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Competency-Based Instruction to Improve the Surgical Resident Technique and Accuracy of the Trauma Ultrasound
Abstract
In a surgical trauma center, programs and workshops have improved the performance on focused abdominal sonogram for trauma (FAST). The purpose of this single-blind study was to prove that a cadaver laboratory competency-based instruction program may be an effective method of FAST training to acquire the skills that would be applied in the trauma room. The study was divided in two parts, laboratory and clinical. Nine surgical residents were divided into two groups: Group I performed the test only once, and Group II performed the training twice. A third “group” was the senior ultrasound technician, whose readings served as our “gold standard” with which to compare the resident readings (Group HI). Using cadavers, a 2-cm catheter was introduced into the peritoneal cavity. Sequential aliquots of normal saline were introduced into the abdominal cavity at 0–, 200–, 400–, 600–, and 1000-cc increments in each group tested. The residents were asked to describe their examinations for the presence or absence of fluid in the abdomen. The ultrasound examination was then performed with the cadaver in three different positions to study if there was any difference of fluid detection in varied positions. True positive, true negative, and accuracy were then calculated comparing the three different groups of test sonographers. In the second part of the study, the same residents were then followed in the trauma room, where they performed the FAST in the absence of the ultrasound technician during emergencies. As in the laboratory, the accuracy of their reading compared with that of the ultrasound technician was also evaluated. From 400 cc and upward, Group II began having an overall significantly superior accuracy than the first group and the technician in most quadrants examined. The trend was apparent for more accurate results in all quadrants and positions by all groups as the fluid was increased. Overall, group II was most superior in detection of intra-abdominal fluid in the cadaver. In the clinical scenario, the residents as a whole had similar accuracy (92% vs 96%) in reading FAST as the ultrasound technician. Our results suggest that surgical residents have the ability to detect fluid in the abdomen, there exists a fast learning curve, and the minimum detection level of fluid was between 200 and 400 cc in the peritoneal cavity in the laboratory. Surgical residents were able to detect intra-abdominal fluid in the trauma situation, as shown by the 92 per cent accuracy of the FAST in the emergency situation. We conclude that a cadaver laboratory training program is an important adjunct to improve the skills of the resident in performing and reading FAST.
... 8e11 The length of didactic training, including hands-on experience, ranged from 2 to 30 h. 12e14 Overall, most studies demonstrated that FAST had excellent accuracy and competency may be acquired with a 1-day course. 8 Smith and coworkers, however, stated that no learning curve was apparent in their series. 11 As a result, McCarter et al and Shackford et al recommended reassessment of the criteria for granting medical staff permission to perform sonography for trauma. ...
... 26 Frezza et al stated that a cadaver-based training programme was an important adjunct to improve the skill of the residents in performing FAST. 8 Furthermore, a review by Shackford et al addressed the relationship between the number of ultrasound procedures required for adequate training and the prevalence of the target disease being investigated; if 20% of the volunteers had positive findings, approximately 30 ultrasound procedures would be required to gain competence. 10 In conclusion, all investigators stated that gaining competence in performing FAST is associated with a steep learning curve. ...
To establish a training course for Prehospital Focused Abdominal Sonography for Trauma (P-FAST) and to evaluate the accuracy of the participants after the course and at the trauma scene.
A training programme was developed to provide medical staff with the skills needed to perform P-FAST. In order to evaluate the accuracy of P-FAST performed by the students, nine participants (five emergency doctors and four paramedics) were followed during their course and in practice after the course. An assessment was made of 200 ultrasound procedures performed during the course in healthy volunteers and in patients with peritoneal dialysis or ascites. Regular P-FAST performed on-scene by the participants commenced immediately following the course. The results for the nine participants (C-group, course group) were compared with those members of medical staff with more than 3 years of experience in FAST (P-group, professional group). A group of physicians untrained in P-FAST served as a control (I-group, indifferent group). P-FAST findings were further verified by subsequent FAST and CT scans in the emergency department.
After the training programme the C-group performed 39 P-FAST procedures without any false negative or false positive findings (100% accuracy). In the P-group, 112 procedures were performed with one false positive case. In the I-group there were 2 false negative cases among the 46 procedures performed.
Following completion of a 1-day P-FAST course, participants were able to perform ultrasound procedures at the scene of an accident with a high level of accuracy.
