Point-of-Care Ultrasound for Central and Peripheral Line Procedures in Neonates

An educational module on point-of-care ultrasound for central line procedures in neonates was developed for this DNP scholarly project. Point-of-care ultrasound for central line procedures is currently underutilized in the neonatal population. Most critically ill neonates require central line access for fluid management, parenteral nutrition, lab draws, blood pressure monitoring, and medications. Central line insertion problems and malposition are two complications that may occur. Using point-of-care ultrasound for central line procedures can improve first-attempt success rates and the accuracy of catheter position, potentially decreasing complications. Many tertiary Newborn Intensive Care Units (NICUs) along the Wasatch Front do not use point-of-care ultrasound for central line procedures because providers have limited education on how to use this tool. Therefore, education for Wasatch Front providers is needed. The objectives for this project were to: (a) create a neonatal point-of-care ultrasound educational module for central line procedures targeting level III NICU providers along the Wasatch Front, (b) present the point-of-care ultrasound educational module to providers along the Wasatch Front, (c) evaluate the effectiveness of the neonatal point-of-care ultrasound educational module by doing a course evaluation, and (d) present the point-of-care ultrasound education and evaluation results to a NICU administration committee. Point-of-care ultrasound is used in a variety of adult specialties. However, neonatal specialists have been slow to adopt point-of-care ultrasound because of limited training, costs, and medical liability concerns. Several recent studies have shown that using point-of-care ultrasound for central line procedures improves attempt rates and procedural time and decreases complications. Providers find it difficult to locate the catheter tip position by using X-ray alone. Researchers have suggested that ultrasounds are a superior tool to radiographs when determining central line position. The project proceeded as follows: (a) participation in the Neonatology Point-of-Care Ultrasound Course November 19 and 20, 2016 at the Children's Hospital of Philadelphia (CHOP); (b) working with an emergency physician using point-of-care ultrasound on patients to learn more about central line insertion and malposition; (c) development of an introductory educational module using ultrasound for central line procedures; (d) submission of an IRB application for project approval; (e) distribution of an educational module, course evaluation and competency check list to several NICU providers and (f) presentation of educational module, evaluation results, and competency checklist to a NICU administration committee. In summary, this project has important implications for NICU providers who care for neonates with central lines. This educational module will help providers become more comfortable using point-of-care ultrasound to assist in central line procedures and may lead to implementation of point-of-care ultrasound in NICUs along the Wasatch Front.

Running head: NEONATAL ULTRASOUND FOR PROCEUDRES Point-of-Care Ultrasound for Central and Peripheral Line Procedures in Neonates Alysha Jenkins, MSN, NNP-BC, APRN, DNP-Student University of Utah 1 NEONATAL ULTRASOUND FOR PROCEDURES 2 Executive Summary An educational module on point-of-care ultrasound for central line procedures in neonates was developed for this DNP scholarly project. Point-of-care ultrasound for central line procedures is currently underutilized in the neonatal population. Most critically ill neonates require central line access for fluid management, parenteral nutrition, lab draws, blood pressure monitoring, and medications. Central line insertion problems and malposition are two complications that may occur. Using point-of-care ultrasound for central line procedures can improve first-attempt success rates and the accuracy of catheter position, potentially decreasing complications. Many tertiary Newborn Intensive Care Units (NICUs) along the Wasatch Front do not use point-of-care ultrasound for central line procedures because providers have limited education on how to use this tool. Therefore, education for Wasatch Front providers is needed. The objectives for this project were to: (a) create a neonatal point-of-care ultrasound educational module for central line procedures targeting level III NICU providers along the Wasatch Front, (b) present the point-of-care ultrasound educational module to providers along the Wasatch Front, (c) evaluate the effectiveness of the neonatal