Running head: POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
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Point of Care Ultrasound (PoCUS) by the Family Nurse Practitioner in the Primary Care Setting
John M. Spurgeon
East Carolina University
A capstone project submitted to the faculty of
East Carolina University College of Nursing
in partial fulfillment of the requirements for the degree of
Doctorate of Nursing Practice with a concentration as
Family Nurse Practitioner
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
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East Carolina University
College of Nursing
Doctor of Nursing Practice
Final Project Approval
Student Name: John M. Spurgeon
Project Title: Point of Care Ultrasound (PoCUS) by the Family Nurse Practitioner in the Primary
Care Setting
Private Review Completed on 19 April, 2017
Public Presentation Completed on 13 April, 2017
Final Project/Final Paper Approval:
As the Chair of this student’s Doctor of Nursing Practice Project Committee, I have reviewed
and approved this student’s project and final paper and agree that he/she has met the project
expectations, including the DNP Essentials, and has completed the project.
DNP Committee Chair Signature:_________________________________Date______________
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Abstract
Ultrasound (US) is currently found predominantly in specialty practices and is not generally
utilized within the primary care environment at the point of care. While several medical schools
have included US training as part of their curriculum and residency programs, it remains a skill
set not commonly taught or even offered to family nurse practitioners (FNP’s). An initial
familiarization for PoCUS was offered to a cohort group of FNP students and other providers at
two locations, Womack Army Medical Center (WAMC), and East Carolina University. Both
locations offer a family nurse practitioner program that confers a doctor of nursing practice
degree upon completion. Familiarization training consisted of didactic and hands-on training
sessions focused on procedural guidance and assessment of the heart, lungs, vascular (deep vein
thrombus, abdominal aortic aneurysm, fluid overload and dehydration), kidney, gallbladder,
bladder, liver, and musculoskeletal systems. Initial training was accomplished in 16 hours of
instruction. Assessment of knowledge and skill was performed pre- and post-training using a
Likert scale tool. After training, the FNP students and providers were assessed for their
likelihood to comfortably embrace the use of US/PoCUS, and their willingness to receive further
training. Participants indicated a variety of responses about prior ultrasound use and training on
the pre-familiarization Likert scale used for the project. After receiving familiarization training,
fifteen out of nineteen study participants indicated they knew how to use US in primary care, and
all project participants indicated that they strongly desired additional training in PoCUS.
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Acknowledgements
First, I would like to express my sincere gratitude to my project chair, Dr Laura Gantt for
her patience, motivation, and immense knowledge. Her continuing support and belief in my
project was instrumental in my success. I cannot imagine having a better advisor and project
chair.
I would also like to thank the rest of my project committee: Dr. Ann King, Dr. Tracey
Robertson, Dr. Mary Pate, and Dr. Robin Webb Corbett, for their insightful comments and
encouragement, but also for the hard questions which helped me explore my project from various
perspectives.
I thank my classmates for the stimulating discussions, and for their guidance during the
sleepless nights when we were working together before deadlines, and for all the fun we have
had in the last three years. I am especially grateful to my study buddies; you know who you are!
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
TABLE OF CONTENTS
CHAPTER 1: Background …………………………………………………………………7
Introduction to the problem ………………………………………………………………...7
Purpose of project…………………………………………………………………………..9
Practice setting for project ………………………………………………………………...10
CHAPTER 2: Research Based Evidence and search strategy…………………………….10
Literature related to education and training in ultrasound…………………………………11
Literature related to competence comparisons and benefits in the use of ultrasound……...13
Literature related to the economic impact of Ultrasound…………………………………..15
Synthesis of evidence: strengths, weaknesses, and gaps in literature………………...........16
Theoretical framework for project guidance……………………………………………….16
CHAPTER 3: Methodology, Goals, and Design…………………………………………..19
Project Goals……………………………………………………………………….……….19
Project Design………………………………………………………………………………20
Needs Assessment…………………………………………………………………………..20
Source and Data Collection…………………………………………………………………21
Method of Collecting Data………………………………………………………………….22
Safety in Training and Research……………………………………………………………22
Resources Used and Cost Analysis…………………………………………………………23
CHAPTER 4: Results………………………………………………………………………23
Types of participants………………………………………………………………………..24
Pre-Likert …………………………………………………………………………………...24
Post- Likert…………………………………………………………………………………25
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POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
Conclusions………………………………………………………………………………...25
CHAPTER 5: Discussion………………………………………………………………….25
Overall strengths and limitations of the project……………………………………………27
Recommendations for practice……………………………………………………………..28
REFERENCES……………………………………………………………………………..30
APPENDICES……………………………………………………………………………...34
TABLES……………………………………………………………………………………38
Chapter 1
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Background
Ultrasound (US) was invented in the 1940’s. From its origins as a device which allowed
limited visualization inside the human body, ultrasound has morphed into smaller machines
capable of performing multiple scanning procedures that were previously conducted by
ultrasound sonographers and radiologists (Moore & Copol, 2011, para. 1).
Several schools have initiated the total immersion and inclusion of ultrasound during
medical school and residency of primary care physicians (Hoppmann et al., 2011, para.1). While
some Family Nurse Practitioners (FNPs) may be aware of the capabilities of ultrasound, it is not
commonly used within the profession and many FNPs lack both access to and training in the use
of ultrasound for primary care.
Introduction to the problem
A literature review revealed only one match that mentioned Nurse Practitioners (NP’s)
using ultrasound; this paper was written by physicians and addressed the training of five NP’s to
perform basic ultrasound techniques relevant in an emergency care setting (Henderson, Ahern,
Williams, Mailhot, & Mandavia, 2009). The author conducted hand searches for information
about use of US by family nurse practitioners, but was unable to find evidence of ultrasound
instruction included in the curriculum of any FNP programs. FNP’s may attend US training
offered after graduation or they may also work in a setting such as obstetrics/ gynecology where
they may receive some on the job training in the use of US. The military (to include FNP’s) does
offer some trauma-related US familiarization training and there have been papers published
concerning the use of US. Stawicki et al. (2010, p. 10) wrote that “there is extensive literature
describing the use of ultrasound by clinicians with diverse backgrounds and training who are
managing a variety of diseases at all levels of the healthcare system.” While some medical
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schools have integrated the familiarization of US into their programs (Hoppmann et al., 2011),
this transition has not occurred in the curriculum of FNP programs. This may be because
ultrasound is not a quick and easy skill to master. Todsen et al. (2016, p. 44) wrote:
Using ultrasonography technology requires technical skills, combined with knowledge
about image interpretation and medical decision making. During the course, physicians
practiced ultrasonography skills on normal anatomy, but not in the synthesis of diagnoses
essential for radiologic image interpretation. Although many of the participants in this
study had several years of clinical experience, we still found that the course had a
significant effect on skills performance and diagnostic accuracy. Therefore, we
recommend that clinicians receive systematic training before they start to use a new
technology (such as ultrasonography) to guide their clinical decisions.
