Hospital Medicine Point of Care Ultrasound Credentialing: An Example Protocol

Ultrasound has been used for decades by radiology, obstetrics-gynecology, and cardiology departments within a comprehensive paradigm in which a physician enters an order, then a trained sonographer performs the study, followed by a physician evaluating and interpreting the images.¹ Unlike the traditional comprehensive paradigm, point-of-care ultrasound (POCUS) is a focused study that is both performed and interpreted by the bedside provider.² POCUS has been demonstrated to improve diagnosis and clinical management in multiple studies.^3-15

The scope of practice in POCUS differs by specialty, as POCUS is done to achieve specific procedural aims (eg, direct the needle to the correct location) or answer focused questions (eg, does the patient have a distended bladder?) related to the specialty. POCUS in hospital medicine (HM) provides immediate answers, without the delay and potential risk of transportation to other hospital areas. It may be used to diagnose pleural effusion, pneumonia, hydronephrosis, heart failure, deep vein thrombosis, and many other pathologies.^5-15 It is important to understand that POCUS performed by HM is a limited study and is not a substitute for more complete ultrasound examinations conducted in the radiology suite or in the echocardiography lab.

POCUS should not be used exclusively in medical decision making, but rather in conjunction with the greater clinical context of each patient, building on established principles of diagnosis and management.

• Credentialing: An umbrella term, which incorporates licensure, education, and certification.
• Privileging: Used to define the scope authorized for a provider by a healthcare organization based on an evaluation of the individual’s credentials and performance.
• Competency: An observable ability of a provider, integrating multiple components, such as knowledge and skills. Since competencies are observable, they can be measured and assessed to ensure their acquisition.
• Certification: The process by which an association grants recognition to a provider who has met certain predetermined qualifications specified by the association. Competence is distinguished from certification, which is defined as the process by which competence is recognized by an external agency.

All of the above mechanisms work together to provide the highest quality of reliability that a practitioner is providing safe, competent care.^16-18

Acknowledging that there are no published guidelines in the realm of HM POCUS, the development of the credentialing process at our institution is consistent with published guidelines by Emergency Medicine societies (the most established physician users of POCUS) and the American Medical Association (AMA).^19-21

The use of emergency ultrasound by physicians in the emergency department is endorsed by the American College of Emergency Physicians (ACEP).¹⁹ ACEP, along with the Society of Academic Emergency Medicine (SAEM), recommends that training in the performance and interpretation of ultrasound imaging be included during residency.²⁰ ACEP and SAEM add that the availability of equivalent training should be made available to practicing physicians. The American Society of Echocardiography has supported the use of POCUS and sees this modality as part of the continuum of care.^23,24

The AMA has also recognized that POCUS is within the scope of practice of trained physicians.²² The AMA further recommended hospital staff create their own criteria for granting ultrasound privileges based on the background and training of the physician and in accordance with the standards set within specific specialties.^22,23

The provision of clinical privileges in HM is governed by the rules and regulations of the department and institution for which privileges are sought. In detailing our policies and procedures above, we intend to provide an example for HM departments at other institutions that are attempting to create a POCUS credentialing program.

An interdisciplinary approach was created by our institution to address training, competency, and ongoing quality assurance (QA) concerns due to the increasing popularity of POCUS and variability in its use. We developed a hospital-wide POCUS committee with, among others, members from HM, emergency medicine, critical care, radiology, and cardiology, with a charter to standardize POCUS across departments. After review of the literature,^{16-18, 20, 21, 23-74} baseline training requirements were established for credentialing and developing a unified delineation of privileges for hospital-wide POCUS. The data support the use of a variety of assessments to ensure a provider has developed competence (portfolio development, knowledge-based examination, skills-based assessment, ongoing QA process). The POCUS committee identified which exams could be performed at bedside for credentialed providers, delineated imaging requirements for each exam, and set up the information technology infrastructure to support ordering and reporting through electronic health records (EHR). While the POCUS committee delineated this process for all hospital providers, we will focus our discussion on the credentialing policy and procedure in HM.