Implementation and Adoption of Neonatal Point-of-Care Ultrasound Across a Regional Collaborative: A Multicenter Survey

Implementation and Adoption of Neonatal Point-of-Care Ultrasound Across a Regional Collaborative: A Multicenter Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Implementation and Adoption of Neonatal Point-of-Care Ultrasound Across a Regional Collaborative: A Multicenter Survey Indrani Bhattacharjee, Sfurti Nath, Romal Jassar, Tanzeema Hossain, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8951146/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Objective To characterize program maturity, infrastructure readiness, and clinical integration of neonatal point-of-care ultrasound (POCUS) across a regional collaborative. Study Design: Cross-sectional survey of neonatal intensive care units participating in the New England Regional POCUS Collaborative. A 34-item survey assessed experience, integration, quality assurance (QA) processes, documentation practices, and training strategies. Data were analyzed descriptively. Result Twenty-eight responses representing predominantly academic NICUs were analyzed. Most programs were early in development, with 69% self-identifying as emerging and 89% reporting fewer than three years of experience. Procedural applications were most common, whereas diagnostic uses were less consistently integrated. Although 62% reported moderate-to-high institutional support, only 23% had established QA processes and routine documentation was uncommon. Conclusion Neonatal POCUS adoption is widespread but developmentally early. Predominance of procedural use and limited integration into major clinical decision-making suggest that maturation of governance structures and training frameworks may be necessary to support sustainable diagnostic expansion Health sciences/Health care/Medical imaging Health sciences/Health care/Diagnosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Point-of-care ultrasound (POCUS) has become an essential bedside tool in neonatal intensive care, supporting real-time assessment of hemodynamics, lung disease, procedural guidance, and early detection of critical illness.¹–³ Over the last decade, neonatal POCUS has accelerated globally, led by consensus guidelines from the European Society for Paediatric and Neonatal Intensive Care (ESPNIC), the Canadian POCUS Working Group, and more recently, the National POCUS Collaborative for Newborn Medicine in the United States.⁴–⁶ The release of the AAP clinical report outlining educational frameworks, barriers, and implementation considerations for neonatal POCUS in 2022, marked a key inflection point by articulating suggestions for training pathways, quality assurance (QA), image archiving, and credentialing—components required for safe and sustainable POCUS implementation. Despite growing consensus guidance, neonatologists lack practical benchmarks describing how POCUS programs evolve in real-world NICU environments, limiting institutions’ ability to plan safe implementation and resource allocation. Around this same period, the New England Regional POCUS Collaborative began to take shape, bringing together NICUs across the region that were independently developing POCUS capacity. The collaborative was created with a goal to offer a practical regional model to support initiation and implementation—facilitating shared teaching, peer mentorship, case and image review, and cross-institutional dialogue about quality assurance (QA) and credentialing. While interest in neonatal POCUS has grown substantially, the pace and structure of implementation differ widely across institutions, influenced by available faculty expertise, administrative support, QA infrastructure, image archiving systems, and training resources. Regional collaboratives may accelerate progress, yet the extent of their influence and the barriers faced by participating NICUs remain poorly understood. To address these gaps, we conducted a multicenter survey across the New England Regional POCUS Collaborative to characterize institutional demographics, program maturity, clinical use patterns, training ecosystems, administrative and QA readiness, and perceived impact of the Collaborative. This report provides the first regional snapshot of neonatal POCUS practice in New England and highlights opportunities to enhance standardization and sustainability as national guidelines continue to evolve. Methods Study Design and Setting We conducted a cross-sectional, multicenter survey of neonatal intensive care units (NICUs) participating in the New England Regional POCUS Collaborative, a network established to support standardized education, quality assurance, shared resources, and practice alignment. Participating sites included academic level III/IV NICUs and select level II community NICUs across five New England states. All sites with active engagement in collaborative activities were eligible to participate. Survey Development A 34-item survey was developed using Qualtrics (Qualtrics XM, Provo, UT) to assess variation in POCUS program structure, institutional readiness, and clinical integration. Survey content was informed by existing society guidelines (ESPNIC, American Academy of Pediatrics (AAP), National POCUS Collaborative), expert input from POCUS-trained neonatologists, and iterative refinement by Collaborative leadership. Survey domains included institutional characteristics, program maturity, administrative and quality assurance (QA) infrastructure, training strategies, clinical applications, documentation and archiving practices, perceived clinical impact, collaborative value, and future priorities. The full survey instrument is provided in Appendix A. Survey Distribution and Data Collection The survey was distributed electronically in November 2025 to POCUS leads, neonatal faculty, and program directors at participating NICUs. The unit of analysis was the responding program rather than individual clinicians. Institutions were encouraged to submit a single consolidated response reflecting consensus practice; individual responses were accepted when a unified response was not available. As such, findings reflect respondent-reported perceptions and may not represent formal institutional-level consensus. Participation was voluntary, and no incentives were offered. Two reminder emails were sent to optimize response rates. Data Analysis Survey responses were exported into Microsoft Excel and analyzed descriptively. Categorical variables are reported