Effectiveness of a simulation-based point-of-care ultrasound course for prehospital providers - a single group quasi-experimental study

Abstract

Objective

Emergency medical service (EMS) professionals are increasingly using point-of-care ultrasound (POCUS) into the prehospital management and triage of critically ill patients. However, few institutions offer organized POCUS training for this community. Our goal was to offer and evaluate the effectiveness of a simulation-based POCUS course for EMS professionals.

Methods

We developed and implemented an eight-hour course to train EMS providers in the fundamentals of POCUS for blunt trauma patients. The course design included lectures, standardized patients hands-on scanning, simulation-based ultrasound cases, clinical cases based on real patients, and an end-of-course review game. Before the day of the course, participants were assigned e-learning modules on the fundamentals of POCUS and on the Extended Focused Assessment with Sonography for Trauma Exam (eFAST). The effectiveness of the course was evaluated using Kirkpatrick’s methodology for Level 1 (course evaluation by participants) and Level 2 (pre- and post-course knowledge assessments including image interpretation). Pre- and post-knowledge scores were presented using means and ranges. Percent improvements and a paired sample t-test with the effect size (Cohen’s d) were used to compare pre-post improvements. For course evaluation ratings, the mean Likert scale rating was calculated.

Results

A total of 128 learners (103 paramedics, 22 flight nurses, and one EMS physician from 32 EMS agencies, as well as two United States Army medics, completed the course. The average age of participants was 39.0 years, and 98 (76.6%) were male. The pre-course assessment mean knowledge score was 67.6% (95% CI 64.7–70.5). The post-course mean knowledge score was 89.0% (95% CI 87.3–97.0), resulting in a 21.4% point increase (p <.001; Cohen’s d = 1.52). We received 122 course evaluations. Participants expressed nearly unanimous strong agreement across all measures, with a mean rating ranging from 4.8 to 4.9 on a 5-point Likert scale questionnaire.

Conclusions

Our data suggests that an 8-hour POCUS course, incorporating e-learning and simulation, can significantly improve EMS providers’ knowledge of the fundamentals of POCUS and image interpretation of eFAST examination in trauma patients. Course evaluation results are highly supportive of this course’s benefits. As EMS agencies increasingly incorporate POCUS for patient care, effective and efficient training methodologies will be critical for successful implementation. Our course offers one approach as part of a comprehensive training program. Further studies should assess POCUS utilization and sustained knowledge retention.

Clinical trial number

Not applicable.

Background

Point-of-care ultrasound (POCUS) is integral to the assessment and evaluation of critically ill patients [1]. The technology allows clinicians to quickly and efficiently identify intra-abdominal and intra-thoracic injuries, including those from blunt or penetrating trauma. The Extended Focused Assessment with Sonography in Trauma (eFAST) has become a gold standard for early screening in trauma [2]. An experienced operator can perform an eFAST in under three minutes with approximately 93% sensitivity and 99% specificity for detecting free fluid in the abdomen and/or pericardial space [3, 4].

The use of POCUS by emergency medical services (EMS) has been extensively studied in United Kingdom, Germany, France, and Italy [4,5,6,7,8,9,10,11]. In these countries physicians often spend more time on the scene, evaluating and treating patients using POCUS as an adjunct for triage, patient assessment, and management in the field [5, 6]. Studies have shown that POCUS is feasible in the prehospital setting and does not significantly increase the scene or transport times of patients [12,13,14,15]. In the United States, only about 4% of EMS systems have implemented use of POCUS for patient evaluation [16, 17]. However, some studies in the prehospital setting show that its use can change patient outcomes and management [3, 18]. One study by Chin et al. demonstrated that paramedics could identify life-threatening conditions, such as tension pneumothorax and cardiac tamponade, using their prehospital assessment with ultrasound for emergencies (PAUSE) protocol [19]. In addition, prehospital ultrasound has been used to determine the proper placement of endotracheal tubes, detect long bone fractures, confirm intraosseous line placement, identify pulmonary edema, and assess cardiac activity in cardiac arrest [20,21,22,23,24,25,26,27,28,29,30].

