Effectiveness of a 3-Day Critical Care Ultrasound Course during Fellowship Training in Anesthesiology

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UNIVERSITÀ DEGLI STUDI DI PISA

Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in

Medicina e Chirurgia

Corso di laurea Medicina e Chirurgia

Tesi di laurea:

EFFECTIVENESS OF A 3-DAY CRITICAL CARE

ULTRASOUND COURSE DURING FELLOWSHIP

TRAINING IN ANESTHESIOLOGY

Relatore:

Chiar.mo Prof. Francesco Forfori

Correlatore:

Dott. Francesco Corradi

Candidato:

Gianluca Notini

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INDEX

-MATERIALS AND METHODS……….10

Participants selection………..10

The SAFE-D approach………..10

Questionnaire and workshop design………...12

-RESULTS……….19 Participants distribution………19 Test results………...19 Influences on self-efficacy………...20 Performance score……….20 Clinical impact………...21 -DISCUSSION……….22 Participants distribution………22 Test results……….23 Influences on self-efficacy……….24 Performance score………....25 Clinical impact………..…26 -CONCLUSION………...27 -FUTURE PROSPECTS………..28 -CHARTS………...29 -REFERENCES………...33

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ABSTRACT

-Background: An increasing number of evidences supports the use of point-of-care ultrasound, especially in critical point-of-care departments. The literature also underlines that trainees can quickly acquire the basic skills. However, there is no agreement on a very effective teaching method.

-Aim: To evaluating the short- and long-term impact of a 3-day critical care ultrasound course during internship training on critical care fellow’s

ultrasound skills, knowledge and attitudes.

-Setting: The study was carried out in Cisanello University Hospital (Pisa) and included 64 medical and surgical fellows.

-Results: Significant improvement was obtained, during the written test, both in correct answers and, above all, in Self Efficacy, which went from 40% at the beginning of the course to 49% in the follow-up lecture, thus showing the effectiveness of this ultrasound imaging course.

-Discussion: The study showed a statistically significant improvement in the knowledge of US imaging, confidence in identifying structures, image

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identification and image acquisition. In the long-term, knowledge of US imaging and confidence in identifying structures declined, suggesting that further education is needed if US is to become a fundamental component of anaesthesiology training and practice.

-Conclusion: Echography has been helpful to the fellows in increasing their findings, altering their clinical diagnosis and therapeutic approach, in reducing their uncertainty.

US equipment availability is necessary to guarantee the long-term effectiveness of the course.

-Key words: Critical care ultrasound (CCUS), Self-Efficacy (SE).

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INTRODUCTION

The twenty-first century has witnessed a dramatic expansion of the availability and use of technology in patient care. Improvements of pre-existing technologies, such as the miniaturization of ultrasound (US) devices, have significantly expanded the range of use for these devices. Trauma Surgery pioneered the use of point-of-care ultrasound.

Emergency Medicine followed by Critical Care then embraced and popularized bedside, provider-performed ultrasound, which was started in the 1970s. Its advantages are widely known, such as the absence of radiation exposure, cost-effectiveness, 24-hour bedside availability and repeatability.

For the critical care patient, instead of concentrating on a specific anatomical district, ultrasonography seems to take great advantage from a total-body approach.

Point-of-care ultrasonography is a rapidly developing field embracing multiple medical specialties including primary care, emergency medicine and critical care medicine departments [1].

Critical care ultrasound (CCUS) is a multidisciplinary technique, where morpho-functional information, obtained with imaging in different anatomical districts, is integrated with clinical data in real-time by the intensivist.

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Its applications include assessing the vascular, cardiopulmonary and abdominal systems, as well as guiding invasive procedures and hemodynamic management [1-2].

