POCUS in Pediatric Anesthesia: Is Standardized Credentialing the Key to Increasing Competency and Utilization?

Elaina E. Lin MD and Myron Yaster MD

Point-of-care ultrasound (POCUS) is to today’s (pediatric) anesthesiologist as essential a tool in diagnosis and treatment as the stethoscope was to previous generations of physicians.  In pediatric anesthesia, the use of ultrasound for procedural indications, such as central and peripheral IV placement, as well as for regional anesthesia and neural blockade, is commonplace and increasingly a fundamental skill set. The American Board of Anesthesiology has recognized POCUS for diagnostic indications as a core skill by testing cardiac and lung POCUS on the Objective Structural Clinical Examination (OSCE) since 2021, with abdominal POCUS being added in 2025.  This means it is only a matter of time before POCUS will be used routinely in pediatric anesthesia clinical practice to evaluate cardiac function, volume status, presence of a pleural effusion, cardiac effusion, pneumothorax, and (we suspect) gastric contents and free fluid in the abdomen. 

In previous PAADs we’ve discussed articles that dealt with the questions of how should training and competency in the obtaining, interpreting, and clinical application of ultrasound be evaluated?  And how do we assure that pediatric anesthesiologists who trained before POCUS training was integrated into residency become proficient, or that skills learned in training don’t atrophy and deteriorate? (12/13/2023 https://ronlitman.substack.com/p/hocus-pocus  and 05/13/2024 https://ronlitman.substack.com/p/there-aint-no-hocus-in-pocus-ultrasound )

In today’s PAAD, Brant et al. ¹ studied how Pediatric emergency departments were credentialing programs and practitioners nationally.  The field of pediatric emergency medicine was an earlier adopter of POCUS for diagnostic indications than the field of pediatric anesthesia and thus the results of their survey may have important implications for us as we look towards the future of POCUS in our field.  Are we ready for this change in practice?  Are there obstacles to overcome?  And do we have to reinvent the wheel?   Today’s article provides us with some insight into how Pediatric Emergency Medicine is dealing with this new era and technology.  I’ve asked Dr. Elaina Lin, from the Children’s Hospital of Philadelphia and who is a nationally recognized expert in pediatric anesthesia POCUS to assist.  Myron Yaster MD

Original article

Brant JA, D'Amico B, Orsborn J, Toney AG, Lam SHF, Mickley M, Ambroggio L. Characterizing Point-of-Care Ultrasound Credentialing in Pediatric Emergency Departments. Pediatr Emerg Care. 2024 Sep 1;40(9):e186-e194. doi: 10.1097/PEC.0000000000003193. Epub 2024 Apr 16. PMID: 38713835.

Emergency medicine has been at the forefront of incorporating POCUS into clinical practice, training and credentialing for decades, with adult emergency medicine incorporating it into their practice in the 1990s and pediatric emergency medicine following suit in the late 2000s.  In 2015, the American Academy of Pediatrics recommended establishing training, credentialing, and standardized image review processes for pediatric emergency departments.  The document also outlined competency criteria for POCUS in PEM providers and recommended establishing a credentialing program for POCUS.

Many of the roadblocks to implementation and adoption into practice that the pediatric emergency medicine physicians faced and have overcome are similar to the current challenges we face today in pediatric anesthesia.  How do you go about incorporating POCUS into mainstream practice for ALL practitioners in your specialty?   In this survey study of pediatric emergency departments that are part of the P2 network (36 institutions responding), they describe the following: “Components include offering some form of POCUS education consisting of a combination of didactics and real-time scanning, giving feedback on scans to Pediatric Emergency Medicine (PEM) fellows and faculty, and having the ability to save scans for QA. However, the majority of providers have a limited amount of time to devote to education (<10 hours or nonrequired time) with some PEDs protecting education time but only a few PEDs offering CME or incentives. Point-of-care ultrasound credentialing is critical in maintaining consistency of image capture and interpretation, guides the appropriate use of ultrasound in clinical decision making, and standardizes care with the goal of improving clinical care.”¹  Thus, more hospitals are pushing to implement credentialing guidelines as the role of non-radiology ultrasound expands.²

At my institution (EL), we offer didactics, hands on training with real-time scanning on pediatric volunteer models, an intensive weekend course, save clinical scans for QA by local POCUS experts, and have a credentialing program in line with the other departments in our institution for those interested in becoming credentialed in diagnostic POCUS.  We also have plenty of ultrasound machines.  Despite the fact that the majority of attendings have taken a POCUS course, we continue to struggle to get everyone comfortable acquiring images and interpreting them in the OR and less than 10% are credentialed.  What are the barriers and how can they be overcome? 

