Emergency ultrasound fellowship training: a novel team-based approach

Training, Competency, and Interdisciplinary Collaboration in Point-of-Care Ultrasound

Point-of-care ultrasound can provide critical diagnostic information and add to procedural safety. As with any clinical skill, however, it must be applied by an adequately trained provider, with systems to ensure safety. Training can include a mix of hands-on training with traditional didactics, online coursework, and simulation, but each carries its own costs and benefits worth of review. Following training it is essential to think about assessment of competency in point-of-care ultrasound to reflect the combination of cognitive and procedural skills that makes up the practice. Within the frameworks described, expansion can be expected across specialty and professional boundaries.

Utilisation and barriers of PoCUS in a rural emergency department - A quality improvement project

Introduction

Point-of-care ultrasound (PoCUS) has been recognised as a tool that leads to more definitive diagnoses and enhances clinical decision-making in rural emergency departments (EDs) where diagnostic imaging is limited. We aimed to determine the current utilisation, barriers and solutions to using PoCUS in this rural Saskatchewan ED.

Methods

Physicians working in the ED participated in a semi-structured interview. An online survey, administered via SurveyMonkey post-interview to provide further context, was used to support qualitative approaches. Interviews were recorded, transcribed and then analysed using inductive interpretation.

Results

Seven physicians completed the quantitative survey with a response rate of 70%. Ten physicians were interviewed with a response rate of 100%. Themes identified were that physicians in this community's ED perceived their skill level as determining whether a scan was diagnostic or not, rather than the specific PoCUS application itself. In addition, they performed scans primarily for the purpose of triage. Inadequate training, Core IP certification certification requirement and intradepartmental logistics were barriers to PoCUS utilisation.

Conclusion

This study showed that ED physicians in this community perceived PoCUS as a clinical adjunct and as a tool to triage patients for further imaging. Results highlight the need to have accessible training for rural physicians to increase PoCUS utilisation, awareness of current Saskatchewan PoCUS guidelines and education on diagnostic applications of PoCUS. Increased use of PoCUS for specific scans could decrease the need for formal imaging and the associated healthcare system resources.

The 2023 Core Content of advanced emergency medicine ultrasonography

In February 2023, the American Board of Emergency Medicine (ABEM) approved modifications to the Advanced Emergency Medicine Ultrasonography (AEMUS) Core Content, which defines the areas of knowledge considered essential for the practice of AEMUS. This manuscript serves as a revision of the AEMUS Core Content originally published in 2014. The revision of the Core Content for AEMUS training aims to establish standardized education and qualifications necessary for AEMUS fellowship program leadership, clinical application, administration, quality improvement, and research. The Core Content provides the organizational framework and serves as the basis for the development of content for the Focused Practice Examination (FPE) administered by ABEM. AEMUS fellowship directors may reference the Core Content when designing AEMUS fellowship curricula to help prepare graduates for the autonomous practice of AEMUS and the FPE. In this article, an updated revision of the previously published AEMUS Core Content is detailed, and the entire development of the Core Content is presented.

Criteria, Processes, and Determination of Competence in Basic Critical Care Echocardiography Training: A Delphi Process Consensus Statement by the Learning Ultrasound in Critical Care (LUCC) Initiative

BACKGROUND

With the paucity of high-quality studies on longitudinal basic critical care echocardiography (BCCE) training, expert opinion guidelines have guided BCCE competence educational standards and processes. However, existing guidelines lack precise detail due to methodological flaws during guideline development.

RESEARCH QUESTIONS

To formulate methodologically robust guidelines on BCCE training using evidence and expert opinion, detailing specific criteria for every step, we conducted a modified Delphi process using the principles of the validated AGREE-II tool. Based on systematic reviews, the following domains were chosen: components of a longitudinal BCCE curriculum; pass-grade criteria for image-acquisition and image-interpretation; and formative/summative assessment and final competence processes.

STUDY DESIGN AND METHODS

Between April 2020 and May 2021, a total of 21 BCCE experts participated in four rounds. Rounds 1 and 2 used five web-based questionnaires, including branching-logic software for directed questions to individual panelists. In round 3 (videoconference), the panel finalized the recommendations by vote. During the journal peer-review process, Round 4 was conducted as Web-based questionnaires. Following each round, the agreement threshold for each item was determined as ≥ 80% for item inclusion and ≤ 30% for item exclusion.

RESULTS

Following rounds 1 and 2, agreement was reached on 62 of 114 items. To the 49 unresolved items, 12 additional items were added in round 3, with 56 reaching agreement and five items remaining unresolved. There was agreement that longitudinal BCCE training must include introductory training, mentored formative training, summative assessment for competence, and final cognitive assessment. Items requiring multiple rounds included two-dimensional views, Doppler, cardiac output, M-mode measurement, minimum scan numbers, and pass-grade criteria. Regarding objective criteria for image-acquisition and image-interpretation quality, the panel agreed on maintaining the same criteria for formative and summative assessment, to categorize BCCE findings as major vs minor and a standardized approach to errors, criteria for readiness for summative assessment, and supervisory options.

INTERPRETATION

In conclusion, this expert consensus statement presents comprehensive evidence-based recommendations on longitudinal BCCE training. However, these recommendations require prospective validation.

