Clinical Training Upgraded to iUltrasound 2.0

FAST ultrasound video log transmission via iPhone for overreading

 

Dan Nguyen

 

Introduction and Justification

Since the early 1980s, bedside ultrasound by emergency physicians has become increasingly popular [1]. The use of FAST ultrasoungraphy has now become an extension of the physical examination of the trauma patient [2]. It provides effective and timely diagnosis of potentially life-threatening hemorrhages and is a decision making tool to help determine the need for transfer to the operating room, CT scanner or angiography suite. In addition, it is cost effective solution with lower cost in manufacturing, telecommunication, and maintenance. Currently, ultrasound is performed in the trauma room by properly trained and credential staff. However, the protocols for education and varieties of teaching media vary from not only among specialties but within them as well.

As the economic healthcare paradigm continues to shift, we must be cognizant of how healthcare payments are now becoming linked with not only cost-effective but also high quality healthcare. This put the increasing responsibility on physicians, hospital staff, and healthcare facilities to closely monitor quality of care. This is why it is important to monitor and improve the quality of ultrasound training. By creating real-time ultrasound transmissions and an electronic procedure log of video and image recorded ultrasound, residents will be able to further assess their clinical skills individually and with resident training staff. It is the hope of this pilot study to develop future training protocols that will improve FAST ultrasound assessment and review complications. This will in turn, enhance the quality of patient care by improving critical diagnosis and improving the quality of clinical skill by student, residents, and attending physicians.

According to studies by Costantino et al. success in ultrasound education does improve with increased didactic training [3]. However, beyond 15 hours of didactic training there is no improvement in resident performance [3]. This is significantly lower than the 40 hours of recommended didactic training by the SAEM [4]. It is the goal of this study to implement a device that will develop a computer database of digitally procedure log of digitally recorded ultrasound images and video captures. This will improve clinical training by increasing the time and efficiency of ultrasound training to the clinical setting instead of increasing didactic lecture. Durning et al. showed that the number of ultrasound scans under supervision is the most critical predictor of successful ultrasound training [5]. Additionally, electronically recorded ultrasound will include benefits such as eliminating bias in recorded complications and allowing the resident to develop a better critical assessment of clinical skill and deficiencies and plan for a modified individual plan of improving quality of diagnosis. Additionally the use of an electronic database will allow hospital administration, healthcare payers, residency directors, etc. to monitor the quality of ultrasound imaging on an administrative level.

 

Review of Literature

Optimal training required for proficiency in bedside ultrasound is unknown. Optimal media for ultrasound training is still being reviewed. In 1994 SAEM released formalized guidelines for ultrasound training [4]. This was followed by the American College of Emergency Physician publishing formalized guidelines in 2001 [1]. However there is no translation of protocols to credentialing criteria and quality assurance programs. Some hospitals have started to develop rigorous credentialing policies and ultrasound review committee systems like at the University of California, San Francisco [6]. However these protocols remain to be studied and embraced by the ACEP or SAEM. Other specialties have also started to develop their own ultrasound training protocols. The American College of Surgeons have published their own guidelines for formalized training including specified levels of training and focused modules for various ultrasound techniques [7]. Ultrasound use has also started to spread in newer realms of medicine, such as EMT’s in rapid assessment of left ventricular systolic function in a pacemaker function [8].

Ultrasound training has even started to be incorporated earlier in undergraduate medical education with high success rates [9]. Barloon et al. reported that 30 minutes of ultrasound training helped Year 2 medical students more accurately estimate liver size compared with students who did not receive ultrasound training [10]. Current literature has showed numerous studies on different techniques and media for clinical training specific to ultrasound scanning. Proctored examinations have shown significant value to retention of ultrasound knowledge after the introduction of an emergency ultrasound curriculum [11].

Many European countries have already high integrated ultrasound programs [12]. Sweden’s resident physicians are required to submit a portfolio of cases on a DVD format for educational review. Additionally in Germany, there is a national program for ultrasound procedures, especially those performed by obstetricians. In fact there are government guidelines linking reimbursement for obstetrical ultrasound payment [12]. This places pressure on hospitals and physicians to increase the quality of care due to financial incentives, compared to monetary caps on procedures which breed a culture of minimal quality care.

