Improving point-of-care ultrasound documentation among emergency medicine residents: a mixed-method implementation research study

Abstract

Objective

To evaluate the effectiveness of a theory-informed, iterative implementation strategy (IS) to improve point-of-care ultrasound (POCUS) documentation compliance among emergency medicine (EM) residents according to American College of Emergency Physicians (ACEP) guidelines in a high-volume emergency department (ED).

Methods

We conducted a 19-month (December 2023–June 2025) mixed-methods implementation study at a tertiary academic ED in India. The Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change guided six iterative IS phases, including education, co-design, workflow optimisation and audit/feedback. Participants were EM residents. The primary outcome was the proportion of POCUS examinations achieving ≥80% compliance with ACEP documentation standards. Compliance trends were analysed across phases and summarised using proportions and medians with IQRs. Qualitative data from five focus group discussions were analysed using CFIR to identify barriers, facilitators and mechanisms of change. Quantitative and qualitative findings were integrated using a joint display.

Results

We assessed 3074 POCUS examinations. The proportion of scans achieving ≥80% compliance increased from 0% at baseline to 35.1% postimplementation. Median compliance rose from 24% (IQR 17–34) to 69% (IQR 54–84). Compliance followed a nonlinear trajectory. Initial phases showed minimal gains (0%–8.7%) due to workflow barriers. A marked acceleration occurred during IS-5 (22.5%) following the introduction of a user-designed, single multimodal form and gamification. Qualitative analysis demonstrated a shift from initial resistance (CFIR: compatibility, complexity) to normalisation (implementation climate), although technical challenges with image archiving persisted.

Discussion

User-centred co-design and peer engagement were key to the improvement, although persistent infrastructure challenges limited further gains and highlighted the need for informatics-enabled solutions. This study demonstrates that low-cost, context-sensitive strategies can enhance POCUS documentation effectively in high-volume, resource-constrained EDs.

Conclusions

A multifaceted, iterative IS guided by theoretical frameworks significantly improved POCUS documentation compliance. User-centred design and participatory engagement were critical mechanisms for sustainable practice change in a resource-variable EM setting.

Trial registration number

CTRI/2024/03/063671.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Point-of-care ultrasound (POCUS) documentation is a well-known quality gap, and most published improvement strategies are not transferable to high-volume, resource-variable settings that lack integrated electronic health records.

WHAT THIS STUDY ADDS

• This mixed-methods study demonstrates that a theory-guided (Consolidated Framework for Implementation Research/Expert Recommendations for Implementing Change) implementation strategy, based on iterative co-design and peer engagement, significantly improved high-quality POCUS documentation (compliance ≥80% rose from 0% to 35.1%).

• Qualitative data showed that user-centred design—specifically a single, co-designed multimodal form—was the critical mechanism for overcoming initial workflow barriers and moving practice from resistance to normalisation.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study offers a feasible and cost-effective roadmap for sustainably enhancing documentation in high-volume settings, demonstrating that significant practice change is achievable without the need for expensive, fully integrated technological infrastructure.

Introduction

Point-of-care ultrasound (POCUS) has fundamentally altered the practice of emergency medicine (EM), improving diagnostic accuracy and procedural safety.1,3 Recognising its impact, POCUS training is now integral to EM residency programmes globally. However, POCUS utilisation frequently outpaces the infrastructure necessary for documentation, quality assurance (QA), and credentialing.⁴ This gap leads to a high prevalence of undocumented examinations, or ‘ghost scans’. This inadequate documentation poses significant risks, including compromised patient safety due to incomplete handovers, lack of QA oversight, medicolegal liability and missed reimbursement opportunities.^{5 6} Robust documentation is also the cornerstone of competency-based learning.^{7 8}

Previous efforts to improve documentation often relied on isolated interventions, such as education or incentives, yielding mixed sustainability.^{6 9} Most quality improvement literature originates from well-resourced settings with integrated electronic health records (EHR).^{10 11} These solutions are often not transferable to high-volume, resource-variable environments, such as India, which face unique structural challenges.12,14 There is a gap in the literature on the use of rigorous implementation science methodologies to address POCUS documentation deficits systematically. Therefore, we aimed to evaluate the effectiveness of an implementation framework-guided, iterative strategy to promote the adoption and implementation of the American College of Emergency Physicians (ACEP) standard reporting guidelines for POCUS among EM residents, in terms of improving adherence to the guidelines, attaining credentialing and enhancing residents’ confidence and proficiency.¹⁵ We hypothesised that a multifaceted, iterative approach would significantly increase documentation compliance.

