Hostname: page-component-77c89778f8-9q27g Total loading time: 0 Render date: 2024-07-17T17:28:32.688Z Has data issue: false hasContentIssue false

Recommendations for the use of point-of-care ultrasound (POCUS) by emergency physicians in Canada

Published online by Cambridge University Press:  19 August 2019

David Lewis*
Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, NB
Louise Rang
Department of Emergency Medicine, Queen’s University, Kingston, ON
Daniel Kim
Department of Emergency Medicine, University of British Columbia, Vancouver, BC
Laurie Robichaud
Department of Emergency Medicine, McGill University, Montreal, QC
Charisse Kwan
Hospital for Sick Children, Toronto, ON
Chau Pham
University of Manitoba, Winnipeg, MB
Allan Shefrin
Children's Hospital of Eastern Ontario, Ottawa, ON
Brandon Ritcey
Department of Emergency Medicine, University of Ottawa, Ottawa, WE
Paul Atkinson
Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, NB
Michael Woo
Department of Emergency Medicine, University of Ottawa, Ottawa, WE
Tomislav Jelic
Department of Emergency Medicine, University of Manitoba, Winnipeg, MB
Genevieve Dallaire
Hôpital du Haut-Richelieu, Université de Sherbrooke, Quebec
Ryan Henneberry
Department of Emergency Medicine, Dalhousie University, Halifax, NS
Joel Turner
Emergency Medicine Department, Jewish General Hospital, Montreal QC, Canada
Rafiq Andani
Prairie Mountain Health, Swan River, Manitoba
Roisin Demsey
Claresholm Hospital, University of Alberta
Paul Olszynski
Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK
Correspondence to: Dr. David Lewis, Department of Emergency Medicine, 400 University Ave., Saint John Regional Hospital, Saint John, NB E2L 4L4; Email:


CAEP Position Statement
Copyright © Canadian Association of Emergency Physicians 2019 



The Canadian Association of Emergency Physicians (CAEP) recognizes the role of point-of-care ultrasound (POCUS) as a valuable adjunct to the delivery of excellent emergency care. With this document, the CAEP Emergency Ultrasound Committee (EUC) updates the previous CAEP POCUS position statementReference Henneberry, Hanson and Healey1 and provides an expanded framework and series of recommendations, based on the current evidence, to guide emergency departments (ED) and their POCUS programs in the delivery of high quality patient care. Evaluating and summarizing the evidence for the use of POCUS is challenging because, unlike other diagnostic tests where research is primarily focused on test performance, the value of POCUS is further scrutinized in terms of patient-oriented outcomes and system performance measures, such as time to diagnosis or length of stay. Add to this the operator-dependent nature of POCUS, and, not surprisingly, the application of POCUS literature becomes understandably complex.

The recommendations reflect the authors’ synthesis of a combination of test performance metrics, patient-oriented outcomes, and system performance measures (when available). To date, there is still a paucity of prospective POCUS research focused on patient-oriented outcomes, but the authors do believe there is sufficient evidence in the current literature to support the recommendations within this document.


The following summary of recommendations is expanded with detailed discussion in the full online version of this position statement.

Scope of practice

The role of POCUS in the practice of emergency medicine (EM) in Canada continues to evolve. The current evidence supports the integration of several potentially life-saving POCUS applications as core skills of the specialty. This list mirrors that of the CAEP EUC's recommended EM Residency emergency ultrasound curriculum.Reference Olszynski, Kim, Chenkin and Rang2

  • Focused assessment with sonography for trauma (FAST includes abdominal and thoracic applications.)

  • Identification of abdominal aortic aneurysm (AAA)

  • Identification of first trimester intrauterine pregnancy (IUP)

  • Thoracic ultrasound (including identification of pneumothorax, hemothorax, pleural effusion, and interstitial lung syndrome)

  • Focused cardiac ultrasound (including assessment of global cardiac activity, gross left ventricular systolic function, right ventricular size, presence of pericardial effusion, and inferior vena cava calibre)

  • Ultrasound-guided vascular access (including peripheral and central vascular access)

This document adopts the evolving approach of collating applications into the following groups: resuscitative, diagnostic, procedural, and therapeutic/monitoring (Table 1; also see Appendix 1). In addition, a clinical, presentation-based approach is recommended where selected applications are combined, to differentiate a diagnosis.

Table 1. POCUS scope of practice in emergency medicine

Training and competency

Training in POCUS should incorporate a significant amount of experience scanning patients in a clinical setting. Such experience may be supplemented by scanning workshops or training sessions that involve volunteers or POCUS simulation. The key features of this learning phase relate to optimizing the physician's skills in generating optimal images, interpreting the images, and incorporating the images into clinical decision-making.