point-of-care ultrasound educational module by doing a course evaluation, and (d) present the point-of-care ultrasound education and evaluation results to a NICU administration committee. Point-of-care ultrasound is used in a variety of adult specialties. However, neonatal specialists have been slow to adopt point-of-care ultrasound because of limited training, costs, and medical liability concerns. Several recent studies have shown that using point-of-care ultrasound for central line procedures improves attempt rates and procedural time and decreases complications. Providers find it difficult to locate the catheter tip position by using X-ray alone. Researchers have suggested that ultrasounds are a superior tool to radiographs when determining central line position. The project proceeded as follows: (a) participation in the Neonatology Point-of-Care Ultrasound Course November 19 and 20, 2016 at the Children's Hospital of Philadelphia (CHOP); (b) working with an emergency physician using point-of-care ultrasound on patients to learn more about central line insertion and malposition; (c) development of an introductory educational module using ultrasound for central line procedures; (d) submission of an IRB application for project approval; (e) distribution of an educational module, course evaluation and competency check list to several NICU providers and (f) presentation of educational module, evaluation results, and competency checklist to a NICU administration committee. In summary, this project has important implications for NICU providers who care for neonates with central lines. This educational module will help providers become more comfortable using point-of-care ultrasound to assist in central line procedures and may lead to implementation of point-of-care ultrasound in NICUs along the Wasatch Front. The committee for this project was Perry Gee, PhD, RN (Chair); Gillian Tufts, DNP, FNP-BC, assistant professor of Nursing (program director); and Pam Hardin, PhD, RN, (assistant dean for DNP Program). Content experts were Dr. Belinda Chan, assistant professor in the Division of Neonatology, Department of Pediatrics at the University of Utah School of Medicine, and Marilyn Rigby, neonatal nurse practitioner manager at Intermountain Health Care. NEONATAL ULTRASOUND FOR PROCEDURES 3 Table of Contents Page Executive Summary 2 Problem Statement 5 Clinical Significance 6 Purpose 7 Objectives 7 Literature Review 8 Definition 8 Uses 8 History of Point-of-Care Ultrasound 9 Adult population 9 Neonatal population 9 Procedures 11 Peripheral arterial lines (PALs) 11 Peripherally inserted central catheter (PICC) lines 11 Umbilical catheters 12 Placement Techniques 12 PALs 12 PICC lines 13 Umbilical lines 13 Accuracy of Catheter Position 14 Benefits of Point-of-Care Ultrasound 14 NEONATAL ULTRASOUND FOR PROCEDURES 4 Patient management 14 Safety 14 Barriers to Using Point-of-Care Ultrasound 15 Training and education 15 Cost 15 Medical liability 15 Conclusion 15 Theoretical Framework 16 Implementation 17 Evaluation 19 Results 20 Recommendations 22 DNP Essentials 23 Conclusion 24 References 26 Appendix A: Point-of-care ultrasound for central line procedures in neonates 29 Appendix B: Introduction to neonatal ultrasound for central lines 34 Appendix C: Institutional Review Board 47 Appendix D: Competency Check List for Ultrasound Guided Vascular Access 48 Appendix E: Neonatal point-of-care ultrasound pre-survey/post survey 49 Appendix F: Phantom Gel Recipe 51 Table 1 56 Appendix G: DNP Poster 59 NEONATAL ULTRASOUND FOR PROCEDURES 5 Problem Statement The smallest, most critically ill newborns require central lines for fluid management, parenteral nutrition, medication administration, and frequent lab draws (Westergaard, Classen, & Walther-Larsen, 2013). Inserting central lines in these neonates can cause many complications such as multiple attempts and hematomas (Wu et al., 2013). Even after placing central lines, the neonates are at risk for other medical complications such as malposition of the catheter that may lead to arrhythmias, thrombosis, endocarditis, perforation, pericardial effusion, and pleural effusion (Ades, 2003; Fleming & Kim, 2011). Many health care providers now recognize pointof-care ultrasound as a superior tool to gain access and determine the correct position of central catheters (Ades, 2003; Harabor & Soraisham, 2014). Despite this recognition, Neonatal Intensive Care Units (NICUs) currently underutilize point-of-care ultrasound for central line placement (Engel, Silva, Baker & Goodman, 2012). Point-of-care ultrasound for central line procedures can potentially decrease health care costs by reducing central line