PoCUS is an affordable, safe, and efficient imaging modality with a wide variety of uses in the medical field, particularly in the emergency setting. Medical providers in Europe have utilized ultrasound for decades and over the last 20 years; its use has exploded in the United States. A PoCUS examination is performed at bedside with immediate results, without radiation exposure to the patient or provider. In addition, ultrasonography is a fraction of the cost of other imaging modalities, including radiography, computed tomography (CT), and magnetic resonance imaging (MRI) which makes it a more accessible imaging option in financially strained circumstances.
Since 1985, the World Health Organization (WHO) has recommended ultrasonography for developing countries because it is portable, inexpensive, non-invasive, safe, and provides information immediately [6, 8]. Via et al. noted that point-of-care ultrasound (PoCUS) has a significant impact in undifferentiated shock, narrowing the differential diagnosis and improving the specificity of early recognition of hypovolemia and septic shock cardiovascular patterns [8]. Because of this, the authors suggest that PoCUS should have an integral role in management of unstable patients in developing countries [8]. In addition, lung PoCUS is very effective for the early diagnosis of various infectious respiratory conditions, which is a leading cause of childhood mortality in developing countries [8, 9]. Short-term medical mission trips to resource-limited regions have been using PoCUS for many years. However, the best strategy to make a lasting change in these areas is to equip local providers with ultrasound machines and the knowledge to use them so they can continuously provide a higher level of care to the local people.
Short-term PoCUS training programs are proven to deliver adequate knowledge and skills to novices [8]. Shah et al. conducted an educational intervention in Rwanda to create an effective PoCUS curriculum for inpatient providers at two of the local hospitals [6]. They concluded that PoCUS is a very teachable skill with an intensive training course and hands-on teaching [6]. They introduced a 9-week course with 1-h lectures three times per week for the first 3 weeks and then one time per week for the remaining 6 weeks with 1–2 h of guided scanning practice following each lecture [6, 7]. The most common clinical practice change noted after the course was a new plan to perform a surgical procedure following the results of the PoCUS [7]. The investigators found other types of changes in the patient care plan based on PoCUS results, including medication changes, referrals to a specialty clinic, cancellation of surgical procedures, and referrals for further radiologic evaluation with CT scanning [7].
More recently, Rominger et al. implemented a 12-month longitudinal PoCUS curriculum for primary care physicians working in rural outpatient clinics in Mexico [5]. They organized 4-day PoCUS teaching sessions each separated by approximately 3–4 months [5]. By having recurring short-term trips, the training did not interrupt the regular schedule of the local physicians and was more feasible for educators traveling to the area. The sessions included lectures and hands-on training focused on different topics at each session. They found that the use of PoCUS changed the patient diagnosis and clinical management in about 1/3 of cases [5]. They demonstrated that bedside PocUS education programs targeted to local physicians in outpatient settings is an effective strategy to equip them with a tool to improve the clinical management of their patients.
The effectiveness of a PoCUS curriculum is not limited to developing countries. A study by Clay et al. focused on United States (US) Internal Medicine residents, found that a single day of intensive PoCUS training at the beginning of the year yielded significant improvement in PoCUS interpretation skills [1, 2]. They used a 30-question assessment to measure bedside PoCUS knowledge prior to, immediately post, and 6 months post-training. Assessment performance increased by almost 25% and remained significantly better at 6 months [1, 2]. Noble et al. also performed an educational study directed towards United States (US) Emergency Medicine physicians and interns [4]. The participants of this study received an “introduction to PoCUS” course. An assessment before and 6 months after the introductory course was administered using a standardized image-based ultrasound test. There was a significant improvement in PoCUS knowledge for both faculty and interns, which also persisted for 6 months following the introductory course [4].
The Hospital Pediatrico Universitario (HOPU) is the principal institution in Puerto Rico offering medical services to the children of Puerto Rico and the Caribbean. HOPU is the pediatric academic institution for the University of Puerto Rico School of Medicine and the clinical center for the pediatric residency program. It is the only pediatric hospital to provide tertiary services to the island and guarantees that its services are accessible to children of all socio-economic levels, including the medically indigent. The Emergency Department (ED) at HOPU receives about 10,000 pediatric patients annually. It is generally a low-flow but high-acuity ED where general pediatricians and residents provide health care 24 h a day, 7 days a week. Prior to this study, there were no ultrasound machines in the Emergency Department and the physicians had no PoCUS training. Access to ultrasound was available through the Radiology Department but since the Radiology Department serves the entire Medical Center and not just the pediatric hospital, obtaining an official ultrasound report takes 24–48 h. Many of the conditions seen in the Emergency Department are easily identified and managed with the appropriate use of PoCUS. For example, the identification of cellulitis, abscess, free fluid in the abdomen (traumatic or nontraumatic), hydronephrosis, pericardial effusion, pleural effusion, appendicitis, intussusception, and global heart function. If the providers have basic PoCUS knowledge and skills, it would greatly aid in the local management of many medical conditions, reduce the number of referrals for imaging, and expedite the care of patients who do have a serious medical or surgical condition.
The objective of this study is to increase ultrasound knowledge and comfort by the ED physicians in the HOPU pediatric emergency department. Although Puerto Rico is a US territory, its pediatric health care model and funding can be likened to a resource-limited site with the closest additional pediatric resources located 1000 miles away in Miami, Florida. Therefore, it is a unique setting which cannot be simply grouped with US facilities or resource-limited ones, so many of the previous studies may not be easily generalizable to this particular institution. Therefore, the authors sought to identify an effective ultrasound curriculum for the HOPU ED providers.