Highlight
– Cardiopulmonary POCUS integrated into hospitalist workflows reduced average length of hospital stay by 30.3%.
– The intervention led to a cumulative saving of 246 hospital bed-days and over $750,000 in direct hospitalization costs.
– Despite comprehensive training, hospitalist independent adoption of POCUS was limited, with 80% of examinations performed by sonographers.
– POCUS guided changes in medical management decisions in 35% of patients assessed.
Study Background and Disease Burden
Dyspnea is a common and clinically challenging symptom in hospitalized adults, with a broad differential diagnosis spanning cardiac, pulmonary, and systemic etiologies. In internal medicine wards, patients frequently present with undifferentiated dyspnea requiring timely diagnostic assessment to guide management. Traditional approaches often rely on physical examination, chest X-rays, laboratory tests, and specialist consultations, which may lead to delays, increased length of stay (LOS), and greater healthcare costs.
Point-of-care ultrasonography (POCUS) of the heart and lungs has emerged as a compelling bedside imaging modality, providing rapid, non-invasive, and dynamic evaluation that can aid in early diagnosis, risk stratification, and therapeutic decisions. While cardiopulmonary POCUS has demonstrated diagnostic accuracy and clinical utility in emergent care settings, its impact on hospital efficiency metrics including LOS and cost in an internal medicine context remains unclear. Furthermore, operationalizing POCUS integration into routine hospitalist workflows requires collaborative models that support skill acquisition and quality assurance.
Study Design
This quality improvement study utilized a type 1 effectiveness-implementation hybrid design with a 6-month stepped-wedge cluster randomized trial format conducted at a tertiary care US hospital from December 7, 2023, to July 2, 2024. The study enrolled adults aged 18 years or older admitted to internal medicine teaching hospitalist teams with undifferentiated dyspnea.
Five hospitalist teams were randomized sequentially to receive the intervention, consisting of structured cardiopulmonary POCUS evaluations performed by hospitalists and/or sonographers, supported remotely by a cardiologist. The control period involved standard care without POCUS implementation.
The primary study outcomes were length of stay (LOS) and hospitalization costs, interpreted within a RE-AIM (reach, effectiveness, adoption, implementation, maintenance) evaluation framework.
Key Findings
The study population included 208 patients (median age 71 years, interquartile range 59–80; 58% female), subdivided into 107 control patients and 101 in the POCUS intervention group.
Effectiveness: Implementation of cardiopulmonary POCUS was associated with a statistically and clinically significant 30.3% reduction in LOS. The mean LOS decreased from 11.9 days (SD 7.5) in controls to 8.3 days (SD 5.2) in the POCUS group (95% CI for reduction 5.5% to 48.9%). This translated into a total of 246 bed-days saved cumulatively.
Cost Impact: Direct hospitalization cost savings of $751,537 were realized in the POCUS group, with incremental cost-effectiveness of $3,055 per hospital bed-day saved, demonstrating favorable economic value.
Clinical Decision-making Impact: Cardiopulmonary POCUS findings prompted alterations in medical management in approximately 35% of patients assessed (30 cases), underscoring the modality’s influence on real-time clinical choices.
Adoption and Implementation: Despite comprehensive training programs, hospitalists performed only 20% (17 patients) of POCUS examinations independently, with the majority relying on sonographers. This limited direct adoption emphasizes ongoing challenges in competency retention, workflow integration, and motivation.
Expert Commentary
The study robustly demonstrates that integrating cardiopulmonary POCUS into routine hospitalist assessment can reduce LOS and costs, contribute to more precise diagnosis, and guide management of complex dyspnea presentations. These outcomes align with emerging evidence supporting POCUS as a high-yield diagnostic adjunct in internal medicine.
However, the observed limited uptake by hospitalists highlights barriers such as the steep learning curve, time constraints, and lack of incentives that are commonly cited in point-of-care ultrasound implementation literature. The reliance on sonographers indicates a possible transitional model but could delay scalability and sustainability.
Future multicenter trials are warranted to optimize tailored training programs, implement tele-support mechanisms, and evaluate professional incentives to embed POCUS as a standard competency among hospitalists. Studies should also examine patient-centered outcomes such as morbidity, readmissions, and long-term functional recovery to further justify widespread adoption.
Conclusion
Cardiopulmonary POCUS presents a transformative tool in the hospitalist management of undifferentiated dyspnea, offering measurable benefits in reducing hospital length of stay and associated costs without compromising diagnostic accuracy. The collaborative model involving hospitalists, sonographers, and remote cardiology expertise facilitates pragmatic implementation.
Overcoming the challenges of hospitalist adoption requires continuous skill development, institutional support, and incentivization. This quality improvement study provides compelling evidence to inform policy and clinical practice reforms aimed at integrating POCUS into routine hospital medicine care pathways, ultimately enhancing patient outcomes and healthcare efficiency.
References
Maganti K, Chen C, Jamthikar AD, Parikh P, Yanamala N, Sengupta PP. Cardiopulmonary Point-of-Care Ultrasonography for Hospitalist Management of Undifferentiated Dyspnea. JAMA Netw Open. 2025 Sep 2;8(9):e2530677. doi:10.1001/jamanetworkopen.2025.30677. PMID: 40911308; PMCID: PMC12413653.