In a study by Dolmans et al. ultrasound procedures logs helped clerkship coordinators by providing a useful overview of the content and nature of the students’ learning experiences in the hospitals. However the logs were not utilized by students, supervisors, and faculty to help improve the structure of student learning [13]. With a video procedure log there would be increased oversight over medical education, where residents and supervisors can readjust the learning experience by catering to individual needs and goals [14, 15]. By embedding the procedure logs into supervision of training, there will be increased importance placed on procedure logs by resident physicians. However the reliability of current logbook data has its pitfall. In a study by Raghoebar-Krieger et al. there were numerous inconsistencies when comparing student procedure logs and feedback data from attending doctors [16]. Diseases were under reported, which lead to a breakdown in clear supervision and feedback, which is important for procedure logs to work

Fung et al. created a similar internet-based learning portfolio in resident education call the KOALA. They created an advanced portfolio of ultrasound images that were link to self-directed hyperlinks [17]. The hope of the study was to reduce the future need for textbooks and CME in favor of creating self-directed study of ultrasound techniques. In addition the internet portfolio provided a media to directly observe ultrasound scans and compare quality of ultrasound scans throughout the hospital [17].

A study by Blaivas et al. published in 2005, compared ultrasound images between commercial cell phone and traditional high-resolution thermal printout in image quality, detail and resolution. There was no statistically significant difference. There was however, a problem with reading measurement and a lower confidence in diagnosis with p-values of .003 and .02 [18]. With the fast developing market of portable cell phone with larger screens and higher resolution, our study reexamines current cell phone technology with real-time ultrasound transmission.

 

 

Research Objectives

1. Reduce the cost of current ultrasound technology by developing an “off-the-shelf” solution to an image/video capture system from commercially available technologies
   1. Prove that consumer available technology (iPhone) can be used for ultrasound transmission and oversight with diagnostic quality images.
2. Development of a video/image recorded ultrasound database for the storage of resident procedure logs.
   1. Better utilize procedure logs and clinical supervision to provide more efficient ultrasound education that will improve diagnostic accuracy and increase user confidence of FAST ultrasound scans.
   2. Enhance current credentialing and quality assessment protocol for FAST (Focused Assessment with Sonography for Trauma) ultrasound training in residency training by utilizing real-time ultrasound transmission and video procedure log of FAST ultrasound scans.

 

 

Research Methodology

 

This study is a comparison of ultrasound images and video outputted directly to an Apple iPhone with ultrasound images ultrasound video directly displayed on the portable ultrasound monitor. This study will take place at a level 1 trauma center ED (Henry Ford Health Systems, Detroit) with an accredited emergency medicine residency program and an active emergency ultrasound program. Currently all residents are trained to use ultrasound under the SAEM (Society of Academic Emergency Medicine) guidelines.

10 FAST ultrasound examinations will be randomly selected from approximately 20 computer recorded FAST ultrasound examination. Examination will only be performed on patient medically require a FAST ultrasound examination based on emergency department protocol. The ultrasound scans will be performed in the emergency department during a 2 week period by the on call emergency medicine resident that is trained and credentialed in the use of FAST ultrasound examination in the emergency department. Computer recorded FAST ultrasound will comprised of 10 second video clips and 1 high resolution image capture of each of the 4 primary views: perihepatic, perisplenic, pelvis & pericardium. All images and video that is computer recorded is also saved to the internal hard drive of the portable ultrasound device. All ultrasound scans will be outputted through VGA signal to the VGA2USB LR Frame Grabber. The converted USB signal will then be sent to a computer laptop. We will use a commercial available laptop produced by HP. The laptop will receive data from the portable ultrasound device through a VGA-to-USB converter box. The computer will then record both images and video at the highest possible resolution onto the internal hard drive. Resolution of the computer recorded ultrasound images and video will only be limited by the output capabilities of the VGA-to-USB converter box. Additionally, the ultrasound video will be streamed real-time through a Skype account to an iPhone. Once the video transmission to the iPhone is confirmed by the operating technician, the ultrasound scan is complete.

