Introduction

Point-of-care ultrasound (POCUS) continues to evolve as an essential adjunct to clinical examination not only in the acute care setting but also in other disciplines such as critical care medicine, internal medicine, and pediatrics. As this modality continues to evolve, a comprehensive training curriculum is an important foundation in medical education to acquire and enhance this skill set.[1] It is well established that medical training using simulation has many advantages when compared to traditional training techniques.[2] To our knowledge, the current literature on POCUS simulation as a training tool is limited.

There is a wide array of simulation and clinical integration strategies for POCUS training. The common approach often begins with workshops and conferences with didactics, phantom, and live models to simulate bedside skills and techniques; this often translates to further learning at the bedside by scanning patients with clinically indicated diagnoses or chief complaints. As established by various oversight governing bodies such as the American Academy of Emergency Physicians (ACEP), competence is then based on achieving specific milestones for knowledge and skill acquisition.[3] However, learning at the bedside without an adequate amount of experience early on in training can often create a stress-induced environment which can be detrimental to the learning environment and potentially harm the patient.

Function

The purpose of this activity is to outline potential strategies and techniques for POCUS simulation. This article intends to highlight the integrative approach of POCUS simulation into training curricula.

Issues of Concern

Currently, available literature to support the efficacy and effectiveness of simulation in POCUS is lacking. Furthermore, it is uncertain as to whether the knowledge and skills acquired through simulation can translate to achieve competency and proficiency by the learner.[4]

Curriculum Development

Since medical simulation has been well-proven to enhance the learner's baseline knowledge and skill, the development of a clinically-integrated POCUS curriculum can serve to improve the learner's experience and achieve their fitness to incorporate this skill into practice.[5] 

Recent literature revealed that learners who spent time on a simulator where they could repeat tasks without the clinical pressures of scanning at the bedside responded positively to this approach.[1] Clinical scenarios with live models, phantoms, and simulator mannequins with abnormal pathology can significantly augment the learners' POCUS education. 

In this regard, an approach to curriculum development of simulation-based POCUS should include establishing comprehensive learning objectives. One such objective commonly used in medical and health care education is Bloom's taxonomy of learning, which emphasizes three main categories: knowledge, skills, and attitudes. Knowledge commonly reflects the assimilation of learned information. The skills category denotes the development of psychomotor and coordinated aspects of machine and examiner interaction. Attitudes represent the combination of knowledge and skills as it relates to learner integration of the concepts into clinical decision-making and professional behavior.[6]

Clinical Clerkships

Currently, there are no standardized guidelines for simulation in POCUS training. However, while recent literature for POCUS training education continues to improve, the integration of simulation is lacking in these guidelines.[7] An approach to incorporate simulation into POCUS training includes utilizing a combination of didactics, practice-based simulation, clinical-based simulation, quality assurance, and feedback, as well as an assessment of competency. 

A basic foundation of POCUS training is, to begin with, didactics to introduce the learner to this modality. This introductory portion of the training can be regarded as vital since it involves becoming familiar with the ultrasound machine and applying this skill to acquiring the desired image.  In this regard, the ACEP policy guidelines on POCUS suggest that rotating between skill and practice improves trainee and faculty engagement.[3] Didactics are often utilized as a precursor to bedside skill training with a live or phantom trainer. It intends to allow the learner to repeatedly practice acquired concepts without considering the clinical setting and patient discomfort while guided by real-time feedback. This approach inevitably increases the confidence of the learner before integrating the skill into the simulated clinical setting.  