CCUS is performed in situations where a functional evaluation, rather than an anatomical one, is needed. Here lies the big difference between an intensivist’s and an internal medicine physician’s approaches: the former may prefer not to follow an anatomical order, since his priority is to rule out potentially life-threatening conditions or look for signs of early organ failure, the latter strives for an “head to toe” exam, to identify clinical situations that might precipitate a patient’s conditions. [3]

With the increased availability and practicality of bedside ultrasound, intensivists worldwide are incorporating this technology into regular practice [4-5].

Now that the value of ultrasound use is increasingly recognized by internal medicine providers, focus has also expanded to ultrasound education in residency training. In 2012, approximately 25 % of internal medicine residency programs had some form of ultrasound training with another 25 % planning on incorporating ultrasound training in the next year [6].

Additionally, there is an increasing body of literature describing the efficacy of curricular modules to teach ultrasound skills to Internal Medicine residents [7]. Programs using both cadaver models and standardized patients have

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demonstrated improvement in resident ultrasound examination skills after a hands-on training module [8-9].

Other approaches include a 30-hour ultrasound course covering many applications held during intern orientation, and an integrated three-year curriculum focused on the cardiovascular limited ultrasound examination (CLUE) [10].

When these ultrasonography skills are applied to clinical care, patients may receive a more accurate diagnosis, expediting their appropriate workup and treatment [11].

In addition, residents also gain confidence from formal training in using ultrasound for invasive procedures [12].

Studies demonstrate that ultrasound-guidance improves the safety of central line placement and thoracentesis [13-14].

There is evidence that the patients of residents trained in bedside ultrasound-guided paracentesis not only received less post-procedural blood product transfusions compared to patients that underwent paracentesis by interventional radiology, but also benefitted from an average total cost reduction of over $500 per procedure for bedside ultrasound-guided paracentesis [15].

With the advent of compact ultrasound devices, it is easier for physicians to enhance their physical examinations. However, although this new tool is widely available, few physicians have US training.

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Physicians frequently perform bedside invasive procedures such as thoracentesis, paracentesis, and central venous catheter placements.

With the advent of compact and handheld ultrasound (US) devices, it is now easier for physicians to enhance their physical examination and procedural skills through the use of bedside US.

Literature suggests that US guidance can enhance patient safety during invasive procedures [16-17].

The results of recent studies in a critical care setting suggest that after a brief but focused training, non-cardiologists can become competent in assessment of cardiac function [18].

Several studies have indeed highlighted the advantages of ultrasound [19], but the feasibility of focused abdominal, renal, and venous ultrasound assessment by intensivists has rarely been studied [20].

This is surprising because many problems, such as suspected pleural effusion, abdominal effusion, bladder distension, obstructive uropathy and deep venous thrombosis, can be identified by very simple ultrasound semiology.

Despite all of this, standardized education does not yet exist [21-22] and remains no consensus on how the education, training and evaluation of these competencies should be achieved [23].

Consequently, critical care ultrasound education can be inconsistent between training programs and may lead to inappropriate ultrasound utilization in critical situations.

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The main goal of ultrasound teaching is to provide the participants with the tools to identify the main semiotic signs that can point to pathological anomalies, in such a way as to help the physician to unravel himself in the differential diagnosis.

The purpose of this study is to evaluate the short- and long-term impact of a 3-day critical care ultrasound course during internship training on critical care fellow’s ultrasound skills, knowledge and attitudes, to assess the difference in abilities and utility of CCUS in different specialty branches and demonstrate that proper use of US devices is a skill that can be quickly learned.

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MATERIALS AND METHODS

Participants selection

The participants consisted of 64 fellows distributed among various specialty branches (ICU, general surgery, urology, cardiology, ORI, orthopedics, OBGYN, endocrinology) and year(s) of service.

This was a prospective observational cohort study examining the effect of a 3-day CCUS course on the previous mentioned fellows.

Inclusion criteria were that the subject needed to be currently enrolled in a medical or surgical fellowship, regardless of the fact that they already had any ultrasound certification.

The SAFE-D Approach

What follows is the description of an approach which aims at providing guide-lines that can help the physician in the mandatory task of disentangling difficult differential diagnosis, without expecting to supply a universal method: the SAFE-D Approach.

