Implementation of transvaginal ultrasound in an emergency department residency program: an analysis of resident interpretation

Portable ultrasound technologies for estimating gestational age in pregnant women: a scoping review and analysis of commercially available models

OBJECTIVES

To identify all available studies assessing the use of portable ultrasound devices for pregnant women, with the specific aim of finding evidence for devices used to determine gestational age and their validity when compared with conventional ultrasound machines. We also wanted to determine what portable ultrasound models are commercially available for obstetric use.

DESIGN

Systematic scoping review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Extracted variables included study design, population, method of ultrasound measurement, devices used and whether studies formally validated accuracy against conventional ultrasound.

RESULTS

We searched four databases-Medline, Embase, CINAHL and Maternal and Infant Care. In total 56 studies from 34 countries were identified; most were observational studies. Across all studies, 27 different portable ultrasound models (from 17 manufacturers) were evaluated. Twenty-one studies assessed use of portable ultrasound for evaluating fetal characteristics or estimating gestational age, and 10 of these were formal validation studies. In total, six portable devices have been validated for gestational age estimation against a conventional ultrasound comparator. The web searches identified 102 portable devices (21 manufacturers). These were a mix of handheld devices that connected to a phone or computer, or laptop-style portable ultrasound devices. Prices ranged from US$1190 to US$30 000 and weight ranged from 0.9 kg to 13.0 kg.

CONCLUSION

While the number of commercially available portable ultrasound devices continues to grow, there remains a lack of peer-reviewed, quality evidence demonstrating their accuracy and validity when compared with conventional ultrasound machines. This review identified some models that may be useful in gestational age estimation in low-resource settings, but more research is required to help implement the technology at scale.

TRIAL REGISTRATION NUMBER

Registered via Open Science Framework (DOI: 10.17605/OSF.IO/U8KXP).

Teaching emergency ultrasound to emergency medicine residents: a scoping review of structured training methods

BACKGROUND

Over the past 2 decades, emergency ultrasound has become essential to patient care, and is a mandated competency for emergency medicine residency graduation. However, the best evidence regarding emergency ultrasound education in residency training is not known. We performed a scoping review to determine the (1) characteristics and (2) outcomes of published structured training methods, (3) the quality of publications, and (4) the implications for research and training.

METHODS

We searched broadly on multiple electronic databases and screened studies from the United States and Canada describing structured emergency ultrasound training methods for emergency medicine residents. We evaluated methodological quality with the Medical Education Research Study Quality Instrument (MERSQI), and qualitatively summarized study and intervention characteristics.

RESULTS

A total of 109 studies were selected from 6712 identified publications. Publications mainly reported 1 group pretest-posttest interventions (38%) conducted at a single institution (83%), training in image acquisition (82%) and interpretation (94%) domains with assessment of knowledge (44%) and skill (77%) outcomes, and training in cardiac (18%) or vascular access (15%) applications. Innovative strategies, such as gamification, cadaver models, and hand motion assessment are described. The MERSQI scores of 48 articles ranged from 0 to 15.5 (median, 11.5; interquartile range, 9.6-13.0) out of 18. Low scores reflected the absence of reported valid assessment tools (73%) and higher level outcomes (90%).

CONCLUSIONS

Although innovative strategies are illustrated, the overall quality of research could be improved. The use of standardized planning and assessment tools, intentionally mapped to targeted domains and outcomes, might provide valuable formative and summative information to optimize emergency ultrasound research and training.

Emergency Ultrasound Training Program in Guyana: Systematic Credentialing Process in a Resource-limited Setting

Ultrasound has become an important skill for emergency physicians. Ultrasound is more crucial in resource-limited settings where diagnostic testing may not be as timely or available at all. In 2015, an emergency medicine ultrasound curriculum was implemented at Georgetown Public Hospital Corporation in Georgetown, Guyana. Implementing an ultrasound-training curriculum in Guyana had four main challenges: limited ultrasound equipment, lack of informational technology infrastructure to record and review ultrasound examinations, availability of local emergency ultrasound expertise, and competing educational needs within the curriculum. These challenges were met with creative solutions and the formation of a formalized curriculum and credentialing process. The experience of creating the program is described along with the curriculum, credentialing process, and plan for sustainability. Since implementation, every graduating resident has displayed competency on final assessment.