Methods

Study design and setting

This was a mixed-methods implementation research study, comprising both a quantitative part that measured ultrasound documentation quality and a qualitative part consisting of focused group discussions (FGDs). The study was conducted between December 2023 and June 2025. The emergency department (ED) sees approximately 350 patients daily. Out of this, around 25% receive a POCUS performed by an EM resident. POCUS is usually done in the red and yellow areas, where a cart-based portable ultrasound machine is available in each region. In our study, we employed a multiphase iterative design. Quantitative compliance curves provided objective change markers, while qualitative data offered context, explanation and actionable feedback. This iterative feedback cycle allowed us to revise and re-implement our strategies effectively.

Selection of participants

All EM residents in the residency programme were included in the study, except those who had not completed POCUS training. All EM residents performing POCUS in the ED were assessed for eligibility. 23 EM residents were enrolled in the quantitative component after written informed consent. All enrolled residents were exposed to the implementation strategies as part of the department-wide workflow change. Participation in qualitative data collection was purposive and based on availability during off-shift hours. Five focus group discussions (FGDs) were conducted at sequential time points with 8, 12, 5, 11 and 9 participants, respectively, to explore the facilitating factors and barriers.

Interventions

The study used implementation frameworks to guide implementation. The Consolidated Framework of Implementation Research (CFIR) helps identify determinants of implementation.¹⁶ The Expert Recommendations for Implementing Change (ERIC) project provided a comprehensive and refined compilation of implementation strategies.¹⁷ The ERIC has compiled 73 distinct implementation strategies. We employed six implementation strategies in this research as follows.

Preimplementation phase: (14 December 2023 to 15 February 2024) baseline data collection.

Implementation strategy 1 (IS-1:16 February−10 May): Education and training. An education and training session was conducted for all EM residents on the ACEP Emergency Ultrasound Guidelines and the utility of standard reporting guidelines.

IS 2 (IS-2:11 May to 10 October) Co-creation and co-design. A working group of academic research team, one ultrasound faculty, three ED leadership (ED faculty) and ED providers (end users) collaborated on designing and implementing the new POCUS documentation process. We co-created and co-designed our ED POCUS documentation templates (online supplemental S2 figure 1). Pilot testing of these co-designed POCUS documentation templates was done.

IS 3 (IS-3: 11 October–30 November) Foundation-building and barrier-elimination package: The pilot-tested and modified documentation process was rolled out across all areas of the ED. Training materials and ongoing support were provided, including image archival techniques.

IS 4 (IS-4: 1 December–15 January) Driven innovation and quality enhancement package: Considering the ideas and strategies suggested by the EM residents during the FGD, new strategies are developed and implemented. Implement automated reminders and prompts.

IS 5 (IS-5:16 January–15 March) Comprehensive optimisation and excellence-driven package: Regular chart audits were conducted to monitor the quality and completeness of POCUS documentation. Feedback on residents’ performance was provided regularly. 5-minute POCUS competitions were conducted, where the best performers were rewarded (online supplemental S2 figure 2A,B).

IS 6 (IS-6:16 March–31 May) Advanced technology integration and excellence sustainment package: Identified and trained a small group of ‘champions’. We implemented strategies suggested during the FGD, like a ‘3-shifts-pendrive’ system for manual image retrieval, supported by a standard Google Drive (online supplemental S2 figure 2C,D).

Postimplementation phase sustainability and consolidation package (June): data were collected to assess the maintenance of the effects of the implementation strategies to sustain the achieved improvement in documentation. We encouraged residents to submit stored scans with the documentation for quality review.