attempts, decreasing the number of X-rays needed to determine correct position, and preventing other serious complications as mentioned above (Fidler, 2011; Wu et al., 2013). Point-of-care ultrasound can also minimize radiation exposure to the neonate (Fleming & Kim, 2011). In the author's experience, many tertiary NICUs along the Wasatch Front do not utilize point-of-care ultrasound for central line placement because providers are not comfortable using this tool. Therefore, education along the Wasatch Front is needed to increase provider comfort level so that point-of-care ultrasound can be implemented in NICUs for central line procedures. NEONATAL ULTRASOUND FOR PROCEDURES 6 Clinical Significance Point-of-care ultrasound is used more frequently in health care today because the equipment has become easily portable and produces high quality images (Moore & Copel, 2011). Point-of-care ultrasound is used in many health care settings such as the emergency room, obstetrics, and intensive care units (Evans et al., 2011). Point-of-care ultrasound is a useful tool because it can provide guidance for procedures such as central line placement, thoracentesis, drainage of abscesses, and lumbar punctures (Moore & Copel, 2011). Central lines are commonly used and account for over 15 million catheter days per year in the United States (Young, 2014). Young (2014) reported that the overall mechanical complication rate of central line catheters is between 15 and 33%. A cohort study done by Eisen et al. (2006) on 385 central venous catheters reported complication rates as follows: failure to place catheter in 22% of patients, arterial puncture 5 %, and catheter malposition 4 %; while pneumothorax, subcutaneous hematoma, hemothorax and asystolic cardiac arrest were 1% or less. The increase in portability of ultrasounds has led researchers to study ultrasound-guided central line placement in adult and pediatric populations (Fidler, 2011). Nichols and Doellman (2007) found that using ultrasound for peripherally inserted central catheters improved the rate of successful first attempts. Additionally, Stokowski, Steele, and Wilson (2009) discovered that thrombosis rates in adults decreased as did referrals to interventional radiology. The Agency for Healthcare Research and Quality (AHRQ) has deemed real-time ultrasound guidance for central line insertion as one of the most important patient safety practices to decrease medical errors (Moore & Copel, 2011). Unfortunately, NICUs have been slow to adopt point-of-care ultrasound into practice, and some researchers have suggested that this slow adoption is due to lack of equipment, absence of neonatal ultrasound probes, limited NEONATAL ULTRASOUND FOR PROCEDURES 7 knowledge, inadequate neonatal research and concern for liability (Nguyen, Casione & Noori, 2016). Fleming and Kim (2011) showed that point-of-care ultrasound in NICUs leads to fewer manipulations of central lines, decreased radiation exposure, faster overall procedural times, and improved accuracy of line position. Other developed countries such as France and New Zealand use point-of-care ultrasound in NICUs and have created successful collaborations with specialties such as pediatric cardiology (Evans et al., 2011). Evans et al. (2011) asserted that neonatal providers in the United States have indicated that they need more education and training on point-of-care ultrasound to feel comfortable using it on a neonate. Implementing point-ofcare ultrasound in NICUs along the Wasatch Front may help to improve patient outcomes and reduce health care costs. Purpose The purpose of this scholarly project is to help NICU providers along the Wasatch Front become proficient in using point-of-care ultrasound for central lines by creating a point-of-care ultrasound educational module and lecture series. Objectives 1. Create a neonatal point-of-care ultrasound educational module for central line procedures targeting NICU providers along the Wasatch Front. 2. Present point-of-care ultrasound education module to NICU providers along the Wasatch Front. 3. Evaluate the effectiveness of the neonatal point-of-care ultrasound educational module by providing a competency check list and pre-/post education survey. 