Point-of-care ultrasound in the evaluation of hospitalized patients. A systematic review of diagnostic accuracy, clinical impact, training and implementation

 

Nº de DOI: 10.34896/RSI.2026.53.38.002

 

 

AUTHORS

1. José Vicente Cargua Pintag. General Practitioner with a Master’s Degree in Healthcare Quality Management and Auditing. Affiliated with the Ecuadorian Armed Forces. Graduate of Universidad Nacional de Chimborazo. Based in Riobamba, Ecuador.https://orcid.org/0009-0003-2616-3473
2. Dayra Michell Tuz Tapia. General Practitioner with a Master’s Degree in Hospital Management and Administration. Affiliated with Private Clinics in Ecuador. Graduate of Universidad Regional Autónoma de Los Andes. Based in Tulcán, Ecuador. https://orcid.org/0009-0009-9769-7281
3. Michael Alejandro Guaman Freire. General Practitioner. Affiliated with Baca Ortiz Hospital. Graduate of Pontificia Universidad Católica del Ecuador. Based in Quito, Ecuador. https://orcid.org/0009-0009-0514-1172
4. Miguel Angel Tito Borja. General Surgeon with a Master’s Degree in Healthcare Management and Administration and a Specialty in General Surgery. Affiliated with Private Clinics in Ecuador. Graduate of Universidad de Las Américas. Based in Quito, Ecuador. https://orcid.org/0009-0006-8003-4199
5. Mishell Dayanara Vargas Saltos. General Practitioner. Affiliated with Hospital General San Francisco IESS. Graduate of Universidad Central del Ecuador. Based in Quito, Ecuador. https://orcid.org/0009-0000-0985-7498

ABSTRACT

Objective: To identify, appraise and synthesize published journal evidence on the diagnostic accuracy, clinical and economic impact, training requirements and implementation barriers of POCUS in the evaluation of hospitalized adults.

Methods: Structured searches of the biomedical journal literature were run in August 2026 using predefined terms and eligibility criteria (adult hospitalized or acutely ill patients; POCUS performed by treating clinicians; peer-reviewed journal articles with a digital object identifier). Twenty-five sources were included: eight systematic reviews or meta-analyses, two randomized trials, six observational, quality-improvement or diagnostic studies, two surveys, and seven guidance documents or narrative reviews. Because of clinical and methodological heterogeneity, results were synthesized narratively, with an explicit rating of how directly each source addressed hospitalized patients.

Results: Diagnostic accuracy is best established for lung ultrasound in cardiogenic pulmonary edema (pooled sensitivity 91.8% versus 76.5% for chest radiography in one meta-analysis) and in pneumonia (pooled sensitivity 94% and specificity 96%), and it is supported for cardiac, venous, pleural and abdominal questions. Outcome evidence is thinner and discordant. A randomized trial of 453 unselected medical inpatients found no significant change in length of stay, whereas focused heart-failure and dyspnea studies, including a 2025 stepped-wedge quality-improvement study of 208 patients, reported shorter stays and lower costs. In that study only 20% of examinations were performed independently by hospitalists, and barriers across the literature consistently centered on training, time and incentives.

Conclusions: POCUS is a diagnostically credible bedside extension of the physical examination for hospitalized adults, with the strongest outcome signal in undifferentiated dyspnea and heart failure. Its benefit depends on operator competence, targeted application and institutional support. Adequately powered multicenter trials that measure inpatient-specific outcomes are still needed.

KEY WORDS

Point-of-care ultrasound, hospital medicine, hospitalized patients, lung ultrasound, diagnostic accuracy, length of stay, medical education, systematic review.

RESUMEN

Objetivo: Identificar, evaluar y sintetizar la evidencia publicada en revistas científicas sobre la precisión diagnóstica, el impacto clínico y económico, los requisitos de formación y las barreras de implementación de la ecografía a pie de cama (POCUS) en la evaluación de adultos hospitalizados.

Métodos: En agosto de 2026 se realizaron búsquedas estructuradas en literatura biomédica utilizando términos y criterios de elegibilidad predefinidos (pacientes adultos hospitalizados o con enfermedad aguda; POCUS realizada por médicos tratantes; artículos revisados ​​por pares con identificador de objeto digital). Se incluyeron veinticinco fuentes: ocho revisiones sistemáticas o metaanálisis, dos ensayos aleatorizados, seis estudios observacionales, de mejora de la calidad o diagnósticos, dos encuestas y siete documentos de orientación o revisiones narrativas. Debido a la heterogeneidad clínica y metodológica, los resultados se sintetizaron de forma narrativa, incluyendo una valoración explícita del grado en que cada fuente abordaba específicamente a pacientes hospitalizados.