Todsen et al. (2016, p. 46) also wrote that use of US is highly operator dependent and that
learning the principles and fundamentals for US is mandatory before beginning to teach specific
skills and procedures. Even after the introduction of and familiarization with basic uses of US in
primary care, the FNP must also be proctored and evaluated to ensure competency and necessary
requirements are met for credentialing by individual work places, institutions, scope of practice
and accrediting organizations.
In addition to the lack of educational opportunities for the FNP to learn how to use US in
primary care, a lack of access to US machines in most primary care settings is also usually a
problem (Moore & Copol, 2011, para. 3). Ultrasound machines are found in radiology
departments and where sonographers practice, but are rarely found outside of these areas except
in some specialty settings such as obstetrics and gynecology, emergency departments, surgery
departments and military healthcare units (Moore & Copol, 2011, para 26). Access to US devices
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and permission to use and practice with them are keys to providing most of the education
required for familiarization and further training. In summary, a provider’s ability to access an
ultrasound device is crucial.
Advances in technology have made US machines cheaper, smaller and with increased
capabilities (Moore & Copol, 2011, para. 1). “US may actually be useful in a nearly head-to-toe
examination of the patient. Few organs seem to be off limits for modern US, including
traditionally overlooked organs such as lung. So, bedside US provides a completely new
approach for clinicians in patient management and care” (Testa, Francesconi, Giannuzzi,
Berardi, & Sbraccia, 2015, p. 1023). Ultrasound is often the only form of imaging available in
austere settings such as the space shuttle, Mount Everest, or battlefields (Moore & Copol, 2011,
para. 26). Stawicki, Howard, Pryor, Bahner, Whitmill, & Dean, (2010, p. 11) wrote that
“technological advances have made modern ultrasound equipment increasingly portable, robust,
easy to use, inexpensive” and that these advances allow ultrasound to be brought to the patient to
obtain diagnostic information in real time.
Purpose of project
This project promoted familiarization with the use of US in the primary care setting by FNP
students and practitioners. This allowed for a gradual building in the student’s confidence and
capabilities, which may influence the likelihood of adoption and integration of PoCUS into
primary care in the future. Outcomes will be assessed using tools (Likert scales) designed to
measure likelihood of using US in the future (Table 1).
Practice setting for project
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A memorandum of agreement (see Appendix C) was completed by Dr. (LTC) Ida
Montgomery, director of the United States Army (U.S. Army) phase two residency program for
FNP students at WAMC, Fort Bragg, North Carolina. This memorandum allowed the project to
be conducted at WAMC by the author. FNP students in this program received some basic
familiarization with the use of US during their phase one training at the Uniformed Services
University of the Health Sciences (USUHS). This project will further familiarize the cohort
group of FNP students with basic US exams and procedures that are applicable to primary care
settings. Since Womack has access and the ability to use US in both training and practice, the
potential to expand after the initial familiarization is feasible and likely. The FNP program at
Womack wants to best prepare their future leaders in primary care to utilize all available assets
that can influence their ability to provide superior care while minimizing referrals. The FNP
program at Womack also places high value on the use of US, especially in austere or combat
mission settings where other forms of diagnostic imaging are not readily available.
Chapter 2
Research Based Evidence and Search Strategy
A literature review was conducted by searching various databases and search engines
using the One Source search option from the East Carolina University libraries page. A search
using the key words ultrasound, primary care, point of care, physical exam, and family nurse
practitioners was conducted. Search results were pulled from PubMed, Cumulative Index to
Nursing and Allied Health Literature (CINAHL), and ProQuest Nursing & Allied Health Source
databases to include journal articles, dissertations, position papers, published manuscripts and
textbooks. Results for a search of FNPs and ultrasound revealed two studies. A total of 79
potential publications were obtained. An emphasis was placed on journal articles and free
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position papers from the last five years. Journal articles, studies, and position papers were hand
sorted and selected by the author based upon key words and applicability to this project.
Literature related to education and training in ultrasound
Several papers have been published concerning education and training in the use of US in
primary care settings, and several medical schools have completely integrated the use of US into
their curricula (Hoppmann et al., 2011, p. 1). The University of South Carolina (USC) US
curriculum was initiated in 2006 across all four years of the medical school program as a
teaching tool, and is used at the point of care as a clinical tool. The students at USC
“overwhelmingly report that ultrasound has enhanced their medical education” and that they
learn focused US assessment well. The USC program also states that:
As ultrasound technology continues to advance and the evidence continues to mount
showing value of point-of-care ultrasound for improving the quality of patient care and
patient safety, the role of ultrasound in medical education and practice will inevitably
expand. It is imperative for those in medical education to ensure that ultrasound
education is introduced and conducted appropriately based on the best available evidence.
Experiences among institutions engaged in ultrasound education should be shared and
guidelines and basic recommendations for ultrasound in medical student curricula should
be established based on well-designed outcome studies, expert recommendations, and
adult learning principles (Hoppmann et al., 2011, p. 11).
In 2014, Memorial University in St. Johns, Newfoundland integrated PoCUS for rural
family medicine into its residency training program (Micks, Smith, Parsons, Locke, & Rodgers,
2016, p. 28). The program was described as a course offering focused assessment with
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sonography for trauma (FAST), early pregnancy assessment, detection of abdominal aortic
aneurism (AAA), and limited cardiac echo. The authors reported that their family medicine
residents completed 10 – 15 supervised US scans prior to moving into their rural placement sites
for further competency evaluation. Competency standards by the Canadian Emergency
Ultrasound Society Independent Practitioner (CEUS IP) guidelines require “50 supervised and
determinate scans in each subject area, followed by written, visual, and practical examinations.”
A study was performed at the Centre for Clinical Education of the Copenhagen
University Hospital. The research was registered and reported as a Consolidated Standards of
Reporting Trials (CONSORT) study. The purpose of the study was to determine if the skills
learned during a focused US course can be transferred and applied to diagnostic performance on
patients (Todsen et al., 2016, p. 40). The researchers split physicians who were blinded by
random assignment to groups. The control group received no training, while the intervention
group received 4 hours of instruction covering basic ultrasound physics and anatomy of the
abdominal organs. The physicians were allowed time to practice on each other prior to
evaluation by the course director and two instructors. An objective structured assessment of
ultrasound skills (OASUS) scoring form was used in this study (see table 2). The OASUS has
been validated in previous studies (Todsen et al., 2015; Todsen et al., 2016, p. 42).
Todsen and colleagues (2015) stated that learning outcomes achieved in a four hour
US course improved diagnostic performance on patients with abdominal conditions when
compared to the control group who did not receive US training. The authors also stated
that, based on their findings, greater than 4 hours of training for new technologies such as
PoCUS would be needed.
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In July of 2012, the University of Minnesota medical school conducted a mandatory 30
hour introductory US course for interns (Schnobrich, Olson, Broccard, & Duran-Nelson, 2013).