... Recommendations regarding the duration of time required to teach participants in the use of FAST vary from 1 hour of practical experience to educational programs lasting 32 hours [20,21]. However, most studies support our findings that FAST can be taught effectively and efficiently during courses lasting only one day [22]. ...
Objective: The Pan-American Trauma Society (PTS) developed a Trauma and Emergency Ultrasound Course
(USET) in response to the requirement for trauma ultrasound training for low-and middle-income countries. The
objective of this study was to evaluate the efficiency of this course.
Method: Pre- and post- course tests were used. And interval estimation of proportions was calculated at 95% CI.
Theoretical and practical pre- and post-course knowledge were assessed with the Wilcoxon Signed Rank test at
0.05 level of statistical significance.
Result: Between 2005 and 2007, 114 students, including general surgeons, emergency medicine physicians,
anesthesiologists, critical care physicians, and residents of these specialties, were trained in seven countries
(Uruguay, Peru, Mexico, Venezuela, Aruba, Colombia, and Ecuador). The difference on complete knowledge ranked
scores before and after the course was statistically significant (p
... Es folgte eine Reihe von Mono-und Multizenterstudien, die verschiedene Lehrmethoden untersuchten und die Untersuchergenauigkeit verglichen. Es wurde geprüft, welches Ausbildungspensum ein sonographisch unerfahrener Arzt absolvieren muss, um eine hohe Untersuchersicherheit zu erreichen [3,6,9,10,12,13,14] Training in emergency sonography for trauma. ...
Die präklinische fokussierte Sonographie beim verunfallten Patienten („prehospital focused abdominal sonography for trauma“, P-FAST) fand in den letzten Jahren Einzug in den bodengebundenen und auch den luftgestützten Rettungsdienst in Deutschland und hat sich hier zunehmend als valide diagnostische Untersuchung bewährt. Ein dem steigenden Einsatz der P-FAST gerecht werdendes, standardisiertes Ausbildungskonzept wurde 2003 von der Arbeitsgemeinschaft Notfallsonographie in Frankfurt/Main entwickelt und wird seitdem als Eintageskurs angeboten. Die Kursstruktur beinhaltet die Vermittlung allgemeiner Kenntnisse der Notfallsonographie, die spezielle Untersuchungstechnik der P-FAST mit einer Vielzahl von pathologischen Befunden, praktischen Übungen an Patienten und Probanden, u. a. in ausgewählten Notfallszenarien mit erschwerten Bedingungen. Nach Absolvierung des Kurses sind die Teilnehmer in der Lage, P-FAST mit einer hohen Untersuchersicherheit anzuwenden. Von besonderer Bedeutung ist dabei nicht nur die strikte Einhaltung des Algorithmus der Untersuchung, sondern auch die sinnvolle Einbindung in das gegebene präklinische Management. In dem Zeitraum von Februar 2003 bis März 2008 wurden insgesamt 540 Teilnehmer im Rahmen dieses eintägigen Kurses in der Anwendung von P-FAST geschult.
... Es folgte eine Reihe von Mono-und Multizenterstudien, die verschiedene Lehrmethoden untersuchten und die Untersuchergenauigkeit verglichen. Es wurde geprüft, welches Ausbildungspensum ein sonographisch unerfahrener Arzt absolvieren muss, um eine hohe Untersuchersicherheit zu erreichen [3,6,9,10,12,13,14] Training in emergency sonography for trauma. ...
In the last decade prehospital focused abdominal sonography for trauma (P-FAST) could be established as a valid on-site diagnostic tool for both air and ground rescue medical services in Germany. An appropriate use of P-FAST demands a standardized training concept. Therefore a 1-day training program was developed by the working group "emergency ultrasound" in Frankfurt/Main and was introduced in 2003. The training consists of lectures on general and specific aspects of emergency ultrasound techniques with demonstrations of numerous pathological findings, intensive hands-on training with patients and volunteers, as well as simulated on-site training. After completing the P-FAST course the participants gained competency to perform prehospital emergency ultrasound with high accuracy. Strict application of the exact technique as well as appropriate integration of the adjunct into the algorithm of prehospital care are the most important prerequisites for successful use of P-FAST. From February 2003 to March 2008 540 participants were trained in P-FAST in the 1-day course.