In this method, questions and answers have only one mandatory characteristic: simplicity, achieved through Yes/No questions.

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• S (SIZE): are anatomical dimensions altered?

• A (AIR): is there an air gathering impeding ultrasound transmission? • F (FLUIDS): is there liquid (water, blood)?

• E (EXCURSION): is the diaphragm excursion within range? • D (DOPPLER): does Doppler give additional information? Here are some of the possible SAFE-D approaches:

CHEST:

S A F E D

HEART AND

PERICARDIUM Monitoring volumes, estimate work of breathing

Pneumopericardium Tamponade

PLEURA Indirect signs of pneumothorax Pleural effusion LUNG AND AIRWAYS Assessment of tracheal trauma Differential diagnosis of non-pulmonary edema B-lines Focused- oriented echocardiography VESSELS Vena cava,

vascular filling DIAPHRAGM Phrenic nerve paralysis, abdominal masses, pulmonary edema, septic shock

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ABDOMEN:

S A F E D

ABDOMEN Biliary tree Perforation Free liquid in

peritoneum Aortic aneurysms,

thrombosis, stenosis

KIDNEY Cortical

thickness Hydronephrosis Resistance index as

shock predictor

LIMBS:

S A F E D

LOWER

LIMB Tissue infection Deep Thrombosis vein

Questionnaire and workshop design

Subjects were used as self-controls and examined at predetermined time points: immediately before (pre-D1, pre-D2…) and immediately after (post-D1, post-D2…) the first three lectures and 3 months after the last one (follow-up lecture).

The subjects were not notified of any of the test answers or scores until after the study was completed.

The 3-day course included general CCUS and basic critical care echography of several body districts:

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• Heart; • Lungs;

• Abdomen (including F.A.S.T. scan); • Thorax;

• Vascular accesses

The format of the course consisted of a 2-hour lecture, a live demonstration on the lecture topic by the expert lecturer and a focused session with ultrasound practice on healthy model volunteers.

To verify CCUS knowledge, each fellow completed a written test before and after each lecture, including the follow-up.

Five major topics were covered, including ultrasound basics (physics, artefacts), cardiac exam, basic pulmonary exam, abdominal exam, basic

vascular anatomy (e.g. aorta, inferior and superior vena cava). The abdominal exam was a modified FAST exam.

Each lecture was organized so as to analyze specific topics:

• Day 1: Principles of Ultrasound Imaging and study of the Chest; • Day 2: Abdomen;

• Day 3: Heart and Vascular accesses;

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DAY 1:

• PRE-TEST (Self Efficacy - 5 minutes) • INTRODUCTION

Presentation of the topics and objectives of the course The applications of ultrasound in emergencies

• ULTRASOUND PHYSICS

Ultrasound physics, biological phenomena and safety, instruments • PROBES AND ADJUSTMENTS

Convex and sectorial linear probe depth, gain, focus, preset • THE SCANS

Exam technique and scans • ECOGRAPHIC IMAGE US semiotic artifacts

• CHEST Normal lung

Interstitial Lung Disease ARDS

Phlogistic and non-phlogistic pulmonary consolidation Air bronchogram

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Characterization and quantification of pleural effusion Pulmonary aeration score

(FBS)

(Weaning from mechanical ventilation) Chest tubes

• POST-TEST (Self Efficacy)

DAY 2:

• PRE-TEST (Self Efficacy - 5 minutes) • ABDOMEN

Identification of major organs (liver, spleen, kidneys, gallbladder, aorta) Identification and quantification of free endoabdominal fluid

Evaluation of gastric stagnation Evaluation of intestinal loops

Vena Cava Evaluation (hypovolemia) Urine retention

Bladder volume evaluation

Ultrasound guided bladder catheterization Paracentesis

FAST protocol

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DAY 3:

