Potential for Use of Portable Ultrasound Devices in Rural and Remote Settings in Australia and Other Developed Countries: A Systematic Review

Figures & data

Table 1 Embase via Ovid Search (Last Performed October 2021)

Search	Keywords	Records
S1	Exp ultrasound/	200,456
S2	Ultraso*.mp.	678,821
S3	S1 or S2	678,821
S4	Sonogr*.mp.	84,038
S5	S3 or S4	716,489
S6	Rural.mp.	212,517
S7	Resource.mp.	247,299
S8	S6 or S7	451,759
S9	S5 and S8	4505
S10	Access*.mp.	798,212
S11	Avail*.mp.	1,792,438
S12	S10 or S11	2,476,007
S13	S9 and S12	1275
S14	Portablemp.	43,939
S15	Handheld.mp.	9518
S16	Pocket.mp.	60,874
S17	Mobile.mp.	159,607
S18	Point-of-care.mp. or “point of care ultrasound”/	39,146
S19	S14 or S15 or S16 or S17 or S18	304,283
S20	S13 and S19	270
S21	Limit S20 to (human and English language and yr=“2010 -Current”)	247

Note: *Truncation symbol for this search and will search all words with the preceding letters .mp. indicates a multi-purpose search across all fields.

Table 2 Inclusion and Exclusion Criteria Used in This Systematic Review

Inclusion Criteria	Exclusion Criteria
• Point-of-care ultrasound used • Mobile ultrasound device used • Rural location • Low-resource setting • Study type  - randomised control trial  - cohort study  - case controlled  - cross-sectional	• Pre-2010 • non-English language • non-human • No outcome measures • Not rural • Not portable US • Niche or irrelevant to Australian experience • Study type  - case studies  - not peer reviewed  - report, opinion piece or editorial  - surveys  - reviews

Table 3 Risk of Bias Quality Assessment of Studies Included in This View, According to the Cochrane RoB2 Criteria.²⁸

Study Author and Year	Assessment Criteria
	Sequence Generation	Allocation Concealment	Blinding of Participants and Personnel	Blinding of Outcome Assessment	Incomplete Outcome Data	Selective Reporting	Other Sources of Bias
Amatya et al. 2018^Citation43	High	High	Unsure	Low	Unsure	Unsure	High
Baker et al. 2021^Citation46	High	High	High	High	Low	High	High
Beaton et al. 2014^Citation34	High	Low	Low	Low	Low	Low	High
Beaton et al. 2015^Citation35	Low	Low	High	Low	Low	Low	High
Bhavnani et al. 2018^Citation40	Low	Low	High	Low	Low	Low	High
Blois 2012^Citation33	High	High	High	High	Low	Low	High
Chavez et al. 2015^Citation41	High	High	Low	Low	Low	Low	High
Dalmacion et al. 2018^Citation42	Low	High	High	High	Low	High	Low
Godown et al. 2015^Citation36	Low	Low	High	Low	Low	High	High
Ketelaars et al. 2013^Citation29	High	High	High	High	High	High	High
Kissoon et al. 2020^Citation44	High	High	High	High	Low	Low	High
Lu et al. 2015^Citation37	Low	High	High	Low	Low	Low	High
Nixon et al. 2018^Citation7	High	High	High	High	Unsure	Unsure	High
Nixon et al. 2018^Citation32	High	High	High	Low	High	Unsure	High
Ploutz et al. 2016^Citation30	High	Low	High	Low	Low	Low	High
Pontet et al. 2019^Citation31	Low	Low	Unsure	High	Low	Low	High
Prager et al. 2018^Citation47	High	High	High	High	Unsure	Unsure	High
Reynolds et al. 2018^Citation45	High	High	High	High	Low	Low	High
Roberts et al. 2014^Citation38	High	High	High	Low	Low	Low	High
Singh et al. 2013^Citation39	High	High	High	Low	Unsure	Unsure	High
Smith et al. 2010^Citation6	High	High	High	High	Low	Low	High
Umuhire et al. 2019^Citation48	High	High	High	High	Low	Low	High
Zanatta et al. 2015^Citation49	High	High	High	High	Unsure	Unsure	Unsure

Figure 1 PRISMA flow diagram showing the process used and records included and excluded at the various stages of this systematic review.