4. Present point-of-care ultrasound education and evaluation results to a NICU administration committee along the Wasatch Front. NEONATAL ULTRASOUND FOR PROCEDURES 8 Literature Review This review will define point-of-care ultrasound and how it is being applied in various health care settings, followed by a brief description about the history of point-of-care ultrasound and how it has evolved in the adult and neonatal populations. Additionally, the review will illustrate some procedures for which point-of-care ultrasound can be used for, including neonatal central line placement. It will examine the evidence related to complications of central catheters and demonstrate how point-of-care ultrasound can reduce these complications. The methods that are used to measure and check placement of central catheters will also be reviewed. Finally, the benefits and barriers to using point-of-care ultrasound in the NICU will be discussed. Definition Point-of-care ultrasound has become a prevalent tool used in clinical health care settings such as intensive care units and emergency departments (Evans et al., 2011). It consists of using real-time ultrasound at the bedside for clinical assessment and patient management (Moore & Copel, 2011). Point-of-care ultrasound has been termed the "visual stethoscope" in health care today because it combines the anatomy and physiology of a patient with an added visual aspect to assist in rapid clinical decision-making (Main, Jarman, Richards & Connolly, 2010, p. 203). Uses Moore and Copel (2011) suggested that point-of-care ultrasound is increasingly being used in a variety of specialties such as anesthesia, surgery, cardiology, obstetrics, maternal-fetal medicine, gynecology, emergency medicine, critical care medicine, orthopedics, radiology, and pediatrics. They also described some of the applications for using point-of-care ultrasound, including procedural guidance, fluid status, and assessment of cardiac anatomy and function. NEONATAL ULTRASOUND FOR PROCEDURES 9 Furthermore, it is useful for the evaluation, diagnosis, and treatment of many organ systems throughout the body (Main et al., 2010). History of Point-of-Care Ultrasound The first ultrasound images published were of the human skull in 1947, followed by abdominal images in 1958 (Moore & Copel, 2011). Ultrasound has been used for many years, mostly by radiologists, cardiologists, and obstetricians (Main et al., 2010). By the 1990s, improvements in ultrasound machine size, image quality, and portability led to increased usage in many different specialty areas (Litchenstein, Van Hoodland, Elbers & Malbrain, 2014). Adult population. Liteplo, Noble, and Atkinson (2012) described one of the first pointof-care ultrasound protocol studies from 2001. The ultrasound protocol was called the undifferentiated hypotensive patient (UHP) study protocol, and it standardized the approach to using ultrasound when evaluating a hypotensive patient. In 2004, a randomized controlled trial was done comparing early ultrasound versus late ultrasound in the management of non-traumatic hypotension in emergency room patients (Liteplo et al., 2012). Many other ultrasound techniques and algorithms are now used in the management of adults, including the lung ultrasound in the critically Ill (LUCI), the bedside lung ultrasound in emergency (BLUE) protocol, the fluid administration limited by lung sonography (FALLS) protocol, and the LUCI-FLR (favoring limitation of radiation) project (Litchenstein et al., 2014). Liteplo et al. (2012) stated that pointof-care ultrasound is frequently used in the adult critical care and emergency settings because it is readily available and eliminates the need to move a patient. It gives real-time answers, provides the ability to monitor response to treatments, and can confirm or exclude different diagnoses (Liteplo et al., 2012). Neonatal population. Point-of-care ultrasound has been successful in the adult NEONATAL ULTRASOUND FOR PROCEDURES 10 population and has been recognized for the superior diagnostic accuracy compared to clinical examination (Evans et al., 2011). Point-of-care ultrasound implementation in the NICU has been slow compared to other acute care areas such as obstetrics and fetal medicine (Engel et al., 2012). Additionally, the limitations of neonatal clinical assessment in cardiovascular monitoring and systemic blood flow have led neonatal providers to inquire about using point-of-care ultrasound (El-Khuffash & McNamara, 2011). It is being used in the neonatal population for assessment of intraventricular hemorrhage or other cranial hemorrhages, cardiac anatomy and function, catheter-related thrombosis, sepsis, congenital anomalies, pleural effusion, hernia, hydrocele or torsion, hematoma, and central line access (Engel et al., 2012). Evans et al. (2011) described the variability of point-of-care ultrasound use in the neonatal population. The authors surveyed the use of the tool in Australia, France, Spain, New Zealand, USA, and Canada. They found neonatologists in France and New Zealand use pointof-care ultrasound to do functional echocardiography with the support of the