Iterative refinement occurred via five FGDs conducted at key intervals (iterative processes 1–5) to analyse feedback, identify barriers and enablers, and modify the IS (figure 1). POCUS documentation templates were refined and modified based on the ideas and suggestions in FGDs.

Figure 1. Project timeline. ACEP, American College of Emergency Physicians; ED, emergency department; EM, emergency medicine; EMR, electronic medical record; FGD, focus group discussion; I-POCUS, integrated point-of-care ultrasound; RESUS,Resuscitation room; US, ultrasound.

Measurements

Quantitative

Proportion of ultrasound examinations done by emergency residents that comply with the standard reporting guidelines for POCUS in ED: This is collected by reviewing all samples of ultrasound examinations conducted by emergency residents in all areas of ED over the 19-month implementation period. The principal investigator collected all samples during their shifts. EM residents’ confidence and proficiency using the ACEP guidelines for reporting POCUS were measured using survey questionnaires. Because the primary outcome was scan-level documentation compliance rather than longitudinal follow-up of a fixed resident cohort, loss to follow-up was not applicable to the main quantitative audit. The confidence surveys were cross-sectional at the preimplementation and postimplementation time points and were not analysed as paired repeated measures.

Qualitative

Qualitative data from FGDs were collected as audio recordings, stored as MP4 files, and later transcribed and used. After adequately training in qualitative research, the principal investigator conducted FGDs using an FGD guide (online supplemental S3). Five FGDs were held at different time intervals. Transcripts of five FGDs were analysed based on the frameworks of CFIR; five domains were discussed. Thematic analysis used the CFIR, with construct ratings ranging from +2 (strong positive influence) to −2 (strong negative influence) (online supplemental S1 table 1).

Outcomes

Primary objective

To estimate the change in proportion of ultrasound examinations done by EM residents that have ≥80% compliance with the standard reporting guidelines for POCUS in the ED.

Secondary objectives

To determine the impact of implementing the ACEP standard reporting guidelines on credentialing. To evaluate the EM residents’ confidence and proficiency. To identify the factors that facilitate or hinder the adoption and implementation of the standard reporting guidelines.

Patient and public involvement

Patients and the public were not involved in this research’s design, conduct, reporting, or dissemination plans. This quality improvement study was focused on the professional documentation practices and educational workflow of EM residents.

Statistical analysis

Quantitative

POCUS documentations were collected as pictures using a mobile device, and content was entered manually into Google Forms linked to Excel sheets. These were connected to Excel sheets, which were coded, cleaned, and analysed using Stata software (V.17). Categorical outcomes were summarised as counts and percentages, and continuous or ordinal compliance scores were summarised using medians and IQRs. The primary outcome was the proportion of scans achieving ≥80% compliance with ACEP documentation standards across implementation phases. Differences in proportions across phases were assessed using χ² test for trend or χ²/Fisher’s exact test, as appropriate. Median compliance across phases was compared using non-parametric methods. Given the quality-improvement design of the study, the quantitative analysis was primarily descriptive. The Cochran-Armitage test for trend was conducted to evaluate whether there was a linear increase in the proportion of compliant scans across implementation phases.

Qualitative

Manual descriptive content analysis was employed to scrutinise the transcripts, with individual statements as the primary analysis unit. A hybrid approach, combining inductive and deductive coding, was utilised to derive codes from the data. These codes were then organised into overarching themes utilising the CFIR model. Additional codes were generated by OpenAI’s GPT-5¹⁸ and Manus.ai software¹⁹ and manually verified. These findings were used as input for the CFIR-ERIC barrier buster tool, which identified high-priority strategies. Integrating quantitative and qualitative findings was achieved through a joint display, which aligned compliance trends with corresponding qualitative insights.

Results

Characteristics of study subjects

23 residents were initially enrolled in the trial after obtaining informed written consent. Online supplemental S1 table 2 summarises baseline data for 23 EM residents. Of these, 39% were first-year, 44% second-year and 17% third-year trainees. Before the study, 61% had received formal POCUS training. Notably, none of the residents used the ACEP-recommended reporting guidelines at baseline.

