Using Simulation Models to Train Clinicians in the Use of Point-of-care Ultrasound
Summary
The present protocol describes an ideal solution to train novices in the use of point-of-care ultrasound devices for the practical clinical skill of visually assessing distinct individual anatomical vascular conditions prior to and during an intended venous vascular cannulation using point-of-care ultrasound in a patient.
Abstract
The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide critical elements of visual and measurable information that proves to be useful in the context of vascular access cannulation, in combination with the practical skill of the clinician performing the cannulation. However, the use of POCUS in this context is to practically train and enable individuals who are novices in using this technique to become proficient in performing this task subsequently on patients in a careful and successful way. The simulation of these vascular conditions may be useful to help healthcare professionals learn, understand, apply, and establish such practical skills for vascular cannulation safely to achieve the desired outcomes. This project intended, through the attendance of a half-day workshop, to establish skills to use POCUS in connection with simulation models and perform specific tasks to enable clinicians to use this method in their clinical practice for vascular access cannulation in patients. A mixed-methods longitudinal study design was used to evaluate the effect of a point-of-care ultrasound workshop for peripheral intravenous cannula insertion, including specific tasks for the participants to be performed on simulation models. A total of 81 individuals participated in 11 half-day workshops through 2021 and 2022. Offering a workshop that uses simulation models in combination with various POCUS devices is useful in establishing this newly learned skill in clinicians, such as measurements of depth, caliper, and direction of a vein with POCUS prior to cannulation providing essential anatomical facts to the operator, which increases the likelihood of first-time success in cannulation.
Introduction
Most patients being admitted to acute hospitals receive at least one peripheral intravenous catheter (PIVC), with the purpose of withdrawing blood, administration of fluids and/or medication, and for diagnostic purposes1. It is common that first-attempt insertions fail, and it has been reported that up to 50% of hospitalized patients have difficult intravenous access (DIVA)2. To alleviate this, the use of ultrasound-guided PIVC insertion (USGPIVC) has been demonstrated to improve insertion success rates, and training and practical education have been recommended for multiple healthcare professions3,4,5. Point-of-care ultrasound (POCUS) at the bedside is nowadays more frequently used to gain vascular access. POCUS has also been described as a useful tool for augmenting the teaching and learning of physical examination6. While several studies have described that training in USGPIVC is likely to enhance the skills of clinicians7,8,9,10, it has not yet been described in detail which specific elements of this training are the essential components to achieve the desired outcomes when applying POCUS for USGPIVC. To achieve this, a combined POCUS and USGPIVC training curriculum was developed covering the essential aspects of the training, which were considered as being the elemental aspects and learning objectives for USGPIVC workshops, including the theoretical background and practical hands-on aspects.
Training novices in the use of POCUS prior to and during vascular access cannulation requires an ideal simulation environment to enable effective learning success which replicates similar anatomical conditions as in a human anatomical environment11. Therefore, simulation models created from chicken breast and fluid-filled modeling balloons were found to be ideal and can be used to generate such a simulation model12. This approach teaches the learner the observational skill of assessing vascular conditions at an individual patient level first in a safe, simulated environment, which helps in the overall decision-making process of choosing the required cannula length, assessment of the vascular depth and width, and vessel direction for an individual patient. This allows for a critical assessment of any future patient's individual anatomical conditions, where a clinician may want to subsequently decide if the planned cannulation is likely to be successful or not. To obtain this information, POCUS-obtained images, when they are interpreted correctly, usually provide reliable and critical elements of information, which, in addition to the clinicians' experience and manual dexterity, are likely to lead to cannulation success.
In the second step, the learner is taught, in this simulative environment, the development of manual dexterity for using the ultrasound probe simultaneously with the manual skill of inserting a cannula, under vision, observing the POCUS screen and the insertion site, into the simulated blood vessel. This observational skill of constantly visualizing the simulated vessel and meticulously observing the needle tip during the insertion process is the most important aspect of the overall learning goal of this simulation activity until the needle tip is ultimately placed in the anatomical area of interest, in this case in the center of a simulated vessel. This process is crucial to avoid unintended and unnecessary vessel injury, tissue, bleeding, or extravasation, as this technique is intended to be subsequently used in a patient in clinical settings by the participant.
