Pre-clinical medical student cardiac point-of-care ultrasound curriculum based on the American Society of Echocardiography recommendations: a pilot and feasibility study

Satoshi Jujo, Jannet J Lee-Jayaram, Brandan I Sakka, Atsushi Nakahira, Akihisa Kataoka, Masaki Izumo, Kenya Kusunose, Natsinee Athinartrattanapong, Sayaka Oikawa, Benjamin W Berg, Satoshi Jujo, Jannet J Lee-Jayaram, Brandan I Sakka, Atsushi Nakahira, Akihisa Kataoka, Masaki Izumo, Kenya Kusunose, Natsinee Athinartrattanapong, Sayaka Oikawa, Benjamin W Berg

Abstract

Background: Cardiac point-of-care ultrasound (POCUS) training has been integrated into medical school curricula. However, there is no standardized cardiac POCUS training method for medical students. To address this issue, the American Society of Echocardiography (ASE) proposed a framework for medical student cardiac POCUS training. The objective of this pilot study was to develop a medical student cardiac POCUS curriculum with test scoring systems and test the curriculum feasibility for a future definitive study.

Methods: Based on the ASE-recommended framework, we developed a cardiac POCUS curriculum consisting of a pre-training online module and hands-on training with a hand-held ultrasound (Butterfly iQ, Butterfly Network Inc., Guilford, CT, USA). The curriculum learning effects were assessed with a 10-point maximum skill test and a 40-point maximum knowledge test at pre-, immediate post-, and 8-week post-training. To determine the curriculum feasibility, we planned to recruit 6 pre-clinical medical students. We semi-quantitatively evaluated the curriculum feasibility in terms of recruitment rate, follow-up rate 8 weeks after training, instructional design of the curriculum, the effect size (ES) of the test score improvements, and participant satisfaction. To gather validity evidence of the skill test, interrater and test-retest reliability of 3 blinded raters were assessed.

Results: Six pre-clinical medical students participated in the curriculum. The recruitment rate was 100% (6/6 students) and the follow-up rate 8 weeks after training was 100% (6/6). ESs of skill and knowledge test score differences between pre- and immediate post-, and between pre- and 8-week post-training were large. The students reported high satisfaction with the curriculum. Both interrater and test-retest reliability of the skill test were excellent.

Conclusions: This pilot study confirmed the curriculum design as feasible with instructional design modifications including the hands-on training group size, content of the cardiac POCUS lecture, hands-on teaching instructions, and hand-held ultrasound usage. Based on the pilot study findings, we plan to conduct the definitive study with the primary outcome of long-term skill retention 8 weeks after initial training. The definitive study has been registered in ClinicalTrials.gov (Identifier: NCT04083924).

Keywords: Curriculum development; Echocardiography; Handheld ultrasound; Medical education; Medical student; POCUS; Point-of-care ultrasound.

Conflict of interest statement

The authors report no conflicts of interest.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Cardiac point-of-care ultrasound curriculum timeline. POCUS, point-of-care ultrasound; ASE, American Society of Echocardiography
Fig. 2
Fig. 2
Excellent quality reference (A) and examples of acceptable (B) and poor quality (C) images of 5 cardiac POCUS views. Legend: Excellent quality reference images (A) refer to 5 cardiac POCUS views obtained by the cardiologist (MI) on the healthy volunteer (SJ) used for all skill tests. Examples of acceptable (B) and poor quality (C) images refer to the 5 views obtained by medical students on the volunteer. The excellent quality reference image (A) of the PLAX demonstrates all 7 structures (LA, LV, LVOT, RV, AV, MV, and IVS); the PSAX demonstrates all 4 structures (round LV, RV, papillary muscles, and IVS); the A4C demonstrates all 8 structures (LA, LV, RA, RV, MV, TV, IAS, and IVS); the S4C demonstrates all 7 structures (LA, LV, RA, RV, IAS, IVS, and liver); and the SIVC visualizes the IVC in a longitudinal fashion, the clear connection of IVC to RA, and the IVC diameter ≥ 1.0 cm at 2 cm from RA-IVC junction. The acceptable quality image (B) of the PLAX does not visualize AV; the PSAX is the mitral level of parasternal long-axis view, not the papillary muscle level; the A4C demonstrates a severely foreshortened LV; the S4C misses the LA and adds the aortic outflow (5-chamber view); and the SIVC does not visualize a clear connection of IVC to RA. The poor quality image (C) of the PLAX does not visualize the AV and the LV is severely foreshortened; the PSAX does not demonstrate a round LV and misses the papillary muscles; the A4C demonstrates a severely foreshortened LV and misses the LA; the S4C misses the RV and does not visualize the LA and the LV well; the SIVC demonstrates the descending aorta instead of the IVC. POCUS, point-of-care ultrasound; PLAX, parasternal long-axis view; PSAX, papillary muscle level of parasternal short-axis view; A4C, apical 4-chamber view; S4C, subcostal 4-chamber view; SIVC, subcostal inferior vena cava view; LA, left atrium; LV, left ventricle; LVOT, left ventricle outflow tract; RV, right ventricle; AV, aortic valve; MV, mitral valve; IVS, interventricular septum; RA, right atrium; TV, tricuspid valve; IAS, interatrial septum; IVC, inferior vena cava
Fig. 3
Fig. 3
Individual skill (A) and knowledge (B) test scores