pediatric cardiologists. Evans et al. suggested that collaboration with cardiologists has helped the neonatal providers develop echocardiogram skills needed for point-of-care ultrasound. In Australia, the introduction of point-of-care ultrasound was initially met with resistance but is now moving forward with implementation and collaboration from pediatric specialties (Evans et al., 2011). The authors report that Spain is progressing but still has some work to do. According to Evans et al., a limited number of neonatal providers actively engage in point-of-care ultrasound in Canada and the United States. Point-of-care ultrasound seems to be evolving, and both countries have several NICUs working toward developing programs (Evans et al., 2011). NEONATAL ULTRASOUND FOR PROCEDURES 11 Procedures Point-of-care ultrasound can be used to assist with such procedures as central and peripheral vascular access, thoracentesis, paracentesis, arthrocentesis, regional anesthesia, incision and drainage of abscesses, localization and removal of foreign bodies, lumbar puncture, and biopsies (Moore & Copel, 2011). Point-of-care ultrasound can assist in procedures, improve the success rate, and decrease complications associated with the procedures (Fidler, 2011). Peripheral arterial lines (PALs). PALs are commonly used in critically ill neonates for lab draws and to monitor central blood pressure (Westergaard et al., 2013). Peripheral arterial line complications include local hematoma, temporary arterial spasm, transient pain, arterial obstruction, infection, arterial thrombosis, arterial embolism, and blood loss (Bajaj, 2017). Excessive trauma during arterial cannulation frequently leads to these complications (Koyfman, 2016). A systematic review done by Tang et al. (2014) showed that using ultrasound guidance versus traditional palpation to start PALs in adults and children resulted in a reduced number of attempts, less procedural time, and fewer hematomas (Tang et al., 2014). Additionally, a Cochrane meta-analysis of ultrasound-guided radial artery catheterization showed first-attempt success was significantly higher and risk of hematoma was lower when ultrasound was used (Aouad-Mauron, Raphael, Sayyid, Farah, & Akl, 2017). Peripherally inserted central catheter (PICC) lines. NICUs commonly use PICC lines for neonates who require intermediate or long-term intravenous (IV) administration, parenteral nutrition, medications, and blood sampling (Westergaard et al., 2013). Westergaard et al. (2013) reported that the most common complications associated with PICC lines are due to mechanical problems, including occlusions, dislodgements, breakage of the catheter, leakage of the catheter, infection, phlebitis, and venous thrombosis. Using of point-of-care ultrasound in PICC line NEONATAL ULTRASOUND FOR PROCEDURES 12 procedures has been shown to increase the rate of successful first attempt, decrease the rate of thrombosis, decrease referrals to interventional radiology, and aid in the ability to visualize and avoid arterial vessels in the adult population (Nichols & Doellman, 2007; Stokowski, Steele & Wilson, 2009). These benefits seen in the adult population can potentially translate to the neonatal population. A study done by Bruzoni, Slater, Wall and Dutta (2013) found that using an ultrasound guided technique versus traditional landmark technique increased the percent of successful first attempts (65% versus 45%) and the percent of success within three attempts (95% versus 74%). They also showed that the cannulation time was 35 minutes with ultrasound versus 43 minutes using the traditional landmark approach (Bruzoni et al., 2013). Umbilical catheters. Umbilical catheters are commonly placed within hours of birth in neonates admitted to the NICU and kept in place for the first 7-10 days of life (Harabor & Soraisham, 2014). Several potential complications may occur due to placement of umbilical catheters, including thrombosis, pericardial or peritoneal effusion, liver tissue necrosis, arrhythmia, and death (Harabor & Soraisham, 2014). Engel et al. (2012) stated that central access can be challenging and proper placement of a catheter tip is important for a safe and complication-free hospital course. Placement Techniques PALs. The traditional way of placing PALs is by using an anatomic landmark technique (Koyfman, 2016). PALs are typically placed in the radial, ulnar, or posterior tibial arteries (Bajaj, 2016). The most common site to place a PAL is in the radial artery (Koyfman, 2016). Koyfman (2016) suggests that the initial puncture site for the radial artery should be over the radial pulse at the proximal flexor crease of the wrist. An