Ultrasound During Critical Care Simulation: A Randomized, Crossover Study. Canadian Journal of Emergency Medicine

ORIGINAL RESEARCH RECHERCHE ORIGINALE

Ultrasound during Critical Care SimulationA Randomized Crossover Study

Paul A Olszynski MD MEd Tim Harris MDDagger Patrick Renihan MEd PhDdagger

Marcel DrsquoEon BSc MEd PhD Kalyani Premkumar MBBS MD MSc (Med Ed) PhD

ABSTRACT

Objectives We sought to compare two ultrasound

simulation interventions used during critical care simulation

The primary outcome was trainee and instructor preference

for either intervention Secondary outcomes included

the identification of strengths and weaknesses of each

intervention as well as overall merits of ultrasound simulation

during high-fidelity critical care simulation The populations

of interest included emergency medicine trainees and

physicians

Methods This was a randomized crossover study with

two ultrasound simulation interventions 25 trainees and

eight emergency physician instructors participated in critical-

care simulation sessions Instructors were involved in session

debriefing and feedback Pre- and post-intervention

responses were analyzed for statistically significant diff-

erences using t test analyses Qualitative data underwent

thematic analysis and triangulation

Results Both trainees and instructors deemed ultrasound

simulation valuable by allowing trainees to demonstrate

knowledge of indications correct image interpretation

and clinical integration (plt 005) Trainees described

increased motivation to develop and use ultrasound skills

The edus2 was the preferred intervention as it enabled

functional fidelity and the integration of ultrasound into

resuscitation choreography Instructors preferred the edus2

as it facilitated better assessment of traineesrsquo skills thus

influencing feedback

Conclusions These findings support the use of ultrasound

simulation during critical care simulations The increased

functional fidelity associated with edus2 suggests that it is the

preferred intervention Further study of the impact on clinical

performance is warranted

REacuteSUMEacute

Objectifs Lrsquoeacutetude visait agrave comparer deux interventions

eacutechographiques simuleacutees dans le cadre de seacuteances

de formation en soins intensifs Le principal critegravere

drsquoeacutevaluation consistait agrave deacuteterminer la preacutefeacuterence des

stagiaires et celle des instructeurs pour lrsquoune ou lrsquoautre

des interventions Les critegraveres drsquoeacutevaluation secondaires

comprenaient les points forts et les points faibles de chacune

des interventions ainsi que les avantages geacuteneacuteraux de la

simulation drsquoeacutechographie dans le cadre de seacuteances de

formation reacutealiste en soins intensifs La population concerneacutee

se composait de stagiaires en meacutedecine drsquourgence et

drsquourgentologues

Meacutethode Il srsquoagit drsquoune eacutetude croiseacutee agrave reacutepartition aleacuteatoire

qui comptait deux interventions eacutechographiques simuleacutees

Vingt-cinq stagiaires et huit urgentologues instructeurs ont

participeacute aux seacuteances de simulation en soins intensifs

Les instructeurs eacutetaient chargeacutes des seacuteances de compte

rendu et de la reacutetroaction des stagiaires Il y a eu analyse des

reacuteponses recueillies avant et apregraves les interventions afin

de deacutegager des eacutecarts statistiquement significatifs agrave lrsquoaide

drsquoanalyses fondeacutees sur le test t Quant aux donneacutees

qualitatives elles ont eacuteteacute soumises agrave une analyse theacutematique

puis agrave la triangulation

Reacutesultats Tant les stagiaires que les instructeurs ont jugeacute

inteacuteressante la simulation drsquoeacutechographie les stagiaires ayant la

possibiliteacute de montrer leur connaissance des indications

drsquointerpreacuteter correctement les images et drsquointeacutegrer la matiegravere

sur le plan clinique (plt005) Les stagiaires ont aussi fait eacutetat

drsquoune motivation accrue pour acqueacuterir des compeacutetences en

eacutechographie et les appliquer En outre la deuxiegraveme interven-

tion srsquoest reacuteveacuteleacutee la formule preacutefeacutereacutee des stagiaires parce

qursquoelle avait un caractegravere fonctionnel reacutealiste et qursquoelle

permettait lrsquointeacutegration de lrsquoeacutechographie dans lrsquoenchaicircnement

