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Ultrasonography training and utilization in surgical critical care fellowships: a program director's survey
j o u r n a l o f s u r g i c a l r e s e a r c h o c t o b e r 2 0 1 7 ( 2 1 8 ) 2 9 2 e2 9 7
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ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Ultrasonography training and utilization in surgical critical care fellowships: a program director’s survey Brian K. Yorkgitis, DO,a,* Elizabeth A. Bryant, MPH,b Gabriel A. Brat, MD, MPH,c Edward Kelly, MD,d Reza Askari, MD,d and Jin H. Ra, MDa a
Division of Acute Care Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida Injury Prevention and Outreach Coordinator, Brigham and Women’s Hospital, Trauma, Burns, and Surgical Critical Care, Boston, Massachusetts c Beth Israel Deaconess Medical Center, Acute Care Surgery and Critical Care, Boston, Massachusetts d Brigham and Women’s Hospital, Trauma, Burns and Surgical Critical Care, Boston, Massachusetts b
article info
abstract
Article history:
Background: Intensivist-performed ultrasound (IPUS) is an adjunctive tool used to assist in
Received 7 February 2017
resuscitation and management of critically ill patients. It allows clinicians real-time in-
Received in revised form
formation through noninvasive methods. We aimed to evaluate the types of IPUS per-
24 May 2017
formed and the methods surgical critical care (SCC) fellows are trained along with
Accepted 16 June 2017
challenges in training.
Available online xxx
Methods: One hundred SCC fellowship directors were successfully sent an email inviting them to participate in a short Web-based survey. We inquired about program character-
Keywords:
istics including hospital type, fellowship size, faculty size and training, dedicated surgical
Critical care ultrasound
critical care beds, and ultrasound equipment availability. The survey contained questions
Surgical education
regarding the program directors’ perception on importance on cost effectiveness of IPUS,
Ultrasound education
types of IPUS examinations performed, fellows experience with IPUS, challenges to training, and presence and methods of quality assurance (QA) programs. Results: A total of 38 (38.0%) program directors completed the survey. Using a 100-point Likert scale, the majority of the respondents indicated that IPUS is important to patient care in the SICU and is cost-effective (mean score 85.5 and 84.6, respectively). Most (34, 89.5%) utilize IPUS and conduct a mean of 5.1 different examination types with FAST being the most prevalent examination (33, 86.8%). Thirty-three (86.8%) programs include IPUS in their SCC training with varying amounts of time spent training. Of these programs, 19 (57.6%) have a specific curriculum. The most frequently used modalities for training fellows were informal bedside teaching (28, 84.8%), hands-on lectures (20, 60.6%) and formal lectures (19, 57.6%). The top three challenges program directors cited for IPUS education was time (23, 69.7%), followed by concerns for ongoing QA (19, 57.6%) and lack of faculty trained in IPUS (18, 53.9%). Only 20 (60.6%) programs review images as a part of QA/quality improvement.
* Corresponding author. Division of Acute Care Surgery, University of Florida College of Medicine-Jacksonville, 655 W. 8th Street, Jacksonville, FL 32209. Tel.: þ1 9042446631; fax: þ1 9042444687. E-mail addresses: [email protected], [email protected] (B.K. Yorkgitis). 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.06.040
yorkgitis et al ultrasound training in surgical critical care fellowships
293
Conclusions: Utilization and training of IPUS is common in SCC fellowships. There is varied education type and training time devoted to IPUS which could lead to gaps in knowledge and care. Development of a standard curriculum for SCC fellowships could assist surgical intensivists in achieving a base of knowledge in IPUS to create a more homogenously trained workforce and standards of care. ª 2017 Elsevier Inc. All rights reserved.
Introduction
Results
Point-of-care ultrasonography (US) is widely used because it is a noninvasive and cost-effective method to assist in the diagnosis and management of patients. In addition, it allows physicians to gain information in real time.1 It is particularly beneficial in intensive care units (ICUs), where it can be brought to bedside and prevent unnecessary movement of critically ill patients.2 Bedside examinations also allow for the care team to continually monitor the patient during the examination.3 With its ease of use, portable nature, and wide array of imaging possibilities, there has been considerable adoption of this technology.2 In 1998, the American College of Surgeons (ACSs) outlined US education recommendations for surgeons, noting that it was imperative that physicians are properly trained to use this technology so they can accurately diagnose and treat patients.4 However, although many studies have demonstrated the efficacy of training physicians in US, many have also found that training is widely variable across the United States, particularly among surgeons.5-8 In response to its widespread use, the Surgical Critical Care Program Directors Society has included General Critical Care Ultrasonography in its recommended training curriculum for surgical critical care fellows.9 However, it is unclear the extent to which the fellows are exposed to US and are trained in this modality. Through an Internetbased survey sent to surgical critical care fellowship program directors (PDs), we sought to identify the number of programs that provide instruction on intensivistperformed ultrasound (IPUS) as well as the methods of training, barriers to training, and time devoted to this education.
