Integrating Point of Care Ultrasound Education into Clinical Practice at the Emergency Department

Round 1

Reviewer 1 Report

Dear Authors

Congratulations on your authentic clinical study of retrospective cases to determine components of competency in the use of POCUS for emergency medicine trainees.

 

Overall, this is an interesting study, which will be of use to others in similar circumstances, who are approaching the evaluation of POCUS. My main concerns with this article are the conclusions which lack the nuance of the results to a point of overly optimistic claims.  Please also address the minor comments below aimed at improving readability for an international audience.

 

Specific comments:

Intro

Line 37 – define EM

 

Line 53-4 – ‘The previous study in our institution [14] took a survey exploring the opinions of learners in regards to the ultrasound curriculum and the learning materials.’ This sentence does not seem to connect with the following statement of what EM residents must know. Did the survey provide this information? Please revise for relevance and readability.

 

Line 57-8 – ‘However, the study of learners’ competence with POCUS has not been studied yet’. Please check the clarity of this sentence.

 

Study Participants

Line 72-3 – ‘Patients were excluded if the 72 data was not completed’ – inform the reader of why this might be so, and provide the percentage of non-completions in the results

 

Data Collection

Line 78 – ‘If the data didn't match, a senior emergency physician was consulted, and the 78 proper information was received’ Please clarify what this means.

 

Line 83 – include the frequency range of each of the transducer configurations.

 

Line 85 – provide the reader with some context regarding what makes an ‘expert’. ?years of experience  ?qualifications. Did the researchers have access to the clinical context of the ultrasound images at the point of rating on the 5-point scale? If they do, then ‘sufficient to detect what the structure is’ will be different to if they don’t.  You say the images are ‘blinded clinical data’, please provide more detail.

 

Line 94 – ‘The image interpretation skill was clarified as agreeing and disagreeing.’ More information needed here.

 

Line 102 – ‘After that, researcher staff graded rating scores in all the competence of POCUS skill according to previous study [15]’. Please make it clearer for the reader, that this was not a previous study by your team, but by another author (e.g., …according to a previous study by Bhatnagar et al [15].

 

Figure 3 – is not necessary

 

Results

Line 129 – this is a very high percentage. Please include some commentary in the Discussion.

 

Line 151 – ‘field of depth’ – consider ‘depth of field’.

 

Paragraph 2 – please revise for grammar – e.g., ‘our residents performed OB-GYN POCUS was limited’ and ‘images gotten from’

 

Line 161 – 3

The statement regarding transabdominal ultrasonography being ‘of poorer quality than transvaginal ultrasonography because of the high occurrence of ultrasound artifacts [20]’ is erroneous. All ultrasound images have artifacts and all EPs who use the modality should have sufficient education and practice to be aware of these. The cited meta-analysis does not mention artifacts nor the difference between TA and TV ultrasound. Please review/delete.

 

Line 167 – please clarify what you mean by ‘difference’.

 

Line 171 – ‘In terms of the competence of image interpretation, our results showed 60.9% rated 171 as “Agree” which graded as satisfactory level of this competency’. 61% seems a very low score for ‘satisfactory’. Competence typically means the person doing the test can do it correctly, how is this the case at 61%? Please include a discussion of this in your Limitations section.

 

It will be important to include in your discussion, commentary around the fact that ‘image quality’ has a confounding factor, in that some patients are much more difficult, and that clinical diagnosis may not be dependent upon images but on the real-time assessment.

 

Conclusion

To conclude that ‘This study identified the competence of POCUS skill after completing our ultrasound training which demonstrated satisfactory image quality scores, satisfactory image interpretation skills, and good clinical integration skills of our learners’ after stating they were poor in O&G and cardiac, is overstating the findings, please revise. The abstract should also reflect this conclusion.

End of comments

Author Response

respond to reviewer 1 as file attached

Author Response File: Author Response.docx

Reviewer 2 Report

Point of care ultrasound (POCUS) is one of the most useful, frequently being implemented bedside imaging method in emergency unit. We must  remember  that this method requires a lot of practice, training and clinical experience thus   emergency medicine residency training programs includes theoretical sessions but also hands-on practice.  Many reports have reported various aspects of this method in emergency work. In the manuscript under review, the authors analyzed an interesting aspect the competence of POCUS skills of emergency residents training in terms of three distict domains : image  acquisition, image interpretation and clinical  integration. As a result an interesting and predictable results were different and sometimes incomplete compliance of self-performed ultrasound images of some body regions by residents with the recordings obtained by experienced physicians. High agreement was found in the image interpretation, clinical integration and image hands-on practice registration of soft tissues and aorta.The lowest compliance of ultrasound recordings made by residents themselves compared to the registrations obtained by experienced doctors, were obtained in the registrations of the reproductive system image and the heart. This results pointed to an important practically insufficient training of residents In addition, the observation results may contribute to the verification of the  emergency medicine residency training program  Due to the high dependence of the diagnosis of abnormalities on the quality of ultrasound recording and experience, the diagnosis time to time requires verification by another method, such as tomography  

I  have a few comments 

1. Line 37 There is only the abbreviation EM, I think the authors should add the “emergency medicine”
2. Line 49, 50 - The number of hours devoted to different body areas examination during POCUS training ( didactic lectures and registration at the patient's bed)  should be more precisely defined and described. This may influence and affect  the result
3. Line  65 – It should be  January 1, 2021 to December 31, 2021
4. The manuscript includes 1,024 studies performed during 2021. It follows that, during the 2-week training, only 40 examinations were assessed  ( taking into account all types of ultrasound examinations). Can I ask for an explanation, if I am not wrong
5. Whether the examinations recorded by residents and experienced specialists were performed on the same echocardiographic equipment? The quality of the equipment can affect the results
6. Line 101 and 102  .. the competence of FOCUS skill according to previous study {15} as table 1.. – How many residents were in the individual performance ranges
7. Figure 1 - Image quality score - I propose to supplement with the number of performed registrations with division into particular types of organs/body areas examined
8. It is recommended to supplement the discussion with results from other centers

Author Response

respond to reviewer 2 as file attached 

Author Response File: Author Response.docx

Reviewer 3 Report

Dear authors,

I had the opportunity to review your manuscript. It is mandatory that you generalize / transfer your findings to a broader audience.

e.g. comapre it in more detail with reports from other centers etc.

Kind regards

Author Response

respond to reviewer 3 as file attached

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

Manuscript can be accepted in the current version

Reviewer 3 Report

Dear authors, thank you very much for revising the manuscript. Kind regards.