Core Content for Pediatric Emergency Medicine Ultrasound Fellowship Training: A Modified Delphi Consensus Study

National survey of diagnostic point of care ultrasound practices and program development in academic neonatal-perinatal medicine centers

OBJECTIVE

To assess diagnostic point of care ultrasound (POCUS) use, presence of programmatic infrastructural elements, and barriers to implementation across neonatal perinatal medicine (NPM) programs in the United States.

STUDY DESIGN

Cross-sectional study. An online survey was distributed to leaders in education or POCUS at ACGME-accredited NPM fellowship programs. National trends were outlined using descriptive statistics and compared by program size.

RESULT

79 of 99 (80%) NPM programs responded. Diagnostic POCUS was available at 71% (n = 56) of sites that responded. Key infrastructural elements were present at <45% of sites, with fellow training being the exception (71%). Many barriers to diagnostic POCUS program implementation were identified and they differed by program size.

CONCLUSION

Diagnostic POCUS is being increasingly adopted despite underdeveloped programmatic infrastructure. Identified barriers suggest a need for collaborative efforts to support the necessary infrastructural elements, and differences by program size suggest a need for tailored approaches for successful integration.

Characterizing Point-of-Care Ultrasound Credentialing in Pediatric Emergency Departments

OBJECTIVE

It is unclear which pediatric emergency departments (PEDs) have a point-of-care ultrasound (POCUS) credentialing process or if this process is consistent per expert guidelines. Our objective was to describe formalized POCUS credentialing processes across PEDs that are active in the pediatric emergency medicine POCUS (P2) Network.

METHODS

A survey was developed from nationally recommended credentialing guidelines. This anonymous survey was sent out to the P2 Network comprising more than 230 members involved in pediatric POCUS. The survey was analyzed using descriptive analysis with counts and percentages.

RESULTS

A total of 36 PEDs responded to the survey. All departments had a faculty member in charge of maintaining the credentialing process, and all faculty members had POCUS education available; 88.6% of education was scheduled didactics or bedside teaching. There were 80.6% of PEDs that had a process for internally credentialing faculty. Some PEDs offered protected education for POCUS, however, 44.8% had <50% of their faculty credentialed. There were 4 PEDs that offered incentives for completion of POCUS credentialing including salary bonuses; only 1 offered shift buy down as incentive. That PED had 100% of its faculty credentialed. All PEDs performed quality assurance on POCUS scans done in the ED, most done weekly. Billing for scans occurred in 26 PEDs. Skin/soft tissue and focused assessment with sonography for trauma were the 2 most common applications credentialed.

CONCLUSIONS

Among PEDs surveyed, there was a lack of standardization of POCUS resources and components of credentialing. Incentives may be beneficial in improving credentialing faculty and standardizing the credentialing process.

A shared point of care ultrasound curriculum for graduate medical education

BACKGROUND

Point of care ultrasound (POCUS) education has grown significantly over the past two decades. Like most curricular items, POCUS education is siloed within individual graduate medical education (GME) programs. The purpose of this study was to evaluate the effectiveness of a shared GME POCUS curriculum between five GME programs at a single institution.

METHODS

Post-graduate-year-1 (PGY-1) residents from emergency medicine (EM), family medicine (FM), internal medicine (IM), combined internal medicine-pediatrics (IM-Peds) and combined emergency medicine-pediatrics (EM-Peds) residency programs were enrolled in a core POCUS curriculum. The curriculum included eleven asynchronous online learning modules and ten hands-on training sessions proctored by sonographers and faculty physicians with POCUS expertise. Data was gathered about the curriculum's effectiveness including participation, pre- and post-curricular surveys, pre- and post-knowledge assessments, and an objective skills assessment.

RESULTS

Of the 85 residents enrolled, 61 (72%) participated in the curriculum. Engagement varied between programs, with attendance at hands-on sessions varying the most (EM 100%, EM-Peds 100%, FM 40%, IM 22%, Med-Peds 11%). Pre- and post-knowledge assessment scores improved for all components of the curriculum. Participants felt significantly more confident with image acquisition, anatomy recognition, interpreting images and incorporating POCUS findings into clinical practice (p < 0.001) after completing the curriculum.

CONCLUSION

In this shared GME POCUS curriculum, we found significant improvement in POCUS knowledge, attitudes, and psychomotor skills. This shared approach may be a viable way for other institutions to provide POCUS education broadly to their GME programs.

Point-of-Care-Ultrasound in Pediatrics: A Review and Update

Point-of-Care-Ultrasound (POCUS) has encountered a tremendous expansion in patient care. POCUS has taken a central role during invasive procedures. POCUS has expanded to most subspecialties from adult to pediatric and neonatal health care. POCUS in pediatrics has also become part of specific critical situations such as myocardial function assessment during cardiac arrest, extracorporeal membrane oxygenation deployment and neurological evaluation. In this review we will go over the most important historical aspects of POCUS. We will also review important aspects of POCUS in the intensive care unit, cardiologist evaluation and in the emergency department among others.