Thirty-eight (38.0%) completed surveys were available for analysis. 73% (n ¼ 28) programs were self-described as university hospitals. All but two training programs were at level I
Table 1 e Fellowship program characteristics (n [ 38). Hospital type
Number (%)
University
28 (73.7)
University affiliated
8 (21.1)
Community
2 (5.3)
Fellows per year 1
10 (26.3)
2
17 (44.7)
3
5 (13.2)
4
6 (15.8)
Trauma center designation Level I
36 (94.7)
Level II
2 (5.3)
Number of designated surgical critical care beds 0
3 (7.9)
1-10
1 (2.6)
11-20
13 (34.2)
21-30
11 (28.9)
31-40
1 (2.6)
>40
8 (21.1)
Used intensivist-performed ultrasound in the care of patients? Yes
33 (86.8)
No
5 (13.2)
Designated ultrasound machines for SICU
Materials and methods An institutional review board approved survey was developed and distributed via an electronic mail invitation to 100 surgical critical care PDs in the United States. Completion of the survey indicated consent. The instrument included questions about the training program, including size, faculty characteristics, location, length of training, primary hospital description, trauma center status, number of designated surgical critical care beds, and availability of US equipment. The survey also queried about PDs’ perception on importance and cost effectiveness of IPUS, types of IPUS examinations performed, fellow engagement and training in various IPUS examinations, challenges to training, and quality assurance (QA) program utilization and methods.
0
6 (15.8)
1
11 (28.9)
2
13 (34.2)
3
5 (13.2)
4
3 (7.9)
Number of fellowship faculty members 5
4 (10.5)
6-10
24 (63.2)
>10
10 (26.3)
Fellowship faculty disciples Surgery
38 (100)
Anesthesia
19 (50.0)
Emergency medicine/critical care
11 (28.9)
Pulmonary critical care
8 (21.1)
294
j o u r n a l o f s u r g i c a l r e s e a r c h o c t o b e r 2 0 1 7 ( 2 1 8 ) 2 9 2 e2 9 7
Fig. 1 e IPUS applications used (n [ 34). (Color version of figure is available online.)
trauma centers (n ¼ 36, 94.7%). Hospitals frequently had between 11-20 designated surgical critical care beds (13, 34.2%). The mean number of US machines designated for surgical critical care use was 1.76 (range 0-5). The mean number of fellows trained per year at each of the programs was 2.5 (range 0-12; Table 1.) The mode number of critical care attendings involved in fellow’s education were >10 (n ¼ 10, 38%). 63.2% (n ¼ 24) of respondents reported that their programs’ faculty included nonsurgical members. Anesthesia critical care physicians were the most common nonsurgical faculty members (n ¼ 19, 50.0%), followed by emergency medicineetrained critical care physicians (n ¼ 11, 28.9%), and last, pulmonary critical care physicians (n ¼ 8, 21.0%). There were four programs (10.5%) that did not have faculty that utilized or were credentialed in IPUS use, and two PDs (5.3%) were unsure if their program’s faculty used or were credentialed in US. The most commonly reported faculty training method in US was attending national conferences (n ¼ 26). The second most common method was local workshops (n ¼ 22), followed by fellowship training (n ¼ 13). Of note, 22 (57.9%) of PDs reported more than one modality as the method of faculty training. Of the completed surveys, 89.5% (n ¼ 34) programs used IPUS. On a scale of 0-100 rating the importance of IPUS (0 meaning not important, 100 critically important), PDs rated IPUS’s importance with a median score of 88 (range 51-100, IQR 20). The median rating PDs gave for cost effectiveness of IPUS was 91 (range 0-100, IQR 26). Half (n ¼ 19) of the PDs reported IPUS decreased the number of pulmonary artery catheters used in their ICUs, and 23.7% (n ¼ 9) were unsure if IPUS reduced pulmonary artery catheters. Among bedside US examinations performed, FAST was the most prevalent (33, 86.8%), followed by vascular access procedure guidance (32, 84.2%) and thorax examination (28, 73.7%) (Fig. 1). 86.8% (n ¼ 33) of PDs reported that ultrasound education is a component of their fellows’ education. Only 57.6% (n ¼ 19) programs offered a specific curriculum and/or formal lectures.
The most common training modality was informal bedside training (n ¼ 28, 84.8%; Fig. 2). Among programs that provided US education, training time varied greatly, with a range of 1.5 to 600 h. One PD reported an unknown amount of time (Table 2). The approximate number of examinations performed varied greatly from <50 to >150. Of the programs offering US education to their fellows, 15 (45.5%) PDs estimated fewer than 100 examinations and 17 (54.5%) PDs reported over 100 examinations per fellow during their training. When PDs were queried to discern the top three challenges for training fellows, 81 challenges were identified by 33 PDs offering US training. Lack of time for training (23, 28.4%), lack of ongoing QA (19, 23.4%), and lack of faculty trained in IPUS (18, 22.2%) were the top responses, respectively (Fig. 3). Conversely, five PDs (15.2%) reported no challenges in training. Of the 33 programs incorporating IPUS training in their fellowship, 13 PDs (39.4%) reported that they did not have a quality improvement (QI) and/or QA program. For programs with QI/QA initiatives (n ¼ 20), the most common methods
Fig. 2 e Instruction methods for fellow training in IPUS (n [ 34). Some programs use more than one method. (Color version of figure is available online.)
yorkgitis et al ultrasound training in surgical critical care fellowships
Table 2 e Fellows’ IPUS experience (n [ 38). Estimated examinations complete during training
Number (%)
0
5 (13.2)
<50
4 (10.5)
51-100
11 (28.9)
101-150
9 (23.7)
>150
8 (21.1)
Unknown
1 (2.6)
Estimated time completing IPUS training 0h
5 (13.2)
5 h
9 (23.7)
6-10 h
7 (18.4)
11-20 h
6 (15.8)
21-30 h
0 (0.0)
31-40 h
3 (7.9)
>40 h
7 (18.4)
Unknown
1 (2.6)
were reviewing electronically stored images (11, 55.0%) and capturing still images (7, 35.0%). Of note, three (9.1%) programs use more than one method for their QA/QI process.
