Assessing the Efficacy of Simulation-Based Education for Paramedics in Extended Focused Assessment with Sonography for Trauma under Physician Guidance

doi:10.21203/rs.3.rs-3403386/v1

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Assessing the Efficacy of Simulation-Based Education for Paramedics in Extended Focused Assessment with Sonography for Trauma under Physician Guidance

https://doi.org/10.21203/rs.3.rs-3403386/v1

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published 20 Feb, 2024

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We investigated the effectiveness of simulation-based education in Focused Assessment with Sonography for Trauma (FAST) to increase the number of Emergency Medical Technicians (EMTs) capable of performing ultrasound examinations in vehicles under the guidance of a physician.

Twenty-eight paramedics watched a 14-minute video on the features of the ultrasound system, its use, and the scanning method for each part of the body. Each participant performed four FAST examinations using a portable ultrasound device, and the task performance was rated using the Task Specific Checklist (TSC) and Global Rating Scale (GRS). The time required for visualizing each examination site and each FAST was assessed.

The primary outcome, time required for each test, significantly decreased with repeated testing (p < 0.001). The secondary outcome, time to complete FAST for each site was significantly shortened for the pericardial cavity, right thoracic cavity, Morrison pouch, and left thoracic cavity. TSC and GRS scores were elevated, and all EMTs could obtain valid images.

The combination of a brief video lecture and hands-on training significantly reduced the time required for FAST performance. Moreover, repeated practice enabled the EMTs to efficiently obtain accurate and clinically useful images.

Health sciences/Health care/Medical imaging/Ultrasonography

Health sciences/Health care

Health sciences/Health care/Health policy

simulation-based education

ultrasound

paramedics

FAST

With technological advances, ultrasound systems have become more compact and portable, enabling their use at the bedside, particularly in emergency situations. Ultrasonography can detect free abdominal fluid with a sensitivity of 90–95% and a specificity of 90–100% (1, 2).

In recent years, point-of-care ultrasonography (POCUS), a type of ultrasonography that can be performed at the bedside by medical personnel to improve clinical decisions and techniques, has gained global acceptance (3). Prehospital POCUS was defined in 2011 as one of the top five research priorities in prehospital clinical care provided by physicians. The utility of prehospital POCUS is currently being demonstrated and is considered feasible (4). A study demonstrated that emergency medical technicians and paramedics performed chest ultrasound examinations on patients in prehospital clinical settings with image quality adequate to determine the presence or absence of lesions (5)

Notably, the utility of Focused Assessment with Sonography for Trauma (FAST), an initial trauma assessment in prehospital emergencies has been widely demonstrated. Specifically, it has been associated with shorter times to surgery, fewer computed tomography studies, shorter hospital stays, fewer complications, and lower costs than those with other assessments (6). Real-time wireless transmission provides reliable images without compromising image quality or legibility compared to digitally recorded images at the inspection site (7) However, it is believed that extensive training through a combination of theoretical learning, hands-on training, and clinical experience is needed to develop expertise in POCUS (4).

In some areas of Japan, transporting a patient to an emergency medical center may require up to an hour, and the situation is even more difficult in severe cases. A demonstration is underway for the regulatory reform to promote legal revision of paramedic practice as a solution to poor medical care in mountainous regions with a declining birthrate and aging population(8) During emergency transport, paramedics perform examinations and procedures in the doctor's car and capture information regarding the patient using onboard cameras. These data are transmitted remotely and in real-time to the doctor at the destination, who verifies the technical effectiveness of the system.

Implementing the aforementioned processes will enable physicians to make diagnostic inferences and prepare for medical treatment and surgical procedures at the receiving institution. Moreover, it will allow EMTs to safely perform specific procedures, which may lead to the prompt provision of medical care upon arrival at the hospital. Ultrasound examinations by EMTs are not currently permitted in Japan; a high-quality educational program is required to implement this service. In addition, only a few reports on ultrasound examinations by EMTs exist globally (9–12)

In this study, we investigated the effectiveness of simulation education in FAST examinations by paramedics under the guidance of a physician.

Twenty-eight EMTs participated. The participants comprised 27 men and one woman (mean age, 40.5 ± 5.9 years; mean length of service, 10.1 ± 5.5 years) (Table 1). Four emergency physicians and four obstetricians/gynecologists provided guidance.

Table 1

Baseline characteristics of the 28 participants
Eligibility (n = 28)
Participants Age				40.5 ± 5.9
Years of continuous service of EMT				10.1 ± 5.5
Male				27 (96%)
Data are expressed as number (percentage) or mean ± standard deviation values. EMT, Emergency Medical Technician

The mean time required for the first to the fourth FAST was 144.6 ± 51.4, 103.9 ± 25.7, 113.6 ± 53.1, and 90.5 ± 31.0 s, respectively. (Fig. 1). Upon repeating the process, we observed significant reductions in time between the first and second tests and between the first and fourth tests. The time required for FAST was significantly shortened by repeating the procedure (p = 0.014, 0.003) (Table 2).

