Efficacy of a certified modular ultrasound curriculum (2024)

Der Anaesthesist Originalien Anaesthesist 2020 · 69:192–197 https://doi.org/10.1007/s00101-020-00730-9 Received: 2 September 2019 Revised: 13 November 2019 Accepted: 26 December 2019 Published online: 13 February 2020 © The Author(s) 2020 R. Tomasi · K. Stark · P. Scheiermann Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany Efficacy of a certified modular ultrasound curriculum Electronic supplementary material The online version of this article (https://doi. org/10.1007/s00101-020-00730-9) provides the two questionnaires in German. The article and additional material are available at www. springermedizin.de. Please enter the title of the article in the search field, the additional material can be found under “Ergänzende Inhalte”. Background In recent years, ultrasound (US) has be- come incorporated into anesthesia and intensive care medicine because it is a use- ful, non-invasive, portable, and relatively low-cost diagnostic imaging method and guiding tool for procedures [3]. Health- care providers need to be trained in or- der to incorporate new procedures into routine clinical practice. Psychom*otor skills are best acquired using a sequenced and step-by-step teaching approach [20]. ere are a variety of widely accepted and published teaching models advanced by Fitts, Simpson and Posner [21]. e number of teaching steps used in these models varies from 2 to 11 [21]. Tak- ing the various teaching models into ac- count, many specialized programs and workshops have been designed to teach sonographic techniques to novice oper- ators. Until now, no program has been found to be superior to the other. Amer- ican and European guidelines have been published to offer assistance in the orga- nization of US teaching programs [27]. In addition, for critical care sonography two international expert statements have acknowledged the challenges in provid- ing appropriate training in echography and critical care US [8, 19]. In Germany this increased use has led to the intro- duction of an US curriculum in teaching programs. In 2011, the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) established a modu- lar curriculum called anesthesia-focused sonography (AFS) [4, 14, 25, 28, 29]. e first module covers basic aspects of the physical principles behind US, sys- tem and transducer technology as well as principlesofdopplersonography[4]. e second module deals with vascular sono- graphic techniques and options for fur- ther use [29] and the third module with US for regional anesthesia [14]. Mod- ule 4 focuses on transthoracic echocar- diography (TTE) [28] and module 5 on the sonography of the thorax and ab- domen [25]. Module 4 was revised af- ter conducting this study in 2017 and is now integrated into a new training concept called “Perioperative fokussierte Echokardiographie in der Anästhesiolo- gie und Intensivmedizin (PFE, perioper- ative focused echocardiography in anes- thesiology and intensive care)”. is new curriculum consists of five modules and has a distinct theoretical and practical division [11]. e AFS curriculum of the German society is a combination of didactic lectures followed by a two- step instructional approach to teach psy- chom*otor skills in the form of hands-on training. Following the course, practi- tioners receive an attendance confirma- tion. A certification aſter additional clin- ical teaching is not issued. ere is an option for obtaining various, however not validated degrees of a certification, provided by the interdisciplinary Ger- man Society of Ultrasound in Medicine (DEGUM). To our knowledge, the ef- ficacy of the AFS modular curriculum of the DGAI has not been validated to date. Performing US based psychom*o- tor skills requires the operator to develop visuomotor and visuospatial skills [20]. Probably, these skills cannot be learned through hands-on training sessions only, but only in the context of everyday clinical practice. erefore, the main objective of this study was to determine if there is a relevant increase of knowledge and of psychom*otor skills for the participants of the AFS curriculum. Material and methods e ethics committee of the Ludwig- Maximilians-University Munich (ethics committee number 593-16) approved the study, and participants provided written informed consent. For this monocen- tric prospective study 41 anesthesiolo- gists of the University Hospital of Mu- nich were enrolled. e anesthesiologists had different prior practical experience in sonography; the only exclusion crite- rion was earlier participation in certified US courses. Of these participants, 22 fol- lowedAFSmodules1–3and19AFSmod- ules 4–5. Modules 1–3 were held in a 2- day course in November 2016 (course 1), and modules 4 and 5 in a 2-day course in February 2017 (course 2). Because of 192 Der Anaesthesist 3 · 2020

