Improving point-of-care ultrasound documentation among emergency medicine residents: a mixed-method implementation research study.

Abstract

Objective: To evaluate the effectiveness of a theory-informed, iterative implementation strategy (IS) to improve point-of-care ultrasound (POCUS) documentation compliance among emergency medicine (EM) residents according to American College of Emergency Physicians (ACEP) guidelines in a high-volume emergency department (ED).

Methods: We conducted a 19-month (December 2023-June 2025) mixed-methods implementation study at a tertiary academic ED in India. The Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change guided six iterative IS phases, including education, co-design, workflow optimisation and audit/feedback. Participants were EM residents. The primary outcome was the proportion of POCUS examinations achieving ≥80% compliance with ACEP documentation standards. Compliance trends were analysed across phases and summarised using proportions and medians with IQRs. Qualitative data from five focus group discussions were analysed using CFIR to identify barriers, facilitators and mechanisms of change. Quantitative and qualitative findings were integrated using a joint display.

Results: We assessed 3074 POCUS examinations. The proportion of scans achieving ≥80% compliance increased from 0% at baseline to 35.1% postimplementation. Median compliance rose from 24% (IQR 17-34) to 69% (IQR 54-84). Compliance followed a nonlinear trajectory. Initial phases showed minimal gains (0%-8.7%) due to workflow barriers. A marked acceleration occurred during IS-5 (22.5%) following the introduction of a user-designed, single multimodal form and gamification. Qualitative analysis demonstrated a shift from initial resistance (CFIR: compatibility, complexity) to normalisation (implementation climate), although technical challenges with image archiving persisted.

Discussion: User-centred co-design and peer engagement were key to the improvement, although persistent infrastructure challenges limited further gains and highlighted the need for informatics-enabled solutions. This study demonstrates that low-cost, context-sensitive strategies can enhance POCUS documentation effectively in high-volume, resource-constrained EDs.

Conclusions: A multifaceted, iterative IS guided by theoretical frameworks significantly improved POCUS documentation compliance. User-centred design and participatory engagement were critical mechanisms for sustainable practice change in a resource-variable EM setting.

Trial registration number: CTRI/2024/03/063671.