Notes: Adapted from Page MJ, McKenzie JE, Bossuyt PM et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372: n71. Creative Commons license and disclaimer available from: http://creativecommons.org/licenses/by/4.0/legalcode²⁶.

Table 4 Summary of the Characteristics of the Studies Included in This Systematic Review Following Data Extraction

Author (s); Journal; Year; Country	Study Types and Relevant Aims	Population; Sample	Method; Equipment; Provider Training	Results
Amatya et al; Int J Emerg Med; 2018; Nepal^Citation43	Prospective cross-sectional study: ● Evaluate POCUS sensitivity for dx of pneumonia compared with CXR; ● Assess reliability of clinicians’ image interpretation.	● Patients suspected of pneumonia attending ED at Patan Hospital; ● Convenience sample of 62 pts, 44 diagnosed with pneumonia on CT.	● Patients evaluated with bedside lung US, chest X-ray, with CT as the gold standard; ● Sonosite M Turbo US machine; ● Emergency physician trained in US	● Lung US = 91% sensitivity and 61% specificity; ● CXR = 73% sensitivity and 51% specificity (p=0.01); ● Inter-rater reliability between expert reviewer and sonographer was 0.79.
Baker et al; Tropical Doctor; 2021; Uganda^Citation46	Cross-sectional study: ● Assess POCUS effectiveness at mobile outreach clinics by: ◦ evaluating type of examinations performed; ◦ how often findings altered pre-test Dx & Tx plan.	● Patients presenting to mobile health clinics in Masindi region of Western Uganda; ● Convenience sample of 144 pts, with 177 scans performed.	● Scans deemed necessary and questionnaire completed by attending physician; ● Philips Lumify US probe attached to Samsung Galaxy tablets; ● Clinics staffed by American board-certified physicians + 2nd and 3rd year residents. Two had completed emergency US fellowships.	● Most frequent scans were: cardiac, obstetric, abdominal, MSK/ST, biliary, urinary tract, pleural, testicular, aorta, thyroid, eFast, FASH; ● In 73%, diagnosis either confirmed (50%) or changed (23%); ● In 53%, US findings changed Tx plan.
Beaton et al; J of the American Society of Echocardiography; 2014; Uganda^Citation34	Prospective observational study: ● Determine sensitivity and specificity of focused echocardiography with HAND US versus STAND US units	● Run in Kampala, Uganda; ● 125 participants in the comparison study: ◦ 60 part of a rheumatic heart disease (RHD) follow-up; and ◦ 65 asymptomatic children for a screening study.	● Scanned by HAND & STAND US machines with WHF 2012 echocardiography protocol. Images interpreted separately and findings compared; ● HAND performed with GE Vscan versus STAND GE Vivid-I; ● Paediatric cardiologist performed all examinations.	● HAND = 90.2% sensitivity and 92.9% specificity for detecting RHD; ● HAND overestimated mitral valve morphologic abnormalities; ● False-negative results (n = 4) due primarily to underestimation of mitral regurgitation length.
Beaton et al; Eur Heart J Cardiovasc Imaging; 2015; Uganda^Citation35	Prospective Comparative study: ● Evaluate performance of HAND compared to STAND for early diagnosis of rheumatic heart disease (RHD) in a field screening study.	● Students from 5 schools in Gulu, Uganda; ● 1420 children scanned, either randomly selected (10%) or previously diagnosed with RHD.	● STAND, then HAND GE Vivid Q/I & Philips CX-50; ● HAND performed with GE Vscan; ● Performed by 5 paediatric cardiologists, 4 paediatric cardiology fellows and 3 senior echo technologists.	● HAND = 78.9% sensitivity and 87.2% specificity for RHD compared to STAND. ● 97.9% sensitive for definite RHD; ● Inter- and intra-reviewer agreement ranged between 66–83 and 71.4–94.1%, respectively.
