POCUS in Acute Medicine

In this edition of Acute Medicine, Knight et al. demonstrate from SAMBA data that access to ultrasound machines and supervision is geographically heterogeneous.1 They raise concerns that this may lead to inequity of provision of Point of Care Ultrasound (POCUS) and the benefits it can provide for patients. This point is well made: Since the development of the Focused Acute Medicine Ultrasound (FAMUS) competencies in 20162 there has been a steady increase in the provision of supervisors to 803 and the number of individuals completing training has increased to 56. Whilst this is to be applauded, our experience concurs with this paper that much of the ultrasound training is concentrated in pockets of expertise in particular hospitals. As part of the AIM curriculum rewrite for 2022, the Special Advisory Group has proposed to the GMC that POCUS competencies become mandatory for all trainees in AIM. This will be supported by half a day of clinical time for training. This is a laudable aim but it is questionable whether, given the number of supervisors and their idiosyncratic distribution, the specialty of Acute Medicine would be able to support accreditation for all trainees. It is estimated that it takes 22 hours of supervision per supervised trainee.1 This is a significant commitment for jobbing consultants, especially with no supporting professional activity time in a job plan. The COVID19 pandemic has shown the value of POCUS lung ultrasound but has also highlighted further these training issues. A joint statement by the FAMUS and Focused Ultrasound in Intensive Care (FUSIC) committees has for the time being suggested that attendance at a course should no longer be a requirement for accreditation.4 This is an understandable attempt to try to keep training going but may have unintended consequences: It is often on courses that people are able to network and find solutions to mentoring and supervision in their areas and hospitals. The welcome support of the Royal College of Radiologists in their newsletter from Autumn 2019 may go some way to helping to fill the gap.5 The support of radiology and sonography departments will certainly lead to a greater number of training opportunities however there are concerns that many radiology departments remain sceptical about the role of POCUS and at an individual hospital level engagement is likely to be variable. As a solution to some of these problems at the Royal Berkshire hospital we have set up the AIM POCUS Academy with the goal of further embedding POCUS within the Acute Medicine department and the wider hospital.6 We are doing this by developing a multi-professional, multidisciplinary approach to POCUS through weekly teaching ‘Ultrarounds’. Links to the Sonography department, Cardiology, Respiratory Medicine, Emergency Medicine, Intensive Care, Vascular Access, Critical Care Outreach and Primary Care has led to a culture in which POCUS is considered a standard of care within the hospital and very much driven by the Acute Medicine department. This provides tremendous opportunities in all areas of the hospital for training and supervision but also the opportunities for different specialties to learn from each other. Individual Physiotherapists, Nurses and the Advanced Critical Care Practitioners in the hospital are either trained or are training up in lung ultrasound, ultrasound for vascular access or focused echocardiography and provide an excellent long term solution to the challenges of mentoring and supervision as they are more permanent members of staff. Where the sonography department and echocardiography department also provide mentorship for FAMUS and FUSIC, the exchange is both ways: Acute Medicine trainees have provided teaching around interpreting liver function testing which has led to rationalisation of inpatient abdominal ultrasounds and have taught sonographers how to interpret lung ultrasound; the echocardiography department are auditing the use of focused scans in specific conditions rather than a complete British Society of Echocardiography (BSE) full data sheet (so for instance in the context of an acute PE the echocardiographer will focus of right heart measures). This has helped to reduce waiting times within these departments. Technology has also helped to embed best practice and facilitate easier mentoring and supervision. Using the Butterfly IQ devices and a triple encrypted ‘cloud’ allows easy archiving of images and the possibility of remote reviewing which can even be in real time. This was invaluable during the COVID pandemic when GPs in our local ‘hot hub’ were trained up to use ultrasound to rule in and rule out COVID pneumonia allowing them to refer onto the ambulatory COVID pathway.6 They were able to share images via the cloud for review by experts in the hospital ensuring an extra degree of governance and oversight. We are trialing a similar system with our ‘Hospital at Home’ team with the hope it may save patients unnecessary visits to hospital for CXR and other imaging. If the specialty of Acute Medicine wants to take ownership of POCUS then we need to up our game and get serious about the supervision and mentoring of our trainees. Whilst the model of the AIM POCUS Academy may not be achievable everywhere, we believe initiatives like ours can act as the model for effective teaching and these centres could potentially provide a regional solution for POCUS training.