Ultrasound in primary care: Consensus recommendations on its applications and training. Results of a 3-round Delphi study

Figures & data

Figure 1. Process flowchart. ¹General Group, 65 family physicians from the ultrasound group of the Catalan Society of Family and Community Medicine who daily perform ultrasound in their clinical practice; ²Core group, 15 family physicians expert in the use of ultrasound, also belonging to the exploratory round group; ³6 members of the core group and 6 radiologists who daily perform ultrasound.

Table 1. Main applications of ultrasound in primary care.

Abdomen: includes liver, gallbladder and bile ducts, spleen, pancreas, large abdominal vessels, kidneys, bladder, gynaecological/obstetric, prostate and scrotal study

Neck: includes thyroid and parathyroid, major salivary glands (submaxillary and parotid), upper airway, vascular bundles and cervical ganglion chains

Musculoskeletal: includes joint, tendon, muscle and bursa assessment, specific for one of the main joints in primary care: shoulder, elbow, wrist, hip, knee, ankle

Soft parts: dermis and epidermis, subcutaneous fatty tissue

Cardiac: evaluation of heart rate, significant dilation of cavities, global contractility, ejection fraction, pericardial effusion, detection of severe valve disease

Thorax: includes chest wall, pleural pathology (pneumothorax, pleural effusion …), pulmonary pathology with interstitial or alveolar (peripheral) involvement and diaphragmatic assessment

Vascular: includes large vessels, supra-aortic trunks, limb veins…

Applications of ultrasound that were approved by consensus after the 3 rounds (‘Procedures with ultrasound’) was accepted by consensus.

Table 2. Indications of ultrasound in Primary Care according to reason of consultation, within the different areas of knowledge and competencies.

	Reason for consultation	Main pathologies to be assessed or discarded
Abdomen  [10] Frasure et al. 2020. USA  [11] Esquerrà et al. 2012. Spain  [12] Lindgaard et al. 2017. Denmark  [13] Speets et al. 2006. Netherlands  [14] Sisó-Almirall et al. 2017. Spain	Abdominal pain	Cholelithiasis and cholecystitis Nephritic lithiasic colic and hydronephrosis screening Pancreatitis Appendicitis Gestation (verification of intrauterine gestation, verification of foetal position before imminent delivery), rule out associated complications (ectopic, multiple, retroplacental haematoma, absence of foetal heartbeat in advanced gestation …) Aortic dissection
	Voiding syndrome and/or haematuria	Nephritic lithiasic colic and hydronephrosis screening Increased prostate volume and post-voiding residue Urinary retention Bladder tumour Urinary tract malformation in patients with repeated urinary tract infections
	Palpable abdominal mass	Hepatomegaly and/or splenomegaly Abdominal aortic aneurysm Ultrasound confirmation of abdominal mass to study and associated complications (adenopathy, abdominal free fluid, liver lesions …)
	Scrotal mass	Varicocele Hydrocele Cystic injury with no warning signs Ultrasound confirmation of solid mass and associated complications
Neck [15] Tarrazo et al. 2019. Spain	Goitre or thyroid disturbance	Thyroid hyperplasia Thyroid nodule and ultrasound classification of palpable nodules Study of nodule in salivary gland Adenopathy
Musculoskeletal [16] Sánchez et al. 2018. Spain [17] Sánchez et al. 2019. Spain	Joint pain	Tenosynovitis, tendinosis, and calcifications Tendon or muscle rupture Joint effusion Bursitis
Soft parts [18] Gottlieb et al. 2020. USA	Nodule or palpable surface mass	Lipoma Adenopathy Abscesses and subcutaneous cysts Abdominal wall hernia
Vascular  [19] Grau et al. 2013. Spain  [20] Needleman et al. 2018. USA	High cardiovascular risk	Determination of carotid intima media thickness Presence of atheroma plaques and impact on carotid flow
	Oedema of the lower extremities	Chronic venous insufficiency Deep vein thrombosis Decompensation of heart failure
Thorax [21] Diaz et al. 2019. Spain [22] Conangla et al. 2020. Spain [23] Evangelista et al. 2016. Spain	Dyspnoea Pleuritic pain	Interstitial involvement of different causes (interstitial pneumonia, diffuse interstitial lung disease…), especially heart failure Pneumonic pulmonary condensation Structural heart disease (combine with high cardiovascular risk study) Pleural effusion Pneumothorax
Emergencies  [24] Stengel et al. 2015. Germany	Shock/cardiac arrest	Multiorgan aetiological study Specific protocols: RUSH^1, SESAME^2, CAUSE^3, FATE^4
	Polytrauma	Free abdominal and thoracic fluid Specific protocols: FAST^5, eFAST^6
	Dyspnoea	Acute respiratory failure Specific protocol: BLUE^7
Eco-guided procedures [17] Sánchez et al. 2019. Spain [25] Huang et al. 2015. China	Need of ultrasound guidance for procedure	Drainage of cysts, abscesses, and bruises Channelling of venous or arterial routes Joint and peri-articular punctures Orotracheal intubation Cricothyroidotomy Thoracentesis and paracentesis Lumbar puncture Suprapubic probing

