Ultrasound Use and Training Available to CRNAs

Dustin Hunter RNAIJosh Leppert RNAI

Gonzaga University/ Sacred Heart Medical CenterMaster of Anesthesiology Education

Background

• The use of ultrasound technology, when performing invasive procedures, is becoming progressively more prevalent

• Ultrasound technology is rapidly becoming one of the gold standards in delivering safer care when performing invasive procedures

• “As our clinical practice evolves, so will the expectations placed on us by patients, surgeons, hospitals, and governing agencies” (Pollard, 2011)

Statement of the Problem

• The improved safety attained with ultrasound is dependent not only on the correct use of ultrasound, but the training and experience of the certified registered nurse anesthetist (CRNA)

• At present, there are no established standards to ensure proficiency in practice or training of the use of ultrasound (Moore, Ding, & Sadhasivam, 2012)

Purpose Statement

• The purpose of this study, through the use of surveys to CRNAs in Washington, Oregon, Idaho, and Montana, is three-fold:

1. To identify the prevalence of ultrasound usage during invasive procedures by CRNAs

2. To identify the prevalence and types of training CRNAs received to operate ultrasound

3. To identify the CRNAs’ sense of the effectiveness of ultrasound training

Research Questions1. What effect does the use of ultrasound have on

patient safety during invasive procedures?2. What types of training in the use of ultrasound

are being implemented?3. What types of comprehensive ultrasound

training opportunities are available?4. What are the measures of effectiveness in the

training of ultrasound?5. What are the measures of effectiveness in the

use of ultrasound?6. What types of comprehensive ultrasound

training opportunities are CRNAs attending?

Review of the Literature

Safety

• The proper use of ultrasound by a skilled provider with training and education can help to minimize the risk of known complications with each procedure

• According to Narouze et al 2012, there are no known absolute contraindications to the use of ultrasound

Safety

• Landmark techniques have limitations, as do nerve stimulators

• Inability to detect sensitive and key structures may lead to major complications

• Landmark techniques and variations in anatomy may require the provider to make multiple attempts and needle passes to achieve blocks or line placement with limited accuracy

Safety

• With ultrasound, local anesthetic can be placed directly around the nerve, resulting in faster onset, longer duration and improved quality block using less local anesthetic” (Griffin & Nicholls, 2010)

• “Using ultrasound, the volume of local anesthetic is reduced, and general consensus appears to suggest that at least a 50% decrease in volume is common”

(Griffin & Nicholls, 2010)

Safety

With an aging population presenting with an increasing range of comorbidities, the demand for a broader choice of surgical anesthetic options to provide optimal clinical care with a decreased risk of complications arises. For many of these patients, general anesthesia may prove to be detrimental and therefor the option of regional anesthesia may be the best anesthetic plan.

Cost Effective• Ultrasound Machine• $15,000

• Average Life Span• 5 years

• Average Blocks• 1,000 per year

•$3/block

• Money Saved• Average time saved• 21 minutes/block

• Cost of OR time• $8/min

• Cost savings per block $168• Cost savings over 5

years $840,000

Cost of a nod of approval from administration

Priceless

Training

• Practitioners using ultrasound without training have been shown to have more complications and lower success rates

• “The major disadvantage often cited is that success is user-dependent, and using ultrasound is a unique skill that requires training and experience to become proficient” (Falyar, 2010)

Training

• Any training is better than no training

• 2 different strategies to teach UGRA is more effective than using the strategies separately

(Gasko et al., 2012)

Training• CME Course on US• Workshops• Books• Internet• YouTube• BlockJock.com• Peer/Mentor

Measures of Effectiveness

• “Anesthesia professionals should participate in an education program to become competent to use advanced medical technology before using that equipment to care for a patient. A quality educational program will not only include training, but also a means to assess and document competence.”