The path to ultrasound proficiency: A systematic review of ultrasound education and training programmes for junior medical practitioners

Background

Point-of-care ultrasound (POCUS) is a form of diagnostic ultrasonography, which has a defined role as a clinical adjunct in patient assessment and management. If it is to continue to develop as a core clinical skill, junior medical practitioners and trainees may benefit from dedicated ultrasound education and familiarisation early in their training. Controversy endures, however, as inappropriate use of this highly technical and operator-dependent imaging modality has negative clinical implications.

Aims

A systematic review was performed to assess the ability of doctors in training to perform clinically appropriate and beneficial diagnostic ultrasound after undergoing a formal training programme.

Methods

Studies meeting pre-defined inclusion criteria were identified in electronic databases MEDLINE, EMBASE, CINAHL, PUBMED and through Google Scholar. Methodological quality was assessed using an established series of indicators.

Results

Fifteen studies were included in the review. Ten of these were performed in the United States, and eight focused on emergency medicine trainees. After the teaching intervention, ten studies assessed overall ultrasound capacity by calculating the collective sensitivity and specificity of trainee-performed ultrasound. Five studies used a standardised objective assessment tool to evaluate ultrasound skills and technique. Studies varied in terms of the specific ultrasound use investigated, teaching programmes used and methodological quality. Consistently identified areas for further research included the definition of the trainee learning curve and what constitutes competency in ultrasound.

Conclusions

Ultrasound can feasibly be incorporated into junior medical practitioner training, but more research is required to assess its effectiveness and appropriateness.

The Practice Guidelines for Primary Care of Acute Abdomen 2015

BACKGROUND

Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine in collaboration with four other medical societies launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines [all clinical questions (CQs) and recommendations are shown in supplementary information].

METHODS

A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen.

RESULTS

A total of 108 questions based on 9 subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended.

CONCLUSIONS

The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.

ACES: Accurate Cervical Evaluation With Sonography

OBJECTIVES

Transvaginal sonographic cervical length screening is an important tool for the evaluation of preterm labor. However, a structured curriculum is lacking in obstetrics and gynecology residency programs. The Accurate Cervical Evaluation with Sonography (ACES) program was developed to address this deficiency and combines an online didactic course with a standardized performance assessment of live scans. We sought to evaluate the effectiveness of the ACES program to teach residents sonographic cervical length assessment.

METHODS

All obstetrics and gynecology residents at our institution were invited to participate from 2012 to 2013. The program consisted of an initial supervised transvaginal cervical evaluation, an online didactic course and written examination, and 5 subsequent supervised scans. The instructor performed an independent cervical length measurement at each encounter. The primary outcome was the difference in cervical length measurement between the resident and instructor. We hypothesized that this difference would decrease over time. At each visit, a 10-item checklist was used for skill assessment. Comparisons of checklist scores over time were also performed.

RESULTS

Seventeen of 20 residents completed at least some of the training, and 10 completed the entire program. The median difference in cervical length measurement between residents and instructors at posttests 3, 4, and 5 improved significantly compared to the pretest scan (all P ≤ .02). Similarly, the checklist scores improved over time (all P ≤ .0008).

CONCLUSIONS

Transvaginal cervical sonography is an important tool in the evaluation of preterm labor. The ACES program provides residents a structured curriculum for cervical evaluation and supervisors a standardized means of evaluating trainees' skills.

Practice Guidelines for Primary Care of Acute Abdomen 2015

Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine, in collaboration with four other medical societies, launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines (all clinical questions and recommendations were shown in supplementary information). A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen. A total of 108 questions based on nine subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended. The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.

Evaluation of waiting times and sonographic findings in patients with first trimester vaginal bleeding at the university hospital of the west indies. Can emergency department ultrasound make a difference?

BACKGROUND

Pregnant female patients with vaginal bleeding in the first trimester are seen commonly in the Emergency Department (ED) at the University Hospital of the West Indies (UHWI), Kingston, Jamaica. The protocol for the management of these patients requires that they have a sonographic evaluation performed for the purpose of localizing the pregnancy where possible, to assist with determining the risk for an ectopic pregnancy. The ultrasound examinations are performed in the radiology department.