A total of 3074 scans were assessed. Compliance has shown a consistent upward trend, especially after January 2025. In the preimplementation phase and IS-1, 0% of scans achieved ≥80% compliance. Compliance started to increase slightly in IS-2 (4.2%) and IS-4 (8.7%). From January to March 2025 (IS-5), approximately 23% of the documents achieved ≥80% compliance. The highest number of documents with ≥80% compliance was recorded between March and May 2025 (IS-6), with 191 documentation, representing 29% of that phase. In the final phase, June 2025, compliance peaked across all thresholds, with 35% of documents achieving ≥80% compliance and 80% reaching ≥50% compliance (online supplemental S4 table 1). 489 scans (15.9%) reached the ≥80% benchmark, reflecting steady improvement with iterative strategies (table 1).

Table 1. Proportion of scans achieving ≥80% compliance^* with ACEP documentation standards across implementation phases.

Implementation phase†	Total scans (N)	≥80% compliant scans (n, %)
Preimplementation (14 December 2023–15 February 2024)	91	0 (0.0)
IS-1: Education and training (16 February–10 May 2024)	215	0 (0.0)
IS-2: Co-creation and co-design (11 May–10 October 2024)	549	23 (4.2)
IS-3: Foundation building and barrier elimination (11 October–30 November 2024)	269	8 (3.0)
IS-4: User-driven innovation and quality enhancement (1 December 2024–15 January 2025)	378	33 (8.7)
IS-5: Comprehensive optimisation and excellence package (16 January–15 March 2025)	683	154 (22.5)
IS-6: Advanced technology integration and sustained excellence (16 March–31 May 2025)	661	191 (28.9)
Postimplementation: Sustainability and consolidation (June 2025)	228	80 (35.1)
Total	3074	489 (15.9)

^*Compliance is defined as scans achieving ≥80% of ACEP documentation elements, including image archiving and structured reporting.

^†Intervention phases represent sequential implementation strategies (IS-1 to IS-6), followed by a postimplementation consolidation phase.

ACEP, American College of Emergency Physicians; IS, implementation strategy.

The Cochran-Armitage test yielded a χ² statistic of 302 with 1 df (p<0.001), providing strong statistical evidence that the proportion of scans meeting the ≥80% compliance threshold increased steadily over implementation phases.

Median POCUS documentation compliance also increased across phases, rising from a median of 24 (IQR 17–34) in the preimplementation phase to 69 (IQR 54–84) in the postimplementation phase (online supplemental S4 figure 1).

There was a sharp increase in compliance beginning in January 2025, marking a clear shift from the consistently low rates of the previous year. This upward trend peaked in March 2025 at 32.1% and in June, reaching the highest compliance rate of 35.1% (figure 2).

Figure 2. Trend run chart of monthly compliance with case volume. FGD, focus group discussion; I-POCUS, integrated point-of-care ultrasound.

As detailed in online supplemental S4 table 2, the proportion of scans achieving ≥80% compliance increased progressively across all residency years following implementation. Second-year residents contributed the most to overall compliance gains, while the highest compliance rates across all resident groups were observed in June 2025, reflecting the sustained impact of ongoing quality improvement interventions.

Use of the co-designed POCUS documentation forms increased progressively over the study period. Uptake increased during IS-2 (19.7%) and rose markedly during IS-3 (63.2%). From IS-5 onwards, adoption was sustained at 64.4%–79.8% (see online supplemental S4 table 3).

Modality-specific analysis revealed that thoracic had the highest overall compliance (47.6% of compliant scans). Cardiac echo followed with 116 compliant cases (23.7%). Smaller modalities had a negligible impact on compliance outcomes (see online supplemental S4 table 4). Following the implementation, residents demonstrated a marked improvement in confidence in performing POCUS exams (65.6% confident postimplementation vs 43.5% preimplementation) (online supplemental S4 table 5).

