary clinical practice both as a diagnostic tool and as an extension of the physical examination. Hospital Medicine (HM) lags behind Emergency Medicine (EM) and Critical Care (CC) in our uptake of such technology, although momentum is gaining. Leaders in HM have published frameworks for competency and credentialing, and the Society for Hospital Medicine has created a pathway for certification.¹ POCUS use is the standard of care for several bedside procedures, but evidence for diagnostic applications is changing rapidly as the literature expands. However, the applicability of this evidence to HM patients can be challenging as most published studies are still from EM and CC settings. This Progress Note focuses on how a hospitalist might incorporate POCUS in the evaluation of adult patients with dyspnea. This topic was chosen after reviewing several relevant studies published in the past five years and recognizing the importance of dyspnea in HM. The Progress Note begins with a review of POCUS for undifferentiated dyspnea before exploring studies of common diagnoses that present with dyspnea, including pneumonia, pleural effusion, and acute decompensated heart failure (ADHF), aiming to update the knowledge of HM providers regarding this technology as well as to stimulate further study in this field.

In collaboration with an academic librarian in March 2019, PubMed was searched for studies published within the past five years using several MESH search terms for POCUS. The search was originally focused to the field of HM using specific search terms, but this yielded a very limited number of studies. Therefore, the search strategy was expanded to include EM and CC studies. This final search generated 346 papers that were supplemented with additional literature searches using references from studies found in the initial search.

Dyspnea is common in HM, both as the reason for a patient’s admission and as a symptom that develops during hospitalization such as after intravenous fluid resuscitation, a possible aspiration event, or central line placement. The differential diagnosis is broad, and multiple studies suggest that POCUS can aid in the evaluation of undifferentiated dyspnea while also being cost effective and avoiding the potential radiation of other testing modalities. The pulmonary POCUS evaluation incorporates a combination of several findings, including “A-lines” or horizontal artifacts from normal aerated lung; “B-lines”, vertical artifacts generated by extra-alveolar fluid, consolidation or “tissue-like pattern”; air bronchograms, consolidated lung surrounding airways; anechoic or hypoechoic areas in dependent zones of the lung; and the presence or absence of pleural sliding.²

In one prospective observational study of five internal medicine residents with no prior POCUS experience and three hours of training, the addition of handheld POCUS devices to usual clinical information improved the diagnostic accuracy for pneumonia, pulmonary edema, pleural effusion, and obstructive lung disease when evaluating patients with a primary complaint of dyspnea (area under the curve [AUC] 0.81 vs 0.87, P < .01).² However, the largest improvements in the operating characteristics were observed with the two residents who received an extended two-week elective of training.

In another study of 383 consecutive patients presenting to the ED with dyspnea, physicians with basic and advanced POCUS training were blinded to all clinical information and recorded a diagnosis after performing a lung POCUS examination. The “ultrasound physician’s” diagnosis was then compared to the treating emergency department (ED) physician’s diagnosis using history, physical, and other diagnostic data. Lung POCUS had a sensitivity and a specificity of 87.6% and 96.2% for pulmonary edema, 85.7% and 99% for pneumonia, 98.2% and 67.3% for asthma/chronic obstructive pulmonary disease (COPD), 46.2% and 100% for pulmonary embolus (PE), and 71.4% and 100% for pneumothorax, respectively.³ The scanning protocol used, the BLUE (Bedside Lung Ultrasound Examination) protocol, was focused on ruling out significant pulmonary etiologies of dyspnea. The protocol classified the finding of normal lung ultrasound (A-line profile) as COPD or asthma since these conditions will have a normal sonographic appearance. This approach could lead to incorrect labeling of other extrapulmonary causes of dyspnea as COPD or asthma. The findings of this study suggest that POCUS is most effective at ruling in pulmonary edema and pneumonia while being most effective at ruling out asthma or COPD as causes of dyspnea. It is both sensitive and specific for pneumothorax. However, as other studies have found, the sensitivity of POCUS for COPD, asthma, and PE was inferior to traditional clinical evaluation.⁴ One of the few studies looking specifically at hospitalized ward patients compared a blinded lung POCUS diagnosis and a discharge clinical diagnosis classified as cardiac, pulmonary, or mixed dyspnea. The authors of that study found an “interstitial pattern” (two areas with more than two B-lines) in 94% of those classified as cardiac on discharge, but POCUS findings were less precise for those discharged with a pulmonary etiology of dyspnea.⁵ Identifying B-lines on lung POCUS appears to be helpful in rapidly differentiating cardiac from pulmonary etiologies of dyspnea.

An additional advantage of POCUS is that multiple organ systems can be evaluated in rapid succession when the etiology of dyspnea is unknown. In a smaller ED study of patients presenting with undifferentiated dyspnea, a diagnosis was recorded after history-taking and physical examination and then recorded again after lung, cardiac, and inferior vena cava POCUS. Clinician diagnostic accuracy improved from 53% to 77% with the use of POCUS (P = .003) compared with the final diagnosis.⁶ The treating physician’s primary impression changed in almost 50% of cases after using POCUS, most of which was driven by improved sensitivity and specificity of ADHF. In another study of 2,700 patients presenting to the ED with dyspnea, cardiopulmonary POCUS shortened the time to diagnosis (186 ± 72 minutes vs 24 ± 10 minutes, P = .025).⁴ These studies suggest that the use of POCUS in the initial evaluation of patients with undifferentiated dyspnea is a valuable tool with respect to diagnostic accuracy and timeliness.

There are several different sonographic findings that can indicate pneumonia, such as consolidation or “hepatization”, the “shred” sign of an irregular border between consolidated lung and aerated lung, unilateral B-lines, and dynamic air bronchograms. Several recent systematic reviews and meta-analyses have investigated the operating characteristics of POCUS for the diagnosis of pneumonia. These reviews are limited by heterogeneity with respect to different patient populations, sonographers, and reference standards, but all three reviews found similar results, with the pooled AUC values ranging from 95% to 98%.^7-9 This recent evidence along with other reviews suggests that lung ultrasound can serve as a primary diagnostic tool in pneumonia and is probably superior to chest radiography.

