BRIEF COMMUNICATION Development and Preliminary Assessment of a Critical Care Ultrasound Course in an Adult Pulmonary and Critical Care Fellowship Program Cidney S. Hulett1, Vikas Pathak2, Jason N. Katz3, Sean P. Montgomery4, and Lydia H. Chang5 1,2,5 Pulmonary Disease and Critical Care Medicine, 3Cardiovascular Disease and Critical Care, and 4Surgery/Trauma and Critical Care, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Abstract Background: The focused ultrasound examination has become increasingly recognized as a safe and valuable diagnostic tool for the bedside assessment of the critically ill patient. We implemented a dedicated on-site critical care ultrasonography curriculum with the goal of developing a model for teaching ultrasound skills to pulmonary and critical care medicine fellows. Methods: The program was comprised of blended didactic and bedside sessions in the following topic domains: fundamentals; vascular access and diagnosis; and abdominal, thoracic, and cardiac ultrasonography. Formal knowledge and image acquisition assessments were performed before and after the program to assess success in meeting predefined learning objectives. Participants completed surveys (on Likert scale 1–5) before and after the program to assess their confidence in ultrasonography knowledge and skills as well as their perception as to training effectiveness.
Results: The preintervention knowledge and bedside image acquisition scores were 71 and 32%, respectively. The global preintervention score was 51%. All postintervention measures demonstrated significant improvement: 89% (P , 0.01), 86% (P , 0.0001), and 87% (P , 0.0001). Preintervention participant confidence in their ultrasound knowledge and skill was 2.9/5, which improved to 4.3/5 (P = 0.007) after intervention. Participants rated the curriculum as meeting course objectives at a mean of 4.8/5. Conclusions: At one academic medical center, the knowledge of eight adult pulmonary and critical care fellowship trainees regarding critical care ultrasound was high at baseline; however, bedside image acquisition skills were poor. A dedicated 6-week educational intervention resulted in highly significant improvements in subject knowledge and image acquisition skills. These preliminary results warrant validation studies at other medical centers. Keywords: critical care ultrasound; focused critical care ultrasound; critical care ultrasound training
(Received in original form December 22, 2013; accepted in final form March 13, 2014 ) Author Contributions: C.H. conceived and conducted the project and involved in training the vascular/thoracic/fundamentals of ultrasound to fellows and data collection. V.P. participated in manuscript preparation. J.K. and S.M. participated in training fellows in cardiac ultrasound. L.C. conceived the project, supervised the project, and participated in data analysis and manuscript preparation. Correspondence and requests for reprints should be addressed to Lydia Chang, M.D., Division of Pulmonary & Critical Care Medicine, University of North Carolina School of Medicine, 130 Mason Farm Road, Chapel Hill, NC 27599. E-mail: [email protected]. This article has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org. Ann Am Thorac Soc Vol 11, No 5, pp 784–788, Jun 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201312-459BC Internet address: www.atsjournals.org
Literature emerging over the past three decades supports the increased use of ultrasound in the intensive care unit (ICU). The use of critical care ultrasound can alter the therapeutic plan in up to 22% ICU patients (1). Many commonly encountered situations in the ICU are more effectively 784
addressed with ultrasound when compared with more conventional methods. Central venous access is accomplished more safely and more successfully under ultrasound guidance than with the traditional landmark technique (2, 3). Diagnosis of pneumothorax using bedside ultrasound
can be more sensitive and specific than chest radiograph (4). Dynamic ultrasound measures of fluid responsiveness have been shown to be more accurate than conventional static measures of volume status, such as central venous pressure and pulmonary artery occlusion pressure (5).
