Medical Students' Competency in EFAST Components: a prospective observational study

doi:10.21203/rs.3.rs-3956163/v1

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Research Article

Medical Students' Competency in EFAST Components: a prospective observational study

https://doi.org/10.21203/rs.3.rs-3956163/v1

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published 12 Sep, 2024

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Background

Ultrasound training in undergraduate medical education is developing, and its incorporation in the curriculum requires careful planning. Extended Focused Assessment Sonography for Trauma (EFAST) is commonly taught to medical students as one of the primary applications of ultrasound. Because false negative EFAST scans can affect patient clinical outcomes, it is essential to evaluate the individual components of this skill. We aim to determine which suboptimal EFAST components students perform after initial training.

Methods

In this prospective observational study, 90 medical students from two final-year cohorts were assessed in EFAST components after uniform training during the emergency medicine clerkship. All validated components of the standard EFAST exam were assessed. Descriptive analysis in individual components of EFAST was performed.

Results

The hepatorenal space, splenorenal space, and pelvic space fluid investigations had the lowest completion rates. Pericardial fluid, pelvic free fluid, and right thoracic pleural fluid investigations were most often incorrectly applied. Fanning was most commonly missed in hepatorenal, splenorenal, and pelvic free fluid investigations. Between 12% and 50% of EFAST components had omitted reporting.

Conclusions

There were significant numbers of incomplete assessments for free intraperitoneal fluid, mostly due to a lack of fanning in the hepatorenal, splenorenal, and pelvic areas. By targeting these challenging areas, trainers can effectively enhance student performance and outcomes. Further research might reveal whether residents and physicians show similar trends in EFAST completion.

EFAST

emergency ultrasound

medical student

emergency medicine

trauma

skill

Point-of-Care Ultrasound (POCUS) is the use of handheld or portable ultrasound at the patient’s bedside [1]. It has become a clinical tool for many doctors in different specialties. It is used to answer focused clinical questions for refining diagnostic and management decisions [2]. Advances in POCUS technology are making it accessible in different clinical settings tailored to various levels of training.

In 2012, the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine included ultrasound as a milestone for emergency medicine residents [3]. The utility of incorporating ultrasound training at both the residency and fellowship levels suggested that trainees would benefit from earlier exposure in medical schools [4]. Ultrasound education is now well established in some undergraduate medical institutions, while many are yet to start. According to Birrane [5], the incorporation of ultrasound into undergraduate medical education is both feasible and beneficial for medical students; however, a number of barriers to establishing ultrasound education have been identified, including a lack of capital, trained faculty, and cramped curriculum [6]. A consensus statement of the World Ultrasound Society concluded that ultrasound training in undergraduate medical education is still in its infancy and that its proper incorporation requires careful planning [7].

Extended Focused Assessment Sonography in Trauma (EFAST) is the application of ultrasound in clinical decision making while managing a multiple trauma patient. It is one of the common protocols used to teach ultrasound in both undergraduate and postgraduate education and is considered one of the main topics of the undergraduate ultrasound curriculum [8–10]. As one of the most common bedside ultrasound procedures practiced in emergency departments, many medical schools worldwide have included EFAST in their emergency medicine clerkship (EMC) curriculum. [11, 12]. Gogalniceanu et al. and Cevik et al. reported the feasibility of training medical students in FAST and EFAST scanning within short time frames, 5 hours and 4 hours, respectively [13, 14].

EFAST has a wide range of sensitivity and specificity [15, 16]. Sensitivity and specificity were found to be lower in trainees [17]. A recent systematic review reported that the sensitivity of EFAST is generally lower than its specificity [18]. Moreover, the reported values differ for the individual components of EFAST. The sensitivity for pericardial fluid was 91%, that for intrabdominal free fluid was 74%, and pneumothorax was 69%, while the specificities for the different components ranged from 94–99% [18]. This indicates that the accuracy of the components of the EFAST scan are different. However, there is no study on the performance of trainees in the different components of EFAST scans after their training.