Pleural effusions are observed with POCUS as anechoic or hypoechoic areas, generally in dependent lung zones. POCUS may provide additional benefit by better characterizing the effusion as having septations or floating fibrin strands. One recent systematic review and meta-analysis including 1,554 patients found that POCUS had excellent sensitivity and specificity (94% and 98%, respectively) in detecting pleural effusion versus chest radiography (51% and 91%, respectively), both compared with reference standard imaging such as computed tomography. The subgroup analysis found that sensitivity was higher for scanners who were intensivists or radiologists than for other physicians (97% vs 90%; P ≤ .001) and also found a nonstatistically significant trend toward reduced sensitivity when pocket-sized devices were used (90% vs 95%, P = .09).¹⁰

It is extremely important to recognize that a POCUS finding of decreased left ventricular ejection fraction is not synonymous with a diagnosis of ADHF. Bedside providers can use POCUS to estimate cardiac function, but other clinical information is required to determine whether the syndrome of ADHF is present. In one study, examinations performed by 10 internists with approximately 18 hours of training in focused cardiac POCUS had a sensitivity and a specificity of 91% and 88%, respectively, for classifying left ventricular systolic function as normal or mildly, moderately, or severely depressed with “good/substantial” agreement (k = 0.77) compared with formal echocardiography.¹¹ The presence of bilateral B-lines as a sign of pulmonary edema suggests accompanying functional decompensation. A meta-analysis of seven articles including 1075 patients in various clinical settings (ED, ICU, and inpatient wards) found a sensitivity of 94.1% and a specificity of 92.4% for using B-lines to diagnose acute cardiogenic pulmonary edema compared with the final clinical diagnosis.¹² Al Deeb et al. examined 226 patients and found similar sensitivity (95.3%) and specificity (88.2%) for diagnosing acute cardiogenic pulmonary edema when nurses were trained to evaluate for bilateral B-lines in dyspneic patients admitted to the hospital, also compared with the adjudicated final diagnosis.¹³ Carlino et al. evaluated dyspneic patients using a three-minute pocket-sized device scan of the heart, lungs, and inferior vena cava and found that no single view offered a substantial improvement in diagnostic accuracy; however, the combination of bilateral B-lines and/or pleural effusion and either a dilated left atrium or left ventricular ejection fraction (LVEF) of <40% had a very high diagnostic accuracy (AUC 0.97).¹⁴ Russell et al. performed a secondary analysis of a prospective observational study of patients with dyspnea and found that a simple three-view scanning protocol looking for the presence of B-lines on the right and left anterior superior lung zones and an LVEF of <45% took an average of one minute and 32 seconds to perform and had 100% specificity for ADHF if all three were positive.¹⁵ Another recent systematic review and meta-analysis of six studies and 1,827 patients found a sensitivity of 88% (CI 75%-95%) for lung POCUS compared with a chest radiography at a sensitivity of 73% (70%-76%) for the diagnosis of ADHF.¹⁶ All these studies suggest that improving the diagnosis of ADHF does not require complex echocardiographic views and is probably more feasible and accessible than many expect.

POCUS continues to show promise for evaluating patients with dyspnea. It is clear that adding a few POCUS examination maneuvers to a provider’s toolbox, such as looking for B-lines and overall cardiac function, can improve the evaluation of dyspneic patients. However, POCUS enthusiasm should not outpace the evidence. The studies discussed in this update highlight an important need for additional research in HM settings and patient populations. Most of the studies were conducted in non-HM patients, with sonographers varying widely in experience, highlighting the importance of proper training. In addition, future studies should investigate outcome measures such as mortality, length of stay, and cost efficacy. Furthermore, those employing POCUS must remember that improved sensitivity for detecting certain conditions can come at the expense of adequate specificity. POCUS findings, although potentially powerful, must always be synthesized with other clinical findings and considered within the larger clinical context for individual patients.

Point-of-care ultrasound (POCUS) continues to gain traction in contemporary clinical practice both as a diagnostic tool and as an extension of the physical examination. Hospital Medicine (HM) lags behind Emergency Medicine (EM) and Critical Care (CC) in our uptake of such technology, although momentum is gaining. Leaders in HM have published frameworks for competency and credentialing, and the Society for Hospital Medicine has created a pathway for certification.¹ POCUS use is the standard of care for several bedside procedures, but evidence for diagnostic applications is changing rapidly as the literature expands. However, the applicability of this evidence to HM patients can be challenging as most published studies are still from EM and CC settings. This Progress Note focuses on how a hospitalist might incorporate POCUS in the evaluation of adult patients with dyspnea. This topic was chosen after reviewing several relevant studies published in the past five years and recognizing the importance of dyspnea in HM. The Progress Note begins with a review of POCUS for undifferentiated dyspnea before exploring studies of common diagnoses that present with dyspnea, including pneumonia, pleural effusion, and acute decompensated heart failure (ADHF), aiming to update the knowledge of HM providers regarding this technology as well as to stimulate further study in this field.

In collaboration with an academic librarian in March 2019, PubMed was searched for studies published within the past five years using several MESH search terms for POCUS. The search was originally focused to the field of HM using specific search terms, but this yielded a very limited number of studies. Therefore, the search strategy was expanded to include EM and CC studies. This final search generated 346 papers that were supplemented with additional literature searches using references from studies found in the initial search.

Dyspnea is common in HM, both as the reason for a patient’s admission and as a symptom that develops during hospitalization such as after intravenous fluid resuscitation, a possible aspiration event, or central line placement. The differential diagnosis is broad, and multiple studies suggest that POCUS can aid in the evaluation of undifferentiated dyspnea while also being cost effective and avoiding the potential radiation of other testing modalities. The pulmonary POCUS evaluation incorporates a combination of several findings, including “A-lines” or horizontal artifacts from normal aerated lung; “B-lines”, vertical artifacts generated by extra-alveolar fluid, consolidation or “tissue-like pattern”; air bronchograms, consolidated lung surrounding airways; anechoic or hypoechoic areas in dependent zones of the lung; and the presence or absence of pleural sliding.²

In one prospective observational study of five internal medicine residents with no prior POCUS experience and three hours of training, the addition of handheld POCUS devices to usual clinical information improved the diagnostic accuracy for pneumonia, pulmonary edema, pleural effusion, and obstructive lung disease when evaluating patients with a primary complaint of dyspnea (area under the curve [AUC] 0.81 vs 0.87, P < .01).² However, the largest improvements in the operating characteristics were observed with the two residents who received an extended two-week elective of training.

In another study of 383 consecutive patients presenting to the ED with dyspnea, physicians with basic and advanced POCUS training were blinded to all clinical information and recorded a diagnosis after performing a lung POCUS examination. The “ultrasound physician’s” diagnosis was then compared to the treating emergency department (ED) physician’s diagnosis using history, physical, and other diagnostic data. Lung POCUS had a sensitivity and a specificity of 87.6% and 96.2% for pulmonary edema, 85.7% and 99% for pneumonia, 98.2% and 67.3% for asthma/chronic obstructive pulmonary disease (COPD), 46.2% and 100% for pulmonary embolus (PE), and 71.4% and 100% for pneumothorax, respectively.³ The scanning protocol used, the BLUE (Bedside Lung Ultrasound Examination) protocol, was focused on ruling out significant pulmonary etiologies of dyspnea. The protocol classified the finding of normal lung ultrasound (A-line profile) as COPD or asthma since these conditions will have a normal sonographic appearance. This approach could lead to incorrect labeling of other extrapulmonary causes of dyspnea as COPD or asthma. The findings of this study suggest that POCUS is most effective at ruling in pulmonary edema and pneumonia while being most effective at ruling out asthma or COPD as causes of dyspnea. It is both sensitive and specific for pneumothorax. However, as other studies have found, the sensitivity of POCUS for COPD, asthma, and PE was inferior to traditional clinical evaluation.⁴ One of the few studies looking specifically at hospitalized ward patients compared a blinded lung POCUS diagnosis and a discharge clinical diagnosis classified as cardiac, pulmonary, or mixed dyspnea. The authors of that study found an “interstitial pattern” (two areas with more than two B-lines) in 94% of those classified as cardiac on discharge, but POCUS findings were less precise for those discharged with a pulmonary etiology of dyspnea.⁵ Identifying B-lines on lung POCUS appears to be helpful in rapidly differentiating cardiac from pulmonary etiologies of dyspnea.