Another possible benefit of prehospital POCUS is its potential to decrease time to diagnosis and to improve patient outcomes in trauma and critical illness. For example, a 2006 multicenter study found that combining physical examination with FAST examination significantly improved specificity and accuracy in determining intra-abdominal bleeding in trauma patients, and resulted in earlier CT scans and changes in patient management and destination hospitals [3]. The findings also showed that prehospital FAST examinations were carried out an average of 35 min sooner than ultrasounds were performed in the ED.

A systematic review showed that the transport of patients to trauma centers, rather than non-trauma centers, led to a 15% reduction in mortality [19]. Taylor et al. found that 21% of EMS systems in the United States were considering implementing bedside ultrasonography [16]. Despite its potential benefits, a major barrier to implementing POCUS in the prehospital setting is the lack of efficient and structured training programs. Several studies have shown that paramedics and other prehospital providers can successfully perform the eFAST examination after a one-day, eight-hour course [12,13,14,15]. Based on the potential for improved patient outcomes, it is essential that prehospital providers in the United States be trained in the use of POCUS, and in the efficient execution and interpretation of the eFAST [17, 18, 31]. Additionally, there is still a need for more research on the best approaches and effective training curricula in POCUS to meet the needs of EMS providers [32, 33].

A needs analysis conducted with local EMS and air transport agencies revealed that a major barrier to the implementation of POCUS in the prehospital setting was a lack of efficient and structured training programs, consistent with findings in previous studies. This led to the development of a training curriculum in EMS POCUS with an initial course focused on POCUS fundamentals and the eFAST protocol. The goal of this study was to implement and evaluate the effectiveness of a simulation-based POCUS course for EMS professionals using the Kirkpatrick methodology for levels 1 (Reaction) and 2 (Learning).

Methods

Study design & setting

This was a single-group quasi-experimental (pretest-posttest) study design to evaluate the effectiveness of, and participant satisfaction with, the course. The study was conducted at the Gordon Center for Simulation & Innovation in Medical Education, University of Miami, Miller School of Medicine. Study reporting followed the STROBE checklist for observational studies (Supplement 1).

Ethics approval and consent to participate

The University of Miami Institutional Review Board approved this study (ID No.: 20170767) on 9/28/2017. Because the study involved evaluation of an educational intervention with aggregated, de-identified data, it qualified for an exemption and a waiver of informed consent.

Participants

We conducted a power analysis for a paired samples t-test with 80% power for detecting a medium effect at alpha = 0.05. The results indicated a required sample size of at least 34. We obtained a sample size of 128, consisting almost entirely of practicing paramedics and flight nurses (including one physician working with EMS and two members of the United States Army medical division) from 32 EMS agencies. Most of the agencies were based in Florida although we also had participants from other states as some of the EMS POCUS courses were offered as part of EMS conferences. Participants were identified by their departmental leaders as integral to the agency’s existing or planned POCUS education program. We included 128 participants who participated in 11 courses between February 2017 and May 2024, and for whom we had complete data. Participants who did not complete the pre- or post-course assessment (incomplete data) were excluded.

Curriculum development

We developed and implemented a one-day (8-hour), in-person POCUS course consisting of didactic lectures, hands-on ultrasound scanning on standardized patients, simulation-based POCUS cases, a clinical case mini-workshop, and a content review. A needs assessment with participating EMS agencies, along with a review of the existing literature. Input from subject matter experts in POCUS, emergency medicine, EMS, and simulation-based healthcare education were used to determine the course content. In addition to incorporating the fundamentals of POCUS and image acquisition and interpretation, we focused on trauma POCUS using the eFAST protocol, as this had the greatest evidence for impact on patient care and outcomes in the prehospital setting. To allow adequate hands-on instruction and deliberate practice, we maintained an instructor-to-learner ratio of ≤ 1:5.

Didactic lectures and hands-on training

Prior to the course, participants were assigned e-learning modules on “Fundamentals of Ultrasound” and the “eFAST,” utilizing SonoSim® Courses (Santa Monica, CA). The one-day course was held over eight hours and the agenda included 2.5 h of lectures, 30 min of interactive cases, 3.5 h of hands-on skills training, and 1 h (30 min each) for pre-course and post-course assessments (Fig. 1). Sessions covered the fundamentals of ultrasound and an introduction to the eFAST, including the views in six different anatomical regions (Fig. 2). Examples of both normal and abnormal findings were presented.

