Current Use, Training, and Barriers to Point-of-Care Ultrasound Use in ICUs in the Department of Veterans Affairs

Abstract

BackgroundPoint-of-care ultrasound (POCUS) has become an integral part of critical care medicine for procedural guidance, bedside diagnostics, and assessing response to treatment. Multiple critical care societies recommend POCUS use, and POCUS training has been a requirement for critical care fellowship since 2012. Yet, current practice patterns of POCUS use in ICUs are not well known.Research QuestionThis study aimed to characterize current POCUS use, training needs, and barriers to use among intensivists.Study Design and MethodsA prospective observational study of all Veterans Affairs (VA) medical centers was conducted between June 2019 and March 2020 using a web-based survey of all chiefs of staff and ICU chiefs. These data were compared with those from a similar survey conducted in 2015.ResultsChiefs of staff and ICU chiefs from 130 VA medical centers were surveyed with 100% and 94% response rates, respectively. At least one physician currently uses POCUS in 93% of ICUs, and 62% of individual physicians were estimated to be using POCUS. The most common POCUS applications were procedural guidance (59%), cardiac ultrasound (55%), and thoracic ultrasound (56%) . Most chiefs (80%) reported teaching POCUS to trainees in their ICU. The most frequently reported barriers to POCUS use were lack of trained providers (48%), lack of funding for training (45%), lack of training opportunities (37%), and lack of image archiving (34%). From 2015 through 2020, POCUS use increased across most applications and an increase in desire for training was seen.InterpretationPOCUS use increased across VA ICUs between 2015 and 2020, but significant gaps remain. Without a deliberate investment in POCUS training and infrastructure for physicians in practice, institutions are unlikely to benefit fully from standardized POCUS use in ICUs. Point-of-care ultrasound (POCUS) has become an integral part of critical care medicine for procedural guidance, bedside diagnostics, and assessing response to treatment. Multiple critical care societies recommend POCUS use, and POCUS training has been a requirement for critical care fellowship since 2012. Yet, current practice patterns of POCUS use in ICUs are not well known. This study aimed to characterize current POCUS use, training needs, and barriers to use among intensivists. A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between June 2019 and March 2020 using a web-based survey of all chiefs of staff and ICU chiefs. These data were compared with those from a similar survey conducted in 2015. Chiefs of staff and ICU chiefs from 130 VA medical centers were surveyed with 100% and 94% response rates, respectively. At least one physician currently uses POCUS in 93% of ICUs, and 62% of individual physicians were estimated to be using POCUS. The most common POCUS applications were procedural guidance (59%), cardiac ultrasound (55%), and thoracic ultrasound (56%) . Most chiefs (80%) reported teaching POCUS to trainees in their ICU. The most frequently reported barriers to POCUS use were lack of trained providers (48%), lack of funding for training (45%), lack of training opportunities (37%), and lack of image archiving (34%). From 2015 through 2020, POCUS use increased across most applications and an increase in desire for training was seen. POCUS use increased across VA ICUs between 2015 and 2020, but significant gaps remain. Without a deliberate investment in POCUS training and infrastructure for physicians in practice, institutions are unlikely to benefit fully from standardized POCUS use in ICUs. Take-home PointsStudy Question: How do critical care physicians in practice currently use point-of-care ultrasound (POCUS), which POCUS applications are most desired for training, and what barriers exist to POCUS use in clinical practice in ICUs?Results: A national survey of ICUs demonstrated that most critical care physicians (62%) currently use ultrasound for procedural guidance, cardiac, and lung exams and that training is most desired in the same applications because lack of training is the greatest barrier to POCUS use.Interpretation: Although POCUS use reportedly increased in ICUs from 2015 through 2020, important gaps in POCUS adoption remain, including use of some POCUS applications that are now considered standard of care, and a deliberate investment in POCUS training and infrastructure is needed to overcome the most common barriers to POCUS implementation. Study Question: How do critical care physicians in practice currently use point-of-care ultrasound (POCUS), which POCUS applications are most desired for training, and what barriers exist to POCUS use in clinical practice in ICUs? Results: A national survey of ICUs demonstrated that most critical care physicians (62%) currently use ultrasound for procedural guidance, cardiac, and lung exams and that training is most desired in the same applications because lack of training is the greatest barrier to POCUS use. Interpretation: Although POCUS use reportedly increased in ICUs from 2015 through 2020, important gaps in POCUS adoption remain, including use of some POCUS applications that are now considered standard of care, and a deliberate investment in POCUS training and infrastructure is needed to overcome the most common barriers to POCUS implementation. Over the last 2 decades, point-of-care ultrasound (POCUS) has become an integral part of critical care medicine. In ICUs, POCUS can rapidly diagnose life-threatening conditions, aid in urgent decision-making, and guide invasive bedside procedures.1Volpicelli G. Elbarbary M. Blaivas M. et al.International evidence-based recommendations for point-of-care lung ultrasound.Intensive Care Med. 2012; 38: 577-591Google Scholar, 2Díaz-Gómez J.L. Mayo P.H. Koenig S.J. Point-of-care ultrasonography.N Engl J Med. 2021; 385: 1593-1602Google Scholar, 3Lau Y.H. See K.C. Point-of-care ultrasound for critically-ill patients: a mini-review of key diagnostic features and protocols.World J Crit Care Med. 2022; 11: 70-84Google Scholar Numerous critical care societies and professional organizations have endorsed POCUS use in critically ill patients.4Mayo P.H. Beaulieu Y. Doelken P. et al.American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography.Chest. 2009; 135: 1050-1060Google Scholar, 5Frankel H.L. Kirkpatrick A.W. Elbarbary M. et al.Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part I: general ultrasonography.Crit Care Med. 2015; 43: 2479-2502Google Scholar, 6Levitov A. Frankel H.L. Blaivas M. et al.Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II: cardiac ultrasonography.Crit Care Med. 2016; 44: 1206-1227Google Scholar, 7Expert Round Table on Echocardiography in ICUInternational consensus statement on training standards for advanced critical care echocardiography.Intensive Care Med. 2014; 40: 654-666Google Scholar, 8Arntfield R. Millington S. Ainsworth C. et al.Canadian recommendations for critical care ultrasound training and competency.Can Respir J. 2014; 21: 341-345Google Scholar, 9Abboud P.A. Kendall J.L. Ultrasound guidance for vascular access.Emerg Med Clin North Am. 2004; 22: 749-773Google Scholar, 10Expert Round Table on Ultrasound in ICUInternational expert statement on training standards for critical care ultrasonography.Intensive Care Med. 2011; 37: 1077-1083Google Scholar To ensure appropriate use, training and competence in critical care POCUS are essential, especially for common applications like echocardiography and lung ultrasound. The Accreditation Council for Graduate Medical Education has emphasized competence in both diagnostic and procedural POCUS and made POCUS training an Accreditation Council for Graduate Medical Education requirement for pulmonary and critical care fellowship in 2012.11Accreditation Council for Graduate Medical Education, ACGME program requirements for graduate medical education in pulmonary and critical care medicine, Accreditation Council for Graduate Medical Education website. Accessed 23 January 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/156_pccm_2022_tcc.pdf.Google Scholar Despite these recommendations, important gaps in POCUS implementation remain, especially inconsistencies and heterogeneity in POCUS training.12Stowell J.R. Kessler R. Lewiss R.E. et al.Critical care ultrasound: a national survey across specialties.J Clin Ultrasound. 2018; 46: 167-177Google Scholar Specifically, the most frequently cited barrier to POCUS education from the perspective of trainees is a lack of trained faculty.13Yorkgitis B.K. Bryant E.A. Brat G.A. Kelly E. Askari R. Ra J.H. Ultrasonography training and utilization in surgical critical care fellowships: a program director’s survey.J Surg Res. 2017; 218: 292-297Google Scholar, 14Carver T.W. Ultrasound training in surgical critical care fellowship: a survey of program directors.J Surg Educ. 2018; 75: 1250-1255Google Scholar, 15Brady A.K. Spitzer C.R. Kelm D. Brosnahan S.B. Latifi M. Burkart K.M. Pulmonary critical care fellows’ use of and self-reported barriers to learning bedside ultrasound during training: results of a national survey.Chest. 2021; 160: 231-237Google Scholar, 16Cheng J. Arntfield R. Training strategies for point of care ultrasound in the ICU.Curr Opin Anaesthesiol. 