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Dissemination and Use of Point-of-Care Ultrasound by
Pediatricians in Europe
A Research in European Pediatric Emergency Medicine Network
Collaborative Survey
Niccolò Parri, MD,* Ron Berant, MD,†Martina Giacalone, MD,* Sarah Dianne Jones, MD,‡
Nir Friedman, MD,§|| and for the REPEM POCUS collaboration
Objective: We surveyed the dissemination and use of point-of-care ultra-
sound (POCUS), physician training levels, and barriers and limitations to
use of POCUS among pediatricians and pediatric emergency medicine
(PEM) physicians across Europe and Israel.
Methods: A questionnaire was distributed through the PEM section of
the European Society for Emergency Medicine and the Research in Euro-
pean Pediatric Emergency Medicine Network.
Results: A total of 581 physicians from 22 countries fully completed the
questionnaire. Participants were primarily pediatric attending physicians
(34.9% [203 of 581]) and PEM attending physicians (28.6% [166 of
581]). Most of the respondents, 58.5% (340 of 581), reported using
POCUS in their practice, and 61.9% (359/581) had undergone POCUS
training. Point-of-care ultrasound courses represented the most common
method of becoming proficient in POCUS. Overall, the Focused Assess-
ment with Sonography in Trauma scan was the mostly taught application,
with 76.3% (274 of 359). Resuscitative, diagnostic, and procedural
POCUS were rated as very useful or useful by the most of respondents.
The lack of qualified personnel to train (76.9% [447 of 581]), and the
insufficient time for physicians to learn, POCUS (63.7% [370 of 581])
were identified as the main limitations to POCUS implementation.
Conclusions: The dissemination of pediatric POCUS in the European and
Israeli centers we surveyed is limited, and its applications are largely restricted
to the Focused Assessment with Sonography in Trauma examination. This is
likely related to lack of training programs. In contrast, the potential value of
use of POCUS in PEM practice is recognized by the majority of respondents.
Key Words: point-of-care ultrasound, survey
(Pediatr Emer Care 2022;00: 00–00)
Point-of-care ultrasound (POCUS) has the potential to support
clinicians by providing real-time information, potentially alter-
ing diagnoses and tailoring individualized care.
1
Recently, pediatric emergency medicine (PEM) physicians
have adopted POCUS to improve diagnosis and assist in proce-
dures.
2
Point-of-care ultrasound use in pediatrics differs from
use in adults with respect to relevant applications.
3
In recent years,
POCUS knowledge and practice have improved, and new PEM-
specific applications have been described and studied.
2,4–6
In con-
trast to the United States and Canada, in Europe there are no PEM
POCUS fellowship programs, consensus education guidelines, or
standardized curricula. To date, there is only a POCUS curriculum
for pediatric critical care in the United Kingdom.
7
Prior literature
on the degree oftraining and use of POCUS by PEM physicians in
the United States shows an increased use over time and increased
training for PEM fellows.
8,9
There are currently no published data on the use of POCUS
by pediatricians or PEM physicians across Europe. For these rea-
sons, we sought to conduct a survey on POCUS practice in pedi-
atricians and PEM physicians in Europe and Israel.
Given that PEM is not recognized as a formal specialty in
most European countries,
10
and that POCUS training is not an of-
ficial part of pediatric residency training programs, we hypothe-
sized widespread differences in participant responses in terms of
overall POCUS use and applications.
The aim of this cross-sectional study was to evaluate the dis-
semination of POCUS, modalities of use, and physician training
levels among a group of European and Israeli pediatricians and
PEM physicians. In addition, we explored the perceived barriers
From the *Department of Emergency Medicine and Trauma Center, MeyerUni-
versityChildren's Hospital, Florence, Italy; †Emergency Department, Schneider
Children's Medical Center of Israel, Petah Tikva, Israel; ‡Department of Emer-
gency Medicine, Alder Hey Alder Hey Children's NHS Foundation Trust, Liverpool,
England, United Kingdom; §Pediatric Emergency Department, Meir Medical
Center, Kfar Saba; and ||Sackler School of Medicine, Tel Aviv University, Tel
Aviv, I s r a e l .
N.P. and R.B. contributed equally to the article.