References

    1. Smith A, Parsons M, Renouf T, Boyd S, Rogers P. A mixed-methods evaluation of a multidisciplinary point of care ultrasound program. Med Teach. 2019;41(2):223–228. doi: 10.1080/0142159X.2018.1461202.
    1. Schnobrich DJ, Mathews BK, Trappey BE, Muthyala BK, Olson APJ. Entrusting internal medicine residents to use point of care ultrasound: Towards improved assessment and supervision. Med Teach. 2018;40(11):1130–1135. doi: 10.1080/0142159X.2018.1457210.
    1. Kirkpatrick JN, Grimm R, Johri AM, Kimura BJ, Kort S, Labovitz AJ, et al. Recommendations for echocardiography laboratories participating in cardiac point of care cardiac ultrasound (POCUS) and critical care echocardiography training: report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2020;33:409-422.e4.
    1. Via G, Hussain A, Wells M, Reardon R, ElBarbary M, Noble VE, et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014;27:683.e1-683.e33.
    1. Breitkreutz R, Price S, Steiger HV, Seeger FH, Ilper H, Ackermann H, Rudolph M, Uddin S, Weigand MA, Müller E, Walcher F, Emergency Ultrasound Working Group of the Johann Wolfgang Goethe-University Hospital, Frankfurt am Main Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. 2010;81(11):1527–1533. doi: 10.1016/j.resuscitation.2010.07.013.
    1. Seetharam K, Kagiyama N, Sengupta PP. Application of mobile health, telemedicine and artificial intelligence to echocardiography. Echo Res Pract. 2019;6(2):R41–R52. doi: 10.1530/ERP-18-0081.
    1. European Society of Radiology. ESR statement on portable ultrasound devices. Insights Imaging. 2019;10:89.
    1. Steinmetz P, Dobrescu O, Oleskevich S, Lewis J. Bedside ultrasound education in Canadian medical schools: a national survey. Can Med Educ J. 2016;7(1):e78–e86. doi: 10.36834/cmej.36646.
    1. Wakefield RJ, Weerasinghe A, Tung P, Smith L, Pickering J, Msimanga T, Arora M, Flood K, Gupta P, Bickerdike S, McLaughlan J, Uttley A, Wilson J, Evans T, Wolstenhulme S, Roberts TE. The development of a pragmatic, clinically driven ultrasound curriculum in a UK medical school. Med Teach. 2018;40(6):600–606. doi: 10.1080/0142159X.2018.1439579.
    1. Cawthorn TR, Nickel C, O’Reilly M, Kafka H, Tam JW, Jackson LC, et al. Development and evaluation of methodologies for teaching focused cardiac ultrasound skills to medical students. J Am Soc Echocardiogr. 2014;27(3):302–309. doi: 10.1016/j.echo.2013.12.006.
    1. Stokke TM, Ruddox V, Sarvari SI, Otterstad JE, Aune E, Edvardsen T. Brief group training of medical students in focused cardiac ultrasound may improve diagnostic accuracy of physical examination. J Am Soc Echocardiogr. 2014;27(11):1238–1246. doi: 10.1016/j.echo.2014.08.001.
    1. Sambi R, Sawula H, Wolfrom B, Newbigging J. Pilot project: does formal bedside training of medical students with a FAST exam increase their knowledge and comfort level with ultrasound use in a community family medicine practice setting? POCUS J. 2017;2(2):15–17. doi: 10.24908/pocus.v2i2.13279.
    1. Kusunose K, Yamada H, Suzukawa R, Hirata Y, Yamao M, Ise T, Yagi S, Akaike M, Sata M. Effects of transthoracic echocardiographic simulator training on performance and satisfaction in medical students. J Am Soc Echocardiogr. 2016;29(4):375–377. doi: 10.1016/j.echo.2015.12.002.
    1. Chaptal M, Tendron L, Claret P-G, Muller L, Markarian T, Mattatia L, Roger C, de la Coussaye JE, Pelaccia T, Bobbia X. Focused cardiac ultrasound: a prospective randomized study of simulator-based training. J Am Soc Echocardiogr. 2020;33(3):404–406. doi: 10.1016/j.echo.2019.10.010.
    1. Johri AM, Durbin J, Newbigging J, Tanzola R, Chow R, De S, et al. Cardiac point-of-care ultrasound: state-of-the-art in medical school education. J Am Soc Echocardiogr. 2018;31(7):749–760. doi: 10.1016/j.echo.2018.01.014.
    1. Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, Lancaster GA. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. BMJ. 2016;355:i5239. doi: 10.1136/bmj.i5239.
