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