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After each didactic session, the participants were separated into small groups for hands-on POCUS practice guided by faculty in emergency medicine, trauma, EMS, critical care nursing, and military surgical teams. All the faculty had extensive POCUS training either during their residency or as additional on-the-job training. The ultrasound devices primarily used in the skills stations included the Sonosite® Edge and Sonosite® SII (FUJIFILM Sonosite®, Bothell, WA-USA). We also incorporated the portable devices [Butterfly iQ3 (Burlington, MA-USA), Lumify (Phillips Ultrasound, Bothell, WA-USA), Vscan Air™ (GE Healthcare, Wauwatosa, WI-USA)] that participating EMS agencies planned to adopt. This allowed participants to practice and become familiar with the devices that would be used in the field, including knobology, anatomical relationships, and artifacts. The participants had several opportunities to acquire and interpret real-time ultrasound images of standardized patients with normal anatomy. Standardized patients were verbally consented to participate and contracted for safety. Additionally, the participants were able to obtain and evaluate images showing pathology in all eFAST regions, utilizing the SonoSim LiveScan® platform (Santa Monica, CA-USA).

The course incorporated ultrasound image artifacts, pearls, and pitfalls, and an interactive case discussion (30-minutes) that engaged the participants on clinical reasoning using real cases and POCUS video clips. The course culminated in an interactive review game (30-minutes) using Kahoot! platform (Oslo, Norway).

eFAST imaging

An eFAST examination included images in six anatomical locations: (1) right upper quadrant (RUQ) / Morrison’s Pouch; (2) subxiphoid and parasternal cardiac; (3) left upper quadrant (LUQ) / splenorenal; (4) suprapubic; and 5 + 6) the pleural interfaces (Fig. 2).

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Curriculum evaluation

Using the principles of Kirkpatrick’s program evaluation, we evaluated the effectiveness of the curriculum for Level 1 (Reaction) and Level 2 (Learning).

Level 1 (Reaction)

At the conclusion of the course, the participants completed an evaluation. Our study team developed the survey instrument, having experts in education research and program evaluation who further tested the instrument’s validity (Supplement 2). It included questions on the relevance and utility of the course in the participants’ current practice, achievement of learning objectives, the overall training environment, and faculty effectiveness. Responses were measured on a five-point Likert scale, with 1 indicating strong disagreement and 5 indicating strong agreement. Participants also provided open-ended feedback.

Level 2 (Learning)

The participants completed a pre-course assessment with 20 multiple-choice questions. This determined their baseline knowledge of POCUS and the eFAST examination. Immediately after the course, the participants completed a content-matched post-course assessment. The assessment items were developed by a team of expert faculty from emergency medicine, ultrasound, medical education, and EMS with experience ranging from 5 to 28 years. Both assessments addressed the course’s learning objectives, and they underwent validation through a rigorous process of development, item analysis, and piloting. The pre-and post-assessment items were the same for all the 11 courses offered. The instructors were blinded to the pre- and post-course assessment results during the course to prevent bias. Additionally, we conducted an item analysis of the pre-and post-course assessments of learners who took the course between 2023 and 2024, to compare their performance in six content areas:1) eFAST scan basics (including knobology, image capture, and view optimization); 2) right upper quadrant view; 3) subxiphoid view; 4) left upper quadrant view; 5) suprapubic/pelvic view; and 6) bilateral views of the pleural interface.

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Data analysis

Using IBM SPSS, v.29, the research team performed a paired samples t-test to compare pre- and post-assessment scores and calculated the effect size (Cohen’s d). The pre-course assessment scores were compared, for any baseline differences across content areas, using analysis of variance (ANOVA). For course evaluation ratings, the mean Likert scale rating for each component was calculated. The satisfaction threshold for the course was set to > 4 on a 5-point Likert scale before the implementation of the study, where 1 was the minimum and 5 was the maximum score for each statement. Data was analyzed by study team members trained in biostatistics.