Table 2

Examination by number of measurements
Number of measurements		Z score	p-value
1st	2nd	−3.041	0.014
1st	3rd	−1.993	0.277
1st	4th	−3.497	0.003
2nd	3rd	−0.337	4.418
2nd	4th	−2.268	0.140
3rd	4th	−1.919	0.330

The time required to visualize each of the six FAST test areas was also compared between the first and the fourth examinations (Table 3). Significant time reductions were observed for pericardial cavity (33.4 ± 23.1/15.3 ± 10.6 s; p = 0.009), right thoracic cavity (25.2 ± 11.8/12.1 ± 8.3 s; p = 0.027), Morrison fossa (19.1 ± 10.8/10.8 ± 6.3 s; p = 0.014), and left thoracic cavity (19.0 ± 8.3/15.6 ± 8.3 s; p = 0.014) examinations. Multiple regression analysis of reductions in FAST time and site examination time showed that the reduction in time of examination for all sites was significantly related to the reduction in FAST time (Table 4).

Table 3

Inspection time by site
	Ⅰ	Ⅱ	Ⅲ	Ⅳ	Ⅴ	Ⅵ
	Pericardial space	Right thoracic cavity	Morrison pouch	Left thoracic cavity	Perisplenic area	Douglas pouch
1st trial	33.4 ± 23.1	25.2 ± 11.8	19.1 ± 10.8	19.0 ± 8.3	21.5 ± 11.8	26.2 ± 14.8
4th trial	15.3 ± 10.6	12.1 ± 8.3	10.8 ± 6.3	15.6 ± 8.3	13.5 ± 9.6	23.1 ± 14.4
p	0.009	0.027	0.014	0.036	0.088	2.630
Inspection time (seconds) is expressed as mean ± standard deviation.

Table 4

**Multiple regression analysis of FAST time reduction and site examination time reduction**
Reduction time	B	β	p-value	95% CI
Pericardial space (Ⅰ)	0.997	0.406	0.000	0.985	1.009
Right thoracic cavity (Ⅱ)	1.009	0.248	0.000	0.989	1.03
Morrison pouch (Ⅲ)	0.994	0.23	0.000	0.976	1.013
Left thoracic cavity (Ⅳ)	1.014	0.191	0.000	0.992	1.036
Perisplenic area (Ⅴ)	0.998	0.244	0.000	0.977	1.019
Douglas pouch (Ⅵ)	1	0.322	0.000	0.987	1.014
CI, confidence interval; FAST, Focused Assessment with Sonography for Trauma

The achievement and quality aspects of the FAST procedures performed by the 28 paramedics were evaluated using the TSC and GRS, respectively. TSC and GRS scores were evaluated for the first and fourth sessions (Figs. 2 and 3). TSC scores for the first and fourth sessions were 9.2 ± 4.0 and 13.5 ± 2.1, respectively, indicating that the fourth session was significantly more successful than the first session (p = 0.000). GRS scores for the first and fourth ultrasound sessions were 21.8 ± 2.2 and 35.5 ± 1.8, respectively, indicating that the fourth ultrasound examination was also superior in quality.

In this study, the total time required for FAST was approximately 1.5 minutes, which was approximately 30 s shorter than that described in existing reports (10). By repeating the process several times, the time required for FAST was reduced to approximately 90 s. The training should cover several aspects, such as the identification of patients who should undergo rapid and simplified ultrasonography, probe application, examination of patients based on their medical conditions, and basic interpretation of images. Moreover, direct instruction by a medical professional and a hands-on training course on the actual probe application are recommended (12). In the present study, the physician provided direct instructions after explaining how to apply the probe and basic interpretation of the images on video.

As for the instruction time, since only FAST was performed as the ultrasound examination, it was considered that the training time should be short. Reportedly, training provided to EMTs on echocardiography and pulmonary echocardiography could be completed in 1–4 h(9, 10, 11, 13). In addition, the training can be conducted with the cooperation of other personnel while on duty. Based on our assessment, clinical training at a medical institution may not be necessary. In this study, approximately two hours of training was considered acceptable.

The examination can be performed during transportation and does not lead to an extension of the transportation time. However, it is suggested that measurement should be performed while the vehicle is stopped, which may increase the time by approximately 2 min(12). Still, reports from other countries do not typically consider transportation times of 1 h as a standard (14) and in mountainous areas such as ours, further investigations are necessary.