des gestes de reacuteanimation De leur cocircteacute les instructeurs ont

eacutegalement indiqueacute leur preacutefeacuterence pour la deuxiegraveme interven-

tion parce qursquoelle facilitait lrsquoeacutevaluation des compeacutetences des

stagiaires et qursquoelle influait par le fait mecircme sur la reacutetroaction

Conclusions Les reacutesultats de lrsquoeacutetude confirment la pertinence

des simulations drsquoeacutechographies dans le cadre de seacuteances de

formation en soins intensifs Crsquoest le caractegravere fonctionnel

reacutealiste de la deuxiegraveme intervention qui en aurait fait la

formule preacutefeacutereacutee Il faudrait mener drsquoautres eacutetudes afin de

deacuteterminer lrsquoincidence de ce type drsquoenseignement sur la

compeacutetence clinique

Keywords Point of Care Ultrasound critical care simulation

From the College of Medicine daggerCollege of Education University of Saskatchewan Saskatoon SK and DaggerRoyal London Hospital London UK

Correspondence to Dr Paul Olszynski Royal University Hospital 103 Hospital Dr Room 2686 Saskatoon SK S7N 0W8 Email polszynski

usaskca

copy Canadian Association of Emergency Physicians 2015 CJEM 20151-8 DOI 101017cem201587

CJEM JCMU 20150(0) 1

INTRODUCTION

Critically ill patients presenting to emergency departmentsare assessed urgently through a variety of approachesIncreasingly emergency physicians are using point-of-careultrasound (PoCUS) to enhance their assessment of suchpatients1-3

Performing resuscitative PoCUS (ultrasonographydirectly related to an acute resuscitation in critical care)1

is made more complex by the patientrsquos precariousclinical state and resulting surroundings creatinglogistical challenges in terms of timing and access tothe patient Effective resuscitative PoCUS relies onsituational awareness understanding of the rationale forperforming a scan at a given time and the ability toaccurately interpret and act on the findings4 Generallyindividual aspects of critical care should be employedin a ldquosimultaneous choreographed approachrdquo5 Suchchoreography strives to minimize interruptions incritical actions while ensuring that the patientundergoes all appropriate assessments and receivesrequired therapies

As such emergency medicine (EM) trainees must notonly master the skill of generating ultrasound imagesbut also become efficient at incorporating suchscanning into their resuscitation Competence inresuscitative PoCUS can thus be divided into threebroad components awareness of indications withassociated rationale the technical skill of imagegeneration with simultaneous interpretation offindings and lastly the appropriate integration offindings into resuscitation The role of simulation forultrasound skill development and competence has onlyrecently gained attention with the majority of currentliterature focusing on ultrasound-guided proceduresand image generationinterpretation67 The incor-poration of PoCUS simulation into high-fidelitysimulation (HFS) through what has been described ashybrid simulation8 may contribute to the developmentof overall resuscitative PoCUS competence Suchhybrid simulations or simulated patient encountersoffer an intermediary step whereby the skills learnedoutside the critical-care context (ie at courses throughscanning volunteers and patients who are otherwisewell) can be re-integrated into a clinical environment ina way that is developmentally appropriate9

Many training programs have already incorporatedresuscitative PoCUS into HFS to varying degreesSome centers may use printed images or offer verbal

descriptions of findings (representing the simplestmethod for integrating ultrasound into critical caresimulation) In contrast Kobayashi et al (2010)published an ultrasound simulation teaching packagethat incorporated a laptop (placed on an audiovisualcart) as a basic ultrasound simulation device10

Expanding upon such integration Kulyk et al incor-porated a simulated ultrasound probe to the laptopconcept (known as the edus2) thus providing traineeswith an opportunity to perform scans in real timeduring HFS11

The purpose of this study was to evaluate two com-parable ultrasound simulation interventions as usedduring HFS Comparing two somewhat similar butdistinct interventions allowed the study team to assessand isolate for the potential value of basic probehandling and other logistical aspects associated with theuse of either intervention