• PRE-TEST (Self Efficacy - 5 minutes) • VASCULAR ACCESSES

Localization

Recognition and differentiation between vein and artery Lumen patency

Echo-guided cannulation Check for correct positioning

Control of procedural complications

• HEART

Cardiac chamber recognition Basic scans

Qualitative evaluation of gross valvular pathologies Pericardial effusion

Cardiac tamponade

• POST-TEST (Self Efficacy)

FOLLOW-UP:

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• HEART SUMMARY

• POST-TEST (Self Efficacy)

18:30 COURSE CLOSURE

• FINAL TEST

The questions, developed by the instructor, were so distributed:

• Day 1: 50% Principles of Ultrasound Imaging and 50% study of the Chest;

• Day 2: Abdomen (Liver and biliary tree, spleen, kidney, pancreas, bladder, principles of FAST-Ultrasound);

• Day 3: 50% Heart and 50% Vascular accesses;

• Follow-up: 30% Lung Ultrasound, 20% Echocardiography, 20% vessels, 20% principles of US imaging, 10% Abdomen.

Each individual testing session randomized the question order and did not provide feedback regarding test performance to minimize subjects’ ability to “learn the test”, so to minimize the recall bias.

In every lecture, each candidate got a score depending on the number of correct answers, which was then calculated as a percentage: this was used to study the increase (or decrease) in positive results for every participant.

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Finally, the subjects were evaluated taking into account their ability to correctly acquire standard ultrasound images, good quality images and identify critical US checkpoints for each district of interest.

To assess ultrasound image acquisition ability, all fellows were evaluated by the instructor during live scanning of the healthy volunteer in each lecture. During the 3 months follow-up lecture, only written tests were evaluated, but the fellows were also questioned about whether the use of CCUS in the last 3 months had brought to:

• increase in findings;

• significant changes in clinical diagnosis; • significant changes in therapeutic strategies; • decrease in diagnostic uncertainty;

• increase in diagnostic uncertainty.

The subjects were also questioned about how many scans they performed each month and what district they used CCUS for, including if at the follow-up they had started using CCUS to study districts they were less confident with before the lectures.

Furthermore, it was decided to evaluate the increase in fellow’s confidence in using the US devices through a variable called Self Efficacy (SE). The fellow had to assign a number, from 1 (non-confident) to 5 (totally confident) to

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quantify his/hers SE and we monitored the increase (or decrease) in percentage of this parameter from the first lecture to the follow-up.

RESULTS

The participants of the course were 64 fellows, 38 women (59%) and 26

men (41%), spread through different years of specialty: 24% 1st year, 24% 2nd year, 32% 3rd year, 16% 4th year and 4% 5th year (let’s consider the fact that most of the anaesthesiology fellows attend their 5th year of specialty elsewhere).

Besides, 27% of them had already taken at least a previous US course, while for the 73% of them this was their first time.

Furthermore, 34% of the fellows worked in ICU, 53% worked in surgeries and ICU-related departments (pain therapy, setting of vascular accesses, pre-hospitalization): the mean of US exams performed in ICU/month was 15 on pre-day 1, which went up to 16 on follow-up day, against the 5 exams performed in non-ICU departments on pre-day 1, which went up to 6 on follow-up day.

In day 1, the average percentage of positive answers in the pre-course written test was 70%, which increased in the post-course written test up to 93% (p=0,001). Similar results were shown in the day 2 and day 3 written tests: 74% vs 83% in day 2 (p=0,016) and 69% vs 85% in day 3 (p=0,009).

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SE evaluation went from 41% pre-day to 52% post-day 1(p=0,000), from 37% pre-day 2 to 38% day 2 (p=0,222) from 49% pre-day 3 to 57% post-day 3 (p=0,000).

We also confronted the difference in SE between pre-day 1 and post-day 3 against SE in the follow-up, showing 40% pre-day 1, 56% (p<0,05) post-day 3 and 49% in the follow-up (p>0,05).