AnnalsATS Volume 11 Number 5 | June 2014
BRIEF COMMUNICATION Despite the known benefits of critical care ultrasound, formal training in focused critical care ultrasound is lacking (6). A national survey of program directors suggests that most critical care medicine fellowship programs do not offer formal training in focused critical care ultrasound (6). In the same survey, 92% of respondents agreed or strongly agreed that ultrasound training is useful, and 80% were interested in getting training for their fellows. In 2009, the American College of Chest Physicians (ACCP) released a consensus statement (7) on competence in critical care ultrasound. It was suggested that mastery each of the following domains defined competence: pleural, vascular, thoracic, and cardiac. Specific skills from each domain were defined and provided as a guide for training to achieve competence and certification. The American Society of Echocardiography (ASE) and the American College of Emergency Physicians (ACEP) published a joint consensus statement in 2010 (8), stressing the importance of focused cardiac ultrasound (FOCUS) in expediting the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment. They made the following statement: “The use of FOCUS requires knowledge of the strengths and limitations of this imaging modality. There are limitations of the FOCUS exam secondary to both the nature of the exam and the training of the individual interpreting the study. Valvular heart disease, diastolic function, and segmental wall motion analysis are examples of cardiac abnormalities that should eventually be assessed by comprehensive echocardiography.” (8). Abnormal findings on FOCUS should be referred for comprehensive echocardiography, other testing, or consultation when the situation allows for this to be done safely. However, FOCUS can identify pathologic processes that can guide resuscitative interventions and be lifesaving. Using the ACCP and ASE/ACEP consensus statements, we identified clear learning objectives for a dedicated critical care ultrasonography curriculum implemented to address the deficit within our training program. Our hypothesis was that the proposed instruction program would advance participant confidence, knowledge, and skills in the realm of critical care ultrasound.
Some of the results of these studies have been previously reported in the form of an abstract (9).
Materials and Methods Setting
The study was conducted at the University of North Carolina Hospitals, an 800-bed tertiary care teaching hospital. All examined patients were located in the 18-bed medical ICU. Subjects
Eight critical care medicine fellows, at different levels of training, participated. Study Design
We created a set of learning objectives (see Appendix E1 in the online supplement) based upon the published ACCP statement on competence in critical care ultrasound (7) and the published ASE/ACEP joint statement on focused cardiac ultrasound (8). The objectives were organized into five distinct domains: basic principles or fundamentals, pleural and lung ultrasonography, basic cardiac ultrasound, abdominal ultrasonography, and vascular ultrasonography (diagnostic and access). All ultrasonography was performed with a MicroMaxx unit equipped with two transducers, one at 5.1 MHz and one at 10.5 MHz (Sonosite, Inc., Bothell, WA). The institutional review board (IRB) reviewed the study and deemed it IRB exempt. The course was administered over a 6-week period (Appendix E2). One module was covered per week, with the exception of the cardiac ultrasound module, which was covered over a 2-week period. The course instructors included a pulmonary and critical care medicine attending, a pulmonary and critical care fellow with extensive ultrasound experience, a critical care surgery attending, and a cardiologist trained in critical care medicine. Each week, the participants received 1 hour of didactic instruction followed by 1 hour of active involvement in an image interpretation workshop and a bedside image acquisition training workshop. During the image interpretation workshop, the participants were challenged to interpret pathologic and nonpathologic images. The image acquisition workshop occurred at the bedside of current medical
Hulett, Pathak, Katz, et al.: Ultrasonography for Critical Care Fellows
ICU patients selected to ensure that relevant images could be reasonably obtained. We adopted a “train to success” strategy (repetitive training on each task until excellence in performance is achieved by each participant) during the bedside image acquisition workshop such that each participant demonstrated proficiency at each of the outlined module objectives by the end of the workshop. We created a knowledge assessment tool and a bedside image acquisition skills assessment tool to evaluate the effectiveness of the educational interventional in meeting learning objectives. The knowledge assessment tool included 46 questions (Appendices E3 and E4) in various formats, including multiple choice questions, true/ false items, matching items, and fill-in–theblank image and video recognition. The bedside assessment tool was comprised of an image acquisition and interpretation skills checklist (Appendix E5); each participant was asked to demonstrate 46 items on the checklist on a patient, and performance was evaluated at the bedside. A self-assessment survey using the Likert scale was created to assess participants’ confidence in representative skills from each domain. Each of the three assessments was performed on all of the participants before and after the educational intervention. Analysis
Participant performance and survey results were described using summary statistics. Analysis of pre- and postintervention performance was performed using paired t test.
