Simulation-Based Training on Basic Obstetrics and Gynecology Ultrasound Skills During COVID Pandemic

Aruna Kumari Yerra¹ · Suneeth Jogi² · Swathi Emmadisetty¹ · Venkatesham Animalla³ · Aparajita D’souza¹

Aruna Kumari Yerra (MS) is an Assistant Professor, Department Obstetrics and Gynecology, ESIC Medical College, Hyderabad, India; Suneeth Jogi (MD) is an Assistant Professor, Department Radiology, ESIC Medical College, Hyderabad, India; Swathi Emmadisetty (MS) is an Assistant Professor, Department Obstetrics and Gynecology, ESIC Medical College, Hyderabad, India; Venkatesham (MSc) is an Assistant Professor, Department of Community Medicine, ESIC Medical College, Hyderabad, India; Aparajita D’souza (MS) is an Professor, Department Obstetrics and Gynecology, ESIC Medical College, Hyderabad, India.

Swathi Emmadisetty emmadisetty.swathi@gmail.com

1 Department Obstetrics and Gynecology, ESIC Medical College, Hyderabad, Telangana 500038, India

2 Department Radiology, ESIC Medical College, Hyderabad, Telangana 500038, India

3 Department of Community Medicine, ESIC Medical College, Hyderabad, Telangana 500038, India

Background
COVID-19 pandemic led to an alarming rise in sickness absenteeism among the radiologists. Anticipating a continued shortage of experienced radiologists in future COVID waves, it is essential to train the medical professionals in basic skills related to ultrasonography to enable them to perform basic Obstetrics and Gynecology (OG) scans safely in emergencies. Virtual reality simulation training is an alternative to conventional ultrasound training.

Methods
A cross-sectional study was conducted during 8-day-long workshop to identify the trainees’ basic, after training knowledge and skills in OG ultrasound and to document their perceptions of the training. Statistical analysis was done using descriptive statistics (percentages and mean standard deviations) and paired t test for comparisons.

Results
A total of 80 health care professionals underwent ultrasound simulation training. It was found that the post-test score in the knowledge domain, instrument handling, basic gynecological skills, and first-trimester antenatal ultrasound skills in the practical domain was significantly higher than the pre-test score (P-value < 0.0001). Out of 80 participants, 45 (56.25%) agreed that ultrasound simulation is an ideal method of teaching and training basic OG skills to the novice. Sixty-six out of 80 (82.5%) felt that the principles of handling a human mannequin are the same as those of real patients. Forty-eight participants out of 80 (60.0%) felt that ultrasound simulation can be used as an ideal tool for self-assessment of health care professionals.

Conclusion
The study showed that ultrasound-based simulation can provide a realistic setting for training and assessment of novices in learning basic skills.

Keywords : COVID-19 · Virtual reality simulation training · Ultrasonography · Skill assessment

Background

Modern Obstetrics and Gynecology (OG) practice is virtually impossible without the use of ultrasonography [1]. The uses range from performing basic tasks like detection of the fetal heart to carrying out invasive procedures like an ultrasoundguided transfusion for fetal anemia. Performing ultrasonography not only requires specialized equipment but also the availability of an expert round the clock. COVID-19 pandemic had a widespread impact on radiologists, increasing their workload and exposure to the virus leading to an alarming rise in sickness absenteeism [2]. In certain parts of the world, this led to delays in appointments, long waiting times for imaging studies, and delays in diagnosis and initiation of treatment, significantly affecting the patient care. With three waves of COVID pandemic in recent years, uncertainty about the future and anticipating a continued shortage of experienced radiologists, it is very essential to train all medical professionals in basic skills related to ultrasonography. The purpose is to enable all the trainees to perform basic OG scans safely in emergencies during the COVID-19 pandemic.

A novice in ultrasonography requires planned and sustained, in-person, hands-on training under the supervision of an expert. The basic skills to be taught during the training should include identification and handling of the probes, identification of correct planes, orientation of side and space and basic knowledge to interpret the dynamic image produced by 3-dimensional probes [3]. Conventional ultrasound training is time-consuming and requires extensive teaching resources [4] and is practically not feasible in busy clinical settings. In addition to this, a trainee in the initial phases of conventional training faces the challenge of being refused by the patient for examination. Thus, providing efficient training while maintaining patient safety [5] has become one of the biggest obstacles in teaching ultrasound skills conventionally.

Many alternate ways have been proposed to teach basic OG ultrasound skills to medical professionals. Virtual reality simulation training [6] is one such approach that trains a novice in a shorter period of time. It allows repeated practice in an environment simulating a clinical one with the trainer having direct control over the trainee which is not feasible in a busy clinical setting [7, 8]. In addition, the skills that are obtained after simulation-based training can be retained for a longer duration [9]. Ultrasound simulators are integrated equipment consisting of a human simulation model, a mock probe connected directly to a computer monitor that displays the ultrasound image depending upon the position and movement of the probe. Virtual reality simulators have simulator metrics that may be used to assess the performance in a simulated setting [10]. A variety of performance standards may be used to discriminate the competent from non-competent performers. [11]

ESIC Medical College is a tertiary health care medical institution, where simulation training is not a part of the OG curriculum. Simulation training when used in conjunction with clinical training can significantly improve the basic skill acquisition in ultrasonography at this institute.