Allen's test is usually performed prior to placement NEONATAL ULTRASOUND FOR PROCEDURES 13 to evaluate for adequate collateral circulation to the palmar arches of the hand (Bajaj, 2017). PICC lines. When placing PICC lines, the vein is usually visualized or palpated by the person doing the procedure. The length of insertion is determined using a tape measure along the course of the vein to the superior vena cava (SVC) using a tape measure (Westergaard et al., 2013). Harabor and Soraisham (2014) explained that this measurement technique is frequently inaccurate. Westergaard et al. (2013) suggested that the tip of the PICC line catheter should be in the distal part of the SVC. Once the PICC line is thought to be the in correct position, an anterior-posterior (AP) radiograph is obtained. PICC lines require additional manipulation up to 85% of the time, thus necessitating multiple chest radiographs to obtain the appropriate position (Harabor & Soraisham, 2014; Westergaard et al., 2013). Umbilical lines. The most common method used to determine umbilical catheter insertion length is to use a regression equation based on birth weight (Fleming & Kim, 2011). The equation used is [(weight × 3 + 9)/2 + 1, in centimeters] for placement in the IVC just outside the RA (Harabor & Soraisham, 2014). Umbilical catheters are then inserted and advanced to the predetermined length from the umbilicus (Fleming & Kim, 2011). An AP and/or lateral radiograph is obtained to check adequacy of the catheter position, but the landmark is often difficult to determine with a frontal radiograph (Harabor & Soraisham, 2014). Fleming and Kim (2011) found that many times catheters are not placed in the optimal position and require repositioning and repeated chest X-rays. Accuracy of Catheter Position Central lines are commonly incorrectly positioned, thus requiring multiple chest X-rays and manipulations to achieve correct placement (Harabor & Soraisham, 2014). Fleming and Kim (2011) cited some studies questioning the low sensitivity and specificity of radiographs to NEONATAL ULTRASOUND FOR PROCEDURES 14 determine central line placement. Harabor and Soraisham (2014) found that 22 out of 51 neonates had UVCs in the heart. Of these, ten were in the right atrium, three in the foramen ovale opening, and nine in the left atrium. The authors also found that it was difficult to determine the catheter tip position by radiograph alone. Ades et al. (2003) suggested that direct visualization of the catheter by ultrasound should be the gold standard to confirm catheter placement. Benefits of Point-of-Care Ultrasound Patient management. Using point-of-care ultrasound for procedures can be faster than conventional placement because it eliminates the time waiting for X- ray confirmation (Engel et al., 2012). Fleming and Kim (2011) showed that point-of-care ultrasound decreased the total time of line placement from 139 to 75 minutes, a 46% decrease. Additionally, manipulation of the catheter is required to obtain the correct position, which leads to multiple X-rays. Point-ofcare ultrasound decreases manipulation of the catheter and decreases the number of x-rays needed (Engel et al., 2012). Fleming and Kim's study (2011) found fewer X-rays per patient in the ultrasound group than in the non-ultrasound group. Safety. Harabor and Soraisham (2012) found that it was difficult to locate a catheter tip position by using a radiograph alone. These authors suggested that a radiograph is not the most adequate imaging technique for positioning a catheter in the ideal location. Their study found that multiple catheters were thought to be in the correct position on a radiograph but by ultrasound they were found to be in the heart. In fact, Ades (2003) suggested that ultrasound is a superior tool to a radiograph when determining central line position (Ades, 2003). As explained earlier, incorrectly positioned catheters can lead to life-threatening complications. Using point- NEONATAL ULTRASOUND FOR PROCEDURES 15 of-care ultrasound can improve the safety for neonates when placing and positioning central lines. Barriers to Using Point-of -Care Ultrasound Training and education. One of the major barriers to point-of-care ultrasound has been lack of education and training for neonatal providers (Evans et al., 2011). Two of the challenges, as shown by Fidler (2011), are time required for training and the requirement of an experienced mentor. Nichols and Doellman (2007) suggest that expertise must be gained over time through practice. A new provider skill must also be learned that involves hand-eye coordination, which may be prove to be difficult initially (Nichols & Doellman, 2007). Cost. Although