Resultados: La precisión diagnóstica está mejor establecida para la ecografía pulmonar en casos de edema pulmonar cardiogénico (sensibilidad combinada del 91,8 % frente al 76,5 % de la radiografía de tórax en un metaanálisis) y neumonía (sensibilidad combinada del 94 % y especificidad del 96 %); asimismo, cuenta con respaldo para evaluaciones cardíacas, venosas, pleurales y abdominales. La evidencia sobre los resultados clínicos es más escasa y discordante. Un ensayo aleatorizado con 453 pacientes médicos hospitalizados no halló cambios significativos en la duración de la estancia, mientras que estudios centrados en insuficiencia cardíaca y disnea —incluido un estudio de mejora de la calidad de 2025 con diseño de *stepped-wedge* y 208 pacientes— reportaron estancias más breves y menores costes. En dicho estudio, solo el 20 % de las exploraciones fueron realizadas de forma independiente por médicos hospitalistas, y las barreras identificadas en la literatura se centraron sistemáticamente en la formación, el tiempo y los incentivos.

Conclusiones: La POCUS constituye una extensión diagnósticamente fiable del examen físico a pie de cama en adultos hospitalizados, mostrando los resultados más sólidos en casos de disnea indiferenciada e insuficiencia cardíaca. Su beneficio depende de la competencia del operador, la aplicación dirigida y el apoyo institucional. Sigue siendo necesaria la realización de ensayos multicéntricos con potencia estadística suficiente que midan resultados específicos en pacientes hospitalizados.

PALABRAS CLAVE

Ecografía a pie de cama (POCUS), medicina hospitalaria, pacientes hospitalizados, ecografía pulmonar, precisión diagnóstica, duración de la estancia, educación médica, revisión sistemática.

INTRODUCTION

Point-of-care ultrasound (POCUS) is a focused, clinician-performed examination that answers a specific bedside question, and it is used with growing frequency by hospitalists and other inpatient physicians. Evidence on its accuracy, and especially on whether it improves outcomes for patients who are already admitted, is scattered across specialties and care settings.

OBJECTIVE

The objective of this systematic review was to identify, appraise and synthesize published journal evidence on the use of POCUS in the evaluation of hospitalized adults. Four review questions guided the work:

1. How accurate is POCUS, performed by non-radiologist clinicians, for the diagnostic questions that arise most often in hospitalized adults?
2. Does bedside POCUS change management, shorten hospital stay, reduce costs or improve patient experience?
3. What training, competency assessment and governance arrangements are recommended to make POCUS safe and reliable?
4. What barriers limit independent use of POCUS by hospital clinicians, and how do these barriers interact with the evidence of benefit?

The review concentrates on diagnostic and monitoring applications. Ultrasound guidance of invasive procedures is a separate body of evidence and was excluded from the primary synthesis, although its importance is acknowledged.

METHODOLOGY

Design and reporting framework:

This work was designed as a systematic review of the published evidence and was structured according to the principles of the PRISMA 2020 statement, which provides a 27-item reporting checklist and flow diagrams for original and updated systematic reviews^5. Several elements of a fully conformant review could not be implemented, and these are stated openly because they bear on how the findings should be read. No protocol was registered in advance. Study selection and data extraction were performed by a single reviewer without independent duplicate screening. The numbers of records retrieved and screened at each stage were not systematically logged, so a PRISMA flow diagram with record counts is not presented. The review should therefore be read as a structured, transparent synthesis of the best available journal evidence rather than as an exhaustive, registered Cochrane-type review.

Eligibility criteria:

Eligibility was defined with a population, intervention, comparator, outcome and study-design framework.

Population. Adults aged 18 years or older who were hospitalized, or who were acutely ill in settings that feed directly into inpatient care, namely emergency departments at the point of admission, medical wards and intensive care units. Evidence from emergency and critical care populations was retained because many diagnostic applications were first validated there, but it was classified as indirect evidence for the ward inpatient (see below). Pediatric populations were excluded.

Intervention. Diagnostic or monitoring POCUS, defined as a focused ultrasound examination acquired and interpreted at the bedside by the treating clinician, with or without remote expert review. Cardiac, lung and pleural, venous, abdominal and inferior vena cava applications were all eligible.

Comparator. Physical examination alone, chest radiography, formal echocardiography or other formal imaging, or usual care without POCUS.

Outcomes. Diagnostic accuracy (sensitivity, specificity, likelihood ratios); changes in diagnosis or management; length of stay; hospitalization costs; use of formal imaging; patient experience; training, competency and governance recommendations; and barriers to adoption.