Bhavani et al; JACC Cardiovasc Imaging; 2018; India^Citation40	Randomised trial: ● Compare outcomes of mHealth (smartphone-connected devices and pocket echocardiography) versus standard echocardiography for heart disease.	● Heart disease clinics in Bangalore; India ● All participants had known structural heart disease ● 253 participants randomised: ◦139 to mHealth; ◦114 to standard care.	● All patients had comprehensive echocardiographs; ● GE Vscan, GE Vivid-E9 & Philips ie33 used for m-Health; ● mHealth by local physicians; ● Sonographers performed standard echograms.	● mHealth group had: ● shorter referral time for interventions; ● increased probability of interventions; ● lower risk of hospitalisation/death. ● Could be due to over-diagnosis in initial scans.
Blois; Can Fam Phys; 2012; Canada^Citation33	Prospective cross-sectional study: ● Evaluate safety and efficacy of US screening for abdominal aortic aneurysm (AAA) by rural family physician.	● Study performed in Grand Forks and Revelstoke, British Columbia, Canada. ● 45 participants screened ● Participants recruited if at least 1 risk factor for AAA.	● Portable US aortic screening with Sonosite TITAN US machine; ● Follow-up by US expert using hospital US equipment; ● Screening performed by GP and follow-up by Sonographers.	● Sensitivity & specificity of GP scans = 100%; ● The mean absolute difference between scan diameter = 0.2cm; ● Correlation = 0.81 (high)
Chavez et al; Lung; 2015; Nepal & Peru^Citation41	Prospective cross-sectional study: ● Assess agreement between WHO pneumonia algorithm and POCUS for pneumonia; ● Determine feasibility of POCUS by GPs in for diagnosis of pneumonia.	● Performed in Sarlahi District, Nepal & Lima, Peru; ● 378 patients; ◦127 controls; ◦82 without clinical pneumonia; ◦169 with pneumonia.	● Chest US using international protocols for lung consolidation; ● SonoSite MicroMAxX & M-Turbo US machines used; ● GPs performed scans after US course developed and delivered.	● WHO algorithm had 69.6% sensitivity and 59.6% specificity; ● Positive & negative likelihood ratios of 1.73 and 0.51 for pneumonia on POCUS; ● Inter-observer agreement for POCUS interpretation between GPs was high.
Dalmacion et al; BMC Pregnancy & Childbirth; 2018; Philippines^Citation42	Prospective Cross-Sectional Study: ● Assess benefits of pregnancy US for early detection of maternal/neonatal conditions; ● Estimate agreement between trainees and trainers, and hand versus reference US scans; ● Estimate maternal and neonatal deaths averted by prenatal handheld US.	● Performed in Parañaque City & Tagum city; ● 460 participants randomly selected from a list of pregnant women at 20–24 weeks.	● Obstetric scan assessed: number of foetuses; foetal viability; presentation; placenta location; amniotic fluid volume. ● Confirmation by trainers; ● Handheld US by GE Vscan with GE Logic Prem as reference; ● Community healthcare workers undertook 3 training modules; ● Expert trainers and sonologist.	● 146 (31.7%) showed abnormalities; ● Approx. 95% agreement between trainees and trainers; ● 99% agreement between Handheld and reference scan; ● Handheld US could have possibly averted 6.3% maternal deaths and 14.6% neonatal deaths.
Godown et al; Pediatrics; 2015; Uganda^Citation36	Observational Cross-sectional Study: ● Determine incremental value of HAND over auscultation to detect rheumatic heart disease (RHD).	● Performed in 5 different schools in Gulu, Uganda; ● 1317 participants out of 4773 screened; ◦Children aged 5–17 years; ◦Any child with RHD indications plus randomly selected group of normal.	● Initial screened with STAND; ● Subset scanned with HAND & auscultation; ● Compared using STAND; ● HAND used GE Vscan; ● STAND used GE Vivid Q/I & Philips CX-50; ● Performed by paediatric cardiologists, senior cardiology fellows or sonographer.	● Sensitivity of HAND = 97.8% for definite RHD, borderline or definite = 78.4% and pathologic aortic insufficiency = 81.8%; ● Sensitivity of auscultation was 22.2%, 16.4% and 13.6% respectively.
