Advanced Practice Nursing and the Use of Ultrasound in Nursing Practice in the USA

Notes

Why POCUS?

  • Enhanced Diagnostic Accuracy
    • Provides real-time imaging to confirm or rule out conditions quickly.
  • Improved Patient Care
    • Facilitates faster decision-making and targeted interventions
    • Reduces exposure to ionizing radiation; decreases need for patient transport
  • Increased Efficiency
    • Reduces the need for additional imaging studies and can streamline workflows.
  • Improved Skills
    • Studies have shown that POCUS improves physical examination skills, knowledge of anatomy, and clinical performance

Training in POCUS

  • Most likely you didn’t get much of this in school (Robust training is rare in NP and PA programs)
  • Good POCUS training is made up of three areas:
    • Basic Concepts: Understanding ultrasound physics, equipment operation, and image interpretation.
    • Hands-On Skills: Practicing scanning techniques on simulators and real patients under supervision.
    • Clinical Integration: Applying skills to real clinical scenarios and interpreting findings within the context of patient management.
  • How can I get POCUS training?
    • Workshops and Courses: Enroll in POCUS training programs offered by medical institutions or professional societies. (Links below)
      • SCCM
      • CHEST
      • SHM
    • Online Modules: Utilize online platforms for self-paced learning and skill enhancement. (Links below)
      • POCUS 101 (free)
      • Toronto PIE (free)
      • Practical POCUS ($)
      • Butterfly ($)
    • Mentorship and Peer Learning: Engage in hands-on sessions with experienced practitioners and participate in peer review.

Certification and Competency

  • Certification and Competency are not the same, you can be competent without being certified (and probably vice versa!)
  • Certification Programs
    • Consider obtaining certification from recognized bodies, such as the American College of Emergency Physicians (ACEP) or the Society of Hospital Medicine (SHM)
    • Somewhat controversial, needed or just spending money?
    • My recommendation is: if you’re new and seeking training anyway, might as well do it in a way as to be certified; if you are experienced, probably little benefit in going back and obtaining certification
  • Ongoing Education
    • Stay updated with continuing education opportunities to maintain proficiency and integrate new techniques
    • QA/QI: Really should have some sort of mechanism where someone else reviews your scan from time to time to ensure you are correct

Billing and Reimbursement

  • Documentation Requirements (in general):
    • Medical Necessity
    • Written Interpretation
    • Date and time of examination
    • Name and hospital identification number of the patient
    • Patient age, date of birth, and sex
    • Name of the person who performed and/or interpreted the study, clinical findings
    • Indication for the study, the scope (complete vs limited), and if this is a repeat study by the same provider, repeat by a different provider, or reduced level of service
    • Impression (including when a study is nondiagnostic) and differential diagnosis, as well as the need for follow on exams and incidental findings
    • Mode of archiving the data (where can the images be found to be viewed)
    • Image Capture
  • These are general guidelines, specific payors may have different rules and you should check with your billing department for confirmation
    • CPT Codes: Current Procedural Terminology (CPT) codes related to POCUS.
    • Professional fees
      • Covers the cost of the provider’s services
      • You can bill for this
    • Technical Fees
      • Covers the cost of the equipment, facilities, etc.
      • Your hospital/practice can bill for this
      • Important when it comes time to convince people to buy new machines

POCUS use by Registered Nurses

“Ultrasound Guided IV Made Easy!” POCUS101.com

  1. Bahl, A., Johnson, S., Hijazi, M., Mielke, N., & Chen, N.-W. (2024). Cost effectiveness of ultrasound-guided long peripheral catheters in difficult vascular access patients. The Journal of Vascular Access, 25(4), 1204–1211.
  2. Gabay, G. (2023, March 06). Nurse-patient interactions in intensive care, transitions along the continuum of hope, and post-discharge management of chronic illness—A mixed methods narrative inquiry. Frontiers in Public Health, 11.
  3. Malik, A., Dewald, O., Gallien, J., Favot, M., Kasten, A., Reed, B., Wells, R., & Ehrman, R. R. (2023). Outcomes of Ultrasound Guided Peripheral Intravenous Catheters Placed in the Emergency Department and Factors Associated with Survival. Open Access Emergency Medicine : OAEM, 15, 177–187.
  4. Schoenfeld, E., Shokoohi, H., & Boniface, K. (2011). Ultrasound-Guided Peripheral Intravenous Access in the Emergency Department: Patient-Centered Survey. Western Journal of Emergency Medicine, 12(4), 475–477.
  5. Tran, Q. K., Flanagan, K., Fairchild, M., Yardi, I., & Pourmand, A. (2022). Nurses and Efficacy of Ultrasound-Guided Versus Traditional Venous Access: A Systemic Review and Meta-Analysis. Journal of Emergency Nursing, 48(2), 145-158.e1.
  6. Vujanić, J., Mikšić, Š., Barać, I., Včev, A., & Lovrić, R. (2022). Patients’ and Nurses’ Perceptions of Importance of Caring Nurse–Patient Interactions: Do They Differ? Healthcare, 10(3), 554.
  7. Ye, X., & Li, M. (2022). Comparison of Ultrasound Guided and Conventional Techniques for Peripheral Venous Catheter Insertion in Pediatric Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Frontiers in Pediatrics, 9, 797705.

Bladder Volume and Urinary Catheter Placement

Bladder Ultrasound Made Easy! POCUS101.com

Gastric Residual

Feeding Tube

Zhang Q, Sun JH, Liu JT, Wang XT, Liu DW. Placement of a Jejunal Feeding Tube via an Ultrasound-Guided Antral Progressive Water Injection Method. Chin Med J (Engl). 2018;131(14):1680-1685. doi:10.4103/0366-6999.235874

Arteriovenous Fistula

    Some good POCUS Resources

    Univ of Toronto Perioperative Interactive Education POCUS – Best interactive POCUS training

    POCUS 101

    The POCUS Atlas – A free online image/clip repository

    Society of Critical Care Medicine Advanced Ultrasound Course

    CHEST Critical Care Ultrasonography – Society of Chest Medicine offers a Certificate in critical care ultrasound. This page details that process and includes links to the various courses that CHEST offers.

    Society of Hospital Medicine POCUS Certificate – Like CHEST, the SHM offers a certification program for POCUS. This page contains information about the process as well as links to a number of different POCUS courses that can be used to meet certification requirements.

    Point of Care Ultrasound Certification Academy – POCUS Academy is another option for certification

    CORE Ultrasound

    University of Utah Echocardiography and Perioperative Ultrasound – Lots of good cases, teaching videos, and more

    Society of Point of Care Ultrasound (SPOCUS) – Lots of good teaching resources

    DIY Ultrasound Phantoms – Want to make your own phantoms for ultrasound teaching?

    Butterfly Ultrasound – Low cost handheld ultrasound device. This site also offers lots of educational resources; some free, some not.

    VAVE Ultrasound – Bluetooth handheld ultrasound device. Lots of educational resources with purchase of device.

    Practical POCUS – Site offering online and live POCUS courses

    SonoSim – Online POCUS training with a simulator probe for practicing the kinetics of POCUS without an ultrasound or patients.

    Resuscitative TEE Project – If you want to learn how to use transthoracic echocardiography in the ICU/ED, I can’t recommend this course enough!