Remodeling Point‐of‐care Ultrasound Education in the Era of COVID‐19

The novel COVID‐19 pandemic will alter the educational experience for medical students, residents, and fellows worldwide. It has already led to significant changes within most hospitals, including the cancellation of elective procedures, clinical rotations, lectures, and educational conferences. This is no different in emergency medicine (EM) residencies and fellowships. As the demand for hospital resources has increased, residents and fellows have had to surrender educational activities and conferences to prioritize clinical duties prompting creative solutions within residencies. ¹

Since 2012, the Accreditation Council for Graduate Medical Education (ACGME) has designated the use of point‐of‐care ultrasound (POCUS) as one of 23 milestone competencies for EM residents. ² The 2016 American College of Emergency Physicians (ACEP) policy statement on emergency ultrasound advises that a trainee should perform a total of 150 to 300 scans as part of POCUS training. ³ Furthermore, the 2011 ACEP Emergency Ultrasound Fellowship Guidelines state that fellows should acquire a minimum of 1,000 ultrasound examinations. ⁴ Although POCUS can significantly enhance clinical decisions, hands‐on ultrasound scanning and teaching has significantly decreased in the emergency department (ED).

Historically, POCUS education has consisted of understanding the indications for imaging, learning skills for image acquisition, interpreting ultrasound images, and learning how to integrate findings into medical decision making. Fellowship training also includes research, preparing and delivering educational lectures, quality assurance (QA), and attendance at national conferences. While the Society of Clinical Ultrasound Fellowship (SCUF) has issued guidance on graduation requirements, ⁵ further education guidelines and suggestions are needed. Herein, we describe several practical strategies for both resident and fellow POCUS education (Table 1).

Table 1.

Strategies for POCUS Education in the Covid‐19 era

Challenges	Recommended Solutions
Image acquisition
Ultrasound machine risk of COVID‐19 transmission Direct observation of hands‐on ultrasound skills Lack of PPE HIPAA compliance Cessation of educational scans	Disinfection and preservation of PPE “Educational distancing” in observing ultrasound scans by tele‐ultrasound to physically distant Use of portable ultrasound handheld devices which may be easier to clean (e.g., Phillips Lumify, Butterfly iQ, and GE Vscan) Tele‐ultrasound modalities (e.g., Phillips Lumify through IIT’s Reacts platform, FaceTime, Butterfly iQ) HIPAA‐compliant platforms (e.g., Phillips Lumify, Zoom, WebEx, uSmart 3200T NexGen‐Terason) Ultrasound simulation devices for image acquisition and procedural skill development (e.g. SonoSim, Vimedix, Blue Phantom, Kyoto Kagaku)
Image interpretation
Real‐time feedback Lack of high‐speed, reliable, and encrypted Internet services	Virtual screensharing for remote image interpretation and QA Discuss with IT to upgrade IP access points and securing data while providing VPNs Tele‐ultrasound feedback Review of homegrown or online image banks (e.g., The POCUS Atlas)
Didactic education—lectures
COVID‐19 restrictions on conferences and gatherings Time and physical restrictions for educators Travel bans	Video conferencing of lectures (e.g., Zoom, WebEx) Feedback and active participation by surveys and polling tools National and international speakers can easily join and contribute to education through video conferences without any travel costs
Didactic—independent learning
Increased clinical duties Motivation Inability to provide supervised assessment	Teaching images virtual library sharing (e.g., DropBox, Google Drive) Self‐directed learning with online modules (e.g., Core Ultrasound, Ultrasound Leadership Academy, and 123 Sonography)

PPE = personal protective equipment; HIPPA = Health Insurance Portability and Accountability Act; QA = quality assurance; IT = information technology; IP = Internet protocol; VPN = Virtual private network; POCUS = point‐of‐care ultrasound.

IMAGE ACQUISITION

COVID‐19 has put a strain on clinical ultrasound educational scanning within the ED for many reasons. First, POCUS is no longer risk‐free. Recent evidence suggests that viruses like COVID‐19 can survive on surfaces up to 72 hours. ⁶ Ultrasound machines, like other surfaces, can act as a fomite, putting both health care workers and non–COVID‐19 patients at risk. Second, PPE is currently scarce, and conservation of masks, gowns, gloves, and face shields for clinical use needs to be considered. ACEP ⁷ and the World Interactive Network Focused on Critical Ultrasound ⁸ have published guidelines on the safe use of ultrasound in the setting of COVID‐19. Distancing measures have circumvented traditional fellow–faculty bedside‐supervised scanning and teaching, which is especially disadvantageous for current and incoming fellows. The risks of exposing residents and fellows to a dangerous and contagious disease for educational reasons must be heavily considered. As a result, many emergency ultrasound programs across the country have stopped educational scanning in their EDs.