2021; 34: 654-658Google Scholar, 17Jarwan W. Alshamrani A.A. Alghamdi A. et al.Point-of-care ultrasound training: an assessment of interns’ needs and barriers to training.Cureus. 2020; 12e11209Google Scholar, 18Galarza L. Wong A. M. The of critical care ultrasound training in a survey of and a of 2017; Scholar A survey of pulmonary and critical care fellowship in that of a POCUS A.K. Spitzer C.R. Kelm D. Brosnahan S.B. Latifi M. Burkart K.M. Pulmonary critical care fellows’ use of and self-reported barriers to learning bedside ultrasound during training: results of a national survey.Chest. 2021; 160: 231-237Google Scholar POCUS training during surgical has been an of of surveyed a POCUS reported of B.K. Bryant E.A. Brat G.A. Kelly E. Askari R. Ra J.H. Ultrasonography training and utilization in surgical critical care fellowships: a program director’s survey.J Surg Res. 2017; 218: 292-297Google R. D. et surgical lack competence in critical care Surg Educ. 2018; 75: Kendall J. C. for assessment diagnostic the learning in surgical Surg Educ. 2016; Scholar Accreditation Council for Graduate Medical Education training physicians in practice have opportunities to POCUS through medical education R. M. Mayo P.H. Koenig S.J. of a critical care ultrasonography 2017; Scholar, J. et al.Critical care ultrasound training: a survey of fellowship directors.J Crit 2014; Scholar, A. L. care ultrasound: a of training and Care Med. Scholar, et of point-of-care ultrasound among of the VA POCUS Training J Med. 2021; Scholar These have been to be for in practice to and the and for et of point-of-care ultrasound among of the VA POCUS Training J Med. 2021; Scholar, G. et of point-of-care ultrasound training during the J. 2021; Scholar, et for a point-of-care ultrasound clinical Med Educ. 2018; Scholar lack of physician training the most cited barrier to POCUS implementation in J. Arntfield R. Training strategies for point of care ultrasound in the ICU.Curr Opin Anaesthesiol. 2021; 34: 654-658Google J. S. P. et to learning and using point-of-care ultrasound: a survey of in North J. 2020; Scholar, R. et use, training, and barriers in point-of-care ultrasound in a national survey of VA Med. 2022; Scholar, et use, training, and barriers in point-of-care ultrasound in in a national survey of VA J Med. Scholar is not well are using POCUS and what barriers exist in ICUs in the observational study of ICUs across that of POCUS were on of of critically ill were with L. L. et al.Point-of-care ultrasound in care assessment of in a observational Care Med. 2015; Scholar study demonstrated that echocardiography was in of to guide in M. C. J.L. et in the A Care Med. 2015; Scholar These heterogeneity in both the of trained in POCUS well of use. To current use, training needs, and barriers to POCUS use in ICUs in the conducted a national survey of all ICUs medical centers in the Veterans Affairs (VA) care A prospective observational study of all VA medical centers was conducted between June 2019 and March 2020 using a web-based A POCUS with physicians from medicine, medicine, medicine, pulmonary medicine, and critical care with the and to and a web-based survey This study was the of the of and was to be The web-based survey on current use, barriers to use, and training needs of POCUS. were with and was of were the to some most all The survey was in a survey was to all chiefs of staff of VA medical centers between and The survey POCUS use, training, and well for all chiefs of medical and surgical ICUs a survey with was to all ICU chiefs to data on diagnostic and procedural POCUS use, training needs, and ICU chiefs reported on POCUS use on of their and their VA medical The survey for ICU chiefs in 2019 but in March 2020 because of the In conducted a similar prospective observational study of all VA medical of all ICU the chiefs of staff the survey to all chiefs the chiefs of staff were using POCUS. To for in data a of ICU that both the 2015 and 2020 was conducted to in POCUS use. the to between survey of the of using POCUS and POCUS training across of POCUS POCUS use and training desired were across all applications reported the to in A of was considered are from 2015 to chiefs of staff of VA medical centers POCUS use, training, and response Chiefs of ICUs response on POCUS use, training needs, and the ICUs, were medical ICUs, were surgical ICUs, and were ICUs. ICUs ICUs were medical ICUs because the medical on survey Table Most ICUs were VA medical centers with ICUs. VA ICUs are on medical and the of most ICUs were in and most were from the The ICUs reported a of ICU with in critical care of VA Medical