The usefulness of FAST in prehospital emergency care has been widely demonstrated. Reportedly, prehospital emergency ultrasound findings led to a change in treatment in 49 of 99 patients (49.5%; 38.7% in the trauma group and 54.4% in the non-trauma group) (15) In other studies, ultrasound examination resulted in changes in transport destination, transport priority, and monitoring requirements (e.g., no need for physician accompaniment) in 33 of 99 patients (16/31 trauma patients and 17/68 non-trauma patients) (6, 16, 17).

Regarding the examination sites, reductions in the imaging times for the pericardial cavity, right thoracic cavity, Morrison pouch, and left thoracic cavity had influenced the shortening of FAST completion times. However, it is unclear whether the shorter examination times for the pericardial cavity are attributed to the improved proficiency in applying the difficult ultrasound technique (owing to repeated use) or to the time taken to familiarize with the technique since it was the first area to be examined. Similarly, whether the reason for the short examination times for the right thoracic cavity, Morrison pouch, and left thoracic cavity was that these right thoracic cavity areas were also examined during the first half of the examination period as in the case of the pericardial cavity, thus getting sufficient time to be familiarized with the technique, is not clear. In the future, it is necessary to establish an educational program, implement the technique in moving ambulances, develop a simple transmission system, and address economic aspects.

The study had some limitations. This was a single-center study. The results cannot be generalized, and care must be taken to ensure that EMTs across the country acquire training on uniform FAST techniques. Moreover, repeated instructions may be necessary to achieve a certain level of skills. There might have been differences in the method and duration of FAST among the four groups based on their years of experience, their teaching by emergency physicians/obstetricians, and their teaching/evaluation methods. Furthermore, as ultrasound devices by various manufacturers were used, discrepancies in the examination procedures might have occurred depending on the equipment used. Moreover, the ultrasonography simulator used in this study only provides normal findings, so further studies are required to learn to detect abnormal findings. This was only a simulation study, and further study is needed to determine the effects of the actual ambulance environment, states of the examination sites, constrained conditions, and internet connection conditions.

This study showed that short video lectures and practical training using an ultrasound simulator under physician guidance significantly reduced the time required by EMTs to perform FAST. In particular, the time required to visualize the pericardial and right thoracic cavities was considered to influence the overall reduction in the time required to perform FAST. Moreover, accurate images that could be utilized by physicians were obtained through repeated procedures. The time required for the FAST examination was comparable to that reported previously, suggesting that information could be collected in a short time during long transport periods. Based on the results of this study, we aim to continue investigating these issues and work towards rendering ultrasound examinations by paramedics under remote physician guidance possible during transport.

Study population

All procedures were conducted in accordance with the ethical standards of the Declaration of Helsinki. This prospective study was approved by the Research Ethics Committee of Okayama University School of Medicine (protocol #2306-015), which waived the need for obtaining informed consent from each participant. This research falls under the category of "research that does not use samples obtained from the human body" under the Ethical Guidelines. However, if informed consent is not obtained, the researcher will notify the research participants or disclose information about the research, including the purpose of use of the information used in the research, and will ensure that the research participants have the opportunity to refuse the implementation or continuation of the research. The research participants are guaranteed the opportunity to reject the research. For this purpose, the documents approved by the Committee for this research are posted on the hospital's website.

Paramedics who volunteered for the simulation education participated in the training. The paramedics did not have any prior training in FAST. Japanese paramedics with up to 25 years of work experience, no previous ultrasound experience, and no physical limitations in performing ultrasound examinations were included in the study.

Practical guidance for FAST was provided by an emergency physician or obstetrician/gynecologist with expertise in ultrasound examinations.

Intervention

A 2-h hands-on training session was held at our hospital in December 2022.

At the beginning of the session, a 14-minute video regarding the principles, features, and usage of ultrasonography equipment, as well as demonstrating how to operate the equipment and interpret ultrasound images, was presented. In addition, the participants were briefed regarding FAST, the six anatomical areas to be assessed during FAST, and how these areas appear on ultrasound images (Figs. 4 and 5).

Subsequently, the participants were divided into four groups of seven. Under the guidance of a physician, the EMTs underwent practical training in FAST using portable ultrasonography equipment to identify the presence of fluid accumulation in the (Ⅰ) pericardial cavity, (Ⅱ) right thoracic cavity, (Ⅲ) Morrison pouch, (Ⅳ) left thoracic cavity, (Ⅴ) perisplenic region, (Ⅵ) Douglas pouch, and other sites (Fig. 6). Four FAST procedures were performed by each participant, and the time required for each procedure at each examination site was measured. The proficiency of FAST was evaluated by two physicians using a Task-Specific Checklist (TSC) (Fig. 7). The quality assurance of FAST was evaluated by two physicians using the Global Rating Scale (GRS) (Table 5)(18) The TSC provides a binary measure of performing various components of a complicated task (scores: ‘‘1’’ for task accomplishment; ‘‘0’’ for task failure). In the present study, “the space between the right liver and the thoracic cavity can be clearly delineated” was added to the list of 25 items in total—this item was deemed necessary to evaluate right pleural effusion. By contrast, the GRS measures the quality of task performance on a five-point scale.