Qualitative results

The five FGDs qualitative findings highlighted barriers and facilitators mapped to the CFIR framework (online supplemental S6 figure 1 and 2). In FGD 1, primary barriers included form accessibility (available resources −2), double documentation (complexity −1) and workflow integration (compatibility −1). Primary enablers included perceived superiority (relative advantage +2). In FGD 2, primary barriers identified were multiple form complexity (complexity −2) and resource accessibility (available resources −1). Primary facilitators identified included peer innovation (adaptability +1). In FGD 3, primary barriers included resource accessibility (available resources −1) and workflow integration issues (compatibility −1). Primary enablers included strong relative advantage (+2) and increased adherence. In FGD 4, facilitators included complete system adoption (implementation climate +2), strong user engagement and innovation capacity. The focus has shifted from overcoming barriers to enhancing excellence and implementing advanced features. In FGD 5, the significant barriers were technical infrastructure and resource management (available resources −2). Strong facilitators included external recognition (cosmopolitanism +1) and documentation success. Qualitative findings were mapped to the CFIR framework, and implementation strategies were identified using the CFIR-ERIC barrier buster tool (RISOME Query tool). Detailed CFIR-based mapping of FGDs and corresponding implementation strategies are provided in the online supplemental S5 tables S5.1–S5.10. The evolution of intervention components across iterative cycles is illustrated in online supplemental S5 figures S5.1–S5.3. Figure 3 illustrates the CFIR framework with mapped FGD themes.

Figure 3. CFIR framework with mapped FGD themes. ACEP, American College of Emergency Physicians; CFIR, Consolidated Framework for Implementation Research; FGD, focus group discussion; POCUS, point-of-care ultrasound.

Integration of findings

The joint display (table 2) demonstrates a progressive improvement in POCUS documentation compliance across sequential implementation strategies. While quantitative data showed negligible early gains (0%–4% ≥80% compliance during IS-1 and IS-2), qualitative findings explained these results stemming from workflow barriers, double documentation and resistance to new routines. The introduction of a multimodality form (IS-4–5), supported by gamification, feedback and peer champions, marked a breakthrough, raising ≥80% compliance to 32% by March 2025.

Table 2. Joint display of quantitative compliance trends and qualitative insights across implementation phases.

Implementation phase and strategy	Quantitative results (≥80% compliance, median %, IQR)	Qualitative insights (FGDs/themes)	Verbatims	Integrated interpretation
Preimplementation (December 2023–February 2024)	0% scans ≥80% compliance; Median 24%, IQR 18	Barriers: lack of training on standard reporting guidelines, existing habits and lack of standard documentation proforma.	“Previously we were writing in the case sheet, no standard forms”	Baseline data collection before implementation of the intervention tool. Residents practising traditional methods of POCUS documentation explain negligible compliance
IS-1: Education and training (February–May 2024)	0% ≥80% compliance; Median 21%, IQR 23	Themes: double documentation, ‘new routine difficult’, lack of integration in ED case records and resistance to changing existing habits.	“Previously we wrote in one sheet, now another form…slightly difficult”	Education alone is insufficient, without integration and reinforcement, compliance stalls. Early resistance and workflow burden explain negligible compliance despite awareness of the need.
IS-2: Co-creation and co-design (May–October 2024)	4% ≥80% compliance; Median 27%, IQR 19	Facilitators: resident ownership, certificate motivation. Barriers: complexity, form inaccessibility and resource gaps.	“We don’t know where exactly the forms are”	Pilot co-design fostered ownership, but limited resources slowed adoption.
IS-3: Foundation building and barrier elimination (October–November 2024)	3% ≥80% compliance; Median 31%, IQR 33	Themes: form inconsistencies, need for simpler templates, resistance softening, limited incentives, Patient overload, time constraints	“During a busy shift, compliance goes down” “If writing is enough, compliance will improve” “Compliance slowly changes with time.”	Median % rose as residents adapted (phased adoption strategy), but structural issues limited high compliance.
IS-4: User-driven innovation and quality enhancement (December 2024–January 2025)	9% ≥80% compliance; Median 38%, IQR 31	Themes: demand for a single multimodal form, strong champion engagement.	“If in one form, we can attach all the modalities and integrate them in the case sheet.” “I made my single form with commonly used modalities.”	User-driven solutions sparked gradual improvement; innovation began to replace resistance.
IS-5: Comprehensive optimisation (January–March 2025)	23% ≥80% compliance; Median 62%, IQR 45	Facilitators: introduction of a single multimodal form, gamification, confidence in core modalities with willingness to change and feedback. Barriers: resource limits.	“Single form happened…documentation is easy, recording takes time.” “5-minute POCUS competition, rewards, regular reminders, training sessions during off shifts needed.”	Breakthrough phase: common multimodality form drove cultural shift. Structured optimisation and engagement strategies produced rapid compliance gains.
IS-6: Advanced technology integration (March–May 2025)	29% ≥80% compliance; Median 65%, IQR 46	Themes: sustainability challenges (video capture, time burden), desire for tech solutions.	“Video recording takes too much time; pen drives get lost.”	Tech adoption raised compliance but plateaued due to workflow integration challenges.
Postimplementation: Sustainability and consolidation (June 2025)	35% ≥80% compliance; Median 69%, IQR 30	Facilitators: shared responsibility, senior support, external validation, peer collaboration. Barriers: storage/device issues.	“Documentation is now routine, but resources are still a challenge” “Even other departments relying on our POCUS documentation”	Compliance normalised; consolidation emphasised sustainability over rapid gains.

