Davide Enrici Baion (1), Stefano Calabrese (2), Leire Zaton Ortega (1), Libera Ferrantino (1), Eleonora Cauli (1), Clara Pautasso (2), Alessandra Prone (3), Davide Tizzani (4), Gianni Ogliero (4), Vincenzo Peloponneso (5), Olivia Cerrina (5), Antonella Bilanzone (2), Pietro Tuttolomondo (1), Enrico Lupia (6), Emanuele Pivetta (6,7)
1) Emergency Department, A.O.U. Città della Salute e della Scienza di Torino, Italy
2) High Dependency Unit, A.O.U. Città della Salute e della Scienza di Torino, Italy
3) Emergency Department, ASL To3 Pinerolo General Hospital, Pinerolo, Italy
4) Emergency Department, ASL To3 Rivoli General Hospital, Rivoli, Italy
5) Emergency Department, ASO Santa Croce e Carle, Cuneo, Italy
6) Emergency Medicine Division, A.O.U. Città della Salute e della Scienza di Torino, and Department of Medical Sciences, University of Turin, Italy
7) Cancer epidemiology unit, Department of Medical Sciences, University of Turin, Italy
Point-of-care ultrasound (POC-US) has been emerged as a new reliable tool in acute care medicine (ACM).
Aim of the study was to collect opinions about usefulness of nursing US in ACM.
Nurses participating in a US course anonymously filled in a multiple-choice questionnarie about usefulness of POCUS in basic and advanced nursing training.
We collected 193 questionnaires. Most of operators found relevant the use of POCUS in ACM but with differences related to the field of application.
Training in POCUS seems to be relevant for most nurses practicing to our survey, with the suggestion to integrate this topic in educational programs.
In 2011, in a commentary published by the New England Journal of Medicine, Moore and Copel(1) presented all possible fields of application of point-of-care ultrsound (POCUS) by listing them for medical specialities but they did not refered to nursing POCUS. However the Authors mentioned sonographic application for procedural guidance, including peripheral vascular access, a field in which nurses are definitively the most valid providers.
In general, the use of POCUS has already been described in acute care nursing (ACN)(2).
Several proof-of-concepts studies were proposed on these topics and POCUS for nurses should be considered an important and interesting topic, awaiting for better evidence for application and teaching program(3).
Our research hypothesis was that POCUS might become a new common skill for nurses working in the acute care medicine (ACM) setting. For this reason we carried out a survey among nurses working in several hospitals in Piedmont, Italy, and we collected information on perceived relevance and possible need of training in nursing POCUS.
This is a survey held in Piedmont, Italy, during 2016. All participants in the "US course for nurses" organized at the Città della Salute e della Scienza di Torino – Molinette University Hospital anonymously answered a four questions multiple-choice questionnarie (see figure). The same questionnarie was filled in by the partecipants to "US course for nurses" offered by the Italian National Society in Emergency Medicine (SIMEU) and held in the Pinerolo General Hospital, and by nurses working in the Emergency Department of Rivoli General Hospital and ASO Santa Croce e Carle Univerisity affiliated Hospital, Cuneo.
Briefly, the questionnaire collected information about previous participation in "US for nurses course" in order to better understand participants’ previous knowledge in US. Then, we have asked the nurses’ opinion on ultrasoud as source of information in their daily practice, and also in which field US might be more informative. The two final questions were about the relevance of a training in US for nurses, the possible burden of a mandatory basic training in US during the school of nursing, and if this training should be mandatory only for nurses working in the ACM.
The study was conducted in accordance with the principles of the declaration of Helsinki for research involving human subjects.
Descriptive data are presented as mean (±SD) or median (with interquartile range, IQR) for continuous variables, and as numbers and percentages for categorical variables. Wilcoxon signed-rank test was used for comparing differences between median values.
Data were collected in Microsoft Excel (Microsoft, Redmond, WA, USA) spreadsheet, and statistical analyses were conducted using Stata 13.0/SE (Stata Corporation, College Station, Texas, USA).