Recommending methods of training and assessing proficiency in POCUS continue to stimulate debate. The CAEP EUC has published, in collaboration with EM training programs, a series of core POCUS objectives for EM residents and recommends that moving forward, completion of residency provides evidence of competency in these applications.Reference Olszynski, Kim, Chenkin and Rang2 For physicians who did not receive POCUS training during residency, the CAEP EUC recommends that the following three components of training be considered essential when appraising a physician's POCUS credentials and determining corresponding privileges:

  1. 1. Clearly defined introduction to the POCUS skill

  2. 2. Traineeship with supervision that may include scanning in both the clinical and non-clinical setting. This training phase should maximize exposure to both normal and abnormal findings and should include exposure to a representative sample of model/patient body habitus.

  3. 3. A summative assessment of knowledge (including clinical integration and comprehension assessments) and an image generation assessment that includes an observed practical exam

Training for invasive POCUS applications, for example, transvaginal, transesophageal echocardiography, and procedural POCUS, may require a greater reliance on simulation. Incorporating simulation into the training for these applications has been shown to be effective and beneficial.Reference Kneebone, Scott, Darzi and Horrocks3Reference Fair, Mallin and Mallemat5

Increasingly, non-physician healthcare providers are using POCUS to enhance their clinical practice. Encouraging evidence exists for both emergency medical services (EMS)/prehospital applicationsReference Brun, Bessereau and Levy6Reference McCallum, Vu, Sweet and Kanji15 and applications used by nurses.Reference Bahl, Pandurangadu, Tucker and Bagan16,Reference Crager, Cinkowski and Gharahbaghian17 It is recommended that POCUS training of these clinicians should include the three components described previously, albeit via a tailored pathway that reflects context and scope of practice.

A growing number of Canadian medical schools have incorporated POCUS into their undergraduate medical education.Reference Steinmetz, Dobrescu, Oleskevich and Lewis18 There is evidence that this can enhance student knowledge and learning of traditional examination skills and also increase student satisfaction.Reference Olszynski, Anderson, Trinder and Domes19 Emergency physicians are well placed and encouraged to facilitate and provide leadership in these programs.

POCUS fellowships are well established in Canada (, and The Royal College of Physicians and Surgeons of Canada (RCPSC) has recently approved an Area of Focused Competence Diploma.20 Emerging EM POCUS leaders are encouraged to use these programs.

Physicians are expected to keep current with evidence and advances in POCUS practice throughout their careers and are supported by the Canadian colleges in their continuing professional development (CPD) and lifelong learning goals.

Emergency POCUS program management

Emergency POCUS program management includes components of program leadership, monitoring and quality assessment recommendations, as well as machine choice and maintenance. Recommendations are provided to assist EDs in developing POCUS leaders and to help those leaders develop expertise and establish robust programs that will enhance patient care.

All EDs with POCUS equipment should have a named physician (POCUS Lead) designated and responsible for development and maintenance of the emergency POCUS program. In smaller and rural hospitals, this role may be assumed by those with other quality improvement responsibilities (see Appendix 5 for Rural EM recommendations). Academic centres and larger EDs should have a POCUS Program Director. Recommended responsibilities for these positions are detailed in the full document and may include administration, education of trainees and staff, quality, and research. EM POCUS leaders are expected to have completed additional POCUS training and, in academic centres, have completed POCUS fellowships or the equivalent.Reference Olszynski, Kim, Chenkin and Rang2 Regional POCUS leadership is recommended, with regional academic centres and their associated geographically located smaller EDs collaborating with respect to program management.

POCUS program quality is not only dependent on robust training and competency, but also documentation standards, image archiving (where applicable), and defined quality management process. Recommendations for these are detailed in the full document. Many larger and academic EDs in Canada are archiving images and clips for every examination performed. This is considered best practice and strongly recommended. A local POCUS quality program is the responsibility of the POCUS Lead (with the appropriate support and resources) and will include ongoing review, support, education, and development.

A POCUS program requires resources, including physician time and administrative support. Departments are expected to balance the competing demands placed on resource allocation in order to support successful program delivery. Many larger academic centres will already have implemented much of these mentioned. Others will have EM quality programs in place that could be expanded to include POCUS quality. Smaller hospitals will have to consider which of the previous recommendations are achievable locally and what support is available regionally, for example, regional archiving, regional POCUS education, and competency development.

An ultrasound machine must be immediately available to an attending emergency physician in the ED at all times. The CAEP EUC recommends that EDs should have a minimum of at least one machine for every distinct clinical area and strongly consider the provision of one ultrasound machine for every attending emergency physician on shift. Recommended ultrasound machine specifications are detailed in the full document.