Discussion Because of its effectiveness and convenience, US is a significant bedside tool for every surgical intensivist.3,8,10,11 As adoption of bedside US increases, surgical critical care (SCC) trainees will need to acquire the skills in its utilization and accurate interpretation of this tool.8 In addition, critical care societies have recommended competency in physician performed US.9,12-15 The Surgical Critical Care Program Directors Society has outlined training in US for fellowship trainees, including incorporating US in daily practice.9 Several authors have studied the minimum training based on professional societies’ recommendations needed in common US performed,
4
2
3 1 23
5 6
18
19
Time for training (23, 28.4%)
Ongoing quality assurance (19, 23.4%)
Lack of faculty trained in this modality (18, 22.2%)
Lack of equipment (6, 7.4%)
No difficules exist (5, 6.2%)
Lack of accuracy (4, 4.9%)
Fellows lack interest in training (2, 2.5%)
Faculty lack interest in training (3, 3.7%)
Fig. 3 e Top challenges to fellow training among programs teaching IPUS (n [ 33 PDs). 81 challenges were identified by PDs. (Color version of figure is available online.)
295
which would likely exceed many of numbers reported by PDs in this survey.16-20 These include the ACS, Society of Critical Care Medicine, American College of Emergency Physicians, and American College of Chest Physicians. These groups have developed US training curricula. Many include minimum required examinations for review to standardize a competency level (Table 3).12-15,21,22 The required number of examinations for American College of Chest Physicians do not include those examinations during skill acquisition while the physician is beginning to use IPUS, only number needed to be submitted for review by the organization.13 Looking closely at the Society of Critical Care Medicine requirements, 140 examination interpretation with 90 examinations is personally performed for proficiency. This number excludes examinations done for procedural use, which were additional 30 examinations.14 Only eight (21.1%) programs come close to these recommendations, achieving greater than 150 examinations. Thus, there exists a significant gap between recommendations and training received. Many of the societies offer courses to instruct physicians on US. Thus, it is not surprising that attending one of these societies’ courses was the most common method of faculty training among survey respondents. However, these courses require participant funding and time away from the participants’ programs to complete. Furthermore, skills acquired at these courses need to be used at the participants’ home institution. Challenges for fellows may occur if faculty at their home institutions are not trained in US or do not have time to observe/review US performed by the fellows.23 This is particularly concerning because the lack of faculty training and lack of time to train fellows were the top two barriers listed to IPUS training of fellows. If we do not empower the future surgical intensivists in delivering IPUS, we will only propagate the challenge of faculty training in this important modality. There is a wide variability in time dedicated to training which could have serious implications for the accuracy of the IPUS performed by these fellows, especially if there are no QI/QA programs in place. Such variation is not infrequent; other US studies have previously demonstrated this among examination types and disciplines.18-20 With time being the most cited barrier to training, 13 (34.2%) PDs did not state that this was a challenge. Programs that developed methods to successfully allocate time for US training can act as a best-practices guides for other programs. Killu et al. studied a comprehensive US curriculum based on the American College of Emergency Physicians model with modifications to the ICU setting. They successfully integrated it into their fellowship.8 This work supports the feasibility of established professional society curriculumebased training encompassed during an SCC fellowship. As a part of any care delivery to patients, QA/QI processes need to be implemented to ensure quality of care, effective education, and to satisfy credentialing requirements.14 The lack of a QA/QI process was listed as the third most common challenge in delivering IPUS education to fellows. Less than two-thirds of the programs had a means of QA/QI for their trainees, making it difficult to determine if training is effective. As outlined by the ACS Ultrasound Examinations by Surgeons, critical care surgeons must adopt QA/QI methods for US to provide the highest quality of care for our patients and education for our peers and trainees.4
296
j o u r n a l o f s u r g i c a l r e s e a r c h o c t o b e r 2 0 1 7 ( 2 1 8 ) 2 9 2 e2 9 7
Table 3 e Professional society required minimum reviewed examinations. ACCP*
Examination Total
21
Cardiac
ACEP
SCCM
25-50 quality reviewed examinations
50 examinations
150-300
10 examinations, five images per examination
140
Lung/pleura
Four examinations, three images per examination
25-50 quality reviewed examinations
30 examinations
Abdominal
Four examinations, four images per examination
25-50 quality reviewed examinations
30 examinations
Three examionations, eight images per examination
25-50 quality reviewed examinations
30 examinations
Vascular/DVT
ACCP ¼ American College of Chest Physicians; ACEP ¼ American College of Emergency Physicians; SCCM ¼ Society of Critical Care Medicine. * Number required for submission for expert review, does not include skill acquisition numbers.
We acknowledge the limitations of an Internet-based survey study. The response rate was 38%, leaving room for additional PDs to provide more data about the current landscape of IPUS training in fellowships. There may be participant bias in the survey, as PDs that have interest in US might have been more inclined to participate in the study. With a survey study, recall bias may play a role in the results.
