(O-F6) A Mixed-methods Study of Barriers and Facilitators to Point-of-care Ultrasound Implementation for Emergency Department Providers at the Durham Veterans Affairs Healthcare System

Objectives: Our primary objective was to identify the facilitators and barriers to optimize our program implementation using the consolidated framework for implementation research (CFIR) and test for impact at a single local ED.

Background: Emergency ultrasound program leaders nationwide recognize that point-of-care ultrasound (POCUS) knowledge retention and utilization are difficult to achieve. Prior studies have identified a lack of provider training with a gap in POCUS knowledge and skills, lack of credentialed ultrasound users, and lack of quality assurance image review as significant barriers to POCUS use. A standardized approach to identifying and addressing barriers to sustainable POCUS implementation is needed to increase POCUS use, reduce radiology ultrasound, and potentially improve emergency department (ED) flow.

Methods: Our mixed-methods study implemented a co-designed multifaceted intervention at the Durham Veterans Affairs ED from November 2021 to October 2022 (12 months) to enhance POCUS usability and sustainability, including education, equipment knowledge, quality review process, and image archiving in the health record. Furthermore, 20/25 (80%) full-time ED providers participated in small or large-group hands-on educational POCUS training sessions between February-May 2022. We conducted 14 semi-structured interviews to identify emergent themes and codes on ED POCUS use and performed team-based coding using inductive then deductive analysis using NVivo. For our impact evaluation, we assessed POCUS program acceptability, effectiveness, and feasibility via provider pre/post-course questionnaires, interviews, and health record data (ED POCUS, radiology ultrasound orders, and ED LOS).

Results: Five POCUS themes emerged: convenience and efficiency, ED environment (space and place), perceptions of high clinical and educational utility of ED POCUS, and peer influences, feedback, and teaching. POCUS facilitators include machine availability, resident teaching, ED procedural POCUS, hands-on group training, colleagues’ contagiousness and enthusiasm, and ultrasound faculty support and guidance. Additionally, ED and hospital leadership support and hospital-wide POCUS collaboration were cited as essential for success. POCUS barriers were time constraints, alternative radiology imaging availability, POCUS knowledge and skills comfort, and eliminating unnecessary and cumbersome steps for image acquisition and documentation/storage. Additional identified needs (image review, faculty credentialing, and an archiving system), require development locally to strengthen provider skills and reduce duplicated radiology studies.
For feasibility and effectiveness, we found no significant change in ED LOS (6.77.5 hours, p=0.0849) and radiology ultrasounds ordered (355361, p=0.417) but a significant increase in ED POCUS (72267 scans, p<0.001), in the six months pre/post-intervention. The most frequently performed POCUS scans were cardiac, DVT, soft tissue, MSK, and biliary, and radiology studies were DVT, biliary, and scrotal US. From pre/post-intervention survey data, overall comfort with performing and teaching diagnostic and procedural POCUS changed minimally. All respondents agreed that POCUS is a useful clinical tool and that residents should learn POCUS, supporting acceptability.

Conclusions: We identified the barriers and facilitators to sustained POCUS training and implementation using the CFIR framework. Our POCUS program is acceptable, effective, and feasible based on survey responses, interviews, and health record data. Future work should address POCUS barriers and incorporate facilitators by tailoring POCUS education and clinical use toward individual providers at each site, using momentum from positive peer feedback, selecting an “ED clinical champion”, and integrating ED and hospital leadership support, with the goal to extend our implementation evaluation into a standardized national scale intervention.