as frequencies and percentages. Continuous variables were summarized using medians and interquartile ranges when applicable; however, most survey items were categorical by design. Given the descriptive objective of the study, no hypothesis testing was performed. Results are presented using tables and figures illustrating program maturity, infrastructure readiness, clinical integration, training strategies, and perceived collaborative impact. Free-text responses were reviewed independently by two investigators and grouped thematically to contextualize quantitative findings. Because responses were anonymous and multiple respondents from a single institution were permitted, analyses were descriptive and interpreted at the respondent-reported program level rather than as weighted institutional estimates. Ethical Considerations The survey assessed institutional practices without patient-level data and qualified as non–human subject’s research. Institutional review board exemption was granted by the coordinating institution (Tufts University). Responses were deidentified and reported in aggregate. Results Institutional Characteristics Twenty-eight survey responses were received from clinicians representing NICUs participating in the New England Regional POCUS Collaborative. Because responses were anonymous and multiple responses per institution were permitted, a precise institutional response rate could not be determined. Respondents predominantly represented academic NICUs (96%), with one community-based program included. Most units were medium-to-large in size, with bed capacities of 20–40 (31%), 41–60 (35%), or > 60 beds (35%). Nearly half of programs reported 1–3 years of clinical POCUS experience (48%), while 41% had less than 1 year of experience, reflecting early-stage regional adoption. Program Maturity Most sites self-identified as having emerging POCUS programs (69%), with 31% reporting more established programs (Fig. 1 ). Routine scan activity varied substantially: 31% reported weekly scanning or supervision, whereas an equal proportion reported rarely or never performing scans. Faculty development trajectories were modest but positive, with most programs reporting slight (46%) or moderate (27%) improvement over the preceding three years; only 8% reported dramatic growth. Figure 1 displays the distribution of survey-reported levels across four maturity domains—experience, integration stage, scan frequency, and institutional support—categorized as low, moderate, or high based on ordinal survey response options. Clinical Integration and Use Cases POCUS was most consistently integrated for procedural applications (Fig. 2 ), particularly umbilical line placement (67%), lumbar puncture (57%), and peripherally inserted central catheter (PICC) guidance (52%). Diagnostic applications were less frequently used, with lung ultrasound reported by 38% of programs and cardiac assessment by 10%. Regarding perceived clinical impact, 48% reported improved procedural speed or safety when POCUS was used, whereas 44% described benefits as modest or inconsistent. Only 12% reported frequent influence on major clinical decision-making. Infrastructure and Administrative Readiness Administrative support for POCUS was generally favorable, with 62% reporting moderate-to-high institutional endorsement, including access to equipment, electronic medical record (EMR) integration assistance, and protected time. However, when institutional factors were examined in relation to both prevalence and perceived impact (Fig. 3 ), protected time and leadership endorsement emerged as high-impact drivers of program success, whereas archiving systems and QA infrastructure remained persistent structural constraints. Formal quality assurance (QA) systems were limited across sites. Only 23% reported an established QA program, 42% were in the process of developing one, and 35% had no formal QA process. Image archiving practices were heterogeneous: 61% reported integrated EMR/picture archiving and communication systems (PACS) or dedicated third-party electronic workflow systems, whereas 39% described archiving as difficult or inconsistent. Routine documentation of POCUS findings in clinical notes was uncommon, with 79% reporting rare or no documentation. Taken together, these findings demonstrate that while institutional interest and equipment access are relatively widespread, operational infrastructure—particularly QA oversight, documentation pathways, and sustainable faculty time allocation—remains incompletely integrated. Collaborative Development and Regional Engagement The developmental trajectory of the New England Regional POCUS Collaborative is illustrated in Fig. 4 . The Collaborative progressed from early regional networking and informal educational exchange to more structured activities, including peer mentorship, shared educational programming, quality assurance discussions, credentialing efforts, and emerging multicenter research and quality improvement initiatives. This trajectory reflects the organizational maturation of the Collaborative over time rather than individual institutional program timelines Discussion This regional survey provides one of the first multi-institutional assessments of neonatal POCUS adoption across New England and demonstrates a network that is engaged and broadly aligned with contemporary national guidance. Most participating NICUs were academic, medium-to-large units, reflecting the typical early diffusion pattern of specialized clinical technologies. Consistent with prior reports, the majority of programs self-identified as emerging and reported less than three years of POCUS experience, underscoring the relative novelty of structured neonatal POCUS implementation in the United States.¹–³ The timing of these findings is notable, as formal U.S. guidance—including the 2022 American Academy of Pediatrics’ clinical report—has only recently provided a standardized framework for training, governance, and quality assurance, likely contributing to the observed early-stage maturity.