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Integration of point-of-care ultrasound (POCUS) simulation curriculum in nurse anesthesia education

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Integration of point-of-care ultrasound (POCUS) simulation curriculum in nurse anesthesia education

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Content POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION

INTEGRATION OF POINT-OF-CARE ULTRASOUND (POCUS) SIMULATION
CURRICULUM IN NURSE ANESTHESIA EDUCATION
by
So Hee Guo

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2023
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION ii

The following manuscript was contributed to in equal parts by Matthew Kook, Jasmin Kung, and
So Hee Guo.

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION iii

Acknowledgements

We would like to acknowledge our advisor, Elizabeth Bamgbose, PhD, CRNA, for
helping us develop the idea and methodology for this paper. Her constant enthusiasm and
motivation carried us through all stages of our capstone project. We would also like to express
our deepest gratitude to Mandeep Singh, MD, and Charles Griffis, PhD, CRNA, for their
valuable feedback and guidance. Lastly, we would like to thank our friends, families, and
classmates for their unconditional support during our journey through our doctorate program.
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION iv

Table of Contents
Acknowledgements………………………………………………………………………...…….iii
List of Tables…………………………………….…………………………………………..……v

List of Figures…………………………………………………………………………………. ...vi

Abstract…………………………………………………………………………………………..vii

Chapter One.………………………...…………………………………………………………….1
Introduction ……………………………………………………………………………….1
Research Question and Specific Aims …………………………………………………... 2
Background and Significance …………………………………………………………… 2
Current Use of POCUS in Medical and Anesthesia Practice……………………..2
Cognitive Load Theory, Simulation Education and POCUS Training…...………4

Chapter Two ……………………………………………………………………………………... 7
Methodology …………………………………………………………………………….. 7

Chapter Three ………………………………………………………...………………………….. 9
Literature Review ……………………………………………………………………… 9
Ultrasound Simulation Training in Anesthesia……...…….……………………...9
Cognitive Load Theory in the Learning Process……………...…………………12
POCUS in Anesthesia Clinical Care…………...………………………………..14

Chapter Four …………………………………………………………………………………….18
Results …………………………………………………………………………………..18

Chapter Five ……………………………………………………………………………………. 22
Discussion ……………………………………………………………………………… 22
Conclusion ………………………………………………………………………………23

References ……………………………………………………………………………………… 24

Appendix…………………………………………………………………………………………29
Appendix A……………………………………………………………………………... 29

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION v

List of Tables
Table 1: List of Definitions………………………………………………………………………..6

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION vi

List of Figures
Figure 1: Cognitive Load Theory ……………………………………………………………….. 4

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION vii

Abstract
Point-of-care ultrasound (POCUS) has the potential to improve patient outcomes, which
has led to its increased use by anesthesia providers in the perioperative setting. POCUS is
defined as an ultrasonographic imaging protocol of targeted organ systems, which can be used
for real-time physiological assessment and diagnostic purposes at the patient’s bedside. Although
POCUS is not a standardized component of nurse anesthesia education, the Council on
Accreditation of Nurse Anesthesia Educational Programs emphasizes its importance by requiring
students to record actual and simulated POCUS cases. Given the gap in current nurse anesthesia
education and the clinical importance of POCUS, the authors performed an extensive literature
review to explore whether an anesthesia-specific POCUS simulation curriculum is an effective
educational model for student registered nurse anesthetists (SRNAs). The literature supports the
use of high-fidelity simulation as an effective means to impart the requisite knowledge and
psychomotor skills required for POCUS; it is often employed in anesthesia residencies. The
authors identified system-specific POCUS assessments applicable to anesthesia practice and used
the existing evidence to develop a simulation-based POCUS curriculum that can be implemented
in nurse anesthesia education.
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 1

Chapter One
Introduction
The diagnostic capabilities provided by point-of-care ultrasound (POCUS) and its ability
to assess physiological response to treatment in real-time has led to its increased use amongst
medical providers. POCUS is defined as an ultrasonographic imaging protocol of targeted organ
systems, which can be used for real-time physiological assessment and diagnostic purposes at the
patient’s bedside (McCormick et al., 2018). While the integration of this technology by critical
care and emergency providers precedes other specialties, the potential to improve patient
outcomes in the perioperative setting emphasizes the importance of POCUS in anesthesia
practice (Pulton & Feinman, 2019).
Despite mounting evidence supporting the use of POCUS in the perioperative setting, a
lack of consensus on how to achieve provider competency exists; there is a need for the
development of an anesthesia-specific curriculum that integrates knowledge with psychomotor
skill development (McCormick et al., 2018). Integrating POCUS into nurse anesthesia education
has been forecasted by the Council on Accreditation of Nurse Anesthesia Educational Programs
(COA); at the time of writing, COA standards require student registered nurse anesthetists
(SRNAs) to track actual and simulated POCUS cases, despite a lack of case number requirement
(COA, 2020).
Emerging evidence supports the use of simulation as an effective method of ultrasound
instruction for novice anesthesia providers (Neelankavil et al., 2012; Niazi et al., 2012). Effective
simulation in medical education is grounded in Cognitive Load Theory (CLT). CLT states
learners possess a limited working memory capacity; when this capacity is exceeded, learning is
impaired. Exposure to novel concepts in complex situations may exceed the working memory
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 2