One hundred ninety three nurses answered the questionnaire. Median age was 39 years (range 22-61 years) with a sex ratio men/women of 0,65. Median number of working years was 13 (range 0-39) of whom 10 in the ACM setting (range 0-36). About two-thirds of the participant nurses (67,4%) worked in the Emergency Department, 12,4% in high dependency unit, 9.3% in the observational unit, and 20.2% in other units (i.e. critical care unit, or other non intensive units). One hundred twenty participants (62.2%) were working in Molinette University hospital.
Only 41 nurses already have some POCUS knowledge (i.e. participation in previous training program or courses).
Most of naïve participants considered POCUS potentially useful during daily practice but with differences related to the field of application. Almost all participants (98.1%) thought it could be useful for peripheral vascular access, 86.2% for bladder evaluation (before and/or after urinary catheterization), 49.7% for nasogastric tube placement, 47.2% for evaluation of fluid status, and 39.6% for lung.
Participant globally scored POCUS global usefulness with a score of 9 out of 10 (IQR 2).
According to the data collected in our study, 183 (94.8%) nurses considered useful to include a POCUS training during the school of nursing, and 191 (98.7%) during any advanced training courses (e.g. master of sciences and/or PhD training programs – p >0.05).
For most of participants inclusion of US on guided peripheral venous access insertion training in both basic (94.8%) and advanced training (99%) might be useful. One hundred sixty four and 168 nurses considered useful a training in US bladder evaluation, 73 and 120 on fluid status evaluation but in contrast with 105 and 72 who did not, for basic and advanced training respectively (p=0.05 and p<0.01). The lung POCUS was considered useful only by 68 and 103 nurses (in basic and advanced courses, respectively), in contrast with 115 and 88 (p<0.01 and p>0.05), and 96 and 114 nurses considered important knowledge and skills on POCUS for NGT insertion (p>0.05 and p=0.01 compared with whom did not consider POCUS as useful for NGT).
Discussion and conclusion
This survey collected opinions of nurses on use of POCUS in daily practice. The results suggested usefulness of POCUS for nursing and need of ad hoc training program during school of nursing and advanced courses. But these results were not equal for all POCUS topics evaluated. Almost all participants agreed about need of such a skill for peripheral venous access and urinary catheterization but not for the other topics evaluated.
A substantial global agreement was found about usefulness teaching of POCUS during school of nursing and advanced course (p>0.05) but for the applications results were different except for peripheral access.
Urinary catheterization with POCUS was judged useful too as well as the NGT placement evaluation, also if with differences in terms of agreement.
The situation was the opposite for evaluation of fluid status and lung. A lot of nurses did not think these topics should be part of the training for nurses. However these results could be affected by a problem in internal validity. Most of participants work in an University hospital (i.e. AOU Città della Salute e della Scienza di Torino – Molinette), a setting that might not be similar to the other istitutions. Both in Emergency department and in HDU, a physician with skill in POCUS is present 24/7 and this presence might reduce the interest in skills different to peripheral access.
Our results might also be partially affected by the baseline characteristics of participants in the survey, in terms of nursing experience (naive providers might be more avid for new technical skills and competences), but not all of our participants were young and unexperienced (see Results paragraph, median age was 39 years with median working experience of 13 years).
However the survey was only held in Piedmont, and in three of the participant instutions the use of POCUS intensively started several years ago, for both physicians and for nurses. And this situation could affect external validity of our results that should be confirmed in different regions.
In conclusion, our preliminary survey suggested the global interest and need of an ad hoc training programs in POCUS for nurses working in the ACM setting and that such a skill training should likely start directly during the school of nursing.
Figure. The questionnaire used during the survey on POCUS for nurses.
- Moore CL, Copel JA. Point-of-care ultrasonography. The New England journal of medicine. 2011;364(8):749-57. Epub 2011/02/25.
- Steinwandel U, Gibson NP, Rippey JC, Towell A, Rosman J. Use of ultrasound by registered nurses-a systematic literature review. Journal of renal care. 2017. Epub 2017/01/26.
- Avadhani A. Should procedural skills be a part of the Acute Care Nurse Practitioner curriculum? Nurse education today. 2017;50:115-8. Epub 2017/01/04.