² A central finding of this study is the substantial variability in institutional readiness and clinical integration despite widespread enthusiasm for POCUS. Although administrative support was commonly reported, essential operational infrastructure—including formal quality assurance, image archiving, and EMR documentation—was inconsistently implemented. Fewer than one-quarter of sites had an established QA program, and routine documentation of POCUS findings was uncommon, underscoring persistent barriers to safe and sustainable practice that are well described in international and U.S. consensus statements. ⁴–⁶ These findings emphasize that institutional endorsement alone is insufficient to achieve program maturity without concurrent investment in workflow integration and governance. Neonatal POCUS integration also remained predominantly procedural, with highest uptake for umbilical line placement, lumbar puncture, and PICC guidance, while diagnostic applications such as lung and cardiac ultrasound were less frequently used. This procedural-first trajectory mirrors national and international experience. ²,⁵ Diagnostic applications require greater faculty expertise, structured training pathways, and robust QA mechanisms—precisely the domains identified as unmet needs in this survey—suggesting that limited diagnostic integration reflects structural and educational constraints rather than lack of clinical interest Beyond neonatology, experiences from pediatric and adult POCUS regional collaboratives further contextualize the developmental stage observed in this study. Multicenter networks in pediatric emergency medicine and adult critical care have shown that early growth is often driven by procedural use and informal mentorship, followed by progression toward structured credentialing, centralized QA, and standardized documentation as programs mature.¹⁶–²¹ These collaboratives similarly report that administrative support alone is insufficient to sustain growth without dedicated faculty development pathways, protected time, and reliable archiving infrastructure. Compared with these more established networks, the New England Neonatal POCUS Collaborative appears to be at an earlier—but expected—phase of maturation, characterized by strong clinician engagement and peer learning but incomplete operational integration. Importantly, prior collaborative models demonstrate that targeted investment in shared QA frameworks, train-the-trainer faculty development, and regional image repositories can accelerate progression from procedural use toward reliable diagnostic integration. ¹⁶–²¹ In addition to shared educational forums, respondents and collaborative experience suggest that more direct mentorship models may further accelerate program maturation. Structured partnerships between established and emerging programs—such as targeted site visits, focused educational workshops (e.g., lung or cardiac POCUS applications), real-time image review, and accessible troubleshooting support—may facilitate skill acquisition beyond periodic virtual meetings alone. Importantly, integration of attending physicians into training pathways emerged as a practical consideration, as variability in faculty expertise may limit broader clinical adoption even when trainee education is well developed. These observations highlight the importance of longitudinal mentorship and faculty development as complementary components of sustainable neonatal POCUS implementation. The priorities identified by respondents—including faculty train-the-trainer programs, credentialing frameworks, shared image repositories, and multi-site quality improvement and research—reflect a natural progression from early adoption toward system-level integration. Similar developmental trajectories have been reported in Canadian, European, and Australasian neonatal POCUS collaboratives, which describe early procedural adoption, heterogeneous QA practices, and reliance on centralized mentorship models during initial growth phases. ⁷–¹² Collectively, these findings suggest that the experience of the New England Collaborative aligns closely with global patterns of neonatal POCUS implementation. An additional structural barrier highlighted by respondents relates to the broader financial climate in healthcare. Although institutional support was frequently described as moderate to high, nearly all respondents identified protected time as a critical unmet need, and over half cited equipment acquisition, QI infrastructure, and archiving systems as necessary supports. In an increasingly fiscally constrained healthcare environment, initiation of a neonatal POCUS program requires upfront investment in equipment, workflow integration, quality assurance oversight, and faculty development. Without dedicated FTE support and administrative prioritization, early enthusiasm may not translate into sustainable integration. These financial and structural realities likely contribute to the gap observed between procedural adoption and broader diagnostic implementation. In summary, this survey highlights a rapidly evolving neonatal POCUS ecosystem across New England characterized by strong clinician engagement and an emerging collaborative infrastructure. However, substantial variability persists in institutional readiness, particularly in QA processes, documentation, and image archiving—core elements required for safe, standardized practice. Procedural POCUS is well established, whereas diagnostic applications remain constrained by training capacity and system-level support. Addressing these gaps through coordinated investment in competency-based education, shared QA resources, and institutional integration will be essential to advancing equitable, sustainable, and high-quality neonatal POCUS practice across the region. From an implementation perspective, these findings suggest that early neonatal POCUS programs may benefit from prioritizing governance infrastructure alongside technical training. Establishing QA pathways, documentation workflows, and protected faculty time early in program development may prevent stagnation at procedural adoption and facilitate progression toward diagnostic integration. Regional collaboratives may serve as scalable mechanisms to support institutions lacking local expertise. Limitations This study has several limitations. Survey responses were self-reported and may reflect individual perception rather than formal institutional policy or objective measures of program maturity. Because multiple responses from the same center were permitted when consolidated responses were not available, findings may not uniformly represent center-level practices. Additionally, participating NICUs were predominantly academic and regionally concentrated in New England, which may limit generalizability to community-based or non-academic settings. Finally, as most programs were early in development, longitudinal outcomes of collaborative