capacity of most learners. Incorporating CLT into POCUS education may provide a foundational
framework for the development of an anesthesia-specific simulation-based curriculum for nurse
anesthesia education.
Research Question and Specific Aims
The PIO (population, intervention, outcome) question guiding this investigative inquiry is
as follows: Is the integration of an anesthesia-specific point-of-care ultrasound simulation
curriculum an effective educational model for student registered nurse anesthetists? Cognitive
Load Theory serves as a theoretical framework guiding this investigative process and
intervention, which has four specific aims:
1. Perform an exhaustive review of the literature regarding the efficacy of ultrasound
simulation in anesthesia training.
2. Examine the literature regarding CLT and its application to simulation-based training and
curriculum development.
3. Identify system-specific POCUS assessments applicable to anesthesia practice.
4. Integrate evidence regarding CLT and simulation to develop an anesthesia-specific
simulation-based curriculum for POCUS training.
Background and Significance
Current Use of POCUS in Medical and Anesthesia Practice
The provider physical assessment at the bedside—at the “point of care”—forms the basis
in which decisions about treatment are made; POCUS has the potential to increase the sensitivity
and specificity of the physical assessment (McCormick et al., 2018). Although the use of
ultrasound as a diagnostic tool in medicine has existed since 1941, it was not until the 1990s that
emergency medicine physicians first recognized the value of POCUS (American College of
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 3

Emergency Physicians, 2001; McCormick et al., 2018). Ultrasound provides health care
professionals clinically significant information that cannot be obtained by physical assessment
alone at the bedside. Today, health care professionals employ POCUS to better answer specific
diagnostic questions, safely guide invasive procedures, and monitor progress or changes in
patient conditions (Kimura, 2017).
Emerging evidence continues to provide new applications of POCUS to improve patient
outcomes. Anesthesia providers can apply ultrasound to assess systems including cardiac,
pulmonary, gastric, vascular, and intracranial pressure, as well as guide fluid management,
neuraxial and regional anesthesia, and vascular access (Novitch et al., 2019; Terkawi et al.,
2013). Using POCUS to evaluate tricuspid annular plane systolic excursion (TAPSE) yields a
high sensitivity of 83.3% and specificity of 80% in diagnostic capability for pulmonary
embolism (Lahham et al., 2019). POCUS improves the ability to identify endotracheal versus
bronchial intubation with a sensitivity of 93% and specificity of 96%, proving superiority over
auscultation, and it is comparable to the gold standard (chest fluoroscopy) for identifying
endotracheal tube position (Ramsingh et al., 2016; Ramsingh et al., 2020). Data also
demonstrates using POCUS as a method to evaluate gastric contents can change the anesthetic
plan and decrease the risk of aspiration (Alakkad et al., 2015). The emergence of the coronavirus
pandemic has presented new clinical applications for POCUS. Ultrasound has a similar
reliability to chest computed tomography, and it is considered by some to be superior to chest
radiography, allowing for rapid diagnosis and treatment of patients with SARS-CoV-2 (Peng,
2020). There are a multitude of clinical applications for POCUS, many of which are applicable
in anesthesia practice.

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 4

Cognitive Load Theory, Simulation Education and POCUS Training
Cognitive load theory (CLT) is a key theoretical framework based on the following
premise: during the learning process, novel information is initially processed and stored in a
limited working memory, and it is eventually transferred to long-term memory for storage and
future retrieval (Van Merriënboer & Sweller, 2010). It is the collection of cognitive schemas and
automation stored in long-term memory that allows health professional experts to interpret
information without processing it in working memory (Van Merriënboer & Sweller, 2010).
Exceeding the capacity or duration of working memory prevents information from transferring
into long-term memory, thus impairing learning (Fraser et al., 2015). Factors that affect the ease
in which information is processed in working memory include the intrinsic nature of the learning
tasks (intrinsic load), how the task is presented to the learner (extraneous load), and how much
working memory resources are used (germane load) when dealing with intrinsic load.
Figure 1
Cognitive Load Theory

Note. Theoretical framework for CLT, depicting the process in which information enters the
working memory and long-term memory (adapted from Atkinson & Shiffrin, 1968).