Results

Participant demographics

Table 1 displays the learner demographics, with a mean age of 39.0 years (range of 23–63 years). Approximately three-quarters (76.6%) of participants were male, and more than three-quarters (80.5%) were paramedics.

Learner performance

The mean score for the pre-course assessment was 67.6% (95% CI 64.7%-70.5%), and the mean for the post-course assessment was 89.0% (95% CI 87.3%-90.7%). The 21.4% point increase (95% CI 18.9–23.9) was statistically significant, with a p-value of < 0.001 (Fig. 3) and a large effect size [Cohen’s d = 1.52]. An ANOVA for pre-course assessment revealed statistically significant differences. These were largely explained by a high mean score in the suprapubic view content area and a low mean score in the bilateral pleural interface content area (Table 2). All the content areas showed statistically significant pre-to-post improvements except for the suprapubic/pelvic view. (Table 2).

Course evaluations

We received 122 course evaluations. Participants expressed nearly unanimous strong agreement on the course’s benefits (Table 3). Selected examples of the participants’ open-ended comments are listed in Table 4. Additionally, a thematic analysis of open-ended responses revealed the following topics:

1. 1.

Course Quality and Content: Participants liked the course, and mentioned it made complex information easy to understand

2. 2.

Instructors and Teaching Methods: Participants praised the instructors for their knowledge and teaching style, which effectively combined lectures with hands-on skills practice.

3. 3.

Hands-on Experience: Participants valued the practical (hands-on) component as they felt it improved their confidence and requested more such sessions in the future.

4. 4.

Future Improvements: Suggestions included offering advanced courses, refresher sessions, and addressing technical issues (troubleshooting) using simulations.

Discussion

Our study demonstrated the effectiveness of a one-day (8-hour) course format for teaching POCUS (eFAST) to EMS professionals. Learners found it relevant and useful for their success in learning the eFAST examination (Kirkpatrick Level 1 - Reaction). The results also show a significant improvement in learners’ knowledge (in post-course assessment) with the basics of eFAST, including knobology, image acquisition, and interpretation (Kirkpatrick Level 2 - Learning). Additionally, in open-text responses, several participants indicated that the course improved their comfort and confidence with using POCUS for eFAST. These findings support the use of an 8-hour course, coupled with pre-learning, as an effective method for teaching eFAST to EMS providers as a starting point to develop POCUS competency, coupled with clinical practice with feedback, and quality assurance.

Although prehospital POCUS is infrequently used by EMS in the United States, interest and implementation are rising [9, 16]. Some of the barriers to more universal implementation includes resource allocation of funds for POCUS equipment, using the technology, equipment limitations, and structured training programs designed for the EMS provider [16, 34]. Certainly, as the portability of ultrasound units has increased and the cost has decreased, this is less of a concern. However, the lack of evidence and competency-based training remains a barrier, such as there is no quality assurance process or a way to do ongoing image review and improvement. Our study addresses one of these barriers by providing evidence for an effective training format.

Prehospital providers can learn image acquisition and interpretation using a simulation-based course combining didactics and hands-on practice [12,13,14]. There is still a question, however, whether skills acquired in the simulation education setting translate to the clinical setting. To that point, Heegaard et al. showed that a six-hour course for paramedics on obtaining eFAST POCUS images correlated with their ability to perform the exam on live patients in the prehospital setting [4]. Several other studies in the simulation education literature have shown that skills learned in the simulation lab transfer to the clinical setting [35,36,37,38]. While our study did not directly assess the transfer of skills to the clinical environment, the significant improvement in learners’ knowledge and confidence suggests that this training format could serve as a foundation for developing clinical competence for POCUS in EMS professionals, coupled with continued deliberate practice. This training approach addresses one of the key barriers to implementing prehospital POCUS by providing a structured, efficient learning format. In our courses, we used the portable POCUS devices that the EMS agencies were already using or considering using. This also helped the participants become familiar with and troubleshoot their devices. This potentially addressed another challenge of using the technology and its limitations (such as battery time, glare from the screen, connectivity, and protection of the device while using it) [34]. Future research should focus on assessing the long-term retention of these skills and their translation to clinical practice, demonstrating the impact of prehospital POCUS on patient morbidity and mortality.