engagement cannot yet be assessed. Conclusion Neonatal POCUS adoption across New England is widespread but remains heterogeneous and largely in early stages of implementation. While clinician engagement and institutional interest are strong, deficiencies in quality assurance, documentation, archiving, and protected faculty time continue to limit consistent diagnostic integration. Procedural applications predominate, consistent with early adoption patterns observed internationally. Regional collaboratives provide a critical framework to align training, governance, and infrastructure, and may accelerate progression from procedural uptake toward sustainable, high-quality diagnostic integration. Strategic investment in standardized education, QA systems, and protected faculty time will be essential to realize the full clinical potential of neonatal POCUS. Declarations Conflict of interest The authors declare that they have no competing financial or non-financial interests related to this study. Ethics approval This study was reviewed by the Tufts University Institutional Review Board and determined to qualify as non–human subjects research. The requirement for informed consent was waived as no patient-level data were collected. Funding No external funding was received for this study. Author contributions IB, SN, and KB conceived and designed the study and coordinated survey distribution. IB analyzed the data and drafted the manuscript. SN, RJ, TH, KS, AS, MC, RT, JS, EA, and KB contributed to survey development, data interpretation, and critical revision of the manuscript. All authors approved the final version. Acknowledgements The authors thank the members of the New England Regional POCUS Collaborative for their participation and engagement in this survey initiative Availability of data and materials The deidentified survey dataset generated and analyzed during the current study is available from the corresponding author upon reasonable request. References Singh Y, Tissot C, Fraga MV, et al. 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: revise 09 Apr, 2026 Review # 2 received at journal 01 Apr, 2026 Reviewer # 2 agreed at journal 12 Mar, 2026 Review # 1 received at journal 02 Mar, 2026 Reviewer # 1 agreed at journal 27 Feb, 2026 Reviewers invited by journal 25 Feb, 2026 Submission checks completed at journal 24 Feb, 2026 First submitted to journal 23 Feb, 2026 Editor assigned by journal 23 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8951146","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":596933011,"identity":"dfd72ca9-3727-409b-bf1c-d99a31b13157","order_by":0,"name":"Indrani 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Turcu","email":"","orcid":"https://orcid.org/0009-0009-6621-7468","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Rodica","middleName":"","lastName":"Turcu","suffix":""},{"id":596933019,"identity":"94a85914-f261-47f4-8b6d-bba5c4b7db4b","order_by":8,"name":"Juan Sanchez-Esteban","email":"","orcid":"","institution":"Women \u0026 Infants Hospital of RI","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"","lastName":"Sanchez-Esteban","suffix":""},{"id":596933020,"identity":"1d456a49-419f-464e-aad5-c5569e5513a1","order_by":9,"name":"Elisa Abdulhayoglu","email":"","orcid":"","institution":"Brigham and Women's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Elisa","middleName":"","lastName":"Abdulhayoglu","suffix":""},{"id":596933021,"identity":"f5ddced2-ba60-40d4-90e5-47dd91bdd0a8","order_by":10,"name":"Kristyn Beam","email":"","orcid":"https://orcid.org/0000-0001-8245-0440","institution":"Beth Israel Deaconess Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Kristyn","middleName":"","lastName":"Beam","suffix":""}],"badges":[],"createdAt":"2026-02-23 23:35:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8951146/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8951146/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103733763,"identity":"09a0c4c3-e737-412c-8287-235fe6ba8b5b","added_by":"auto","created_at":"2026-03-02 09:29:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":111721,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Survey-Reported Program Maturity Domains: \u003c/strong\u003eHeatmap showing self-reported maturity across experience, integration, scan frequency, and institutional support, with most programs reporting low-to-moderate maturity and minimal high-level integration.\u003c/p\u003e","description":"","filename":"OnlineFigure1NEPOCUSJOP.png","url":"https://assets-eu.researchsquare.com/files/rs-8951146/v1/c70ec01178e77764bc6bd64a.png"},{"id":103733743,"identity":"34bb5e98-c3af-498c-af66-c70713766e86","added_by":"auto","created_at":"2026-03-02 09:29:26","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":44349,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClinical integration and POCUS use cases: \u003c/strong\u003ePercentage of sites reporting routine POCUS use by indication, demonstrating higher adoption for procedural applications compared with diagnostic uses.\u003c/p\u003e","description":"","filename":"OnlineFigure2NEPOCUSJOP.png","url":"https://assets-eu.researchsquare.com/files/rs-8951146/v1/c5c256f6c658c5d77f625a96.png"},{"id":103733686,"identity":"0ebd9a54-b538-4b5b-86ce-a6ae4d76c8c8","added_by":"auto","created_at":"2026-03-02 09:29:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21244,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCapacity versus constraint matrix: \u003c/strong\u003eScatter plot mapping institutional facilitators and barriers by prevalence and perceived impact, identifying training time and leadership endorsement as high-impact drivers and archiving systems as persistent constraints.\u003c/p\u003e","description":"","filename":"OnlineFigure3NEPOCUSJOP.png","url":"https://assets-eu.researchsquare.com/files/rs-8951146/v1/fcf4011cc7047eb94603c9a9.png"},{"id":103733732,"identity":"c852f283-8f3b-4c6c-875e-0202fe29c9b6","added_by":"auto","created_at":"2026-03-02 09:29:21","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":60741,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNew England Regional POCUS Collaborative growth timeline: \u003c/strong\u003eTimeline illustrating the progressive development of the Collaborative from initial formation through education, quality assurance, mentorship, credentialing, and research expansion.