December 2024
“POCUS is the use of limited ultrasound (US) protocols performed at the patients bedside to assess a wide range of clinical conditions. This is distinctly different to the Sonographer and Radiologist delivered departmental studies which require many years of training and experience to provide a systematic structured assessment” ( Clare 2022)
In line with the statement above by Dr Sarbjit Clare MBE, Consultant in Acute Medicine and Deputy Medical Director, Sandwell and West Birmingham Hospitals NHS Trust, in her seminal publication Ultrasound for the Generalist (Clare S and Duncan C., 2022), the Institute of Podiatrists recognises the enormous potential that POCUS has to aid the Podiatrist in point of care clinical decision making. In this respect the IoP view POCUS in the same category as other clinical point-of-care practitioner information tools such as using a vascular doppler, a 10g monofilament, a stethoscope or a 128Hz tuning fork (for example).
The tools that podiatrists use in their day to day practice have evolved over the years and continue to evolve. With every evolution the requirement for a podiatrist to understand their tools is a given and must be taken as an obligation, not least in respect of the necessity to be fully compliant with the legal standards laid out by the Health and Care Professions Council , which is the sole UK legal arbiter and regulator of podiatry standards. (see resources) In particular (but not exclusively) the following – standard 1. ‘Practice safely and effectively within their scope of practice’, standard 4. ‘Practice as an autonomous professional, exercising their own professional judgement’, standard 11 . ‘Assure the quality of their practice’ and standard 13. ‘Draw on appropriate knowledge and skills to inform practice’.
This clearly lays the responsibility for ensuring that such practice is safe upon the individual autonomous professional, and that responsibility is identical in respect of whatever tool the practitioner uses, be it a POCUS device or a 128Hz tuning fork. In the view of the IoP it is the practitioners duty to understand and internalise the following 7 key areas in respect of POCUS:
- What is US and specifically POCUS.
- Safety considerations of its use, including its necessary limitations.
- The medical context of US.
- Safe and effective operation of typical POCUS devices.
- The recognition and identification of US generated images.
- Physiological images vis-à-vis pathological images.
- Treatment and referral decisions made in respect of images viewed.
Again, the IoP applauds and endorses the declared view of Professor Dan Lasserson MA MD MRCGP FRCP (Edin) Professor of Acute Ambulatory Care, Warwick University and Clinical Lead, Hospital at Home, Oxford University Hospitals NHS Foundation Trust, as follows : “Point of care ultrasound (POCUS) has become an essential tool within acute specialties to enhance bedside diagnostics, facilitate safe interventional procedures and guide referral to specialist services. It is vital for this tool to be expanded to community and prehospital settings where access to definitive investigations is limited. With the evolution of technology, ultrasound is becoming increasingly available due to reducing costs, machine size and remote image review for quality assurance purposes. This skill is invaluable for clinicians at all levels of training from medical school through to consultancy and allied healthcare professionals in any discipline” (Clare S, Duncan C (eds) 2022).
Furthermore, the IoP recognises that some established diagnostic services and providers may believe that POCUS is a ‘disruptor’ to their own models of business (and profit?) and seek to either control or eliminate it – viz: “Is point-of-care ultrasound disruptive innovation? Formulating why POCUS is different from conventional comprehensive ultrasound” (Weile J, et al 2018). In respect of the foregoing, the IoP believes unequivocally that POCUS is indeed firmly and clearly outwith the purview of traditional imaging services as Weil J and colleagues maintain: “The perspective of this paper is mutual understanding of similarities and differences between conventional and point-of-care ultrasound. Only with this understanding can the stakeholders collaborate and use the full spectrum of ultrasound for the benefit of the patient”. This leads on to our declared position that when practiced by legally regulated and highly qualified healthcare specialists such as podiatrists, POCUS can be practiced safely and responsibly within the framework of the 7 mandatory key points previously identified to the considerable benefit of the patients to whom it is applied.
In respect of training for POCUS, the IoP recognise that there is no single defined standard syllabus, although many parties (who in some cases offer such training on a fee basis) lay claim to one, as is often the case in many areas of Healthcare. We therefore hold to reliance upon the HCPC standards of practice previously quoted, plus the 7 key requirements above, and use that as guidance in respect of Continuing Professional Development learning events concerning POCUS designed and laid on by the IoP.
Much of the necessary background knowledge appropriate to POCUS is available to registered podiatrists via self-directed learning, utilising our recommended publications from recognised experts in POCUS and, most importantly, clinical human anatomy without which no ultrasonography at any level can be competently comprehended; ( Clare 2022, Loukas and Burns 2024, Loukas and Tubbs 2024). Nowadays, in the 21st century there are also truly vast resources specifically in respect of POCUS online from highly respected practitioners and institutions widely available by both subscription from such as the New York School of Regional Anaesthesia (see resources) and Wolters Kluwers digital and hybrid human anatomy (see resources), as well as a plethora of detailed public domain videos on YouTube from sonographers, specialists, physicians and academic institutions.
Once a viable standard of background knowledge has been acquired this should then be complimented by sufficient hands-on practice to acquaint the practitioner with practical device use, this can usually be acquired by attending an introductory practical ‘hands on’ CPD event and will give a base for the practitioner to build their advancing knowledge upon. In respect of IoP members wishing to enjoy IoP level four insurance for POCUS use, the foregoing is a mandatory requirement, together with ongoing continuing learning which is in any event a requirement of HCPC standards of practice in all areas of a podiatrists professional practice.
The Health and Social Care Act (2008) lays out clearly the requirements for registration with the Care Quality Commission for what it terms ‘captured’ activities. Paragraph 7 of that act and associated sub paragraphs deal with captured activities that are provided as ‘a service’ , so if a practitioner set up a ‘diagnostic and reporting service’ that would be clearly captured by the act and require CQC registration. Using clinical tools at point of care by a clinician to audit the homeostasis of a patient, be that by using a stethoscope, a 128Hz tuning fork, a vascular doppler or a POCUS ultrasound device is not in the view of the IoP ‘providing a specific service’, it is simply part of the practitioner gathering information to enable safe, responsible and effective clinical decisions to be made by the practitioner to the benefit of the patient.
In line with the HCPC standards previously quoted, the use of any clinical tool, or any clinical decision made by a practitioner as ‘an autonomous professional’, should be line with their ‘own professional judgement’ with the practitioner recognising that they are responsible for such clinical decisions and tool use. Practitioners are reminded that they are responsible for keeping appropriate records, so that should they be called to account for their clinical activities and clinical decisions they can clearly lay out the foregoing for interested parties and stakeholders.
References
Dr Sarb Clare, Dr. Chris Duncan (eds) Ultrasound for the Generalist 1pp: A Guide to Point of Care Imaging. Cambridge University Press, 2022.
Weile J, Brix J, Moellekaer AB, . Crit Ultrasound J. 2018 Oct 1;10:25.
Loukas M, Burns D. Essential Ultrasound Anatomy. (2nd Edn) Wolters Kluwers (pub) 2024
Loukas M, Tubbs RS, Grays Clinical Photographic Dissector of the Human Body. Elsevier (pub) 2024.
Resources
Wolters Kluwer online portal : https://www.lww.co.uk/
New York School of Regional Anaesthesia: https://www.nysora.com/
(IoP V1. Rev 1. 2024)