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Creation and Validation of a Simulator for Neonatal Brain Ultrasonography

Posted Dec 31, 2016 Updated Apr 10, 2023
By Andy Tsai MD PhD , Carol E. Barnewolt MD , Sanjay P. Prahbu MBBS , Reimi Yonekura MS , Andrew Hosmer MET , Noah E. Schulz MS , Peter H. Weinstock MD PhD
9 min read

Rationale and Objectives

Historically, skills training in performing brain ultrasonography has been limited to hours of scanning infants for lack of adequate synthetic models or alternatives. The aim of this study was to create a simulator and determine its utility as an educational tool in teaching the skills that can be used in performing brain ultrasonography on infants.

Materials and Methods

A brain ultrasonography simulator was created using a combination of multi-modality imaging, three-dimensional printing, material and acoustic engineering, and sculpting and molding. Radiology residents participated prior to their pediatric rotation. The study included (1) an initial questionnaire and resident creation of three coronal images using the simulator; (2) brain ultrasonography lecture; (3) hands-on simulator practice; and (4) a follow-up questionnaire and re-creation of the same three coronal images on the simulator. A blinded radiologist scored the quality of the pre- and post-training images using metrics including symmetry of the images and inclusion of predetermined landmarks. Wilcoxon rank-sum test was used to compare pre- and post-training questionnaire rankings and image quality scores.

Results

Ten residents participated in the study. Analysis of pre- and post-training rankings showed improvements in technical knowledge and confidence, and reduction in anxiety in performing brain ultrasonography. Objective measures of image quality likewise improved. Mean reported value score for simulator training was high across participants who reported perceived improvements in scanning skills and enjoyment from simulator use, with interest in additional practice on the simulator and recommendations for its use.

Conclusions

This pilot study supports the use of a simulator in teaching radiology residents the skills that can be used to perform brain ultrasonography.

Introduction

Brain ultrasonography is a study frequently performed on neonates. In 2015 alone, 1459 such studies were performed at our tertiary-care children’s hospital, with the most common indications being a drop in hematocrit, enlarging anterior fontanelle, prematurity, pre- and peri-extracorporeal membrane oxygenation evaluations, and abnormal neurologic examination. Most of these studies were requested on an emergent basis, and they often play an essential role in guiding management . Given the ubiquity, time sensitivity, and importance of this examination, brain ultrasonography is a technique radiology trainees are expected to learn during residency training . However, most graduating residents are not proficient in performing this type of examination. The lack of supervision, structure, and assessment of competency during training had been cited as potential causes of this inadequacy . Additional pediatric radiology fellowship training is often required to attain proficiency.

Historically, brain ultrasonography is taught through a “master-apprentice” educational model in which an experienced provider performs the examination as the trainee observes. The trainee then attempts to perform the test under close supervision, slowly gaining the necessary psychomotor skills required to successfully perform the task . This approach has several drawbacks, including longer imaging times, patient discomfort/inconvenience/medical fragility, limited accessibility of patients, and risk of a suboptimal examination. In an increasingly demanding and time-constrained healthcare environment, opportunities for consistent trainee supervision and effective learning are becoming fewer and far between, further compromising this traditional master-apprentice educational model. Other medical fields that require skills training are faced with similar challenges and have turned to simulation training with varying degrees of success .

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Materials and Methods

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Construction of Simulator Model

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Figure 1, Brain ultrasonography simulator model. Top row shows the simulator model as viewed from different angles. Bottom row shows the corresponding appearance of the simulator model with the overlying skin cover removed and the plastic skull split in the sagittal plane for better visualization of the underlying brain phantom.

Figure 2, Real-time scanning of the simulator model using a vector probe on a clinical ultrasound system (GE LOGIQ E9, GE Healthcare, Waukesha, WI). Left-hand panel shows coronal imaging at the level of the superior orbital rim. Right-hand panel shows coronal imaging at the level of the Sylvian fissures depicting the lateral ventricles.

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Brain Phantom

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Plastic Skull

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Skin Cover

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Assembly Process

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Study Participants

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Structure of Training Session

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Primer

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Pre-training Assessment

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Initial questionnaire

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Creation of ultrasound images using the simulator

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Figure 3, Representative examples of resident creation of ultrasound images using the simulator model pre-training and post-training. The high-resolution ultrasound images shown here were exported from the picture archiving and communication system. (a) Resident A was instructed to create a coronal image at the level of the orbits. Pre-training image was tilted with asymmetric appearance of the superior orbital rims. Post-training image was straight with symmetric appearance of the superior orbital rims. The objective image quality score improved from 1/3 to 3/3. (b) Resident B was instructed to create a coronal image at the level of the temporal lobes. Both pre- and post-training images were obliquely oriented and not in the true coronal plane, resulting in asymmetric appearance of the temporal lobes. The objective image quality score stayed the same pre- and post-training at 2/3. (c) Resident C was instructed to create a coronal image at the level of the Sylvian fissures. Pre-training image was tilted and not in the true coronal plane, resulting in asymmetric appearances of the lateral ventricles and the Sylvian fissures. Post-training image was straighter with a more symmetric appearance of the lateral ventricles and the Sylvian fissures. The objective image quality score improved from 2/3 to 3/3.

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Didactic Lecture

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Hands-on Simulator Practice

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Post-training Assessment

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Follow-up questionnaire

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Re-creation of ultrasound images using the simulator

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Image Quality Scoring

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Statistical Analysis

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Results

Participant Demographics

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Pre- and Post-training Questionnaires

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Image Quality

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Completion Time

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Discussion

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Academic Radiology, Volume 24, Issue 1
Journals General Radiology
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