Study designs. Systematic reviews and meta-analyses, randomized trials, cohort, quality-improvement and diagnostic studies, surveys, and professional guidance documents or narrative reviews that synthesized the hospital-medicine literature. Case reports and conference abstracts were excluded.

Publication criteria. Full-text articles in peer-reviewed journals, published in English between 2010 and 2026, with a digital object identifier.

Information sources and search strategy:

Searches were conducted on 3 and 4 August 2026 through web-based search of the indexed biomedical literature, including PubMed-indexed journals, PubMed Central and publisher platforms. Search concepts combined terms for the technology (point-of-care ultrasound, POCUS, bedside ultrasound, hand-carried or handheld ultrasound, lung ultrasound, focused cardiac ultrasound) with terms for the setting (hospitalist, hospital medicine, inpatient, hospitalized, internal medicine ward) and with outcome or topic terms (diagnostic accuracy, meta-analysis, length of stay, cost, training, competency, barriers, position statement). Additional condition-specific searches were run for pulmonary edema and heart failure, pneumonia, pleural effusion and pneumothorax, deep vein thrombosis, shock, pulmonary embolism and perioperative care.

Study selection:

Titles and abstracts were screened against the eligibility criteria, and full texts or detailed abstracts were examined for potentially eligible sources. Twenty-five sources were included in the final synthesis.

Data extraction:

For each source, the following information was recorded: design, population and setting, ultrasound application, operator (hospitalist, sonographer, resident or expert), comparator, principal quantitative results, stated limitations and the clinical domain addressed. Extraction was limited to information that was accessible in the abstract or full text. For a minority of sources, notably some emergency-department diagnostic studies and meta-analyses, only abstract-level or bibliographic information was available, and no effect sizes were extracted from them. Their findings are described in general terms and are not used to support numerical statements.

Appraisal of evidence:

Because the sources were heterogeneous, a single formal tool could not be applied uniformly. For diagnostic accuracy sources, the four domains of the QUADAS-2 tool (patient selection, index test, reference standard, and flow and timing) were used as a conceptual framework for critical reading,[6] but domain-level scores were not generated, since primary studies were not re-extracted and the reviewers’ own appraisals in the underlying meta-analyses were relied on. For trials and quality-improvement studies, appraisal considered allocation, blinding, outcome definition, adjustment for confounding and generalizability.

Each source was also given a directness rating. A source was rated direct if its population consisted predominantly of hospitalized ward patients or its recommendations were written for hospital clinicians, partly indirect if it drew on mixed emergency, critical care and inpatient populations, and indirect if its population was predominantly emergency-department based. An overall certainty of evidence for each domain was then assigned qualitatively as higher, moderate or low, taking account of study design, consistency, directness and precision.

Synthesis:

Meta-analysis was not undertaken. The included meta-analyses had already pooled their primary data, the clinical questions and operators differed, and a second round of pooling would have double-counted patients. Results are presented narratively and organized by clinical question and outcome domain, with tables summarizing the main quantitative findings. As the review used only published data, ethical approval was not required.

RESULTS

Characteristics of the included sources:

Twenty-five journal sources met the eligibility criteria and were included in the synthesis. They comprised eight systematic reviews or meta-analyses, two randomized trials, six observational, quality-improvement or diagnostic studies, two surveys of clinicians, and seven guidance documents or narrative reviews. Their publication dates ranged from 2012 to 2025. A minority of sources, chiefly the two trials, the 2025 implementation study and the prospective inpatient cohort, were rated as direct evidence for hospitalized ward patients, while the remainder were partly indirect or indirect because they drew on emergency or intensive care populations or were written as general recommendations.

Diagnostic accuracy in conditions common to hospitalized patients:

Cardiogenic pulmonary edema and acute heart failure:

The strongest and most consistent accuracy data concern lung ultrasound for cardiogenic pulmonary edema. A systematic review and meta-analysis of six prospective cohort studies representing 1827 patients, which directly compared bedside lung ultrasound with chest radiography in adults with dyspnea suggestive of acute decompensated heart failure, found that ultrasound was more sensitive than radiography with comparable specificity. The authors translated this into clinical terms by estimating that, for every 100 patients with dyspnea due to cardiogenic pulmonary edema, lung ultrasound would identify about 15 more cases than radiography without additional false-positive results⁷. A later meta-analysis that searched five databases through February 2021 and included eight observational studies with 2787 patients reached the same conclusion with higher precision: lung ultrasound had a pooled sensitivity of 91.8% compared with 76.5% for chest radiography, and a pooled specificity of 92.3% compared with 87.0%⁸.