REPEM PEM POCUS collaboration: Javier Benito Fernandez (Cruces
University Hospital, Bilbao, Spain), Alain Gervaix (University Hospital of
Geneva, Switzerland), Silvia Bressan (Department of Pediatrics, University
of Padova, Padova, Italy), Diana Moldovan (Tirgu Mures Emergency
Clinical County Hospital, Tirgu Mures, Romania), Zsolt Bognar (Heim Pal
Children's Hospital, Budapest, Hungary), Hayri L. Yilmaz (Cukurova
University Medical Faculty, Adana, Turkey), Henriette Moll (Erasmus
MC—Sophia, Rotterdam, the Netherlands), Dorien Geurts (Erasmus
MC—Sophia, Rotterdam, the Netherlands), Luigi Titomanlio (Hopital
Universitaire Robert-Debre, Paris, France), Saïd Hachimi-Idrissi (Critical
Care Department, University Hospital Ghent, Ghent, Belgium), Ricardo
M. Fernandes (Departamento de Pediatria Hospital de Santa Maria, Centro
Hospitalar Lisboa Norte, Lisbon, Portugal), Ozlem Teksam (Division of
Pediatric Emergency Medicine, Department of Pediatrics, Hacettepe
University, Ankara, Turkey), Eylem Ulas Saz (Division of Emergency
Medicine, Department of Pediatrics, Ege University Faculty of Medicine,
Izmir, Turkey), Gerard Cheron (Necker Enfants Malades Hospital, Paris,
France), Mihai Gafencu (University of Medicine and Pharmacy “Vi ctor
Babes,”Timisoara, Romania), Ena Pritišanac (Medical University of Graz,
Department of Pediatrics and Adolescent Medicine, Graz, Austria), Aude
Tonson La Tour (Division of Pediatric Emergency, University Hospital of
Geneva, Geneva, Switzerland), Alexandra Petrovska (University Hospital
Motol, Prague, Czech Republic).
Disclosure: The authors declare no conflict of interestand no source of funding.
Author Contributions: N.P. conceptualized and designed the study, drafted the
initial manuscript, and reviewed and revised the manuscript. R.B.
conceptualized and designed the study, drafted the initial manuscript, and
reviewed and revised the manuscript. M.G. coordinated and supervised data
collection, drafted the initial manuscript, critically reviewed and revised the
manuscript, and overviewed the revisions of the manuscript. S.D.J.
conceptualized and designed the study, and reviewed and revised the
manuscript. N.F. drafted the initial manuscript, critically reviewed and
revised the manuscript, and overviewed the revisions of the manuscript. All
authors approved the final manuscript as submitted and agree to be
accountable for all aspects of the work.
All members of the PEM POCUS collaborative research group actively
contributed to the study development at their sites.
Reprints:Niccolò Parri, MD,Department of Pediatric Emergency Medicine and
Trauma Center, Meyer Children's Hospital, viale Pieraccini 24, Firenze
50139, Italy (e‐mail: niccolo.parri@meyer.it).
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 074 9-5161
ORIGINAL ARTICLE
Pediatric Emergency Care •Volume 00, Number 00, Month 2022 www.pec-online.com 1
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
and limitations to the dissemination of POCUS among pediatri-
cians and PEM physicians across Europe and Israel.
METHODS
We assessed physicians' perspectives using a Web-based
questionnaire. Respondents were recruited through the PEM sec-
tion of the European Society for Emergency Medicine (EUSEM)
and the Research in European Pediatric Emergency Medicine
(REPEM) Network. The EUSEM is a nonprofit scientific organi-
zation whose aim is to promote and foster the concept, philosophy,
and art of emergency medicine across Europe. In 2020, it included
37 European national societies of emergency medicine.
11
The
REPEM network is part of the PEM section of EUSEM, and its
mission is to improve emergency care for children through high
standard national and multinational research. Israel is a member
of both the EUSEMand REPEM. A national lead for each country
of REPEM was recruited and was asked to forward the survey link
(RedCAP software) to emergency department (ED) staff in his or
her hospital. The national lead was chosen from REPEM mem-
bers who demonstrated interest in both research and POCUS.
The national lead was in charge of disseminating the survey to
PEM networks available in his or her country. This snowball ap-
proach,
12
in which the receiver of the survey was allowed to for-
ward the link to anyone who was deemed eligible for the survey,
was chosen to obtain as many responses as possible from hospital
staff within each REPEM member country and within countries
where there was less participation in professional associations.