METHODS

Study design

This was a prospective randomized crossovertrial involving post-graduate specialist trainees in EM(trainees) and EM physicians involved in PoCUSteaching (instructors) Trainees and instructorsparticipated in a day-long simulation-based critical careultrasound course This research project was approvedby the Behavioural Research Ethics Board of both theUniversity of Saskatchewan Research Ethics Board(BEH 12-292) and by Barts Health Trust NHS(ReDA 9017)

Study setting and population

This study was conducted at Medical EducationTraining Suite Whipps Cross Hospital WhippsCross Road Leytonstone London UK The traineepopulation was recruited from the London SpecialistSchool of Emergency Medicine A total of 25 EMtrainees participated in the study over four separatecourse dates EM instructors were selected by the localstudy supervisor (TM) based on expertise in PoCUSand overall teaching skill-set Of the eight facultyphysicians in the study five were full-time consultantsin EM The remaining three were senior trainees(chosen by TH) deemed sufficiently experienced inEM and PoCUS to serve as instructors for the course

Olszynski et al

2 20150(0) CJEM JCMU

Study interventions

The edus2 is a PoCUS simulator that is comprised of amodified ultrasound probe and laptop11 When usedwithin a high-fidelity simulation (HFS) setting the edus2plays pre-recorded video clips of areas of interest throughthe coupling of those videos to specific Radio FrequencyIdentification Device (RFID) cards placed under the skinof any commercially available HFS mannequin Passingthe edus2 probe over a RFID card located beneath amannequinrsquos skin initiates a video clip of the correspond-ing anatomic area (on the HFS mannequin) to be viewedby the trainee on the simulator screen Multiple scans arepossible during any given scenario (by placing several cardsunder the skin of the mannequin) however no imagemanipulation can take place (clips play to completion oncethe probe passes over the RFID tag under the skin)

The second ultrasound simulation interventionwas a laptop placed on an audiovisual cart During a givenscenario trainees can bring the laptop to the mannequinrsquosbedside and choose the desired clip as labeled withinthe case folder10 While this intervention lacks probemanipulation it is an established method of integratingsome cognitive aspects of resuscitative PoCUS into criticalcare simulation (what to scan image interpretation andintegration) Both interventions require minimal financialinvestment (beyond an existing HFS infrastructure) asboth can run on used laptops In addition bothinterventions could be used with real standardized patients

Study protocol

Trainees were randomized based on order of arrival tothe simulation centre into two groups (A or B) with twoto four trainees per group Each trainee group wasassigned to one of two study arms that involved both theuse of the edus2 as well as the simple laptop for a total offour HFS scenarios Group A trainees completed theirfirst two cases with the edus2 followed by two cases withthe use of the laptop Group B was assigned the samecases but with the PoCUS interventions presented inreverse order All trainees completed an entrance MCQ(multiple choice question) exam (based on the AmericanCollege of Emergency Physicianrsquos EMSONO onlineexam12 permission obtained) as a means of establishinglevel of knowledge as well as the success of grouprandomization (Figure 1)

Each HFS scenario was followed by a standardizeddebriefing session led by an instructor and a course

facilitator In order to capture differences in the debriefingexperiences that followed each intervention the EMphysician instructors were surveyed These surveys focusedon the performance of the PoCUS interventions as well asthe debriefing experiences that followed each casePre- and post-intervention responses (10-point

Likert scale) were compared and analyzed in order todetermine the strengths of either intervention as wellas for direct comparison

Scenario development

The four cases were chosen from the ultrasound casesimulation package prepared by Kobayashi et al (2010)They represent the shock or peri-arrest states associatedwith the following conditions ruptured aortic aneurysmblunt abdominal trauma with hemoperitoneum cardiactamponade and cardiac arrest secondary to massivepulmonary embolism10

Outcome measures

The primary outcome was trainee and instructorpreference for either intervention Secondary outcomesincluded identification of strengths and weaknesses ofeach intervention as well as overall merits of PoCUSsimulation during critical care simulation

Data analysis

Quantitative data included test and survey scores(Likert scale) The significance (alpha) level for allanalysis was set at plt 05 t test analyses were used for

Figure 1 Study Design

Ultrasound during critical care simulation


comparisons of pre- and post-intervention scores withininterventions as well as comparisons between the twointerventions at different time-points