Results Global Evaluation
The mean global knowledge score of critical care ultrasonography, which included assessment of all five major content domains, was 71% (95% confidence interval [CI], 63–79) before the course; this improved significantly to a mean of 89% (95% CI, 80–97) after the course (P = 0.01) (Figures 1 and 2). The mean baseline bedside image acquisition skills score was low at 31% (95% CI, 23–39); this improved to 85% (95% CI, 77–93) after the course (P , 0.0001). The average course evaluation score was 4.8 on the Likert scale (range, 4.4–5.0). Mean baseline 785
BRIEF COMMUNICATION intervention (P = 0.3). Fellows’ selfassessment score (Likert score) was 3.7 (95% CI, 3.2–4.3) before the course and improved to 4.7 after the hands-on experience (95% CI, 4.5–5.0; P = 0.0047) (Figure 3). Cardiac Ultrasound
The mean knowledge assessment score before was 58% (95% CI, 36–79) before intervention, which improved to 86% (95% CI, 71–100) after training (P = 0.05) (Figures 1 and 2). Surprisingly, mean bedside skills assessment before intervention was 0% (95% CI, 0–2); this improved significantly to 79% (95% CI, 64–94) after training (P , 0.0001). Fellows’ confidence in cardiac skill was 1.6 (95% CI, 1.1–2.1) before training and 4.0 (95% CI, 3.2–4.7) after training (P = 0.0004) (Figure 3). Thoracic Ultrasound Figure 1. Knowledge assessment before and after course.
self-assessment on the Likert scale was 2.9 (95% CI, 2.4–3.4) and improved to 4.3 (95% CI, 3.8–4.8) after the course (P = 0.007) (Figure 3). We also analyzed fellow knowledge, skills, and self-assessment within each of the five content domains: fundamentals and cardiac, thoracic, abdominal, and vascular ultrasonography.
Fundamentals of Ultrasonography
The mean preintervention knowledge score was 83% (95% CI, 74–91), which improved to 91% (95% CI, 82–100; P = 0.04) (Figures 1 and 2). The bedside image acquisition skills assessment of ultrasonography fundamentals score was 93% before the training (95% CI, 78–100), which improved to 100% (95% CI, 100–100) on the test after
The mean thoracic ultrasound knowledge score before the course was 79% (95% CI, 74–84%), which improved to 92% (95% CI, 85–98) after the course (P = 0.003) (Figures 1 and 2). The bedside skills score was 42% (95% CI, 35–49) before the training, which improved to 88% (95% CI, 81–95) after the bedside training (P = 0.0001). The mean self-assessment score on the Likert scale improved from 3.1 (95% CI, 2.3–3.9) to 4.5 (95% 3.9–5.0; P = 0.03) (Figure 3). Abdominal Ultrasound
The mean baseline knowledge score was 100% precourse; hence, it did not change after intervention (Figures 1 and 2). Mean baseline bedside skills assessment was only 35% (95% CI, 16–54) but improved significantly to 89% (95% CI, 82–96) after the course (P = 0.0005). Fellow selfassessment on the Likert scale improved from 2.7 (95% CI, 1.7–3.6) to 4.0 (95% CI, 3.4–4.5; P = 0.04) (Figure 3). Vascular Ultrasound
Figure 2. Bedside skill assessment before and after the course.
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The preintervention mean knowledge score was 53% (95% CI, 29–76), which improved to 71% (95% CI, 51–92) after the course (P = 0.07) (Figures 1 and 2). Bedside assessment of the vascular skills was 50% (95% CI, 40–59) before the course and improved to 87% (95% CI, 79–95) after the training (P = 0.0002). The Likert score was 3.3 (95% CI, 2.7–3.9) before the course AnnalsATS Volume 11 Number 5 | June 2014
BRIEF COMMUNICATION
Figure 3. Likert score (participant’s satisfaction before and after the course).
and 4.3 (95% CI, 3.6–5) after the course (P = 0.01) (Figure 3).
Discussion Our results show that a dedicated critical care ultrasound training incorporated into a fellowship training program can increase knowledge about critical care ultrasonography and significantly increases image acquisition skills. Our results also demonstrated that fellows felt more confident after the workshop than before it. In our study, baseline cognitive understanding of critical care ultrasound was fairly good, particularly within the fundamentals of ultrasonography (83%), thoracic ultrasound (79%), and abdominal ultrasound (100%). The baseline knowledge of cardiac ultrasound (58%) and vascular ultrasound (about 58%) was not as good. Despite a fair fund of knowledge overall before the curriculum, all fellows demonstrated very poor image acquisition skill, with a mean score of 31% that improved to 89% after training. This was particularly pronounced for cardiac ultrasound; precurriculum image acquisition performance was near 0% but improved to 79% after the workshop.
