Simulator-based ultrasound training for identification of endotracheal tube placement in a neonatal intensive care unit using point of care ultrasound

Khushboo Qaim Ali, Sajid Bashir Soofi, Ali Shabbir Hussain, Uzair Ansari, Shaun Morris, Mark Oliver Tessaro, Shabina Ariff, Hasan Merali, Khushboo Qaim Ali, Sajid Bashir Soofi, Ali Shabbir Hussain, Uzair Ansari, Shaun Morris, Mark Oliver Tessaro, Shabina Ariff, Hasan Merali

Abstract

Background: Simulators are an extensively utilized teaching tool in clinical settings. Simulation enables learners to practice and improve their skills in a safe and controlled environment before using these skills on patients. We evaluated the effect of a training session utilizing a novel intubation ultrasound simulator on the accuracy of provider detection of tracheal versus esophageal neonatal endotracheal tube (ETT) placement using point-of-care ultrasound (POCUS). We also investigated whether the time to POCUS image interpretation decreased with repeated simulator attempts.

Methods: Sixty neonatal health care providers participated in a three-hour simulator-based training session in the neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH), Karachi, Pakistan. Participants included neonatologists, neonatal fellows, pediatric residents and senior nursing staff. The training utilized a novel low-cost simulator made with gelatin, water and psyllium fiber. Training consisted of a didactic session, practice with the simulator, and practice with intubated NICU patients. At the end of training, participants underwent an objective structured assessment of technical skills (OSATS) and ten rounds of simulator-based testing of their ability to use POCUS to differentiate between simulated tracheal and esophageal intubations.

Results: The majority of the participants in the training had an average of 7.0 years (SD 4.9) of clinical experience. After controlling for gender, profession, years of practice and POCUS knowledge, linear mixed model and mixed effects logistic regression demonstrated marginal improvement in POCUS interpretation over repeated simulator testing. The mean time-to-interpretation decreased from 24.7 (SD 20.3) seconds for test 1 to 10.1 (SD 4.5) seconds for Test 10, p < 0.001. There was an average reduction of 1.3 s (β = - 1.3; 95% CI: - 1.66 to - 1.0) in time-to-interpretation with repeated simulator testing after adjusting for the covariates listed above.

Conclusion: We found a three-hour simulator-based training session had a significant impact on technical skills and performance of neonatal health care providers in identification of ETT position using POCUS. Further research is needed to examine whether these skills are transferable to intubated newborns in various health settings.

Trial registration: ClinicalTrials.gov Identifier: NCT03533218 . Registered May 2018.

Keywords: Endotracheal tube; Neonates; Point of care ultrasound; Resuscitation; Simulation; Ultrasound training.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Low cost ultrasound simulator. a The beef gelatin and psyllium fiber block, with cut-off 10 mL syringe. b Syringe barrel being used to create 2 lm within the block. The plug created within the syringe by passage of the syringe through the block is then expelled from the syringe by depressing the plunger – one such plug is displayed next to the now empty syringe. c The white arrow indicates the simulated trachea, while the black arrow indicates the simulated esophagus. d The completed simulator, with a plug partially inserted into the simulated esophagus. When the plug is fully inserted, the simulator produces the sonographic appearance of a tracheal intubation. When the plug is removed, the simulator produces the sonographic appearance of an esophageal intubation
Fig. 2
Fig. 2
Ultrasound images on the Simulator model Tracheal Intubation. a Static ultrasound image of a patient with the ETT in the trachea, with linear ultrasound probe held in transverse orientation over the anterior neck at the level of the sternal notch. b & c Static ultrasound images of beef gelatine model with plug inserted into simulated esophagus, simulating the ultrasound appearance of a tracheal intubation
Fig. 3
Fig. 3
Ultrasound images on the model: Esophageal Intubation. a Static ultrasound image of an esophageal intubation in a patient, with linear ultrasound probe held in transverse orientation over the anterior neck at the level of the sternal notch. b & c Static ultrasound images of beef gelatin model with plug removed from simulated esophagus, simulating the ultrasound appearance of an esophageal intubation
Fig. 4
Fig. 4
Aggregate correct identification and interpretation of simulator ETT position with each test
Fig. 5
Fig. 5
Time-to-interpretation (in seconds) with 95% CIs

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