The change in SE in the different days of the course can also be measured in relation to whether the candidate had already taken a US course before: those who had, showed 52% SE in pre-day 1, 60% in post-day 3 and 51% in follow-up, those who hadn’t showed 35% SE in pre-day 1, 54% in post-day 3 and 39% in follow-up (p=0,12 day 1, p=0,76 day 3, p=0,24 f-up).

Additionally, we evaluated how the availability of US instrumentation in the various departments influenced SE: where US equipment was available, SE went from 60% in post-day 3 to 47% in follow-up, whereas fellows who did not have regular access to US equipment, SE went from 20% in post-day 3 to 27% in follow-up (p=0,001 day 3, p=0,00 follow-up).

The mean number of US exams/month/candidate went up from 12 in pre-day 1 to 15 in follow-up (p=0,203).

Then, we analysed the increase in the number of candidates (as a %) who had started evaluating body districts previously ignored:

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• pre-day 1: 37 % of them declared to perform US evaluation of the heart, 6% abdomen, 2% FAST, 54% thorax, 51% vessels and vascular accesses, 5% diaphragm, 2% nerve blocks, 0% TCD;

• follow-up: 46% heart, 25%abdomen, 13% FAST, 58% thorax, 54 % vessels, 4 % diaphragm, 2% nerve blocks, 0%TCD.

Finally, we tried to assess what the clinical impact of this course had been, by asking the participants 5 specific questions with yes/no answers in the follow-up day, in particular whether the course had:

• helped in increasing their findings, 96% yes; • altered their clinical diagnosis, 73% yes; • altered their therapeutic approach, 83% yes; • reduced their uncertainty, 86% yes;

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DISCUSSION

The first charts show what the group of participants was made of: 38 women and 26 men [fig.1], distributed amongst 5 years of specialty [fig.2], the most representative of which was the third one (32%) and with more than half of them (53%) working in surgeries and ICU related departments [fig.3]. Moreover, 27% of them had already attended at least one US course [fig.5] which, as we’ll see later on, directly affected the results in SE.

At the follow-up, the fellows working in ICU departments performed an average of 16 US exams/month (against the 15 US exams/month in pre-day 1), significantly more than the average of 6 US exams/month (against the 5 US exams/month in pre-day 1) performed by their colleagues working elsewhere: this shows how ICUs have definitely become essential, not only in patient care, but for the participants’ educational role as well [fig.4]. It is also true that many would have not expected to see 6 exams performed in non-ICU departments, such as in surgeries, but probably a number closer to 0: this shows how US imaging is slowly finding its way in these areas as well, especially in pre-hospitalizations, where its use, instead of X-rays, allows the hospital to save a great deal of money and the patient to not be exposed to radiation (in particular, echo-thorax is performed).

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Anyway, it’s important to underline that, in both cases, (ICU and non-ICU) the average number of US exams/month performed increased, pointing to the efficacy of the course.

The short-term effectiveness of the lectures is clearly stated by the difference in results between the pre- and the post-test that took place before and after every lecture: in each day an improvement of at least 15-20% was reached [fig.6].

These findings relate with the growth in SE: each day, the post-test shows educating the fellows in a particular set of arguments, increases their confidence [fig.7]

Day 2, however, seems to contradict with the other data, as the post-test is only up by 1%: this can easily be explained if we consider the fact that only 6% of the participants had performed abdomen exams with US technology before the beginning of the course.

Indeed, looking at them more closely, we can see how day 1 and day 3 data have statistical significance (p<0,05), whereas day 2 doesn’t (p=0,222).

The long-term effectiveness of the course is a direct consequence of the participants’ growth in confidence: the candidates have increased the number of US exams/month since the beginning of the course [fig.8].

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SE can be analysed from different point of views:

• First of all, there was a definite growth from before the beginning of the course (40%) to the follow-up (49%, p>0,05) which states the success of the course itself.