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 5

Based on CLT, instructional designs can maximize training efficiency by managing
intrinsic load, minimizing extraneous load, and optimizing germane load. Several CLT principles
are highly relevant to simulation training design in the medical profession. A common approach
to dealing with high intrinsic load is the segmentation of information, which divides the learning
objectives into manageable chunks and avoids cognitive overload. This enables students to store
a larger amount of information into working memory (Fraser et al., 2015). The concept of pre-
training also aids in learning novel information by helping early schema construction to occur,
allowing the learner to freely use working memory resources for optimal learning in real clinical
scenarios (Fraser et al., 2015).
The modality principle refers to a cognitive load learning effect (Fraser et al., 2015).
Based upon this principle, a strategy consisting of a dual modality of information delivery, such
as the incorporation of both visual and auditory cues, reduces extraneous cognitive load. This
type of strategy is commonly utilized in simulation training to enhance the learning and memory
of students. Given the clinical relevance of CLT and its application to simulation education, the
authors have decided to use this theory as the theoretical framework for the basis of the
curriculum.
Table 1 provides a list of working definitions for reference throughout this paper.

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 6

Table 1
Definition of Terms
Term Definition
E-point septal separation
(EPSS)
The amount of separation between anterior leaflet of the mitral
valve and the septum in early diastole; approaches 0 mm in
healthy individuals.
Focused assessment with
sonography for trauma
(FAST)
An ultrasonographic examination used to diagnose and quantify
the presence of hemoperitoneum or hemopericardium resulting
from injury or surgical procedures.
Geomagic Touch™ A motorized device by 3D Systems® that provides touch
sensation via force feedback; it is often used in simulation,
training, and skills assessment.
Hand motion analysis
(HMA)
A type of analysis that captures the number of hand movements
during the performance of a procedure; it measures technical
proficiency in skill-based training programs.
High-fidelity simulator A simulator that produces dynamic anatomical images that can be
manipulated by a mock ultrasound probe; these simulators are
commercially produced and are costly (US $3,000 - $50,000).
Low-fidelity simulator A simulator that produces non-changing, static anatomical
images; these simulators are usually cheaper and are often hand-
made.
Point-of-care ultrasound
(POCUS)
An ultrasonographic imaging protocol of targeted organ systems,
which can be used for real-time physiological assessment and
diagnostic purposes at the patient’s bedside.
Progressive part practice A method in which a skill is segmented into part tasks and
learned in a progressive fashion.
Reaction time to sound
stimulus
Relative reaction time to the sound stimulus is used as a proxy for
change in cognitive load; a lower reaction time indicates reduced
cognitive load.
Visible Ear Simulator A simulator that features 3D stereo-graphics, haptic interaction
with Geomagic Touch™, on-screen step-by-step guides for
temporal bone procedures, and an integrated tutor function.
(Andersen et al., 2018; Lewiss et al., 2014; McCormick et al., 2018; McGraw et al., 2019;
Ramsingh et al., 2014)

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 7

Chapter Two
Methodology
A multiple-step search strategy due to the complexity of the topic was employed by the
authors. The first step was a comprehensive systematic literature search using PubMed,
CINAHL, and Google Scholar databases, performed separately by each topic of interest in the
literature review: ultrasound simulation in anesthesia, Cognitive Load Theory in the learning
process, and POCUS and anesthesia. Keywords utilized for the literature search included:
POCUS, ultrasound, anesthesia, simulation, education, and Cognitive Load Theory. Citations
from all selected articles were further reviewed for identification of additional relevant
references for inclusion in this study.
The initial search resulted in 132 research articles. Articles in the English language
published from 2009 to 2020 were initially screened through title and abstract. Further evaluation
for relevancy was performed based on the following inclusion criteria: (a) identified the use of
ultrasound simulation in anesthesia practice, (b) examined how CLT is applied to the learning
process, or (c) identified the use of POCUS in anesthesia practice. A final selection of 12 articles
was included in the literature review.
The authors selected SonoSim® as the simulation software to deliver the proposed
curriculum (SonoSim, 2020). This platform was chosen for its extensive ultrasound education
library with real patient cases and interactive simulation ultrasound probe, allowing users to
develop the psychomotor skills necessary for POCUS. The module library delivers didactic
contents on anatomy, physiology, and techniques through an interactive multimedia format
utilizing animation, audio presentation, dynamic ultrasound, and computer graphic images
(SonoSim, 2020). The ability for self-pacing within SonoSim® library and the flexibility to learn
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 8

outside of the classroom setting allowed these authors to design a curriculum based on CLT to
optimize long-term learning in nurse anesthesia students. It is important to note there is no
conflict of interest or funding being offered by SonoSim® for the purpose of this investigation.
Current evidence was evaluated to identify areas pertinent to anesthesia practice,
including but not limited to cardiac, airway, respiratory, vascular, neuraxial, and gastrointestinal
systems assessment. Specific modules were selected from the SonoSim® library based on their
pertinence to anesthesia practice. The final deliverable is an organized curriculum of modules
and their corresponding Mastery Tests—a final knowledge assessment offered by SonoSim®
(SonoSim, 2020). This curriculum is designed to be delivered over the course of eight weeks.