Although EFAST has multiple individual components, it is usually taught and assessed as one skill. Since the findings of EFAST are critical in decision making in patients with severe trauma, it is important to know the reasons for missed or incomplete components in both clinical practice and training. While trainees may exhibit acceptable performance on the EFAST, it is crucial to understand and identify the specific components that they find challenging.

We aimed to define the components of EFAST that medical students perform poorly after an initial training. This information will help educators facilitate targeted interventions to enhance trainees’ awareness and understanding, thereby promoting improved performance and patient outcomes by decreasing errors in their future clinical practice.

Study Design and Setting

Ethical approval

for the study was obtained from the Research and Graduate Studies Ethics Committee (Reference No: ERS_2017_5643).

Study Setting and Population

The United Arab Emirates University College of Medicine and Health Sciences' EMC is a four-week rotation for final-year medical students [19]. One of the clinical skills taught in the EMC curriculum is EFAST protocol. This is a retrospective analysis of prospectively collected EFAST assessment data from over two years.

Study Protocol

Participants

The participants were final-year medical students who were tested on EFAST stations in their Objective Structured Clinical Examination (OSCE) during 2016-17 and 2017-18 academic years.

Ultrasound Equipment

Training and testing were performed with a Siemens Acuson P300 ultrasound machine with a low-frequency (2–5 MHz) convex transducer and a high-frequency (8–18 MHz) linear transducer.

Teaching Sessions

During the 2016–17 and 2017–18 academic years, a single tutor with 15 years of experience in POCUS (AAC) taught all final-year medical students how to perform EFAST on simulated patients in the clinical skills lab. The students received a one-hour didactic lecture on basic physics, knobology, artifacts, and the EFAST technique, followed by a two-hour practical session on human models under the tutor’s supervision. Three intraperitoneal (hepatorenal space, splenorenal space, pelvic space) and four intrathoracic views (right and left pneumothorax investigation, right and left intrathoracic free fluid investigation) and subcostal pericardial views were used in EFAST training. Students were instructed on the application, normal, and pathological views during the didactic session. They learned how to achieve an acceptable view for each sonographic window during the practical session. Throughout the didactic and practical sessions, details of anatomy landmarks, views, fanning, tilting, and reporting were provided. Direct feedback on performance was given to every student to improve their hand skills. Simulated patients with a normal body mass index were used for both the training and assessment. Throughout their clerkship time, the students were needed to perform at least three EFAST assessments on trauma patients in the Emergency Department under the direct supervision of an attending emergency physician. Last, during the final week of rotation before the OSCE, the students received an additional 2-hour free practice on human models. In the early years of medical school, students had no other structured emergency medicine rotation and no official, standardized EFAST training and assessment.

Assessment

The same tutor who conducted didactic and practical sessions (AAC) evaluated the students' EFAST performance on simulated patients in a station as part of the final clerkship OSCE (Table 1: Evaluated components of EFAST in OSCE form). All validated components of the standard EFAST exam are included in the assessment form [14]. The Emergency Medicine Clerkship OSCE included eleven stations (8 active stations) of six minutes each.