Qualitative data analysis included thematic andemergent analysis from written responses in self-reportsand online survey feedback The author and a secondevaluator (KT) independently completed thematicanalysis of the qualitative data The thematic analysis thenunderwent triangulation where only themes agreed to bytwo assessors were included in the final analysis

RESULTS

Average pre-intervention MCQ score for all traineeswas 715 which suggests familiarity with PoCUS aswould be expected for middle-level trainees Most of thetrainees (2125) had had previous HFS experience withthe majority of trainees having had 3-5 previous HFSexperiences Nearly all had attended a level I PoCUScourse or equivalent (2125) Trainees responded that todate previous HFS experiences had only poorly if at allintegrated resuscitative PoCUS into HFS with a meanscore of 326 out of 10 (SD 273)

Primary study question

The primary study outcome was trainee and instructorpreference for either intervention Trainees preferred theedus2 intervention to the simple laptop Initial surveyresponses demonstrated that trainees rated the twointerventions similarly (see Figure 2) Both interventionswere deemed to be an improvement from previousexperiences in all of the evaluated aspects of theinterventions No statistically significant difference wasidentified between the edus2 and laptop interventionUpon completion of the qualitative survey (a few weeksafter the course) all respondents (2025 study participants)indicated a preference for the edus2 As one trainee put itldquoholding the probe makes the simulation closer to realityand real timerdquo The themes of ldquoreal-timerdquo and ldquohands-onuserdquo dominated the survey responses This was contrastedwith the artificial nature of the videos found on the laptopldquoThe laptop meant you were trying to find the correct[clip] which detracted from the simulationrdquo

Instructors rated the edus2 as the superior trainingintervention as compared to both previous experiencesand the laptop intervention (see Figures 3 and 4) Uponreview of qualitative data features identified with the edus2included the ability to assess trainee use of PoCUS in real

time as well as basic probe handling ldquoI was able to assesstheir use of [ultrasound] in cardiac arrest and the timing ofecho with CPRrdquo This theme relates to the previouslydescribed concept of resuscitation choreography

012345678910

Previous

Laptop

edus2

Figure 2 Trainees were asked how well the simulation

scenario (previous laptop or edus2) addressed the

following aspects of Resuscitative PoCUS

All comparisons to previous experiences were statistically

significant (plt 005) No statistically significant difference

was observed between the laptop and edus2

0

1

2

3

4

5

6

7

8

9

10

Previous

Laptop

edus2

Figure 3 Instructors were asked how well the simulation



Laptop intervention scores did not meet statistical

significance (plt 005)

Olszynski et al


Secondary outcomes

No statistically significant differences in MCQ scoreswere generated after completion of the first two cases

In terms of impact of the session on their clinicalwork the majority of trainees expressed an increasedawareness of indications for use of PoCUS As onetrainee commented the course increased ldquothe numberof situations in which I would consider usingultrasoundrdquo This theme was coupled with what traineesdescribed as an increased ldquoenthusiasm for practicing[ultrasound] scanning [and] an appreciation of the valueof [ultrasound] scanning in management of critically illpatientsrdquo The day-long session impacted training byencouraging most trainees ldquoto seek more training in[ultrasound] scanning and to reach Level I sign off andbeyondrdquo More advanced trainees described a lesserimpact as they ldquoalready use [ultrasound] scanning as apart of [their] examinationrdquo in many patient encountersbut they also noted that the session inspired them toldquoget involved in [ultrasound] teachingrdquo

Both interventions were rated favorably in termsof integrating PoCUS into HFS when compared toprevious experiences (see Figures 2 and 4) Facultymembers commented that both interventions allowedfor ldquoa reasonable assessment of [knowledge] ofindicationsrdquo and noted that the interventions clearlyldquoadded PoCUS into the decision making processrdquo

The next series of questions posed to instructorsrelated to the impact the PoCUS interventions had on thedebriefing sessions (see Figure 4) One faculty participantexplained that the edus2 allowed for ldquofeedback oneverything from positioning of equipment tocommunication with patient to documentation andmedico-legal issuesrdquo On the other hand faculty felt thelaptop intervention offered them very little insightinto trainee skills and as such made it hard to bring upPoCUS skills during debrief This ldquolack of ownership ofthe skill made the feedback less applicable to the traineesrdquo

