Point-of-care ultrasound (POCUS) has become an important diagnostic and monitoring modality in the management of critically ill and injured patients (1). Performed and interpreted at the bedside by the treating physician, POCUS provides rapid assessment of hemodynamics and organ pathology and can improve diagnostic accuracy, clinical decision-making, and procedural safety across a wide range of emergency presentations (2). In emergency medicine, POCUS is most commonly used in the form of focused assessment with sonography for trauma (FAST) or extended FAST in trauma, lung ultrasound in acute respiratory failure, and focused cardiac ultrasound during resuscitation (3–5). In Chinese EDs, trauma and injury-related complaints constitute a substantial proportion of visits (around one-third in some hospitals), which further underscores the clinical relevance of FAST and extended FAST in routine practice (6).

Despite these advantages, real-world POCUS utilization by emergency and critical care physicians remains highly variable. Surveys from high-income countries show that many emergency departments (EDs) still do not have mature POCUS programs and that use is strongly influenced by institutional context and physician training (7–10). In some national and regional surveys, only a minority of EDs report routine use of physician-performed POCUS, with substantially higher adoption in academic than in community hospitals and with marked variation in indications, training requirements and quality-assurance processes (9, 10). Multispecialty critical care surveys similarly indicate that most clinicians report at least occasional use of cardiac, lung or abdominal POCUS, but only a subset use these applications routinely in key scenarios such as undifferentiated hypotension or in-hospital cardiac arrest (11, 12). Across these studies, limited training opportunities, lack of competency and the absence of structured quality-assurance systems are repeatedly identified as major barriers to broader POCUS utilization.

In China, interest in POCUS within emergency and critical care practice has expanded rapidly, and national expert groups have begun to promote standardized training, competency-based curricula and quality-control frameworks for bedside ultrasound (13). However, China’s tiered healthcare system may introduce additional structural disparities in POCUS utilization (14). Tertiary teaching hospitals typically have greater access to ultrasound equipment, subspecialty expertise and formal training opportunities. In contrast, secondary and non-teaching hospitals, particularly those in less developed regions, may face constraints related to staffing, equipment and educational resources. Existing Chinese studies have largely focused on single centers, specific specialties such as intensive care, anesthesiology or prehospital care, or individual applications such as FAST or focused cardiac ultrasound, and have emphasized technical performance rather than patterns of use in routine emergency care. Consequently, comprehensive multicenter data describing how often POCUS is used by emergency physicians, in which clinical scenarios it is applied and how physician- and hospital-level factors influence its utilization remain limited.

Against this backdrop, we conducted a multicenter cross-sectional questionnaire survey of emergency physicians in Henan Province, China. Our objectives were to describe how frequently and in which clinical scenarios POCUS is used, to summarize POCUS-related training and self-perceived competence, and to examine physician- and hospital-level characteristics associated with POCUS utilization. By clarifying patterns and factors associated with POCUS use in this large provincial sample, this study aims to provide empirical evidence to inform future training strategies, equipment planning and policy development for emergency POCUS in China.

In this multicenter cross-sectional survey of emergency physicians in Henan Province, more than half of respondents reported any current use of POCUS in their clinical practice, yet 44.1% reported not using POCUS at all. Among users, procedural guidance and FAST or extended FAST were the most common applications, whereas routine use during cardiac arrest was uncommon and self-rated competence was modest; among non-users, lack of an ultrasound machine in the ED and lack of skills were the leading reported barriers. In multivariable logistic regression analyses, higher educational level and working in tertiary and teaching hospitals were independently associated with POCUS use, and in a sensitivity model that additionally adjusted for hospital bed size and annual ED volume, the association with tertiary status was attenuated while larger bed size and higher ED volume remained strongly associated with POCUS use.

Our findings are consistent with international survey literature showing that POCUS diffusion is heterogeneous and closely tied to institutional capacity (7, 15). In a California ED survey, bedside ultrasound adoption differed markedly by institutional setting and was higher in academic environments than community sites, with variation in availability, credentialing, and quality assurance processes (7). These observations parallel our sensitivity analysis. In that analysis, hospital bed size and annual ED volume were strongly associated with POCUS use, whereas the association with tertiary hospital status was attenuated and no longer statistically significant. This pattern suggests that “hospital grade” may function partly as a proxy for resource capacity and clinical throughput rather than as an independent factor.

Barriers identified in our survey align with multispecialty critical care survey data indicating that lack of training, perceived competency gaps, and absence of structured quality support are common obstacles to broader uptake (15, 16). Because ED equipment data were not collected in the same way for all respondents and we did not independently verify machine availability, reports of “no ultrasound machine in the ED” should be interpreted as perceived lack of accessible equipment rather than a definitive absence of ultrasound capability. Taken together, these findings support an implementation strategy that combines equipment planning with scalable competency-based training and ongoing quality oversight (17). Conceptually, this is consistent with the broader view of POCUS as a clinician skill that requires longitudinal supervised practice and feedback rather than a one-time course. In lower-volume settings, such training could be delivered through a combination of brief focused courses, supervised scanning logbooks, periodic image review, and regional or tele-mentoring networks that allow clinicians to obtain feedback on recorded examinations. For cardiac arrest, practical approaches include predefining a POCUS operator within the resuscitation team, limiting image acquisition to brief pauses during rhythm checks, and using standardized protocols that specify when to defer ultrasound if views are inadequate or if image acquisition would prolong chest compression interruptions.