OBJECTIVE

This retrospective study was conducted to evaluate how long patients wait for a pelvic ultrasound. We also sought to establish how many patients had ultrasound findings that would have allowed safe discharge home.

METHODS

The records of 150 patients seen in the six-month period from January 1 to July 30, 2008 were examined. Data were extracted pertaining to age, time to see an emergency room doctor, time taken for ultrasound examination to be obtained from the radiology department and the ultrasound findings.

RESULT

Fifty-four per cent presented to the Emergency Department with a complaint of vaginal bleeding and abdominal pain, 29% with bleeding only, 16% with abdominal pain only and one with syncope. One hundred and sixteen of the patients enrolled had an ultrasound performed at UHWI. The average waiting time for an ultrasound was 3.8 ± 2.5 hours. The majority (66/116) of the patients had an intrauterine pregnancy (IUP) demonstrated on ultrasound. Twenty-nine had no IUP, free fluid or adnexal mass. These 95 patients would likely have been discharged home. Ten patients had an adnexal mass with or without free fluid, and ten had free fluid only on ultrasound. One patient was found to have a definite ectopic pregnancy. These 21 patients would have been referred for evaluation by the obstetrician on call for further management.

CONCLUSION

The majority of patients had sonographic findings that would have allowed safe and timely discharge from the Emergency Department had ultrasound been available at the point of care.

Critical appraisal of emergency medicine education research: the best publications of 2012

OBJECTIVES

The objective was to critically appraise and highlight medical education research published in 2012 that was methodologically superior and whose outcomes were pertinent to teaching and education in emergency medicine (EM).

METHODS

A search of the English language literature in 2012 querying Education Resources Information Center (ERIC), PsychInfo, PubMed, and Scopus identified EM studies using hypothesis-testing or observational investigations of educational interventions. Two reviewers independently screened all of the publications and removed articles using established exclusion criteria. This year, publications limited to a single-site survey design that measured satisfaction or self-assessment on unvalidated instruments were not formally reviewed. Six reviewers then independently ranked all remaining publications using one of two scoring systems depending on whether the study methodology was primarily qualitative or quantitative. Each scoring system had nine criteria, including four related to methodology, that were chosen a priori, to standardize evaluation by reviewers. The quantitative study scoring system was used previously to appraise medical education published annually in 2008 through 2011, while a separate, new qualitative study scoring system was derived and implemented consisting of parallel metrics.

RESULTS

Forty-eight medical education research papers met the a priori criteria for inclusion, and 33 (30 quantitative and three qualitative studies) were reviewed. Seven quantitative and two qualitative studies met the criteria for inclusion as exemplary and are summarized in this article.

CONCLUSIONS

This critical appraisal series aims to promote superior education research by reviewing and highlighting nine of the 48 major education research studies with relevance to EM published in 2012. Current trends and common methodologic pitfalls in the 2012 papers are noted.

The Application of Hand-Held Ultrasound Scanner in Teaching of Telemedicine and Rural Medicine

Stethoscope, the symbol of modern medicine has been in place for more than 150 years. However, this reliable diagnostic instrument has started showing its age with the arrival of a newer diagnostic instrument: the hand-held ultrasound.

Hand-held ultrasound is rapidly expanding in many specialties but not yet in obstetrics and gynecology. There is a paucity of literature on the application of hand-held ultrasound in obstetrics and gynecology, in contrast to a large volume of literature published by other specialties. Several studies demonstrated that medical students and residents can improve the accuracy of their physical examinations with the use of hand-held ultrasound. Similarly, physical examinations performed by hospitalists with hand-carried ultrasound are more accurate than those performed without the instrument. Advances in technology have contributed to the improvement of image quality and portability. As a result, these devices become increasingly available in many clinical settings such as point of care, telemedicine and rural medicine. The quality of ultrasound images of the hand-held scanner is inferior to those of standard laptop ultrasound. However, the hand-held ultrasound requires much less time for setup.

Although there have been recommendations for training guidelines for operators of hand-held ultrasound, standards for optimal training to achieve level of competency have not been determined.

How to cite this article

Wright J, Noriega O, Ho H. The Application of Hand-Held Ultrasound Scanner in Teaching of Telemedicine and Rural Medicine. Donald School J Ultrasound Obstet Gynecol 2014;8(1):87-91.