DISCUSSION

Our conceptual framework (Figure 5) illustrates keyconcepts supporting the use of PoCUS simulation inHFS Learning takes place according to Bloomrsquos threedomains12 Development is paired through interplaybetween the trainee and the instructorpreceptor Asper Cognitive Load Theory (CLT)13 as traineesbecome more proficient with PoCUS (relying less on

short-term memory and more on both long-term andmotor memory) they become increasingly capable offocusing on the clinical picture before them Instructorscan identify aspects of trainee PoCUS use thatmay require further development and subsequentlycan create opportunities for deliberate practiceSimultaneously clinical competence can be assessedusing Millerrsquos framework14 while recognizing thechallenges inherent to the assessment of critical careskills (namely the infrequency and non-standardizabilityof such cases) Lastly Kirkpatrickrsquos Hierarchy ofEvidence15 allows one to evaluate whether transfer oflearning has taken place and may help with

0

2

4

6

8

10

Impact on debrief Assess PoCUS skills

Previous

Laptop

edus2



following training aspects of Resuscitative PoCUS



Figure 5 Conceptual Framework

PoCUS ndash Point of Care Ultrasound ZPD - Zone of Proximal

Development



determining if the intervention will have any impact onactual patient care16

In terms of PoCUS integration into HFS traineesrated both interventions favorably This may be relatedto the fact that both interventions though not identicaloffered trainees a simplified form of the more complextask of resuscitative PoCUS As Kneebone et al statedone of the strengths of simulation is that it ldquoofferscontrollable levels of challenge that can be adjustedaccording to individual needrdquo9

Thematic analysis of the qualitative data revealed thatall trainees preferred the edus2 to the laptop as itoffered ldquoa more hands on experience in real timerdquoDespite recreating only the basics of image generationuse of the edus2 challenges the trainee to consider thelogistical challenges of appropriate use (for example theproper sequence of PoCUS during cardiac arrest hasbeen questioned)17 Furthermore the establishedresuscitation sequences of trauma cardiac arrest andundifferentiated shock are not identical1819 neither isthe integration of PoCUS into these scenarios Basedon the findings of this study and related simulationliterature the next step should be to teach PoCUSchoreography in HFS Existing evidence of improvedteam performance2021 and resuscitation2223 supportsthe use of simulation interventions for the integrationof resuscitative PoCUS

Simultaneously probe driving skills can be taughtoutside the clinical context As such resuscitative PoCUSmay be best taught through a combination of trainingenvironments This type of ldquoprogressive fidelityrdquo24 mayprove to be an efficient way to teach as complex andmultidimensional a skill as resuscitative PoCUS

The edus2 and the laptop represent two ways ofintegrating PoCUS into HFS Other options includeplacing a diagnostic trainer (ie CAE Vimedix) besidethe HFS mannequin This trainer can then be turnedto and used when indicated during a scenario25 Eachof these approaches represent varying degrees ofengineered and psychological fidelity and as such alsorepresent the spectrum of cost (where increasingengineered fidelity is generally associated withincreasing costs)24

Hamstra et al (2014) recently addressed the challengesassociated with fidelity given that increased engineeredfidelity doesnrsquot always result in increased educationalvalue26 They coined the term ldquofunctional fidelityrdquo andmoreover the concept of ldquofunctional task alignmentrdquowhere a given simulation intervention is defined by the

learning objectives and tasks associated withthe clinical skill rather than the interventionsphysical resemblance This approach frames theevaluation of our two PoCUS simulation interventionsnot by their semblance to the real equipment but ratherby each interventionrsquos ability to address learningobjectives and simulate the desired set of tasks Whenintroducing resuscitative PoCUS into critical caresimulation it can be argued that it is clinical integration(knowing when to scan what to scan and how tointerpret findings within the case) that is of greatestinterest Specific image generation on the other handcan be taught outside the critical care context While bothinterventions met several of the objectives as related toresuscitative PoCUS skills the edus2 was found to meetmore of the desired tasks and therefore showed betterfunctional task alignment