Given the length of this pandemic and possible future global emergencies, unique solutions are sought to continue POCUS education. Tele‐ultrasound with screen sharing could help mitigate the loss of these bedside scanning sessions. Through tele‐ultrasound, an educator can be in a separate geographic location while providing instruction to the scanner. Recent evidence has demonstrated the utility of tele‐ultrasound through FaceTime (Apple Inc.) in allowing an expert POCUS examiner to remotely guide a novice scanner. ⁹ Other technological solutions also include portable ultrasound devices such as the Phillips Lumify (Philips Healthcare CX50 CompactXtreme), which can connect through IIT’s Reacts platform (Innovative Imaging Technologies), can link ultrasound educators to the bedside thereby reducing risk to the educators while still providing instruction.

Tele‐ultrasound has been shown to be effective with novice learners even after only a brief training period in different parts of the world. ¹⁰ Instruction can be provided synchronously or asynchronously. Tele‐ultrasound already thrives in EM training programs in Uganda and Rwanda, where faculty in the United States review images and provide feedback to residents. ¹¹ It also provides an opportunity to collaborate with international partners and augment the education of trainees who can learn from their peers across the globe. Tele‐ultrasound is a unique solution at a time when less is more.

Ultrasound simulation devices can also be used to augment image acquisition skills. SonoSim (SonoSim Inc.) is one such product. Trainees manipulate a probe on a simulated patient and see the effects of their hand movement on acquisition of images and, as such, learn to scan. Other ultrasound simulators can be used for such learning include Vimedix (CAE Healthcare), Blue Phantom (CAE Healthcare), and Kyoto Kagaku (Kyoto Kagaku Co.). Ultrasound guidance for procedural techniques can also be learned through simulation, as phantom models exist to simulate central/peripheral vascular access, nerve blocks, lumbar puncture, thoracentesis, and other invasive procedures.

Finally, as ultrasound machines become less expensive and more portable, they become more accessible. With a personal ultrasound device, residents and fellows could practice on themselves or family members. This may not be an effective means of identifying pathology but could be useful in learning anatomic relationships, sonographic landmarks, and variations in technique.

IMAGE INTERPRETATION

Learning how to interpret images is a critical component of ultrasound education. Image review for QA purposes can serve as a platform for much of this education. In fact, QA programs are an integral part of successful POCUS divisions. Images are usually secured on a middleware software that can be accessed remotely. Using online conferencing software, image review can be done virtually through screen sharing. This format allows educators and participants to simultaneously view images and participate in the learning process together. Ensuring feedback to ED staff on the quality of their scans can be continued for both education and reimbursement compliance.

To streamline such efforts, divisions may benefit from discussions with information technology (IT) departments to upgrade remote access to POCUS images and electronic medical records. Informational security should be a priority to ensure protecting personal data by using virtual private networks (VPNs).

Image review can also be accomplished outside of QA. Most mature POCUS programs have databases of teaching images replete with classic and atypical examples of pathology which could be reviewed together with faculty. Trainees review images and video clips of anatomy and pathology and artifacts and learn various scanning techniques and pitfalls of scanning. Like for QA, remote videoconferencing software can facilitate such sessions.

DIDACTIC EDUCATION

Lectures

Amidst the uncertainty of a pandemic, some programs may prefer to maintain a traditional didactic structure. However, the desire to cultivate camaraderie and connection during the changing clinical atmosphere may lead programs to prefer online video conferencing. Utilizing a video‐based conferencing platform, such as Zoom (Zoom Video Communications, Inc.) or WebEx (Cisco WebEx), trainees can continue to meet regularly and learn. Video‐based conferencing platforms offer the ability to screen share slides in real time as well as a record didactics for future viewing. Lecturers can maximize class engagement by using surveys and polling tools, which can be synchronously incorporated.

Further, by offering video‐based lectures, national speakers who usually would not have been able to speak due to travel restrictions are able to do so with incredible ease. Programs can share live or recorded lecture content across multiple institutions, enhancing further dissemination of knowledge. As the pandemic evolves, video‐based platforms provide a unique solution to POCUS didactic education. This may provide a new opportunity for more active participation through national organizations such as SAEM, ACEP, AIUM, and SCUF.

Independent Learning

A vital component of all ultrasound education is self‐directed learning. This has never been as important when faced with COVID‐19. Online videos such as 5 Minute Sono ¹² and/or paid subscriptions to Ultrasound Learning Academy ¹³ can mitigate the inability to practice educational POCUS outside of clinical work. Tangible, measurable goals will be needed to assess the efficacy of self‐directed learning. For fellows, the Advanced Emergency Medicine Ultrasound Examination ¹⁴ will be an important standard that will ensure competence regardless of training environment.

CONCLUSION

COVID‐19 has changed point‐of‐care ultrasound education for fellows and residents. The use of tele‐ultrasound, virtual didactics, asynchronous learning and has the potential to augment point‐of‐care ultrasound education and facilitate clinical practice, even in this period of a global pandemic. Future global crises may also disrupt education; swift adaptation of these guidelines to address disruptions while also maintaining excellence in point‐of‐care ultrasound education is highly encouraged.

AEM Education and Training 2020;4:321–324