POLICY STATEMENT

Point-of-Care Ultrasonography by Pediatric Emergency Physicians

AMERICAN ACADEMY OF PEDIATRICS
Committee on Pediatric Emergency Medicine

SOCIETY FOR ACADEMIC EMERGENCY MEDICINE

AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

Pediatric Emergency Medicine Committee

WORLD INTERACTIVE NETWORK FOCUSED ON CRITICAL ULTRASOUND

POLICY STATEMENT
Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children

Point-of-Care Ultrasonography by Pediatric Emergency Physicians

Key words: ultrasound, ultrasonography, point of care, emergency
department, pediatric emergency medicine, imaging.
ABBREVIATIONS: US, ultrasonography; ED, emergency
department; ACEP, American College of Emergency
Physicians; PEM, pediatric emergency medicine;
CT, computed tomography.
0196-0644/$-see front matter
Copyright © 2015 by the American College of Emergency Physicians.
http://dx.doi.org/10.1016/j.annemergmed.2015.01.028

[Ann Emerg Med. 2015;65:472-478.] Point-of-care US can expedite clinical decisionmaking, direct follow-
up diagnostic imaging, aid in procedural guidance and improve
ABSTRACT patient satisfaction.1-6 Point-of-care US is designed to answer
Point-of-care ultrasonography is increasingly being used to specific yes/no questions in real time. The point-of-care
facilitate accurate and timely diagnoses and to guide procedures. It US examination has important qualities as an imaging modality.
is important for pediatric emergency physicians caring for patients There is no need to transport a patient outside of the emergency
in the emergency department to receive adequate and continued department (ED), examinations can be performed at all hours,
point-of-care ultrasonography training for those indications used examinations may be repeated, and there is no ionizing radiation
in their practice setting. Emergency departments should have exposure. Moreover, it may help direct further evaluation so as to
credentialing and quality assurance programs. Pediatric emergency avoid unnecessary and costly testing.
medicine fellowships should provide appropriate training to Clinician-performed US has been used and accepted since the
physician trainees. Hospitals should provide privileges to physicians 1960s, when obstetricians and cardiologists first adopted the
who demonstrate competency in point-of-care ultrasonography. technology. Use of US by those specialists is endorsed by various
Ongoing research will provide the necessary measures to define professional radiology organizations.7,8 At present, nonphysician
the optimal training and competency assessment standards. providers, such as nurses and out-of-hospital care workers, are
Requirements for credentialing and hospital privileges will vary and also using point-of-care US as a part of their practice.9-17
will be specific to individual departments and hospitals. As more
physicians are trained and more research is completed, there should
be one national standard for credentialing and privileging in point-
MINIMIZING RADIATION EXPOSURE
of-care ultrasonography for pediatric emergency physicians. One of the appealing aspects of US is its inherent safety. It
relies on sound waves and not x-rays to generate images. In many
instances, computed tomography (CT) imaging or radiography
INTRODUCTION are the optimal diagnostic modalities in the evaluation of the
Point-of-care ultrasonography (US) is a focused ultrasonography pediatric patient; however, there is an increasingly large body of
performed and interpreted at the patient’s bedside by a health literature emphasizing and delineating the risks of ionizing
care provider in conjunction with his/her clinical examination. radiation, particularly from CT.18-31 Pediatric patients are