There are several benefits of bedside critical care ultrasound, including the lack of delay in performance of indicated exams, avoidance of transport of the critically ill patient, the ability to use serial exams, and the ability of the primary physician to correlate ultrasound examination findings to the dynamic clinical situation (10, 11). Despite its benefits, significant barriers to integration of ultrasound training into a critical care fellowship remain, including lack of faculty trained in ultrasound use and fellow turnover. Our study indicates that incorporation of a formal critical care ultrasonography course in pulmonary and critical care fellowship training may significantly improve knowledge and the bedside skill set, which would improve patient care. It also boosts the confidence of the in-training fellows. We recommend including didactic sessions and hands-on teaching in these training sessions. Cardiac ultrasound particularly seems to be the domain that fellows have greatest deficit in baseline knowledge and skillset and can be improved significantly with proper training. This was corroborated by Beraud and colleagues (12). These investigators implemented a focused transthoracic echocardiography curriculum for critical care medicine fellows participating in
Hulett, Pathak, Katz, et al.: Ultrasonography for Critical Care Fellows
1- and 2-year training programs. They assessed the ability of critical care medicine fellows to obtain and interpret focused transthoracic echocardiography images from critically ill patients and a from transthoracic echocardiography simulator. At the end of the curriculum, the fellows were able to expeditiously obtain essential focused transthoracic echocardiography views: parasternal long axis, parasternal short axis, apical four chambers, subcostal four chambers, and subcostal inferior vena cava. Our study had several significant limitations. It was performed at a single center, with only a small number of fellows enrolled. We also did not measure and evaluate use of the skills acquired during clinical rotations in the ICU. Course objectives were generated by local instructors from consensus statements, but a wider peer review would have been beneficial in establishing generalizability for all fellows in training. Knowledge and skill assessment tools were also generated by the course instructors, and these tools would benefit from validation and vetting on a wider scale. Further investigation is warranted in a larger forum with a larger number of participants with validated assessment tools. Knowledge and skill assessment tools were also generated by the course instructors, and these tools would benefit from validation and vetting on a wider scale. After this course was completed, the American Thoracic Society published a six-part course on ICU ultrasound (13–18). Elements of this course might be incorporated into the curriculum of future on-site fellowship program training courses.
Conclusions A formal curriculum dedicated to critical care ultrasound can be developed and implemented on site in a fellowship training program. After validation studies testing longer-term retention of knowledge and bedside skills on trainees at other broadly representative medical centers, the curriculum described here might form the basis of a widely applicable onsite critical care ultrasound course curriculum. n Author disclosures are available with the text of this article at www.atsjournals.org.
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BRIEF COMMUNICATION References 1 Lichtenstein D, Axler O. Intensive use of general ultrasound in the intensive care unit: prospective study of 150 consecutive patients. Intensive Care Med 1993;19:353–355. 2 Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein: a prospective comparison to the external landmark-guided technique. Circulation 1993;87:1557–1562. 3 Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein: a prospective, randomized study. Anesth Analg 1991;72:823–826. 4 Ding W, Shen Y, Yang J, He X, Zhang M. Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis. Chest 2011; 140:859–866. 5 Carr BG, Dean AJ, Everett WW, Ku BS, Mark DG, Okusanya O, Horan AD, Gracias VH. Intensivist bedside ultrasound (INBU) for volume assessment in the intensive care unit: a pilot study. J Trauma 2007; 63:495–500, discussion 500–502. 6 Eisen LA, Leung S, Gallagher AE, Kvetan V. Barriers to ultrasound training in critical care medicine fellowships: a survey of program directors. Crit Care Med 2010;38:1978–1983. 7 Mayo PH, Beaulieu Y, Doelken P, Feller-Kopman D, Harrod C, Kaplan A, Oropello J, Vieillard-Baron A, Axler O, Lichtenstein D, et al. American College of Chest Physicians/La Societ ´ e´ de Reanimation ´ de Langue Française statement on competence in critical care ultrasonography. Chest 2009;135:1050–1060. 8 Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of