The five-day course consisted of web-based, didactic and hands on training. On day 5, the interns
were tested to see what they had learned.
In post-course testing, learners demonstrated the ability to acquire images, had
significantly increased knowledge scores (P < .001), and demonstrated good performance
on practical scenarios designed to test abilities in image acquisition, interpretation, and
incorporation into medical decision making. In the post course survey, learners strongly
agreed (4.6 of 5.0) that ultrasound skills would be valuable during residency and in their
careers (Schnobrich et al., 2013, p. 493).
The results indicated that interns were able to improve their knowledge and skills;
however, additional training and experience would be needed in order allow the interns to
independently perform US for patient care decisions.
Literature related to competence comparisons and benefits in the use of ultrasound
In the past, radiologists and sonographers have been protective of their “turf.” While this
is understandable, the rapid expansion and increased prevalence of ultrasound, along with its
increased capabilities, makes it easier for a provider to utilize it to assist with making clinical
decisions; this also prevents a referral to another specialist provider, which may result in delays
in care and additional costs.
In 1997, the Royal College of General Practitioners (GP’s) and Radiologists proposed a
training program that allowed GP’s to perform primary care basic US examinations. This
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generated concern amongst radiologists about the adequacy and appropriateness of the training.
A postal questionnaire was sent to General Practitioners (GP’s) to assess for multiple issues,
such as potential workload, level of interest in ultrasound training, and the willingness and ability
of local radiology departments to participate in training of the GP’s (Robinson et al., 1997, p.
293). Table 3 shows the data obtained by the questionnaire.
A study was performed in 2013 comparing point of care cardiac US performed by a
novice examiner compared to the gold standard of a cardiology specialist (Frederickson, Olsen,
Andersen, & Sloth, 2013, p. 2). A cardiac US was performed by a novice examiner at the point
of care, looking for six outcome categories: 1) pericardial effusion, 2) left ventricular dilation, 3)
right ventricular dilation, 4) left ventricular hypertrophy, 5) left ventricular failure, 6) aortic
stenosis. Examiners were blinded to the patient’s previous medical history and echo exams. The
results were analyzed by an independent blinded specialist cardiologist who reviewed the US
examinations and diagnoses by both the novice examiner and the cardiology specialist. There
were 102 patients examined by performing 612 assessments. There was agreement between the
novice and cardiologist specialist in 95.6% of the cases. This resulted in a sensitivity of 0.91 and
specificity of 0.97. The kappa coefficient of agreement between observers was 0.88.
PoCUS use by non-radiologist physicians continues to rise. The top five users are
cardiologists, vascular surgeons, primary care physicians, general and other surgeons, and
urologists (Levin, Rao, Parker, & Frangos, 2011, p. 773). However, Levin et al. (2011, p. 772)
state that “radiologists consider themselves the leaders in noncardiac ultrasound, and the leading
producers of education and research in that technique.”
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Five nurse practitioners (NP’s) working in an emergency department at the Southern
California Medical Department were given a 16-hour block of ultrasound instruction in
emergency medicine (EM) followed by 1 year of physician-supervised clinical instruction
(Henderson et al. 2009, p.352). After this period of training, the NP’s achieved a 93% accuracy
rate of detecting disease pathology and a 98% rate of detecting lack of disease pathology. This
resulted in a specificity level of 98% and a sensitivity of 93%. The study concluded that “NP’s
are able to perform focused ED US with a high degree of adequacy and accuracy.”
A paper by Wilson, Scully and Rawlings (2015, para. 1) described the benefit of realtime, dynamic imaging US, eliminating patient exposure to ionizing radiation and allowing USguided injections to be performed in the office, as opposed to the operating room. “Bedside US is
a safe and reliable technique, with worldwide use expanding in various clinical settings, it is
considered the stethoscope of the 21st century” (Testa et al. 2015, para. 1).
Literature related to economic impact of ultrasound
An economic analysis revealed that bedside US can produce consistent savings,
economic profit, and other medical benefits (Schnobrich et al., 2013, para. 2). Wilson et al.,
(2015, p.1) also wrote that implementation of ultrasound-guided injections has therapeutic,
financial, and provider role implications because of its clinical use for procedural guidance and
subsequent billing.
A Medicare physician fee schedule by SonoSite / Fujifilm (2016) is listed in table 5,
showing some of the more common US procedures that can be performed in a primary care
setting along with the payments for service.
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Synthesis of Evidence: Strengths, Weaknesses & Gaps, in Literature
Literature concerning use of US by FNPs has been limited to specialty settings such as
the emergency department or obstetrics (Henderson et al., 2009, p. 352). Literature concerning
the use of US in primary care has historically been oriented toward physician providers and
usually published in physician journals.
The literature reviewed demonstrates that US is starting to be used in primary care and
that it is a skill taught in medical school and specialty training courses and fellowships. While
the use of ultrasound continues to evolve, the fact that it is now being used in primary care
settings, and who is using it under what conditions, raises questions and issues that must be
addressed in order to implement the use of US by FNPs. As such, more research or projects to
assess the impact of FNPs performing PoCUS should be performed.
Key concepts and definitions can be found in appendix A.
Theoretical Framework for Project Guidance
The Diffusion of Innovations theory was first published in 1962 by Dr. Everett Rogers
(Rogers, 1962). Diffusion describes how an innovation is communicated through channels over
time by members of a social system (Rogers, 2003). Innovation is defined as “a new idea,
device, or method and the act or process of introducing new ideas, devices, or methods”
("Definition of Innovation," n.d.). Professor Deborah Lekham of Duke University further
described innovation as “An idea, practice, or product perceived to be new by the relevant
individual or group” in her presentation on Diffusion of Innovations (Lekan, 2008, p. 7). She
elaborated by defining an idea as a new way of thinking about something, practice as a new way
of doing something, and product as new equipment, device or technology.
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The Diffusion of Innovation Theory (Rogers, 1962) is easily understood using the
example of cellular phones and their almost exclusive use within our culture today. Early cell
phones were large, limited in function, and available for use by only a small group of people who
initially adopted and used them during their development. Today they are accepted as the norm
and it is almost unheard of for someone not to have and use a cell phone. In the same way,
cellular phones have replaced traditional telephone lines, ultrasound’s increased accuracy and
portability allows healthcare providers outside of specialized practices such as obstetrics and the
emergency department to perform ultrasound at the point of care. Emergency and trauma
providers have developed specialized scanning techniques that allow them to assess, triage and
treat many patients that in years past would have been delayed because of the need for other
diagnostic imaging such as x-ray, computerized tomography or magnetic resonance imaging
(Moore & Copol, 2011, p. 2).
When applying the Diffusion of Innovation theory to the specific concept of FNP
adoption of US for use in primary care, there are five distinct categories of “adopters” as they
start to embrace the use of this innovative technology. As seen in Table 6, Rogers defines these
adopters as innovators, early adopters, early majority, late majority and laggards (Rogers, 2003).