Fig. 1 9 Custom made gelatine puncture model. The figure shows a tip of a regional anesthesia nee- dle in a noodle in in-plane puncture technique and b cross-section of a noodle embedded in gelatine the different focus of the two courses, prior participation in course 1 was not mandatory in order to attend course 2. To assess baseline knowledge, all par- ticipants of course 1 filled out a 15- question multiple choice test in the hospital without external sources of in- formation 1 week before participating in the courses (the multiple choice test is provided as a supplement). In brief, the multiple choice test was created in Microsoſt Word (Microsoſt Corporation, Redmond, WA, USA). A maximum of 30 points could be achieved. Together with the multiple choice test, all partici- pants performed two practical exercises to assess psychom*otor skills. To test visuomotor skills, a longitudinal (in- plane) puncture technique [6] was used on a custom made puncture model (. Fig. 1). e goal of the task was to penetrate a noodle (Barilla, Tortiglioni, 9mm; Barilla, Parma, Italy) embedded in gelatine at 3cm depth with the tip of a regional anesthesia needle (Uni- plex NanoLine, Pajunk R  , Geisingen, Germany) using an in-plane puncture technique and to confirm that the tip of the needle is in the required position. A 38 mm 10–12 Hz linear transducer was used to visualize the real-time track of the needle to the target. An intervention imaging preset was selected which used a grey scale map with a frame rate of 24.5 frames per second and one focal zone. First, the time needed to complete the skill was measured (test 1). e time was started when the needle was picked up by the trainee and stopped when the trainee stated that the needle was inside the lumen of the noodle in the required position. is essentially mirrors the clinical use of US, as in a clinical setting there is no instructor to state whether the needle is in the correct place. It is up to the judgment of the operator and whether he considers the puncture to be successful. e time was only utilized for further analysis if the tip of the needle was correctly inside the noodle. Other- wise the task was considered incorrectly performed and this was recorded in the data. An instructor rated the task as 0 when during the entire procedure the needle tip and the shaſt were never observed on two dimensional (2D) real- time visualization, as 1 when the needle shaſt but not the tip was observed, as 2 when the needle tip but not the shaſt was observed, and a mark of 3 was obtained when both the tip of the needle and shaſt were continually observed. To test visuospatial skills, the trainees had to demonstrate a 2D image of the ax- illary brachial plexus on a human model (test 2) visualizing prespecified struc- tures. All participants performed the skill on the same human model. To ob- tain the best view of the brachial plexus a linear transducer was to be placed in the transverse plane at the lateral border of pectoralis major muscle. To optimize image quality, appropriate depth, focus range and gain had to be set by the op- erator. e structures of interest for this task were the axillary artery, the axillary veins, and the four terminal branches of the brachial plexus: the median (super- ficial and lateral to the artery), the ulnar (superficial and medial to the artery) and radial (posterior and lateral or medial to the artery) and the musculocutaneous (between the biceps and coracobrachialis muscles) nerves. Once the trainees were able to display all anatomical structures of interest on a 2D image, they had to print this image and correctly label the anatom- ical structures displayed on the printout. For each correctly identified anatomi- cal structure, 0.5 points were allocated and a maximum of 3 points could be achieved. In addition, the time taken to create the image was measured. e time was started when the operator picked up the transducer and stopped when print- ing of the image was started. To determine the increase of knowl- edge and of performance in psychom*otor skills, the multiple choice test with identi- cal questions in a randomized order plus the skills tests were repeated 1 week aſter the course. e following results were examined for each assessment: scores of the multiple choice tests, time to success- fully perform test 1, the scores for needle visualization of test 1, time to success- fully perform a 2D image of the axillary brachial plexus visualizing the aforemen- tioned structures of interest, and scores of the anatomical structures visualized in the trainee made images. For the pretest and posttest of course 2, a presentation in Microsoſt Power- Point (Microsoſt Corporation) with a 20- question multiple choice test regarding the evaluation of US sequences or im- ages were created. e questions were related to the topics covered by the AFS modules 4 and 5 and are provided as a supplement. e participants could ac- cess the computer-based diagnostic test under their clinic account, but the an- swers were marked on an enclosed an- swer sheet. Multiple answers were pos- sible. e numbers of correct answers were not stated in the question. If the question was answered completely cor- rect, 2 points were given, with partially correct answers being worth 1 point and Der Anaesthesist 3 · 2020 193

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