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 9

Chapter Three
Literature Review
Ultrasound Simulation Training in Anesthesia
A prospective, randomized controlled trial by Neelankavil et al. (2012) evaluated
simulation effectiveness in teaching basic principles of transthoracic echocardiography (TTE) to
anesthesia residents; basic principles included anatomical knowledge and image acquisition. A
final sample consisted of 59 residents randomized into a simulation or control group. Each group
received a 45-minute didactic session on TTE indications, anatomy, views, manipulation, and
evaluation of volume status and ischemia. The simulation group was then exposed to a 15-
minute introduction to TTE, followed by 30 minutes of simulation time; the control group was
exposed to video-based training created by a cardiac anesthesiologist. Both groups were
evaluated by a posttest and their performance of a TTE examination on a volunteer subject. After
initial training, the simulation group scored significantly better on the written posttest compared
to the control group (68.2% vs 57.9% respectively; p < 0.001). Compared with the control group,
the simulation group obtained higher quality images (p = 0.003), correctly identified more
anatomic structures (p = 0.003), and obtained views more efficiently—measured by average time
acquiring each view (p < 0.001). After a second training session, the simulation group
maintained significantly higher scores in all measured variables.
Weber et al. (2019) performed a single-center, prospective randomized controlled trial
evaluating three methods of educating anesthesia and intensive care residents in transesophageal
echocardiography (TEE). Examined methods included: a one-on-one mannequin-based TEE
simulator, one-on-one teaching in the operating room on a live patient (often referred to as the
“golden standard”), and e-learning didactic education; each group had two training sessions. A
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 10

sample of 51 residents were randomized into three groups; 17 residents per group provided a
power of 80% at a significance level of 0.05. All three groups were evaluated by posttest after
their first training session, a practical portion after their first and second training sessions,
followed by an additional practical portion three months later. The simulation group scored
significantly better on the posttest (p = 0.005), and significantly better on the first (p = 0.008),
second (p = 0.015), and third (p = 0.022) practical tests.
Ferrero et al. (2014) were the first to compare the effect of mannequin-based TEE
simulation with conventional (didactic) training on skill acquisition in obtaining TEE images on
live patients. This prospective randomized controlled trial consisted of 42 anesthesia residents;
21 residents in each group provided 89% power to detect a meaningful difference. Each group
received 45 minutes of training. The didactic group utilized PowerPoint instruction (with video
clips) on image acquisition, anatomy, and probe manipulation. The simulation group consisted of
a didactic session integrated with a mannequin-based simulator. Each individual was asked to
obtain 10 standard TEE views on an actual patient. The simulation group obtained higher quality
images (p = 0.016) and higher scores in obtaining all but one view (p = 0.021); no significant
difference in time required to complete TEE examinations was observed. The authors adjusted
for patient-specific variables by subtracting resident scores from attending scores; the average
adjusted score was significantly lower amongst the simulation group compared with the control
group (p = 0.027). These data indicate simulation-trained residents demonstrated better skill
acquisition compared to their conventionally trained colleagues.
A prospective randomized controlled trial by Niazi et al. (2012) evaluated the effect of
low-fidelity simulated (Table 1) ultrasound-guided nerve blocks in novice operator performance.
Thirty residents, excluding those with previous experience, were randomized into a simulation or
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 11

conventional group. Each group received four, half-hour didactic lectures on ultrasound guided
peripheral nerve blocks. The simulation group was then exposed to a one hour-long teaching
session with hands-on practice; the conventional group did not receive additional training.
Successful blocks on actual patients were tracked for three weeks. Successful attempts between
the groups were compared with χ
2
tests. The simulation group completed more successful blocks
compared with the control group (144 vs 98; p = 0.016). More residents achieved proficiency in
the simulation group (80% vs 40%); however, these results were not statistically significant (p =
0.0849).
Ramsingh et al. (2014) performed a single-center, prospective, blinded trial comparing
the effectiveness of a model/simulation-guided ultrasound curriculum with the standard didactic
lecture in teaching perioperative POCUS to anesthesia residents; learning objectives focused on
cardiopulmonary function, fluid volume status, and evaluation of severe thoracic and abdominal
injuries through focused assessment with sonography in trauma (FAST) examination (Table 1).
A sample of twenty anesthesiology residents from a university medical center was evenly
divided into two intervention groups. The didactic group was exposed to 90-minute one-on-one
lectures by an expert sonographer; the model/simulation group was exposed to 90-minute
education sessions led by the same sonographer using both a human model and simulation
mannequin. Each group completed a multiple-choice pretest prior to education, followed by a
posttest and ultrasound examination on a standardized patient three weeks later; the posttest
consisted of questions that required application of learned content, rather than recall of
information. Nonparametric Wilcoxon tests showed no significant difference in pretest scores
between the two groups. The model/simulation group scored significantly higher on the posttest
(p = 0.04) and on the standardized patient examination (p = 0.04). These data indicate improved
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 12