The Diffusion of Innovation in Health Care report by the California Health Care
Foundation (Cain & Mittman, 2002, p. 5) discusses 10 dynamics or factors of importance when
innovation diffuses into a group. Some of the key factors for adoption by nursing are discussed
in subsequent paragraphs.
Relative advantage is the potential value or benefit for adoption of innovation compared
to current practice, which influences the rate of adoption (Cain & Mittman, 2002, p. 5). “What’s
in it for me,” or “how can this affect me” are the questions nurses will ask themselves when
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considering a new practice or device. Early adopters and early majority innovators will often be
the first to realize the relative advantage of technology adoption (Rogers, 2003).
Observability is the extent to which adopters can see the favorable adoption of innovation
by others, which improves its potential rate of adoption (Cain & Mittman, 2002, p. 5). When an
FNP observes another provider performing an assessment or intervention with US, they become
more likely to adopt it into their practice. The two most common reasons why FNPs do not adopt
and use US are simple. They do not know how and do not have someone to teach them. The
early adopters and early majority innovator nurses will usually be the first to use observability to
their advantage due to their predisposition.
Communication is the path leaders and others use to promote the innovation and it greatly
influences the rate and pattern of adoption (Cain & Mittman, 2002, p. 5). Leadership influence
can also be a major factor. If a key leader decides that an innovation will not be adopted and
informs potential users, like FNPs, that they will not use a technology innovation, it is very
difficult to overcome. Sometimes the innovative adopter can overcome these barriers.
Innovation spreads faster amongst groups that are similar (Cain & Mittman, 2002, p. 5).
FNPs that practice in areas where US is used frequently, such as emergency departments or
obstetrics, are usually quicker to embrace a technology innovation such as US when compared to
FNPs practicing in other settings. Norms, rules, social networks, innovation diffusion and
adoption are affected by the rules, hierarchies and communication network a group uses (Cain &
Mittman, 2002, p. 5).
Compatibility is the ability of an innovation to coexist within technologies and social
patterns already in place, which improves the rate of adoption and diffusion (Rogers, 2003). An
example would be a small emergency department where the physicians see themselves as the
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only providers that are “privileged” or credentialed to use ultrasound. This can influence a FNP’s
ability to access and use the ultrasound machine for assessment and procedures.
Disruptive innovation can also be a factor. The stethoscope is over 200 years old, the
blood pressure cuff is a youngster at 135 years, while the defibrillator is only 70 years old. With
ultrasound being a relatively new innovation outside of radiology, other providers have been
slow to implement its use. Testa et al. (2015) wrote that “bedside US is a safe and reliable
technique, with worldwide use expanding in various clinical settings, it is considered the
stethoscope of the 21st century.”
Chapter 3: Methodology, Goals, and Design
Project Goals
The goal of this project was to expose FNP students to the use of ultrasound in primary
care. The project director postulated that after FNP students have completed the series of seven
familiarization classes on the use of US in primary care, they would be more likely to use US in
the future and would desire further training.
While the project was designed to expose and familiarize FNP students with the use of
US in primary care, other providers at WAMC also attended. The FNP students were required to
attend by the WAMC FNP program director. The same data was collected on the current FNPs
and other providers to assess for differences in likelihood to adopt and use US in primary care.
While the focus was on FNP students, other providers have received some training in the use of
US.
The literature reviewed suggests that providers who are trained in the use of US and have
access to it are able to make faster decisions and reduce referrals and delays in care. Literature
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regarding education and training in US is physician-oriented and demonstrates that US is taught
in some medical schools with a primary emphasis on trauma and critical care. Primary care US is
just starting to be mentioned in published papers.
Project Design
A cohort of Womack FNP students, other providers, and East Carolina
University students received familiarization training in primary care ultrasound techniques
(Table 7). IRB approval (see Appendix B) was obtained and familiarization training was initiated
in the summer of 2016. Planned preceptorships and competency evaluation was not performed
due to lack of trained preceptors and US machines. The end goal was for FNP students to
integrate US into their primary care practice during physical assessments, or for specific
evaluations, and / or procedural guidance.
Needs Assessment
In order to provide the training for the project, a literature review was conducted to assess
for procedures commonly performed and applicable in this setting. While there are US
procedures for almost all body systems, many medical schools have standardized what skills and
techniques are taught to providers that will practice in primary care.
The project author was trained in the use of US while serving on active duty in both
Combat Support Hospitals (CSH), and Forward Surgical Teams (FST). He also completed a
familiarization course in the use of US in primary care at the University of South Carolina
School of Medicine’s Ultrasound Institute. Based on the information and skills learned there, and
with knowledge of recent needs of the military after consulting with the FNP site director at
WAMC, a decision was made about what training would be offered.
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Training and skills that were taught to the initial group at WAMC are listed in Table 7.
These skills were taught in blocks of instruction approximately every two weeks. Skills taught
were selected after comparing multiple programs, as well as training and skills taught to
physicians, while eliminating some procedures that are not currently in the scope of practice for
some FNP’s. This includes procedures such as thoracotomies, insertion of chest tubes, and
percutaneous drainage of fluids from organs. The skills taught were based upon the introduction
to point of care ultrasound course taught at the University of South Carolinas, School of
Medicine Ultrasound Institute (University of South Carolina School of Medicine Ultrasound
Institute [USCSOM], 2016).
Other factors considered in planning the training was that the cohort group of military
students at WAMC are often trauma focused, in addition to being primary care providers. US
skills are commonly taught in the military for those medical providers attending the Uniformed
Services University of the Health Sciences (Nurse Practitioners and Physicians) and also
tactically at the combat surgical hospital and forward surgical team level. While these skills are
valuable to military members, a determination was made in consultation with Dr. Ida
Montgomery, the phase II director of FNP training at WAMC to focus during this project on
primary care skills.
Source and Data Collection
For this project, all providers (with an emphasis on FNP students) that received education
and training completed a pre-familiarization survey (Table 1), prior to each series of instruction
as and then afterwards to assess for a change in opinion. Surveys were conducted for the types
of familiarization training to assess for differences based upon the level of complexity of the
familiarization training offered. The pre-familiarization survey collected basic data such as type
of provider, student status, and previous experience. The pre-survey also assessed for previous
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US experience and beliefs concerning the use of US based on a seven point Likert scale. After
training and familiarization, a post-familiarization survey was completed, using a seven point
Likert scale to assess the student’s opinion on their ability to use US in primary care, their belief
or likelihood that they would personally use US in primary care for the procedure covered in the
series of familiarization trainings, and their willingness or desire to receive further training in
primary care US.
Method of Collecting Data
Once initial training and familiarization was completed at WAMC, the data was collected
from the surveys, and entered into a secure database by the project director. Analysis of the data
using SPSS software was conducted and the findings were then integrated to address project
outcomes.