Conclusions Multiple critical care societies have identified ICU US as integral to patient care. The results of this study show that it is a common modality taught to SCC fellows. However, this study found that there is a high degree of variability in the utilization, education, and quality review processes among SCC fellowships in the United States. This valuable tool requires adequate training and ongoing QI/QA to assure it is used in the most effective and safe manner. The current landscape of IPUS training among SCC fellowships found in this investigation indicates a need for education and quality measure standardization to enable future surgical intensivist readiness for its utilization at the bedside.
Acknowledgment Authors’ contributions: The research idea and development was the work of B.K.Y., E.A.B., G.A.B., R.A., and E.K. The survey tool was created and edited by B.K.Y., E.A.B., G.A.B., and E.K. The data were collected and reviewed by B.K.Y., E.A.B., and J.H.R. The manuscript was drafted and reviewed by B.K.Y., E.A.B., J.H.R., R.A., and E.K.
Disclosure All the authors declare no conflicts of interest to disclose.
references
1. Abu-Zidan FM. Point-of-care ultrasound in critically ill patients: where do we stand? J Emerg Trauma Shock. 2012;5:70e71. 2. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364:749e757.
3. Guillory RK, Gunter OL. Ultrasound in the surgical intensive care unit. Curr Opin Crit Care. 2008;14:415e422. 4. American College of Surgeons. Statement on ultrasound examinations by surgeons. Committee on emerging surgical technology and education, American College of surgeons. Bull Am Coll Surg. 1998;83:37e40. 5. Beggs AD, Thomas PRS. Point of use ultrasound by general surgeons: review of the literature and suggestions for future practice. Int J Surg. 2013;11:12e17. 6. Langlois SLP. Focused ultrasound training for clinicians. Crit Care Med. 2007;S35:S138eS143. 7. Society of American Gastrointestinal and Endoscopic Surgeons. Guidelines for granting ultrasound privileges for surgeons. Available at: https://www.sages.org/publications/ guidelines/guidelines-for-granting-of-ultrasonographyprivileges-for-surgeons/. Accessed May 30, 2017. 8. Killu K, Coba V, Mendez M, et al. Model point-of-care ultrasound curriculum in an intensive care Unit fellowship program and its Impact on patient management. Crit Care Res Pract. 2014;2014:934796. 9. Surgical Critical Care Program Directors Society. Surgical critical care training curriculum. Available at: http:// sccpds.org/wp-content/uploads/2013/01/TA_99_2_2010_ 06_07_ALAM_203917_SDC2a.pdf. Accessed May 30, 2017. 10. Royce CF, Canty DJ, Faris J, et al. Core review: physicianperformed ultrasound: the time has come for Routine Use in Acute care medicine. Anesth Analg. 2012;115:1007e1028. 11. Kameda T, Taniguchi N. Overview of point-of-care abdominal ultrasound in emergency and critical care. J Intensive Care. 2016;4:53. 12. Mandapakala C, Lee S. The role of critical care specialties in the certification and credentialing of bedside ultrasonography. Availabe at: http://www.sccm.org/ Communications/Critical-Connections/Archives/Pages/TheRole-of-Critical-Care-Specialty-Societies-in-the-Certificationand-Credentialing-of-Bedside-Ultrasonography.aspx. Accessed May 30, 2017. 13. American College of Chest Physicians. Critical care ultrasound. Available at: http://www.chestnet.org/Education/AdvancedClinical-Training/Certificate-of-Completion-Program/ Critical-Care-Ultrasonography. Accessed May 30, 2017. 14. Official Statement of the Society of Critical Care Medicine. Recommendations for achieving and maintaining competence and credentialing in critical Care ultrasound with focused cardiac ultrasound and advanced critical care echocardiography. Available at: http://journals.lww.com/ ccmjournal/Documents/Critical%20Care%20Ultrasound.pdf. Accessed May 30, 2017. 15. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Socie´te´ de Re´animation de langue Franc¸aise. Chest. 2009;135:1050e1060. 16. Chisholm CB, Dodge WR, Balise RR, et al. Focused cardiac ultrasound in training: how much is enough? J Emerg Med. 2013;44:818e822.
yorkgitis et al ultrasound training in surgical critical care fellowships
17. Jang T, Aubin C, Naunheim R. Minimum training for Right Upper Quadrant ultrasonography. Am J Emerg Med. 2004;22:439e443. 18. Ahern M, Mallin MP, Weitzel S, et al. Variability in ultrasound education among emergency medicine Residencies. West J Emerg Med. 2010;11:314e318. 19. Kim DJ, Theoret J, Liao MM, et al. The current state of ultrasound training in Canadian emergency medicine programs: perspectives from program directors. Acad Emerg Med. 2012;19:1073e1078. 20. Mosier JM, Malo J, Stolz LA, et al. Critical care ultrasound training: a survey of US fellowship directors. J Crit Care. 2014;29:645e649.