\u003c/p\u003e","description":"","filename":"OnlineFigure4NEPOCUSJOP.png","url":"https://assets-eu.researchsquare.com/files/rs-8951146/v1/acae1530e9e2fc4db97ac4d7.png"},{"id":103733831,"identity":"363b9e6e-36d4-467d-ad42-1143424ae049","added_by":"auto","created_at":"2026-03-02 09:29:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1030776,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8951146/v1/3f9554e9-c5e4-41f3-a3df-dc56f0d6f84a.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Implementation and Adoption of Neonatal Point-of-Care Ultrasound Across a Regional Collaborative: A Multicenter Survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003e Point-of-care ultrasound (POCUS) has become an essential bedside tool in neonatal intensive care, supporting real-time assessment of hemodynamics, lung disease, procedural guidance, and early detection of critical illness.\u0026sup1;\u0026ndash;\u0026sup3; Over the last decade, neonatal POCUS has accelerated globally, led by consensus guidelines from the European Society for Paediatric and Neonatal Intensive Care (ESPNIC), the Canadian POCUS Working Group, and more recently, the National POCUS Collaborative for Newborn Medicine in the United States.⁴\u0026ndash;⁶ The release of the AAP clinical report outlining educational frameworks, barriers, and implementation considerations for neonatal POCUS in 2022, marked a key inflection point by articulating suggestions for training pathways, quality assurance (QA), image archiving, and credentialing\u0026mdash;components required for safe and sustainable POCUS implementation. Despite growing consensus guidance, neonatologists lack practical benchmarks describing how POCUS programs evolve in real-world NICU environments, limiting institutions\u0026rsquo; ability to plan safe implementation and resource allocation.\u003c/p\u003e \u003cp\u003eAround this same period, the New England Regional POCUS Collaborative began to take shape, bringing together NICUs across the region that were independently developing POCUS capacity. The collaborative was created with a goal to offer a practical regional model to support initiation and implementation\u0026mdash;facilitating shared teaching, peer mentorship, case and image review, and cross-institutional dialogue about quality assurance (QA) and credentialing.\u003c/p\u003e \u003cp\u003eWhile interest in neonatal POCUS has grown substantially, the pace and structure of implementation differ widely across institutions, influenced by available faculty expertise, administrative support, QA infrastructure, image archiving systems, and training resources. Regional collaboratives may accelerate progress, yet the extent of their influence and the barriers faced by participating NICUs remain poorly understood.\u003c/p\u003e \u003cp\u003eTo address these gaps, we conducted a multicenter survey across the New England Regional POCUS Collaborative to characterize institutional demographics, program maturity, clinical use patterns, training ecosystems, administrative and QA readiness, and perceived impact of the Collaborative. This report provides the first regional snapshot of neonatal POCUS practice in New England and highlights opportunities to enhance standardization and sustainability as national guidelines continue to evolve.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003e We conducted a cross-sectional, multicenter survey of neonatal intensive care units (NICUs) participating in the New England Regional POCUS Collaborative, a network established to support standardized education, quality assurance, shared resources, and practice alignment. Participating sites included academic level III/IV NICUs and select level II community NICUs across five New England states. All sites with active engagement in collaborative activities were eligible to participate.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurvey Development\u003c/h3\u003e\n\u003cp\u003eA 34-item survey was developed using Qualtrics (Qualtrics XM, Provo, UT) to assess variation in POCUS program structure, institutional readiness, and clinical integration. Survey content was informed by existing society guidelines (ESPNIC, American Academy of Pediatrics (AAP), National POCUS Collaborative), expert input from POCUS-trained neonatologists, and iterative refinement by Collaborative leadership. Survey domains included institutional characteristics, program maturity, administrative and quality assurance (QA) infrastructure, training strategies, clinical applications, documentation and archiving practices, perceived clinical impact, collaborative value, and future priorities. The full survey instrument is provided in Appendix A.\u003c/p\u003e\n\u003ch3\u003eSurvey Distribution and Data Collection\u003c/h3\u003e\n\u003cp\u003eThe survey was distributed electronically in November 2025 to POCUS leads, neonatal faculty, and program directors at participating NICUs. The unit of analysis was the responding program rather than individual clinicians. Institutions were encouraged to submit a single consolidated response reflecting consensus practice; individual responses were accepted when a unified response was not available. As such, findings reflect respondent-reported perceptions and may not represent formal institutional-level consensus. Participation was voluntary, and no incentives were offered. Two reminder emails were sent to optimize response rates.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eSurvey responses were exported into Microsoft Excel and analyzed descriptively. Categorical variables are reported as frequencies and percentages. Continuous variables were summarized using medians and interquartile ranges when applicable; however, most survey items were categorical by design. Given the descriptive objective of the study, no hypothesis testing was performed. Results are presented using tables and figures illustrating program maturity, infrastructure readiness, clinical integration, training strategies, and perceived collaborative impact. Free-text responses were reviewed independently by two investigators and grouped thematically to contextualize quantitative findings. Because responses were anonymous and multiple respondents from a single institution were permitted, analyses were descriptive and interpreted at the respondent-reported program level rather than as weighted institutional estimates.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003eThe survey assessed institutional practices without patient-level data and qualified as non\u0026ndash;human subject\u0026rsquo;s research. Institutional review board exemption was granted by the coordinating institution (Tufts University). Responses were deidentified and reported in aggregate.