Safety in Training and Research
In regards to the use of ultrasound on live tissue, the American Institute of Ultrasound in
Medicine [AIUM] has made the following position statement:
Diagnostic ultrasound has been in use since the late 1940s. There are no confirmed
adverse biological effects on patients resulting from this usage. Although no hazard has
been identified that would preclude the prudent and conservative use of diagnostic
ultrasound in education and research, experience from normal diagnostic practice may or
may not be relevant to extended exposure times and altered exposure conditions. It is
therefore considered appropriate to make the following recommendation: When
examinations are carried out for purposes of training or research, ultrasound exposures
should be as low as reasonably achievable (ALARA) within the goals of the
study/training. In addition, the subject should be informed of the anticipated exposure
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
23
conditions and how these compares with normal diagnostic practice. Repetitive and
prolonged exposures on a single subject should be justified and consistent with prudent
and conservative use (American Institute of Ultrasound in Medicine, 2012).
These recommendations were included in informed consent documents and were
reviewed by the Institutional Review Board (IRB).
Resources Used and Cost Analysis
Training was conducted at WAMC and did not require any actual monetary cost due to
equipment, personnel, and availability of resources within the organization. Resources that were
utilized during this project included US machines, classroom space with projection/computer
equipment, patient gurneys/beds, phantom and human models.
The WAMC FNP students attended as part of their biweekly skills checklist per their site
director. Other providers were free to attend as their schedule allowed. This training did not
interfere with the provision of patient care at WAMC.
CHAPTER 4: Results
The likelihood or willingness to adopt US into a primary care assessment was evaluated
using a pre-and post-familiarization training Likert scale survey for beliefs and attitudes. Data
was analyzed using SPSS version 24. Descriptive statistics and frequencies were calculated using
the data from the participants’ Likert scales.
Initial orientation and familiarization with the use of US for assessment and screening of
abdominal aortic aneurysm (AAA) and deep vein thrombosis (DVT) in the lower extremities was
conducted in the fall of 2016 to a group of FNP graduate students at East Carolina University
and a cohort group of FNP graduate students from the U.S. Army residency at WAMC. The
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
24
results listed in this paper are taken from the data obtained from this first orientation and
familiarization. The decision to provide initial orientation and familiarization with US to include
screening for AAA and DVT at both institutions was selected because it was one of the easier
skills to present and practice and its selectivity and sensitivity are high. Wagner & colleagues,
(2016, p. 1), wrote that “use of ultrasound to screen for AAA represents one of its most well
established applications in primary care. Sensitivity and specificity for the detection of AAA
with US are reportedly 98.9% and 99% respectively.” For the screening and imaging of DVT
using US, Burnside, Brown, and Kline (2008) conducted a systematic review and reported “an
overall sensitivity of 95% and specificity of 96% for detection of DVT.”
Types of Participants
East Carolina University had a total of eight participants, with six FNP graduate students
and two current FNP providers. The U.S. Army at WAMC had a total of eleven participants
including four FNP students, six FNP providers, and one Doctor of Osteopathic Medicine (D.O.).
Table 8 summarizes the participants.
Pre - Likert
Participants indicated a variety of responses to the first three items s on the Likert scale
survey tool prior to beginning the training. The survey items were:

I have received Ultrasound training before
32%

I have used Ultrasound before
53%

I have access to Ultrasound in my practice
74%
Table 9 shows that fifteen out of nineteen participants reported access to ultrasound in
their work environment, with six reporting previous training, and ten previous use of US.
Participants previous experience with US use is listed in tables 10-13. Participants experience
varied in the use of US, with some participants strongly disagreeing in their ability to use US in
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
25
primary care and likelihood to perform the procedure taught. A difference between the groups
was observed when the military cohort reported that nine out of eleven (82%) indicated access to
US, while the ECU cohort indicated that one out of eight (13%) had US access.
Post - Likert
After familiarization training, participants were asked to complete a post familiarization
assessment for attitudes or likelihood to adopt with the results listed in the tables below. The
results are illustrated in Tables 14-17. The post – Likert surveys indicated that sixteen of
nineteen (84%) participants agreed they knew how to perform the procedure after training and
would likely perform it. All 19 (100%) participants agreed that they would like to receive further
training on the use of US in primary care, with 95% indicating they very strongly agreed, and 5%
strongly agreeing.
Conclusions
The data collected from the Likert surveys indicates that previous experience and / or
exposure to the use of ultrasound predisposes some to favorable opinions towards adoption and
utilization of ultrasound in primary care when compared to others who have not had exposure.
The author did not explore offering the Likert scale tool to individuals and groups who did not
attend the orientation and familiarization opportunities. This may have helped indicate the level
or likelihood to adopt and use US by comparing those with no training, use, or access to
ultrasound to those who have.
CHAPTER 5: Discussion
The Diffusion of Innovation Theory clearly predicts the process of adoption of
ultrasound, as it has with other new technologies; in fact, articles have already been written about
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
26
ultrasound using the Evaluation Tool for Ultrasound Skills Development and Education
(ETUDE; Woo, Frank, & Lee, 2014, para. 2).
All project participants indicated on both the pre- and post-Likert scale surveys that US
should be utilized in primary care, and that they would like to receive further training in the use
of US in primary care. Likert scale scores for these two questions were rated by participants as
either strongly agree or very strongly agree.
With medical schools integrating US early in graduate medical education, medical
students and residents become accustomed to its routine use and integration. There is no data
available that suggests that this would not be feasible for other providers, such as FNP’s, to learn
and use ultrasound. The University of South Carolina School of Medicine states that their
Introduction to Point of Care Ultrasound, offered through their Ultrasound Institute, “is
appropriate for physicians, nurse practitioners, and physician assistants who work in a primary
care, hospitalist, or urgent care setting. No previous ultrasound imaging experience is needed”
(University of South Carolina Medical School, 2016, para. 7). The more providers are trained in
the use of ultrasound, the more they will be able to influence others around them. Today, most
healthcare providers use a stethoscope as a primary diagnostic point of care tool, although it was
originally designed over 200 years ago. The stethoscope’s diagnostic capability is limited by
proper technique, body habitus, skill of the provider and the ability of that provider to interpret
what has been heard to make an educated guess by using differential diagnosis. If trying to
determine what is going on inside a patient’s lung, most healthcare providers will order labs,
listen with the stethoscope, perhaps perform further respiratory tests, order breathing treatments,
and possibly x ray or other forms of imaging. Wagner et al. (2016) wrote that “point of care
ultrasound can improve patient safety. diagnostic and procedural accuracy, patient and provider
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
27
satisfaction, and the overall efficiency of patient care.” A simple lung US performed at the
patient’s bedside has been proven to be superior to a chest x-ray and usually requires less of a
wait, not to mention the reduction in patient exposure to radiation (Adriono et al., 2010, para. 5).
Overall strengths and limitations of the project
Almost everyone involved in the study indicated a positive response and likelihood to
attend further training and possibly integrate US use into their practice.