Building Consensus on the Point-of-Care Ultrasound Skills Required for Effective Healthcare Service Delivery at District Hospitals in South Africa: A Delphi Study

BACKGROUND

Despite the widespread availability of ultrasound machines in South African district hospitals, there are no guidelines on the competency in point-of-care ultrasound (POCUS) use required by generalist doctors in this setting. This study aimed to define the required POCUS competencies by means of consensus via the Delphi method.

METHODS

An online Delphi process was initiated in June 2022, using the existing American Academy of Family Physicians' ultrasound curriculum (84 skillsets) as the starting questionnaire. Panelists were selected across the country, including two from district hospitals in each province and two from each academic family medicine department in South Africa (N = 36). In each iterative round, the participants were asked to identify which POCUS skillsets were essential, optional (region-specific), or non-essential for South African district hospitals. This process continued until consensus (>70% agreement) was achieved on all of the skillsets.

RESULTS

Consensus was achieved on 81 of the 84 skillsets after 5 iterative rounds (96.4%), with 3 skillsets that could not achieve consensus (defined as <5% change over more than 2 consecutive rounds). The final consensus identified 38 essential, 28 optional, and 15 non-essential POCUS skillsets for the South African district hospital context.

CONCLUSIONS

The list of essential POCUS skillsets provided by this study highlights the predominance of obstetric- and trauma-based skillsets required for generalist healthcare workers in South African district hospitals. The findings will require priority setting and revalidation prior to their implementation across the country.

Educator's blueprint: A primer on consensus methods in medical education research

Consensus methods such as the Delphi and nominal group techniques are increasingly utilized within medical education research. This educator's blueprint paper provides practical strategies regarding five key steps for ensuring best practices when using consensus methods. These strategies include deciding which consensus method is best, developing the initial questionnaire, identifying the participants, determining the number of rounds and consensus threshold, and describing and justifying any modifications. These strategies will help guide education researchers on their next study using consensus methods.

Recommendations for Cardiac Point-of-Care Ultrasound in Children: A Report from the American Society of Echocardiography

Cardiac point-of-care ultrasound has the potential to improve patient care, but its application to children requires consideration of anatomic and physiologic differences from adult populations, and corresponding technical aspects of performance. This document is the product of an American Society of Echocardiography task force composed of representatives from pediatric cardiology, pediatric critical care medicine, pediatric emergency medicine, pediatric anesthesiology, and others, assembled to provide expert guidance. This diverse group aimed to identify common considerations across disciplines to guide evolution of indications, and to identify common requirements and infrastructure necessary for optimal performance, training, and quality assurance in the practice of cardiac point-of-care ultrasound in children. The recommendations presented are intended to facilitate collaboration among subspecialties and with pediatric echocardiography laboratories by identifying key considerations regarding (1) indications, (2) imaging recommendations, (3) training and competency assessment, and (4) quality assurance.

Establishing the international research priorities for pediatric emergency medicine point-of-care ultrasound: A modified Delphi study

BACKGROUND

The Pediatric Emergency Medicine (PEM) Point-of-care Ultrasound (POCUS) Network (P2Network) was established in 2014 to provide a platform for international collaboration among experts, including multicenter research. The objective of this study was to use expert consensus to identify and prioritize PEM POCUS topics, to inform future collaborative multicenter research.

METHODS

Online surveys were administered in a two-stage, modified Delphi study. A steering committee of 16 PEM POCUS experts was identified within the P2Network, with representation from the United States, Canada, Italy, and Australia. We solicited the participation of international PEM POCUS experts through professional society mailing lists, research networks, social media, and "word of mouth." After each round, responses were refined by the steering committee before being reissued to participants to determine the ranking of all the research questions based on means and to identify the high-level consensus topics. The final stage was a modified Hanlon process of prioritization round (HPP), which emphasized relevance, impact, and feasibility.

RESULTS

Fifty-four eligible participants (16.6%) provided 191 items to Survey 1 (Round 1). These were refined and consolidated into 52 research questions by the steering committee. These were issued for rating in Survey 2 (Round 2), which had 45 participants. At the completion of Round 2, all questions were ranked with six research questions reaching high-level consensus. Thirty-one research questions with mean ratings above neutral were selected for the HPP round. Highly ranked topics included clinical applications of POCUS to evaluate and manage children with shock, cardiac arrest, thoracoabdominal trauma, suspected cardiac failure, atraumatic limp, and intussusception.

CONCLUSIONS

This consensus study has established a research agenda to inform future international multicenter PEM POCUS trials. This study has highlighted the ongoing need for high-quality evidence for PEM POCUS applications to guide clinical practice.

