Ultrasound Use and
Training Available
to CRNAs
Dustin Hunter RNAI
Josh Leppert RNAI
Gonzaga University/ Sacred Heart Medical Center
Master 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 Questions
1. 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
What types of training have you participated in after your formal
anesthesia education
72.6%
54.8%
50.0%
33.9%
53.2%
51.6%
41.9%
6.5%
Obstacles to Ultrasound Use
Low on the priority
list
2%
Coverage to allow
training
4%
Lack of procedures
available
11%
Time constraints
(turnover time)
22%
Lack of administrative
support
13%
Lack of
colleague
support
9%
Cost of equipment
17%
Difficulty in
maintaining Cost of training
skills
9%
9%
Training
would
have to
be done
on
vacation
time
4%
Frequency of Ultrasound Use
Rarely
11%
Only When
Other Methods
Fail
3%
Every
procedure
36%
During Most
Procedures
50%
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 CDRom 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.13652044.2009.06200.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.