Table 1

Components of EFAST in OSCE Marking Sheet
Preparation
1. Introduce him/herself to the patient appropriately and explains procedure. Completed /Not Attempted
2. Warns the patient for cold gel. Completed / Not Attempted
3. Choose the right transducer to start to exam. Completed / Wrong Selection
4. Place transducer marker to correct direction. Completed / Wrong Application
Investigation
1. Pericardial Fluid (Correctly shows subcostal pericardial view, Uses transthoracic parasternal long axis view as back up, reports) Completed/Partially Completed/Inadequately Done/Not Attempted/Wrong Application
2. Intraperitoneal Fluid – Hepatorenal Space (Places the transducer mid axillary - costal margin line point, shows the Morrison pouch, applies fanning to investigate all area of Morrison pouch, reports) Completed/Partially Completed/Inadequately Done/Not Attempted/Wrong Application
3. Right Thoracic Pleural Fluid (hemothorax) (Places the transducer mid axillary point, shows the diaphragm, shows lung, diaphragm, and liver view, reports) Completed/Partially Completed/Inadequately Done/Not Attempted/Wrong Application
4. Intraperitoneal Fluid – Splenorenal Space (Places the transducer posterior axillary - Xiphoid line point, shows the splenorenal space, applies fanning to investigate all area of splenorenal space, reports) Completed/Partially Completed/Inadequately Done/Not Attempted/Wrong Application
5. Left Thoracic Pleural Fluid (hemothorax) (Places the transducer posterior axillary line, shows the diaphragm, shows lung, diaphragm and spleen view, reports) Completed/Partially Completed/Inadequately Done/Not Attempted/Wrong Application
6. Pelvic Free Fluid (Correctly applies transvers view above symphysis pubis, applies fanning in transvers view and shows all area, correctly apply sagittal view above symphysis pubis, applies fanning in sagittal view and shows all area, reports) Completed/Partially Completed/Inadequately Done/Not Attempted/Wrong Application
7. Right Pneumothorax (Places the transducer midclavicular, 2nd 3rd intercostal point, shows two ribs and pleural movements on screen, correctly applies M-mode, Reports) Completed/Partially Completed/Inadequately Done/Not Attempted/Wrong Application
8. Left Pneumothorax (Places the transducer mid clavicular, 2nd 3rd intercostal point, shows two ribs and pleural movements on screen, correctly applies M-mode, Reports) Completed/Partially Completed/Inadequately Done/Not Attempted/Wrong Application

Data Collection and Marking

To create OSCE evaluation sheets, the Electronic Objective Structured Clinical Evaluation (eOSCE) desktop program was used [20]. To mark stations, an iOS tablet running the eOSCE application was used. Data for each student's performance were collected in a cloud-based platform, and the results were downloaded as an Excel spreadsheet. On the marking sheet, there were 12 components. The EFAST exam components listed in the marking sheet (Table 1) included two categories: preparation and investigation. The preparation section had four components and was coded as completed and not attempted or wrong selection/application. The investigation section had eight components coded as completed, partially completed, inadequately done, not attempted, and wrong application options. The "completed" box was checked if the student achieved all the required items in an EFAST component. The "partially completed" box was checked if the student achieved more than half of the required items but not all. If the student achieved less than half of the required items in an EFAST component “inadequately done,” the box was checked. Other options on the form were “not attempted” for missed components and “wrong application” if an incorrect examination was applied in that particular EFAST component. In the comments section of the marking sheet, the examiner wrote important areas that the student overlooked or had done wrongly.

Analysis

Descriptive analyses were performed to address common missing steps for each EFAST component. Examiner notes were reviewed to address common mistakes or issues. Nonparametric statistical methods were used. Fisher's exact test was used to determine the significance of the association between two categorical variables. Mann‒Whitney U tests were used for continuous variables. Values are presented as medians and ranges or numbers and percentages where applicable. Statistical significance was defined as a probability less than 0.05. The Statistical Package for the Social Sciences was used to analyze the data (IBM-SPSS version 28, Chicago, IL).

There were five student groups in each academic year and a total of 146 students (66 in 2016–17 and 80 in 2017–18). Six out of the ten student groups (90 students, 62%) received an EFAST station in their clerkship OSCE. Twenty-six students (2 groups) were in the 2016–17 academic year, and 64 students (4 groups) were in the 2017–18 academic year. Seventy percent of the students (63) were female. There were no differences between the students in the two academic years in terms of gender distribution, final EM marks, final OSCE marks, EFAST station marks, or OSCE marks (without EFAST station) (Table 2).

Table 2

Students and their emergency medicine marks in two academic years
	2016-17 (n = 26)	2017-18 (n = 64)	P value
Gender			0.313
Female	16 (61.5%)	47 (73.4%)
Male	10 (38.5%)	17 (26.6%)
EM Final Mark	84.5 (78.0–89.0)	84.5 (67.0–90.0)	0.819
EM OSCE Mark	80.8 (71.8–85.9)	80.0 (67.8–89.8)	0.383
EFAST Station Mark	75.0 (45.8–91.7)	70.8 (33.3–100)	0.932
EM OSCE Mark (without EFAST Station)	81.6 (72.4–87.0)	80.7 (67.7–90.7)	0.317
Fisher's exact and Mann-Whitney U tests were used to calculate p values. Nominal values were presented as a number and a percentage. Continuous numbers were presented as median and range. EM: Emergency Medicine, OSCE: Objective Structured Clinical Examination, EFAST: Extended Focused Assessment with Sonography in Trauma.