Of course, it is also true that there was a significant decrease from the

end of the 3rd _{lecture (56%, p<0,05) to the follow-up, caused by the lack}

of consistency in US training[fig.9], although this last datum is not statically significant. This means that the SE was preserved and that the

US course is unquestionably useful;

• Secondly, having attended a US course before the beginning of this one, certainly had its consequences: those who had, always showed greater SE than those who hadn’t [fig.10].

Again, the value at the end of the 3rd _{lecture was higher than the}

follow-up, remarking the lack of consistency in US training. Furthermore, it’s interesting to notice how, in the first group, the reinforcement that was obtained with the close lessons, was cancelled in the following 3

months, whereas in the 2nd _{group, SE showed proportionally greater}

growth: in order to keep up SE as time goes by, it’s necessary to re-take courses and always be updated.

Finally, it’s worth noticing how SE before the beginning of the course (52%), is quite close to SE in the follow-up (49%), again showing the validity of this course;

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• Thirdly, SE is greater in the departments in which echo equipment is available: the training must be connected to the possibility of exercising and practicing. This directly affected the fellows confidence [fig.11]. Once more, the image shows the decline in SE from the end of the third lecture to the follow-up in the group where US equipment is available. However, in the group where US equipment isn’t available, in the same time frame, SE went up by 7%, meaning that the confidence gained during the course wasn’t shaken by the difficulty of performing US exams without the supervision of the instructor, on the contrary it grew stronger.

After the first 3 lectures, the candidates, as a result of the enhanced confidence, started evaluating body districts previously ignored [fig.12].

Significant differences were found between the topics that were studied during the lectures, where we registered a growth of US-based evaluations in all the districts, as hoped, and those that were not: in particular, the abdomen saw the greater increase, going up to 4 times its starting level (however, it still has wide margins for improvement, since we still are at only 25%). The multiorgan study (echo-FAST) raise was directly influenced by the previous data. Significant increase (9%) was also registered in the study of the heart. Thorax and vascular accesses are the two areas that showed the least improvement, but we must remember that these are also the two aspects that

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had already been studied by more than 50% of the participants before the course, not only by those who had already taken at least one US course, but by the others too, as in our ICU, thorax and vascular accesses-US based approaches are daily performed.

Diaphragm, nerve blocks and TCD (transcranial-Doppler) showed no improvement, due to the fact that were not discussed during the lectures: this means that the course is effective in stimulating the fellows in exploring the topics dealt with during the lectures.

One of the future goals, will be to incorporate these issues in the lectures and in the department as well, as they are point marks in the anesthesiology curriculum.

Finally, the last 5 questions that we proposed to the candidates during the follow-up, were used to evaluate the clinical impact of the course, with remarkable results [fig.13]: almost everyone stated the importance of CCUS in increasing findings of US semiotic (96%), reducing clinical uncertainty (86%) and influencing the therapeutic approach (83%), roughly 4 out of 5 found no increase in clinical uncertainty (noteworthy is the mirror-like aspect of the last two columns) and almost 3 out of 4 declared that the use of CCUS brought to modifying the clinical diagnosis.

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CONCLUSION

This study showed undeniable improvement in ultrasound interpretation and resourceful clinical applications immediately afterwards and at the 3-months follow-up.

Future studies are needed to formally assess ultrasound image acquisition skills and clinical outcomes related to the addition of bedside ultrasound analysis, but our hope is to have given a solid basis upon which to build an increasingly more effective training method.

The long-term consolidation of the acquired skills and abilities remains a big issue to be targeted: all data we collected point to a reduction of SE at the follow-up.

These slight decreases in knowledge and confidence may reflect individual candidate’s interest in the use of US. Individuals who are not inherently interested in using US may seek out fewer opportunities to apply their knowledge and skills. Alternatively, a fellow may be interested but may not have the opportunity to apply and practice this learned skill.

However, both skills and confidence are higher at the follow-up than at the beginning of the course, thus showing its undoubted value both in the short- and in the long-term.