retention and clinical application of content amongst the model/simulation group. The authors
acknowledge sample size as a key limitation; a power analysis was not delineated in their
publication.
Cognitive Load Theory in the Learning Process
Using the principles of CLT, McGraw et al. (2019) evaluated the effect of a progressive
part practice (Table 1) curriculum to teach ultrasound-guided internal jugular catheterization to
blinded novice residents, compared to the local standard of a single simulation session. A sample
of 16 residents was enrolled in the intervention group and 46 residents in the control group. The
intervention group was enrolled in the curriculum: advanced preparation (online videos, online
reading materials, and pre-tests), followed by three 2-hour training sessions that consisted of
online reading and pre-tests, basic introduction to ultrasound and probe handling, and practice on
models. Hand motion analysis (HMA) (Table 1) data was collected at the beginning and end of
each training session for all residents in the intervention group, and at the end of the single
simulation session for all residents in the control group; this data was used to measure technical
proficiency in catheterization. Nonparametric Mann-Whitney U tests showed that the HMA
results of the intervention group were significantly better than the results of the control group at
the end of the third 2-hour session (p < 0.001), clustering around the expert benchmark. The
study, despite the lack of randomization and large sample size, suggests a progressive part
practice curriculum may be an effective approach to teaching procedural skills, allowing
residents more working memory capacity to manage the increased cognitive load in the clinical
environment.
Andersen et al. (2018) performed a prospective, controlled cohort study to determine if
repeated virtual reality (VR) simulation practice of the mastoidectomy procedure induced a
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 13

lower cognitive load and higher dissection performance compared with the traditional cadaver
dissection environment. Nine post-graduate otorhinolaryngology residents were selected into the
intervention group, while 28 residents participated in the control group. Both groups attended
temporal bone courses, consisting of 1.5 days of lectures, a VR simulation training block, and
two days of dissection training on a cadaver; only the intervention group completed prior VR
simulation training with Visible Ear Simulator and Geomagic Touch™ (Table 1). Baseline
reaction times to a sound stimulus were collected before and after each practice block and
cadaver procedure. Results showed relative reaction time in VR simulation decreased
significantly with repeated practice (p < 0.002), and the performance in cadaver dissection by the
intervention group was superior to the control group (p < 0.01). Linear mixed models revealed
that after the interventional training, the relative reaction time decreased by 15 percentage points
(p < 0.001); the interventional group had a lower relative reaction time during the cadaver
dissection training compared to the control group (p < 0.01). The study data suggest that the VR
simulation training assisted subsequent learning in the complex dissection learning environment,
as evidenced by the consistent lower relative reaction time and the higher performance.
A randomized, controlled trial conducted by Bjerrum et al. (2013) explored the
effectiveness of integration of physical demonstrations into simulation training for the
bronchoscopy procedure. A total of 48 medical students were randomly assigned to either the
interventional group or the control group. All students—novices in bronchoscopy and
bronchoscopy simulators—completed eight bronchoscopy simulation training cases, while the
interventional group observed three physical demonstrations of the simulated bronchoscopy on a
model performed by an instructor. All participants were tested with pre-, post-, and 3-week
retention tests. The interventional group outperformed the control group in all post-training
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 14

simulator metrics tests except one and the 3-week retention test (p ≤ 0.001). Study results
suggest that training can be further enhanced by adding modelling examples consisting of a
living demonstration.
POCUS in Anesthesia Clinical Care
Ramsingh et al. (2016) conducted a prospective, double-blinded, randomized control
study comparing the sensitivity and specificity of POCUS Pulmonary Tree and Lung expansion
Ultrasound Study (PLUS) versus auscultation in determining tracheal, right main stem bronchus,
or left main stem bronchus intubation. Forty-seven patients were recruited and randomized into
three groups: tracheal, right stem bronchus, or left stem bronchus. Four anesthesiologists each
performed a different task in each case: intubation, repositioning of the endotracheal (ETT) with
fiber-optic, auscultation, and ultrasound. Both the auscultator and the sonographer were blinded
to ETT placement at the time of examination. Each intubation placement was verified by both
auscultation and PLUS exam, and sensitivity and specificity were compared. Auscultation
showed a sensitivity of 66% and a specificity of 59% in differentiating tracheal versus bronchial
intubations, whereas POCUS showed a sensitivity of 93% and specificity of 96%, respectively.
The auscultation group identified tracheal versus bronchial intubation at 62% (26 of 42), and
POCUS group at 95% (40 of 42) (p = 0.0005). These results show that POCUS provides superior
diagnostic capability in ETT placement confirmation both in sensitivity and specificity, and is
able to identify bronchial intubations at a much higher rate compared to auscultation alone.
Koundal et al. (2019) conducted a prospective observational study assessing the
correlation between measurements obtained through POCUS and difficult laryngoscopy and
intubation. Two hundred patients requiring general anesthesia and tracheal intubation between
the ages of 20 and 60 were enrolled, and the study was conducted over 12 months in 2017.
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 15