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Emergency Physicians. J Am Soc Echocardiogr 2010;23: 1225–1230. Hulett C, Katz J, Mongomery S, Chang L. Effectiveness of a critical care ultrasound (ccus) curriculum in a critical care medicine fellowship program [abstract]. CHEST Journal 2012;142:533A–533A. Beaulieu Y, Marik PE. Bedside ultrasonography in the ICU: part 1. Chest 2005;128:881–895. Beaulieu Y, Marik PE. Bedside ultrasonography in the ICU: part 2. Chest 2005;128:1766–1781. Beraud AS, Rizk NW, Pearl RG, Liang DH, Patterson AJ. Focused transthoracic echocardiography during critical care medicine training: curriculum implementation and evaluation of proficiency. Crit Care Med 2013;41:e179–e181. De Backer D, Fagnoul D. Intensive care ultrasound: VI. Fluid responsiveness and shock assessment. Ann Am Thorac Soc 2014;11:129–136. Boniface KS, Calabrese KY. Intensive care ultrasound: IV. Abdominal ultrasound in critical care. Ann Am Thorac Soc 2013;10:713–724. Doerschug KC, Schmidt GA. Intensive care ultrasound: III. Lung and pleural ultrasound for the intensivist. Ann Am Thorac Soc 2013;10:708–712. Silverberg MJ, Kory P. Intensive care ultrasound: II. Central vascular access and venous diagnostic ultrasound. Ann Am Thorac Soc 2013;10:549–556. Bakhru RN, Schweickert WD. Intensive care ultrasound: I. Physics, equipment, and image quality. Ann Am Thorac Soc 2013;10: 540–548. Schmidt GA, Schraufnagel D. Introduction to ATS seminars: intensive care ultrasound. Ann Am Thorac Soc 2013;10:538–539.
AnnalsATS Volume 11 Number 5 | June 2014
Abstract Background: The focused ultrasound examination has become increasingly recognized as a safe and valuable diagnostic tool for the bedside assessment of the critically ill patient. We implemented a dedicated on-site critical care ultrasonography curriculum with the goal of developing a model for teaching ultrasound skills to pulmonary and critical care medicine fellows. Methods: The program was comprised of blended didactic and bedside sessions in the following topic domains: fundamentals; vascular access and diagnosis; and abdominal, thoracic, and cardiac ultrasonography. Formal knowledge and image acquisition assessments were performed before and after the program to assess success in meeting predefined learning objectives. Participants completed surveys (on Likert scale 1–5) before and after the program to assess their confidence in ultrasonography knowledge and skills as well as their perception as to training effectiveness.
Results: The preintervention knowledge and bedside image acquisition scores were 71 and 32%, respectively. The global preintervention score was 51%. All postintervention measures demonstrated significant improvement: 89% (P , 0.01), 86% (P , 0.0001), and 87% (P , 0.0001). Preintervention participant confidence in their ultrasound knowledge and skill was 2.9/5, which improved to 4.3/5 (P = 0.007) after intervention. Participants rated the curriculum as meeting course objectives at a mean of 4.8/5. Conclusions: At one academic medical center, the knowledge of eight adult pulmonary and critical care fellowship trainees regarding critical care ultrasound was high at baseline; however, bedside image acquisition skills were poor. A dedicated 6-week educational intervention resulted in highly significant improvements in subject knowledge and image acquisition skills. These preliminary results warrant validation studies at other medical centers. Keywords: critical care ultrasound; focused critical care ultrasound; critical care ultrasound training
(Received in original form December 22, 2013; accepted in final form March 13, 2014 ) Author Contributions: C.H. conceived and conducted the project and involved in training the vascular/thoracic/fundamentals of ultrasound to fellows and data collection. V.P. participated in manuscript preparation. J.K. and S.M. participated in training fellows in cardiac ultrasound. L.C. conceived the project, supervised the project, and participated in data analysis and manuscript preparation. Correspondence and requests for reprints should be addressed to Lydia Chang, M.D., Division of Pulmonary & Critical Care Medicine, University of North Carolina School of Medicine, 130 Mason Farm Road, Chapel Hill, NC 27599. E-mail: [email protected]. This article has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org. Ann Am Thorac Soc Vol 11, No 5, pp 784–788, Jun 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201312-459BC Internet address: www.atsjournals.org
Literature emerging over the past three decades supports the increased use of ultrasound in the intensive care unit (ICU). The use of critical care ultrasound can alter the therapeutic plan in up to 22% ICU patients (1). Many commonly encountered situations in the ICU are more effectively 784
addressed with ultrasound when compared with more conventional methods. Central venous access is accomplished more safely and more successfully under ultrasound guidance than with the traditional landmark technique (2, 3). Diagnosis of pneumothorax using bedside ultrasound
can be more sensitive and specific than chest radiograph (4). Dynamic ultrasound measures of fluid responsiveness have been shown to be more accurate than conventional static measures of volume status, such as central venous pressure and pulmonary artery occlusion pressure (5).