472 Annals of Emergency Medicine Volume 65, no. 4 : April 2015

 Policy Statement

particularly sensitive to ionizing radiation, given the larger organ- faculty and trainees, as well as managing administrative tasks,
specific dosing they receive with each study, the increased such as outlining credentialing pathways and performing quality
susceptibility of these organs to radiation-induced cancer, and the assurance image reviews. Standardized and universally accepted
increased life span over which children may develop radiation- criteria for what designates a point-of-care expert are likely to
induced cancers.21 In response to this risk, several national evolve over time as advanced training programs are established.
campaigns have been initiated to reduce the use of unnecessary In departments or divisions without point-of-care US-trained
CT imaging in pediatric patients. These include efforts by the individuals, departmental leadership should consider sending
Society for Pediatric Radiology,32 the National Council on an individual or group of individuals with interest to receive
Radiation Protection and Measurements,33 the Food and Drug additional training in point-of-care US. Alternatively, an
Administration,34 and the National Cancer Institute.35 In expert from another department (eg, general emergency
summary, when imaging is indicated, practitioners should medicine, radiology) may assume these responsibilities and
attempt to optimize the use of nonradiating diagnostic work collaboratively with ED leaders.
modalities, such as US. Point-of-care US training varies, depending on the practitioner’s
prior education and practice environment. Until now, most
pediatric emergency physicians have received little or no point-of-
INDICATIONS FOR POINT-OF-CARE care US instruction as part of their training. It is important that
ULTRASONOGRAPHY PEM fellowship programs provide adequate training, including
Pediatric emergency physicians can use point-of-care US as a measurements of competency for trainees. Point-of-care US
diagnostic or procedural adjunct in the evaluation of patients in education is now an American Board of Pediatrics requirement for
the ED. Diagnostic applications are those that assist in diagnosis pediatric emergency medicine fellowship programs.36 Consensus
and inform medical decisionmaking. Procedural applications education guidelines and a model curriculum were recently
may be “US-assisted” or “static,” or “US-guided,” also referred published.37 There are 2 training pathways for physicians: a
to as “dynamic.” Static US is defined as using US prior to the “training-based” pathway for current trainees, and a “practice-
procedure, identifying anatomic structures, and determining based” pathway for faculty without prior experience. The details
the ideal circumstances for the procedure to be performed. of such pathways are outlined in the accompanying technical
The procedure itself is performed without the use of US. In report.38
contrast, in dynamic US, the US and procedure are performed Prior to performing a point-of-care US examination for
simultaneously. medical decisionmaking, pediatric emergency physicians must
Clinical applications will be practice-specific and based on the demonstrate application-specific competency. During this
patient population, incidence of disease, and the availability of “training” phase, the point-of-care US expert should review all
resources, such as 24-hour attending radiologist coverage, US examinations in a timely manner. Practitioners can receive
availability of US technicians, and distance/transfer times to relevant feedback regarding their examinations. In addition,
facilities that can provide US imaging. ED leaders should novice practitioners should be supervised at the bedside in order
determine which point-of-care US examinations will be most to ensure that the examinations are being performed correctly.
useful to their practice environments. Physicians would then apply Examination reviews and bedside supervision may be performed
for institutional privileges in those specific areas. There will be a by a department or division “expert” or by another physician
natural transition period for physicians who did not receive point- already credentialed to perform US for that indication.
of-care US education as part of their graduate medical training. These educational scans should not be utilized for medical
Therefore, the indications for which clinicians use point-of-care decisionmaking or billing purposes, and this should be clearly
US will evolve over time as the education is disseminated communicated to patients and their families.
throughout the PEM community. Finally, clinicians should be Given that a point-of-care US examination is intended to be a
aware that point-of-care US is better used as a “rule-in” and not focused examination, training requirements necessarily differ
a “rule-out” diagnostic modality. The absence of an abnormal from those set forth by other specialty organizations, such as the
finding should not indicate a normal examination. For example, American College of Radiology and other specialty organizations.
nonvisualization of an intussusception with high clinical concern A similar distinction was made in the 2002 training guidelines
must prompt further evaluation. Likewise, when findings other adopted by the American Society of Echocardiography, which
than those sought to “rule in” a diagnosis are encountered, a more outlined basic training requirements for anesthesiologists
complete imaging evaluation is warranted. performing perioperative echocardiography, which differed
from the more rigorous training needed for more consultative
cardiology-performed echocardiography.39 Competency and
POINT-OF-CARE ULTRASONOGRAPHY subsequent credentialing within a division or department may be
TRAINING, CREDENTIALING, AND PRIVILEGING achieved after performing a specified number, or range, of accurately
Prior to implementing a program in the ED, departmental performed and interpreted point-of-care US examinations. With the
leaders should identify a core group of individuals with expertise lack of robust data supporting a specified number of examinations
in point-of-care US. This group is responsible for educating per indication, some guidelines suggest 25 to 50 examinations