Ultrasonographic measurements were obtained in the pre-operative area with patients lying
supine with maximal chin lift; following induction, the laryngoscopy was performed by
anesthesiologists blinded to the ultrasound findings. Statistical analysis was performed to
compute sensitivity and specificity of POCUS measurements in predicting difficult
laryngoscopy, and correlation with Cormack-Lehane (CL) grade 3 and 4 was used as a
confirmatory predictor of difficult intubation. Depth of the pre-epiglottic space (Pre-E) and
distance from the epiglottis to the midpoint of the distance between the vocal cords (E-VC) were
obtained through POCUS to calculate pre-E/E-VC values, with a sensitivity of 82.8% and
specificity of 82% in predicting difficult airway. Soft tissue neck measurements obtained through
POCUS at the level of hyoid bone to skin (DSHB) had a moderate positive correlation with CL
grading (r = 0.551, p = 0.00), whereas the POCUS measurement at the level of thyrohyoid
membrane, from skin to epiglottis midway between the hyoid bone and thyroid cartilage,
(DSEM) had a strong positive linear correlation with CL grading (r = 0.701, p = 0.00). The Pre-
E/E-VC ratio calculated from POCUS measures indicated a strong positive relationship (r =
0.787, p = 0.00), while the hyomental distance ratio had a moderate negative correlation with CL
grading (r = -0.671, p = 0.00). This study provides promising data of POCUS as a predictive
indicator for difficult intubation; however, some limitations include exclusion of obese patients
with BMI > 30 kg/m
2
, inter-subject variability and operator efficiency variability, and the fact
that difficult laryngoscopy, which provides visual assessment of patient’s airway, does not
necessarily result in difficulty with ETT insertion.
Cowie (2009) conducted a prospective observational study examining the feasibility and
usefulness of focused cardiovascular ultrasound (FOCUS) performed by anesthesia providers in
perioperative settings. The study included 50 patients requiring a focused transthoracic
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 16

echocardiogram (TTE) from May 2007 to 2008. Data were collected on clinical indications for
FOCUS, estimations of cardiac function through left and right ventricular volume and function,
along with atrioventricular, aortic, and pulmonic valves. Data also included the impact of
FOCUS on the choice of anesthetic technique, fluid and vasoactive management, invasive
cardiac monitoring, and referral to formal cardiac evaluation. The patient population included 30
males and 20 females (60% and 40%, respectively), ranging from 16 to 96 years of age, and a
mean age of 65. Depending on the FOCUS result, patient management was adjusted
accordingly—the most common adjustment was use of invasive hemodynamic monitoring, while
others included postponing cases for further cardiac evaluation, switching surgical plans to more
conservative, less invasive strategies, and changing the anesthesia management through different
induction agents and techniques. All patients examined with FOCUS had a formal TTE at a later
date, which confirmed preliminary findings from FOCUS, and eighty-four percent of the patients
had changes in perioperative anesthesia care.
McKaigney et al. (2014) conducted a prospective observational study examining the
predictive relationship between mitral-valve E-point septal separation (EPSS) (Table 1) to
quantitative, calculated left ventricular ejection fraction (LVEF). Eighty adult subjects enrolled
as a convenience sample in 2012 underwent a comprehensive transthoracic echocardiogram;
within 24 hours of the TTE, emergency department (ED) physicians who were blinded to the
TTE results performed a bedside 4-view basic echocardiogram. The investigators obtained the
parasternal long-axis view and measured the EPSS during early diastole as the smallest distance
between the tip of the anterior valve leaflet and the interventricular septum. Measurements of
LVEF were made through the comprehensive TTE and were categorized into normal (LVEF >
55%), moderate dysfunction (30% < LVEF < 55%), or severe systolic dysfunction (LVEF <
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 17

30%). Linear regression showed that EPSS is a statistically significant predictor (p < 0.001) of
calculated LVEF. The sensitivity and specificity of the EPSS greater than 7 mm for severely
reduced LVEF were 100% (95% CI: 62.9-100.0) and 51.6% (95% CI: 38.6-64.5), respectively;
the sensitivity and specificity of the EPSS greater than 8 mm for any systolic dysfunction was
83.3% (95% CI: 62.6-95.2) and 50.0% (95% CI: 29.2-70.9), respectively. This study shows that
EPSS measurements obtained through a bedside ultrasonography strongly correlate with
calculated LVEF assessed through comprehensive TTE.