AnnalsATS Volume 11 Number 5 | June 2014
BRIEF COMMUNICATION Despite the known benefits of critical care ultrasound, formal training in focused critical care ultrasound is lacking (6). A national survey of program directors suggests that most critical care medicine fellowship programs do not offer formal training in focused critical care ultrasound (6). In the same survey, 92% of respondents agreed or strongly agreed that ultrasound training is useful, and 80% were interested in getting training for their fellows. In 2009, the American College of Chest Physicians (ACCP) released a consensus statement (7) on competence in critical care ultrasound. It was suggested that mastery each of the following domains defined competence: pleural, vascular, thoracic, and cardiac. Specific skills from each domain were defined and provided as a guide for training to achieve competence and certification. The American Society of Echocardiography (ASE) and the American College of Emergency Physicians (ACEP) published a joint consensus statement in 2010 (8), stressing the importance of focused cardiac ultrasound (FOCUS) in expediting the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment. They made the following statement: “The use of FOCUS requires knowledge of the strengths and limitations of this imaging modality. There are limitations of the FOCUS exam secondary to both the nature of the exam and the training of the individual interpreting the study. Valvular heart disease, diastolic function, and segmental wall motion analysis are examples of cardiac abnormalities that should eventually be assessed by comprehensive echocardiography.” (8). Abnormal findings on FOCUS should be referred for comprehensive echocardiography, other testing, or consultation when the situation allows for this to be done safely. However, FOCUS can identify pathologic processes that can guide resuscitative interventions and be lifesaving. Using the ACCP and ASE/ACEP consensus statements, we identified clear learning objectives for a dedicated critical care ultrasonography curriculum implemented to address the deficit within our training program. Our hypothesis was that the proposed instruction program would advance participant confidence, knowledge, and skills in the realm of critical care ultrasound.
Some of the results of these studies have been previously reported in the form of an abstract (9).
Materials and Methods Setting
The study was conducted at the University of North Carolina Hospitals, an 800-bed tertiary care teaching hospital. All examined patients were located in the 18-bed medical ICU. Subjects
Eight critical care medicine fellows, at different levels of training, participated. Study Design
We created a set of learning objectives (see Appendix E1 in the online supplement) based upon the published ACCP statement on competence in critical care ultrasound (7) and the published ASE/ACEP joint statement on focused cardiac ultrasound (8). The objectives were organized into five distinct domains: basic principles or fundamentals, pleural and lung ultrasonography, basic cardiac ultrasound, abdominal ultrasonography, and vascular ultrasonography (diagnostic and access). All ultrasonography was performed with a MicroMaxx unit equipped with two transducers, one at 5.1 MHz and one at 10.5 MHz (Sonosite, Inc., Bothell, WA). The institutional review board (IRB) reviewed the study and deemed it IRB exempt. The course was administered over a 6-week period (Appendix E2). One module was covered per week, with the exception of the cardiac ultrasound module, which was covered over a 2-week period. The course instructors included a pulmonary and critical care medicine attending, a pulmonary and critical care fellow with extensive ultrasound experience, a critical care surgery attending, and a cardiologist trained in critical care medicine. Each week, the participants received 1 hour of didactic instruction followed by 1 hour of active involvement in an image interpretation workshop and a bedside image acquisition training workshop. During the image interpretation workshop, the participants were challenged to interpret pathologic and nonpathologic images. The image acquisition workshop occurred at the bedside of current medical
Hulett, Pathak, Katz, et al.: Ultrasonography for Critical Care Fellows
ICU patients selected to ensure that relevant images could be reasonably obtained. We adopted a “train to success” strategy (repetitive training on each task until excellence in performance is achieved by each participant) during the bedside image acquisition workshop such that each participant demonstrated proficiency at each of the outlined module objectives by the end of the workshop. We created a knowledge assessment tool and a bedside image acquisition skills assessment tool to evaluate the effectiveness of the educational interventional in meeting learning objectives. The knowledge assessment tool included 46 questions (Appendices E3 and E4) in various formats, including multiple choice questions, true/ false items, matching items, and fill-in–theblank image and video recognition. The bedside assessment tool was comprised of an image acquisition and interpretation skills checklist (Appendix E5); each participant was asked to demonstrate 46 items on the checklist on a patient, and performance was evaluated at the bedside. A self-assessment survey using the Likert scale was created to assess participants’ confidence in representative skills from each domain. Each of the three assessments was performed on all of the participants before and after the educational intervention. Analysis
Participant performance and survey results were described using summary statistics. Analysis of pre- and postintervention performance was performed using paired t test.