References (Optional): 1. American College of Emergency Physicians. ACEP guidelines Policy Statement. Ultrasound guidelines: Emergency, Point-of-care, and clinical ultrasound guidelines in medicine. Revised June 2016. https://www.acep.org/patient-care/policy-statements/ultrasound-guidelines-emergency-point-of--care-andclinical-ultrasound-guidelines-in-medicine/
2. Moore CL, Molina AA, Lin H. Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography. Ann Emerg Med. 2006 Feb;47(2):147-53.
3. Feng W, Ye X, Lv H, et al. Current use and training needs of point-of-care ultrasound in emergency departments: a national survey of VA hospitals. AJEM. 2019;1784-1805.
4. Stein JC, River G, Kalika I, et al. A survey of bedside ultrasound use by emergency physicians in California. J Ultrasound Med. 2009 Jun;28(6):757-63.
5. Mosier JM, Malo J, Stolz LA, et al. Critical care ultrasound training: A survey of US fellowship directors. Journal of Critical Care. August 2014;29(4):645-649.
6. Schnikkte N, Damewood S. Identifying and Overcoming Barriers to Resident Use of Point-of-Care Ultrasound. West J Emerg Med. 2019 Oct 14;20(6):918-925.
7. IFEM. Point-of-care-ultrasound curriculum guidelines. March 2014. https://www.emssa.org.za/wp-content/uploads/2014/10/IFEM-Point-of-Care-Ultrasound-Curriculum-Guidelines.pdf
8. Schott CK, LoPresti CM, Boyd JS, et al. Retention of Point-of-Care Ultrasound Skills Among Practicing Physicians: Findings of the VA National POCUS Training Program. Am J Med. 2021 Mar;134(3):391399.e8.
9. Warner G. Applying the consolidated framework for implementation research to identify barriers affecting implementation of an online frailty tool into primary health care: a qualitative study. BMC Health Serv Res. 2018; 18:395.
10. Trischler J, Pervan S, Kelly S, et al. The value of codesign: the effect of customer involvement in service design teams. Journal of Service Research. 2018;2(1)75-100.
11. Slattery P, Saeri AK, Bragge P. Research co-design in health: a rapid overview of reviews. Health Res Policy Syst. 2020 Feb 11;18(1):17. doi: 10.1186/s12961-020-0528-9. PMID: 32046728; PMCID: PMC7014755.
12. Palmer VJ, Weavell W, Callander R, et al. The Participatory Zeigeist: an explanatory theoretical model of change in an era of coproduction and codesign in healthcare improvement. Med Humanit. 2019;45:247257.
13. Bate P, Robert G. Experience-based design: redesigning the system around the patient to co-designing services with the patient. Qual Saf Health Care. 2006;15:307-310.
14. Choi YJ, Jung JY, Kwon H. Effectiveness of ultrasound education in point-of-care ultrasound-assisted physical examinations in an emergency department: a before-and-after study. Medicine. 2017;96:25(e7269).
15. Blans MJ, Pijl MEJ, Van de Water JM, et al. The implementation of POCUS and POCUS training for residents: the Rinjstate approach. The Netherlands Journal of Medicine. 2020;78(3).
16. Brant JA, Orsborn J, Good R, et al. Evaluating a longitudinal point-of-care ultrasound (POCUS) curriculum for pediatric residents. BMC Medical Education. 2021;21:64.
17. Butki N, Long J, Butki A, et al. A Novel “Train the Trainer” emergency medicine resident point-of-care ultrasound course: a feasibility study. SMRj. 2020;4(2).
18. Milagros CM, Preparing for Interview Research: The Interview Protocol Refinement Framework. The Qualitative Report. 2016; 21:5, 811-831.
19. QSR International Pty Ltd. (2018) NVivo (Version 12), https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home.
20. PASS 2021 Power Analysis and Sample Size Software (2021). NCSS, LLC. Kaysville, Utah, USA, ncss.com/software/pass.
21. HEW, K.F., LO, C.K. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ 18, 38 (2018). https://doi.org/10.1186/s12909-018-1144-z.
22. Flanagan ME, Plue L, Miller KK, Schmid AA, Myers L, Graham G, Miech EJ, Williams LS, Damush TM. A qualitative study of clinical champions in context: Clinical champions across three levels of acute care. SAGE Open Med. 2018 Aug 1;6:2050312118792426.

Funding (Optional): This study is funded by an SAEMF/AEUS grant.