The premise of this study is to duplicate a scenario where a residency director, ultrasound director, attending, or resident can review recently performed FAST ultrasound scans for the purposes of assessing accuracy of diagnosis, evaluate quality improvement, and improve clinical skills. The 10 computer recorded FAST ultrasound data and the ultrasound recorded data will be graded by a hospital credentialed sonologist with a minimum of 5 years of experience. Approximately 1 week after ultrasound images are randomly selected 2 credentialed emergency sonologists (radiologist stationed with the emergency medicine department) with extensive ultrasound experience including study performance, interpretation and ultrasound education will review ultrasound database. Ultrasound review will include video replayed back on the portable ultrasound device and video replayed back on the iPhone. For practical purpose, real-time transmission via the iPhone will not be reviewed real-time by the sinologist. However, replayed ultrasound transmission will simulate real-time transmission.

For each ultrasound image, the reviewers will be initially asked for an initial interpretation of the images and video captures. Afterward, each reviewer is given a short clinical vignette of the patient’s complaint in addition to a procedure log of complication from the emergency medicine resident that performed the FAST ultrasound examination. Reviewers are allowed to manipulate the images as needed including increasing image size, changing contrast, etc. Then each image will be graded on the following: (1) total image quality, (2) image resolution, defined as the sharpness and crispness of the image and lack of haziness/blurriness; (3) image detail, defined as the clarity of organ outlines and ease with which boundaries of structures are seen and defined; (4) optimal quality image that is required for optimal review for resident training purposes. Each reviewer will rank their impressions on a 10-point Likert scale with 1 being the worst and 10 the best. All data will be filled out on a standardized data form, which will then be entered into a computerized database. Statistical analysis will include descriptive statistics and a paired t test with 95% intervals. Data will be analyzed using standard statistically

For safety consideration, a separate dedicated portable ultrasound device will still be kept in all resuscitation room in the emergency department according to emergency department protocol. If there are technical problems while scanning a patient with the proposed ultrasound transmission apparatus, the physician will be able to use the standard ultrasound device at the attending or resident physician’s discretion.

 

Materials

-GE Portable Ultrasound

-iPhone 3G:

3.5 inch (diagonal) widescreen Multi-Touch display, 480-by-320-pixel resolution at 163 ppi, Dimension 4.5 inches (height) x 2.4 inches (width) x 0.48 inch (depth), 16 GB flash drive capacity, UMTS/HSDPA (850, 1900, 2100 MHz), GSM/EDGE (850, 900, 1800, 1900 MHz), Wi-Fi, (802.11b/g), Bluetooth 2.0 + EDR, Video formats supported: H.264 video, up to 1.5 Mbps, 640 by 480 pixels, 30 frames per second,; MPEG-4 video, up to 2.5 Mbps, 640 by 480 pixels, 30 frames per second, Simpler Profile with AAC-LC audio up to 160 Kbps, 48kHz, stereo audio in .m4v, .mp4, and .mov file formats, 2.0 megapixel camera.

-HP Pavilion Laptop dv2700t series

Windows Vista Home Premium, Pentium® Core™ 2 Duo Processor T5750 (2.0 GHz), 14.1” diagonal WXGA HP BrightView Widescreen Display (1280 x 800), 2GB DDR2 System Memory (2 Dimm), 128MB NVIDIA GeForce 8400m GS, Intel® PRO/Wireless 4965AGN Network, 120GM 5400RPM SATA Hard Drive,

-VGA2USB LR Frame Grabber (made by Epiphan Systems Inc.)

-Skype Account (commercial video streaming website)

-Remote Computer Access

-Public Wi-Fi access at the Henry Ford Health Systems Downtown Detroit Main Campus

 

 

Limitations/Potential Future Amendments

-Small sampling size may provide a biased analysis for the efficacy of video ultrasound logs

-Development of an all-in-one device for ultrasound recording and transmission will allow for easier mobile setup of ultrasound scans.

-After the release of the iPhone 3G, third party developers will be able to develop higher quality online conferencing clients for use on the iPhone or Apple may develop proprietary video conferencing software.

-Future tests can include computer laptops with an integrated video camera

-Future research should expand on the development of an online database (FTP) for remote access from any Wi-Fi capable device.