and ICUs that care were on their and the of medicine medicine have of and have to of and and some to teaching ICU have of and have to of and and some to teaching are ICU medical surgical VA Veterans Veterans that care were on their and the have of and have to of and and some to teaching in a Table of POCUS and Training in POCUS in ICUs ICUs that care were on their and the ICU of of physicians in of physicians in reported in of physicians reported POCUS use using ICUs with physician using using POCUS for ICUs with training ICU physicians with POCUS training, ICUs with desire for POCUS ICUs with to POCUS trained in POCUS in are critical care medical ICU medical POCUS point-of-care surgical that care were on their and the of physicians in reported of physicians reported in a are ICU medical surgical VA Veterans Veterans are critical care medical ICU medical POCUS point-of-care surgical all ICUs, 93% reported least one physician currently using POCUS for diagnostic procedural of 62% of individual ICU physicians POCUS in medical ICUs, in surgical ICUs, in Although of all ICUs reported using POCUS for most a was between ICUs in of compared with medical surgical ICUs The most frequently POCUS applications were procedural guidance cardiac (55%), thoracic (37%), and vascular ultrasound POCUS is reported to be of ICUs for and diagnostic cardiac POCUS of ICUs POCUS for evaluation of and advanced applications were of ICUs using echocardiography of ICUs reported using procedural POCUS across the procedural applications that are considered standard of care, of ICUs reported using POCUS for for for and for cardiac and pulmonary POCUS applications were reported to be of ICUs for assessment of 62% for for for for and for pulmonary of ICUs reported not an ultrasound the ICUs current POCUS use, a of ultrasound were for use, with an of ICU. A of these ICUs reported least one ultrasound not with A of ultrasound were reported for ICU use and ultrasound were between the ICU and A of ultrasound were the VA in ICUs, and ultrasound were an physician in ICUs of ICUs reported archiving POCUS ICU chiefs reported a desire for training in cardiac and pulmonary POCUS applications and with desire for training in procedural guidance and and vascular diagnostic applications of physicians POCUS training was reported medical education during fellowship In some ICU chiefs reported that of their physicians POCUS training through medical education training A training desire for training current use, was for some diagnostic POCUS applications of ICU chiefs a to POCUS training for their POCUS use and desire for training for applications are in POCUS education of of ICU chiefs reported training in their ICUs of POCUS training to medical physician and is in Most ICUs reported POCUS education to with that POCUS during the ICU Most reported that of their ICU physicians POCUS use for bedside and diagnostic POCUS use. ICU physicians in medical and surgical ICUs reported in POCUS use compared with those in ICUs Most ICUs reported one barrier to POCUS use, and not barriers to POCUS use. of training and barriers were reported of ICUs, with barriers to POCUS infrastructure and ultrasound barriers reported of ICUs were lack of trained providers (48%), lack of funding for training (45%), lack of training opportunities (37%), and lack of image archiving to POCUS in of ICUs of trained of funding for of training of funding for At least one of the training barriers of image of funding for of standard of funding for of of At least one of the infrastructure barriers of ultrasound of funding for POCUS At least one of the barriers barriers point-of-care ultrasound. in a POCUS point-of-care ultrasound. compared data from critical care that in both 2015 and of these ICUs were in were in and medicine and ICUs in 2020, and ICUs and 2 ICUs. The of ICUs was similar to the for all in Table an increase in POCUS use was across all applications for diagnostic cardiac applications The increase in ICUs using POCUS applications from for to for vascular POCUS all diagnostic the increase was an increase in diagnostic POCUS use from 2015 to 2020 diagnostic cardiac POCUS use for assessment of use for advanced not and use for evaluation of and in POCUS use for procedural guidance from 2015 through 2020, use for and POCUS use for and not and use reported for From 2015 through 2020, the desire for training increased for all POCUS diagnostic and procedural applications in a the desire for training of all diagnostic POCUS applications increased but not for all procedural POCUS applications for in POCUS use for cardiac, and vascular applications are in Ultrasound increased from 