Creation of a novel course for the advanced emergency medicine ultrasound focused practice designation examination

Introduction

The American Board of Emergency Medicine recently established a new certification pathway in advanced emergency medicine ultrasound (AEMUS). Eligible applicants come from a wide range of experience but must pass the same examination to become certified. This study sought to evaluate a novel review course targeting a wide range of learners for a new examination.

Methods

This was a cross-sectional study evaluating the outcomes of the American College of Emergency Physicians (ACEP) AEMUS review course. The program evaluation survey was designed to collect outcomes across multiple Kirkpatrick levels, including overall satisfaction, topic-specific satisfaction, topic-specific coverage, topic-specific confidence before and after the course, topic-specific perceived knowledge before and after the course, and changes in practice.

Results

Seventy-four of 79 participants (93.7%) completed the survey. Mean course satisfaction was 4.59/5.00 (95% CI 4.47-4.72). Confidence to pass examination components increased for the following topics: administration, advanced left ventricle (LV), education, head and neck, hepatobiliary, male genitourinary, musculoskeletal, nonobstetric gynecology, pediatrics, physics, procedures, research, right ventricle, and venous/arterial. Perceived knowledge increased for the following topics: administration, advanced LV, education, head and neck, male genitourinary, musculoskeletal, pediatrics, physics, procedures, renal/bladder, research, right ventricle, and venous/arterial. Fifty-three of 74 participants (71.6%) stated they would change their practice based on the course. Examples of changes in practice include increased use of ultrasound for advanced abdominal, musculoskeletal, pediatric, and procedural applications. Future work will determine the impact on longer-term outcomes and focused practice designation (FPD) examination pass rates.

Conclusion

The ACEP AEMUS FPD review course demonstrated high levels of satisfaction, increased participant confidence, increased perceived knowledge, and several self-reported changes in participants' ultrasound practice.

Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception

OBJECTIVES

The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers.

METHODS

We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared.

RESULTS

Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci.

CONCLUSIONS

Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.

Protocol for a Delphi Consensus Study to Determine the Essential and Optional Ultrasound Skills for Medical Practitioners Working in District Hospitals in South Africa

With increasing access to point of care ultrasound (POCUS) at district hospitals in South Africa, there is a lack of standardisation of skillsets among medical practitioners working at this level of care. This study protocol aims to use the Delphi process to achieve expert consensus on the essential and optional ultrasound skills required for medical practitioners working in district hospitals in South Africa. In alignment with the Delphi method, several iterative rounds will be implemented from June to November 2022. Purposive sampling will be conducted, through the recruitment of two representatives from each academic department of family medicine and two medical doctors working in district hospitals in each province in the country (N = 36). The POCUS skillsets published by the American Academy of Family Physicians will be circulated in the first iterative round, following which participants may suggest further additions. Once a consensus target of 70% has been achieved, the Delphi process will be finalised. The Delphi process and data analysis will be facilitated by an online Delphi platform. Findings from the study will provide insight into the design of the curriculum for POCUS training for medical practitioners in district hospitals and registrars in family medicine departments across the country.

The P2Network-Advancing Pediatric Emergency Care With Point-of-Care Ultrasound

ABSTRACT

Over the last 2 decades, the use of point-of-care ultrasound (POCUS) in pediatric emergency medicine (PEM) has grown exponentially. In 2014, a group of PEM POCUS leaders met and formed the P2Network. The P2Network provides a platform to build collaborative relationships and share expertise among members from various countries and practice settings. It works with educators and researchers within and outside of the field to advance POCUS practice in PEM. As an organization, the P2Network promotes the evidence-based application of POCUS to facilitate and improve care in the PEM setting and addresses issues related to integration of the PEM POCUS practitioner in this nascent field. The P2Network is building and augmenting its infrastructure for PEM POCUS research and education and has already made some progress in the areas, with published manuscripts and ongoing clinical research studies under its sponsorship. Future goals include developing a PEM POCUS research agenda, formalizing teaching and assessment of PEM POCUS skills, and implementing multicenter research studies on potentially high impact applications.

Agreement With Pediatric Suprapatellar Bursa Effusion Assessments by Point-of-Care Ultrasound After Remote Training

BACKGROUND

The ease of instruction for point-of-care ultrasound (POCUS) to detect suprapatellar bursa (SPB) effusions in pediatric patients is unknown. Considering in person limitations because of the coronavirus pandemic, strategies for POCUS education by remote learning are necessary.