Volume 65, no. 4 : April 2015 Annals of Emergency Medicine 473

Policy Statement

needed to achieve competency.40 However, physicians should not implementing quality improvement activities, and acquiring
interpret this recommendation as a “one-size-fits-all” approach, as and maintaining hospital privileges.
examinations vary in difficulty and, therefore, may require more 4. Pediatric emergency medicine fellowship programs should
experience to establish competency. In addition, the number of have a structured point-of-care US education curriculum and
examinations performed may not always best define competency. As competency assessment for fellows in training.
point-of-care US incorporates both cognitive and psychomotor 5. Standardized, universally accepted criteria for what defines
components, individual physicians may gain competency at varying point-of-care US expertise should be developed in the near
rates that may be independent of a predetermined numerical goal future by national organizations such as the American Academy
and better assessed through simulation, observed structured clinical of Pediatrics, Society for Emergency Medicine, and/or ACEP.
examinations, or direct observation during clinical shifts.
Hospital privileging committees should provide an opportunity
for privileging in specific pediatric point-of-care US examinations. SUMMARY
Written requirements for privileging should be delineated. There is an increasing demand for pediatric emergency
Building on the recommendations set forth by the ACEP, when physicians to become adept in point-of-care US. Mounting
a physician applies for appointment or reappointment to the evidence supports the benefits to pediatric patients. This
medical staff and for clinical privileges, the process should policy statement and accompanying technical report have
include assessment of current competency by the point-of-care been developed to define a structured and safe program for the
US director.40 Because point-of-care US is a relatively new integration and implementation of point-of-care US by
technology for pediatric emergency physicians, some specialists pediatric emergency physicians.
and hospital privileging committees may not be familiar with
the precedent already set forth for point-of-care US and the This document is copyrighted and is property of the American
benefits to patient care. Therefore, pediatric emergency Academy of Pediatrics and its Board of Directors. All authors have
physicians should educate those who are unfamiliar with its use, filed conflict of interest statements with the American Academy of
citing the established literature attesting to emergency physicians’ Pediatrics. Any conflicts have been resolved through a process
ability to accurately perform and interpret point-of-care US approved by the Board of Directors. The American Academy of
examinations.5,41-104 Additionally, pediatric emergency physicians Pediatrics has neither solicited nor accepted any commercial
should consider collaboration with radiologists and expert involvement in the development of the content of this publication.
sonographers when implementing point-of-care US into Policy statements from the American Academy of Pediatrics
their ED. benefit from expertise and resources of liaisons and internal (AAP)
and external reviewers. However, policy statements from the
American Academy of Pediatrics may not reflect the views of the
POINT-OF-CARE ULTRASONOGRAPHY liaisons or the organizations or government agencies that they
DOCUMENTATION represent.
Once pediatric emergency physicians are credentialed to
The guidance in this statement does not indicate an exclusive
perform point-of-care US for a particular application, they can
course of treatment or serve as a standard of medical care.
integrate the point-of-care US examination into patient care. Variations, taking into account individual circumstances, may be
Details of the point-of-care US examination must be documented appropriate.
at the time of performance in the medical record. Specifically,
documentation should include the indication for the examination, All policy statements from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
structures/organs identified, and the interpretation.105 If the study
revised, or retired at or before that time.
is inadequate, this should also be noted. Images should be
archived, ideally electronically, and entered as part of the electronic August 25, 2014
health record, for ease of retrieval and review. Published jointly in Pediatrics, Annals of Emergency Medicine,
Academic Emergency Medicine, and Critical Ultrasound Journal.
RECOMMENDATIONS
1. Pediatric emergency physicians should be familiar with the
LEAD AUTHORS
definition and application of point-of-care US and the utility
Jennifer R. Marin, MD, MSc
for patients in the ED.
Resa E. Lewiss, MD
2. Pediatric emergency physicians who integrate point-of-care
US in their patient care should be competent in point-of-care
examinations that are specific and relevant to their clinical FINANCIAL DISCLOSURE/CONFLICT OF INTEREST
environment. Dr. Lewiss has no financial disclosures or potential conflicts of
3. For EDs with a pediatric emergency medicine point-of-care interest.
US program, there must be a process in place for educating Dr. Marin receives support from 3rd Rock Ultrasound, LLC for
and assessing practitioner skill, maintaining quality assurance, serving as teaching faculty.

