Implementation of point of care ultrasound curriculum in pediatric intensive care unit

Abstract

Background : Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into bedside decision making is underway. The established benefits of point-of-care ultrasound have given rise to multiple new and innovative curriculums to incorporate ultrasound teaching into medical education and quality improvement initiative. Methods : This study was done in a 24 bedded tertiary PICU in Bangalore with availability of a portable ultrasound machine in the unit. We integrated a curriculum consisting of traditional didactics combined with hands-on sessions given to the fellows over a period of 4 weeks. Following this, the PICU fellows implemented the POC ultrasound curriculum into their daily practice in managing ICU patients, under supervision from ICU staff physicians, who were instructors in POC ultrasound. They were required to fill a proforma which asked them to document the reason for the use of POCUS, their findings and the decision made based on the findings for each system examined, namely, Cardiovascular (CVS) and Hemodynamics, Lung and Abdomen. The images of the POCUS scans were stored and reviewed by experts consisting of senior PICU physicians and Radiologists every week where the proforma along with images were examined and evaluated for their quality of images, correlation of findings and justification for decisions on a weekly basis. The improvement in skill level of fellows based on the evidence of quality of images, their interpretation and decisions and also the impact on patient care including finding a new diagnosis or change in patient management was reviewed over a period of 2 months after training. Results : Fifty POC ultrasound studies were done in the 2 months period and were reviewed for analysis. The most common exams performed were CVS and hemodynamic assessment (32) followed by lung/pleural exams (15) and abdominal exams (3). The examination supported the clinical assessment in 80 % (40/50) of instances. It changed the management. It led to a significant change of management in 20% (10/50) of the cases. In CVS and Hemodynamic assessment, the major use was for determining fluid responsiveness (22/32) followed by need of optimizing inotropy (9/32) and pericardial drainage (1/32). In Lung/Pleura assessment, determining the area of the lung involved and differentiating atelectasis and consolidation was the most common use (9/15) which led to change in position (proning/lateral position) followed by documenting the residual fluid in the pleural cavity (4/15) and identifying pneumothorax (2/15). Abdominal scan was done only in cases of trauma to look for fluid collection. As a quality training initiative, on evaluation we also found that the quality of images improved during the period of study with experience of the fellows and also their interpretation of the US findings were correct. Conclusion : Implementation of POC ultrasound in the ICU with a structured fellowship curriculum is feasible and may successfully equip fellows with a fundamental understanding of ultrasound physics, anatomy, and disease recognition. The periodic evaluation of the findings by experts helps maintain the quality of the curriculum. In our study, it resulted in change of management in 1/5th of the cases.