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Point-of-care ultrasound streamlines care, curbs costs – and saves lives
POCUS has proven itself a cost-effective diagnostic tool that enhances the physical exam, says one Jefferson Healthcare physician. Money is not wasted on excessive testing and patients avoid the hospital because their disease is recognized quickly.
By Bill Siwicki
October 10, 2024 01:06 PM
One of the biggest daily challenges faced by healthcare providers is obtaining accurate diagnostic answers in a timely manner. Clinicians spend years training in physical diagnosis, mastering techniques such as listening to hearts and lungs with a stethoscope, palpating the abdomen, and examining painful joints.
THE PROBLEM
But even in the most expert hands, these traditional diagnostic methods lack the precision needed, said Dr. Stephen Erickson, a board-certified family medicine physician providing care at Jefferson Healthcare's Townsend Clinic.
"To compensate for this, we rely heavily on costly lab tests, time-consuming imaging studies and further interventions to confirm diagnoses," he explained. "In fact, the cost of diagnostic testing in the U.S. healthcare system is staggering. Annual spending on imaging procedures, including expensive X-rays, CTs and MRIs, has been rapidly rising. We're now spending more than $100 billion on these procedures annually.
"Beyond the financial burden, these tests often come with long wait times, contributing to delays in patient care, unnecessary hospitalizations and increased anxiety for patients," he continued. "This inefficiency strains healthcare resources and impacts clinical workflows, making timely and accurate decision making even harder to achieve."
Point-of-care ultrasound, or POCUS, is helping clinicians overcome many of these challenges, he contended. With the ability to visualize the body at the point of care using a pocket-sized ultrasound, clinicians can streamline the diagnostic process, improve accuracy, and save time and money, he said.
"In fact, POCUS has been shown to outperform traditional diagnostic methods in several cases," Erickson noted. "For much of my career, for instance, a suspicion of pneumonia automatically led to ordering a chest X-ray. Today, we know from multiple research studies that lung ultrasound not only provides quicker and less expensive results but is also more sensitive in detecting pneumonia.
"POCUS is transforming the diagnostic landscape, empowering clinicians to make faster, more informed decisions, and ultimately improving patient outcomes," he added.
PROPOSAL
POCUS technology proposes to resolve the problem of diagnostic delays and inaccuracies across many clinical settings, centered on bringing real-time imaging capabilities directly to the bedside.
"Traditionally, medical imaging was confined to specialized radiology departments, with doctors often relying on bulky, expensive equipment like ultrasound cards, CT scans, MRIs or X-rays to get a comprehensive view of a patient's internal structures," Erickson said. "This process, while still highly valuable in some cases, can introduce significant delays, especially in time-sensitive emergency scenarios or in rural settings where access to radiology is often limited.
"POCUS technology changes this by decentralizing imaging and making it accessible to clinicians outside of the radiology department," he continued. "The handheld nature of POCUS devices enables clinicians to perform targeted, immediate scans at the patient's side, without having to wait for specialized equipment or personnel."
POCUS has the ability to provide immediate answers to critical, yes or no, diagnostic questions. For example, in situations where the primary concern is whether a patient is experiencing internal bleeding, a detailed MRI or CT scan may not be immediately necessary. POCUS offers a faster way to detect or rule out such conditions right then and there, he added.
"Plus, new devices on the market in the last half decade have even made it possible to image the whole body with a single, all-in-one probe," Erickson noted. "By placing this technology in the hands of emergency room doctors, nurse practitioners and physician assistants, POCUS offered a streamlined solution to reduce dependency on costly and time-consuming imaging studies.
"It allowed medical professionals to identify urgent issues – such as pleural effusions, pneumothorax or cardiac tamponade – quickly and confidently, guiding immediate treatment decisions," he continued. "This real-time diagnostic tool, then, was supposed to alleviate the problem by providing a faster and more direct method of assessment, particularly in environments where delays in diagnosis could result in poor patient outcomes or when quick decisions were needed for effective triage."
POCUS technology has enabled healthcare providers to bypass traditional bottlenecks in diagnostic processes while still delivering accurate and life-saving information, he added.
"By doing so, it promised to enhance workflow efficiency, reduce wait times and potentially lower healthcare costs, all while improving patient care quality," he said.
MEETING THE CHALLENGE
At Jefferson Healthcare, the integration of POCUS technology began with its deployment in the emergency department, where physicians urgently needed rapid diagnostic capabilities at any time of day.
"Initially, ER doctors used POCUS to quickly assess critical conditions such as internal bleeding, lung problems and cardiac function, which helped streamline decision making and guide immediate treatments," Erickson explained. "The benefits of POCUS in providing fast, reliable diagnostics without the delays of traditional imaging soon became apparent, leading other departments to request access to their own devices.