ED, emergency department; FGD, focus group discussion; IS, implementation strategy; POCU, point-of-care ultrasonography.

Limitations

Limitations include the single-centre scope and potential Hawthorne effects, such as reliance on paper-based documentation, which limits transferability to fully digital environments. The principal investigator conducted data collection during their shifts. While this approach ensured consistency, it is important to acknowledge the variability in the number of scans captured per phase and the potential for missed samples (such as patients quickly being moved out of the ED). We could not integrate the co-designed POCUS documentation forms into existing ED case records, a strategy suggested across FGDs by residents. This might have helped in achieving a higher compliance rate. The initial goalpost was set high at 80%. Although 35.1% ≥80% compliance was achieved, significant progress was observed at lower cutoffs. The 19 month timeline may not fully capture the stabilisation of the implementation curve. Furthermore, persistent barriers discussed throughout the study, such as the lack of funds for sustained incentive programmes and the non-integration of POCUS forms into the existing ED case record—a strategy consistently requested in FGDs-likely hampered further gains. The primary quantitative analyses were not adjusted for potential confounders such as residency year, prior POCUS experience, modality mix or case volume. Although subgroup analyses by residency year and modality showed broadly similar improvement patterns across phases, these were exploratory and do not replace a fully adjusted analysis. Therefore, the observed improvements should be interpreted as phase-level associations rather than causal effect estimates. Selection bias is also possible, particularly in the qualitative component, because residents who participated in focus groups or engaged more actively with the intervention may have been more motivated towards POCUS documentation.

Discussion

This mixed-methods implementation research study evaluated the effectiveness of a theory-informed, iterative strategy to improve POCUS documentation among EM residents in a high-volume academic tertiary centre in India. Using the Consolidated Framework for Implementation Research and the ERIC, the study aimed to enhance adherence to documentation guidelines and workflows.^{16 17 20} Over 19 months, the study demonstrated a significant transformation in documentation practices. There might be a Hawthorne effect because scan documentation was collected by a single investigator; this can be reduced by phase-wise, routine data collection during usual clinical practice and by using predefined objective documentation criteria rather than subjective assessment and data capture by a third person or an automated system.

The proportion of scans achieving the rigorous benchmark of ≥80% compliance increased from 0% at baseline to 35.1% postimplementation, with median compliance reaching 69%.