Our findings are likely generalizable to other EMS providers, as the sample included providers from diverse pre-hospital systems (e.g., HEMS, fire rescue, and military). This diversity in our study population strengthens the applicability of our findings to various prehospital settings. Additional deliberate practice, along with quality assurance oversight, is critical to the effectiveness of EMS POCUS. Newer artificial intelligence (AI)-based ultrasound systems that incorporate guided image acquisition, abnormality detection, and anatomic labeling can help reduce the learning curve and operator subjectivity/dependence for prehospital providers. They can also assist with the implementation of POCUS [39]. In addition, the use of AI-based ultrasound devices can help with training and practice when an expert POCUS instructor is not available to provide guidance and feedback. Future longitudinal research is needed to demonstrate the impact of our training on learners’ application and use of POCUS in the field. along with their comfort in scanning women, people with breast tissue, and those with varying levels of BMI. Data collection methods, such as performance monitoring to ensure correct image acquisition and interpretation of the findings in the field, and chart reviews for patient outcomes, can be useful.

Limitations

While this study suggests that a single-day (8-hour) course is successful at teaching the fundamentals of ultrasound and the techniques necessary to obtain and interpret eFAST images correctly, it has some limitations. Our study used a quasi-experimental design, which lacked a control group due to a scarcity of available learners. Therefore, a causal effect of our curriculum on improved ability cannot be proven. Perhaps in the future, a control group given open-access asynchronous ultrasound study material could be evaluated alongside our study cohort to determine the true efficacy of our curriculum. We used convenience sampling, which suffers from a self-selection bias, meaning we may have recruited more motivated participants with different characteristics than the wider pool of prehospital providers. This might have resulted in a positive bias among participants when evaluating the training. In the future, we could potentially expand our cohort to include all individuals in a particular prehospital system to try and reduce this self-selection bias. Additionally, having a true experimental study design and randomly assigning participants to the control and intervention groups can help eliminate such possible bias. No blinding was implemented in our study since it was a single-group pretest/posttest design. Our study was limited to the lower levels (1 and 2) of Kirkpatrick’s model, and additional studies in the future should address higher learning levels: 3 (behavior) & 4 (impact). In the future, we plan to incorporate additional skills assessment methods, such as direct observation using skills checklists. This will also allow for deliberate practice and training opportunities for learners. Finally, our study does not address skill retention among participants in the weeks to months following the course. Skill decay occurs if skills are not used regularly, and additional training may be needed. There is limited research about skill retention for EMS professionals participating in an ultrasound training course, requiring more research in this area.

Conclusion

This study demonstrates that a single-day (8-hour), simulation-based course can help teach ultrasound fundamentals and eFAST image interpretation techniques to EMS professionals. Further studies are necessary to determine if this type of course can lead to improved patient outcomes, and to what extent EMS professionals retain knowledge and skills in the weeks and months after participating in such a course. Understanding that a one-day program is not sufficient for mastery of this new skill, additional practice and a comprehensive oversight program with experienced POCUS clinicians was recommended to all participating EMS agencies. Moreover, future studies should examine if an expanded and ongoing training program, including proctored scanning time in the clinical setting and online teaching modules, can result in better learning outcomes and skill retention.

Data availability

The datasets analyzed for this study are available from the corresponding author upon reasonable request.

Abbreviations

CT:

Computed Tomography

EMS:

Emergency Medical Services

eFAST:

Extended focused assessment with sonography in trauma

FAST:

Focused Sonography in Trauma

GCSIMEd:

Gordon Center for Simulation and Innovation in Medical Education

HEMS:

Helicopter Emergency Medical Services

IVC:

Inferior vena cava

IBM:

International Business Machines

LUQ:

Left Upper Quadrant

POCUS:

Point-of-care Ultrasound

PAUSE:

Prehospital Assessment with Ultrasound for Emergencies

RUQ:

Right Upper Quadrant

UK:

United Kingdom

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