To enhance the response rate, reminder emails were sent at 5, 7,
12, and 24 weeks after the initial email. A POCUS champion from
nations outside REPEM was identified and contacted through Re-
search Gate (www.researchgate.com) and Linkedin (www.
linkedin.com) to access the survey. Data were collected between
June 2017 and March 2018.
The questionnaire was developed based on a survey pub-
lished by Marin et al,
8
which was adapted for our purpose. The
questionnaire was pretested for clarity and relevance by 3 physi-
cians from the research group; 5 pediatric residents from Italy,
the United Kingdom, and France; and 5 PEM residents, all from
Italy. The latter were pediatric residents who were completing a
PEM specialization during their last 2 years of their pediatric res-
idency. Their suggestions were used to revise and clarify the ques-
tionnaire. The final version of the survey included 27 questions
that measured 8 specific details about the dissemination and uses
of POCUS, applications that were most commonly performed,
training received, and any barriers and limitations to dissemination.
The respondents were physicians asked to report their use of
POCUS and their opinions regarding the barriers and limitations
to the dissemination of POCUS in their countries. The question
response options were yes or no, multiple-choice, open-ended
short answers, or categorical response types, or 5-point Likert
scale response types. For questions with categorical responses,
we also provided an “other”category, for which we solicited a free-
text response. Data were analyzed with STATA 11.0 (StataCorp, Col-
lege Station, Tex). We excluded from our analysis those surveys that
were not fully completed. Free-text “other”responses were either
reclassified to one of the listed responses or analyzed as new re-
sponses. For the question on the perceived importance of POCUS
diagnostic applications, we used the yes/no/don't know format, as
described throughout the literature.
2–6,13–16
For questions regard-
ing procedural and resuscitative applications, we used a 5-point
Likert scale. For questions involving Likert scales, we combined
responses into 3 meaningful groups for ease of interpretation:
(1) almost always/most of the time, occasionally/rarely, or never;
(2) strongly agree/agree, neutral or indifferent, or disagree/strongly
disagree; and (3) definitely a role/probably a role, unsure of the role
or definitely no role/probably no role, and very useful/useful, indiffer-
ent, or useless/not very useful.
8
The institutional review board at our
institution reviewed and approved all study procedures.
RESULTS
We obtained responses from 634 physicians from 22 differ-
ent countries. For our analysis, we considered 581 completed sur-
veys (Table 1). The majority of participants worked as pediatric at-
tending physicians (217 [36.2%]) or PEM attending physicians
(214 [35.7%]). Country of origin and characteristics of hospitals
of the respondents are reported in Tables 1 and 2.
In 62.2% (361 of 581) of hospitals, radiologist-performed ul-
trasound (US) service was available 24/7 in the hospital. In 28.9%
(168 of 581) of hospitals, radiology US was available on call for
emergencies overnight and during weekends. Of the 581, 46
(7.9%) described other alternative organizational structures for
US imaging (eg, on call overnight and during weekends for spe-
cific conditions such as ovarian torsion, testicular torsion, and in-
tussusception; Table 2).
A total of 60.6% (352 of 581) of the EDs used POCUS, 75%
were pediatric EDs. Of the 581respondents, 340 (58.5%) reported
using POCUS. The frequency of use was reported as “almost al-
ways”or “most of the time”(cumulative 53.5% [182 of 340;
Table 2). For the majority of EDs using POCUS, 40.1% (141 of
352), there was no POCUS leader in their ED (Table 2). Sixty-
two percent (359/581) of respondents had undertaken some train-
ing on POCUS. Courses, consisting of 1 or more days of training
on various techniques, were the most frequently reported choice
for respondents to learnPOCUS. Of these, 44% (158 of 359) were
specific to pediatric US emergencies and 36.5% (131 of 359) to
adult US emergencies (Table 3).