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eInstitutional Characteristics\u003c/h2\u003e \u003cp\u003e Twenty-eight survey responses were received from clinicians representing NICUs participating in the New England Regional POCUS Collaborative. Because responses were anonymous and multiple responses per institution were permitted, a precise institutional response rate could not be determined. Respondents predominantly represented academic NICUs (96%), with one community-based program included. Most units were medium-to-large in size, with bed capacities of 20\u0026ndash;40 (31%), 41\u0026ndash;60 (35%), or \u0026gt;\u0026thinsp;60 beds (35%). Nearly half of programs reported 1\u0026ndash;3 years of clinical POCUS experience (48%), while 41% had less than 1 year of experience, reflecting early-stage regional adoption.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProgram Maturity\u003c/h3\u003e\n\u003cp\u003eMost sites self-identified as having emerging POCUS programs (69%), with 31% reporting more established programs (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Routine scan activity varied substantially: 31% reported weekly scanning or supervision, whereas an equal proportion reported rarely or never performing scans. Faculty development trajectories were modest but positive, with most programs reporting slight (46%) or moderate (27%) improvement over the preceding three years; only 8% reported dramatic growth. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays the distribution of survey-reported levels across four maturity domains\u0026mdash;experience, integration stage, scan frequency, and institutional support\u0026mdash;categorized as low, moderate, or high based on ordinal survey response options.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eClinical Integration and Use Cases\u003c/h2\u003e \u003cp\u003ePOCUS was most consistently integrated for procedural applications (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), particularly umbilical line placement (67%), lumbar puncture (57%), and peripherally inserted central catheter (PICC) guidance (52%). Diagnostic applications were less frequently used, with lung ultrasound reported by 38% of programs and cardiac assessment by 10%. Regarding perceived clinical impact, 48% reported improved procedural speed or safety when POCUS was used, whereas 44% described benefits as modest or inconsistent. Only 12% reported frequent influence on major clinical decision-making.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInfrastructure and Administrative Readiness\u003c/h2\u003e \u003cp\u003eAdministrative support for POCUS was generally favorable, with 62% reporting moderate-to-high institutional endorsement, including access to equipment, electronic medical record (EMR) integration assistance, and protected time. However, when institutional factors were examined in relation to both prevalence and perceived impact (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), protected time and leadership endorsement emerged as high-impact drivers of program success, whereas archiving systems and QA infrastructure remained persistent structural constraints.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFormal quality assurance (QA) systems were limited across sites. Only 23% reported an established QA program, 42% were in the process of developing one, and 35% had no formal QA process. Image archiving practices were heterogeneous: 61% reported integrated EMR/picture archiving and communication systems (PACS) or dedicated third-party electronic workflow systems, whereas 39% described archiving as difficult or inconsistent. Routine documentation of POCUS findings in clinical notes was uncommon, with 79% reporting rare or no documentation.\u003c/p\u003e \u003cp\u003eTaken together, these findings demonstrate that while institutional interest and equipment access are relatively widespread, operational infrastructure\u0026mdash;particularly QA oversight, documentation pathways, and sustainable faculty time allocation\u0026mdash;remains incompletely integrated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCollaborative Development and Regional Engagement\u003c/h2\u003e \u003cp\u003eThe developmental trajectory of the New England Regional POCUS Collaborative is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The Collaborative progressed from early regional networking and informal educational exchange to more structured activities, including peer mentorship, shared educational programming, quality assurance discussions, credentialing efforts, and emerging multicenter research and quality improvement initiatives. This trajectory reflects the organizational maturation of the Collaborative over time rather than individual institutional program timelines\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e This regional survey provides one of the first multi-institutional assessments of neonatal POCUS adoption across New England and demonstrates a network that is engaged and broadly aligned with contemporary national guidance. Most participating NICUs were academic, medium-to-large units, reflecting the typical early diffusion pattern of specialized clinical technologies. Consistent with prior reports, the majority of programs self-identified as emerging and reported less than three years of POCUS experience, underscoring the relative novelty of structured neonatal POCUS implementation in the United States.\u0026sup1;\u0026ndash;\u0026sup3; The timing of these findings is notable, as formal U.S. guidance\u0026mdash;including the 2022 American Academy of Pediatrics\u0026rsquo; clinical report\u0026mdash;has only recently provided a standardized framework for training, governance, and quality assurance, likely contributing to the observed early-stage maturity.\u0026sup2;\u003c/p\u003e \u003cp\u003eA central finding of this study is the substantial variability in institutional readiness and clinical integration despite widespread enthusiasm for POCUS. Although administrative support was commonly reported, essential operational infrastructure\u0026mdash;including formal quality assurance, image archiving, and EMR documentation\u0026mdash;was inconsistently implemented. Fewer than one-quarter of sites had an established QA program, and routine documentation of POCUS findings was uncommon, underscoring persistent barriers to safe and sustainable practice that are well described in international and U.S. consensus statements. ⁴\u0026ndash;⁶ These findings emphasize that institutional endorsement alone is insufficient to achieve program maturity without concurrent investment in workflow integration and governance.