"Over time, the body of evidence regarding the usefulness of POCUS has grown," he continued. "With this, more and more specialties have asked to have their own POCUS device in their department. To name a few common use cases – in the anesthesia department, POCUS is used to improve the precision of nerve blocks and to assess patients preoperatively for conditions like gastric aspiration risk."
Obstetricians can use POCUS to monitor fetal well-being and positioning, enhancing both routine assessments and responses to emergent situations. Similarly, in orthopedic, rheumatology and sports medicine, POCUS can be a tool to guide more accurate joint injections and to diagnose tendon or ligament injuries with greater precision.
In primary care, physicians use POCUS not only for diagnostics but also as a patient education tool, showing real-time imaging to help patients understand their diagnoses.
"While POCUS started as a standalone tool, it eventually became integrated with electronic health records and imaging databases, enabling clinicians to seamlessly document and share findings with other providers," Erickson said. "In our institution, we have Butterfly iQ handheld POCUS devices deployed in each primary care clinic, our infusion center and our pre-anesthesia ward.
"We also have cart-based ultrasound machines from multiple manufacturers in various locations in our hospital," he continued. "All POCUS machines are networked with DICOM links to our Epic EHR and PACS servers to allow for more optimal workflow and image accessibility across the continuum of care. We also use Butterfly Compass workflow software for QA review of images coming from any POCUS device across the organization."
RESULTS
The POCUS technology has proven itself to be a cost-effective diagnostic tool that significantly enhances the physical examination, Erickson reported.
"One of the challenges of trying to quantify the success of leveraging POCUS is that it is very difficult to measure the money that was not wasted on excessive testing, or the patients who did not end up in the hospital because their disease was recognized more quickly," he noted. "That said, I think any clinician using POCUS can tell you of cases where this occurred."
Erickson offered a few examples of such cases that took place in the past few months.
"A patient who came to my office late in the afternoon with symptoms to suggest a blood clot in a leg vein," he explained. "This is potentially dangerous because an untreated blood clot can break off, go to the heart, and cause a deadly embolism.
"Traditionally this patient would be sent to the emergency room because I can't get a venous ultrasound exam scheduled quickly enough as an outpatient," he continued. "By doing a POCUS exam at a cost of less than $50, I was able to get my answer, start the right treatment and avoid a $2,000 emergency department bill."
Another example: Placement of intrauterine contraceptive devices can be unpredictably painful for some women.
"A quick POCUS scan before placing an IUD can screen for anatomic variations that are likely to result in pain or even dangerous complications such as uterine perforation," Erickson said. "And after IUD placement, women are traditionally asked to come back in six weeks for a second pelvic exam to confirm that the IUD remains in its proper location.
"It has brought great patient satisfaction to instead perform a quick ultrasound to more accurately confirm IUD position without the patient needing to get undressed," he added.
And a final example: An elderly patient who was unable to talk due to a previous stroke was brought in by his spouse because he "just hadn't been acting right."
"My physical exam yielded little useful information as to why," Erickson explained. "It was hard to know if he needed extensive testing, or reassurance. POCUS, however, quickly demonstrated new, severe systolic heart failure. He was sent right to the emergency department where further tests confirmed a large, silent heart attack.
"I shudder to think about the outcome of that case if I hadn't had my POCUS device," he said.
ADVICE FOR OTHERS
"My advice for healthcare organizations that may be thinking about bringing in POCUS technology is to start setting up the IT system interfaces early to be ready for expanded POCUS use in the future," Erickson advised. "Many departments may eventually want POCUS, and each may have their own ideas of what is best for them.
"But an IT or biomedical department doesn't want to be saddled with trying to manage multiple systems that can't work together," he continued. "Get stakeholders to agree on two or three preferred vendors of ultrasound equipment and take the time to set up the DICOM links to your EHR and PACS. Set up standardized training in these workflows for each new user to make sure proper documentation standards are being followed."
These things take time, but they get progressively harder to institute across multiple departments the longer that non-standardized practices have proliferated, he concluded.
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I have to say this is by no means an unexpected finding. In the hands of sensible physicians use of ultrasound can provide very rapid clinical information and diagnostic answers – often at the patient bedside.
So what is not to like? The most important aspect is that ultrasound use – especially at the bedside – makes extra demands on anatomical and pathological knowledge that may have lost its earlier importance and needs re-awakening when expert radiological opinion is not readily accessible!
This is a good thing but a change we need to be aware of!
David.
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