TABLE 1. Country of Origin of Respondents
Country n (%)
Albania 20 (3.4)
Austria 37 (6.4)
Belgium 36 (6.2)
Bulgaria 1 (0.2)
Czech Republic 1 (0.2)
Estonia 3 (0.5)
France 61 (10.5)
Germany 1 (0.2)
Greece 1 (0.2)
Hungary 55 (9.5)
Israel 22 (3.8)
Italy 105 (18)
Lithuania 27 (4.6)
Netherlands 13 (2.2)
Poland 17 (3)
Portugal 52 (8.9)
Romania 16 (2.7)
Spain 55 (9.5)
Sweden 1 (0.2)
Switzerland 4 (0.7)
Turkey 52 (8.9)
United Kingdom 1 (0.2)
Total 581 (100)
Parri et al Pediatric Emergency Care •Volume 00, Number 00, Month 2022
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Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Overall, the emergency applications that were most com-
monly taught in courses were the Focused Assessment with
Sonography in Trauma (FAST; 76.3% [274 of 359]), lung US
(59.9% [215 of 359]), and focused echocardiography (39.8%
[143 of 359]). For procedures, US-guided or US-assisted periph-
eral line access was the most common (34.5% [124 of 359]) appli-
cation taught (Table 4).
When exploring the use of the different POCUS applications,
less than half of the respondents who used POCUS performed the
FAST examination “almost always”or “most of the time”(cumu-
lative 43.2% [152 of 340]), lung US “occasionally”or “rarely”
(cumulative 35.8% [126 of 340]), and focused echocardiography
“occasionally”or “rarely”(cumulative 31.6% [111 of 340]). More
than 50% of the participants reportedthat they “never”used any of
the other POCUS applications including peripheral access or to
assist with procedures (Fig. 1).
Respondents rated the utility of all the POCUS applications
reported in the survey as “very useful”or “useful,”with the excep-
tion of ocular US in trauma, which was scored as “indifferent”by
36.7% (213 of 340; Fig. 2). The global opinion on the impact of
POCUS on patient management was positive. More than 60% of
respondents “agreed”(37.9% [220 of 581]) or “strongly agreed”
(32.7% [190 of 581]) that using POCUS shortened ED stays.
Most of the participants agreed that POCUS improved the quality
of care by helping to make more accurate diagnoses (“agree”
51.1% [297 of 581] and “strongly agree”34.1% [198 of 581])
and narrowing differential diagnoses, as well as expediting care
(“agree”55.1% [320 of 581] and “strongly agree”31.5% [183
of 581]; Table 5). Respondents “agreed”or “strongly agreed”that
a lack of qualified personnel to adequately train physician staff
(76.9% [447 of 581]) and insufficient time for physicians to learn
POCUS (63.7% [370 of 581]) were the main barriers to POCUS
implementation (Fig. 3).
DISCUSSION
It is reported that PEM POCUS has become an integral part
of the care of children presenting to the ED, especially in North
America,
9
with the majority of pediatric EDs providing official
POCUS training to their fellows.
17,18
In our study, we demonstrate
that PEM POCUS use in pediatric EDs across a group of Euro-
pean and Israeli centers connected through the EUSEM is much
lower as compared with that described by Marin et al.
8
A total of 33.4% of respondents reported that their EDs do
not use POCUS, and 41.5% of the physicians never used POCUS
themselves. According to Marin et al,
8
most pediatric EDs across
the United States provide PEM POCUS training to their fellows.
In Canada, Hoeffe et al
17
reported that 5 of the 9 PEM fellowship
TABLE 2. Characteristics of Surveyed Physicians and Their
Medical Centers
n(%)
Current position of respondents
Pediatric attending physician 217 (36.2)
PEM attending physician 214 (35.7)
Pediatric resident 79 (13.2)
Emergency medicine attending physician 56 (9.4)
PEM fellow 27 (4.5)
Pediatric intensivist/anesthetist 6 (1)
Total 599* (100)
Hospital type
Pediatric university/teaching hospital 258 (44.4)
General hospital/teaching hospital 198 (34.1)
Community/district hospital 125 (21.5)
Total 581 (100)
Setting
Pediatric ED (standalone) 297 (51.1)
General/acute pediatrics 108 (18.6)
Pediatric ED associated with general (adult) ED 77 (13.2)
Mixed ED 68 (11.7)
Pediatric unit intensive care 23 (4)
Other
†
5 (0.9)
Outpatient/clinic 3 (0.5)
Total 581 (100)
ED trauma center designation
No 302 (52)
Yes 279 (48)
Total 581 (100)
EDuseofPOCUS
Yes 352 (60.6)
No 194 (33.4)
Don't know 35 (6)
Total 581 (100)
POCUS leader, director or equivalent
‡
No 141 (40.1)
Yes, PEM physicians 100 (28.4)
Don't know 72 (20.4)
Yes, EM physicians 39 (11.1)
Total 352 (100)
Radiology US service availability
US available 24 h, 7/7 (radiologist in the hospital at all times) 361 (62.2)
US available 24 h, 7/7 (radiologist available, on c all for
emergencies overnight and during weekends)
168 (28.9)
Other
§
46 (7.9)
US not available 3 (0.5)
Don't know 3 (0.5)
Total 581 (100)
Have you ever used POCUS
Yes 340 (58.5)
No 241 (41.5)
Total 581 (100)
How often do you use POCUS
||
Almost always 89 (26.2)
Most of the time 93 (27.3)
Occasionally 83 (24.4)
TABLE 2. (Continued)
Rarely 75 (22.1)
Never 0
Total 340 (100)
*Eighteen respondents reported having multiple positions.