LIMITATIONS

This study has several limitations Unlike this studymost simulation intervention studies are designed to belongitudinal and as such harness the fullest potential ofkey constructs like deliberate practice27 Furthermoretrainees were asked about the perceived impact ofthe single session on their future clinical work andeducation but we did not followverify those reportsnor does the study inform us of the impact of repeatedexposure to the interventionDespite significant efforts to reduce personal bias it

is possible that the lead authorrsquos involvement in thesessions (as the voice of the simulated patientsand presenter of the two interventions) while alsobeing co-developer of the edus2 may have biased someof the trainee and faculty responses Several steps weretaken during the design and implementation of thestudy to mitigate bias The decision to carry outthe study at another institution served to minimizepersonal biases and conflicts of interest that mayexist between the lead author and studentsinstructorsat his institution Secondly the use of previouslydesigned cases by Kobayashi et al ensured that theHFS scenarios were not biased toward one type ofintervention or the other Thirdly the lead authorholds no patents or commercial interests pertaining tothe edus2 or related ultrasound simulation productsThe edus2 is under a creative commons copyright andas such is to be shared and further developed in an openand non-commercial fashion

Olszynski et al


FUTURE RESEARCH

Developing a repertoire for use of PoCUS duringresuscitation and emergent care will require deliberatepractice Future studies could be directed at determiningwhether repeated exposures to this training interventionresults in better use of resuscitative PoCUS during realresuscitation

CONCLUSION

The integration of resuscitative PoCUS into criticalcare HFS represents an evolution of PoCUS training inresidency This progression is driven by a desire by bothEM trainees and faculty to safely integrate PoCUS intothe care of critically ill patients The findings of the studysupport the integration of PoCUS into HFS Suchintegration was found to be of value to both trainees andinstructors in terms of allowing trainees to demonstrateknowledge of indications as well as correct imageinterpretation The edus2 was identified as being asuperior teaching intervention as it allowed for greaterfunctional integration of PoCUS into critical care(real time and hands-on) significantly better assessment oftrainee skills and subsequently had greater impact onsession debrief and formative feedback

Acknowledgments A sincere thank you to Ms MeganHall-Jackson (MA Clinical Education) whose insights and assistanceprofoundly improved this studyrsquos design This submission would notbe possible without her enthusiasm for simulation-based medicaleducation We would also like to thank Ms Krista Trinder MSc(College of Medicine University of Saskatchewan) and MrK Shawn Davidson PhD (Clinical Research Scientist Departmentof Medicine Laval University Sainte Foy Quebec) for their assis-tance with data analysis and technical writing

Competing Interests None to declare

REFERENCES

1 American College of Emergency Physicians Emergencyultrasound guidelines - 2008 Available at httpwwwaceporgcontentaspxid=32182 (accessed 14 August 2015)

2 Atkinson P Ross P Henneberry R Coming of age emergencypoint of care ultrasonography in Canada CJEM 201416(4)265-8

3 Henneberry J Hanson A Healey A et al Use of point ofcare sonography by emergency physicians CJEM 201214(2)106-12

4 Socransky S Wiss R Point-of-care ultrasound for emergencyphysicians The EDE Book The E2E Course Inc 2012

Available at httpwwwede2coursecom (accessed 14August 2015)

5 Berg RA Hemphill R Abella BS et al Part 5 adultbasic life support 2010 American Heart AssociationGuidelines for Cardiopulmonary Resuscitation andEmergency Cardiovascular Care Circulation 2010122(18 Suppl 3)S685-705

6 Mendiratta-Lala M Williams T de Quadros N et al Theuse of a simulation center to improve resident proficiency inperforming ultrasound-guided procedures Acad Radiol201017(4)535-40

7 Sidhu HS Olubaniyi BO Bhatnagar G et al Role ofsimulation-based education in ultrasound practice trainingJ Ultrasound Med 201231(5)785-91

8 Girzadas DV Jr Antonis MS Zerth H et al Hybridsimulation combining a high fidelity scenario with a pelvicultrasound task trainer enhances the training and evaluationof endovaginal ultrasound skills Acad Emerg Med 200916(5)429-35

9 Kneebone RL Scott W Darzi A et al Simulation andclinical practice strengthening the relationship Med Educ200438(10)1095-102