An additional advantage of POCUS is that multiple organ systems can be evaluated in rapid succession when the etiology of dyspnea is unknown. In a smaller ED study of patients presenting with undifferentiated dyspnea, a diagnosis was recorded after history-taking and physical examination and then recorded again after lung, cardiac, and inferior vena cava POCUS. Clinician diagnostic accuracy improved from 53% to 77% with the use of POCUS (P = .003) compared with the final diagnosis.⁶ The treating physician’s primary impression changed in almost 50% of cases after using POCUS, most of which was driven by improved sensitivity and specificity of ADHF. In another study of 2,700 patients presenting to the ED with dyspnea, cardiopulmonary POCUS shortened the time to diagnosis (186 ± 72 minutes vs 24 ± 10 minutes, P = .025).⁴ These studies suggest that the use of POCUS in the initial evaluation of patients with undifferentiated dyspnea is a valuable tool with respect to diagnostic accuracy and timeliness.

There are several different sonographic findings that can indicate pneumonia, such as consolidation or “hepatization”, the “shred” sign of an irregular border between consolidated lung and aerated lung, unilateral B-lines, and dynamic air bronchograms. Several recent systematic reviews and meta-analyses have investigated the operating characteristics of POCUS for the diagnosis of pneumonia. These reviews are limited by heterogeneity with respect to different patient populations, sonographers, and reference standards, but all three reviews found similar results, with the pooled AUC values ranging from 95% to 98%.^7-9 This recent evidence along with other reviews suggests that lung ultrasound can serve as a primary diagnostic tool in pneumonia and is probably superior to chest radiography.

Pleural effusions are observed with POCUS as anechoic or hypoechoic areas, generally in dependent lung zones. POCUS may provide additional benefit by better characterizing the effusion as having septations or floating fibrin strands. One recent systematic review and meta-analysis including 1,554 patients found that POCUS had excellent sensitivity and specificity (94% and 98%, respectively) in detecting pleural effusion versus chest radiography (51% and 91%, respectively), both compared with reference standard imaging such as computed tomography. The subgroup analysis found that sensitivity was higher for scanners who were intensivists or radiologists than for other physicians (97% vs 90%; P ≤ .001) and also found a nonstatistically significant trend toward reduced sensitivity when pocket-sized devices were used (90% vs 95%, P = .09).¹⁰

It is extremely important to recognize that a POCUS finding of decreased left ventricular ejection fraction is not synonymous with a diagnosis of ADHF. Bedside providers can use POCUS to estimate cardiac function, but other clinical information is required to determine whether the syndrome of ADHF is present. In one study, examinations performed by 10 internists with approximately 18 hours of training in focused cardiac POCUS had a sensitivity and a specificity of 91% and 88%, respectively, for classifying left ventricular systolic function as normal or mildly, moderately, or severely depressed with “good/substantial” agreement (k = 0.77) compared with formal echocardiography.¹¹ The presence of bilateral B-lines as a sign of pulmonary edema suggests accompanying functional decompensation. A meta-analysis of seven articles including 1075 patients in various clinical settings (ED, ICU, and inpatient wards) found a sensitivity of 94.1% and a specificity of 92.4% for using B-lines to diagnose acute cardiogenic pulmonary edema compared with the final clinical diagnosis.¹² Al Deeb et al. examined 226 patients and found similar sensitivity (95.3%) and specificity (88.2%) for diagnosing acute cardiogenic pulmonary edema when nurses were trained to evaluate for bilateral B-lines in dyspneic patients admitted to the hospital, also compared with the adjudicated final diagnosis.¹³ Carlino et al. evaluated dyspneic patients using a three-minute pocket-sized device scan of the heart, lungs, and inferior vena cava and found that no single view offered a substantial improvement in diagnostic accuracy; however, the combination of bilateral B-lines and/or pleural effusion and either a dilated left atrium or left ventricular ejection fraction (LVEF) of <40% had a very high diagnostic accuracy (AUC 0.97).¹⁴ Russell et al. performed a secondary analysis of a prospective observational study of patients with dyspnea and found that a simple three-view scanning protocol looking for the presence of B-lines on the right and left anterior superior lung zones and an LVEF of <45% took an average of one minute and 32 seconds to perform and had 100% specificity for ADHF if all three were positive.¹⁵ Another recent systematic review and meta-analysis of six studies and 1,827 patients found a sensitivity of 88% (CI 75%-95%) for lung POCUS compared with a chest radiography at a sensitivity of 73% (70%-76%) for the diagnosis of ADHF.¹⁶ All these studies suggest that improving the diagnosis of ADHF does not require complex echocardiographic views and is probably more feasible and accessible than many expect.

POCUS continues to show promise for evaluating patients with dyspnea. It is clear that adding a few POCUS examination maneuvers to a provider’s toolbox, such as looking for B-lines and overall cardiac function, can improve the evaluation of dyspneic patients. However, POCUS enthusiasm should not outpace the evidence. The studies discussed in this update highlight an important need for additional research in HM settings and patient populations. Most of the studies were conducted in non-HM patients, with sonographers varying widely in experience, highlighting the importance of proper training. In addition, future studies should investigate outcome measures such as mortality, length of stay, and cost efficacy. Furthermore, those employing POCUS must remember that improved sensitivity for detecting certain conditions can come at the expense of adequate specificity. POCUS findings, although potentially powerful, must always be synthesized with other clinical findings and considered within the larger clinical context for individual patients.

Point-of-care ultrasound (POCUS) continues to gain traction in contemporary clinical practice both as a diagnostic tool and as an extension of the physical examination. Hospital Medicine (HM) lags behind Emergency Medicine (EM) and Critical Care (CC) in our uptake of such technology, although momentum is gaining. Leaders in HM have published frameworks for competency and credentialing, and the Society for Hospital Medicine has created a pathway for certification.¹ POCUS use is the standard of care for several bedside procedures, but evidence for diagnostic applications is changing rapidly as the literature expands. However, the applicability of this evidence to HM patients can be challenging as most published studies are still from EM and CC settings. This Progress Note focuses on how a hospitalist might incorporate POCUS in the evaluation of adult patients with dyspnea. This topic was chosen after reviewing several relevant studies published in the past five years and recognizing the importance of dyspnea in HM. The Progress Note begins with a review of POCUS for undifferentiated dyspnea before exploring studies of common diagnoses that present with dyspnea, including pneumonia, pleural effusion, and acute decompensated heart failure (ADHF), aiming to update the knowledge of HM providers regarding this technology as well as to stimulate further study in this field.

In collaboration with an academic librarian in March 2019, PubMed was searched for studies published within the past five years using several MESH search terms for POCUS. The search was originally focused to the field of HM using specific search terms, but this yielded a very limited number of studies. Therefore, the search strategy was expanded to include EM and CC studies. This final search generated 346 papers that were supplemented with additional literature searches using references from studies found in the initial search.