474 Annals of Emergency Medicine Volume 65, no. 4 : April 2015

 Policy Statement

PEDIATRIC POINT-OF-CARE ULTRASOUND WORK GROUP Matthew Fields, MD

Jennifer R. Marin, MD, MSc, Chairperson, Lead Author Robert S. Hockberger, MD
Resa E. Lewiss, MD, Lead Author James F. Holmes, Jr, MD, MPH
Alyssa M. Abo, MD Lauren Hudak, MD
Stephanie J. Doniger, MD, RDMS Alan E. Jones, MD
Jason W. Fischer, MD, MSc Amy H. Kaji, MD, PhD
David O. Kessler, MD, MSc, RDMS Ian B. K. Martin, MD
Jason A. Levy, MD, RDMS Christopher Moore, MD, RDMS, RCMS
Vicki E. Noble, MD, RDMS Nova Panebianco, MD, MPH
Adam B. Sivitz, MD
James W. Tsung, MD, MPH AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, PEDIATRIC
Rebecca L. Vieira, MD, RDMS
EMERGENCY MEDICINE COMMITTEE, 2013-2014
AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON Lee S. Benjamin, MD, FACEP, Chairperson
PEDIATRIC EMERGENCY MEDICINE, 2013-2014 Isabel A. Barata, MD, FACEP, FAAP
Joan E. Shook, MD, MBA, FAAP, Chairperson Kiyetta Alade, MD
Alice D. Ackerman, MD, MBA, FAAP Joseph Arms, MD
Thomas H. Chun, MD, MPH, FAAP Jahn T. Avarello, MD, FACEP
Gregory P. Conners, MD, MPH, MBA, FAAP Steven Baldwin, MD
Nanette C. Dudley, MD, FAAP Kathleen Brown, MD, FACEP
Susan M. Fuchs, MD, FAAP Richard M. Cantor, MD, FACEP
Marc H. Gorelick, MD, MSCE, FAAP Ariel Cohen, MD
Natalie E. Lane, MD, FAAP Ann Marie Dietrich, MD, FACEP
Brian R. Moore, MD, FAAP Paul J. Eakin, MD
Joseph L. Wright, MD, MPH, FAAP Marianne Gausche-Hill, MD, FACEP, FAAP
Michael Gerardi, MD, FACEP, FAAP
LIAISONS Charles J. Graham, MD, FACEP
Lee Benjamin, MD – American College of Emergency Physicians Doug K. Holtzman, MD, FACEP
Kim Bullock, MD – American Academy of Family Physicians Jeffrey Hom, MD, FACEP
Elizabeth L. Robbins, MD, FAAP – AAP Section on Hospital Paul Ishimine, MD, FACEP
Medicine Hasmig Jinivizian, MD
Toni K. Gross, MD, MPH, FAAP – National Association of Madeline Joseph, MD, FACEP
EMS Physicians Sanjay Mehta, MD, Med, FACEP
Elizabeth Edgerton, MD, MPH, FAAP – Maternal and Child Aderonke Ojo, MD, MBBS
Health Bureau Audrey Z. Paul, MD, PhD
Tamar Magarik Haro – AAP Department of Federal Affairs Denis R. Pauze, MD, FACEP
Angela Mickalide, PhD, MCHES – EMSC National Resource Nadia M. Pearson, DO
Center Brett Rosen, MD
Cynthia Wright, MSN, RNC – National Association of State W. Scott Russell, MD, FACEP
EMS Officials Mohsen Saidinejad, MD
Lou E. Romig, MD, FAAP – National Association of Emergency Harold A. Sloas, DO
Medical Technicians Gerald R. Schwartz, MD, FACEP
Sally K. Snow, RN, BSN, CPEN, FAEN – Emergency Nurses Orel Swenson, MD
Association Jonathan H. Valente, MD, FACEP
David W. Tuggle, MD, FAAP – American College of Surgeons Muhammad Waseem, MD, MS
Paula J. Whiteman, MD, FACEP
STAFF Dale Woolridge, MD, PhD, FACEP
Sue Tellez

SOCIETY FOR ACADEMIC EMERGENCY MEDICINE (REVIEWERS) FORMER COMMITTEE MEMBERS

Steven B. Bird, MD Carrie DeMoor, MD
Andra L. Blomkalns, MD James M. Dy, MD
Kristin Carmody, MD Sean Fox, MD
Kathleen J. Clem, MD, FACEP Robert J. Hoffman, MD, FACEP
D. Mark Courtney, MD Mark Hostetler, MD, FACEP
Deborah B. Diercks, MD, MSc David Markenson, MD, MBA, FACEP

Volume 65, no. 4 : April 2015 Annals of Emergency Medicine 475

Policy Statement

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ULTRASOUND BOARD OF DIRECTORS (REVIEWERS) pulmonary edema by prehospital physician care providers. BMC Med
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CT scans in childhood and subsequent risk of leukaemia and
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