Ketelaars et al; J Emerg Med; 2013; Netherlands^Citation29	Retrospective cross-sectional study: ● Evaluate impact of US on treatment plan in a Helicopter Emergency Medical Service (HEMS).	● Performed by Dutch HEMS across 3895 miles 2 service area in eastern Netherlands; ● 281 patients with US as deemed necessary by HEMS team.	● Scans of the chest and abdomen following with standardised method including thorax, heart, pericardium and aorta; ● Sonosite Micromaxx; ● Doctors trained in emergency US	● 326 examinations performed on 281 (11%) patients; ● Treatment plan changed in 60 (21%) patients.
Kissoon et al; PLoS ONE; 2013; Guyana^Citation44	Cross-sectional observational descriptive analysis; ● Quantify use of US & impact on care in local emergency department (ED).	● Performed in ED at Georgetown Public Hospital; ● 173 patients with 426 individual scans performed; ◦ Patients deemed needing US by attending physician.	● Data recorded on each US exam, including further treatment and disposition; ● POCUS equipment unspecified; ● Scans performed by Registrars, Residents & General Medical Officers.	● 196 (46%) of studies positive; ● US changed final patient disposition for 276 (64.8%); ● US aided the decision to admit (22.8%), discharge (22.8%), specialist review (14.3%) and surgery (23.4%).
Lu et al; J Amer Soc of Echo; 2015; Uganda^Citation37	Prospective cross-sectional study: ● Determine best simplified screening criteria for rheumatic heart disease (RHD) using HAND.	● Performed in 5 different schools in Gulu, Uganda; ● 1439 participants for HAND: ◦ 447 randomly assigned, 992 for indications; ◦ Children aged 5–17 years; ◦ Children with RHD indications, plus randomly selected group normal.	● Initial screening with STAND using GE Vivid Q/I or Philips CX-50; ● Subset underwent HAND with GE Vscan; ● STAND & HAND performed by paediatric cardiologists, fellows, and experienced sonographers.	● Combined criteria of mitral regurgitation jet length ≥ 15cm or any aortic insufficiency sensitivity = 73.3% and specificity = 82.4%; ● Sensitivity for definite RHD = 97.9%; ● With prevalence of 4%, subsequent STAND of positive HAND studies would reduce STAND by 80%.
Nixon et al; J Prim Health Care; 2018; New Zealand^Citation7	Retrospective cross-sectional study: ● Characterise POCUS use in Rural Hospitals, with focus on volume and range of studies; ● Secondary aim of providing perspective of participating doctors.	● Performed at 6 rural hospitals; ● 1014 patient results included; ● Patients deemed needing US by the attending physician.	● Form retrospectively completed with patient details and findings; ● POCUS equipment unspecified; ● All participating doctors were senior rural generalists with formal POCUS training.	● Most common scans: cardiac (18%); IVC/JVP (14%); gallbladder (13%); renal (11%); FAST (7%); bladder (6%); leg veins (6%); and lungs (5%); ● Doctors considered POCUS had a positive, significant effect due to diagnostic certainty; ● Challenges included: skills maintenance; lack of system for set-up; lack of quality control.
Nixon et al; Aust J Rural Health; 2018; New Zealand^Citation32	Retrospective cross-sectional study: ● Assess POCUS skills of rural doctors in obtaining and interpreting images; ● Secondary aim to assess impact of POCUS on diagnostic decision making and patient management.	● Study performed in 6 rural hospitals of NZ; ● 1014 patients, with 1248 examinations; ● Patients deemed needing US by the attending physician.	● Form retrospectively completed with patient details and findings; ● POCUS equipment unspecified; ● All participating doctors were senior rural generalists with formal POCUS training.	● 90% of images correctly interpreted compared to formal imaging or final diagnosis; ● 87% of scans contributed to or changed the diagnosis; ● 4% reduction in patients needing admission or transfer larger hospital; ● 71% POCUS scans had positive impact on patient care; ● 3% scans had potential for harm.