Results Global Evaluation
The mean global knowledge score of critical care ultrasonography, which included assessment of all five major content domains, was 71% (95% confidence interval [CI], 63–79) before the course; this improved significantly to a mean of 89% (95% CI, 80–97) after the course (P = 0.01) (Figures 1 and 2). The mean baseline bedside image acquisition skills score was low at 31% (95% CI, 23–39); this improved to 85% (95% CI, 77–93) after the course (P , 0.0001). The average course evaluation score was 4.8 on the Likert scale (range, 4.4–5.0). Mean baseline 785
BRIEF COMMUNICATION intervention (P = 0.3). Fellows’ selfassessment score (Likert score) was 3.7 (95% CI, 3.2–4.3) before the course and improved to 4.7 after the hands-on experience (95% CI, 4.5–5.0; P = 0.0047) (Figure 3). Cardiac Ultrasound
The mean knowledge assessment score before was 58% (95% CI, 36–79) before intervention, which improved to 86% (95% CI, 71–100) after training (P = 0.05) (Figures 1 and 2). Surprisingly, mean bedside skills assessment before intervention was 0% (95% CI, 0–2); this improved significantly to 79% (95% CI, 64–94) after training (P , 0.0001). Fellows’ confidence in cardiac skill was 1.6 (95% CI, 1.1–2.1) before training and 4.0 (95% CI, 3.2–4.7) after training (P = 0.0004) (Figure 3). Thoracic Ultrasound Figure 1. Knowledge assessment before and after course.
self-assessment on the Likert scale was 2.9 (95% CI, 2.4–3.4) and improved to 4.3 (95% CI, 3.8–4.8) after the course (P = 0.007) (Figure 3). We also analyzed fellow knowledge, skills, and self-assessment within each of the five content domains: fundamentals and cardiac, thoracic, abdominal, and vascular ultrasonography.
Fundamentals of Ultrasonography
The mean preintervention knowledge score was 83% (95% CI, 74–91), which improved to 91% (95% CI, 82–100; P = 0.04) (Figures 1 and 2). The bedside image acquisition skills assessment of ultrasonography fundamentals score was 93% before the training (95% CI, 78–100), which improved to 100% (95% CI, 100–100) on the test after
The mean thoracic ultrasound knowledge score before the course was 79% (95% CI, 74–84%), which improved to 92% (95% CI, 85–98) after the course (P = 0.003) (Figures 1 and 2). The bedside skills score was 42% (95% CI, 35–49) before the training, which improved to 88% (95% CI, 81–95) after the bedside training (P = 0.0001). The mean self-assessment score on the Likert scale improved from 3.1 (95% CI, 2.3–3.9) to 4.5 (95% 3.9–5.0; P = 0.03) (Figure 3). Abdominal Ultrasound
The mean baseline knowledge score was 100% precourse; hence, it did not change after intervention (Figures 1 and 2). Mean baseline bedside skills assessment was only 35% (95% CI, 16–54) but improved significantly to 89% (95% CI, 82–96) after the course (P = 0.0005). Fellow selfassessment on the Likert scale improved from 2.7 (95% CI, 1.7–3.6) to 4.0 (95% CI, 3.4–4.5; P = 0.04) (Figure 3). Vascular Ultrasound
Figure 2. Bedside skill assessment before and after the course.
