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 21^st 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. (2^nd 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)

Injections of medicines including  intra and peri – articular injection therapies

 by HCPC registered Podiatrists with POM-A annotation

Qualified podiatrists who are awarded licences in POM-A (prescription only medicine- administration), as either part of their undergraduate degree or as stand-alone qualifications are given statutory permission to administer medicines by injection that they may lawfully access**. The POM-A licence also contains a specific permission to obtain (without the usually required prescription) :  a range of injectables which include various local anaesthetics, adrenaline (epinephrine) and the anti-inflammatory synthetic steroid methylprednisolone. This permission continues whilst said podiatrist remains on the statutory register of the Health and Care Professions Council, and ceases should they leave, or be removed from, the stated register.

Whilst so registered they can legally obtain**all of the medicines above, including the steroid, and administer** them, without further training or permission.

However, it is a requirement of safe and responsible practice that podiatrists with POM-A  must ensure that they a) have a full and detailed understanding of the pharmacology of said medicines including their pharmacokinetics and pharmacodynamics (essentially how the body affects the drugs and the drugs affect the body) and b) they have suitable medical indemnity insurance for use of the items above. In respect of the local anaesthetics, a) is included in the approved courses which grants POM-A ,  so b) is included in most malpractice policies. In respect of the licensed steroid however, the Institute requires the completion of an approved course which explains, in substantial detail, the action of when TO use, and perhaps even more importantly when NOT to use the permitted steroid.  By virtue of the holding of a POM-A licence it is clear that the holders are already trained and safe injectors and the simple techniques of safe administration will already be known, but nonetheless, these are specifically restated (with some practical tips and information pearls) during the course and delegates to the course will readily grasp the analogy between  local anaesthetics and steroids.

To this end, the Institute’s course is designed by, and taught by, highly qualified podiatrist independent prescribers and due to its carefully designed structure permits the Institute’s insurers to offer insurance cover to allow members who have successfully attended the Institute’s approved course to commence its use independently without requiring further permission or ‘mentoring’. **Prescription-only-medicines that usually require prescription by a recognised prescriber can, where defined by law, be made available to defined members of certain legally regulated professions under statutory ‘exemptions’ to the 1968 Medicines act and its numerous subsequent amendments. The exempted substances may be purchased at retail or wholesale from regulated pharmacies or other legal UK sources. Note that ‘administration’ in the context of the above must be within the professional activities of the aforesaid practitioner with the said ‘exemption’.  The exemption is not in law a ‘prescription’ and does not permit mixing of medicines,  nor does it permit the holder of said exemption to direct  others to mix and or administer them (a patient specific direction from a registered prescriber is required for directing others to mix/administer) The position of epinephrine is less well determined by the above, as this falls within the parameters applying to medicine identified as being within schedule 19 of the 1968 medicines act (and amendments) wherein its legal category is relaxed when used with the provable intent of saving or preserving life in an emergency situation.

All members of the Institute of Chiropodists and Podiatrists (IOCP) and College of Foot Health can now access eIntegrity’s e-learning resources to support their professional development.

Members can use the Statutory and Mandatory Training, Dementia e-Learning Programme and Antimicrobial Resistance learning sessions. The programmes have been chosen for their relevance to practitioners in the IOCP – which represents HCPC[1]-registered podiatrists, podiatric surgeons and chiropodists in the UK.

Beverley Wright, Vice-Chair of the Board of Education, from the IOCP, said: “We’re pleased to offer these three programmes as a free benefit to our members, as part of our commitment to them.

“The practice of health and social care is built on effective communication and the ability to problem solve. This can be achieved remotely via distance learning programmes, such as eIntegrity’s, to develop our members’ understanding of statutory and mandatory content on Government and health guidelines, rules and regulations, and to facilitate professional development. It provides a foundation for all working aspects of our members’ practice.

“In today’s society there are a number of aspects that underpin health and social care, where continued professional development (CPD) is required and needs to be considered when delivering care. These CPD resources help equip members with the knowledge and understanding of key health issues, focusing on the main conditions prevalent in our society today.”

Richard Bryant, from eIntegrity, said: “We are delighted to make our e-learning available to the institute. Now, more than ever, we know that health and care professionals are finding our e-learning resources invaluable to support their development.

“We look forward to building on our relationship with the institute in the longer term and finding out how best we can support their members.”

[1] Health and Care Professions Council

MEMBERS – please login to the members area of our website (top right) for full terms & conditions, user guides and for further details on how you can sign up.

Whilst the Coronavirus pandemic has changed the ways  in which we are all working, or not in many cases, people around the world are embracing and testing boundaries of modern technology. This is also true of our team at Head Office. As always the IOCP are committed to maintaining and offering our members the best possible service and support until such a time that we can start to go back to normal.

Therefore we have launched weekly Wednesday webinars, aptly dubbed “Wed-inars” to keep members and fellow podiatry colleagues in-touch and earning CPD during our period of downtime. It’s FREE, it’s for YOU!

Our first webinar was held on the 1st April and was warmly received by all attendees. If you missed it, a recording of the meeting can be found via our events pages or via our social sites.

The subjects are added to our events calendar on our website. You can register either via our Facebook page or by emailing info@iop-uk.org with the subject line “Wed-inar CPD”.

From the 17th April, we will be introducing FHP Fridays for our Foot Health Practitioner friends of The College of Foot Health. More details of these will be released shortly.

If you are a Podiatrist or a FHP and would like a specific topic covered please get in touch and we’ll see what we can do!

Stay Safe.