2015 through POCUS were in the ICUs in 2015 compared with in 2020 A but increase in ICUs ultrasound was from 2015 through 2020 to A significant lack of POCUS training for physicians was from 2015 through Most ICUs not have a for to POCUS most chiefs of staff and ICU chiefs to a national VA POCUS in 2020, which not from 2015. Most ICUs currently do not have an image significant since 2015. most ICUs reported in a in 2020 the ICUs compared from 2015 through 2020, currently POCUS which has not since 2015 of ICUs reported POCUS in the in survey was To conducted the national survey of POCUS use among critical care physicians in and ICUs across the VA care current use and desire for training in POCUS well barriers to POCUS use, which can guide POCUS implementation in critical care medicine. care medicine is a with physicians training is in medicine, medicine, and M. training in critical care in the Care 2018; Scholar and significant heterogeneity in POCUS recommendations and from the critical care societies these G. Elbarbary M. Blaivas M. et al.International evidence-based recommendations for point-of-care lung ultrasound.Intensive Care Med. 2012; 38: 577-591Google P.H. Beaulieu Y. Doelken P. et al.American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography.Chest. 2009; 135: 1050-1060Google Scholar, 5Frankel H.L. Kirkpatrick A.W. Elbarbary M. et al.Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part I: general ultrasonography.Crit Care Med. 2015; 43: 2479-2502Google Scholar, 6Levitov A. Frankel H.L. Blaivas M. et al.Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II: cardiac ultrasonography.Crit Care Med. 2016; 44: 1206-1227Google Scholar, 7Expert Round Table on Echocardiography in ICUInternational consensus statement on training standards for advanced critical care echocardiography.Intensive Care Med. 2014; 40: 654-666Google Scholar, 8Arntfield R. Millington S. Ainsworth C. et al.Canadian recommendations for critical care ultrasound training and competency.Can Respir J. 2014; 21: 341-345Google Round Table on Ultrasound in ICUInternational expert statement on training standards for critical care ultrasonography.Intensive Care Med. 2011; 37: 1077-1083Google A. L. care ultrasound: a of training and Care Med. G. A. M. et al.International evidence-based recommendations for cardiac 2014; Scholar Although that POCUS is an for critical care study for lack of POCUS training and use of both diagnostic and procedural POCUS among intensivists. In of ICUs from 2015 through 2020, the desire for training increased but the reported barriers to POCUS implementation from a care perspective have been have been POCUS training during critical care but have been POCUS use among critical care physicians on of the similar have been but with important J.R. Kessler R. Lewiss R.E. et al.Critical care ultrasound: a national survey across specialties.J Clin Ultrasound. 2018; 46: 167-177Google Y.H. et al.Point-of-care ultrasound training among in a Med 2020; Scholar study a response of 100% from chiefs of staff and 94% from ICU which is with response of and were to data from 2015 through 2020, in POCUS use and training across a care A key of study is that procedural and diagnostic POCUS use is not in ICUs, for applications that be considered standard of of these POCUS applications have been national including the College of Chest the of Care and the of P.H. Beaulieu Y. Doelken P. et al.American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography.Chest. 2009; 135: 1050-1060Google Scholar, 5Frankel H.L. Kirkpatrick A.W. Elbarbary M. et al.Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part I: general ultrasonography.Crit Care Med. 2015; 43: 2479-2502Google Scholar, 6Levitov A. Frankel H.L. Blaivas M. et al.Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II: cardiac ultrasonography.Crit Care Med. 2016; 44: 1206-1227Google for and Care on the use of ultrasound for Accessed Scholar, K.M. Care A of for and Scholar, R. D. et on the use of ultrasound guidance for a statement of the of Med. 2018; Scholar, J. et on the use of ultrasound guidance for a statement of the of Med. Scholar, R. D. B.K. et on the use of ultrasound guidance for and vascular in a statement of the of Med. Scholar, R. et on the use of ultrasound guidance for a statement of the of Med. Scholar, D. B.K. et al.Point-of-care ultrasound for a statement of the of Med. Scholar, point-of-care and clinical ultrasound in Med. 2017; Scholar study barriers to POCUS use, most lack of training, but data not the in implementation of POCUS use, which be in POCUS use increased an of from 2015 through 2020 of ICUs reported using procedural POCUS