Additional meta-analyses and multicenter studies conducted in the emergency department, where patients with undifferentiated dyspnea are first evaluated before being admitted, point in the same direction. A systematic review of point-of-care ultrasonography for acute cardiogenic pulmonary edema in patients presenting with acute dyspnea, a systematic review on the diagnosis of acute heart failure in the emergency department, a multicenter Italian study of lung ultrasound-implemented diagnosis of acute decompensated heart failure, and a study of ultrasound for acute dyspnea that combined cardiac, lung and venous examinations all examined the contribution of bedside ultrasound to diagnostic accuracy in dyspneic patients^9,10,11,12. These sources were classified as indirect evidence for ward inpatients, because their populations were evaluated at the time of emergency presentation, and effect sizes were not extracted from the sources for which only abstract-level information was available. A further systematic review pooled lung ultrasound across three emergency diagnoses, namely pneumonia, acute heart failure and exacerbations of chronic obstructive pulmonary disease or asthma¹³.

Pneumonia:

For pneumonia, a systematic review and meta-analysis of lung ultrasound in adults identified 2726 records, assessed 45 in detail and analyzed 10 eligible studies. Six of those studies enrolled hospitalized or emergency-department adults with suspected pneumonia, and four enrolled critically ill adults. Pooled sensitivity was 94% (95% confidence interval 92% to 96%) and pooled specificity 96% (94% to 97%), with a positive likelihood ratio of 16.8, a negative likelihood ratio of 0.07 and an area under the curve of 0.99¹⁴. These values are high enough to be clinically useful for both ruling in and ruling out pneumonia, but the authors specifically concluded that the technique performs well when conducted by highly skilled sonographers. That qualification matters for the question of whether the figures can be transposed to hospitalists with brief training, and it is discussed below.

Other applications relevant to hospitalists:

A narrative review of the hospitalist literature identified the diagnostic POCUS applications of greatest relevance in hospital medicine. These were cardiac ultrasound for left ventricular systolic function, pericardial effusion and severe mitral regurgitation; lung ultrasound for pneumonia, pleural effusion, pneumothorax and pulmonary edema; abdominal ultrasound for ascites, aortic aneurysm and hydronephrosis; and venous ultrasound for central venous volume assessment and lower-extremity deep vein thrombosis. The review concluded that hospitalists and other front-line providers, as well as trainees at various levels, achieved moderate to excellent diagnostic accuracy after brief training programs for most of these applications². A subsequent overview in a general medical journal reinforced the position of compression ultrasonography as a rapid and accurate way to detect deep vein thrombosis, described the sonographic signs used to diagnose pneumothorax, in which a lung point is virtually pathognomonic whereas absent lung sliding is less specific, and presented meta-analyses of pleural, lung and venous applications³. The Society of Hospital Medicine position statement listed the same core applications and noted that some hospitalists additionally assess the eyes, stomach, bowel, ovaries, pregnancy and testes, and perform regional anesthesia, although these are not part of the core scope¹.

An international consensus process produced evidence-based recommendations for lung ultrasound that standardize acquisition and interpretation of findings such as pleural sliding, B-lines and consolidations, and these recommendations underpin most of the lung ultrasound literature cited above¹⁵. Finally, a comparative study of handheld ultrasound versus physical examination in patients referred for transthoracic echocardiography and a study of patient satisfaction with bedside ultrasound have both been cited as evidence that bedside ultrasound adds accuracy to the clinical examination and is well received by patients^16,17.

Impact on clinical management, length of stay and costs:

Randomized trials:

Two randomized trials evaluated length of stay as a primary outcome in general medical inpatients, and a systematic review of the clinical impact of POCUS in internal medicine inpatients identified them as the only randomized cardiac trials with that endpoint^4,18. The first was an unblinded, parallel-group trial at a single teaching hospital in which 453 adult medical inpatients, referred for standard echocardiography for indications that hand-carried echocardiography could investigate, were randomized to care guided by hospitalist-performed hand-carried echocardiography or to usual care. The geometric mean length of stay was 46.1 hours in the intervention group and 46.9 hours in the control group, a 1.7% reduction that was not statistically significant (95% confidence interval -12.1% to 9.8%). In post hoc subgroup analyses, however, care guided by hand-carried echocardiography shortened length of stay in participants referred for heart failure (P = .0008), and among participants who underwent both examinations hospitalists reported that the hand-carried study changed management in 37%¹⁹.

The second trial, in internal medicine patients with heart failure, evaluated a lung ultrasound-guided strategy and reported that it efficiently drove management and speeded up discharge time. Patients with acute coronary syndrome, respiratory conditions or obesity were excluded²⁰.