†
Other: 2 neonatal unit, 1 gastroenterology, 2 hematology/oncology.
‡
The total of respondents is equal to the number of centers using
POCUS at the time of the survey.
§
Different local organizations with a radiologist on call for emergencies
overnight and during weekends for specific conditions such as ovarian tor-
sion, testicular torsion, and intussusception.
||
The total of respondents is equal to the number of physicians who de-
clared to use POCUS at the time of the survey.
Pediatric Emergency Care •Volume 00, Number 00, Month 2022 Use of POCUS by Pediatricians in Europe
© 2022 Wolters Kluwer Health, Inc. All rights reserved. www.pec-online.com 3
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
programs have an official POCUS curriculum. Acuna et al
18
showed that POCUS programs in pediatric EDs have succeeded
in many of the goals set forth by the 2015 American Academy
of Pediatrics policy statement to establish an official POCUS
curriculum. However, in our study, only 1.4% of the respondents
were trained as part of an official curriculum (Table 3). The gap
between North America and Europe regarding POCUS training
can be explained by the fact that education programs for pediatric
POCUS, as well as fellowships, are lacking in Europe. Among the
5 POCUS fellowship-trained physicians in our survey, all com-
pleted their POCUS fellowship in North America. In our survey,
courses were the most reported training method for clinicians to
become proficient in POCUS. These courses represented a more
practice-based training method for those physicians who did not
receive POCUS training during their residency program. Most
of the courses in Europe and Israel covered a single or small num-
ber of POCUS applications, in contrast to a POCUS fellowship
that may develop a deeper comprehension of advanced applications,
teaching methods, and administrative issues. The applications that
were most frequently learned by respondents were FAST, followed
by lung and cardiac. These results match the 3 applications most fre-
quently taught in PEM fellowship programs in Canada, as reported
by Hoeffe et al.
17
The FAST examination was noted as the most used applica-
tion in everyday practice, regardless of whether the respondent's
hospital had a trauma center. Acuna et al
18
recently showed that
FAST is the most used application by PEM fellows trained in
the United States. This correlates with earlier surveys
9,14
and
could be because the FAST examination is one of the most studied
applications of POCUS
14–16,19,20
and because FAST is mostly per-
formed and interpreted by ED physicians because of its multiple
advantages in the evaluation of injured patients.
20–22
Of note, although almost all the applications were judged as
“useful”or “very useful”in evaluating children in the ED (Fig. 2),
the reported use of certain applications was low (Fig. 1).
One possible explanation for thesegaps may be that, in many
hospitals, radiologist-performed US was available 24/7. This may
decrease the use of POCUS by physicians and decrease hospital
management endorsement for POCUS as a fundamental skill of
clinicians (Table 2). Another reason for the low use of POCUS
may be that the population we surveyed was composed mainly
of pediatricians working incountries where PEM is still not recog-
nized as a subspecialty.
10
Therefore, it is likely that these respon-
dents were not trained in the appropriate incorporation of POCUS
into everyday work in the pediatric ED.
One of the reasons that may prevent the implementation of
POCUS is the lack of sufficient literature to support the use of
POCUS by PEM physicians (Fig. 3). In the last 10 years, there
has been an increase in the literature supporting the use of POCUS
in pediatrics, and there have been a number of studies attesting to
the safety and efficiency of POCUS-guided or POCUS-assisted
procedures.