Table 3

shows the components of the EFAST marking sheet and student performances. The most successfully completed EFAST components by students were pericardial fluid, right chest pneumothorax, and left chest pneumothorax investigations (78.9%, 66.7%, and 63.3%, respectively). The three components in the abdominopelvic investigation section had the lowest “completed” marks: intraperitoneal fluid – hepatorenal space (31.1%), intraperitoneal fluid – splenorenal space (31.1%), and pelvic free fluid (28.9%). The top three components marked as "wrong application" in the investigation section were pericardial fluid (8.9%), right thoracic pleural fluid (6.7%), and pelvic free fluid (6.7%) investigations.
Table 3: EFAST Components and Student Performances
Steps of OSCE in Marking Sheet	Completed	Partially Completed	Inadequately Done	Not Attempted	Wrong Application
	N (%)	N (%)	N (%)	N (%)	N (%)
Preparation
Introduce him/herself to the patient appropriately and explains procedure.	73 (81.1)	N/A	N/A	14 (18.8)	N/A
Warns the patient for cold gel.	43 (47.8)	N/A	N/A	47 (52.2)	N/A
Choose the right transducer to start to exam.	89 (98.9)	N/A	N/A	N/A	1 (1.1)
Place transducer marker to correct direction.	83 (92.2)	N/A	N/A	N/A	7 (7.8)
Investigation
Cardiac Investigation
Pericardial Fluid	71 (78.9)	11 (12.2)	-	-	8 (8.9)
Abdomino-Pelvic Investigation
Intraperitoneal Fluid – Hepatorenal Space	28 (31.1)	57 (63.3)	3 (3.3)	-	2 (2.2)
Intraperitoneal Fluid – Splenorenal Space	28 (31.1)	55 (64.4)	3 (3.3)	-	4 (4.4)
Pelvic Free Fluid	26 (28.9)	41 (45.6)	16 (17.8)	1 (1.1)	6 (6.7)
Thoracic Investigation
Right Thoracic Pleural Fluid (hemothorax)	31 (34.4)	34 (37.8)	12 (13.3)	7 (7.8)	6 (6.7)
Left Thoracic Pleural Fluid (hemothorax)	33 (36.7)	34 (37.8)	6 (6.7)	13 (14.4)	4 (4.4)
Right Pneumothorax	60 (66.7)	14 (15.6)	6 (6.7)	8 (8.9)	2 (2.2)
Left Pneumothorax	57 (63.3)	10 (11.1)	4 (4.4)	15 (16.7)	4 (4.4)
OSCE: Objective Structured Clinical Examination, EFAST: Extended Focused Assessment with Sonography in Trauma. N/A; not available/applicable.

Missed Items in Each EFAST Investigation Component ( Table 4 )