Implementation and quality-improvement studies:

The most recent and most detailed inpatient dataset is a 2025 quality-improvement study with a stepped-wedge cluster-randomized implementation design, conducted at a tertiary hospital in the United States between December 2023 and July 2024 in five internal medicine teaching hospitalist teams. It enrolled 208 patients with undifferentiated dyspnea, 107 in the control group and 101 in the POCUS group, and 60% of all participants were admitted because of congestive heart failure. Structured cardiopulmonary POCUS (a cardiac examination plus a six-zone lung examination, with the inferior vena cava assessed through a subcostal view) was performed on the first day of admission using handheld probes by hospitalists, supported by sonographers, and final interpretation was undertaken by two cardiologists blinded to clinical data⁴.

POCUS was associated with a 30.3% reduction in expected length of stay (95% confidence interval 5.5% to 48.9%), with mean stay falling from 11.9 days in the control group to 8.3 days in the POCUS group. Cumulatively, this corresponded to 246 fewer bed-days (713 versus 959 days) and direct cost savings of $751,537, an incremental cost-effectiveness ratio of $3055 saved per hospital bed-day. Reviewers judged that POCUS changed the medical decision in 30 patients (35%), which included a new diagnosis in 12 (14%), a change in medical therapy in 6 (7%) and exclusion of a cardiopulmonary cause of dyspnea by a normal examination in 12 (14%). Thirty-day readmissions did not differ significantly between groups (23% versus 19%, P = .57), and 90-day readmissions were nonsignificantly lower in the POCUS group (17% versus 23%, P = .33)⁴.

A prospective cohort study of internal medicine POCUS evaluated its association with length of stay, hospitalization costs and use of formal imaging. As summarized by the investigators of the 2025 implementation study, that cohort found that the availability and selective use of POCUS by hospitalist teaching teams was associated with cost reductions even though length of stay was not significantly different^4,21.

Systematic reviews of clinical impact:

The systematic review of the clinical impact of POCUS in internal medicine inpatients appraised the entire body of evidence on this question, and the 2025 trial authors, who cited it, described the available randomized evidence as limited and conflicting^4,18. A separate systematic review and meta-analysis of POCUS in patients with acute-onset dyspnea reported improved clinical outcomes; pooled effect sizes were not extracted for this review, and its populations came from acute presentations rather than from the ward alone²².

Training, competency assessment and governance:

Guidance documents were consistent about the way POCUS should be taught and supervised. The Society of Hospital Medicine position statement observed that standards for hospitalist training and assessment had not been established, and it laid out criteria for training. Training should occur across multiple types of patients, such as obese, cachectic and postsurgical patients, and in several settings, including the intensive care unit, general wards and emergency department. Training and feedback should occur in real time, specific applications should be taught rather than a broad “hospitalist POCUS”, and once competency is achieved, continuing education and feedback are necessary to maintain it¹. The statement distinguished a certificate of completion, which is proof of participation in an educational activity, from certification of competency, which attests to basic competence within a defined scope. It recommended longitudinal programs with mentored feedback and periodic assessment, because without supervision skills decay. It noted that no national board certification in POCUS was available to hospitalists, that residency-based pathways best fulfill the training criteria, and that sonographers, although well suited to teach image acquisition, should not be the sole instructors on how to integrate findings into clinical decisions. It also acknowledged that some hospitalists may be unable or unwilling to achieve competency in image acquisition¹.

Governance recommendations included local credentialing in line with specialty-specific guidance, programmatic quality assurance, billing through the procedural codes for focused or limited ultrasound examinations, and documentation of the clinical question, the findings and the procedure note for ultrasound-guided procedures. A resolution of the American Medical Association was cited, recommending that hospitals follow specialty-specific guidelines for privileging decisions and stating that ultrasound imaging is within the scope of practice of appropriately trained physicians¹. The American Society of Echocardiography has issued recommendations for echocardiography laboratories that participate in cardiac POCUS and critical care echocardiography training, which shows that cardiology and imaging departments are expected to be partners in training rather than gatekeepers²³. More recent practice-oriented literature has focused on the small set of core skills that hospitalists should master first, and a point-counterpoint debate has addressed the question of whether POCUS should be a required skill for all hospitalists^24,25.