    1. Lancaster GA, Thabane L. Guidelines for reporting non-randomised pilot and feasibility studies. Pilot feasibility Stud. 2019;5(1):114. doi: 10.1186/s40814-019-0499-1.
    1. Thabane L, Ma J, Chu R, Cheng J, Ismaila A, Rios LP, Robson R, Thabane M, Giangregorio L, Goldsmith CH. A tutorial on pilot studies: the what, why and how. BMC Med Res Methodol. 2010;10(1):1. doi: 10.1186/1471-2288-10-1.
    1. Graham CR. Blended learning systems: definition, current trends, and future directions. In: Bonk CJ, Graham CR, editors. The handbook of blended learning: global perspectives, local designs. San Francisco: Pfeiffer Publishing; 2006. pp. 3–21.
    1. Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Med Teach. 2013;35(10):e1511–e1530. doi: 10.3109/0142159X.2013.818632.
    1. Fisher J, Viscusi R, Ratesic A, Johnstone C, Kelley R, Tegethoff AM, Bates J, Situ-Lacasse EH, Adamas-Rappaport WJ, Amini R. Clinical skills temporal degradation assessment in undergraduate medical education. J Adv Med Educ Prof. 2018;6(1):1–5.
    1. Rappaport CA, McConomy BC, Arnold NR, Vose AT, Schmidt GA, Nassar B. A prospective analysis of motor and cognitive skill retention in novice learners of point of care ultrasound. Crit Care Med. 2019;47(12):e948–e952. doi: 10.1097/CCM.0000000000004002.
    1. Neskovic AN, Skinner H, Price S, Via G, De Hert S, Stankovic I, et al. Focus cardiac ultrasound core curriculum and core syllabus of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2018;19(5):475–481. doi: 10.1093/ehjci/jey006.
    1. Breitkreutz R, Uddin S, Steiger H, Ilper H, Steche M, Walcher F, et al. Focused echocardiography entry level: new concept of a 1-day training course. Minerva Anestesiol. 2009;75:285–292.
    1. Edrich T, Seethala RR, Olenchock BA, Mizuguchi AK, Rivero JM, Beutler SS, Fox JA, Liu X, Frendl G. Providing initial transthoracic echocardiography training for anesthesiologists: simulator training is not inferior to live training. J Cardiothorac Vasc Anesth. 2014;28(1):49–53. doi: 10.1053/j.jvca.2013.07.011.
    1. Mitchell C, Rahko PS, Blauwet LA, Canaday B, Finstuen JA, Foster MC, Horton K, Ogunyankin KO, Palma RA, Velazquez EJ. Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2019;32(1):1–64. doi: 10.1016/j.echo.2018.06.004.
    1. Soni NJ, Arntfield R, Pierre K. Point-of-care ultrasound. 1. Philadelphia: Saunders; 2014.
    1. Butterfly Network Inc. Butterfly iQ User manual. 2019. . Accessed 20 Jul 2021.
    1. Julious SA. Sample size of 12 per group rule of thumb for a pilot study. Pharm Stat. 2005;4(4):287–291. doi: 10.1002/pst.185.
    1. Cohen J. Statistical power analysis for the behavioral sciences. 2. Hillsdale, NJ: Lawrence Erlbaum; 1988.
    1. Faraone SV. Interpreting estimates of treatment effects: implications for managed care. P T. 2008;33(12):700–711.
    1. Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15(2):155–163. doi: 10.1016/j.jcm.2016.02.012.
    1. Cho Y, Je S, Yoon YS, Roh HR, Chang C, Kang H, Lim T. The effect of peer-group size on the delivery of feedback in basic life support refresher training: a cluster randomized controlled trial. BMC Med Educ. 2016;16(1):167. doi: 10.1186/s12909-016-0682-5.
    1. Pringle RK. Guidance hypothesis with verbal feedback in learning a palpation skill. J Manipulative Physiol Ther. 2004;27(1):36–42. doi: 10.1016/j.jmpt.2003.11.004.
    1. Chung HS, Dieckmann P, Issenberg SB. It is time to consider cultural differences in debriefing. Simul Healthc. 2013;8(3):166–170. doi: 10.1097/SIH.0b013e318291d9ef.
    1. AHA. Guidelines BLS ILT Course FAQ. 2015:2015 . .
    1. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and t. J Am Soc Echocardiogr. 2010;23(7):685–713. doi: 10.1016/j.echo.2010.05.010.