Hence, this study was conducted.

To identify the trainees’ basic knowledge and skills in OG ultrasound.
To determine the acquired knowledge and skills after the ultrasound simulation training.
To document their perceptions to the simulation-based ultrasound training program.

Methodology

Study site and study period: A cross-sectional study was conducted by the Department of Radiodiagnosis in collaboration with the Department of Obstetrics and Gynecology,

ESIC Medical College, Hyderabad, Telangana, between July 9, 2021, and July 16, 2021, as a part of 8-day Obstetrics and Gynecology ultrasound simulation training workshop.

Inclusion and Exclusion criteria: All the health care professionals (junior residents/senior residents/faculty/specialists) working in the institute and who consented to participate were included in the study. Professional radiologists, medical undergraduates, interns and health care professionals from other hospitals were excluded from the study. Institutional Ethical Clearance was taken (Ref No: 799/U/IEC/ESICMC/F0389/09/2021). After assuring confidentiality, informed consent was taken from the study participants.

Methodology in detail: A cross-sectional study was conducted during the 8-day-long workshop on Obstetrics and Gynecology ultrasound simulation training. As a part of the workshop, a simulation module was tailored to train the health care professionals in instrument handling (selection of appropriate transducer/awareness regarding freezing and unfreezing the image/switching on the color mode/taking measurements and orientation of side and space), basic gynecology (using sagittal and coronal planes of uterus, cervix and ovaries) and normal early pregnancy ultrasound scan (identifying gestational sac/yolk sac/cardiac activity and measuring crown-rump length).

Data collection tool: A self-administered, predesigned questionnaire was made; peer-reviewed, internally validated (Cronbach’s alpha score = 8.1) was used for data collection. The questionnaire included 4 parts: demographic details, 4 items related to trainees’ basic knowledge in ultrasonography (knowledge domain), 4 items related to trainees’ practical skills in ultrasound (skill domain) and 10 items related to perceptions of the trainees to the simulation module (perception domain). Basic demographic details like age, gender and profession were taken from all the study participants.

The workshop was conducted for 8 h in a day enrolling 10 candidates per session. At the beginning of the workshop, all the participants had an hour-long didactic lecture on basics of ultrasound simulation technology and its role in clinical practice. Two US mentor medical simulators (Simbionix 3D systems from Vishal Surgical Equipment Co, Hyderabad, Telangana) with a realistic probe switch and a true-to-life complex ultrasound image, were used for the ultrasound simulation training. All the participants were introduced to the simulator by three mentors (trainee: trainer ratio of 10:3).The trainees were assessed in instrument handling and basic gynecology and the first-trimester antenatal ultrasound with a pre-test (how much practical skills they know before the training). Then, the principal investigator oriented the trainees to these basic concepts through a 15-min short lecture followed by demonstration of instrument handling and above ultrasound procedures for 45 min. After demonstration, all the participants were given hands-on practice on the ultrasound simulator under direct observation of the trainer. Their learning of practical skills was assessed later by a posttest (how much of practical skills the trainees achieved at the end of training session). The time taken to complete the task before and after the training was also noted. The perceptions of the trainees to ultrasound simulation program were taken. A total of 2 h (1-h theory and 1 h of practical orientation) training was given to each participant, and 2.5 h were spent on their assessment.

All the items in the knowledge domain were marked as yes = 1 and no = 0, and items in the practical skill domain were marked as optimally skilled = 2; partially skilled = 1 and missed = 0 in pre-test and optimally attained = 2, partially attained = 1 and missed = 0 in the post-test. The perceptions of trainees were rated on a 3-point Likert scale agree = 2; neither agree nor disagree = 1 and disagree = 0. Statistical analysis: The data collected were coded and entered on a Microsoft Excel sheet and analyzed. Descriptive analysis was made using percentages and mean standard deviations. Paired t test was used for comparisons.

Declarations

Conflict of interest The authors declare that there is no conflicts of interest.

Human or Animal Rights This article does not involve any human or animal participants.

Informed Consent Informed consent was obtained from all individual participants included in the study.

Ethical Statement The study was approved by the Institutional Ethical Committee vide no: ESICMC/SNR/IEC-F0389/09/2021, Version no. V01. It was in accordance with ethical standards of institutional ethical committee and Helsinki Declaration. After assuring confidentiality, informed consent was taken from the study participants. This study is in line with the principles of Helsinki Declaration.

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