Ploutz et al; Heart; 2016; Uganda^Citation30	Prospective cross-sectional comparative study: ● Evaluate performance of simplified echo screening by non-experts.	● Two public primary schools in Gulu participated; ● 1002 primary students screened, with 956 paired exams in the final study.	● HAND using GE Vscan by non-experts and STAND with GE Vivid Q by experts; ● HAND studies performed by 2 nurses with intensive training; ● Cardiologists performed STAND.	● 95.5% of children were normal; ● 33% with borderline RHD & 12% with definite RHD; ● Simplified approach had sensitivity = 74.4% and specificity = 78.8% for any RHD; ● Sensitivity for definite RHD = 90.9%.
Pontet et al; US J; 2019; Uruguay^Citation31	Prospective randomised control trial: ● Analyse diagnostic and treatment implications of POCUS-driven protocol in first 5 days of Intensive Care Unit (ICU) admission.	● Two major referral hospitals in Montevideo; ● 80 participants, randomised in two groups, POCUS versus control; ● All patients were 18 years or older and required mechanical ventilation on ICU admission.	● POCUS group underwent standardised US-driven protocol; ● Control group received conventional management. ● GE Logiq-e US used; ● US-trained Intensivist performed POCUS.	● POCUS group used fewer resources in first 5 days in ICU; ● POCUS gave better characterisation of admission diagnosis in 35% and changed in management in 60%; ● POCUS group had lower fluid balance at 48 and 96 hours post-admission and less ventilation (51±57 days vs 88±94).
Prager et al; Prehosp & Disaster Med; 2018; Canada^Citation47	Retrospective cross-sectional study: ● Characterise the use of POCUS at a remote, multi-day music festival; ● Secondary aim to consider impact on patient care and resource utilisation.	● Study performed in Pemberton, British Columbia; ● When available, POCUS used on 28 patients from the 686 who presented.	● Patients evaluated by physicians and POCUS performed as necessary; ● Structured survey of patient and scan details completed; ● GE Vscan was used; ● Physicians self-reported US training/experience - 9 novices, 6 intermediates, and 2 advanced.	● POCUS narrowed diagnosis in 64% of cases, altered diagnosis in 21%, and changed management in 39%; ● Burden on resources utilization reduced in 46% of cases; ● Absolute risk reduction of 1.3% for hospital transferred patients.
Reynolds et al; PLoS ONE; 2018; Tanzania^Citation45	Prospective cross-sectional study: ● Characterise utilisation and impact of POCUS on ED clinical decision-making.	● Performed at Muhimbili National Hospital; ● POCUS performed on 784 pts, with 986 studies completed; ● Any ED patient requiring US was included, when available, if research assistant also present.	● POCUS performed with protocols used by all providers; ● Patient & scan details recorded; ● Sonosite mTurbo used; ● Doctors performing scans included 12 specialists, 10 residents and 17 registrars.	● Cases included trauma, abdo/ pelvic pain, respiratory signs; ● Most common scans were eFAST, cardiac, female pelvic studies; ● POCUS changed diagnosis or management in 29% of cases; ● Rates of change increased to 45% if patients had multiple POCUS studies performed.
Roberts et al; Circulation; 2014; Australia^Citation38	Prospective cross-sectional study: ● Define prevalence of RHD in remote Indigenous children; ● Compare echo findings with non-indigenous children in the same region.	● Performed in Northern & Central Australia; ● 5237 scans performed, with 4999 included in the study; ● High-risk cohort included Indigenous children in remote areas; ● Low-risk cohort from local cities with above average socio-economic status.	● Basic demographic details obtained and abbreviated echo protocol used on GE Vivid e/I US machines; ● If any abnormality, a more intensive echo performed; ● Scans reported blindly by cardiologists; ● Experienced cardiac sonographers performed echoes.	● Of 3946 high-risk children, 34 met WHF criteria for definite RHD with prevalence of 86/1000; ● 66 were borderline RHD, with prevalence of 167/1000; ● Of 1053 low-risk children, none met the criteria for definite RHD, and 5 for borderline RHD.
