Ultrasound injections (UGIP)

Self Assessment (possible?)

ACSEP US Peer Review Group (PRG) 2015-16

Contributing members US PRG

• Kevin Boundy

• Larry Bryant (retired)

• Charles Howse

• David Humphries

• Jonathon King

• Simon Locke

• Paul Ohmsen

• Steve Reid

• Jeni Saunders

• Roy Saunders

Ultrasound clinical roles

Roles

• Diagnostic

• Injections (accuracy)

• Dynamic (rehabilitation)– AHD – Scapula function

– Fascicular length – muscle strength (ecc)

– Pennation angle - strength (all), EMG

ACSEP ultrasound phases

• 2012 – Peer review groups

• 2016 – ACSEP council acknowledges US normal

component of clinical practice

• 2016 - ACSEP Fellows opinions

• Injections important

• Diagnostic US not important

• Dynamic US – no opinion

Reality of UGIP training

• World wide non-radiological disciplines use simple

training strategies / courses**

• Patients are used as training models (Harding, McIntyre

2011)

**Bennet Best Prac Res Clin anaesthiol 2009

After educational US courses

• Participants feel untrained in injections

• Proficient (seeing) – imaging nerves accurately

• Weaknesses (doing) - nerve blocks

• Proposed solution

• Integrating theory (imaging) with practical skill

acquisition

Hocking, Mcintyre 2011

Trainee Errors**

• Needle (10%)

• Transducer (10%)

Conclusion:Simultaneous needle manipulation with device operation requires “dedicated training” i.e. specific skill training

**Sites et al 2004,07

Training/ Skills for UGIP

Didactic categories

in UGIP

Understanding device operation

Imageoptimisation

Image interpretation

Visualisation of needle

insertion and injection

Sites et al Regional Anaes Pain Med 2009

Self assessment (2008)

Definition:

“a personal evaluation of one’s professional

attributes and abilities against perceived norms”

Colthart et al Medical Teacher 2008

Self assessment

• Practical skills may be better self assessed than

knowledge based activities

• Accuracy improved by increasing knowledge of the

standard.

• Self assessment is but 1 tool

• Role needs to be defined by research for every day

practice

Colthart et al Medical Teacher 2008

Methods

Method

• Technical themes

• Preparation, Procedure, safety, team work, infection

control (ACSP newsletter 2016)

• Tasks

• Importance (core, critical, advanced)

• Difficulty (easy, moderate, difficult)

• DELPHI process

• 2 iterations

• 75% agreement (+/_)

Preliminary scan Theme Task Calssification Difficulty rating

Did the operator identify the relevant surface anatomy prior to scanning? preparation Core easy

Can the operator correctly identyfy sonoanatomy and target e.g. tendon (anisotropy) preparation

Can the operator correctly identify the target e.g. bursa, paratenon, tendon, nerve preparation Core moderate

Identify blood vessels (doppler) safety

Identify pathology preparation

Mark entry and transducer position procedural skills

Did the operator store images for patient notes? safety

Planning intervention

In Plane or out of plane, correct ergonomics? procedural skills

Can trajectory of needle potentially cause problems procedural skills

Trajectory (degrees) procedural skills

Distance to target (cms) procedural skills

Target depth (cms) - vertical procedural skills

Choice of appropriate needle for task - pythagoras theorem procedural skills

Were bvs in needle path identified? procedural skills

Injectate (type - need to know effect, problems) preparation

Was an assistant required (appropriate decision)? team working

Needle

Tip visible (beginning, middle, end) procedural skills

Was hydrolocation needed and used prior to target injection? procedural skills

Failure to recognise visual cues when using hydrolocation procedural skills

Was the needle tip accurately placed (beginning, middle, end)? procedural skills

Length of needle visible whan advancing procedural skills

How many adjustemnts were needed to ensure proper path? (max acceptable number 5) deduct score? procedural skills

Optimising image and outcomes

Was the needle advanced to the target without visualisation? procedural skills

If the image was lost was the needle moved (forward)rather than probe? procedural skills

Was the information from the skin and insertion point ignored when the needle or image was lost? (cues) procedural skills

Misaligns needle and transducer while advancing procedural skills

Injection Task

Following the Injection, any toxicity from LA (low critically) safety

Was the syringed aspirated immediately before injecting at target? safety

Was the syringed aspirated immediately before injecting bolus at hydrolocation? safety

At the best site for injection, were BVs at site (Doppler) safety

Was the needle at target accurate (<5mm away)? safety

Final Measures (score 28 max)

• Is the needle tip visible?

• Was the needle tip accurately placed?

• Length of needle visible?

• Needle advanced without seeing tip?

• Does not misalign needle and transducer when

advancing

• No. of adjustments necessary (<5)

• Accuracy (1mm)

Self assessment tasks

Deep (2016 - 4cms) Superficial (2015 - 2cms)

Nerve

Needle

ArteryNerve

Results

Injection scores

Site (N=8) Score (M,SD)Self

assessDifference

Superficial 23.4 (2.1) 22.3 (4.8) NS

Deep 24.5 (1.9) 23.5 (3.1) NS

Total 23.9 (2.0) 22.9 (4.0) NS

Proportion total score (Max 28)

Site (N=8) Score (M,SD) Score %

Superficial 23.4 (2.1) 85

Deep 24.5 (1.9) 85

Total 23.9 (2.0) 85

Conclusion

Self Assessment in UGIP is a realistic

option compared with external

assessment

Conclusion

• Identify relevant skills / errors* *• Needle, transducer (20%)

• Technical skills training requires deliberate practice (Ericsson 1993)

• Deliberate practice may involve• Simulators

• Cadaver courses (expensive)

**Sites et al 2004,07

Conclusion

“Further information is needed to increase understanding of how self assessment can improve learning and professional clinical practice”

Colthart et al Medical Teacher 2008