Dyspnea is common in HM, both as the reason for a patient’s admission and as a symptom that develops during hospitalization such as after intravenous fluid resuscitation, a possible aspiration event, or central line placement. The differential diagnosis is broad, and multiple studies suggest that POCUS can aid in the evaluation of undifferentiated dyspnea while also being cost effective and avoiding the potential radiation of other testing modalities. The pulmonary POCUS evaluation incorporates a combination of several findings, including “A-lines” or horizontal artifacts from normal aerated lung; “B-lines”, vertical artifacts generated by extra-alveolar fluid, consolidation or “tissue-like pattern”; air bronchograms, consolidated lung surrounding airways; anechoic or hypoechoic areas in dependent zones of the lung; and the presence or absence of pleural sliding.²

In one prospective observational study of five internal medicine residents with no prior POCUS experience and three hours of training, the addition of handheld POCUS devices to usual clinical information improved the diagnostic accuracy for pneumonia, pulmonary edema, pleural effusion, and obstructive lung disease when evaluating patients with a primary complaint of dyspnea (area under the curve [AUC] 0.81 vs 0.87, P < .01).² However, the largest improvements in the operating characteristics were observed with the two residents who received an extended two-week elective of training.

In another study of 383 consecutive patients presenting to the ED with dyspnea, physicians with basic and advanced POCUS training were blinded to all clinical information and recorded a diagnosis after performing a lung POCUS examination. The “ultrasound physician’s” diagnosis was then compared to the treating emergency department (ED) physician’s diagnosis using history, physical, and other diagnostic data. Lung POCUS had a sensitivity and a specificity of 87.6% and 96.2% for pulmonary edema, 85.7% and 99% for pneumonia, 98.2% and 67.3% for asthma/chronic obstructive pulmonary disease (COPD), 46.2% and 100% for pulmonary embolus (PE), and 71.4% and 100% for pneumothorax, respectively.³ The scanning protocol used, the BLUE (Bedside Lung Ultrasound Examination) protocol, was focused on ruling out significant pulmonary etiologies of dyspnea. The protocol classified the finding of normal lung ultrasound (A-line profile) as COPD or asthma since these conditions will have a normal sonographic appearance. This approach could lead to incorrect labeling of other extrapulmonary causes of dyspnea as COPD or asthma. The findings of this study suggest that POCUS is most effective at ruling in pulmonary edema and pneumonia while being most effective at ruling out asthma or COPD as causes of dyspnea. It is both sensitive and specific for pneumothorax. However, as other studies have found, the sensitivity of POCUS for COPD, asthma, and PE was inferior to traditional clinical evaluation.⁴ One of the few studies looking specifically at hospitalized ward patients compared a blinded lung POCUS diagnosis and a discharge clinical diagnosis classified as cardiac, pulmonary, or mixed dyspnea. The authors of that study found an “interstitial pattern” (two areas with more than two B-lines) in 94% of those classified as cardiac on discharge, but POCUS findings were less precise for those discharged with a pulmonary etiology of dyspnea.⁵ Identifying B-lines on lung POCUS appears to be helpful in rapidly differentiating cardiac from pulmonary etiologies of dyspnea.

An additional advantage of POCUS is that multiple organ systems can be evaluated in rapid succession when the etiology of dyspnea is unknown. In a smaller ED study of patients presenting with undifferentiated dyspnea, a diagnosis was recorded after history-taking and physical examination and then recorded again after lung, cardiac, and inferior vena cava POCUS. Clinician diagnostic accuracy improved from 53% to 77% with the use of POCUS (P = .003) compared with the final diagnosis.⁶ The treating physician’s primary impression changed in almost 50% of cases after using POCUS, most of which was driven by improved sensitivity and specificity of ADHF. In another study of 2,700 patients presenting to the ED with dyspnea, cardiopulmonary POCUS shortened the time to diagnosis (186 ± 72 minutes vs 24 ± 10 minutes, P = .025).⁴ These studies suggest that the use of POCUS in the initial evaluation of patients with undifferentiated dyspnea is a valuable tool with respect to diagnostic accuracy and timeliness.

There are several different sonographic findings that can indicate pneumonia, such as consolidation or “hepatization”, the “shred” sign of an irregular border between consolidated lung and aerated lung, unilateral B-lines, and dynamic air bronchograms. Several recent systematic reviews and meta-analyses have investigated the operating characteristics of POCUS for the diagnosis of pneumonia. These reviews are limited by heterogeneity with respect to different patient populations, sonographers, and reference standards, but all three reviews found similar results, with the pooled AUC values ranging from 95% to 98%.^7-9 This recent evidence along with other reviews suggests that lung ultrasound can serve as a primary diagnostic tool in pneumonia and is probably superior to chest radiography.

Pleural effusions are observed with POCUS as anechoic or hypoechoic areas, generally in dependent lung zones. POCUS may provide additional benefit by better characterizing the effusion as having septations or floating fibrin strands. One recent systematic review and meta-analysis including 1,554 patients found that POCUS had excellent sensitivity and specificity (94% and 98%, respectively) in detecting pleural effusion versus chest radiography (51% and 91%, respectively), both compared with reference standard imaging such as computed tomography. The subgroup analysis found that sensitivity was higher for scanners who were intensivists or radiologists than for other physicians (97% vs 90%; P ≤ .001) and also found a nonstatistically significant trend toward reduced sensitivity when pocket-sized devices were used (90% vs 95%, P = .09).¹⁰

It is extremely important to recognize that a POCUS finding of decreased left ventricular ejection fraction is not synonymous with a diagnosis of ADHF. Bedside providers can use POCUS to estimate cardiac function, but other clinical information is required to determine whether the syndrome of ADHF is present. In one study, examinations performed by 10 internists with approximately 18 hours of training in focused cardiac POCUS had a sensitivity and a specificity of 91% and 88%, respectively, for classifying left ventricular systolic function as normal or mildly, moderately, or severely depressed with “good/substantial” agreement (k = 0.77) compared with formal echocardiography.¹¹ The presence of bilateral B-lines as a sign of pulmonary edema suggests accompanying functional decompensation. A meta-analysis of seven articles including 1075 patients in various clinical settings (ED, ICU, and inpatient wards) found a sensitivity of 94.1% and a specificity of 92.4% for using B-lines to diagnose acute cardiogenic pulmonary edema compared with the final clinical diagnosis.¹² Al Deeb et al. examined 226 patients and found similar sensitivity (95.3%) and specificity (88.2%) for diagnosing acute cardiogenic pulmonary edema when nurses were trained to evaluate for bilateral B-lines in dyspneic patients admitted to the hospital, also compared with the adjudicated final diagnosis.¹³ Carlino et al. evaluated dyspneic patients using a three-minute pocket-sized device scan of the heart, lungs, and inferior vena cava and found that no single view offered a substantial improvement in diagnostic accuracy; however, the combination of bilateral B-lines and/or pleural effusion and either a dilated left atrium or left ventricular ejection fraction (LVEF) of <40% had a very high diagnostic accuracy (AUC 0.97).¹⁴ Russell et al. performed a secondary analysis of a prospective observational study of patients with dyspnea and found that a simple three-view scanning protocol looking for the presence of B-lines on the right and left anterior superior lung zones and an LVEF of <45% took an average of one minute and 32 seconds to perform and had 100% specificity for ADHF if all three were positive.¹⁵ Another recent systematic review and meta-analysis of six studies and 1,827 patients found a sensitivity of 88% (CI 75%-95%) for lung POCUS compared with a chest radiography at a sensitivity of 73% (70%-76%) for the diagnosis of ADHF.¹⁶ All these studies suggest that improving the diagnosis of ADHF does not require complex echocardiographic views and is probably more feasible and accessible than many expect.