    1. Eignor, D. R. The standards for educational and psychological testing. In: K. F. Geisinger, B. A. Bracken, J. F. Carlson, J.-I. C. Hansen, N. R. Kuncel, S. P. Reise, & M. C. Rodriguez editors, APA handbook of testing and assessment in psychology, Vol. 1. Test theory and testing and assessment in industrial and organizational psychology; 2013. p. 245–50. American Psychological Association., 2013
    1. Cheng A, Nadkarni VM, Mancini MB, Hunt EA, Sinz EH, Merchant RM, Donoghue A, Duff JP, Eppich W, Auerbach M, Bigham BL, Blewer AL, Chan PS, Bhanji F, American Heart Association Education Science Investigators; and on behalf of the American Heart Association Education Science and Programs Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research Resuscitation education science: educational strategies to improve outcomes from cardiac arrest: a scientific statement from the American Heart Association. Circulation. 2018;138(6):e82–122. doi: 10.1161/CIR.0000000000000583.
    1. Messick S. Validity. In: Linn R, editor. Educational measurement. 3. New York: American Council on Education and Macmillan; 1989. pp. 13–104.
    1. Cook DA, Hatala R. Validation of educational assessments: a primer for simulation and beyond. Adv Simul (London, England). 2016;1:31.
    1. Padilla JL, Benítez I. Validity evidence based on response processes. Psicothema. 2014;26:136–144.
    1. Kumar A, Barman N, Lurie J, He H, Goldman M, McCullough SA. Development of a point-of-care cardiovascular ultrasound program for preclinical medical students. J Am Soc Echocardiogr. 2018;31:1064-1066.e2.
    1. Wilkinson JS, Barake W, Smith C, Thakrar A, Johri AM. Limitations of condensed teaching strategies to develop hand-held cardiac ultrasonography skills in internal medicine residents. Can J Cardiol. 2016;32(8):1034–1037. doi: 10.1016/j.cjca.2015.10.008.
    1. Andersen GN, Viset A, Mjølstad OC, Salvesen O, Dalen H, Haugen BO. Feasibility and accuracy of point-of-care pocket-size ultrasonography performed by medical students. BMC Med Educ. 2014;14(1):156. doi: 10.1186/1472-6920-14-156.
    1. Ho AMH, Critchley LAH, Leung JYC, Kan PKY, Au SS, Ng SK, Chan SKC, Lam PKN, Choi GYS, Wai JKM, Lee APW, Chan SO. Introducing final-year medical students to pocket-sized ultrasound imaging: teaching transthoracic echocardiography on a 2-week anesthesia rotation. Teach Learn Med. 2015;27(3):307–313. doi: 10.1080/10401334.2015.1044657.
    1. Nelson BP, Hojsak J, Dei Rossi E, Karani R, Narula J. Seeing is believing: evaluating a point-of-care ultrasound curriculum for 1st-year medical students. Teach Learn Med. 2017;29(1):85–92. doi: 10.1080/10401334.2016.1172012.
    1. Kobal SL, Lior Y, Ben-Sasson A, Liel-Cohen N, Galante O, Fuchs L. The feasibility and efficacy of implementing a focused cardiac ultrasound course into a medical school curriculum. BMC Med Educ. 2017;17(1):94. doi: 10.1186/s12909-017-0928-x.
    1. Neelankavil J, Howard-Quijano K, Hsieh TC, Ramsingh D, Scovotti JC, Chua JH, Ho JK, Mahajan A. Transthoracic echocardiography simulation is an efficient method to train anesthesiologists in basic transthoracic echocardiography skills. Anesth Analg. 2012;115(5):1042–1051. doi: 10.1213/ANE.0b013e318265408f.
    1. Fuchs L, Gilad D, Mizrakli Y, Sadeh R, Galante O, Kobal S. Self-learning of point-of-care cardiac ultrasound - Can medical students teach themselves? PLoS One. 2018;13(9):e0204087. doi: 10.1371/journal.pone.0204087.
    1. Yao G, Hong TP, Lee P, Newbigging J, Wolfrom B. Point-of-care ultrasound training for family medicine residents: examining the outcomes and feasibility of a pilot ultrasound curriculum. POCUS J. 2019;4(2):22–26. doi: 10.24908/pocus.v4i2.13692.
    1. Bashir K, Aftab A, Farook KS, Anjum S, Pathan S, Bhutta Z, et al. Research: emergency medicine residents’ acquisition of point-of-care ultrasound knowledge and their satisfaction with the flipped classroom andragogy. POCUS J. 2018;3(1):2–5. doi: 10.24908/pocus.v3i1.13301.

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