Barriers to independent use:

Two surveys and the implementation study provide converging information on barriers. In a survey of practicing internists in six North American institutions, lack of training and time constraints during rounds were highlighted as key obstacles to learning and using POCUS, and the participants in the 2025 implementation study reported closely similar barriers, whereas they did not regard personal attitudes about its usefulness, the lack of external requirements or the inability to bill as important^4,26. A survey of hospitalists described aspirational, safety and knowledge deficits that prevented them from practicing POCUS²⁷. In the 2025 implementation study, only 17 of 84 examinations (20%) were performed independently by hospitalists, while sonographers performed the remaining 80%, and qualitative interviews attributed this to insufficient training in image acquisition and interpretation, time constraints during rounds and a lack of incentive to incorporate POCUS as standard care⁴.

Certainty of evidence by domain:

Across domains, the certainty of the evidence ranged from moderate to low. Diagnostic accuracy of lung ultrasound for pulmonary edema was rated moderate, on the basis of consistent findings in two meta-analyses of prospective or observational cohorts, although the populations were predominantly emergency presentations. Accuracy for pneumonia was also rated moderate, with the caveat of operator expertise. Evidence on clinical outcomes was rated low, because the two available randomized trials differed in population and design, the most recent inpatient study was a single-center quality-improvement study with a retrospective, unblinded assessment of decision changes, and no multicenter trials were found. Evidence on training and governance rests on consensus statements, and evidence on barriers was rated moderate because surveys and implementation data agree.

DISCUSSION

This review examined what is known about POCUS in the evaluation of hospitalized adults and arrived at a layered answer. At the level of diagnostic accuracy, the evidence is encouraging and reasonably consistent: lung ultrasound outperforms chest radiography for cardiogenic pulmonary edema and has high pooled accuracy for pneumonia, and a broader set of cardiac, venous, pleural and abdominal applications is supported by moderate-quality hospital-medicine literature^2,7,8,14. At the level of patient outcomes, the picture is more nuanced. One randomized trial of unselected inpatients found no meaningful reduction in length of stay, a focused heart-failure trial and a recent stepped-wedge implementation study of patients with undifferentiated dyspnea suggested shorter stays and lower costs, and a prospective cohort study suggested cost reductions without a significant change in length of stay^4,19,21. At the level of implementation, independent use by hospitalists remains low even after dedicated training, and the barriers are consistent across surveys and implementation data^4,26,27. These three layers are connected, and the central message of this review is that a test that is accurate in expert hands does not automatically become a beneficial intervention in ordinary practice.

The distance between diagnostic accuracy and patient benefit is a familiar problem in the evaluation of any diagnostic test, and POCUS is no exception. For a test to improve outcomes, its result has to change a decision, the changed decision has to be the right one, and the downstream treatment has to be effective. The lung ultrasound meta-analyses establish the first link by showing that a clinician at the bedside can identify pulmonary edema with greater sensitivity than a radiograph can, and the estimate that about 15 additional cases per 100 would be detected without extra false positives illustrates the size of the potential gain⁷. The inpatient trials examine the later links, and they show how dependent the result is on context.

The difference between the two randomized trials in the literature is instructive. In the earlier trial, hospitalists performed a focused echocardiographic examination in unselected medical inpatients who had already been referred for a standard echocardiogram, and the examination was one input among many in a population in which most patients would have had a normal or unchanged management plan. The overall effect on length of stay was null, but in the subset referred for heart failure the effect was significant, and management changed in more than a third of patients who had both examinations¹⁹. The heart-failure trial examined lung ultrasound in a population with a clearly defined clinical question and an intervention (diuresis guided by congestion) whose dose can be titrated against the ultrasound findings, and it found benefit in discharge time²⁰. The 2025 study then applied a combined cardiopulmonary examination early in admission to patients with undifferentiated dyspnea, 60% of whom had heart failure, and recorded a large reduction in stay and costs⁴. Read side by side, the studies support a hypothesis rather than prove a rule: POCUS probably shortens hospital stay where the clinical question is specific, where the result leads quickly to an actionable therapeutic change, and where the baseline pathway is slow, for instance because formal echocardiography is delayed. It probably does little in populations where the pretest probability of a management-changing finding is low.

Several cautions apply to the most favorable study. It was a single-center quality-improvement initiative in which the effect on length of stay was estimated with a gamma mixture model, the adjudication of whether POCUS changed management relied on an unblinded retrospective medical-record review, and final interpretation was provided by cardiologists who reviewed the stored images, so the intervention was not simply “a hospitalist with a handheld probe” ⁴. Moreover, the subgroup that benefited most was the long-stay group, which suggests that the average effect reflects a small number of patients with very long admissions, and this makes the estimate sensitive to a few cases. The estimated 30.3% reduction, with a confidence interval from 5.5% to 48.9%, should be read in this light, and the cost estimate is specific to one payer environment and should not be transposed to other health systems⁴.