Singh et al; J Amer Soc of Echo; 2013; India^Citation39	Prospective cross-sectional study: ● Assess feasibility of focused echo studies with long-distance assessment of images for patients with cardiovascular disease.	● Performed in a remote rural community in northern India; ● Patients recruited for study if symptomatic; ● 1021 US exams interpreted.	● Protocol driven echocardiographic studies performed and uploaded to web-based platform for remote interpretation; ● GE Vscan & Vivid I/Q US used; ● Volunteer expert sonographers.	● Median time to interpretation was 11:44 hours; ● 207 scans (20.3%) had minor and 170 (16.7%) major abnormalities.
Smith et al; South African Med J; 2010; South Africa^Citation6	Prospective observational Study: ● Assess use and accuracy of an existing US machine for FAST scanning in an emergency department (ED).	● Performed in rural KwaZulu-Natal, Nqwelezane Hospital; ● 72 scans included; ● Included blunt or penetrating thoracic or abdominal trauma, if a trained doctor was available.	● FAST scan performed, with findings confirmed by either CT or laparotomy; ● Aloka SSD 500 B-scan machine; ● Three ED doctors accredited for FAST performed the scans.	● 72 FAST scans, 52 for blunt and 20 for penetrating trauma; ● 20.8% were positive; ● FAST had 100% specificity and overall sensitivity = 71.4%; ● 81.3% sensitivity for blunt, and 62.5% for penetrating injuries.
Umuhire et al; US J; 2019; Rwanda^Citation48	Prospective cross-sectional observational study: ● Determine proportion of acute dyspnoea cases where US changed the diagnosis; ● Determines if multi-organ US improve accuracy and confidence in dyspnoea.	● Performed at University Teaching Hospital of Kigali; ● Patients presenting to the ED with breathlessness; ● 100 patients scanned, 99 used in final results.	● Physical examination performed; ● Another doctor performed Heart, IVC, Lungs, FASH & DVT US, with SonoSite M-Turbo US machine; ● Lead ‘sonographer’ had received US training, was enrolled in US fellowship and had passed ultrasound clinical skills assessment.	● Most common diagnoses were acute decompensated heart failure (26.3%) and pneumonia (21.2%); ● US altered diagnosis in 66% of cases; ● Physician diagnostic accuracy increased from 34.7% to 88.8%; ● Mean diagnostic confidence increased from 3.5 to 4.7 (Likert).
Zanatta et al; Emerg Care J; 2015; Italy^Citation49	Cross sectional observational study: ● Evaluate role of Critical Care Ultrasound (CCUS) on diagnostic and therapeutic procedures in the emergency department.	● Cazzavillan Hospital, Arzignano; ● 241 patients scanned; ● Patients presenting with: shock, cardiac arrest, dyspnoea, non-traumatic chest pain, abdominal pain, abdominal or chest trauma, and suspected DVT.	● Initial clinical assessment then POCUS performed by the same physician; ● Esaote MyLab 30 US machine; ● Operators were certified emergency physicians who had completed competency training for Ultrasound in Life Support.	● Final diagnosis compared with CCUS vs clinical assessment was respectively (P=0.014): ◦ dyspnea - 82.5% vs 49.1%; ◦ thoracic pain - 71.9% vs 40.6%; ◦ abdominal pain - 76.2% vs 45%; ◦ suspected DVT - 80.0% vs 43.6%; ◦ shock - 80.0% vs 20%. ● eFAST correctly ruled out trauma complications in 81.1%.

Abbreviations: CXR, Chest X-ray; CT, Computed Tomography; DVT, Deep Vein Thrombosis; Dx, Diagnosis; ED, Emergency Department; (e) FAST, (extended) Focussed Assessment with Sonography in Trauma; FASH, Focussed Assessment with Sonography for HIV-associated tuberculosis; GP, General Practitioner; HAND, Hand-held US unit; IVC/JVP, Inferior Vena Cava/Jugular Venous Pulse; MSK/ST, Musculoskeletal/Soft Tissue; STAND, Portable US unit; Tx, Treatment; US, Ultrasound; WHF, World Heart Foundation; WHO, World Health Organisation.

Figure 2 Barchart showing the range of ultrasound examination types and the number of articles in this systematic review that included each type of examination.

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