297
21. American College of Surgeons. National Ultrasound Faculty. Available at: https://www.facs.org/education/accreditation/ verification/ultrasound/exported. Accessed May 30, 2017. 22. American College of Emergency Physicians. Ultrasound guidelines: emergency, point-of-care and clinical guidelines in medicine. 2016. Available at: https://www.acep.org/Clinical– Practice-Management/Ultrasound/. Accessed May 30, 2017. 23. Eisen LA, Leung S, Gallagher AE, Kvetan V. Barriers to ultrasound training in critical care medicine fellowships: a survey of program directors. Crit Care Med. 2010;38:1978e1983.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Ultrasonography training and utilization in surgical critical care fellowships: a program director’s survey Brian K. Yorkgitis, DO,a,* Elizabeth A. Bryant, MPH,b Gabriel A. Brat, MD, MPH,c Edward Kelly, MD,d Reza Askari, MD,d and Jin H. Ra, MDa a
Division of Acute Care Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida Injury Prevention and Outreach Coordinator, Brigham and Women’s Hospital, Trauma, Burns, and Surgical Critical Care, Boston, Massachusetts c Beth Israel Deaconess Medical Center, Acute Care Surgery and Critical Care, Boston, Massachusetts d Brigham and Women’s Hospital, Trauma, Burns and Surgical Critical Care, Boston, Massachusetts b
article info
abstract
Article history:
Background: Intensivist-performed ultrasound (IPUS) is an adjunctive tool used to assist in
Received 7 February 2017
resuscitation and management of critically ill patients. It allows clinicians real-time in-
Received in revised form
formation through noninvasive methods. We aimed to evaluate the types of IPUS per-
24 May 2017
formed and the methods surgical critical care (SCC) fellows are trained along with
Accepted 16 June 2017
challenges in training.
Available online xxx
Methods: One hundred SCC fellowship directors were successfully sent an email inviting them to participate in a short Web-based survey. We inquired about program character-
Keywords:
istics including hospital type, fellowship size, faculty size and training, dedicated surgical
Critical care ultrasound
critical care beds, and ultrasound equipment availability. The survey contained questions
Surgical education
regarding the program directors’ perception on importance on cost effectiveness of IPUS,
Ultrasound education
types of IPUS examinations performed, fellows experience with IPUS, challenges to training, and presence and methods of quality assurance (QA) programs. Results: A total of 38 (38.0%) program directors completed the survey. Using a 100-point Likert scale, the majority of the respondents indicated that IPUS is important to patient care in the SICU and is cost-effective (mean score 85.5 and 84.6, respectively). Most (34, 89.5%) utilize IPUS and conduct a mean of 5.1 different examination types with FAST being the most prevalent examination (33, 86.8%). Thirty-three (86.8%) programs include IPUS in their SCC training with varying amounts of time spent training. Of these programs, 19 (57.6%) have a specific curriculum. The most frequently used modalities for training fellows were informal bedside teaching (28, 84.8%), hands-on lectures (20, 60.6%) and formal lectures (19, 57.6%). The top three challenges program directors cited for IPUS education was time (23, 69.7%), followed by concerns for ongoing QA (19, 57.6%) and lack of faculty trained in IPUS (18, 53.9%). Only 20 (60.6%) programs review images as a part of QA/quality improvement.
* Corresponding author. Division of Acute Care Surgery, University of Florida College of Medicine-Jacksonville, 655 W. 8th Street, Jacksonville, FL 32209. Tel.: þ1 9042446631; fax: þ1 9042444687. E-mail addresses: [email protected], [email protected] (B.K. Yorkgitis). 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.06.040
yorkgitis et al ultrasound training in surgical critical care fellowships
293
Conclusions: Utilization and training of IPUS is common in SCC fellowships. There is varied education type and training time devoted to IPUS which could lead to gaps in knowledge and care. Development of a standard curriculum for SCC fellowships could assist surgical intensivists in achieving a base of knowledge in IPUS to create a more homogenously trained workforce and standards of care. ª 2017 Elsevier Inc. All rights reserved.
Introduction
Results
Point-of-care ultrasonography (US) is widely used because it is a noninvasive and cost-effective method to assist in the diagnosis and management of patients. In addition, it allows physicians to gain information in real time.1 It is particularly beneficial in intensive care units (ICUs), where it can be brought to bedside and prevent unnecessary movement of critically ill patients.2 Bedside examinations also allow for the care team to continually monitor the patient during the examination.3 With its ease of use, portable nature, and wide array of imaging possibilities, there has been considerable adoption of this technology.2 In 1998, the American College of Surgeons (ACSs) outlined US education recommendations for surgeons, noting that it was imperative that physicians are properly trained to use this technology so they can accurately diagnose and treat patients.4 However, although many studies have demonstrated the efficacy of training physicians in US, many have also found that training is widely variable across the United States, particularly among surgeons.5-8 In response to its widespread use, the Surgical Critical Care Program Directors Society has included General Critical Care Ultrasonography in its recommended training curriculum for surgical critical care fellows.9 However, it is unclear the extent to which the fellows are exposed to US and are trained in this modality. Through an Internetbased survey sent to surgical critical care fellowship program directors (PDs), we sought to identify the number of programs that provide instruction on intensivistperformed ultrasound (IPUS) as well as the methods of training, barriers to training, and time devoted to this education.