point-of-care ultrasound has become less expensive over the years, the equipment and maintenance costs can be substantial. Nichols and Doellman (2007) found that the general costs to get started with ultrasound include machine costs, micro introducer kits, needle guide kits (optional), and ultrasound sheath kits, with the total cost ranging from $10,000 to $15,000 (Nichols & Doellman, 2007). Medical liability. Neonatologists are concerned about the liability and possible litigation that point-of-care ultrasound may incur (Evans et al., 2011). This notion likely comes from the quantity of litigation faced by obstetricians and radiologists using ultrasound (Nguyen et al., 2016). Evans et al. (2011) suggested that congenital heart disease is the most feared misdiagnosis. An analysis of law suits done by Nguyen et al. (2016) found no misdiagnosis or failure-to-interpret cases regarding point-of-care ultrasound and neonatologists. In conclusion, point-of-care ultrasound is commonly used in the adult and pediatric populations. There are limited data regarding the use of point-of-care ultrasound for procedures in neonates. Point-of-care ultrasound has been suggested to decrease the procedural time, NEONATAL ULTRASOUND FOR PROCEDURES 16 improve the accuracy of catheter position, and decrease ionizing radiation exposure, thereby leading to improved patient care and outcomes. Point-of-care ultrasound certainly warrants further research and consideration in the neonatal population. Theoretical Framework The theoretical framework chosen for this DNP project is Attention Relevance Confidence Satisfaction (ARCS) Model of Motivational Design by John Keller. This framework has been used to improve the motivational appeal in learning (Keller, 1987). This kind of framework is necessary to use for the development of an educational module and lecture series because it focuses on how to teach effectively and motivate the learner. The four key elements in this learning model are Attention, Relevance, Confidence, and Satisfaction (ARCS) (Keller, 1987). These four elements will be incorporated throughout the creation and design process of the educational module and lecture. The first key element in the model is attention. Keller suggested that attention can be gained by perceptual and inquiry arousal. Perceptual arousal uses surprise or uncertainty, whereas inquiry arousal uses challenging questions or problems that need to be solved (Keller, 1987). Many methods can be used to gain the attention of a learner such as playing devil's advocate or brainstorming activities (Keller, 1987). Using this key element in the beginning slides of the educational module and initial part of the lecture will get the participants to think critically and brainstorm about the topic. The second key element in the model is relevance. According to Keller (1987), education needs to be relevant to the learner. He suggested that the instructor should inquire about the learner's interests and explain how the new education will enhance existing skills. Keller believes the instructor should also state why the subject matters to the learner and how the new NEONATAL ULTRASOUND FOR PROCEDURES 17 education relates to the future. He suggests the instructor provide the learners opportunities for responsibility, authority, and interpersonal influence to keep them motivated. The instructor should model enthusiasm for the subject being taught and provide the learners with alternative methods to accomplish their goals if needed (Keller, 1987). The educational module will include vital points such as the importance of incorporating this topic into practice, how it will specifically enhance and improve their NICU skills, and how they can safely use point-of-care ultrasound as a health care tool in the future. The next key element in the model is confidence. Keller (1987) encourages the instructor to assist others to see their likelihood for success. He recommends that instructors allow for small steps of growth during the learning process and provide objectives and evaluation criteria to help the learners meet their goals. Learners like to have control over their own learning to keep them motivated (Keller, 1987). The educational module will include several different approaches to learning, such as pictures, videos, personal experiences, and hands-on experiences to give the learners a greater depth of understanding. These different learning techniques will be designed to increase learner confidence and success in using point-of-care ultrasound during central line procedures. The last key element in this model is satisfaction. To improve learner satisfaction, learners should be