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 18

Chapter Four
Results
The authors propose an 8-week curriculum encompassing the necessary sonographic
modalities for anesthesia providers. Selected SonoSim® modules are based on the current
evidence supporting POCUS in anesthesia practice, as well as POCUS curricula identified in the
literature to have been successfully implemented into anesthesia residency programs. The
proposed curriculum is presented in Appendix A.
The first week of the curriculum focuses on developing the foundational knowledge and
psychomotor skills required for POCUS. These topics include ultrasound physics, appropriate
probe selection, probe orientation, and image optimization (Meineri et al., 2018). The learner
will complete the SonoSim® Core Clinical module: Fundamentals of Ultrasound, as well as the
accompanying SonoSimulator® assignment. This module includes the interpretation of common
ultrasound artifacts, imaging modes, and an introduction to the physics of doppler imaging; these
concepts will aid the learner with future sonographic assessments.
Venous and arterial vascular image acquisition for the purposes of assessment and
cannulation are important skills for the anesthesia provider (Ramsingh et al., 2015). Nurse
anesthesia residents are likely to encounter opportunities for ultrasound guided vascular
procedures early in their clinical residency; for this reason, these skills will be the focus of the
second and third weeks of the curriculum. These modules focus on probe selection and
manipulation, image acquisition and identification of anatomic structures, needle identification
and guidance, and cannulation. The following Sonosim® Core Clinical modules will be
completed over these two weeks: Peripheral Venous Access, Ultrasound-Guided Internal Jugular
Vein Cannulation, Ultrasound-Guided Femoral Line Placement, and Ultrasound-Guided
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 19

Subclavian Vein Cannulation. The accompanying SonoSimulator® modules will also be
completed.
The fourth week is oriented towards basic cardiac sonography. The curriculum introduces
core cardiac concepts in week four and revisits more complex cardiac concepts in weeks seven
and eight; this is due to the complexity of cardiovascular assessment. This module focuses on
probe selection and positioning, as well as the four most common sonographic views of the
heart: parasternal long and short axes; apical 4-chamber; and subxiphoid/inferior vena cava
(IVC) views. The student will learn to identify normal anatomic structures and motion—
including the IVC and its correlation to pulmonary artery pressure (Ramsingh et al., 2015;
Sanders et al., 2019). The learner will complete the SonoSim® Core Clinical module:
Cardiology with the accompanying SonoSimulator® assignment.
The fifth week focuses on basic pulmonary and airway sonography which will include
transducer selection, appropriate probe placement, probe manipulation, normal intercostal views,
as well as identification of the pulmonary and thoracic anatomy. The learner will become
familiar with ultrasound image characteristics and artifacts that are unique to the lung: lung
sliding, lung pulse, seashore sign, barcode sign, A-lines and B-lines. The SonoSim® Core
Clinical modules: Pulmonary and Airway will prepare the learner to understand the clinical
significance of sonographic signs and determine the underlying pathologies corresponding to
them—pneumothorax, pleural effusion, and lung consolidation. The airway module will serve as
an introduction to utilizing ultrasound to assist with endotracheal intubation and cricothyrotomy.
(Sanders et al., 2019). The learner will then complete the accompanying SonoSimulator®
assignments.
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 20

The cardiac and pulmonary modules serve as foundations to the sixth week of the
curriculum, which focuses on assessment with sonography for trauma—the FAST examination.
The SonoSim® Core Clinical: eFAST Protocol will help the learner understand the indications
for FAST, transducer selection, sonographic windows, anatomic structure identification, and
differentiation between positive and negative examinations (Ramsingh et al., 2015). The student
will also complete the SonoSim® Core Clinical: Aorta/IVC and the accompanying
SonoSimulator®; this content will complement both cardiovascular and FAST assessments.
The final two weeks of the curriculum focus on advanced cardiac concepts. These
concepts necessary for anesthesia providers include left and right ventricular evaluation,
evaluation of volume and hemodynamic status, and assessment of valvular abnormalities
(Ramsingh et al., 2015; Sanders et al., 2019). The learner will complete the SonoSim®
Advanced Clinical: Focused Cardiac Ultrasound (FOCUS) – Part I and Part II during weeks
seven and eight, respectively; the accompanying SonoSimulator® assignment will also be
completed.
Additional content relevant to anesthesia providers that is not part of the proposed
curriculum is ocular sonography. The relationship between the optic nerve sheath diameter and
intracranial pressure (ICP) has been well established, and ocular ultrasound is often utilized in
the assessment of ICP (Ramsingh et al., 2015). Completion of the SonoSim® Core Clinical:
Ocular module and its corresponding SonoSimulator® modules specific to the optic nerve sheath
and ICP will supplement the resident’s learning. Nurse anesthesia residents are also encouraged
to complete more simulations than assigned, should time permit. Repetition is a key component
in developing the psychomotor skills necessary for a solid foundation in POCUS.
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 21

The proposed curriculum and its components are based on the existing literature in
POCUS education, as it applies to anesthesiology. The authors acknowledge that nurse
anesthesia programs may vary in their ability to implement this curriculum in its entirety due to
varying time constraints; program leaders may alter the time frame in which the curriculum is
completed, as well as the simulation assignments as they see necessary.