Thirty-eight (38.0%) completed surveys were available for analysis. 73% (n ¼ 28) programs were self-described as university hospitals. All but two training programs were at level I
Table 1 e Fellowship program characteristics (n [ 38). Hospital type
Number (%)
University
28 (73.7)
University affiliated
8 (21.1)
Community
2 (5.3)
Fellows per year 1
10 (26.3)
2
17 (44.7)
3
5 (13.2)
4
6 (15.8)
Trauma center designation Level I
36 (94.7)
Level II
2 (5.3)
Number of designated surgical critical care beds 0
3 (7.9)
1-10
1 (2.6)
11-20
13 (34.2)
21-30
11 (28.9)
31-40
1 (2.6)
>40
8 (21.1)
Used intensivist-performed ultrasound in the care of patients? Yes
33 (86.8)
No
5 (13.2)
Designated ultrasound machines for SICU
Materials and methods An institutional review board approved survey was developed and distributed via an electronic mail invitation to 100 surgical critical care PDs in the United States. Completion of the survey indicated consent. The instrument included questions about the training program, including size, faculty characteristics, location, length of training, primary hospital description, trauma center status, number of designated surgical critical care beds, and availability of US equipment. The survey also queried about PDs’ perception on importance and cost effectiveness of IPUS, types of IPUS examinations performed, fellow engagement and training in various IPUS examinations, challenges to training, and quality assurance (QA) program utilization and methods.
0
6 (15.8)
1
11 (28.9)
2
13 (34.2)
3
5 (13.2)
4
3 (7.9)
Number of fellowship faculty members 5
4 (10.5)
6-10
24 (63.2)
>10
10 (26.3)
Fellowship faculty disciples Surgery
38 (100)
Anesthesia
19 (50.0)
Emergency medicine/critical care
11 (28.9)
Pulmonary critical care
8 (21.1)
294
j o u r n a l o f s u r g i c a l r e s e a r c h o c t o b e r 2 0 1 7 ( 2 1 8 ) 2 9 2 e2 9 7
Fig. 1 e IPUS applications used (n [ 34). (Color version of figure is available online.)
trauma centers (n ¼ 36, 94.7%). Hospitals frequently had between 11-20 designated surgical critical care beds (13, 34.2%). The mean number of US machines designated for surgical critical care use was 1.76 (range 0-5). The mean number of fellows trained per year at each of the programs was 2.5 (range 0-12; Table 1.) The mode number of critical care attendings involved in fellow’s education were >10 (n ¼ 10, 38%). 63.2% (n ¼ 24) of respondents reported that their programs’ faculty included nonsurgical members. Anesthesia critical care physicians were the most common nonsurgical faculty members (n ¼ 19, 50.0%), followed by emergency medicineetrained critical care physicians (n ¼ 11, 28.9%), and last, pulmonary critical care physicians (n ¼ 8, 21.0%). There were four programs (10.5%) that did not have faculty that utilized or were credentialed in IPUS use, and two PDs (5.3%) were unsure if their program’s faculty used or were credentialed in US. The most commonly reported faculty training method in US was attending national conferences (n ¼ 26). The second most common method was local workshops (n ¼ 22), followed by fellowship training (n ¼ 13). Of note, 22 (57.9%) of PDs reported more than one modality as the method of faculty training. Of the completed surveys, 89.5% (n ¼ 34) programs used IPUS. On a scale of 0-100 rating the importance of IPUS (0 meaning not important, 100 critically important), PDs rated IPUS’s importance with a median score of 88 (range 51-100, IQR 20). The median rating PDs gave for cost effectiveness of IPUS was 91 (range 0-100, IQR 26). Half (n ¼ 19) of the PDs reported IPUS decreased the number of pulmonary artery catheters used in their ICUs, and 23.7% (n ¼ 9) were unsure if IPUS reduced pulmonary artery catheters. Among bedside US examinations performed, FAST was the most prevalent (33, 86.8%), followed by vascular access procedure guidance (32, 84.2%) and thorax examination (28, 73.7%) (Fig. 1). 86.8% (n ¼ 33) of PDs reported that ultrasound education is a component of their fellows’ education. Only 57.6% (n ¼ 19) programs offered a specific curriculum and/or formal lectures.
The most common training modality was informal bedside training (n ¼ 28, 84.8%; Fig. 2). Among programs that provided US education, training time varied greatly, with a range of 1.5 to 600 h. One PD reported an unknown amount of time (Table 2). The approximate number of examinations performed varied greatly from <50 to >150. Of the programs offering US education to their fellows, 15 (45.5%) PDs estimated fewer than 100 examinations and 17 (54.5%) PDs reported over 100 examinations per fellow during their training. When PDs were queried to discern the top three challenges for training fellows, 81 challenges were identified by 33 PDs offering US training. Lack of time for training (23, 28.4%), lack of ongoing QA (19, 23.4%), and lack of faculty trained in IPUS (18, 22.2%) were the top responses, respectively (Fig. 3). Conversely, five PDs (15.2%) reported no challenges in training. Of the 33 programs incorporating IPUS training in their fellowship, 13 PDs (39.4%) reported that they did not have a quality improvement (QI) and/or QA program. For programs with QI/QA initiatives (n ¼ 20), the most common methods
Fig. 2 e Instruction methods for fellow training in IPUS (n [ 34). Some programs use more than one method. (Color version of figure is available online.)
yorkgitis et al ultrasound training in surgical critical care fellowships
Table 2 e Fellows’ IPUS experience (n [ 38). Estimated examinations complete during training
Number (%)
0
5 (13.2)
<50
4 (10.5)
51-100
11 (28.9)
101-150
9 (23.7)
>150
8 (21.1)
Unknown
1 (2.6)
Estimated time completing IPUS training 0h
5 (13.2)
5 h
9 (23.7)
6-10 h
7 (18.4)
11-20 h
6 (15.8)
21-30 h
0 (0.0)
31-40 h
3 (7.9)
>40 h
7 (18.4)
Unknown
1 (2.6)
were reviewing electronically stored images (11, 55.0%) and capturing still images (7, 35.0%). Of note, three (9.1%) programs use more than one method for their QA/QI process.