POCUS continues to show promise for evaluating patients with dyspnea. It is clear that adding a few POCUS examination maneuvers to a provider’s toolbox, such as looking for B-lines and overall cardiac function, can improve the evaluation of dyspneic patients. However, POCUS enthusiasm should not outpace the evidence. The studies discussed in this update highlight an important need for additional research in HM settings and patient populations. Most of the studies were conducted in non-HM patients, with sonographers varying widely in experience, highlighting the importance of proper training. In addition, future studies should investigate outcome measures such as mortality, length of stay, and cost efficacy. Furthermore, those employing POCUS must remember that improved sensitivity for detecting certain conditions can come at the expense of adequate specificity. POCUS findings, although potentially powerful, must always be synthesized with other clinical findings and considered within the larger clinical context for individual patients.

The recent designation of Pediatric Hospital Medicine (PHM) as a board-certified subspecialty has provided the opportunity to define which skills are core to hospitalist practice. One skill that is novel to the field and gaining traction is point-of-care ultrasonography (POCUS). POCUS differs from traditional ultrasonography in that it is performed at the bedside by the primary clinician and aims to answer a focused clinical question (eg, does this patient have a skin abscess?) rather than to provide a comprehensive evaluation of the anatomy and physiology. The proposed advantages of POCUS include real-time image interpretation, cost savings, procedural guidance to minimize complications, and reduction of ionizing radiation. Although specialties such as Critical Care (CC) and Emergency Medicine (EM) have integrated POCUS into their practice and training, best practices in PHM have not been defined. This Progress Note is a summary of recent evidence to update past reviews and set the stage for future PHM POCUS research and education.

We met with an academic librarian in March 2019 and performed a search of PubMed using Medical Subject Headings (MESH) terms associated with POCUS as well as Pediatrics. We limited our search to studies published within the past five years. The search was originally focused to the field of PHM before expanding to a broader search since very few studies were found that focused on Hospital Medicine or general pediatric ward populations. This initial search generated 274 publications. We then performed a supplemental literature search using references from studies found in our initial search, as well as further ad hoc searching in Embase and Google Scholar.

After our literature search, we reviewed the PHM core competencies and identified the common clinical diagnoses and core skills for which there is POCUS literature published in the past five years. These included acute abdominal pain, bronchiolitis, pneumonia, skin and soft tissue infection, newborn care/delivery room management, bladder catheterization, fluid management, intravenous access, and lumbar puncture (LP). We chose to focus on one skill and two diagnoses that were generalizable to pediatric hospitalists across different settings and for which there was compelling evidence for POCUS use, such as pneumonia, skin abscess, and LP. We found few studies that included general pediatric ward patients, but we considered EM and CC studies to be relevant as several pediatric hospitalists practice in these clinical settings and with these patient populations.

POCUS can be useful for diagnosing pneumonia by direct visualization of lung consolidation or by identification of various sonographic artifacts that suggest pathology. For example, “B-lines” are vertical artifacts that extend from the pleura and suggest interstitial fluid or pneumonia when they are present in abnormally high numbers or density. POCUS can also be used to diagnose parapneumonic effusions by scanning dependent areas of the lung (eg, the diaphragm in children sitting upright) and looking for anechoic or hypoechoic areas.

Three recent meta-analyses found favorable operating characteristics when using POCUS for the diagnosis of pneumonia in children, with summary sensitivities of 93%-94% and specificities of 92%-96%.^1-3 However, these meta-analyses were limited by high heterogeneity due to the inclusion of multiple different care settings and the use of variable reference standards and sonographic criteria for diagnosing pneumonia. POCUS is superior to chest radiography for evaluating parapneumonic pleural effusions,⁴ allowing for rapid identification of loculations, fibrin strands, and proteinaceous material, and for serial bedside evaluation of effusion size and characteristics.

Additional advantages of POCUS include avoidance of ionizing radiation and the potential for cost and time savings. Two studies demonstrated reductions in radiography use and improved cost, although they were not conducted on hospitalized patients. One randomized controlled trial (RCT) conducted in a pediatric emergency department (ED) demonstrated a 38.8% reduction in chest radiography use without increasing the ED length of stay (EDLOS), antibiotic use, or unscheduled follow-up visits.⁵ A retrospective matched cohort study conducted in another pediatric ED reported that when compared with patients evaluated by chest radiography, those evaluated by POCUS had significantly shorter EDLOS (−60.9 min) and mean health systems savings ($187 per patient).⁶ We believe that POCUS has value in the evaluation and management of pneumonia and parapneumonic effusions, although further studies investigating patient outcomes and involving inpatient populations are required.

POCUS can augment the physical examination, helping to both avoid unnecessary incision and drainage (I+D) procedures and detect drainable fluid collections. Abscess is suggested when hypoechoic material without vascular flow is detected, and although other structures such as vessels, cysts, and lymph nodes can mimic skin abscesses, this is a relatively straightforward examination for clinicians to learn.

Two meta-analyses found that POCUS had high sensitivity for diagnosing skin abscesses in the ED.^7,8 A pediatric subgroup analysis conducted in a study by Barbic et al. found a sensitivity and a specificity of 94% (95% C: 88%-98%) and 83% (95% C: 47%-97%), respectively.⁷ Subramaniam et al. included six studies (four pediatric) with 800 patients (653 ≤ 18 years old) and found an overall pooled sensitivity of 97% (95% C: 94%-98%) and a specificity of 83% (95% C: 75%-88%).⁸ No subgroup analysis was performed, but the included pediatric studies reported sensitivities and specificities between 90%-98% and 68%-87%, respectively.

Although POCUS performs better than physical examination for the diagnosis of drainable abscesses, evidence regarding patient outcomes is mixed. A retrospective review from four pediatric EDs found that integration of POCUS lowered treatment failure rates, defined as any incision and drainage (I+D) or surgical manipulation after discharge from the initial ED visit (4.4% vs 15.6%, P < .005).⁹ A single-center retrospective cohort study found that POCUS reduced EDLOS by a median of 73 minutes (95% C: 52-94 min) when compared with radiology-performed studies.¹⁰ The aforementioned study conducted by Barbic et al. found that in pediatric studies, POCUS led to a change in management (eg, whether or not to attempt I+D) in 14%-27% of patients.⁷ However, a multicenter prospective observational cohort study involving seven pediatric EDs found that despite changing the management in 22.9% of cases, POCUS was not associated with any statistically significant differences in treatment failure rates, EDLOS, discharge rates, use of sedation, or use of alternative imaging.¹¹ These studies were limited by a lack of randomization or control group and emphasize the need for RCTs that measure patient outcomes. Future studies should investigate how POCUS can be used in inpatient settings both for initial diagnosis of drainable abscesses and for serial evaluation of evolving phlegmon or incompletely drained collections.