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FUTURE PROSPECTS

To answer the necessity to maintain the skills and confidence gained after the course, every intensivist should have the opportunity to practice on a daily basis and/or have to take closer re-training courses to ensure a constant increase of abilities in "small steps".

29 0 5 10 15 20 25 30 35 40 Sex M 26 F 38 N p ar ti ci p an ts Participants distribution (1) [1] 0 10 20 30 40 Year of specialty 1st 24 2nd 24 3rd 32 4th 16 5th 4 % Participants distribution (2) [2] 0 10 20 30 40 50 60 Department ICU 34 Surgeries and ICU-related 53 No Pisa 8 % Participants distribution (3)

0

5

10

15

20

US evaluations pre- vs -post course

Mean US exams / month ICU Mean US exams / month non-ICU

[3] _[4]

30 0 10 20 30 40 50 60 70 80 US course-pre Yes 27 No 73 % Participants distribution (4) 0 10 20 30 40 50 60 70 80 90 100

Day 1 Day 2 Day 3

Pre 70 74 69 Post 93 83 85 % co rr e ct an sw e rs

Written test results during the 3 lectures p= 0,001 p= 0,016 p= 0,009 0 10 20 30 40 50 60

SE day 1 SE day 2 SE day 3

pre 41 37 49

post 52 38 57

%

SE

SE results during the first 3 lectures

p=0,222 p<0,001 0 2 4 6 8 10 12 14 16 N° US exams/month Pre Day 1 12 F-up 15 US evaluations/month pre- vs -post course

p<0,001

[5]

Topics: Physics and Abdomen Heart and vascular

accesses

[6]

Topics: Physics and Abdomen Heart and vascular

accesses [7] p= 0,203 [8] Chest Chest

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Variations SE pre- vs post-course p<0,05 p>0,05 0 10 20 30 40 50 60 SE pre-day 1 SE post-day 3 SE f-up US course yes 52 60 51 US course no 35 54 39 %

Influence of previous US course on SE p= 0,24 0 10 20 30 40 50 60 SE post-day 3 SE f-up US available 60 47 US non available 20 27 %

Influence of equipment availabiltity on SE [9] [10] p= 0,76 p= 0,12 [11] p= 0,001 p= 0,001

32 0 10 20 30 40 50 60 Heart Abdom en

FAST Thorax Vessels Diaphr agm Blocks TCD Pre-day 1 37 6 2 54 51 5 2 0 F-up 46 25 13 58 54 4 2 0 % U S ev al ua tion s / di st rict

Performance score

%

Clinical impact

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REFERENCES

[1] L. Neri, E. Storti, and D. Lichtenstein, “Toward an ultrasound curriculum for critical care medicine,” Critical Care Medicine, vol. 35, no. 5, pp. S290–S304, 2007.

[2] P. Ferrada, S. Murthi, R. J. Anand, G. V. Bochicchio, and T. Scalea, “Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in critically ill trauma patients,” Journal of Trauma—Injury,

Infection and Critical Care, vol. 70, no. 1, pp. 56–64, 2011.

[3] L. Ball, F. Corradi, P. Pelosi, “Ultrasonography in critical care medicine: the WAMS approach”, ICU Management, vol.12, no. 2, pp. 30-33, 2012.

[4] G. A. Schmidt, “ICU ultrasound. Te coming boom,” Chest, vol. 135, no. 6, pp.

1407–1408, 2009.

[5] H. Quintard, I. Philip, and C. Ichai, “French survey on current use of ultrasound in the critical care unit: ECHOREA,” Annales Francaises d’Anesthesie et de

34

[6] Schnobrich DJ, Gladding S, Olson APJ, Duran-Nelson A (2013) Pointof-care ultrasound in internal medicine: a National Survey of Educational Leadership. J Grad Med Educ 5(3):498–502. doi:10.4300/JGME-D-12-00215.1

[7] Schnobrich DJ, Olson APJ, Broccard A, Duran-Nelson A (2013) Feasibility and acceptability of a structured curriculum in teaching procedural and basic diagnostic ultrasound skills to internal medicine residents. J Grad Med Educ