Discussion Because of its effectiveness and convenience, US is a significant bedside tool for every surgical intensivist.3,8,10,11 As adoption of bedside US increases, surgical critical care (SCC) trainees will need to acquire the skills in its utilization and accurate interpretation of this tool.8 In addition, critical care societies have recommended competency in physician performed US.9,12-15 The Surgical Critical Care Program Directors Society has outlined training in US for fellowship trainees, including incorporating US in daily practice.9 Several authors have studied the minimum training based on professional societies’ recommendations needed in common US performed,
4
2
3 1 23
5 6
18
19
Time for training (23, 28.4%)
Ongoing quality assurance (19, 23.4%)
Lack of faculty trained in this modality (18, 22.2%)
Lack of equipment (6, 7.4%)
No difficules exist (5, 6.2%)
Lack of accuracy (4, 4.9%)
Fellows lack interest in training (2, 2.5%)
Faculty lack interest in training (3, 3.7%)
Fig. 3 e Top challenges to fellow training among programs teaching IPUS (n [ 33 PDs). 81 challenges were identified by PDs. (Color version of figure is available online.)
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which would likely exceed many of numbers reported by PDs in this survey.16-20 These include the ACS, Society of Critical Care Medicine, American College of Emergency Physicians, and American College of Chest Physicians. These groups have developed US training curricula. Many include minimum required examinations for review to standardize a competency level (Table 3).12-15,21,22 The required number of examinations for American College of Chest Physicians do not include those examinations during skill acquisition while the physician is beginning to use IPUS, only number needed to be submitted for review by the organization.13 Looking closely at the Society of Critical Care Medicine requirements, 140 examination interpretation with 90 examinations is personally performed for proficiency. This number excludes examinations done for procedural use, which were additional 30 examinations.14 Only eight (21.1%) programs come close to these recommendations, achieving greater than 150 examinations. Thus, there exists a significant gap between recommendations and training received. Many of the societies offer courses to instruct physicians on US. Thus, it is not surprising that attending one of these societies’ courses was the most common method of faculty training among survey respondents. However, these courses require participant funding and time away from the participants’ programs to complete. Furthermore, skills acquired at these courses need to be used at the participants’ home institution. Challenges for fellows may occur if faculty at their home institutions are not trained in US or do not have time to observe/review US performed by the fellows.23 This is particularly concerning because the lack of faculty training and lack of time to train fellows were the top two barriers listed to IPUS training of fellows. If we do not empower the future surgical intensivists in delivering IPUS, we will only propagate the challenge of faculty training in this important modality. There is a wide variability in time dedicated to training which could have serious implications for the accuracy of the IPUS performed by these fellows, especially if there are no QI/QA programs in place. Such variation is not infrequent; other US studies have previously demonstrated this among examination types and disciplines.18-20 With time being the most cited barrier to training, 13 (34.2%) PDs did not state that this was a challenge. Programs that developed methods to successfully allocate time for US training can act as a best-practices guides for other programs. Killu et al. studied a comprehensive US curriculum based on the American College of Emergency Physicians model with modifications to the ICU setting. They successfully integrated it into their fellowship.8 This work supports the feasibility of established professional society curriculumebased training encompassed during an SCC fellowship. As a part of any care delivery to patients, QA/QI processes need to be implemented to ensure quality of care, effective education, and to satisfy credentialing requirements.14 The lack of a QA/QI process was listed as the third most common challenge in delivering IPUS education to fellows. Less than two-thirds of the programs had a means of QA/QI for their trainees, making it difficult to determine if training is effective. As outlined by the ACS Ultrasound Examinations by Surgeons, critical care surgeons must adopt QA/QI methods for US to provide the highest quality of care for our patients and education for our peers and trainees.4
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j o u r n a l o f s u r g i c a l r e s e a r c h o c t o b e r 2 0 1 7 ( 2 1 8 ) 2 9 2 e2 9 7
Table 3 e Professional society required minimum reviewed examinations. ACCP*
Examination Total
21
Cardiac
ACEP
SCCM
25-50 quality reviewed examinations
50 examinations
150-300
10 examinations, five images per examination
140
Lung/pleura
Four examinations, three images per examination
25-50 quality reviewed examinations
30 examinations
Abdominal
Four examinations, four images per examination
25-50 quality reviewed examinations
30 examinations
Three examionations, eight images per examination
25-50 quality reviewed examinations
30 examinations
Vascular/DVT
ACCP ¼ American College of Chest Physicians; ACEP ¼ American College of Emergency Physicians; SCCM ¼ Society of Critical Care Medicine. * Number required for submission for expert review, does not include skill acquisition numbers.
We acknowledge the limitations of an Internet-based survey study. The response rate was 38%, leaving room for additional PDs to provide more data about the current landscape of IPUS training in fellowships. There may be participant bias in the survey, as PDs that have interest in US might have been more inclined to participate in the study. With a survey study, recall bias may play a role in the results.