The study’s central finding is that sustainable improvement in POCUS documentation is achievable in a resource-variable setting through a multifaceted, adaptive approach. The observed documentation compliance followed a nonlinear S-shaped trajectory, highly consistent with diffusion-of-innovations theory.²¹ The initial phases (IS-1 to IS-3), spanning nearly a year, showed minimal quantitative gains (0%–4% compliance). This prolonged lag phase reflects inherent resistance to new routines and significant structural barriers. The initial stagnation underscores a fundamental principle of implementation science: education alone (IS-1) cannot change practice.²²

The joint display analysis reveals a clear linkage between compliance trends and contextual determinants. During the preimplementation phase and IS-1, 0% of scans were compliant. The introduction of co-creation and pilot testing (IS-2) yielded a modest 4% compliance. However, FGD-1 revealed significant barriers. While residents recognised the relative advantage (CFIR construct) of standardised documentation, this was overwhelmed by complexity (double documentation) and compatibility issues (workflow disruption, difficulty locating forms).

The critical turning point occurred with implementing the single common multimodality POCUS form in January 2025 (start of IS-5). This innovation, combined with the ‘comprehensive optimisation’ package (IS-5)—including feedback, competitions and rewards—led to a rapid acceleration in compliance (from 9% in IS-4 to 22.5% in IS-5). The rapid acceleration observed from January 2025 (IS-5) onwards signifies that the implementation efforts reached a critical mass, aligning with threshold and tipping dynamics diffusion concepts.²³ This breakthrough phase demonstrated that addressing the ‘complexity’ barrier through user-driven design was essential for widespread adoption.

IS-6 and the postimplementation phase represented a transition to advanced features while sustaining core success. Compliance reached a peak of 35.1% but plateaued. FGD5 explained this plateau by highlighting persistent workflow integration challenges, particularly regarding video recording and resource constraints (eg, lost pen-drives).

The commitment to participatory research was a critical mechanism. This engagement was pivotal in transforming initial resistance into active innovation. The participatory approach ensured the intervention was contextually appropriate and sustainable by fostering ownership and accountability.^{24 25} The study fostered a favourable implementation climate (+2 in later FGDs). Strategies such as gamification (POCUS competitions), structured feedback and identifying peer champions transformed documentation from an administrative burden to a shared quality improvement goal.^{9 26}

Improvements were not uniform across modalities. Gains were concentrated in high-volume scans. Thoracic ultrasound showed the most substantial improvement. This emphasises that implementation strategies cannot be ‘one-size-fits all’.

Despite the significant gains, the study highlights persistent challenges. The demands of a high-volume ED remained a significant barrier (compatibility −1).^{25 27} A critical infrastructural gap was the lack of an integrated image-archiving system—reliance on manual processes introduced friction and failures. In contrast, automated EHR-integrated workflows and archival to Picture archiving and communication system (PACS)/POCUS repositories have increased documentation completion and eased QA downstream.^{10 11} This study demonstrates that low-cost co-designed tools can normalise documentation in resource-variable contexts even without full automation.

Clinical implications

This study’s findings have direct clinical implications. By significantly improving POCUS documentation, our low-cost, iterative strategy enhances patient safety and continuity of care by ensuring critical findings are readily available for clinical handovers. This intervention creates a formal, auditable record for medicolegal accountability and provides the essential foundation for a robust QA and credentialing programme. While our study proves that sustainable improvement is feasible in resource-variable settings without an integrated EHR, the ideal next step for institutions is to prioritise embedding standardised POCUS documentation into the ED’s electronic medical record. Investment in secure, centralised image archiving solutions (PACS) remains crucial for long-term QA and medico-legal safety.^{28 29} On a national level, where ED-specific POCUS documentation standards are often lacking,¹⁴ our experience provides context-sensitive, feasible building blocks that can inform future guidance. Future studies across multiple centres should look at whether these findings hold in other settings and whether the improvements can be sustained over time. Using better integrated image-archiving platforms and collecting more detailed scan-level data would permit adjusted analyses of how implementation strategies influence documentation quality.

Conclusions

In summary, this study demonstrates that an iterative, CFIR-guided, mixed-methods approach can significantly and sustainably improve POCUS documentation compliance. Combining user-centred design, continuous feedback and champion engagement was critical for overcoming initial resistance and fostering innovation. Sustaining and maximising these improvements requires ongoing attention to workflow integration and investment in technical infrastructure for image archiving.

Data availability statement

Data are available on reasonable request.