Programs should have a clear policy for infection control, that includes machine hygiene (including keyboard, controls, screen, and cart) and the transducers.2126

Pediatric emergency POCUS

Pediatric emergency medicine (PEM) has embraced the potential of POCUS to improve care for their patients.Reference Vieira, Hsu and Nagler27 Recommended core POCUS competencies for PEM physicians include eFAST, Focused Cardiac, Thoracic, IUP, Soft Tissue, and Vascular Access. Although clinical indications and use of POCUS in adults and children overlap greatly, our recommendations consider the important differences existing between the two populations. These are detailed in the full document and include resuscitation, lung, neck, ocular, renal/bladder, skull fracture, abdomen, testes, hip and fractures.

Training and competency assessment for PEM POCUS applications follows the same recommendations as those outlined in the previous section on training and competency.

Emergency POCUS research

The CAEP EUC would not be able to make these recommendations without the body of evidence provided by quality POCUS research. With a greater focus on outcome-centred research, researchers will need to establish networks to design and run the large-scale multi-centre studies required to answer these important patient outcome questions that remain unanswered.Reference Lewiss, Chan and Sheng28


Table 2 shows the recommendation categories and themes. The complete list of recommendations is detailed in the full online document.

Table 2. Summary of recommendation categories and highlighted themes


These recommendations are intended to provide both motivation and support while being adopted by Canadian EDs. It is anticipated that the rate and completeness of adoption will vary depending on department size, leadership, and resources. The CAEP EUC will continue to provide leadership and support towards improving EM POCUS standards and will complete and publish an annual survey to measure adoption of the recommendations.


The future of POCUS in EM will be influenced by patient outcomes, research, medical school curricula, and technological advances. Local and national leadership is needed to ensure that future generations of emergency physicians will integrate POCUS seamlessly as part of their everyday practice to the benefit of their patients.

Supplementary material

The supplementary material for this article can be found at

Competing interests

None declared.



