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Table 3 Educational focus of the studies

From: Educational standards for training paramedics in ultrasound: a scoping review

Study Education Method Educational Focus Duration Education details Results
Baldaranov et al. \2015 [20] Didactic (online) + practical Application & interpretation 2-months A course of 2-months. Web based curricula designed in two parts: (1) theoretical and (2) real life training under neurological supervision. Study is ongoing.
Booth et al. 2015 [14] Didactic & practical Application, knowledge & interpretation 2 h of lectures & 4 h of practical and simulation Paramedics were trained to under-take two attempts at a subxiphoid and parasternal long axis view and to assess images for the following: movement, function, rhythm, fluid and chambers. This systematic approach focused on evaluating the presence and quality of cardiac movement, and to detect conditions amenable to therapeutic intervention. To simulate actual OHCA, some scanning was performed on the floor. Participants completed a pre-course and post-course questionnaire. 88% obtained successful views during timed 10s pulse check Theoretical knowledge improved (54% pre-course to 89% post course)
Brooke et al. 2011 Didactic & practical Application, knowledge & interpretation 2-day education & training program Participants reviewed the pathophysiology and management of patients with pneumothorax before learning to differentiate the normal and abnormal sonographic appearance of the lungs. Lung US was taught in a systematic manner. Following the program, the participants were assessed by (1) the ability to detect the presence or absence of a pneumothorax using 30 prerecorded lung US video clip images and (2) an OSCE. All paramedics passed examination with standard judged to be equivalent to that expected of candidates in thoracic module of College of Emergency Medicine level 2 US program.
Cappa et al. 2015 [28] Not Reported Not Reported Not Reported Not Reported A non-statistically significant decrease (9.2%) in the use of central lines in the ED following implementation of paramedic and nursing-led ultrasound program.
Chin et al. 2013 [16] Didactic & practical Application & interpretation 1 h lecture & 1 h practical Paramedics received training on the basics of ultrasonography, the PAUSE protocol, image acquisition, and basic image interpretation, followed by a 1-h hands-on session. An Emergency Physician trained in bedside US demonstrated the following views on a human model: a thoracic view of the pleural interface of the lung, a subxiphoid cardiac view, and a parasternal long cardiac view. Participants were then assessed by (1) image recognition and (2) the ability to acquire an adequate view of the left and right pleural interfaces and one view of the heart without assistance. Average score 9.1/10 on image recognition test 6 paramedics were unable to identify cardiac standstill. 100% of images acquired by paramedics were satisfactory to evaluate PTX 55% of paramedics obtained satisfactory cardiac views
Heegaard et al. 2004 [7] Didactic & practical Application & interpretation 7 h training program followed by 8 h of hands-on supervised training in ED Introduction to US, physics and the use of US within air medical practice. This was followed by information on echocardiography, abdominal US, pelvic and obstetrical US, and the FAST examination with a demonstration. The 3-h practical session involved individual instruction before each clinician performed a further 8-h in an ED on emergency patients. In addition, learning resources were made available via a website. At the end of 6 weeks a final training session was provided and skills were assessed. This included (1) a written test and (2) a practical imaging test. These same tests were administered 1 year from the initiation of the program. US for pericardial effusion: sensitivity & specificity 100% (1/86 cases positive), no false negative or false positive cardiac US Abdominal trauma cases: sensitivity 60%, and specificity 93%.
Immediately post-course questionnaire score of 82% vs. percentage when administered 1 year later - 71%
Heiner & McArthur 2010 [17] Didactic & practical Application & interpretation 2- min orientation/training Participants received a 2-min standardized orientation and training session ensuring familiarization with examination of the semi-opaque fracture model. They then sonographically evaluated the 5 completely opaque models. Sensitivity of 97.5% and specificity of 95.0% across 5 different fracture patterns.
Knapp et al. 2012 [22] Didactic & practical Application & interpretation 1 h online home based study program followed by 4 h training program A four- hour training program that consisted of a didactic lecture, practice scanning, and testing scenarios. All participants underwent a pre- and post-training written test. The final testing scenarios included one normal and abnormal cardiac, and one normal and abnormal FAST. All scenarios were performed on live standardized patients and graded in an OSCE format. Average score on the pre and post-test was 73% and 95% respectively (p < 0.0001). EMS providers (n = 90) scored on average 98.9 points out of 100 on the OSCE testing stations. EMT-Ps (n = 70) scored, on average 98.9 points out of 100 on the OSCE stations. Average score for EMT-Is (n = 20) was 99.1 points out of 100 on the OSCE stations.
Lahham et al. 2015 [21] Didactic & practical Application & interpretation 3-h session on POCUS that included didactics, hands-on training and a final test. A three-hour session on POCUS including didactics, hands-on training and a final test was conducted. Participants then used POCUS in a clinical setting during dispatch calls and saved scans related to: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest. The scans were later evaluated by two independent ultrasound fellowship-trained emergency physicians. Paramedics were able to obtain adequate scans 89% of the time. Two scans were considered of inadequate diagnostic quality. Two cardiac arrest studies were reported and paramedics correctly identified both of these cases as cardiac standstill.
Lema et al. 2014 [26] Didactic & practical Application & interpretation 10 min lecture and hands-on session Subjects intubated four cadavers without POCUS guidance and were assessed for correct tube placement by an emergency physician. All participants then underwent a 10-min lecture and hands-on session about POCUS identification of tracheal versus esophageal tube placement. Participants then intubated four cadavers using POCUS guidance and were assessed for correct tube placement. Correct tube placement improved from 87.1% (n = 132) without POCUS to 95.3% (n = 128) with POCUS guidance (p = 0.018).