LP is commonly performed by pediatric hospitalists, although success can be influenced by numerous factors, including provider and staff expertise, patient anatomy, and body habitus. Requiring multiple attempts can increase patient discomfort and parental anxiety. Failure to obtain cerebrospinal fluid can delay diagnosis or leave providers in uncertain clinical situations that may commit patients to prolonged antibiotic courses. POCUS can be used to identify anatomic markers such as interspinous processes, anatomic midline, and depth of the ligamentum flavum.¹² It can also be used to identify epidural hematomas after failed LPs to avoid additional unsuccessful attempts.¹³ POCUS guidance for LP has been described using both static (preprocedural marking) and dynamic (scanning during the procedure) techniques, although most of the studies use the static approach. The Society for Hospital Medicine POCUS Task Force has recently released a position statement recommending that POCUS should be used for site selection before performing LP in adult patients when providers are adequately trained.¹² Although this position statement was for adult patients, recent evidence suggests that there is also benefit in Pediatrics.

Two recent meta-analyses have investigated POCUS use for pediatric LPs.^14,15 Olowoyeye et al. included four studies with a total of 277 patients and found that POCUS use was associated with a reduction in traumatic taps (risk ratio [RR] = 0.53, 95% C: 0.13-0.82) when compared with landmark approaches.¹⁴ However, there was no statistically significant reduction in LP failure, number of needle insertion attempts, or procedure length. A more recent meta-analysis performed a pediatric subgroup analysis of six studies including 452 patients and found a statistically significant reduction in traumatic taps (13.7% vs 31.8%, risk difference = −21.3%, 95% C: −38.2% to −4.3%) and number of needle insertion attempts (1.53 vs 2.07, mean difference = −0.47, 95% C: −0.73 to −0.21).¹⁵ The primary outcome of LP success trended toward favoring POCUS, but it was not statistically significant (88.4% vs 74.0%, OR = 2.55, 95% C: 0.99-6.52). We believe that recent evidence suggests that there is benefit in using POCUS when hospitalists attempt pediatric LPs, particularly when physical landmarks are difficult to identify or after failed attempts. However, adequate training with simulation and supervised practice should be undertaken before integrating this into clinical practice.

Evidence accumulated in the past five years has built on previous work suggesting that POCUS has a role in the diagnosis of pneumonia and skin abscess and in the performance of LPs. However, gaps in the literature remain when applying POCUS in PHM. Only a few studies to date were conducted in non-CC inpatient settings, and although several pediatric hospitalists work in EDs or care for critically ill children, our largest population comprises general pediatric ward patients. Studies have also used ultrasonographers with variable POCUS training and clinical experience, which makes comparing or combining studies challenging since POCUS is dependent on provider skills. Studies involving PHM providers and inpatient populations are needed. Additional studies evaluating the process and outcome measures are also needed to understand whether the theoretical advantages are consistently realized in real-world PHM practice. Finally, PHM-specific curricula should be designed in collaboration with various PHM stakeholders and with specialties who already have robust POCUS training pathways. There is opportunity within PHM for multi institutional research collaboration, identification of best practices, and development of PHM-specific training for fellowship and faculty development programs.

The recent designation of Pediatric Hospital Medicine (PHM) as a board-certified subspecialty has provided the opportunity to define which skills are core to hospitalist practice. One skill that is novel to the field and gaining traction is point-of-care ultrasonography (POCUS). POCUS differs from traditional ultrasonography in that it is performed at the bedside by the primary clinician and aims to answer a focused clinical question (eg, does this patient have a skin abscess?) rather than to provide a comprehensive evaluation of the anatomy and physiology. The proposed advantages of POCUS include real-time image interpretation, cost savings, procedural guidance to minimize complications, and reduction of ionizing radiation. Although specialties such as Critical Care (CC) and Emergency Medicine (EM) have integrated POCUS into their practice and training, best practices in PHM have not been defined. This Progress Note is a summary of recent evidence to update past reviews and set the stage for future PHM POCUS research and education.

We met with an academic librarian in March 2019 and performed a search of PubMed using Medical Subject Headings (MESH) terms associated with POCUS as well as Pediatrics. We limited our search to studies published within the past five years. The search was originally focused to the field of PHM before expanding to a broader search since very few studies were found that focused on Hospital Medicine or general pediatric ward populations. This initial search generated 274 publications. We then performed a supplemental literature search using references from studies found in our initial search, as well as further ad hoc searching in Embase and Google Scholar.

After our literature search, we reviewed the PHM core competencies and identified the common clinical diagnoses and core skills for which there is POCUS literature published in the past five years. These included acute abdominal pain, bronchiolitis, pneumonia, skin and soft tissue infection, newborn care/delivery room management, bladder catheterization, fluid management, intravenous access, and lumbar puncture (LP). We chose to focus on one skill and two diagnoses that were generalizable to pediatric hospitalists across different settings and for which there was compelling evidence for POCUS use, such as pneumonia, skin abscess, and LP. We found few studies that included general pediatric ward patients, but we considered EM and CC studies to be relevant as several pediatric hospitalists practice in these clinical settings and with these patient populations.

POCUS can be useful for diagnosing pneumonia by direct visualization of lung consolidation or by identification of various sonographic artifacts that suggest pathology. For example, “B-lines” are vertical artifacts that extend from the pleura and suggest interstitial fluid or pneumonia when they are present in abnormally high numbers or density. POCUS can also be used to diagnose parapneumonic effusions by scanning dependent areas of the lung (eg, the diaphragm in children sitting upright) and looking for anechoic or hypoechoic areas.

Three recent meta-analyses found favorable operating characteristics when using POCUS for the diagnosis of pneumonia in children, with summary sensitivities of 93%-94% and specificities of 92%-96%.^1-3 However, these meta-analyses were limited by high heterogeneity due to the inclusion of multiple different care settings and the use of variable reference standards and sonographic criteria for diagnosing pneumonia. POCUS is superior to chest radiography for evaluating parapneumonic pleural effusions,⁴ allowing for rapid identification of loculations, fibrin strands, and proteinaceous material, and for serial bedside evaluation of effusion size and characteristics.

Additional advantages of POCUS include avoidance of ionizing radiation and the potential for cost and time savings. Two studies demonstrated reductions in radiography use and improved cost, although they were not conducted on hospitalized patients. One randomized controlled trial (RCT) conducted in a pediatric emergency department (ED) demonstrated a 38.8% reduction in chest radiography use without increasing the ED length of stay (EDLOS), antibiotic use, or unscheduled follow-up visits.⁵ A retrospective matched cohort study conducted in another pediatric ED reported that when compared with patients evaluated by chest radiography, those evaluated by POCUS had significantly shorter EDLOS (−60.9 min) and mean health systems savings ($187 per patient).⁶ We believe that POCUS has value in the evaluation and management of pneumonia and parapneumonic effusions, although further studies investigating patient outcomes and involving inpatient populations are required.