Table 4: Missed items by students in each EFAST investigation component.
Components and Items of EFAST in OSCE Marking Sheet	Yes N (%)	No N (%)
Cardiac Investigation
Pericardial Fluid
• Correctly shows subcostal pericardial view	69 (76.7)	21 (23.3)
• Uses transthoracic parasternal long axis view as back up (n = 21)	12 (57.1)	9 (42.9)
• Reports	79 (87.8)	11 (12.2)
Abdomino-Pelvic Investigation
Intraperitoneal Fluid – Hepatorenal Space
• Place the transducer mid axillary - costal margin line point	86 (95.6)	4 (4.4)
• Shows the Morrison pouch	80 (88.9)	10 (11.1)
• Applies fanning to investigate all area of Morrison pouch	38 (42.2)	52 (57.8)
• Reports	70 (77.8)	20(22.2)
Intraperitoneal Fluid – Splenorenal Space
• Place the transducer posterior axillary - Xiphoid line point	81 (90.0)	9 (10.0)
• Shows the splenorenal space	82 (91.1)	8 (8.9)
• Applies fanning to investigate all area of splenorenal space	38 (42.2)	52 (57.8)
• Reports	63 (70.0)	27 (30.0)
Pelvic free fluid investigation
• Correctly apply transvers view above symphysis pubis	81 (90.0)	9 (10.0)
• Applies fanning in transvers view and shows all area	45 (50.0)	45 (50.0)
• Correctly apply sagittal view above symphysis pubis	73 (81.1)	17 (18.9)
• Applies fanning in sagittal view and shows all area	41 (45.6)	49 (54.4)
• Reports	66 (73.3)	24 (26.7)
Thoracic Investigation
Left Thoracic Pleural Fluid (hemothorax)
• Place the transducer posterior axillary line	59 (65.6)	31 (34.4)
• Shows the diaphragm	67 (74.4)	23 (25.6)
• Shows lung, diaphragm and spleen view	56 (62.2)	34 (37.8)
• Reports	45 (50.0)	45 (50.0)
Right Thoracic Pleural Fluid (hemothorax)
• Place the transducer mid axillary point	60 (66.7)	30 (33.3)
• Shows the diaphragm	69 (76.7)	21 (23.3)
• Shows lung, diaphragm and liver view	53 (58.9)	37 (41.1)
• Reports	45 (50.0)	45 (50.0)
Right Pneumothorax
• Place the transducer mid clavicular, 2nd 3rd intercostal point	76 (84.4)	14 (15.6)
• Shows two ribs and pleural movements on screen	74 (82.2)	16 (17.8)
• Correctly applies M-mode	68 (75.6)	22 (24.4)
• Reports	69 (76.7)	21 (23.3)
Left Pneumothorax
• Place the transducer mid clavicular, 2nd 3rd intercostal point	66 (73.3)	24 (26.7)
• Shows two ribs and pleural movements on screen	64 (71.1)	26 (28.9)
• Correctly apply M-mode	66 (73.3)	24 (26.7)
• Reports	64 (71.1)	26 (28.9)

The majority of the students were able to find anatomical structures and show appropriate views in each component. However, there were items in each component that were missed to be considerably high. Students lacked the skill to apply fanning in hepatorenal, splenorenal and pelvic windows. Lack of reporting of findings was the main item missed in thoracic pleural fluid investigations.

The investigations of the hepatorenal space, splenorenal space, and pelvic space free fluid had the lowest full completion rates. Pericardial fluid, pelvic free fluid, and right thoracic pleural fluid investigations were the components most frequently marked as wrong application. Fanning was most commonly overlooked in hepatorenal, splenorenal, and pelvic free fluid investigations. Additionally, there was a lack of reporting in the investigations of thoracic pleural fluid. This fragmented application and reporting reveals a significant challenge in ensuring comprehensive EFAST scans, which are crucial for accurate assessments. Addressing these issues is imperative to enhance the overall quality of EFAST examinations for undergraduate students.

There are no other studies in the literature that have specifically reported the completion rate of individual components of EFAST scans by trainees. Since the frequency of incomplete scans will affect the accuracy of EFAST, the high number of partially completed scans for intraperitoneal fluid suggests that there is an increased risk of false negative scans. Addressing incomplete scans is important because it impacts diagnostic accuracy and patient care. Our study found that more than 60% of scans in the hepatorenal and splenorenal areas were incomplete. This finding needs to be correlated with findings from clinical studies. A review of EFAST scans in trauma patients found that the most common cause of false negative scans was missing free fluid in the pelvis, right hypochondrium, or left hypochondrium, with 31% of these false negative scans necessitating operative or interventional radiology procedures [21]. This highlights the clinical relevance of conducting complete scans, including a proper fanning technique.