Almost every accuracy estimate in the literature depends on who holds the probe. The pneumonia meta-analysis stated explicitly that the technique performs well when conducted by highly skilled sonographers,[14] and in the 2025 implementation study 80% of examinations were carried out by sonographers rather than by hospitalists⁴. The hospitalist literature, on the other hand, argues that clinicians and trainees at various levels reach moderate to excellent accuracy after brief training for most core applications². These statements are not contradictory, but they imply that the figures reported in meta-analyses are best understood as an upper bound for newly trained clinicians and as a reasonable expectation only for operators who have completed deliberate practice, supervision and quality assurance.

This has two practical consequences. First, a limited examination can show what is present but cannot reliably exclude disease outside the windows examined, so a clinician at an early stage of training should treat a normal scan as a reason to continue the evaluation rather than to stop it. Second, health systems that want the accuracy documented in the literature must also build the infrastructure that produced it. The Society of Hospital Medicine position statement is explicit on this point: competence requires training across patient types, real-time feedback, application-specific teaching and continuing maintenance, and a certificate of attendance is not proof of competence¹. The recommendations of the American Society of Echocardiography for laboratories that participate in POCUS training reinforce the idea that imaging departments are natural partners in training, image review and quality assurance²³.

The literature reveals a tension in the way POCUS training is organized. Residency-based training offers the best chance of satisfying the criteria for competence, but most current hospitalists completed training before POCUS entered residency curricula, so alternative pathways, such as workshops, local mentors and longitudinal programs, are needed in the interim¹. Short courses are efficient for introducing a concept, but skills decay without supervised practice, and the one-time certificate is an imperfect proxy for competence. The more recent literature has emphasized focusing on a small number of core skills rather than on breadth, which fits the position statement’s recommendation to teach specific applications rather than a generic “hospitalist POCUS” ^1,24.

A debate has also emerged about whether POCUS should become a required skill for hospitalists, as expressed in a point-counterpoint exchange²⁵. The evidence reviewed here does not settle it, but it does inform it. Arguments for a requirement draw on the accuracy of the core applications, the speed of the bedside pathway and the possibility of reduced stay and cost. Arguments against it draw on the limited and conflicting trial evidence, on the fact that independent use remained low even in a motivated academic environment, and on the position statement’s recognition that some clinicians may be unable or unwilling to master image acquisition^1,4. An evidence-informed middle position is that POCUS should be offered and supported as a core competency within hospital medicine, with defined scopes of practice, but that a mandatory requirement should wait for stronger outcome data and for validated, feasible competency assessments.

The consistency of the barriers found in the literature is striking. Insufficient training, time pressure on rounds and a lack of incentive explain most of the shortfall in independent use^4,26,27. Notably, the participants in the 2025 study did not regard inability to bill or personal doubts about the technique as important barriers, so interventions that improve reimbursement alone are unlikely to change behavior⁴. The collaborative model tested in that study, in which hospitalists, sonographers and a remote cardiologist shared the work, appears to be a pragmatic solution that delivered benefit but also came at the price of dependence on sonographer availability on weekdays and between 8:00 and 17:00⁴. That model may be difficult to scale, as the authors recognized, and it creates a risk that the clinician’s own skills are never developed.

Implementation strategies suggested by the evidence include protected time for supervised scanning, local champions who provide longitudinal feedback, image archiving with review, integration of POCUS documentation in the electronic record and consideration of incentives for those who complete credentialing^1,4. Cloud-based image storage, used in the 2025 study, allowed later blinded expert review and is an enabling technology for quality assurance⁴. Documentation should record the clinical question, findings and impression so that downstream clinicians can interpret the study¹.

Patient experience has received less attention in the inpatient literature than diagnostic accuracy. A study conducted in the emergency department found that bedside ultrasound maximized patient satisfaction, which is plausible because patients see their own anatomy and hear an explanation in real time, but this remains a hypothesis for the ward¹⁷. POCUS also carries potential harms that are rarely quantified: a false-positive finding may prompt an unnecessary test or treatment, a false-negative finding may provide false reassurance, and incidental findings may lead to cascades of follow-up imaging. Quality assurance programs should therefore track not only the proportion of examinations that change management but also the proportion in which the bedside interpretation was discordant with the reference standard.