10 Kobayashi L Shapiro M Nagdev A et al Emergencymedicine ultrasound simulation (US S) case simulationpackage 2010 Available at httpswwwmededportalorgpublication531 (accessed 14 August 2015)

11 Kulyk P Olszynski P Emergency department ultrasoundsimulator Acad Emerg Med 201219(S1)35

12 American College of Emergency Physicians Emergencyultrasound exam 2014 Available at httpwwwemsonocomacepexamhtml (accessed 14 August 2015)

13 Bloom BS Engelhart MD Furst EJ et al Taxonomy ofEducational Objectives The Classification of Educational GoalsHandbook I Cognitive Domain New York David McKayCompany 1956

14 van Merrieumlnboer JJ Sweller J Cognitive load theoryin health professional education design principles andstrategies Med Educ 201044(1)85-93

15 Miller GE The assessment of clinical skillscompetenceperformance Acad Med 199065(9 Suppl)S63-7

16 Kirkpatrick D Great Ideas Revisited Techniques forEvaluating Training Programs Revisiting Kirkpatricksfour-level model Train Dev 199650(1)54-9

17 Ripley J The Sonocave blog 2014 Available at httpthesonocavecom (accessed 14 August 2015)

18 Lanctot YF Valois M Beaulieu B EGLS Echo-guided lifesupport An algorithmic approach to undifferentiated shockCrit Ultrasound J 20113123-9

19 Weingart SD Duque D Nelson B Rapid ultrasound for shockand hypotension (RUSH-HIMAPP) 2009 Available at httpemcritorgrush-examoriginal-rush-article (accessed 14August 2015)

20 Kim J Simulation and medical education In Acuteresuscitation and crisis management (ed D Neilipovitz)Ottawa ON University of Ottawa Press 2008 17-26

21 Weller JM Nestel D Marshall SD et al Simulationin clinical teaching and learning Med J Aust 2012196(9)594



22 Sawyer T Sierocka-Castaneda A Chan D et al Deliberatepractice using simulation improves neonatal resuscitationperformance Simul Healthc 20116(6)327-36

23 Norman G Dore K Grierson L The minimal relationshipbetween simulation fidelity and transfer of learningMed Educ 201246(7)636-47

24 Brydges R Carnahan H Rose D et al Coordinatingprogressive levels of simulation fidelity to maximizeeducational benefit Acad Med 201085(5)806-12

25 Parks AR Atkinson P Verheul G et al Can medicallearners achieve point-of-care ultrasound competency usinga high-fidelity ultrasound simulator a pilot studyCrit Ultrasound J 20135(1)9

26 Hamstra SJ Brydges R Hatala R et al Reconsidering fidelityin simulation-based training Acad Med 201489(3)387-92

27 Ericsson KA Krampe RT Tesch-Romer C The role ofdeliberate practice in the acquisition of expert performancePsychol Rev 1993100(3)363-406

Olszynski et al


INTRODUCTION

Critically ill patients presenting to emergency departmentsare assessed urgently through a variety of approachesIncreasingly emergency physicians are using point-of-careultrasound (PoCUS) to enhance their assessment of suchpatients1-3

Performing resuscitative PoCUS (ultrasonographydirectly related to an acute resuscitation in critical care)1

is made more complex by the patientrsquos precariousclinical state and resulting surroundings creatinglogistical challenges in terms of timing and access tothe patient Effective resuscitative PoCUS relies onsituational awareness understanding of the rationale forperforming a scan at a given time and the ability toaccurately interpret and act on the findings4 Generallyindividual aspects of critical care should be employedin a ldquosimultaneous choreographed approachrdquo5 Suchchoreography strives to minimize interruptions incritical actions while ensuring that the patientundergoes all appropriate assessments and receivesrequired therapies