Strengths of this project were the attitudes of the U.S. Army participants who were
always enthusiastic and asking questions about further training and potential use of US in
primary care. A dissemination briefing was conducted with the WAMC participants after the
project completion and all agreed that they would like to continue with US education in the
future. The lead researcher at WAMC proposed a future program aimed at integration into the
primary care environment starting in urgent care.
An unexpected limitation in the conduct of the study within the military environment was
trying to “borrow” an US machine. Instructors and students were frequently forced to use a
machine that was outdated and no longer supported by the original manufacturer. This older
technology made it more difficult for everyone involved to acquire acceptable images to study.
Having ready access to current US machines with the accuracy and ability to capture superior
imaging may have influenced the participant’s overall responses on the Likert scales related to
attitude and likelihood to adopt US. The importance of being able to reinforce a skill with the
ability to readily visualize and identify an issue on ultrasound increases student confidence and
cannot be overemphasized. Furthermore, the author is also learning to use ultrasound. Having a
true subject matter expert may have made significant differences in the outcomes and opinions of
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
28
the participants.
Recommendations for practice
A FNP trained in the use of primary care ultrasound can reduce the need for unnecessary
referrals to higher, more expensive levels of care while also maintaining that level of patient
provider respect and trust that we all strive for. Patients want to believe that they will be able to
visit their provider and that they will be able to take care of them, then and there, without further
complication. When this is not possible, the patient depends on the provider to explain and guide
them through other processes that may be necessary.
Medical students and physicians are rapidly adopting the use of US for point of care use.
Integrating US into the curriculum of new nurses would help them to visualize and understand
the location, appearance and relationship to other body structures and organs not usually
appreciable with a stethoscope or traditional methods of examination. By starting the early
integration of US into the nursing programs, nurses can continue to improve upon their skills and
capabilities as they gain experience and/ or seek further education.
Currently, FNPs have little incentive to learn US on their own. Most FNP’s are expected
to see a certain number of patients a day using traditional methods such as
observation/inspection, palpation, percussion and auscultation. Expecting a provider to set aside
time to learn a complex procedure and technique after they are already in practice may be
unrealistic. Teaching FNP students and other providers US early in their careers will allow
them to build upon these skills as they progress through school so that it becomes second nature
and a standard of practice when they see patients. Routine use of US while in school brings about
a greater understanding of anatomy and physiology while also promoting patient-provider
interaction with results that both can see. The World Heart Organization published a paper that
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
29
stated “It is becoming increasingly apparent that training our medical students to use ultrasound
earlier in their careers can allow them to develop diagnostic skills that far exceed the traditional
exam that physicians have been taught for centuries” (Fox, Marino, & Fischetti, 2014, para. 6).
Medical students and physicians are rapidly adopting the use of US for point of care use.
Possibly, in the future, the profession of nursing will integrate US into nursing school
curriculums for the same reasons medical schools have.
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
30
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Appendix A
Definitions
Family Nurse Practitioner (FNP).
Nurse Practitioner (NP) specialties can be: Family NPs, Pediatric NPs, Adult NPs, Geriatric
NPs, Women’s Health Care NPs, Neonatal NPs, Acute Care NPs, Occupational Health NPs,
Certified Nurse Midwives, and Certified Registered Nurse Anesthetists.
Point of Care Ultrasound (PoCUS): Ultrasound performed at bedside, in clinic, (not radiology
/sonographer setting).
Real Time Ultrasound (RTUS): ultrasound performed “live” in motion mode for procedure or
exam.
Ultrasound (US): The National Institute of Biomedical Imaging and Biomedical Engineering
classifies US into two separate categories, diagnostic and therapeutic. Diagnostic ultrasound “is a
non-invasive diagnostic technique used to image inside the body” (National Institute of Health
[NIH], July 2016, para. 2), while therapeutic ultrasound is defined as “sound waves above the
range of human hearing but does not produce images. Its purpose is to interact with tissues in the
body such that they are either modified or destroyed” (National Institute of Health [NIH], July
2016, para. 3),
Womack Army Medical Center (WAMC): Army hospital located at Fort Bragg, North Carolina.
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
35
Appendix B
IRB Approval
EAST CAROLINA UNIVERSITY
Office of Research Integrity and Compliance (ORIC)
University & Medical Center Institutional Review Board (UMCIRB)
Brody Medical Sciences Building, 4N-70• 600 Moye Boulevard • Greenville, NC 27834
Office 252-744-2914 Fax 252-744-2284 www.ecu.edu/irb
TO:
John Spurgeon, ECU College of Nursing, DNP
Program
FROM:
Office for Research Integrity & Compliance (ORIC)
DATE:
July 1, 2016
Doctor of Nursing Practice (DNP) Project
TITLE:
Point of Care Ultrasound
This activity has undergone review on 7/1 /2016 by the ORIC to determine if IRB approval is
necessary. A Doctor of Nursing Practice candidate is going to implement a process
improvement initiative for providers at Womack Hospital in the use of ultrasound at point of
care. Pre-and post-assessment of knowledge and skills will be conducted. Womack Army
Medical Center HPA determined this project did not meet the definition of research and we
concur.
This activity is deemed outside of UMCIRB jurisdiction because it does not meet the current
federal descriptions for human subject research. Therefore, this activity does not require
UMCIRB approval. Contact the office if there are any changes to the activity that may require
additional UMCIRB review or before conducting any human research activities.
Relevant Definitions for Human Subject Research:
•
•
Research means a systematic investigation, including research development, testing and
evaluation, designed to develop or contribute to generalizable knowledge. Activities which
meet this definition constitute research for purposes of this policy, whether or not they are
conducted or supported under a program which is considered research for other purposes.
For example, some demonstration and service programs may include research activities
Human subject means a living individual about whom an investigator (whether
professional or student) conducting research obtains:
(1) Data through intervention or interaction with the individual, or
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
(2)
36
Identifiable private information.
The UMCIRB applies 45 CFR 46, Subparts A-D, to all research reviewed by the
UMCIRB regardless of the funding source. 21 CFR 50 and 21 CFR 56 are applied to all
research studies under the Food and Drug Administration regulation. The UMCIRB
follows applicable International Conference on Harmonization Good Clinical Practice
guidelines.
IRB00000705 East Carolina U IRB (Biomedical) IORG0000418
IRB00003781 East Carolina U IRB (BehavioraVSS) IORG0000418
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
37
Appendix C
Letter of Support / Approval from WAMC
DEPARTMENT OF THE ARMY
WOMACK ARMY MEDICAL CENTER FORT BRAGG, NORTH CAROLINA
28310-5000
REPLY TO
ATTENTION OF:
MCXC-DME-GME
7 June 2016
MEMORANDUM FOR John Spurgeon, RN, East Carolina University, Family Nurse
Practitioner Doctor of Nursing Practice Student
SUBJECT: Review of student project "Point of Care Ultrasound (PoCUS) by the Family Nurse
Practitioner in the Primary Care Setting"
l. This project has been reviewed by Womack Army Medical Center (WAMC) Human
Protection Administrator, Caryn Duchesneau, CIP. It has been determined that this project
does not meet the definition of research as defined by 32 CFR 219.102 (d).
