Surgical Critical Care and Ultrasound Training: Changing the Paradigm

Cassandra L Cardarelli, MD1, Glaser Jacob, MD2, Matthew Vasquez, MD1, Thomas Scalea, MD3, Sarah Murthi, MD2. 1Walter Reed National Military Medical Center, Bethesda, MD, USA, 2Critical Care Ultrasound Dept, Dept of Surgery and Critical Care, UMMS, Balt, MD, USA, 3Department of Surgery and Surgical Critical Care, UMMS, Baltimore, MD, USA

OBJECTIVE: The ideal method to train physicians in point of care ultrasound (POCUS) remains unclear. In surgical critical care, there is no current standard. Critical Care fellowship training at the R Adams Cowley Shock Trauma Center (STC) includes a one month rotation in the Critical Care Ultrasound Program (CCUP), with an emphasis on ultrasound (US) for trauma and hemodynamic echocardiography. Recognizing gaps in our training, we have modernized our training pathway and aim to validate it against historical means.

METHODS: Outgoing Critical Care Fellows (OF) from the 2013-2014 year group were tested in the areas of US knowledge, image interpretation, acquisition and technical skills. FAST, lung, cardiac, vascular, and US physics were tested. Confidence was also evaluated. Incoming fellows (IF) were tested at the beginning of the academic year, and again after completing a one day ultrasound introduction course, “The Leading Edge”.  The new curriculum was implemented for the IF group, and quarterly assessments have been made as the new training algorithm is validated.

RESULTS: Eleven outgoing and 30 incoming fellows (Surgical (ISF) and Medical (IMF)) comprised the study group (n=41); 59% were surgeons. Identified training gaps included image interpretation, advanced cardiac imaging, and lung ultrasound. Knowledge and skills scores were significantly lower in both IF groups when compared to OF. After completing “The Leading Edge,” ISF and IMF skills significantly increased (p=0.0074, 0.0001 respectively)-approaching the skill level of the OF. After the one day course there was a significant difference in scores between the ISF and IMF (p=0.0029). Quarterly evaluations indicate both IF groups have maintained skills as compared to the expert group (ISF/IMF, p=0.2902 and p=0.1391); ISF did not have a significant degradation of skills over this time period, however IMF noted a loss.

CONCLUSIONS: The ideal algorithm for training ultrasound is unknown. Knowledge gaps in our current curriculum prompted a change in training. Preliminary results reveal that a one day introductory course along with a month long course of guided clinical practice allowed Critical Care fellows to attain expert skills and knowledge in ultrasound. The training algorithm also led to improved confidence and self-reported competence in ultrasound use. Our new curriculum is being evaluated for efficacy and retention of skills, thus far with optimistic results. It remains to be seen whether this change will allow for long term retention or improvement in overall Ultrasound expertise.

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