In our cohort, procedural guidance and FAST or extended FAST were the most frequently reported applications. This pattern is consistent with the long-standing role of FAST in trauma triage and the widespread use of ultrasound guidance for bedside procedures in emergency care. However, POCUS use during cardiac arrest was not routine. This finding is consistent with data from intensive care settings, where POCUS is often used selectively during cardiac arrest rather than as a standard component of every resuscitation. In a national survey of ICUs in the Department of Veterans Affairs, clinicians reported limited formal training, uncertainty about indications and how best to integrate POCUS into resuscitation, as well as concerns about interfering with chest compressions, as important barriers to more widespread use (12). In a prospective cohort study, use of POCUS during resuscitation was associated with prolonged pauses in cardiopulmonary resuscitation, reinforcing concerns that ultrasound may disrupt workflow if it is not carefully integrated into the arrest algorithm (18). These convergent findings across ED and ICU contexts suggest that increasing ultrasound use during resuscitation may require targeted training focused on rapid image acquisition and interpretation with strict attention to minimizing interruptions to chest compressions, together with local protocols that integrate POCUS into resuscitation roles and timing and clearly define when ultrasound should be deferred.

In the primary adjusted model, higher educational level and institutional factors were associated with POCUS use. In the sensitivity analyses, the association between tertiary hospital status and POCUS use was attenuated after additional adjustment for hospital size and ED volume, whereas larger hospital size and higher ED volume remained strongly associated with POCUS use. This pattern is plausible because larger hospitals and higher-volume EDs typically have greater access to equipment, more opportunities for supervised scanning and stronger educational infrastructure, and hospital grade, bed size and ED volume are conceptually overlapping and likely correlated. From a policy perspective, these findings suggest that closing the equipment gap and expanding structured training access in smaller or lower-volume settings may be more impactful than interventions anchored solely to hospital grade. Overall, because this study is cross-sectional and relies on self-reported measures, all regression results should be interpreted as associations rather than causal effects.

Age showed borderline significance in the primary model and became statistically significant in the sensitivity model, with a small effect size. This may reflect residual confounding by practice environment or differences in clinical experience not fully captured by professional title. Given the modest magnitude and threshold sensitivity, this finding should be interpreted cautiously and viewed as hypothesis-generating.

This study has several strengths, including a large physician sample across a wide range of public secondary and tertiary hospitals in a major province and the simultaneous examination of physician- and hospital-level characteristics. Limitations should also be considered. First, because the survey was disseminated by local coordinators and participation was voluntary, we could not determine how many eligible physicians actually received the link or calculate a physician-level response rate, so selection bias is possible and POCUS use may be overestimated. In addition, our sampling frame was restricted to public secondary and tertiary hospitals with at least 500 inpatient beds, and hospital identifiers were not collected, so we could not account for potential within-hospital clustering. These findings are therefore most directly applicable to mid- to large-sized public hospitals in Henan Province, and POCUS diffusion in smaller primary or rural hospitals is likely lower than suggested by our estimates. Second, eligibility was restricted to physicians with at least 3 years of emergency medicine experience, so junior physicians and residents were not represented and patterns of POCUS use and associations with age, educational level and professional title may differ in these groups. Third, all data were self-reported, and the primary outcome captured any current POCUS use rather than routine or time-bound use, while self-rated POCUS skill level and perceived impact on clinical decision-making reflect subjective perceptions rather than objective performance or clinical outcomes. In addition, we compared POCUS users and non-users across multiple physician- and hospital-level variables and reported percentages for numerous multi-response items without formal adjustment for multiple testing, so these exploratory comparisons should be interpreted with caution because some statistically significant differences may reflect chance. Fourth, ED equipment availability was not measured in the same way for all respondents and equipment was not independently verified, so responses about “no ultrasound machine in the ED” should be interpreted as perceived lack of access rather than definitive absence of ultrasound capability. Fifth, although the survey platform restricted submissions to one per IP address, this approach may not fully prevent duplicate participation and may also have excluded some eligible physicians who shared a workstation or network.

In this large provincial survey of emergency physicians, POCUS use was common but unevenly implemented, with persistent barriers related to equipment and training and limited routine use during cardiac arrest. Institutional context and resource-related capacity appeared to be important correlates of POCUS uptake. These findings support targeted strategies combining equipment provision, competency-based training pathways, and programmatic quality support to expand effective POCUS integration in emergency care.