-Future research should experiment with using other device that are portable and Wi-Fi capable (PSP®, computer laptops, palm, blackberry, etc).

 

Literature Cited

 

1. American College of Emergency Physicians. ACEP emergency ultrasound guidelines. 2001. Annals of Emergency Medicine. 38: 470-481.
2. Marik, P. E. & Mayo, P. 2008. Certification and training in critical care ultrasound. Intensive Care Medicine. 34:215-217.
3. Costantino, T. G., Satz, W. A., Stahmer, S. A., & Dean, A. J. 2003. Predictors of success in emergency medicine ultrasound education. Academic Emergency Medicine. 10(2):180-183.
4. Witting, M. D., Euerle, B. D., & Butler, K. H. 1999. A comparison of emergency medicine ultrasound guidelines of the Society for Academic Emergency Medicine. Annal of Emergency Medicine. 34(5):604-609.
5. Durning, S. J., Cation, L. J., & Jackson, J. L. 2007. Are commonly used resident measurement associated with procedural skills in internal medicine residency training? Society of General Internal Medicine. 22:357-361.
6. Stein, J. C., & Nobay, F. 2008. Emergency department ultrasound credentialing: A sample policy and procedure. The Journal of Emergency Medicine, ?, ?-?.
7. Staren, E. D., Knudson, M. M., Rozycki, G. S., Harness, J. K., Wherry, & Shackford, S. R. 2006. An evaluation of the American College of Surgeons’ ultrasound education program. The American Journal of Surgery. 191:489-496.
8. Ghani, S. N., Kirkpatrick, J. N., Spencer, K. T., Smith, G. L., Burke, M. C., Kim, S. S., Desai, A. D., & Knight, B. P. 2006. Rapid assessment of left ventricular systolic function in a pacemaker clinic using a hand-carried ultrasound device. Journal of Interventional Cardiology Electrophysiology. 16:39-43.
9. Butter, J., Grant, T. H., Egan, M., Kaye, M., Wayne, D. B., Carrion-Carrie, V., & McGaghie, W. C. 2007. Does ultrasound training boost Year 1 medical student competence and confidence when learning abdominal examination? Medical Education. 41:843-848.
10. Barloon, T. J., Brown, B. P., Abu-Yousef, M. M. 1998. Teaching physical examination of the adult liver with the use of real-time sonography. Academic Radiology. 5:101-103.
11. Noble, V. E., Nelson, B. P., Sutingco, A. N., Marill, K. A., & Cranmer, H. 2007. Assessment of knowledge retention and the value of proctored ultrasound exams after the introduction of an emergency ultrasound curriculum. BioMed Central Medical Education. 7(40):1-5.
12. Brezinka, C. 2006. Training, certification and CME in obstetric ultrasound scan in Europe. European Clinic Obstetrics Gynecology. 1:223-226.
13. Dolmans, D., Schmidt, A., van der Beck, J., Beintema, M., & Gerver, W. J. 1999. Does a student log provide a means to a better structure clinical education? Medical Education. 33:89-94.
14. Vanek, E. P., Barrigua-Unal, R. M., Hekelman, F. P., Hull, A. L., Lindley, B. D., Barely, B. E., Krackov, S. K., & Packman, C. H. 1999. Use of patient encounter documentation (log) systems at three medical school. Teaching Learning Medicine. 5: 164-168.
15. Ferrel, B. G. 1991. Demonstrating the efficacy of the patient log-book as a program evaluation tool. Academic Medicine. 66(9): s49-s51.
16. Raghoebar-Krieger, H. M. J., Sleiffer, D. Bender, W. Steward, R. E., & Popping, R. 2001. The reliability of logbook data of medical students: an estimation of interobserver agreement, sensitivity and specificity. Medical Education. 35:624-631.
17. Fung, M. F. k., Walker, M., Fung, K. F. K., Temple, L., Lajoie, F., Bellemare, G., & Bryson, S. C. 2000. An internet-based learning portfolio in resident education: the KOALA™ multicentre proramme. Medical Education. 34:474-479.
18. Blaivas M., Lyon, M., & Duggal, S. 2005. Ultrasound image transmission via camera phones for overreading. American Journal of Emergency Medicine. 23:433-438.