2. Approval by the WAMC RB is not required. You are free to add and remove staff as needed.
3. This project can be conducted at WAMC as a process improvement initiative. LTC Ida
Montgomery will provide oversight of this activity.
4. Point of contact for this action is the undersign.
Uniformed Services University of the Health Sciences
Daniel K. Inouye Graduate School of Nursing
Director, DNP Phase 11 Site, WOMACK, Fort Bragg
w: 910-907-8663 c: 254-290-3492
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
38
Tables
Table 1
Pre – Familiarization Ultrasound Survey
Date_______________________
I am a Student? Y/ N
MD/DO
PA
FNP/NP
18D
(Circle all that apply)
I have received Ultrasound training before
I have used Ultrasound before
I have access to Ultrasound in my practice
Yes
Yes
Yes
Strongly Disagree
Question
1
I know how to perform 1 ultrasound
procedure
2
I know how to perform up to 5
ultrasound procedures
3
I know how to perform greater than 9
ultrasound procedures
4
I believe that Ultrasound can be used in
primary care
5
I know how to use Ultrasound for
primary care
6
I know how to use Ultrasound to
perform the procedure/intervention
being taught today
I am likely to perform the
procedure/intervention being taught
today in the primary care setting
7
1
2
3
No
No
No
Neither
4
Strongly Agree
5
6
7
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
39
Post – Familiarization Survey
Procedure / Intervention Taught _________________________________________________
Strongly Disagree
Question
1
I believe that Ultrasound can be used in
primary care
2
I know how to use Ultrasound for
primary care
3
I know how to use Ultrasound to
perform the procedure/intervention
being taught today
I am likely to perform the
procedure/intervention being taught
today in the primary care setting
I would be comfortable performing the
procedure taught today when I have
completed competency evaluation
I would like to receive further education
and training about the use of ultrasound
in primary care
4
5
6
1
2
3
Neither
4
Strongly Agree
5
6
7
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
40
Table 2
Objective Structured Assessment of Ultrasound Skills (OSAUS) scale
Likert scale
Item
1
1. Indication for the
examination*: if applicable.
Reviewing patient history and
knowing why the examination is
indicated
2. Applied knowledge of
ultrasound equipment: familiarity
with the equipment and its
functions, i.e. selecting probe,
using buttons and application of
gel
3. Image optimization:
consistently ensuring optimal
image quality by adjusting gain,
depth, focus, frequency, etc.
4. Systematic examination:
consistently displaying systematic
approach to the examination and
presentation of relevant structures
according to guidelines
5. Interpretation of images:
recognition of image pattern and
interpretation of findings
2
3
4
5
Displays poor
knowledge of the
indication for the
examination
Displays some
knowledge of the
indication for the
examination
Displays ample
knowledge of the
indication for the
examination
Unable to operate
equipment
Operates the
equipment with
some experience
Familiar with
operating the
equipment
Fails to optimize
images
Competent image
optimization but
not done
consistently
Consistent
optimization of
images
Unsystematic
approach
Displays some
systematic
approach
Consistently
displays systematic
approach
Unable to interpret
any findings
Does not
consistently
interpret findings
correctly
Consistently
interprets findings
correctly
6. Documentation of examination:
Does not document
image recording and focused
any images
verbal/written documentation
7. Medical decision-making: if
Unable to integrate
applicable. Ability to integrate
findings into
scan results into the care of the
medical decision
patient and medical decision
making
making
Consistently
Documents most
documents relevant
relevant images
images
Excellent
Able to integrate
integration of
findings into a
findings into
clinical context
medical decision
making
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
41
Table 3
_____________________________________________________________________________________
Total number
of respondents
n = 225 (%)
Level of interest in training
Not
Moderately
interested
interested
n = 108 (%) n = 80 (%)
Very
interested
n = 35 (%)
Current access to obstetric ultrasound
Open 108 (48.0)
51 (47.2)
Indirect 76 (33.8)
36 (33.3)
Other 20 (8.9)
8 (7.4)
Combination 13 (5.8)
9 (8.3)
Unanswered 8 (0.5)
4 (3.7)
40 (50.0)
27 (33.8)
4 (5.0)
7 (8.8)
2 (2.5)
17 (48.6)
12 (34.3)
1 (2.9)
4 (11.4)
1 (2.9)
Current access to non-obstetric ultrasound
Open 174 (77.3)
86 (79.6)
Indirect 22 (9.8)
5 (4.6)
Other 12 (5.4)
7 (6.5)
Combination 9 (4.0)
6 (5.6)
Unanswered 8 (0.5)
4 (3.7)
62 (77.5)
10 (12.5)
4 (5.0)
2 (2.5)
2 (2.5)
26 (74.3)
6 (17.1)
1 (2.9)
1 (2.9)
1 (2.9)
55 (68.8)
19 (54.3)
6 (7.5)
5 (14.3)
6 (7.5)
1 (1.3)
8 (22.9)
0
2 (2.5)
9 (11.3)
1 (1.3)
0
3 (8.6)
0
13 (16.3)
18 (22.5)
0
7 (20.0)
5 (14.3)
1 (2.9)
Preferred future method of providing
diagnostic ultrasound
Open access 164 (72.9)
87 (80.6)
Practice-based facilities with a visiting
ultrasonographer 17 (7.6)
6 (5.6)
Practice-based facilities with a trained
general practitioner 16 (7.1)
2 (1.9)
Indirect access 4 (1.8)
3 (2.8)
Mobile unit manned by
ultrasonographer 2 (0.9)
0
Combination of options 20 (8.9)
10 (9.3)
Unanswered 2 (0.9)
0
Previous ultrasound
experience 25 (11.0)
5 (4.6)
Higher obstetric training 49 (21.8) 26 (24.0)
Higher radiology training 1 (0.4)
0
(Robinson, Potterton, & Owen, 1997, p. 293).
Results of the postal questionnaire to general practitioners in the former Northern region (n = 225).
questionnaire to assess for multiple issues such as potential workload, level of interest in
ultrasound training, and the willingness and ability of local radiology departments to participate
in training of the GP’s (Robinson, et al. 1997, p. 293).
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
42
Table 4
Ultrasound Payment Information
Payment Information
CPT
Code
76536
76705
76881
76942
93306
93308
G0389
76775
93970
76604
CPT Code descriptor
Ultrasound of soft tissues of head and neck
(e.g., thyroid, parathyroid, parotid), real time
with image documentation
Ultrasound, abdominal, real time with image
documentation); limited (e.g., single organ,
quadrant, follow-up)
Ultrasound, extremity, nonvascular, real-time
with image documentation; complete
Ultrasonic guidance for needle placement
(e.g., biopsy, aspiration, injection, localization
device), imaging supervision and interpretation
Echocardiography, transthoracic, real time
with image documentation (2D) includes Mmode recording when performed; complete,
with spectral Doppler and color flow Doppler.