Lyon et al. 2012 [23] Didactic & practical Application & interpretation 25 min instructional session A cadaver was used as a model for demonstrating the presence or absence of the SLS. A total of 6 intubations, yielding a total of 48 trials, were performed. With bag valve ventilation and endotracheal intubation, the pleural movements of the cadaver result in the appearance of the SLS. When intubated in the esophagus, bag valve ventilation results in no pleural movement and, thus, no SLS. The cadavers were randomly intubated, using a random number generator, in the trachea or in the esophagus. The presence or absence of the SLS was confirmed before each trial by the investigators. Correct identification in 46 out of 48 trials. At the 9-month follow up the presence of absence of SLS was identified in 56/56 trials resulting in sensitivity and specificity of 100%.
Press et al. 2013 [24] Didactic & practical Application, knowledge & interpretation 2 h lectures & hands-on training followed by real patient training over 6 weeks Baseline knowledge was ascertained via a pre-test before a 2-h lecture. In an instructor-participant ratio of 1:4 participants completed a FAST on different models. The second stage of training occurred over a 6-week period. APPs in groups of two attended a 4-h practical session with one of three emergency ultra-sonographers. APPs performed a minimum of four EFAST with supervised instruction on real patients. Six Web-based educational modules, 10–20 min in length progressively covered the techniques of EFAST scanning. Three weeks into the second phase of training, APPs practiced EFAST on trauma patients in flight. Finally, APPs attended a 1-h classroom lecture reviewing EFAST techniques and imaging. The pre-training test was re-administered and an OSCE was administered immediately after the post-training test. Mean score for online module pretest was 43% (0 of 33 passed). Mean score post-test 78% (28 of 33 passed) 79% passed OSCE first attempt
Quick et al. 2016 [8] Didactic & practical Application & interpretation Single series of lectures followed by real time US examinations. Training consisted of didactic series of lectures, followed by real-time US examinations of the thorax on healthy human volunteers. Live animal models; (swine) were also utilised to visualise both normal and abnormal thoracic US findings. Pre-hospital sensitivity of 68% and specificity 96% compared to sensitivity of 84% and specificity of 98% in emergency department of same patients. Aeromedical accuracy 91% vs surgeon 98% in the diagnosis of pneumothoraces.
Roline et al. 2013 [27] Didactic (online) & practical Application & interpretation 15 min online lecture + 60 min hands-on training Care providers reviewed a standardized 15-min lecture online, which incorporated a review of thoracic ultrasound followed by a 60-min hands-on training session on healthy models during flight in the supine position. Participants evaluated the presence or absence of the sliding lung sign and recorded 6-s video clips of each side of the chest during that time. 58% of patients had thoracic US. Substantial agreement (kappa = 0.67) between helicopter operator and expert reviewer who looked at images later. Reviewer rated 54% of the images taken as ‘good’ quality.
Ulneur et al. 2011 [18] Didactic & practical Application & interpretation 4 h didactic training + 4 h hands-on training Training was provided by a radiologist to conduct a FAST assessment. Results were recorded as positive/negative for free fluid in each case. Following training, 127 patients were evaluated by the paramedics. Patients then underwent abdominal US by radiology specialists who were blind to the study protocol but not to the clinical status of the patients. Computerized abdominal tomography (CAT) was ordered as desired by general surgeon consultants and evaluated by radiologists who were blind to the study. The gold standard for the presence of free fluid was the official radiologist reports of USG and CAT. Paramedic performed FAST: sensitivity 84.62%, specificity 97.37%
West et al. 2014 [19] Didactic & practical Application & interpretation 4-h course involving both lecture and hands-on training Training consisted of a 4-h course taught by a certified ultra-sonographer and board certified emergency physician. The course involved both lecture and hands on portions with access and training on both control and positives. After the training course a 2-week waiting period was allowed to lapse prior to simulation testing. False-positive rate of 59% significantly higher than the false-negative rate of 41% (p < 0.01). Overall sensitivity of FAST scan in MCI was 67% and specificity of 56%. Average 121.8 s per exam.
Walcher et al. 2010 Didactic & practical Application & interpretation 1-day course Participants were introduced to the concepts of US and FAST in trauma. During three practical sessions, participants performed FAST under the supervision of experienced clinical instructors with a ratio of 1:2. Each participant performed up to 30 ultrasound procedures. Initially, participants performed the standardised procedure of FAST on both healthy volunteers and patient volunteers. Participants then learnt how to perform the ultrasound procedure under difficult circumstances. Finally, real-time scenarios of healthy or patient volunteers found in critical situations following an accident were presented. During the study period of 12 months, FAST investigations were performed on-scene and later evaluated for time and accuracy. The accuracy of the findings were verified using FAST and CT scanning in the emergency department as the gold standard. Results from the 9 participants (C-group) compared with results from 2 other groups: P-group (10 trauma surgeons trained in FAST with <3 years experience) & I-group (9 ED flight physicians using US occasionally but not formally trained) After training C-group achieved 100% accuracy (in 39 procedures) No significant difference between C group vs P group or I group
Vitto et al. 2015 [25] Didactic (including online component) + practical Knowledge & application 6 h US training course over 4 month period Participants completed a pre-test followed by a 90-min didactic lecture and 90-min hands on simulation session. Following this they were given 24/7 access to the POCUS. Four months following initial training the participants completed another 90-min didactic lecture and 90-min hands on simulation before completing a post-test questionnaire and survey. Pretest and post test scores were 78% and 85% respectively.