Impact of Insurance Benefits and Education on Point-of-Care Ultrasound Use in a Single Emergency Department: An Interrupted Time Series Analysis

Background and Objectives: Point-of-care ultrasound (POCUS) is a useful tool that helps clinicians properly treat patients in emergency department (ED). This study aimed to evaluate the impact of specific interventions on the use of POCUS in the ED. Materials and Methods: This retrospective study used an interrupted time series analysis to assess how interventions changed the use of POCUS in the emergency department of a tertiary medical institute in South Korea from October 2016 to February 2021. We chose two main interventions—expansion of benefit coverage of the National Health Insurance (NHI) for emergency ultrasound (EUS) and annual ultrasound educational workshops. The primary variable was the EUS rate, defined as the number of EUS scans per 1000 eligible patients per month. We compared the level and slope of EUS rates before and after interventions. Results: A total of 5188 scanned records were included. Before interventions, the EUS rate had increased gradually. After interventions, except for the first workshop, the EUS rate immediately increased significantly (p < 0.05). The difference in the EUS rate according to the expansion of the NHI was estimated to be the largest (p < 0.001). However, the change in slope significantly decreased after the third workshop during the coronavirus disease 2019 pandemic (p = 0.004). The EUS rate increased significantly in the presence of physicians participating in intensive POCUS training (p < 0.001). Conclusion: This study found that expansion of insurance coverage for EUS and ultrasound education led to a significant and immediate increase in the use of POCUS, suggesting that POCUS use can be increased by improving education and insurance benefits.

Implementation of pulmonary ultrasound training for critical care advanced practice providers

BACKGROUND AND PURPOSE

The use of pulmonary ultrasound (US) in the critical care setting has been increasing over the past 2 decades. The use of advanced practice providers (APPs) in the critical care setting is also increasing. Limited data exist regarding the clinical and educational impact of a formal pulmonary US training course for APPs working in critical care settings.

METHODS

A preimplementation and postimplementation comparative design focused on the development and implementation of a formal pulmonary US course for novice critical care APPs.

CONCLUSIONS

Eleven APPs underwent formal pulmonary US training. There was a significant increase in pulmonary US knowledge after the course, with pretest median of 13 and posttest median of 22 (p < .001; maximum score = 23). Presurvey and postsurvey comparison showed overall increase in skill and clinical use of pulmonary US. After the course, participating APPs reported a greater frequency of clinical decision-making based on US examination as measured by presurvey and postsurvey results.

IMPLICATIONS FOR PRACTICE

Implementation of a formal pulmonary US course for critical care APPs improved pulmonary US knowledge, skill, and utilization, and impacted clinical decision-making and should be a highly recommended addition to the practice setting.

Interventions to Increase Point-of-Care Ultrasound Use in a Pediatric Emergency Department

OBJECTIVE

We sought to determine which interventions have effectively increased point-of-care ultrasound (US) use in a pediatric emergency department (ED).

DESIGN/METHODS

We evaluated the impact of specific interventions conducted over a 5-year period (2010-2015) on point-of-care US performance in a tertiary care pediatric ED. Ultrasound use by attending physicians and fellows was ascertained from a departmental database. Interventions assessed included the following: (1) initiation of an US fellowship, (2) acquisition of a second US machine, (3) performance of an US-related research project in the department, (4) initiation of faculty US curriculum, (5) earlier introduction of US education for pediatric emergency medicine fellows, and (6) administrative mandate dictating faculty requirements for credentialing. Mean monthly US use was trended over time using statistical process control methodology, and the impact of major interventions was analyzed using interrupted time-series analyses.

RESULTS

The mean number of US scans increased from 2.0 to 5.9 per attending per month and from 4.3 to 7.1 per fellow per month over the study period. Using interrupted time-series analyses, we observed the only intervention to significantly increase attending US utilization was an administrative credentialing mandate, with an associated increase of 6% per month (incidence rate ratio, 1.06; 95% confidence interval, 1.01-1.11).

CONCLUSIONS

Point-of-care US use has increased over time for both fellows and attending physicians. We observed that an administrative mandate led to a significant increase in US use among attending physicians.

Central Venous Catheterization: Are We Using Ultrasound Guidance?

OBJECTIVES

To assess the self-reported frequency of use of ultrasound guidance for central venous catheterization by emergency medicine (EM) residents, describe residents' perceptions regarding the use of ultrasound guidance, and identify barriers to the use of ultrasound guidance.

METHODS

A longitudinal cross-sectional study was conducted at 5 academic institutions. A questionnaire on the use of ultrasound guidance for central venous catheterization was initially administered to EM residents in 2007. The same questionnaire was distributed again in the 5 EM residency programs in 2013.

RESULTS

In 2007 and 2013, 147 and 131 residents completed questionnaires, respectively. A significant increase in the use of ultrasound guidance for central venous catheterization was reported in 2013 compared to 2007 (P< .001). In 2007, 53% (95% confidence interval, 44%-61%) of residents reported that they were initially trained in central venous catheterization using ultrasound guidance compared to 96% (95% confidence interval, 92%-99%) in 2013 (P < .0001). In 2007, more residents thought that faculty were insufficiently adopting ultrasound (42% versus 9%), and there was a lack of ultrasound teaching during residency training (14% versus 5%) compared to 2013.

CONCLUSIONS

The use of self-reported ultrasound guidance for central venous catheterization significantly increased from 2007 to 2013 at academic institutions. Most residents were aware of the benefits of using ultrasound guidance. Although faculty adoption of ultrasound for central venous catheterization remains a barrier, it has decreased.