Objective: Our study aimed to test whether a one-hour short training model for Focused Assessment with Sonography in Trauma (FAST) training would increase the visual skills of paramedics who had no previous training in this field. Material and Method: Our study was planned as a prospective, uncontrolled experimental study. A short training module was applied to 27 paramedics who were inexperienced in E-FAST Ultrasonography (USG). The first test was applied and the final test was applied after the training and their success in distinguishing normal and pathological case images was evaluated. Results: 55.6% of the participants were women, 74.1% were new graduates, and their average age was 21.58 ± 9.60 years. When the answers given by the participants to the first test and the last test were evaluated; While 31.9% of the participants answered "I did not understand" to many questions in the first test, after the training, it was seen that 82.9% could form ideas for all tests. When the correct response rates of the participants to the first test and the last test were examined, a statistically significant increase was observed (p
The Federated Council of Internal Medicine has developed a resource guide to help internal medicine residency programs produce internists who are prepared for today's practice of internal medicine and the challenges of practice in the future. The guide situates general internal medicine as the primary care profession that focuses on preventive, short-term, and long-term care of adult patients. It assumes that a single pathway is sufficient for educating general internists and subspecialty-bound trainees. It identifies the learning experiences that should be part of general internal medicine residency training, lists the clinical competencies that are important for primary care practice, and describes the role of the integrative disciplines that should inform the care of every patient. It also describes a process that program directors and local program committees can use to develop competency-based curricula.
Objective: Although sonographic screening for blunt abdominal trauma is gaining acceptance, standards for implementation, training, credentialing, and quality control remain to be established. Design: This prospective study examines a Level I trauma service experience with the de novo establishment of a trauma ultrasound (US) program credentialed through the Department of Surgery under the auspices of Continuous Quality Improvement. Materials and Methods: All trauma surgeons attended a combined didactic and hands on 8-hour trauma US course. Abdominal sonography was subsequently performed on patients with potential blunt abdominal trauma followed by a standard diagnostic evaluation, which included computed tomographic scan, diagnostic peritoneal lavage, or observation. Measurements and Main Results: Three hundred patients were studied over a 4-month period. They averaged 35 years of age with an average injury severity score of 12. The time required to perform the US examination averaged less than 3 minutes. Standard diagnostic evaluation included computed tomographic scan (21%), diagnostic peritoneal lavage (45%), and observation (34%). US examinations resulted in 277 true negatives, 17 true positives, two false positives, and four false negatives for a sensitivity of 81.0%, a specificity of 99.3%, and an accuracy of 98.0%. Annualized cost savings with the use of US evaluation versus standard diagnostic evaluation would amount to over $100,000.00. Conclusions: This experience with the de novo implementation of a trauma US program suggests that the training and credentialing requirements in this study are sufficient to provide surgeon ultrasonographers with acceptable competence in US diagnosis of blunt abdominal trauma.
Ultrasound diagnostic imaging, having been used in Germany in the trauma setting for more than 15 years, has unique qualities that give it distinct advantages over other tests (DPL, CT), and is gradually gaining acceptance by surgeons in the United States. In this prospective study, experienced surgeon sonographers successfully used ultrasound as the primary adjuvant modality to detect hemoperitoneum and pericardial effusion in injured patients. The ultrasound evaluations of 371 patients demonstrated that in 65 patients with significant injuries, ultrasound detected 53, that is, had an 81.5% sensitivity and 99.7% specificity. They conclude that ultrasound should be the primary adjuvant instrument for the evaluation of injured patients because it is rapid, accurate, and is potentially cost-effective.
The effect of examiner experience on the detection of ultrasound findings in ectopic pregnancy was assessed in a retrospective study.
Records and examinations of 267 consecutive patients with surgically proven ectopic pregnancy were reviewed. Patients were divided into two groups: (1) those who were examined by faculty during the day (182 examinations) and (2) those who were examined by resident physicians at night (85 examinations).
A statistical difference was found in the incidence of adnexal mass, free fluid, sac within the mass, and corpus luteum cyst.
Examiner experience has a strong effect on the diagnostic accuracy of ultrasound examination. Adnexal abnormalities may be difficult to identify because of confusion with loops of bowel or other pelvic structures. Faculty follow-up and review are important in patient management.
Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities used in the evaluation of patients with suspected blunt abdominal trauma (BAT). DPL is fast and accurate but is associated with complications. CT is also accurate, yet requires stability and transportability of the patients. Ultrasound (US) has been suggested as an aid in evaluating BAT. We evaluated US in the initial assessment of BAT in 1000 patients. Patients were eligible for the study if they met specified trauma criteria and had suspected BAT. We then followed the outcome of the patients and their further work-up. US showed a sensitivity of 88%, a specificity of 99%, and an accuracy of 97% for detecting intraabdominal injuries. We conclude that emergency ultrasound may be used as the initial diagnostic modality for suspected blunt abdominal trauma.