POCUS can augment the physical examination, helping to both avoid unnecessary incision and drainage (I+D) procedures and detect drainable fluid collections. Abscess is suggested when hypoechoic material without vascular flow is detected, and although other structures such as vessels, cysts, and lymph nodes can mimic skin abscesses, this is a relatively straightforward examination for clinicians to learn.

Two meta-analyses found that POCUS had high sensitivity for diagnosing skin abscesses in the ED.^7,8 A pediatric subgroup analysis conducted in a study by Barbic et al. found a sensitivity and a specificity of 94% (95% C: 88%-98%) and 83% (95% C: 47%-97%), respectively.⁷ Subramaniam et al. included six studies (four pediatric) with 800 patients (653 ≤ 18 years old) and found an overall pooled sensitivity of 97% (95% C: 94%-98%) and a specificity of 83% (95% C: 75%-88%).⁸ No subgroup analysis was performed, but the included pediatric studies reported sensitivities and specificities between 90%-98% and 68%-87%, respectively.

Although POCUS performs better than physical examination for the diagnosis of drainable abscesses, evidence regarding patient outcomes is mixed. A retrospective review from four pediatric EDs found that integration of POCUS lowered treatment failure rates, defined as any incision and drainage (I+D) or surgical manipulation after discharge from the initial ED visit (4.4% vs 15.6%, P < .005).⁹ A single-center retrospective cohort study found that POCUS reduced EDLOS by a median of 73 minutes (95% C: 52-94 min) when compared with radiology-performed studies.¹⁰ The aforementioned study conducted by Barbic et al. found that in pediatric studies, POCUS led to a change in management (eg, whether or not to attempt I+D) in 14%-27% of patients.⁷ However, a multicenter prospective observational cohort study involving seven pediatric EDs found that despite changing the management in 22.9% of cases, POCUS was not associated with any statistically significant differences in treatment failure rates, EDLOS, discharge rates, use of sedation, or use of alternative imaging.¹¹ These studies were limited by a lack of randomization or control group and emphasize the need for RCTs that measure patient outcomes. Future studies should investigate how POCUS can be used in inpatient settings both for initial diagnosis of drainable abscesses and for serial evaluation of evolving phlegmon or incompletely drained collections.

LP is commonly performed by pediatric hospitalists, although success can be influenced by numerous factors, including provider and staff expertise, patient anatomy, and body habitus. Requiring multiple attempts can increase patient discomfort and parental anxiety. Failure to obtain cerebrospinal fluid can delay diagnosis or leave providers in uncertain clinical situations that may commit patients to prolonged antibiotic courses. POCUS can be used to identify anatomic markers such as interspinous processes, anatomic midline, and depth of the ligamentum flavum.¹² It can also be used to identify epidural hematomas after failed LPs to avoid additional unsuccessful attempts.¹³ POCUS guidance for LP has been described using both static (preprocedural marking) and dynamic (scanning during the procedure) techniques, although most of the studies use the static approach. The Society for Hospital Medicine POCUS Task Force has recently released a position statement recommending that POCUS should be used for site selection before performing LP in adult patients when providers are adequately trained.¹² Although this position statement was for adult patients, recent evidence suggests that there is also benefit in Pediatrics.

Two recent meta-analyses have investigated POCUS use for pediatric LPs.^14,15 Olowoyeye et al. included four studies with a total of 277 patients and found that POCUS use was associated with a reduction in traumatic taps (risk ratio [RR] = 0.53, 95% C: 0.13-0.82) when compared with landmark approaches.¹⁴ However, there was no statistically significant reduction in LP failure, number of needle insertion attempts, or procedure length. A more recent meta-analysis performed a pediatric subgroup analysis of six studies including 452 patients and found a statistically significant reduction in traumatic taps (13.7% vs 31.8%, risk difference = −21.3%, 95% C: −38.2% to −4.3%) and number of needle insertion attempts (1.53 vs 2.07, mean difference = −0.47, 95% C: −0.73 to −0.21).¹⁵ The primary outcome of LP success trended toward favoring POCUS, but it was not statistically significant (88.4% vs 74.0%, OR = 2.55, 95% C: 0.99-6.52). We believe that recent evidence suggests that there is benefit in using POCUS when hospitalists attempt pediatric LPs, particularly when physical landmarks are difficult to identify or after failed attempts. However, adequate training with simulation and supervised practice should be undertaken before integrating this into clinical practice.

Evidence accumulated in the past five years has built on previous work suggesting that POCUS has a role in the diagnosis of pneumonia and skin abscess and in the performance of LPs. However, gaps in the literature remain when applying POCUS in PHM. Only a few studies to date were conducted in non-CC inpatient settings, and although several pediatric hospitalists work in EDs or care for critically ill children, our largest population comprises general pediatric ward patients. Studies have also used ultrasonographers with variable POCUS training and clinical experience, which makes comparing or combining studies challenging since POCUS is dependent on provider skills. Studies involving PHM providers and inpatient populations are needed. Additional studies evaluating the process and outcome measures are also needed to understand whether the theoretical advantages are consistently realized in real-world PHM practice. Finally, PHM-specific curricula should be designed in collaboration with various PHM stakeholders and with specialties who already have robust POCUS training pathways. There is opportunity within PHM for multi institutional research collaboration, identification of best practices, and development of PHM-specific training for fellowship and faculty development programs.

The recent designation of Pediatric Hospital Medicine (PHM) as a board-certified subspecialty has provided the opportunity to define which skills are core to hospitalist practice. One skill that is novel to the field and gaining traction is point-of-care ultrasonography (POCUS). POCUS differs from traditional ultrasonography in that it is performed at the bedside by the primary clinician and aims to answer a focused clinical question (eg, does this patient have a skin abscess?) rather than to provide a comprehensive evaluation of the anatomy and physiology. The proposed advantages of POCUS include real-time image interpretation, cost savings, procedural guidance to minimize complications, and reduction of ionizing radiation. Although specialties such as Critical Care (CC) and Emergency Medicine (EM) have integrated POCUS into their practice and training, best practices in PHM have not been defined. This Progress Note is a summary of recent evidence to update past reviews and set the stage for future PHM POCUS research and education.

We met with an academic librarian in March 2019 and performed a search of PubMed using Medical Subject Headings (MESH) terms associated with POCUS as well as Pediatrics. We limited our search to studies published within the past five years. The search was originally focused to the field of PHM before expanding to a broader search since very few studies were found that focused on Hospital Medicine or general pediatric ward populations. This initial search generated 274 publications. We then performed a supplemental literature search using references from studies found in our initial search, as well as further ad hoc searching in Embase and Google Scholar.

After our literature search, we reviewed the PHM core competencies and identified the common clinical diagnoses and core skills for which there is POCUS literature published in the past five years. These included acute abdominal pain, bronchiolitis, pneumonia, skin and soft tissue infection, newborn care/delivery room management, bladder catheterization, fluid management, intravenous access, and lumbar puncture (LP). We chose to focus on one skill and two diagnoses that were generalizable to pediatric hospitalists across different settings and for which there was compelling evidence for POCUS use, such as pneumonia, skin abscess, and LP. We found few studies that included general pediatric ward patients, but we considered EM and CC studies to be relevant as several pediatric hospitalists practice in these clinical settings and with these patient populations.