across are to the of ICUs are bedside ultrasound guidance are not bedside These be J. R. in of the and between and those Scholar Most data that POCUS use is not for some common including and common diagnostic POCUS applications that be considered standard of care in ICUs, assessment of and were not most critical care physicians in practice training diagnostic POCUS use was that lack of training and barriers which data that ICUs reported POCUS use during compared with those medical surgical ICUs. The ICUs reported physicians and physicians with POCUS use which these ICUs reported POCUS use during that trainees in ICUs, providers with in POCUS use barriers to POCUS use in ICUs. The barriers reported were lack of trained lack of funding for training, lack of training lack of image and lack of funding for to of training and barriers have been reported barriers to POCUS use critical care J.R. Kessler R. Lewiss R.E. et al.Critical care ultrasound: a national survey across specialties.J Clin Ultrasound. 2018; 46: 167-177Google J. et al.Critical care ultrasound training: a survey of fellowship directors.J Crit 2014; Y.H. et al.Point-of-care ultrasound training among in a Med 2020; Scholar well physicians from R. et use, training, and barriers in point-of-care ultrasound in a national survey of VA Med. 2022; et use, training, and barriers in point-of-care ultrasound in in a national survey of VA J Med. R. et use and barriers to point-of-care ultrasound in a national survey of VA medical J Med. Scholar The greatest desire for POCUS training was for cardiac, and procedural POCUS training was the most desired training in Y.H. et al.Point-of-care ultrasound training among in a Med 2020; Scholar is that the most POCUS cardiac, and procedural were the applications with the greatest desire for A similar was in et use, training, and barriers in point-of-care ultrasound in in a national survey of VA J Med. M. et use and training needs of point-of-care ultrasound in a national survey of VA J Med. 37: Scholar and R. et use, training, and barriers in point-of-care ultrasound in a national survey of VA Med. 2022; C. et national needs assessment of point-of-care ultrasound training for Clin Scholar in 2015 and 2020, the greatest desire for training was in the most frequently POCUS clinical use of POCUS increased to POCUS use to the of POCUS adoption in The training among critical care physicians for applications is The POCUS training is POCUS training in medical and but for physicians in practice, the to training is through medical education Without a deliberate investment in POCUS training for physicians in practice, institutions are unlikely to the of and POCUS use among critical care have the desire for training in cardiac, and procedural POCUS These data can a needs assessment for of and training for critical care among cardiac POCUS evaluation of and advanced were in for POCUS are to and training, the greatest barrier to POCUS implementation in ICUs is lack of including image standard and Although POCUS an of the a ultrasound is the general from professional organizations is to POCUS and to in the point-of-care and clinical ultrasound in Med. 2017; practice for of an ultrasound Ultrasound Med. 2020; M. et for and competence and in critical care ultrasound with cardiac ultrasound and advanced critical care of Care website. Accessed Scholar POCUS be for and but POCUS for clinical have in the archiving and with of a with POCUS to the training POCUS infrastructure to POCUS and use significant investment and that study has Despite the response rates, self-reported data from chiefs of staff and ICU chiefs that have data were from critical care physicians in VA medical which to care the VA care a of medical centers that are critical care physicians practice medical and critical care medicine is a with training and practice to for and ICUs and chiefs staff the ICUs. the survey was between 2015 and 2020, some of and the have in Although most ICUs reported using POCUS for procedural guidance and common diagnostic POCUS applications that can be considered standard of care have not been in ICUs. Despite an increase in POCUS use from 2015 through 2020, barriers adoption of POCUS use in ICUs, including lack of trained funding and of training, and image critical care training is most desired in cardiac, and procedural POCUS a deliberate investment in POCUS infrastructure and training for physicians in practice, institutions are unlikely to benefit fully from standardized POCUS use in ICUs. J. S. is the of Veterans Affairs P. L. funding from the of Veterans Veterans of and This is the of with and the use of the Veterans Care in