1.Henneberry, RJ, Hanson, A, Healey, A, et al. Use of point of care sonography by emergency physicians. Can J Emerg Med 2012;14(2):106–12.Google Scholar
2.Olszynski, P, Kim, D, Chenkin, J, Rang, L. The core emergency ultrasound curriculum project: a report from the Curriculum Working Group of the CAEP Emergency Ultrasound Committee. CJEM 2018;20(2):176–82.10.1017/cem.2017.44Google Scholar
3.Kneebone, RL, Scott, W, Darzi, A, Horrocks, M. Simulation and clinical practice: strengthening the relationship. Med Educ 2004;38(10):1095–102.Google Scholar
4.Arntfield, R, Pace, J, McLeod, S, et al. Focused transesophageal echocardiography for emergency physicians-description and results from simulation training of a structured four-view examination. Crit Ultrasound J 2015;7(1):27.Google Scholar
5.Fair, J, Mallin, M, Mallemat, H, et al. Transesophageal echocardiography: guidelines for point-of-care applications in cardiac arrest resuscitation. Ann Emerg Med 2018;71(2):201–7.Google Scholar
6.Brun, P-M, Bessereau, J, Levy, D, et al. Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma. Am J Emerg Med 2014;32(7):817.e12.10.1016/j.ajem.2013.12.063Google Scholar
7.Bleeg, RC. Ultrasound in the Royal Danish Air Force search and rescue helicopter: 2 case reports. Air Med J 2017;36(3):138–9.Google Scholar
8.Nelson, BP, Melnick, ER, Li, J. Portable ultrasound for remote environments, part I: feasibility of field deployment. J Emerg Med 2011;40(2):190–7.Google Scholar
9.Nelson, BP, Melnick, ER, Li, J. Portable ultrasound for remote environments, part II: current indications. J Emerg Med 2011;40(3):313–21.10.1016/j.jemermed.2009.11.028Google Scholar
10.Rudolph, SS, Sørensen, MK, Svane, C, Hesselfeldt, R, Steinmetz, J. Effect of prehospital ultrasound on clinical outcomes of non-trauma patients – a systematic review. Resuscitation 2014;85(1):2130.Google Scholar
11.Steiger, HV, Rimbach, K, Müller, E, Breitkreutz, R. Focused emergency echocardiography: lifesaving tool for a 14-year-old girl suffering out-of-hospital pulseless electrical activity arrest because of cardiac tamponade. Eur J Emerg Med 2009;16(2):103–5.Google Scholar
12.O'Dochartaigh, D, Douma, M. Prehospital ultrasound of the abdomen and thorax changes trauma patient management: a systematic review. Injury 2015;46(11):2093–102.10.1016/j.injury.2015.07.007Google Scholar
13.O'Dochartaigh, D, Douma, M, MacKenzie, M. Five-year retrospective review of physician and non-physician performed ultrasound in a Canadian critical care helicopter emergency medical service. Prehosp Emerg Care 2017;21(1):2431.10.1080/10903127.2016.1204036Google Scholar
14.O'Dochartaigh, D, Douma, M, Alexiu, C, Ryan, S, MacKenzie, M. Utilization criteria for prehospital ultrasound in a Canadian critical care helicopter emergency medical service: determining who might benefit. Prehosp Disaster Med 2017;32(5):536–40.10.1017/S1049023X1700646XGoogle Scholar
15.McCallum, J, Vu, E, Sweet, D, Kanji, HD. Assessment of paramedic ultrasound curricula: a systematic review. Air Med J 2015;34(6):360–8.Google Scholar
16.Bahl, A, Pandurangadu, AV, Tucker, J, Bagan, M. A randomized controlled trial assessing the use of ultrasound for nurse-performed IV placement in difficult access ED patients. Am J Emerg Med 2016;34(10):1950–4.Google Scholar
17.Crager, S, Cinkowski, C, Gharahbaghian, L. Training nurses to assess fluid status using point-of-care ultrasound. Crit Care Med 2018;46(1):178.Google Scholar
18.Steinmetz, P, Dobrescu, O, Oleskevich, S, Lewis, J. Bedside ultrasound education in Canadian medical schools: a national survey. Can Med Educ J 2016;7(1):e7886.Google Scholar
19.Olszynski, P, Anderson, J, Trinder, K, Domes, T. Point-of-care ultrasound in undergraduate urology education: a prospective control-intervention study. J Ultrasound Med; 2018. Available at: (accessed May 13, 2018).Google Scholar
20.The Royal College of Physicians and Surgeons of Canada. Discipline recognition: Areas of Focused Competence (AFC) programs; 2018. Available at: (accessed May 13, 2018).Google Scholar
21.College of Physicians and Surgeons of British Columbia. Reprocessing requirements for ultrasound probes; 2017. Available at: (accessed May 13, 2018).Google Scholar
22.Basseal, JM, Westerway, SC, Juraja, M, et al. Guidelines for reprocessing ultrasound transducers. Australas J Ultrasound Med 2017;20(1):3040.Google Scholar
23.American Institute of Ultrasound in Medicine. Guidelines for cleaning and preparing external- and internal-use ultrasound probes between patients, safe handling, and use of ultrasound coupling gel; 2018. Available at: (accessed May 13, 2018).Google Scholar
24.Ontario Agency for Health Protection and Promotion (Public Health Ontario) PIDAC. Infection prevention and control for clinical office practice. 1st Revision. Toronto, ON: Queen's Printer for Ontario; 2015. Available at: (accessed May 13, 2018).Google Scholar
25.Sonography Canada. Professional practice guidelines and policy statements for Canadian sonography; 2014. Available at: Eng Rev 03Feb2017 final/pdf/1/1033 (accessed May 13, 2018).Google Scholar
26.Ontario Agency for Health Protection and Promotion (Public Health Ontario). Provincial Infectious Diseases Advisory Committee. Best practices for cleaning, disinfection and sterilization of medical equipment/devices. 3rd ed. Toronto, ON: Queen's Printer for Ontario; 2013. Available at: (accessed May 13, 2018).Google Scholar
27.Vieira, RL, Hsu, D, Nagler, J, et al. Pediatric emergency medicine fellow training in ultrasound: consensus educational guidelines. Acad Emerg Med 2013;20(3):300–6.Google Scholar
28.Lewiss, RE, Chan, W, Sheng, AY, et al. Research priorities in the utilization and interpretation of diagnostic imaging: education, assessment, and competency. Acad Emerg Med 2015;22(12):1447–54.Google Scholar
Figure 0

Table 1. POCUS scope of practice in emergency medicine

Figure 1

Table 2. Summary of recommendation categories and highlighted themes

Supplementary material: PDF

Lewis et al. supplementary material

CAEP PoCUS Position Statement 2019 Full text
Download Lewis et al. supplementary material(PDF)
PDF 334.4 KB
Supplementary material: PDF

Lewis et al. supplementary material

CAEP PoCUS Position Statement - 2019 - Appendices
Download Lewis et al. supplementary material(PDF)
PDF 266.1 KB
Supplementary material: PDF

Lewis et al. supplementary material

DE´CLARATION DE L’ACMU - E´DU - 2019 - Annexes
Download Lewis et al. supplementary material(PDF)
PDF 295.2 KB
Supplementary material: PDF

Lewis et al. supplementary material

DE´CLARATION DE L’ACMU - E´DU - 2019 - Sommaire
Download Lewis et al. supplementary material(PDF)
PDF 194.8 KB
Supplementary material: PDF

Lewis et al. supplementary material

Download Lewis et al. supplementary material(PDF)
PDF 434.5 KB