Point of Care Ultrasound Education in Neurocritical Care: A Call to Action
Published on: November 20, 2023
Point-of-care ultrasound (POCUS) is increasingly being recognized as an essential skill for critical care providers, intended to enhance clinical assessments to improve patient care. Beyond its adaptation for procedural guidance, bedside ultrasound assessments can provide critical diagnostic information in a timely manner to guide real-time decision making for the acutely ill patient. An accumulating body of evidence has shown that POCUS can improve clinical outcomes and lower medical costs.
Over the past decade, there has been widespread adaptation of bedside ultrasonography by various critical care specialties, with respective governing societies issuing guidelines and position statements encouraging the use of POCUS. However, the field of neurocritical care has yet to fully embrace this innovative field, and neurocritical care training programs vary in their efforts to provide accessible, well-structured educational programs for trainees.
Application in Neurocritical Care
Patients with acute brain injury are predisposed to multiple cardiopulmonary complications, and knowledge and competency in POCUS has particular advantageous applications in neurocritical care. POCUS might help in identifying the underlying etiology or comorbid conditions in patients with acute ischemic stroke, such as intracardiac thrombus or heart failure. In patients with subarachnoid hemorrhage and traumatic brain injury, stress cardiomyopathy is common and volume status is of paramount importance. Bedside ultrasonography can be used to differentiate etiologies of hypotension, guide volume resuscitation, and provide serial hemodynamic assessments for nuanced treatment strategies. Acute respiratory failure, commonly encountered in neurocritical care patients, can be effectively assessed, and managed with basic lung ultrasonography skills. More advanced applications such as evaluation of diaphragmatic function, can be useful in predicting readiness for extubation in patients with neuromuscular respiratory dysfunction.
Aside from general ultrasound applications, the field of bedside neuro-ultrasonography has also undergone an important transformation in recent years. Important applications of neuro-POCUS include assessments of cerebral blood flow and velocities, signs of raised intracranial pressure, and diagnosis of intracranial mass lesions or midline shifts. Transcranial doppler POCUS assessments can be used to serially monitor evolving vasospasm in subarachnoid hemorrhage patients or evolving cerebral perfusion patterns in patients with acute brain injury of various etiology. This can be used to guide therapy initiation and determine treatment effect.
Current State of Point of Care Ultrasound in Neurocritical Care
POCUS adaptation amongst neurocritical care providers is thought to be highly variable. Data on POCUS use and competency across neurocritical care programs is lacking; a recently concluded nationwide survey of POCUS skills and utilization by neurocritical care practitioners will likely provide some valuable insights. In addition to the overall dearth of neurocritical care literature on POCUS, most publications are primarily focused on the neuro-ultrasound specific applications, with little on the body ultrasound applications in the neuro-critically ill population.
Notably, there is also an absence of professional society issued guidelines or position statement on bedside ultrasonography for neurocritical care practitioners. In contrast, societies such as Society of Critical Care Medicine (SCCM), American College of Emergency Physicians (ACEP), and the American College of Chest Physicians (ACCP) have provided detailed guidelines with guidance regarding scope of practice and recommendations regarding training and defining competency.
Perhaps unsurprisingly, POCUS is not universally taught across neurocritical care fellowships nationwide. When training is provided, there is typically no standardized curriculum or competency evaluation. Conspicuously, the neurocritical care Accreditation Council for Graduate Medical Education (ACGME) common programs requirement makes no mention of POCUS. In comparison, ACGME common program requirements for critical care medicine designated POCUS as a core knowledge area, and surgical critical care ACGME program requirements emphasize knowledge of cardiac ultrasound in the critical care setting. ACGME program requirements for POCUS in acute care residencies such as emergency medicine and anesthesiology are robust and detailed.
Challenges and Proposed Solutions
The barriers to universal neurocritical care orientated POCUS training are multifold. Many fellowship programs lack sufficient presence of ultrasound competent faculty with time and funding to successfully develop and implement an ultrasound curriculum. In addition, many institutions have limited access to ultrasound machines and lack archival and image review software that enables a formal process of skill assessment with quality assurance of providers acquiring ultrasound images.
One approach to addressing institutional limitations involves leveraging national workshops and courses backed by professional societies such as SCCM and ACEP to build early critical care ultrasonography skills. However, the high cost of a national course may prohibit many from accessing this resource. In such cases, regional collaborative efforts bringing together POCUS experts from multiple institutions to teach in a workshop setting may be a good alternative. Additionally, a multidisciplinary approach in collaboration with other specialties with established POCUS programs (e.g., emergency medicine physicians and other critical care specialists) within single institutions may prove beneficial in the initial stages of designing a curriculum. Institution-wide efforts to encourage POCUS utilization include integrating POCUS imaging and documentation into Electronic Medical Record (EMR) systems and incorporating billing protocols into the workflow, which can improve documentation as well as provide a revenue stream to fund ultrasound programs.
Ultimately, achieving widespread POCUS adoption requires support and guidance from professional bodies. Guidelines issued should affirm the practice of ultrasound for neurocritical care, in addition to defining appropriate scope of practice, and make recommendations for training necessary to achieve competence. Further, it would be prudent to form a task force comprised of neurointensivists along with experts from other critical care specialties to formally design the outline of a neurocritical care-oriented POCUS curriculum and oversee its implementation.
NCS hosts an Ultrasound Section that has been instrumental in bringing together POCUS enthusiasts to foster academic collaborations and drive educational efforts within the neurocritical care community. In addition to monthly meetings, Ultrasound section members leverage social media via X (formerly known as Twitter) and TikTok to educate and disseminate information.
Notable efforts by this group include the POCUS webinar series. The webinar recordings from the first series, designed to teach basic bedside ultrasound skills in a neurocritical care setting, are currently accessible to members as a free educational resource on the NCS website. The recently commenced second webinar series is targeted towards providers who are interested in more advanced bedside ultrasound applications. The Ultrasound section also organizes a TCD workshop as well as a POCUS and body ultrasound workshop at the NCS annual meeting, geared towards beginners who are intent on hands-on training. Lastly, section leadership supports recurring publications of POCUS case studies in Currents to increase awareness and education within the neurocritical care community.
Modern intensive care practice necessitates the incorporation of bedside ultrasonography. Given its proven clinical utility, it is hoped that more neurocritical care programs will begin to formally implement POCUS training and education, along with the development of a dedicated curriculum by professional organizations. Collaborative efforts to gather data on POCUS application and its impact on neurocritical care patients will enable bedside ultrasound to become a standard tool in providing high quality neurocritical care.
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