Our good friend and colleague, Dr. Bill Greeley, says that when evaluating a (new) program and presenting it to hospital management it always comes down to resources and personnel.   How does a department provide the time for training, supervision, credentialing, and quality improvement?  How does a department buy multiple ultrasound machines?  Interestingly, Brand et al point out that POCUS can generate revenue for each completed scan.  Indeed, “several studies have looked at limitations to implementing successful billing and found that improvement in standardization of documentation and QA led to improvement in billing.”^1,3,4  Thus, the resources to pay for some of this may come from the procedures themselves.

The POCUS train is on the tracks and rolling; we can either drive the engine or be run over.  The ASA Ad Hoc Committee on Point-of-Care Ultrasound released a committee work product on training and privileging guidelines for diagnostic POCUS.⁵ As a subspecialty, we can’t afford to be left out in developing programs and credentialing for POCUS. This is a real challenge to our profession – and a real opportunity!  A recent survey of pediatric anesthesia fellowship programs showed that less than half of fellowship programs had a POCUS curriculum.⁶

Should the Pediatric Anesthesia Program Directors’ Association (PAPDA) support a standardized POCUS curriculum for ACGME-approved programs?  Should the SPA work to establish shared standards for credentialing in our specialty, so that local departments can take that to their institutions without having to reinvent the wheel?  Should one or 2-day courses be made available at our national meetings to support learners that may come from institutions without the resources locally?  Would you use ultrasound differently if you completed the process of credentialing?  Send your thoughts and comments to Myron who will  post in a Friday Reader response.

PS: From Myron: An editorial on ultrasound as an essential tool in pediatric anesthesia was just published in the December issue of Pediatric Anesthesia

Editorial

O'Brien EM, Lin EE. The power of POCUS in every pocket: Handheld ultrasound the new essential tool? Paediatr Anaesth. 2024 Dec;34(12):1185-1186. doi: 10.1111/pan.15016. Epub 2024 Oct 1. PMID: 39350698.

“While HPOCUS equipment is more expensive than the stethoscope, it is significantly less costly than traditional point of care (laptop sized, cart based) systems. Handheld ultrasound systems run approximately $2000 - $10 000 USD per unit, whereas a traditional point of care system costs $50 000–$70 000 USD including the probes. For the cost of a single traditional point of care system, a department or provider can purchase several handheld systems. The ease of transporting these systems, which easily fit in your pocket and can be used with software downloaded to your existing smartphone or tablet, increases the utility of a single system which can be used for multiple locations within a hospital or even for practices with multiple hospital locations.”7

References

1.           Brant JA, D'Amico B, Orsborn J, et al. Characterizing Point-of-Care Ultrasound Credentialing in Pediatric Emergency Departments. Pediatric emergency care 2024;40(9):e186-e194. (In eng). DOI: 10.1097/pec.0000000000003193.

2.           Smalley CM, Fertel BS, Broderick E. Standardizing Point-of-Care Ultrasound Credentialing Across a Large Health Care System. Joint Commission journal on quality and patient safety 2020;46(8):471-476. (In eng). DOI: 10.1016/j.jcjq.2020.03.009.

3.           Ng C, Payne AS, Patel AK, Thomas-Mohtat R, Maxwell A, Abo A. Improving Point-of-Care Ultrasound Documentation and Billing Accuracy in a Pediatric Emergency Department. Pediatr Qual Saf 2020;5(4):e315. (In eng). DOI: 10.1097/pq9.0000000000000315.

4.           Lahham S, Moeller J, Kurzweil A, et al. Evaluation of Adherence to Emergency Department Point-of-Care Ultrasound Documentation and Billing Following Intervention. J Med Ultrasound 2022;30(3):211-214. (In eng). DOI: 10.4103/jmu.jmu_76_21.

5.           American Society of Anesthesiologists Committee Work Product on Diagnostic Point-of-Care Ultrasound. Committee Work Product on Diagnostic Point-of-Care Ultrasound.  https://www.asahq.org/standards-and-practice-parameters/resources-from-asa-committees#POC

6.           O'Brien EM, Guris RD, Quarshie W, Lin EE. The state of point-of-care ultrasound training in pediatric anesthesia fellowship programs in the United States: A survey assessment. Paediatric anaesthesia 2024;34(6):544-550. (In eng). DOI: 10.1111/pan.14851.

7.O'Brien EM, Lin EE. The power of POCUS in every pocket: Handheld ultrasound the new essential tool? Paediatric anaesthesia 2024;34(12):1185-1186. (In eng). DOI: 10.1111/pan.15016