\u003c/p\u003e \u003cp\u003eNeonatal POCUS integration also remained predominantly procedural, with highest uptake for umbilical line placement, lumbar puncture, and PICC guidance, while diagnostic applications such as lung and cardiac ultrasound were less frequently used. This procedural-first trajectory mirrors national and international experience. \u0026sup2;,⁵ Diagnostic applications require greater faculty expertise, structured training pathways, and robust QA mechanisms\u0026mdash;precisely the domains identified as unmet needs in this survey\u0026mdash;suggesting that limited diagnostic integration reflects structural and educational constraints rather than lack of clinical interest\u003c/p\u003e \u003cp\u003eBeyond neonatology, experiences from pediatric and adult POCUS regional collaboratives further contextualize the developmental stage observed in this study. Multicenter networks in pediatric emergency medicine and adult critical care have shown that early growth is often driven by procedural use and informal mentorship, followed by progression toward structured credentialing, centralized QA, and standardized documentation as programs mature.\u0026sup1;⁶\u0026ndash;\u0026sup2;\u0026sup1; These collaboratives similarly report that administrative support alone is insufficient to sustain growth without dedicated faculty development pathways, protected time, and reliable archiving infrastructure. Compared with these more established networks, the New England Neonatal POCUS Collaborative appears to be at an earlier\u0026mdash;but expected\u0026mdash;phase of maturation, characterized by strong clinician engagement and peer learning but incomplete operational integration. Importantly, prior collaborative models demonstrate that targeted investment in shared QA frameworks, train-the-trainer faculty development, and regional image repositories can accelerate progression from procedural use toward reliable diagnostic integration. \u0026sup1;⁶\u0026ndash;\u0026sup2;\u0026sup1;\u003c/p\u003e \u003cp\u003eIn addition to shared educational forums, respondents and collaborative experience suggest that more direct mentorship models may further accelerate program maturation. Structured partnerships between established and emerging programs\u0026mdash;such as targeted site visits, focused educational workshops (e.g., lung or cardiac POCUS applications), real-time image review, and accessible troubleshooting support\u0026mdash;may facilitate skill acquisition beyond periodic virtual meetings alone. Importantly, integration of attending physicians into training pathways emerged as a practical consideration, as variability in faculty expertise may limit broader clinical adoption even when trainee education is well developed. These observations highlight the importance of longitudinal mentorship and faculty development as complementary components of sustainable neonatal POCUS implementation.\u003c/p\u003e \u003cp\u003eThe priorities identified by respondents\u0026mdash;including faculty train-the-trainer programs, credentialing frameworks, shared image repositories, and multi-site quality improvement and research\u0026mdash;reflect a natural progression from early adoption toward system-level integration. Similar developmental trajectories have been reported in Canadian, European, and Australasian neonatal POCUS collaboratives, which describe early procedural adoption, heterogeneous QA practices, and reliance on centralized mentorship models during initial growth phases. ⁷\u0026ndash;\u0026sup1;\u0026sup2; Collectively, these findings suggest that the experience of the New England Collaborative aligns closely with global patterns of neonatal POCUS implementation.\u003c/p\u003e \u003cp\u003eAn additional structural barrier highlighted by respondents relates to the broader financial climate in healthcare. Although institutional support was frequently described as moderate to high, nearly all respondents identified protected time as a critical unmet need, and over half cited equipment acquisition, QI infrastructure, and archiving systems as necessary supports. In an increasingly fiscally constrained healthcare environment, initiation of a neonatal POCUS program requires upfront investment in equipment, workflow integration, quality assurance oversight, and faculty development. Without dedicated FTE support and administrative prioritization, early enthusiasm may not translate into sustainable integration. These financial and structural realities likely contribute to the gap observed between procedural adoption and broader diagnostic implementation.\u003c/p\u003e \u003cp\u003eIn summary, this survey highlights a rapidly evolving neonatal POCUS ecosystem across New England characterized by strong clinician engagement and an emerging collaborative infrastructure. However, substantial variability persists in institutional readiness, particularly in QA processes, documentation, and image archiving\u0026mdash;core elements required for safe, standardized practice. Procedural POCUS is well established, whereas diagnostic applications remain constrained by training capacity and system-level support. Addressing these gaps through coordinated investment in competency-based education, shared QA resources, and institutional integration will be essential to advancing equitable, sustainable, and high-quality neonatal POCUS practice across the region.\u003c/p\u003e \u003cp\u003eFrom an implementation perspective, these findings suggest that early neonatal POCUS programs may benefit from prioritizing governance infrastructure alongside technical training. Establishing QA pathways, documentation workflows, and protected faculty time early in program development may prevent stagnation at procedural adoption and facilitate progression toward diagnostic integration. Regional collaboratives may serve as scalable mechanisms to support institutions lacking local expertise.