2
Although potentially a less commonly reported bar-
rier to PEM POCUS utilization, this may be an important area
for future research.
In addition, in our study, procedural and resuscitative appli-
cations were considered to have a less central role in PEM, possi-
bly because of lack of training, which deterred physicians from
using these applications.
In regard to barriers for POCUS implementation, a lack of
available time for learning was the most commonly noted in our
study. Becoming competent at performing POCUS requires that
physicians dedicate time and effort for training. This was also re-
ported as the primary barrier for not implementing POCUS in a
previous study by Moore et al.
23
A lack of qualified personnel
to adequately train clinicians was reported as the second main bar-
rier for POCUS implementation and may be related to the factthat
the majority (60.5%) of respondents indicated that they did not
know if a POCUS leader existed at their institution (Table 2).
We can speculate that the absence of such a person could hinder
the teaching of POCUS and the assimilation of it into daily
practice.
TABLE 3. POCUS Training
Respondents who had POCUS training, n (%) 359 (61.8)
Type of training, n (%)
Course 293 (81.6)
Informal bedside teaching 45 (12.5)
Teaching as a part of resident training 12 (3.4)
Fellowship training 5 (1.4)
Self-taught 3 (0.8)
Other* 1 (0.3)
Total 359 (100)
Type of course/workshop, n (%)
Pediatric emergency 158 (44.0)
Adult emergency 131 (36.5)
Pediatric and adult emergency 54 (15.0)
Other
†
16 (4.5)
Total 359 (100)
*One month point-of-care rotation during fellowship.
†
Other: 3 general US, 2 general pediatric US, 5 neonatal US, 2 regional
nerve block, 4 procedural US.
TABLE 4. Applications Taught During Courses
Respondents who had POCUS training, n (%) 359 (61.8)
Diagnostic applications, n (%)
Trauma (FAST) 274 (76.3)
Lung 215 (59.9)
Focused cardiac/echocardiography 143 (39.8)
Dehydration/shock 133 (37.0)
MSK (eg, hips, fractures, skull, forearm, elbow) 127 (35.4)
Renal 124 (34.5)
Bladder volume 118 (32.9)
Focused abdomen (eg, appendicitis, pyloric stenosis) 105 (29.2)
RUSH 101 (28.1)
Soft tissue 96 (26.7)
Cardiac arrest 88 (24.5)
Neonatal transfontanelle/cranial 88 (24.5)
Ocular 68 (18.9)
Vascular (eg, DVT) 50 (13.9)
Ocular trauma 30 (8.3)
Pregnancy 22 (6.1)
Procedural applications, n (%)
Vascular access, peripheral line 124 (34.5)
Vascular access, central line 96 (26.7)
Regional anesthesia/nerve block 38 (10.6)
Other*, n (%) 10 (2.8)
DVT indicates deep vein thrombosis; MSK, musculoskeletal; RUSH,
rapid US in shock.
*Other: 5 neonatal hips, 1 thyroid, 4 missing.
Parri et al Pediatric Emergency Care •Volume 00, Number 00, Month 2022
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Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Previous literature has shown that the primary barrier
for POCUS learning in both the United States and Canada
identified a lack of trained faculty,
17,18
despite the fact that
POCUS-trained faculty or POCUS program existence is much
more widespread in the United States compared with Europe or
Israel. One potential solution could be the creation of POCUS
fellowship within centers, which have established POCUS
leaders.
Our survey has several limitations. First, we cannot estimate
the response rate to our survey, which makes interpretation of our
FIGURE 1. Reported frequency of use of the most relevant pediatric POCUS applications. The frequency of use was calculated among 58.5%
(340 of 581) of respondents reported using POCUS. DVT, deep vein thrombosis; IVC, inferior vena cava; MSK, musculoskeletal; RUSH, rapid
US in shock and hypotension.
FIGURE 2. Utility of all the POCUS diagnostic, procedural, and resuscitative applications in evaluating children in the ED. DVT, deep vein
thrombosis; ETT, endotracheal tube; IVC, inferior vena cava; MSK, musculoskeletal; RUSH, rapid US in shock and hypotension.
Pediatric Emergency Care •Volume 00, Number 00, Month 2022 Use of POCUS by Pediatricians in Europe
© 2022 Wolters Kluwer Health, Inc. All rights reserved. www.pec-online.com 5
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
study results difficult. The approach we used to disseminate the
survey,
12
even though validated by previous research, does not al-
low calculation of the total number reached, and this may lead
to bias.