786
The preintervention mean knowledge score was 53% (95% CI, 29–76), which improved to 71% (95% CI, 51–92) after the course (P = 0.07) (Figures 1 and 2). Bedside assessment of the vascular skills was 50% (95% CI, 40–59) before the course and improved to 87% (95% CI, 79–95) after the training (P = 0.0002). The Likert score was 3.3 (95% CI, 2.7–3.9) before the course AnnalsATS Volume 11 Number 5 | June 2014
BRIEF COMMUNICATION
Figure 3. Likert score (participant’s satisfaction before and after the course).
and 4.3 (95% CI, 3.6–5) after the course (P = 0.01) (Figure 3).
Discussion Our results show that a dedicated critical care ultrasound training incorporated into a fellowship training program can increase knowledge about critical care ultrasonography and significantly increases image acquisition skills. Our results also demonstrated that fellows felt more confident after the workshop than before it. In our study, baseline cognitive understanding of critical care ultrasound was fairly good, particularly within the fundamentals of ultrasonography (83%), thoracic ultrasound (79%), and abdominal ultrasound (100%). The baseline knowledge of cardiac ultrasound (58%) and vascular ultrasound (about 58%) was not as good. Despite a fair fund of knowledge overall before the curriculum, all fellows demonstrated very poor image acquisition skill, with a mean score of 31% that improved to 89% after training. This was particularly pronounced for cardiac ultrasound; precurriculum image acquisition performance was near 0% but improved to 79% after the workshop.
There are several benefits of bedside critical care ultrasound, including the lack of delay in performance of indicated exams, avoidance of transport of the critically ill patient, the ability to use serial exams, and the ability of the primary physician to correlate ultrasound examination findings to the dynamic clinical situation (10, 11). Despite its benefits, significant barriers to integration of ultrasound training into a critical care fellowship remain, including lack of faculty trained in ultrasound use and fellow turnover. Our study indicates that incorporation of a formal critical care ultrasonography course in pulmonary and critical care fellowship training may significantly improve knowledge and the bedside skill set, which would improve patient care. It also boosts the confidence of the in-training fellows. We recommend including didactic sessions and hands-on teaching in these training sessions. Cardiac ultrasound particularly seems to be the domain that fellows have greatest deficit in baseline knowledge and skillset and can be improved significantly with proper training. This was corroborated by Beraud and colleagues (12). These investigators implemented a focused transthoracic echocardiography curriculum for critical care medicine fellows participating in
Hulett, Pathak, Katz, et al.: Ultrasonography for Critical Care Fellows
1- and 2-year training programs. They assessed the ability of critical care medicine fellows to obtain and interpret focused transthoracic echocardiography images from critically ill patients and a from transthoracic echocardiography simulator. At the end of the curriculum, the fellows were able to expeditiously obtain essential focused transthoracic echocardiography views: parasternal long axis, parasternal short axis, apical four chambers, subcostal four chambers, and subcostal inferior vena cava. Our study had several significant limitations. It was performed at a single center, with only a small number of fellows enrolled. We also did not measure and evaluate use of the skills acquired during clinical rotations in the ICU. Course objectives were generated by local instructors from consensus statements, but a wider peer review would have been beneficial in establishing generalizability for all fellows in training. Knowledge and skill assessment tools were also generated by the course instructors, and these tools would benefit from validation and vetting on a wider scale. Further investigation is warranted in a larger forum with a larger number of participants with validated assessment tools. Knowledge and skill assessment tools were also generated by the course instructors, and these tools would benefit from validation and vetting on a wider scale. After this course was completed, the American Thoracic Society published a six-part course on ICU ultrasound (13–18). Elements of this course might be incorporated into the curriculum of future on-site fellowship program training courses.
Conclusions A formal curriculum dedicated to critical care ultrasound can be developed and implemented on site in a fellowship training program. After validation studies testing longer-term retention of knowledge and bedside skills on trainees at other broadly representative medical centers, the curriculum described here might form the basis of a widely applicable onsite critical care ultrasound course curriculum. n Author disclosures are available with the text of this article at www.atsjournals.org.
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AnnalsATS Volume 11 Number 5 | June 2014