METHODS

We crafted a 90-minute didactic training that was presented via a remote learning format. The main outcome of interest was the interobserver reliability of SPB effusion assessment by novice sonologists compared with POCUS faculty. Novice sonologists were pediatric emergency medicine (PEM) fellows. Pediatric emergency medicine fellows interpreted longitudinal SPB examinations obtained in our pediatric emergency department from July 2013 to June 2020. Assessments were performed 2 months after the remote training. Pediatric emergency medicine fellows had a limited experience performing these musculoskeletal scans and were blinded to POCUS faculty and each other's assessments. Interobserver reliability was assessed with Cohen κ coefficient. Second, we calculated test characteristics of knee radiography compared with PEM POCUS faculty determination of SPB effusion by ultrasound. We further explored how effusion size measured by POCUS impacted the diagnosis by knee radiography. A receiver operator characteristic curve of knee radiography diagnosis of SPB effusion was created using the maximal height of SPB effusion by POCUS as the predictor variable.

RESULTS

A total of 116 SPB scans in 71 patients were assessed. From this group, 70 scans were of affected knees and 46 scans were of contralateral, asymptomatic knees. The mean age of patients was 10 years and 46% were girl. The prevalence of SPB effusions was 42%. The κ coefficients between the 3 novice sonologists and POCUS faculty were 0.75 (0.62-0.87), 0.77 (0.65-0.89), and 0.83 (0.72-0.93) with 88%, 89%, and 91% agreement. Knee radiography exhibited an overall sensitivity of 65% (95% confidence interval [CI], 46-79%), specificity of 84% (95% CI, 60-97%), negative predictive value of 55% (95% CI, 43-66%), and positive predictive value of 88% (95% CI, 73-96%) to diagnose SPB effusions. The area under the receiver operator characteristic curve was 0.850. With an SPB height cutoff of 4 mm as true positives, radiography had a sensitivity of 81% and a specificity of 83%.

CONCLUSIONS

After a remote teleconference didactic session, PEM fellows were able to successfully diagnose SPB effusions using a longitudinal view with substantial interobserver reliability. Knee radiography exhibited limited sensitivity to rule out SPB effusions.

Development of Core Contents of Point-of-Care Ultrasound Curriculum for Pediatric Emergency Medicine Physician Training: A Modified Delphi Survey

BACKGROUND

As the frequency of ultrasound use in pediatric emergency departments increases, it is necessary to train pediatric emergency medicine (PEM) physicians on pediatric point-of-care ultrasonography (POCUS). We discussed the core content of POCUS applications and proposed a POCUS training curriculum for PEM physicians in South Korea.

METHODS

Twenty-three experts were included if had performed over 1500 POCUS scans, had at least three years of experience teaching POCUS to physicians, were POCUS instructors or had completed a certified pediatric POCUS program. Experts rated 61 possible POCUS applications in terms of the importance of their inclusion in a PEM POCUS curriculum using the modified Delphi technique.

RESULTS

In round one, twelve (52.2%) out of 23 experts responded to the email. Eleven experts satisfied the inclusion criteria. Eleven experts participated in round one of a survey and agreed on 27 (44.3%) out of a total of 61 items. In round two, all 11 experts participated in the survey; they agreed on two (5.9%) of the remaining 34 items, and no items were excluded.

CONCLUSION

Using the Delphi method, 61 applications were discussed, and a consensus was reached on 29 core applications.

Diagnostic Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound has become an essential part of pediatric emergency medicine training and practice. It can have significant clinical benefits, including improving diagnostic accuracy and decreasing length of stay, and does not require radiation exposure for patients. In this review, we summarize the current diagnostic point-of-care ultrasound applications in pediatric emergency medicine, their evidence, and techniques.

Evaluating a longitudinal point-of-care-ultrasound (POCUS) curriculum for pediatric residents

BACKGROUND

POCUS is a growing field in medical education, and an imaging modality ideal for children given the lack of ionizing radiation, ease of use, and good tolerability. A 2019 literature review revealed that no US pediatric residency programs integrated obligatory POCUS curricula. Our objective was to provide a formalized POCUS curriculum over multiple years, and to retrospectively assess improvement in resident skills and comfort.

METHODS

During intern year, pediatric residents received didactics and hands-on scanning opportunities in basic POCUS applications. Their evaluation tools included pre- and post-surveys and tests, and a final performance exam. In the second and third years of residency, all participants were required to complete 8 hours per year of POCUS content review and additional hands-on training. An optional third-year curriculum was offered to interested residents as career-focused education elective time.

RESULTS

Our curriculum introduced POCUS topics such as basic and advanced cardiac, lung, skin/soft tissues and procedural based ultrasound to all pediatric residents. Among first-year residents, application-specific results showed POCUS comfort level improved by 61-90%. Completed evaluations demonstrated improvement in their ability to recognize and interpret POCUS images. Second- and third-year residents reported educational effectiveness that was rated 3.9 on a 4-point Likert scale. Four third-year residents took part in the optional POCUS elective, and all reported a change in their practice with increased POCUS incorporation.

CONCLUSIONS

Our longitudinal pediatric residency POCUS curriculum is feasible to integrate into residency training and exhibits early success.