Once an adequate comfort level is achieved, subsequent opportunities for clinical simulation or supervised bedside training are necessary. This may include live patient scans with an expert supervising the session. However, as mentioned previously, the bedside patient training approach may negatively affect the stress-induced environment and expectations of the learner. Therefore, it preferable to utilize clinical scenarios in a controlled environment to simulate bedside clinical training. This allows for real-time feedback by the supervising expert to enhance the development of learner skills and techniques. Furthermore, this can augment psychomotor training, learner positioning, interpersonal skill, and professionalism and educate patients and families as it relates to their clinical presentation. Appropriately designed cases can be used to assess a trainee's ability to recognize both common and rare diagnoses and demonstrate reproducible image acquisition and interpretation.[8] While it is well recognized that simulation-based learning cannot replace clinical experience, it can serve as a valuable adjunct to comprehensive POCUS training.[9] 

Simultaneous quality assurance of images acquired by the trainee is also an essential part of POCUS training. This oversight can be done during a supervised scan, whether by simulation or during clinical management. If this is not possible, immediate quality assurance of the images acquired and submitted by the learner should be completed in a timely fashion.  Expert sonographers can also complete a subsequent review of acquired images to provide the trainee with feedback that reinforces learned concepts and skills. 

By definition, measurement of competency is intended to assess baseline knowledge of POCUS technique and skill. This often includes evaluating the trainee's understanding of the ultrasound equipment utilized to acquire quality images for clinical integration and management of patient care. Assessment of competency may be done by written examination that emphasizes basic ultrasound concepts in the clinical setting based on POCUS applications central to the common clinical encounters (i.e., focused cardiac ultrasound for chest pain). 

Procedural Skills Assessment

A pitfall of POCUS simulation is that it may reproduce procedural training.[1] In this regard, direct observational tools (DOT) are useful to assess learner progression for technical skill competency before introducing in situ clinical scenarios and subsequent bedside integration for patient care. This includes having the learner meet established benchmarks for competency before matriculating to clinical simulation. 

Continuing Education

An essential adjunct to POCUS training is establishing opportunities for continuing medical education (CME).  Common forms of CME include other external workshops, participation in a local or national conference that corresponds to POCUS, and self-directed learning. As with other forms of CME, self-directed asynchronous learning depends on the learners' commitment and time to improve and reinforce techniques and skills gained in the workshops and the classroom setting.  As POCUS continues to evolve, a wide array of literature and an online library of images are now available for self-directed learning, which may also supplement didactics. 

As the novice sonographer becomes experienced, technical skill and clinical integration are vital to sustaining POCUS competency. If possible, the sonographer needs to engage in workshop activities, self-directed learning, and simulation to continue improving the skills acquired and learning new applications; this can be done as frequently as needed or annually.

Clinical Significance

The clinical integration of POCUS to acute and critical management has improved the approach to patient care. As an adjunct to current healthcare education, POCUS is proving to be vital to enhance the patient experience for rapid and efficient diagnoses. Studies show that POCUS education can improve healthcare management.[10] As POCUS continues to evolve, evidence shows that its utilization can change management and patient disposition, therefore, enhancing healthcare education.[11] As a result, incorporating POCUS into healthcare education can subsequently improve healthcare management. 

Pearls and Other Issues

POCUS has become an integral part of patient care. Effective strategies for ultrasound simulation include developing an effective curriculum that is comprehensive in adherence to the recommended POCUS policy as outlined by ACEP. As such, simulation strategies should include didactics and clinical integration at the bedside. However, merely incorporating simulation into the POCUS curriculum is not sufficient as further understanding of simulation-based POCUS is needed to understand its effectiveness in preparing learners for clinical practice.

Enhancing Healthcare Team Outcomes

Evidence shows that POCUS can improve patient-centered care, and it has been shown to alter the treatment of acute and critically ill patients, decrease ED length of stay, and improve outcomes.[12] The clinical integration of POCUS will improve medical team functions at the bedside in critically ill patients.[13] Much of the understanding of the use of POCUS derives from ongoing literature that shows the benefit of this integration to clinical management. While the most common use of this modality exists primarily in the acute care and critical care setting, this integration of POCUS into medical education will invariably affect other disciplines as well, which may lead to collaborative management and coordinated patient care.