The strengths of the review are its focus on hospitalized adults, its attention to the entire chain from accuracy through outcomes to implementation, its explicit rating of the directness of the evidence, and its restriction to peer-reviewed journal sources with verifiable identifiers. Its limitations are considerable and should be considered when interpreting the conclusions. The review was not registered and was conducted by a single reviewer without duplicate screening, and a formal flow diagram with record counts is not available. The search relied on web-based access to indexed journals rather than on direct, documented searches of multiple bibliographic databases, so relevant studies may have been missed; this applies in particular to shock, pulmonary embolism, deep vein thrombosis, abdominal applications and perioperative inpatient care, for which only general statements from review articles could be used. For several sources only abstract-level information was available, and no effect sizes were extracted from them. Formal risk-of-bias tools were not applied, and the certainty ratings are qualitative. Finally, the evidence base is dominated by North American academic centers, and findings may not generalize to health systems with different staffing, device availability and training cultures.

Because these methodological shortcomings are real, the findings are best regarded as a well-grounded evidence synthesis that can inform practice and teaching discussions, and as a platform on which a fully registered review with independent screening, multiple-database searching and formal GRADE assessment can be built. Authors who plan to submit this work to a journal should complete these steps before submission.

For practice, trained clinicians can reasonably use lung ultrasound as a first-line bedside adjunct in dyspneic patients with suspected pulmonary edema or pneumonia, recording the results and confirming doubtful findings by formal imaging. For education, programs should invest in application-specific, longitudinal training with real-time feedback and competency assessment rather than one-off courses. For health systems, the key investments are protected time, quality assurance, image storage and credentialing.

For research, several priorities emerge. First, multicenter randomized or stepped-wedge trials should test POCUS-guided pathways in well-defined inpatient populations, such as dyspnea, suspected heart failure, hypotension and suspected venous thromboembolism, with outcomes that include length of stay, readmission, mortality, diagnostic yield, harms and cost. Second, trials should report who performed the examination and what level of training they had, so that effects attributable to technology can be separated from those attributable to expert operators. Third, validated, feasible competency assessment tools are needed that can be applied in busy ward environments. Fourth, implementation research should test strategies, such as incentives, protected time and artificial-intelligence guidance for image acquisition and B-line counting (an automated B-line counter was used in the 2025 study), that increase independent use⁴. Fifth, global applicability should be examined, because low-cost handheld devices may be especially valuable where formal imaging is limited.

CONCLUSIONS

POCUS is a diagnostically credible extension of the bedside examination for hospitalized adults. Lung ultrasound is more sensitive than chest radiography for cardiogenic pulmonary edema and has high pooled sensitivity and specificity for pneumonia, and a wider group of cardiac, venous, pleural and abdominal applications is supported by hospital-medicine reviews. The evidence that POCUS improves patient outcomes is promising but not yet conclusive: an unselected-patient randomized trial showed no overall change in length of stay, whereas focused heart-failure and dyspnea studies, including a recent stepped-wedge implementation study, reported shorter stays, lower costs and frequent changes in management.

The benefit of POCUS depends on three conditions: a specific clinical question, an operator who has been trained and supervised to a defined standard, and an organization that provides time, image storage, quality assurance and governance. Independent use by hospitalists remains limited, and the most consistent barriers are insufficient training, lack of time and absence of incentives. Hospital leaders and educators should therefore treat POCUS as a program to be built, not a device to be purchased.

Further multicenter trials with inpatient-specific outcomes and transparent reporting of operator expertise are needed, together with validated competency assessments and implementation research. Until that evidence is available, a reasonable course is to adopt POCUS for well-validated applications, to train and credential clinicians carefully, to document findings and to confirm doubtful results with formal imaging.

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APPENDICES

TABLE 1. Key quantitative findings from the principal sources:

Domain	Source	Design and population	Principal result
Pulmonary edema	Maw et al.[7]	Meta-analysis, 6 studies, 1827 patients	Lung ultrasound more sensitive than chest radiography, similar specificity; about 15 additional cases detected per 100
Pulmonary edema	Chiu et al.[8]	Meta-analysis, 8 studies, 2787 patients	Sensitivity 91.8% versus 76.5%; specificity 92.3% versus 87.0%
Pneumonia	Chavez et al.[14]	Meta-analysis, 10 studies	Sensitivity 94%, specificity 96%, LR+ 16.8, LR- 0.07, with highly skilled operators
Length of stay	Lucas et al.[19]	Randomized trial, 453 medical inpatients	1.7% shorter stay, not significant; shorter in heart-failure subgroup; management changed in 37%
Length of stay and cost	Maganti et al.[4]	Stepped-wedge quality-improvement study, 208 inpatients with dyspnea	Stay 30.3% shorter; 246 bed-days and $751,537 saved; decision changed in 35%
Adoption	Maganti et al.[4]	Same study	Only 20% of POCUS examinations performed independently by hospitalists

Source: Prepared by the authors.