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 22

Chapter Five
Discussion
Despite increasing data supporting the application of POCUS in anesthesia, it is not
currently a mandated component of nurse anesthesia education, and different nurse anesthesia
programs have varying ability to implement such education. SonoSim® pairs education modules
with high-fidelity simulation case scenarios and provides learners the flexibility to learn and
practice the necessary psychomotor skills at their own pace. The research shows high-fidelity
simulation is an effective training modality; when combined with cognitive load theory,
SonoSim® provides a foundational model for developing the knowledge and psychomotor skills
required for POCUS.
Although the proposed SonoSim® curriculum provides high-fidelity simulation and
flexibility tailored to nurse anesthesia programs and their residents, the authors acknowledge
some limitations. A major limiting factor is cost: the SonoSim® interface requires the purchase
of high-fidelity simulation probes and software packages. The cost of SonoSim® is
approximately $1,500 per student resident, which puts financial strain on either institutions or
learners. Given that nurse anesthesia programs may not formally include POCUS training in their
curricula, it may also be challenging to allocate an adequate time required for the incorporation
of this curriculum. The proposed curriculum is extrapolated from physician residency programs,
which may have differing time commitments compared with nurse anesthesia programs.
Additionally, SonoSim® currently does not offer regional anesthesia modules—a vital
component of anesthesia education. A further note is made regarding the proposed curriculum
focusing on adult scenarios; future opportunities for improvement to the curriculum would be
inclusive of pediatric sonography.
POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 23

While there exists strong evidence supporting the use of POCUS simulation within
physician residencies, additional research is indicated to explore the benefits of simulated
POCUS training in nurse anesthesia education. Furthermore, future research should be aimed to
assess how well the proposed SonoSim® curriculum translates into clinical practice by
examining provider competency, such as through a final practicum with the use of standardized
patients.
Conclusion
The current literature supports the integration of an anesthesia-specific point-of-care
ultrasound simulation curriculum as an effective educational model for student registered nurse
anesthetists. SonoSim® provides a flexible high-fidelity simulation experience that can be
translated into clinical practice and integrated into nurse anesthesia programs. As the field of
nurse anesthesiology continues to advance, the ability to accurately diagnose and assess our
patients’ physiological responses to treatment in the perioperative setting becomes increasingly
important; the incorporation of the authors’ proposed curriculum may fulfill this educational
need.

POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 24

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POCUS SIMULATION IN NURSE ANESTHESIA EDUCATION 29

Appendix A
Week # Core Clinical Assignment
Week 1

Due: _____
Core Clinical:
1. Fundamentals of Ultrasound
Procedure:
2. Introduction to Ultrasound Guided
Procedures
Fundamentals: All

Week 2

Due: _____
Procedure:
1. Peripheral Venous Access
2. Ultrasound-Guided Internal
Jugular Vein Cannulation

Peripheral Venous Access: 1-5

Jugular Vein Cannulation: 1-5
Week 3

Due: _____
Procedure:
1. Ultrasound-Guided Femoral Line
Placement
2. Ultrasound-Guided Subclavian Vein
Cannulation
Femoral Line Placement: 1-5

Subclavian Cannulation: 1-5
Week 4

Due: _____
Core Clinical:
1. Cardiology
Cardiology: 1-4, 5-9
Week 5

Due: _____
Core Clinical:
1. Pulmonary
2. Airway
Pulmonary: 1-3, 5,6

Airway: 1-4
Week 6

Due: _____
Core Clinical:
1. eFAST
2. Aorta/IVC
eFAST: 1-4

Aorta/IVC: 1, 3, 5, 7-10
Week 7

Due: _____
Advanced Clinical:
1. FoCUS Part I
FoCUS Part I: 1-7
Week 8

Due: _____
Advanced Clinical:
1. FoCUS Part II
FoCUS Part II: 1-7

Abstract (if available)

Abstract Point-of-care ultrasound (POCUS) has the potential to improve patient outcomes, which has led to its increased use by anesthesia providers in the perioperative setting. POCUS is defined as an ultrasonographic imaging protocol of targeted organ systems, which can be used for real-time physiological assessment and diagnostic purposes at the patient’s bedside. Although POCUS is not a standardized component of nurse anesthesia education, the Council on Accreditation of Nurse Anesthesia Educational Programs emphasizes its importance by requiring students to record actual and simulated POCUS cases. Given the gap in current nurse anesthesia education and the clinical importance of POCUS, the authors performed an extensive literature review to explore whether an anesthesia-specific POCUS simulation curriculum is an effective educational model for student registered nurse anesthetists (SRNAs). The literature supports the use of high-fidelity simulation as an effective means to impart the requisite knowledge and psychomotor skills required for POCUS; it is often employed in anesthesia residencies. The authors identified system-specific POCUS assessments applicable to anesthesia practice and used the existing evidence to develop a simulation-based POCUS curriculum that can be implemented in nurse anesthesia education.

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Creator Guo, So Hee Lee (author)

Core Title Integration of point-of-care ultrasound (POCUS) simulation curriculum in nurse anesthesia education

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Degree Conferral Date 2022-05

Publication Date 04/21/2022

Defense Date 03/20/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag anesthesia,anesthesiology,cognitive load theory,Education,nurse anesthesia,Nurse Anesthesiology,OAI-PMH Harvest,POCUS,Point-of-Care Ultrasound,simulation,ultrasound

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