There is evidence that different ultrasound applications in emergency medicine differ in their learning curve. A study reported that the number of exams needed for soft tissue exams was only 18, while for good interpretation skills for right upper quadrant ultrasound examination, the number of scans needed was 90 [22]. Bleahr et al. also highlighted that EFAST needed 57 examinations to reach its highest interpretation plateau [22]. Acceptable interpretation comes with experience by using proper ultrasound techniques on a daily basis. Our students did not have the chance to examine a high number of patients during the 4 weeks of emergency medicine clerkship. However, our study demonstrated that uniform training of EFAST results in variances in different components of EFAST during a short period of time. This suggests different learning curves for individual components of EFAST, which need to be realized by EFAST trainers. Tailoring training programs to address these differences is essential to ensure consistent and competent performance across all aspects of EFAST.

Incomplete documentation of EFAST scans in clinical retrospective studies was up to 30% [21]. In our study, the lack of reporting ranged from 12.2% in the pericardial window to 50% in the hepatorenal and splenorenal windows. These results reveal the prevalence of incomplete reports in EFAST scans, suggesting a need for more comprehensive practices ensuring the accuracy of EFAST assessments and reporting.

Limitations

This study has various limitations. First, the whole process of training and assessment was completed within four weeks. The four-week duration may be too short for the effective acquisition and retention of competencies, suggesting that a longer, more spread-out training period might be more beneficial for solidifying learning outcomes. Similarly, the limited exposure to sonography, comprising only 3 hours of training and 3 supervised exams, may not be sufficient for medical students to acquire acceptable interpretation skills, which typically require regular practice with proper ultrasound techniques. Therefore, the findings might not be applicable to training conducted over longer periods of time, such as residency programs. Second, the study did not assess retention of the learned skills after six months or longer periods. Third, the assessment scans were conducted on simulated patients with easy-to-scan anatomy. These conditions may not be applicable to real-life trauma patients. Another limitation of this study is the small sample size, which may have affected our results. Finally, only one trainer conducted both the training and the EFAST assessment of all the students. This may have affected the reliability of the assessment. Nevertheless, the long ultrasound teaching experience of the assessor may have reduced this effect.

In summary, final-year medical students performed significant numbers of incomplete EFAST assessments for free intraperitoneal fluid, mostly due to a lack of fanning in the hepatorenal, splenorenal, and pelvic areas. This should be considered by educators and trainers, including senior physicians, in both undergraduate and postgraduate training programs. This finding has also been reported in clinical studies. Further studies on the assessment of EFAST competencies in residents and other physicians will indicate whether this pattern of incomplete scans and missed reporting exists after training programs in other training and clinical settings.

AAC Arif Alper Cevik (2nd and corresponding author)

EFAST Extended Focused Assessment Sonography for Trauma

EMC Emergency Medicine Clerkship

OSCE Objective Structured Clinical Examination

eOSCE Electronic Objective Structured Clinical Evaluation

POCUS Point-of-Care Ultrasound

Ethics approval and consent to participate: The study was approved by the Research and Graduate Studies Ethics Committee, United Arab Emirates University, Al Ain, UAE (Reference No: ERS_2017_5643).

The ethics committee waived written informed consent as the study used anonymous data from a mandatory training and assessment component of the last two years of Emergency Medicine Clerkship.

I certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Consent for publication: Not applicable

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

Competing interests: The authors declare that they have no competing interests

Funding: No research funding was used for this study.

Authors' contributions: AAC and FMAZ conceived the study and designed the trial. AAC supervised and conducted the trial and data collection. FMAZ provided statistical advice on the study design. VGP organized the data and extracted component details from data forms. AAC analyzed the data. AAC and MF drafted the manuscript, and all authors contributed substantially to its revision. AAC takes responsibility for the paper.

Acknowledgements: Not applicable

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No competing interests reported.

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published 12 Sep, 2024

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Medical Students' Competency in EFAST Components: a prospective observational study

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Abstract

Background

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Conclusions

Background

Methods

Study Design and Setting

Study Setting and Population

Study Protocol

Participants

Ultrasound Equipment

Teaching Sessions

Assessment

Data Collection and Marking

Analysis

Results

Discussion

Limitations

Conclusions

Abbreviations

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