Despite this limitation, we felt that this approach was the
most feasible way to answer our main question regarding the dis-
semination of POCUS among pediatricians in Europe and Israel.
The lack of a large and structured European PEM network mirrors
the lack of recognition of PEM as a formal subspecialty in most
European countries.
10
Second, we did not receive responses from all of the European
countries, and the number of responses within nations was not
balanced. As a result, this may have led to a selection bias. Conse-
quently, our data might not reflect the true state of POCUS use in
pediatric EDs in Europe, especially in nations such as the United
Kingdom, where PEM and POCUS are already well accepted. For
example, we had a preponderance of responses from Italy. One of
the reasons may be that POCUS in Italy is well established and its
use in adult emergency medicine is well documented.
Our respondents reflect the state of POCUS dissemination
in a group of PEM centers across Europe and centers connected
by the EUSEM and REPEM. It may be argued that our survey
represented a group of physicians more enthusiastic about POCUS,
and thus, the survey could potentially be biased in this regard.
If a selection bias was introduced, it is potentially an overesti-
mation rather than underestimation of the dissemination and
use of POCUS among pediatricians working in EDs in Europe
and Israel.
Third, our survey was targeted at attending physicians and
did not include trainees or residents in pediatrics or PEM. We
admit the possibility that this could have further underrepre-
sented the population of POCUS users, considering that trainees
may be more likely to learn POCUS and be more interested
in technology. On the other hand, considering the limited lit-
erature available as to the extent of accreditation and quality
of POCUS training within the pediatric community, our goal
was to have a snapshot of POCUS users who are already trained
in pediatrics or PEM and who are currently working in the coun-
tries surveyed.
In conclusion, our work provides data on a wide sample of
European and Israeli EDs and physicians, and demonstrates that
the use of POCUS in PEDs is low, compared with PEM POCUS
dissemination in North America, which is likely due to the lack of
POCUS leaders and structured training programs. In contrast, the
potential value of POCUS is recognized by most of the respon-
dents. The development of POCUS fellowships, as well as a com-
mon POCUS core cur riculum to train pediatricians, could help de-
velop and spread the use of POCUS in Europe and Israel. A
follow-up study may provide insight into the evolution of POCUS
in European and Israeli pediatric EDs.
TABLE 5. Impact of POCUS on Clinical Practice and Patient Management
Strongly Agree,
n(%)
Agree,
n(%)
Indifferent,
n(%)
Disagree,
n(%)
Strongly Disagree,
n(%)
POCUS increases length of stay in the ED 17 (2.9) 69 (11.9) 69 (11.9) 222 (38.2) 204 (35.1)
POCUS decreases length of stay in the ED 190 (32.7) 220 (37.9) 101 (17.4) 55 (9.4) 15 (2.6)
POCUS makes me a safer doctor 141 (24.27) 288 (49.57) 130 (22.38) 22 (3.79) 0
POCUS helps me make more accurate diagnoses 198 (34.1) 297 (51.1) 77 (13.2) 8 (1.4) 1 (0.2)
POCUS narrows differential diagnoses and expedites care 183 (31.5) 320 (55.1) 64 (11.0) 14 (2.4) 0
POCUS increases the use of further investigations 49 (8.4) 140 (24.1) 106 (18.2) 229 (39.4) 57 (9.9)
POCUS decreases the use of x-rays and CT 153 (26.3) 294 (50.6) 80 (13.8) 54 (9.3) 0
POCUS improves overall patient care 178 (30.6) 345 (59.4) 43 (7.4) 15 (2.6) 0
POCUS helps reduce overall costs 123 (21.2) 270 (46.5) 126 (21.7) 2 (0.3)
In bold font, we highlighted the highest percentages of respondents combined into 3 meaningful groups (strongly agree/agree, indifferent, and disagree/
strongly disagree).
CT indicates computed tomography.
FIGURE 3. Barriers and limitations to the implementation of POCUS.
Parri et al Pediatric Emergency Care •Volume 00, Number 00, Month 2022
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Pediatric Emergency Care •Volume 00, Number 00, Month 2022 Use of POCUS by Pediatricians in Europe
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