Table 5

**Global Rating Scale**
Skin contact
1	2	3	4	5
Insufficient amount of gel used, inadequate skin contact of probe		Appropriate amounts of gel are used, and in most cases, adequate skin contact is achieved		Always use the appropriate amount of gel to achieve adequate skin contact
Image Adjustment
1	2	3	4	5
Improper gain or depth settings		Gain and depth are properly adjusted but may need to be adjusted many times during the procedure		Adjust gain and depth to appropriate levels only once at the beginning of each section
Initial probe placement
1	2	3	4	5
Frequent readjustment of the probe position on the skin or only an inadequate field of view is obtained		Can correctly position probe for proper field of view, but needs occasional readjustment		With minimal readjustment, the probe can be correctly positioned to obtain the proper view on the first try
Image sweep
1	2	3	4	5
After the measurement position is fixed, keep changing the position		Once the probe position is established, the movement is almost smooth		After the probe position is established, the probe moves subtly in a smooth sweep
Positioning and probe handling
1	2	3	4	5
Repeatedly assume awkward positions or hold probes in an inconvenient or inappropriate manner		Occasionally, they may assume awkward positions or hold the probe in an inappropriate manner		Assume a comfortable position and hold the probe in an appropriate manner
Execution time (less than 2 minutes should be considered average)
1	2	3	4	5
Excessive time required to complete the test		Finish the exam in an average amount of time		Finish the exam fast enough to get a passing score
Flow of the procedure (is it done according to the procedure)
1	2	3	4	5
There are many jumps between anatomical areas that are consistently unorganized		Mostly organized, but occasionally jumps between anatomical areas		Move smoothly from area to area to complete the procedure
System of government
1	2	3	4	5
Cannot complete the exam without significant guidance		Able to work accurately with moderate guidance		Able to work independently without direction
Overall Performance
1	2	3	4	5
Unacceptable performance, multiple critical deficiencies	Unacceptable performance, some serious defects	Unacceptable performance, minor deficiencies only	Acceptable performance	Outstanding performance, expert FAST performers

The ultrasound equipment used in this study was a Vscan Air™ CL (GE HealthCare Japan Co., Ltd., Tokyo, Japan) with a 2–5-MHz convex probe (SonoAlpha handheld echo c5lc; Taisho Biomed Instruments Co., Ltd., Osaka, Japan), a 3.5–5-MHz convex probe (Lumify; Philips Japan Co., Ltd., Tokyo, Japan), and a 2–5-MHz convex probe (iViz air Ver.5; FUJIFILM Medical Co., Ltd., Tokyo, Japan). The ultrasonography simulator used was FAST/ER FAN (KYOYO KAGAKU Co., Ltd., Kyoto, Japan).

Outcomes

The primary outcome was the time required for FAST. Four FAST procedures were performed, and the mean measurement time was calculated. The measurement started when the participant placed the ultrasound probe on the simulator until the probe was released from the simulator after the ultrasound of the Douglas fossa was performed. Secondary outcomes were the measurement time for each of the six examination sites, the TSC score, and the GRS score.

Statistical analyses

T-tests, one-way analysis of variance, Wilcoxon’s signed rank tests modified by Bonferroni’s method, and multiple regression analysis were performed. A p-value < 0.05 was considered statistically significant. The analysis was performed using Excel statistics (BellCurve for Excel statistical software program; Social Survey Research Information Co., Ltd., Tokyo, Japan) and SPSS version 26.0 (IBM Co., Ltd., Tokyo, Japan).

Ethics approval and consent to participate: This prospective study was approved by the Research Ethics Committee of Okayama University Medical Department (protocol number: 2306-015), which waived the requirement for obtaining informed consent from each participant.

Consent for publication: Not applicable

Authors’ information

Department of Obstetrics and Gynecology and Department of Emergency and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences

E-mail: [email protected]

Acknowledgments

Suzuki Iryotokei: Statistical analysis

Author’s contributions

AO: Conceptualization, Methodology, Formal analysis, Writing - original draft

JM: Conceptualization, Methodology, Writing - review & editing, Supervision

KA: Conceptualization, Methodology, Investigation

HN: Investigation

HO: Investigation, Statistics

TM: Investigation

SM: Investigation

KT: Investigation

SK: Investigation

EE: Investigation

AN: Methodology, Writing - review & editing, Supervision

HM: Methodology, Writing - review & editing, Supervision

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare no competing interests.

Funding: Research Project on Development and Establishment of Advanced Services by Cabinet Office, Government of Japan, FY2022

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No competing interests reported.

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Assessing the Efficacy of Simulation-Based Education for Paramedics in Extended Focused Assessment with Sonography for Trauma under Physician Guidance

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