POCUS can be useful for diagnosing pneumonia by direct visualization of lung consolidation or by identification of various sonographic artifacts that suggest pathology. For example, “B-lines” are vertical artifacts that extend from the pleura and suggest interstitial fluid or pneumonia when they are present in abnormally high numbers or density. POCUS can also be used to diagnose parapneumonic effusions by scanning dependent areas of the lung (eg, the diaphragm in children sitting upright) and looking for anechoic or hypoechoic areas.

Three recent meta-analyses found favorable operating characteristics when using POCUS for the diagnosis of pneumonia in children, with summary sensitivities of 93%-94% and specificities of 92%-96%.^1-3 However, these meta-analyses were limited by high heterogeneity due to the inclusion of multiple different care settings and the use of variable reference standards and sonographic criteria for diagnosing pneumonia. POCUS is superior to chest radiography for evaluating parapneumonic pleural effusions,⁴ allowing for rapid identification of loculations, fibrin strands, and proteinaceous material, and for serial bedside evaluation of effusion size and characteristics.

Additional advantages of POCUS include avoidance of ionizing radiation and the potential for cost and time savings. Two studies demonstrated reductions in radiography use and improved cost, although they were not conducted on hospitalized patients. One randomized controlled trial (RCT) conducted in a pediatric emergency department (ED) demonstrated a 38.8% reduction in chest radiography use without increasing the ED length of stay (EDLOS), antibiotic use, or unscheduled follow-up visits.⁵ A retrospective matched cohort study conducted in another pediatric ED reported that when compared with patients evaluated by chest radiography, those evaluated by POCUS had significantly shorter EDLOS (−60.9 min) and mean health systems savings ($187 per patient).⁶ We believe that POCUS has value in the evaluation and management of pneumonia and parapneumonic effusions, although further studies investigating patient outcomes and involving inpatient populations are required.

POCUS can augment the physical examination, helping to both avoid unnecessary incision and drainage (I+D) procedures and detect drainable fluid collections. Abscess is suggested when hypoechoic material without vascular flow is detected, and although other structures such as vessels, cysts, and lymph nodes can mimic skin abscesses, this is a relatively straightforward examination for clinicians to learn.

Two meta-analyses found that POCUS had high sensitivity for diagnosing skin abscesses in the ED.^7,8 A pediatric subgroup analysis conducted in a study by Barbic et al. found a sensitivity and a specificity of 94% (95% C: 88%-98%) and 83% (95% C: 47%-97%), respectively.⁷ Subramaniam et al. included six studies (four pediatric) with 800 patients (653 ≤ 18 years old) and found an overall pooled sensitivity of 97% (95% C: 94%-98%) and a specificity of 83% (95% C: 75%-88%).⁸ No subgroup analysis was performed, but the included pediatric studies reported sensitivities and specificities between 90%-98% and 68%-87%, respectively.

Although POCUS performs better than physical examination for the diagnosis of drainable abscesses, evidence regarding patient outcomes is mixed. A retrospective review from four pediatric EDs found that integration of POCUS lowered treatment failure rates, defined as any incision and drainage (I+D) or surgical manipulation after discharge from the initial ED visit (4.4% vs 15.6%, P < .005).⁹ A single-center retrospective cohort study found that POCUS reduced EDLOS by a median of 73 minutes (95% C: 52-94 min) when compared with radiology-performed studies.¹⁰ The aforementioned study conducted by Barbic et al. found that in pediatric studies, POCUS led to a change in management (eg, whether or not to attempt I+D) in 14%-27% of patients.⁷ However, a multicenter prospective observational cohort study involving seven pediatric EDs found that despite changing the management in 22.9% of cases, POCUS was not associated with any statistically significant differences in treatment failure rates, EDLOS, discharge rates, use of sedation, or use of alternative imaging.¹¹ These studies were limited by a lack of randomization or control group and emphasize the need for RCTs that measure patient outcomes. Future studies should investigate how POCUS can be used in inpatient settings both for initial diagnosis of drainable abscesses and for serial evaluation of evolving phlegmon or incompletely drained collections.

LP is commonly performed by pediatric hospitalists, although success can be influenced by numerous factors, including provider and staff expertise, patient anatomy, and body habitus. Requiring multiple attempts can increase patient discomfort and parental anxiety. Failure to obtain cerebrospinal fluid can delay diagnosis or leave providers in uncertain clinical situations that may commit patients to prolonged antibiotic courses. POCUS can be used to identify anatomic markers such as interspinous processes, anatomic midline, and depth of the ligamentum flavum.¹² It can also be used to identify epidural hematomas after failed LPs to avoid additional unsuccessful attempts.¹³ POCUS guidance for LP has been described using both static (preprocedural marking) and dynamic (scanning during the procedure) techniques, although most of the studies use the static approach. The Society for Hospital Medicine POCUS Task Force has recently released a position statement recommending that POCUS should be used for site selection before performing LP in adult patients when providers are adequately trained.¹² Although this position statement was for adult patients, recent evidence suggests that there is also benefit in Pediatrics.

Two recent meta-analyses have investigated POCUS use for pediatric LPs.^14,15 Olowoyeye et al. included four studies with a total of 277 patients and found that POCUS use was associated with a reduction in traumatic taps (risk ratio [RR] = 0.53, 95% C: 0.13-0.82) when compared with landmark approaches.¹⁴ However, there was no statistically significant reduction in LP failure, number of needle insertion attempts, or procedure length. A more recent meta-analysis performed a pediatric subgroup analysis of six studies including 452 patients and found a statistically significant reduction in traumatic taps (13.7% vs 31.8%, risk difference = −21.3%, 95% C: −38.2% to −4.3%) and number of needle insertion attempts (1.53 vs 2.07, mean difference = −0.47, 95% C: −0.73 to −0.21).¹⁵ The primary outcome of LP success trended toward favoring POCUS, but it was not statistically significant (88.4% vs 74.0%, OR = 2.55, 95% C: 0.99-6.52). We believe that recent evidence suggests that there is benefit in using POCUS when hospitalists attempt pediatric LPs, particularly when physical landmarks are difficult to identify or after failed attempts. However, adequate training with simulation and supervised practice should be undertaken before integrating this into clinical practice.

Evidence accumulated in the past five years has built on previous work suggesting that POCUS has a role in the diagnosis of pneumonia and skin abscess and in the performance of LPs. However, gaps in the literature remain when applying POCUS in PHM. Only a few studies to date were conducted in non-CC inpatient settings, and although several pediatric hospitalists work in EDs or care for critically ill children, our largest population comprises general pediatric ward patients. Studies have also used ultrasonographers with variable POCUS training and clinical experience, which makes comparing or combining studies challenging since POCUS is dependent on provider skills. Studies involving PHM providers and inpatient populations are needed. Additional studies evaluating the process and outcome measures are also needed to understand whether the theoretical advantages are consistently realized in real-world PHM practice. Finally, PHM-specific curricula should be designed in collaboration with various PHM stakeholders and with specialties who already have robust POCUS training pathways. There is opportunity within PHM for multi institutional research collaboration, identification of best practices, and development of PHM-specific training for fellowship and faculty development programs.