Some authors have previously recommended implementing and integrating ultrasound into the medical school curriculum, using low-cost simulation models and small teaching groups13. Others have recommended developing structured training programs followed by a hands-on session in a simulated environment14. It has also been described that the use of ultrasound helps with procedural success and may reduce risks for patients15. Others have observed that using POCUS and USGPIVC to train clinicians in the emergency department (ED) has increased the use of this approach in the short term. Still, there may also exist a lack of consistency in formalized education programs for vascular access7,16,17. In contrast, others have described that formalized vascular access training leads to improved adherence to best practices for PIVC insertion11.
The aim of this educational approach was to simulate a comparable visual and dexterity experience for learners so that they could replicate and apply this skill in a clinical setting and on patients in the future. An observational longitudinal mixed methods study approach was chosen, and electronic surveys were used to assess the confidence level of workshop participants using ultrasound (POCUS) in connection with peripheral venous cannulation. The surveys were first used in simulation models and subsequently used in the clinical specialty of workshop participants in admitted patients.
The workshop was divided into three parts. First, participants were introduced to some basic principles and theories of using ultrasound in the space of vascular access cannulation in an interactive learning environment. In a second approach, the workshop facilitator demonstrated the vascular access assessment approach using a simulator with a simulated artificial vessel created, demonstrating the observation of vessel depth, size, and direction through transverse and longitudinal view and observation using POCUS. This was followed by a demonstrated cannulation using POCUS and the simulator through the workshop facilitator, as participants were then invited to practice this task themselves on their individual simulators. At the workshop conclusion, participants were individually assessed on their skill of identifying and measuring vessel size, depth, and direction using transverse and longitudinal views in the simulator, followed by ultrasound-guided cannulation of the simulated vessel. After the workshop attendance, participants were invited to rate their confidence skills in using USPIVC in an electronic survey. At 8 weeks after the workshop attendance, participants were again invited to respond in an electronic survey if they had applied this adopted skill in their individual clinical setting.
Protocol
Representative Results
Discussion
Vascular access cannulation of difficult venous conditions requires experience, manual dexterity, and continuous observation of the progress of the needle tip position while the cannula is advanced through human tissue into the intravascular space18. While the use of ultrasound has become more prevalent in the use in patients with difficult venous access2, it is also necessary that junior clinicians and novices become familiar with the use of ultrasound in connection with i…
Disclosures
The authors have nothing to disclose.
Acknowledgements
The author would like to thank Dr. James Rippey, Sonologist at Sir Charles Gairdner Hospital, Nedlands, Western Australia, for guidance and instructions on how to create the used simulation model in the experiment. This project did not receive any institutional financial support.
Materials
| BD Insyte Autogard BC Pro shielded IV catheter with blood control technology (PIVC) | BD | 318054 | |
| Catheter tipped syringe 30 or 50 ml | BD Plastipak | 301229, 300865 | |
| Celeste Nitrile Powder Free Examination gloves sizes S/M/L (non-sterile) | Celeste | CLS121 | |
| Goliath Cling wrap | Goliath | ||
| modelling balloons 260 Q | Qualatex | 99321 | |
| Point-of care ultrasound device, eg. Philips Lumify or Vscan Air | Philips or GE Healthcare | https://www.usa.philips.com/healthcare/product/HC989605450382/lumify-c5-2-curved-array-transducer | |
| probe cover for Philips lumify | Philips | https://www.usa.philips.com/healthcare/product/HC989605450382/lumify-c5-2-curved-array-transducer | |
| raw chicken breast | |||
| Sunsonic Ultrasound Transmission Gel 250 ml | Sunsonic | LG250 | |
| Tasty Herbal Infusion Rosehip Tea | Tasty | ||
| Victorinox Fibrox Chef's Knife 20 cm | Victorinox | 40520 |
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