5(3):493–497. doi:10.4300/JGME-D-12-00214.1

[8] Dulohery MM, Stoven S, Kurklinsky AK et al (2014) Ultrasound for internal medicine physicians: the future of the physical examination. J Ultrasound Med 33(6):

10051011.doi:10.7863/ultra.33.6.1005

[9] Skalski JH, Elrashidi M, Reed DA, McDonald FS, Bhagra A. Using standardized patients to teach point-of-care ultrasound-guided physical

examination skills to internal medicine residents. 2015.

http://www.jgme.org/doi/abs/10.4300/JGME-D-14-00178.1.

[10] Kimura BJ, Amundson SA, Phan JN, Agan DL, Shaw DJ (2012) Observations during development of an internal medicine residency training program in

35

cardiovascular limited ultrasound examination. J Hosp Med 7(7):537–542. doi:10.1002/jhm.1944

[11] Andersen GN, Graven T, Skjetne K et al (2015) Diagnostic influence of routine point-of-care pocket-size ultrasound examinations performed by medical residents. J Ultrasound Med 34(4):627–636.doi:10.7863/ultra.34.4.627

[12] Keddis MT, Cullen MW, Reed DA et al (2011) Effectiveness of an ultrasound training module for internal medicine residents. BMC Med Educ 11:75. doi:10.1186/1472-6920-11-75

[13] Randolph AG, Cook DJ, Gonzales CA, Pribble CG (1996) Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature.

Crit Care Med 24(12):2053–2058. http://www.ncbi.nlm.nih.gov/pubmed/8968276.

Accessed 14 July 2015

[14] Barnes TW, Morgenthaler TI, Olson EJ, Hesley GK, Decker PA, Ryu JH (2005) Sonographically guided thoracentesis and rate of pneumothorax.

36

[15] Barsuk JH, Cohen ER, Feinglass J et al (2014) Cost savings of performing paracentesis procedures at the bedside after simulation-based education. Simul Healthc 9(5):312–318. doi:10.1097/SIH.0000000000000040

[16] Duncan DR, Morgenthaler TI, Ryu JH, Daniels CE.

Reducing iatrogenic risk in thoracentesis: establishing best practice via experiential training in a zero-risk environment. Chest 2009; 135:1315–1320

[17] Brass P, Hellmich M, Kolodziej L, Kullmer B, Schick G, Schregel

W.Traditional landmark versus ultrasound guidance for central vein

catheterization. The Cochrane Library

website. doi:10.1002/14651858.CD006962. Accessed July 9, 2013.

[18] Vignon P, Dugard A, Abraham J, Belcour D, Gondran G, Pepino F, Marin B, Francois B, Gastinne H (2007). Focused training for goal-oriented hand-held echocardiography performed by non cardiologist residents in the intensive-care unit. Intensive Care Med 33:1795–1799

[19] Schacherer D, Klebl F, Goetz D, Buettner R, Zierhut S, Schoelmerich J, Langgartner J (2007).Abdominal ultrasound in the intensive-care unit: a 3-year survey on 400 patients.

37

Intensive Care Med 33:841–844

[20] Lichtenstein D, Axler O (1993). Intensive use of general ultrasound in the intensive-care unit. Prospective study of 150 consecutive patients. Intensive Care Med 19:353–355

[21] J. M. Mosier, J. Malo, L. A. Stolz et al., “Critical care ultrasound training: a survey of US fellowship directors,” Journal of Critical Care, vol. 29, no. 4, pp.

645–649, 2014.

[22] L. A. Eisen, S. Leung, A. E. Gallagher, and V. Kvetan, “Barriers to ultrasound training in critical care medicine fellowships: a survey of program directors,”

Critical Care Medicine, vol. 38, no.10, pp. 1978–1983, 2010.

[23] P. H. Mayo, “Training in critical care echocardiography,” Annals of Intensive