As such emergency medicine (EM) trainees must notonly master the skill of generating ultrasound imagesbut also become efficient at incorporating suchscanning into their resuscitation Competence inresuscitative PoCUS can thus be divided into threebroad components awareness of indications withassociated rationale the technical skill of imagegeneration with simultaneous interpretation offindings and lastly the appropriate integration offindings into resuscitation The role of simulation forultrasound skill development and competence has onlyrecently gained attention with the majority of currentliterature focusing on ultrasound-guided proceduresand image generationinterpretation67 The incor-poration of PoCUS simulation into high-fidelitysimulation (HFS) through what has been described ashybrid simulation8 may contribute to the developmentof overall resuscitative PoCUS competence Suchhybrid simulations or simulated patient encountersoffer an intermediary step whereby the skills learnedoutside the critical-care context (ie at courses throughscanning volunteers and patients who are otherwisewell) can be re-integrated into a clinical environment ina way that is developmentally appropriate9

Many training programs have already incorporatedresuscitative PoCUS into HFS to varying degreesSome centers may use printed images or offer verbal

descriptions of findings (representing the simplestmethod for integrating ultrasound into critical caresimulation) In contrast Kobayashi et al (2010)published an ultrasound simulation teaching packagethat incorporated a laptop (placed on an audiovisualcart) as a basic ultrasound simulation device10

Expanding upon such integration Kulyk et al incor-porated a simulated ultrasound probe to the laptopconcept (known as the edus2) thus providing traineeswith an opportunity to perform scans in real timeduring HFS11

The purpose of this study was to evaluate two com-parable ultrasound simulation interventions as usedduring HFS Comparing two somewhat similar butdistinct interventions allowed the study team to assessand isolate for the potential value of basic probehandling and other logistical aspects associated with theuse of either intervention

METHODS

Study design

This was a prospective randomized crossovertrial involving post-graduate specialist trainees in EM(trainees) and EM physicians involved in PoCUSteaching (instructors) Trainees and instructorsparticipated in a day-long simulation-based critical careultrasound course This research project was approvedby the Behavioural Research Ethics Board of both theUniversity of Saskatchewan Research Ethics Board(BEH 12-292) and by Barts Health Trust NHS(ReDA 9017)

Study setting and population

This study was conducted at Medical EducationTraining Suite Whipps Cross Hospital WhippsCross Road Leytonstone London UK The traineepopulation was recruited from the London SpecialistSchool of Emergency Medicine A total of 25 EMtrainees participated in the study over four separatecourse dates EM instructors were selected by the localstudy supervisor (TM) based on expertise in PoCUSand overall teaching skill-set Of the eight facultyphysicians in the study five were full-time consultantsin EM The remaining three were senior trainees(chosen by TH) deemed sufficiently experienced inEM and PoCUS to serve as instructors for the course

Olszynski et al


Study interventions



Study protocol







Outcome measures


Data analysis







RESULTS






012345678910

Previous

Laptop

edus2







0

1

2

3

4

5

6

7

8

9

10

Previous

Laptop

edus2






Olszynski et al


Secondary outcomes





DISCUSSION



0

2

4

6

8

10


Previous

Laptop

edus2








Development










LIMITATIONS



Olszynski et al


FUTURE RESEARCH


CONCLUSION




REFERENCES































Olszynski et al


Study interventions



Study protocol







Outcome measures


Data analysis







RESULTS






012345678910

Previous

Laptop

edus2







0

1

2

3

4

5

6

7

8

9

10

Previous

Laptop

edus2






Olszynski et al


Secondary outcomes





DISCUSSION



0

2

4

6

8

10


Previous

Laptop

edus2








Development










LIMITATIONS



Olszynski et al


FUTURE RESEARCH


CONCLUSION




REFERENCES































Olszynski et al




RESULTS






012345678910

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Olszynski et al


Secondary outcomes





DISCUSSION



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Development










LIMITATIONS



Olszynski et al


FUTURE RESEARCH


CONCLUSION




REFERENCES































Olszynski et al


Secondary outcomes





DISCUSSION



0

2

4

6

8

10


Previous

Laptop

edus2








Development










LIMITATIONS



Olszynski et al


FUTURE RESEARCH


CONCLUSION




REFERENCES































Olszynski et al









LIMITATIONS



Olszynski et al


FUTURE RESEARCH


CONCLUSION




REFERENCES































Olszynski et al


FUTURE RESEARCH


CONCLUSION




REFERENCES































Olszynski et al








Olszynski et al


Documents

Ultrasound During Critical Care Simulation: A Randomized, Crossover Study. Canadian Journal of Emergency Medicine