(APSF COT, 2013)

Measures of Effectiveness

• Currently there are NO REQUIRED competencies for US

• “Achieving the goals of improving patient safety, interventional efficacy, and overall patient satisfaction will require the learner to set their own self-directed path towards defining their clinical interests, scope of practice, and skills self-assessment” (Pollard, 2011)

Methodology

• Qualitative Design• Nominal and ordinal data

• Survey Monkey• Anonymous electronic survey

• Data Analysis • Charts, Graphs, Cross-tabulations, Free-text

• Demographic• CRNAs in WA, OR, ID, and MT

Findings• 106 participants responded to our survey

• Areas of practice• 55 participants (53%) independent practice• 26 participants (25%) medical direction• 23 participants (22%) medical supervision

• 35 participants do not use ultrasound

• 71 participants use ultrasound

Workshop/C

onferen

ce

Computer-base

d (self-g

uided)

Internet

(YouTu

be, etc

.)

Clinica

lly tr

ained

(site

specific)

Trial a

nd error

Trained

by a co

lleagu

e

Textbook

None

72.6%

33.9%

54.8%

50.0% 53.2%51.6%

41.9%

6.5%

What types of training have you participated in after your formal anesthesia education

Lack of administrative support

13%

Lack of colleague support

9%

Cost of equipment17%

Cost of training9%Difficulty in maintaining skills

9%

Time constraints (turnover time)

22%

Coverage to allow training

4%

Lack of procedures available

11%

Low on the priority list2%

Training would have to be done on vacation time

4%

Obstacles to Ultrasound Use

Rarely11%

Only When Other

Methods Fail3%

During Most Procedures

50%

Every procedure36%

Frequency of Ultrasound Use

Recommendations

•Any training is better than no training

•Multiple methods of training is better than a single method

Recommendations

• We believe that adequate training and access to US ultimately affects the patient and should be a part of every anesthesia provider’s practice

Any Questions?

References• Anesthesia Patient Safety Foundation. (2013, Winter). Training

anesthesia professionals to use advanced medical technology. Newsletter: The official Journal of the Anesthesia Patient Safety Foundation, 27, No. 3, 45-72.

• Anesthesia Patient Safety Foundation Committee on Technology. (2013, Winter). Training anesthesia professionals to use advanced medical technology. APSF NEWSLETTER, 27, No. 3, 50-51.

• Gasko, J., Johnson, A. D., Sherner, J., Crag, J., Gegel, B., Burgert, J., ... FRANZEN, 1. (2012, August). Effects of using simulation versus CD-Rom in the performance of ultrasound-guided regional anesthesia. AANA Journal , 80, No. 4, S56-S59.

• Griffin, J., & Nicholls, B. (2010). Ultrasound in regional anesthesia. Anaesthesai Journal of the Association of Anesthetists of Great Britain and Ireland, 65(), 1-12. http://dx.doi.org/10.111/j.1365-2044.2009.06200.x

References• Moore, D. L., Ding, L., & Sadhasivam, S. (2012). Novel real-time

feedback and integrated simulation model for teaching and evaluating ultrasound-guided regional anesthesia skills in pediatric anesthesia trainees. Pediatric Anesthesia, 22, 847-853.

• http://dx.doi.org/10.1258/ult.2011.011039• Narouze, S. N., Provenzano, D., Peng, P., Eichenberger, U., Chul Lee, S.,

Nicholls, B., & Moriggl, B. (2012, November-December). The American Society of Regional Anesthesia and PainMedicine, the European Society of Regional Anaesthesiaand Pain Therapy, and the Asian Australasian Federationof Pain Societies Joint Committee Recommendations foreducation and training in ultrasound-guided interventionalpain procedures. Regional Anesthesia and Pain Medicine, 37, Number 6, 657-664.

• Pollard, BSc, MD, MEd, FRCPC, B. A. (2011). Ultrasound guidance for vascular access and regional anesthesia. Toronto, Canada: JB Graphics.