Echocardiography, transthoracic, real time
with image documentation (2D) includes Mmode recording when performed; follow-up or
limited study
Ultrasound, real time with image
documentation; for abdominal aortic aneurysm
(AAA) screening.
Ultrasound, retroperitoneal (e.g., renal, aorta,
nodes), real time with image documentation,
limited
Evaluation of extremity veins for venous
incompetence or deep vein thrombosis
Ultrasound, Chest, (includes mediastinum) real
time with image documentation
Medicare Physician Fee Schedule National Average (2016)
Global
Professional Technical
Payment Payment
Payment
$117.52 $28.66
$88.05
$92.44
$30.10
$62.34
$116.80
$32.25
$84.55
$61.98
$34.04
&27.95
$230.02
$64.99
$165.52
$125.76
$26.15
$99.60
$117.16
$29.74
$87.42
$58.76
$29.38
$29.38
$240.32
$34.32
$34.32
$89.15
$27.93
$61.22
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
43
Table 5
Ultrasound Procedural Guidance Payment Information
CPT
Code
10022
20604
20606
20611
CPT Code descriptor
Fine needle aspiration; with imaging
guidance
Arthrocentesis, aspiration and/or injection;
small joint or bursa with ultrasound
guidance, with permanent recording and
reporting
Arthrocentesis, aspiration and/or injection;
intermediate joint or bursa with ultrasound
guidance, with permanent recording and
reporting.
Arthrocentesis, aspiration and/or injection;
major joint or bursa with ultrasound
guidance, with permanent recording and
reporting
Medicare
Physician Fee
Schedule National Average*
Hospital
Outpatient
Prospective
Payment System
(OPPS)†
Facility APC
APC
Payment code
Payment
Nonfacility
Payment
$142.95 $142.95
5072
$480.64
$73.81
$47.29
5441
$223.76
$81.69
$54.46
5441
$223.76
$93.51
$63.42
5441
$223.76
Table adapted from (SonoSite / Fujifilm, 2016)
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
44
Table 6
Categories of Adoption
Innovator
2.5%
Early adopter
13.5%
Early majority
34%
About one third of the members of a group and are willing to
adopt an innovation before the average individual
Late majority
34%
About one third of a group, skeptical, resistant to change and need
encouragement to adopt an innovation
Laggards
16%
Suspicious of innovation and may isolate themselves from the
group to avoid using technology that is not traditional
Educated, accepts risks, seen as cutting edge and motivated to be
an agent of change and gatekeeper
Leaders and visionaries using information from innovators to
make adoption decisions and disseminate innovative technology.
(Rogers, 2003).
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
45
Table 7
Subjects to be taught for familiarization of ultrasound in primary care
Type of training
Purpose of training
Training outcomes / goals
US machine operations
familiarization
Knobology, physical
characteristics, types of
transducers and how they are
used, Patient preparation
Saving and
manipulating/measuring images
Examine the heart in
To assess global heart function Can assess for normal
Parasternal Long Axis (PLAX)
pathophysiology, conduction
and Apical 4-chamber views
delays, flow rates/ejection
fractions, valvular disorders,
left side /right side failure
Perform basic US exams of the Assess abdominal aorta for
abdominal
aneurysm, IVC for size and
contractility, right upper
quadrant (liver and gall
bladder), right and left kidneys,
and urinary bladder.
AAA has a very poor survival
rate, IVC status can indicate
fluid overload/ dehydration.
Gall bladder, bladder and
kidneys can be assessed for
normal size appearance,
function and presence of stones.
Liver can be assessed for
normal size/function,
pathophysiology. (also used as a
“window to see into the
abdomen)
Perform MSK ultrasound examsAssess for normal / abnormal
of the knee and shoulder.
function and pathophysiology
Can be used for evaluation of
torn ligaments, muscles. Also
used for needle guided
arthrocentesis and injections
Perform vascular access
Needle guided “real time” for Preserves patient’s vascular
central, peripheral venous, and system, increases success rate
arterial access.
of first time passes, increase
Increases likelihood of
successful therapy and patient
satisfaction
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
46
DVT screen
Assess for clots/ location/need Reduces risk of Pulmonary
for surgery/or anticoagulant
Emboli
therapies
Acquire images of the lung
pleura
Demonstrate the presence or
Can identify PE, Pneumothorax,
absence of lung sliding, B lines Hemothorax, Consolidation,
(two dimensional) and A lines Pneumonia, Pulmonary
(one dimensional) in addition to effusion, can help differentiate
lung artifact and other signs
between Bronchiolitis, Viral vs
Bacterial Pneumonia, Asthma
vs COPD
Combine ultrasound exams of Assess global function of these
heart, IVC and lungs, known as systems during a rapid exam
a Cardiopulmonary Limited
/physical assessment
Ultrasound Exam /CLUE)
Table 8
Provider type
ECU student FNP
Military student FNP
DO
ECU FNP
Military FNP
Total
6
4
1
2
6
19
Can rapidly identify greatest
priority for a patient in distress
allowing a quicker /appropriate
intervention
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
47
Table 9
US training before
yes
no
Total
6
13
19
Used US before
Has access to US
10
9
19
14
5
19
Table 10
Pre-Likert - I know how to perform 1 US procedure
very strongly disagree
disagree
agree
strongly agree
very strongly agree
Total
9
1
4
1
4
19
5 US procedure 9 US procedure
16
2
1
0
0
19
Table 11
Pre- Likert – I believe ultrasound can be used in primary care
neither
agree
strongly agree
very strongly agree
Total
1
2
1
15
19
Table 12
Pre- Likert – I know how to use ultrasound for primary care
very strongly disagree
strongly disagree
disagree
neither
very strongly agree
Total
13
1
3
1
1
19
17
1
1
0
0
19
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
Table 13
Pre-Likert - I know how to perform the intervention / procedure taught today
Frequency
very strongly disagree
12
strongly disagree
2
disagree
3
neither
1
strongly agree
1
Total
19
Table 14
Post- Likert - I believe that ultrasound can be used in primary care
Frequency
strongly agree
1
very strongly agree
18
Total
19
Table 15
Post -Likert - I am likely to perform the procedure/intervention taught today in the
primary care setting
Frequency
disagree
1
neither
2
agree
7
strongly agree
6
very strongly agree
3
Total
19
48
POINT OF CARE ULTRASOUND (POCUS) BY THE FAMILY
Table 16
Post Likert – I know how to use ultrasound for primary care
Frequency
strongly disagree
1
disagree
2
neither
1
agree
10
strongly agree
4
very strongly agree
1
Total
19
Table 17
Post- Likert- I would like to receive further education and training in the use of
ultrasound in primary care
Frequency
strongly agree
2
very strongly agree
17
Total
19
49