Hemoperitoneum represents a major indication for surgical intervention after trauma. To improve the ability of surgical residents and trauma physicians to detect intraperitoneal and pericardial fluid using ultrasound as a diagnostic modality, we conducted a focused trauma ultrasound workshop consisting of discussion of ultrasound physics, demonstration of instrumentation, review of pertinent literature, videotaped demonstration, and "hands-on" teaching of the skills utilizing live patient models. The ultrasound probes were placed in four standard locations--right and left upper quadrants, epigastrium, and Pouch of Douglas. Skills acquisition was tested by pre- and postworkshop performance on 12 sonograms (3 for each location, 6 were positive for fluid). Thirty physicians (21 residents and 9 staff: Group I) who attended the workshop were compared to 30 matched controls (Group II). The results (means +/- SD) were as follows (R = number right, I = number of "indeterminate," W = number of wrong responses out of 12, *P < 0.05 compared to Group II): [Table: see text] False positive (%) and false negative (%) decreased from 12.9 +/- 1.5 to 8.9 +/- 5.3 and 15.0 +/- 10.4 to 5.0 +/- 5.2, respectively, in Group I but did not change in Group II. Postworkshop ability to detect fluid was significantly (P < 0.05) improved, with no major differences between residents and staff. Our data suggest that these workshops can significantly improve the skills of nonradiologists in sonographic identification of pericardial and intraperitoneal fluid and should therefore be considered an essential component of ultrasound training for trauma physicians.
To assure quality of orientation and meet JCAHO standards in the operating room (OR), educators and managers reviewed curriculum and educational resources. Using competency-based education in a perioperative program clearly defines expectations for the OR nurse.
To evaluate the diagnostic utility of abdominal diagnostic ultrasonography (DUS) performed by emergency physicians for intraperitoneal fluid caused by blunt abdominal trauma (BAT).
The design was a prospective, blind, observational study. During a 15-month period, a convenience sample of patients presenting to the ED with BAT necessitating CT scan of the abdomen, diagnostic peritoneal lavage (DPL), or laparotomy was studied. Scans were performed by an emergency medicine (EM) attending, or a resident supervised by an attending, using a real-time sector ultrasound scanner with a 3.5-MHz probe. Training in DUS included a 1-hour didactic session and 1 hour of practice on human volunteers. Free intraperitoneal fluid was defined as an anechoic stripe in the hepatorenal, bladder-rectal, or splenorenal space, and constituted a positive DUS study. Free intraperitoneal fluid detected on abdominal CT scan, DPL, and/or laparotomy was the criterion standard.
Of 110 patients scanned, 13 were excluded secondary to technical difficulty or lack of diagnostic follow-up modalities. Of the remaining 97 patients, there were 24 females and 73 males, ranging from ages 2 to 78 years. DUS detected intraperitoneal fluid in 21 subjects, including 3 false positives. There were 6 false-negative DUS examinations. DUS had a sensitivity of 75% (95% CI 53-90%), a specificity 96% of (95% CI 89-99%), and an accuracy of 91% (95% CI 83-96%). No false-positive or false-negative DUS study occurred after the first 67 cases. The mean interval for a DUS scan was 4.9 +/- 2.9 minutes, ranging from 0.5 to 16 minutes, and the mean intervals were not different between the positive and the negative studies. The accuracies of DUS were similar in the pediatric patients, 97% (95% CI 83-100%), and in the adults, 88% (95% CI 78-95%). The hepatorenal view provided the highest sensitivity as well as the least number of uninterpretable scans of the 3 DUS views.
Emergency physicians with minimal training can use DUS with fair sensitivity and good specificity and accuracy to detect free intraperitoneal fluid in both pediatric and adult BAT victims. The hepatorenal view provides the highest sensitivity for intraperitoneal fluid, although the 3-view series (with hepatorenal, bladder-rectal, and splenorenal spaces) can typically be performed within 5 minutes and may increase the specificity and accuracy.
Defining competence: A methodological review of skills in assessing clinical competence
- G R Norman
Assessment of technical skill in assessing clinical competence
- J Watts
- W B Fieldman