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. Survey responses were self-reported and may reflect individual perception rather than formal institutional policy or objective measures of program maturity. Because multiple responses from the same center were permitted when consolidated responses were not available, findings may not uniformly represent center-level practices. Additionally, participating NICUs were predominantly academic and regionally concentrated in New England, which may limit generalizability to community-based or non-academic settings. Finally, as most programs were early in development, longitudinal outcomes of collaborative engagement cannot yet be assessed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNeonatal POCUS adoption across New England is widespread but remains heterogeneous and largely in early stages of implementation. While clinician engagement and institutional interest are strong, deficiencies in quality assurance, documentation, archiving, and protected faculty time continue to limit consistent diagnostic integration. Procedural applications predominate, consistent with early adoption patterns observed internationally. Regional collaboratives provide a critical framework to align training, governance, and infrastructure, and may accelerate progression from procedural uptake toward sustainable, high-quality diagnostic integration. Strategic investment in standardized education, QA systems, and protected faculty time will be essential to realize the full clinical potential of neonatal POCUS.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing financial or non-financial interests related to this study.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003eThis study was reviewed by the Tufts University Institutional Review Board and determined to qualify as non\u0026ndash;human subjects research. The requirement for informed consent was waived as no patient-level data were collected.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo external funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor contributions\u003c/h2\u003e \u003cp\u003eIB, SN, and KB conceived and designed the study and coordinated survey distribution. IB analyzed the data and drafted the manuscript. SN, RJ, TH, KS, AS, MC, RT, JS, EA, and KB contributed to survey development, data interpretation, and critical revision of the manuscript. All authors approved the final version.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003e The authors thank the members of the New England Regional POCUS Collaborative for their participation and engagement in this survey initiative\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe deidentified survey dataset generated and analyzed during the current study is available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSingh Y, Tissot C, Fraga MV, et al. 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Anesth Analg 2015;120:1041\u0026ndash;1053. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1213/ANE.0000000000000701\u003c/span\u003e\u003cspan address=\"10.1213/ANE.0000000000000701\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-perinatology","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jp","sideBox":"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)","snPcode":"41372","submissionUrl":"https://mts-jper.nature.com/cgi-bin/main.plex","title":"Journal of Perinatology","twitterHandle":"@jperinatology","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8951146/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8951146/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo characterize program maturity, infrastructure readiness, and clinical integration of neonatal point-of-care ultrasound (POCUS) across a regional collaborative.\u003c/p\u003e\u003ch2\u003eStudy Design:\u003c/h2\u003e \u003cp\u003e Cross-sectional survey of neonatal intensive care units participating in the New England Regional POCUS Collaborative. A 34-item survey assessed experience, integration, quality assurance (QA) processes, documentation practices, and training strategies. Data were analyzed descriptively.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eTwenty-eight responses representing predominantly academic NICUs were analyzed. Most programs were early in development, with 69% self-identifying as emerging and 89% reporting fewer than three years of experience. Procedural applications were most common, whereas diagnostic uses were less consistently integrated. Although 62% reported moderate-to-high institutional support, only 23% had established QA processes and routine documentation was uncommon.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eNeonatal POCUS adoption is widespread but developmentally early. Predominance of procedural use and limited integration into major clinical decision-making suggest that maturation of governance structures and training frameworks may be necessary to support sustainable diagnostic expansion\u003c/p\u003e","manuscriptTitle":"Implementation and Adoption of Neonatal Point-of-Care Ultrasound Across a Regional Collaborative: A Multicenter Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-02 09:27:43","doi":"10.21203/rs.3.rs-8951146/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2026-04-09T11:25:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2026-04-01T12:13:51+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2026-03-12T16:21:19+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2026-03-03T02:52:55+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2026-02-27T17:25:16+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2026-02-25T12:47:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-24T16:09:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Perinatology","date":"2026-02-23T23:32:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-23T23:32:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-perinatology","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jp","sideBox":"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)","snPcode":"41372","submissionUrl":"https://mts-jper.nature.com/cgi-bin/main.plex","title":"Journal of Perinatology","twitterHandle":"@jperinatology","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b17b4d98-d892-44dd-99a6-98ae301db43c","owner":[],"postedDate":"March 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":63518893,"name":"Health sciences/Health care/Medical imaging"},{"id":63518894,"name":"Health sciences/Health care/Diagnosis"}],"tags":[],"updatedAt":"2026-05-11T18:02:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-02 09:27:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8951146","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8951146","identity":"rs-8951146","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}