Conclusions Multiple critical care societies have identified ICU US as integral to patient care. The results of this study show that it is a common modality taught to SCC fellows. However, this study found that there is a high degree of variability in the utilization, education, and quality review processes among SCC fellowships in the United States. This valuable tool requires adequate training and ongoing QI/QA to assure it is used in the most effective and safe manner. The current landscape of IPUS training among SCC fellowships found in this investigation indicates a need for education and quality measure standardization to enable future surgical intensivist readiness for its utilization at the bedside.
Acknowledgment Authors’ contributions: The research idea and development was the work of B.K.Y., E.A.B., G.A.B., R.A., and E.K. The survey tool was created and edited by B.K.Y., E.A.B., G.A.B., and E.K. The data were collected and reviewed by B.K.Y., E.A.B., and J.H.R. The manuscript was drafted and reviewed by B.K.Y., E.A.B., J.H.R., R.A., and E.K.
Disclosure All the authors declare no conflicts of interest to disclose.
references
1. Abu-Zidan FM. Point-of-care ultrasound in critically ill patients: where do we stand? J Emerg Trauma Shock. 2012;5:70e71. 2. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364:749e757.
3. Guillory RK, Gunter OL. Ultrasound in the surgical intensive care unit. Curr Opin Crit Care. 2008;14:415e422. 4. American College of Surgeons. Statement on ultrasound examinations by surgeons. Committee on emerging surgical technology and education, American College of surgeons. Bull Am Coll Surg. 1998;83:37e40. 5. Beggs AD, Thomas PRS. Point of use ultrasound by general surgeons: review of the literature and suggestions for future practice. Int J Surg. 2013;11:12e17. 6. Langlois SLP. Focused ultrasound training for clinicians. Crit Care Med. 2007;S35:S138eS143. 7. Society of American Gastrointestinal and Endoscopic Surgeons. Guidelines for granting ultrasound privileges for surgeons. Available at: https://www.sages.org/publications/ guidelines/guidelines-for-granting-of-ultrasonographyprivileges-for-surgeons/. Accessed May 30, 2017. 8. Killu K, Coba V, Mendez M, et al. Model point-of-care ultrasound curriculum in an intensive care Unit fellowship program and its Impact on patient management. Crit Care Res Pract. 2014;2014:934796. 9. Surgical Critical Care Program Directors Society. Surgical critical care training curriculum. Available at: http:// sccpds.org/wp-content/uploads/2013/01/TA_99_2_2010_ 06_07_ALAM_203917_SDC2a.pdf. Accessed May 30, 2017. 10. Royce CF, Canty DJ, Faris J, et al. Core review: physicianperformed ultrasound: the time has come for Routine Use in Acute care medicine. Anesth Analg. 2012;115:1007e1028. 11. Kameda T, Taniguchi N. Overview of point-of-care abdominal ultrasound in emergency and critical care. J Intensive Care. 2016;4:53. 12. Mandapakala C, Lee S. The role of critical care specialties in the certification and credentialing of bedside ultrasonography. Availabe at: http://www.sccm.org/ Communications/Critical-Connections/Archives/Pages/TheRole-of-Critical-Care-Specialty-Societies-in-the-Certificationand-Credentialing-of-Bedside-Ultrasonography.aspx. Accessed May 30, 2017. 13. American College of Chest Physicians. Critical care ultrasound. Available at: http://www.chestnet.org/Education/AdvancedClinical-Training/Certificate-of-Completion-Program/ Critical-Care-Ultrasonography. Accessed May 30, 2017. 14. Official Statement of the Society of Critical Care Medicine. Recommendations for achieving and maintaining competence and credentialing in critical Care ultrasound with focused cardiac ultrasound and advanced critical care echocardiography. Available at: http://journals.lww.com/ ccmjournal/Documents/Critical%20Care%20Ultrasound.pdf. Accessed May 30, 2017. 15. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Socie´te´ de Re´animation de langue Franc¸aise. Chest. 2009;135:1050e1060. 16. Chisholm CB, Dodge WR, Balise RR, et al. Focused cardiac ultrasound in training: how much is enough? J Emerg Med. 2013;44:818e822.
yorkgitis et al ultrasound training in surgical critical care fellowships
17. Jang T, Aubin C, Naunheim R. Minimum training for Right Upper Quadrant ultrasonography. Am J Emerg Med. 2004;22:439e443. 18. Ahern M, Mallin MP, Weitzel S, et al. Variability in ultrasound education among emergency medicine Residencies. West J Emerg Med. 2010;11:314e318. 19. Kim DJ, Theoret J, Liao MM, et al. The current state of ultrasound training in Canadian emergency medicine programs: perspectives from program directors. Acad Emerg Med. 2012;19:1073e1078. 20. Mosier JM, Malo J, Stolz LA, et al. Critical care ultrasound training: a survey of US fellowship directors. J Crit Care. 2014;29:645e649.
297
21. American College of Surgeons. National Ultrasound Faculty. Available at: https://www.facs.org/education/accreditation/ verification/ultrasound/exported. Accessed May 30, 2017. 22. American College of Emergency Physicians. Ultrasound guidelines: emergency, point-of-care and clinical guidelines in medicine. 2016. Available at: https://www.acep.org/Clinical– Practice-Management/Ultrasound/. Accessed May 30, 2017. 23. Eisen LA, Leung S, Gallagher AE, Kvetan V. Barriers to ultrasound training in critical care medicine fellowships: a survey of program directors. Crit Care Med. 2010;38:1978e1983.