Table 3. Progressive plan for training in ultrasound in Primary Care.

Level of competence	Concepts and learning method	Assessment and skills
A	Basic physical principles Basic principles of ultrasound and general notions of using the ultrasound scanner. Both concepts can be studied in a theoretical framework (for example, a virtual environment). It includes management of the ultrasound apparatus, as well as basic concepts of image optimisation (definition and concept of the different ultrasound artefacts and how to interpret or minimise them), and the understanding and management of the different modes of examination (B, M, colour Doppler, pulsed Doppler). Must be accredited by theoretical examination (e.g. multiple choice answer type)	Basic physical principles of ultrasound General use of an ultrasound device, including the different modes and basic buttons
B	Normal ultrasound anatomy The support can be in the format of images or videos and face-to-face training is not necessary. It includes ultrasound indications, patient preparation, image optimisation concepts and scanning systematics, as well as the interpretation of normal anatomy images. It must be accredited by means of a theoretical examination that includes the interpretation of images or videos of normal anatomy (both anatomical schemes and ultrasound images)	Normal anatomy of the exploration area Preparation (of the patient) needed to carry out the ultrasound examination of the area
C	Normal ultrasound anatomy It requires face-to-face training through practices in healthy model or simulation model. Special emphasis on image optimisation, scanning systematics, interpretation of normal images and recording and reporting of ultrasound. It must be accredited by practical exam in healthy model or simulation (it is advisable to define and use a checklist of skills)	Perform a systematic ultrasound examination, identifying the different anatomical structures under normal conditions
D	Pathological ultrasound Support may be in image or video format. Special emphasis on the interpretation of the images, recording and documentation of the ultrasound (report with description of the findings), possible diagnostic orientation and clinical decision according to this diagnostic orientation. It must be accredited by means of a theoretical examination that includes the interpretation of pathological images or videos, or by means of a practical examination with a medical simulation mannequin that permits the pathology to be simulated	Possible pathology that affects the exploration area Description of pathological images
E	Ultrasound in conditions of real clinical practice This requires training in real patients, referred for clinical reasons, establishing a concordance between the learner and the tutor. It may be accredited by demonstrating a good agreement with the tutor (not less than 0.7) by direct practical examination or by presenting a portfolio of ultrasounds performed, in the format of clinical cases with the videos recorded and the written reports	Practical skills under conditions of routine clinical practice

Table 4. Minimum number of hours needed to qualify for accreditation of each level of competence.

	A	B	C	D	E
Abdomen	5	25	50	20	50
Neck		8	10	10	25
Musculoskeletal (one joint)		8	10	10	25
Soft parts		8	10	15	25
Chest (cardiac or pulmonary)		8	10	15	25
Vascular		8	10	10	25

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