allowed to use newly gained skills as soon as possible, with the instructor paying personal attention to each learner as able and giving positive feedback (Keller, 1987). As an instructor, it will be essential to give the learner's personal attention and encouraging feedback. The instructor should also seek out various central line procedure opportunities for the learners so that they can use their new knowledge and skills to become comfortable and competent with the process. NEONATAL ULTRASOUND FOR PROCEDURES 18 Implementation This project required several important implementation steps to be successful. One of the beginning steps was to develop a PowerPoint presentation for the DNP defense requirement at the University of Utah (see Appendix A). The first objective was to create a neonatal point-ofcare ultrasound educational module for central line procedures targeting NICU providers along the Wasatch Front. The objective was met by participation in the Neonatology Point-of-Care Ultrasound Course November 19th and 20th at the Children's Hospital of Philadelphia (CHOP). The author's knowledge and comfort level regarding neonatal point-of-care ultrasound significantly increased after attending this course. The author also worked with an emergency department (ED) physician to become more proficient in using point-of-care ultrasound for central line procedures. Finally, a neonatal point-of-care ultrasound educational module was developed. The second objective was to present the point-of-care ultrasound educational module to NICU providers along the Wasatch Front (see Appendix B), followed by submission of an IRB application for project approval; the IRB determined this project to be exempt (see Appendix C). Initially, the educational module was presented to a small pilot group. This pilot group provided additional suggestions, and changes were made to the module accordingly. Next, the point-ofcare educational module was presented to several NICU providers on February 13, 16, and 21, 2017. The third objective was to evaluate the effectiveness of the educational module by providing a competency check list and pre-/post course survey. A competency checklist was created and given to participants at the end of the presentation and hands-on skills station (see Appendix D). An on-line pre-/post course survey tool was created using the RedCap program to NEONATAL ULTRASOUND FOR PROCEDURES 19 determine the effectiveness of the educational module (see Appendix E). Data from the survey were collected and analyzed via RedCap. The last objective was to present the educational module, pre-/post course survey, and competency checklist to a NICU administration committee. At this meeting, the goal was to get feedback from the committee members about the possibility of implementing point-of-care ultrasound in the hospital's NICU. Several steps need to be implemented to start a neonatal ultrasound program in the NICU. Evaluation The author attended the Neonatology Point-of-Care Ultrasound course and learned the basics of neonatal point-of-care ultrasound, networked with experts in neonatal point-of-care ultrasound, and found colleagues willing to mentor and help with the module. Additionally, while working with an ED physician, the author improved her clinical skills using point-of-care ultrasound for central line procedures. Submission of an IRB application resulted in the project being exempt. A neonatal pointof-care ultrasound educational module, pre-/post course survey, and competency checklist were developed and subsequently approved by the content experts and chair. The educational module was then presented to a small pilot group. The pilot group had helpful suggestions, and changes were made to the educational module, checklist, and evaluation based on feedback from the pilot group. The neonatal point-of-care ultrasound educational module was then presented to NICU providers along the Wasatch Front. A pre-/post course survey was developed using the RedCap program and given to participants. Data were collected from the survey and the results were analyzed. The educational module, survey results, and competency check list were presented at a NEONATAL ULTRASOUND FOR PROCEDURES 20 NICU administration meeting. This meeting allowed the author to collect feedback and thoughts on implementing neonatal point-of-care ultrasound in the hospital NICU. A few of the committee members showed great interest in using point-of-care ultrasound. These members plan to help facilitate the implementation of neonatal point-of-care ultrasound in the NICU. Results The educational module was presented to NICU providers along the Wasatch Front. The lecture was scheduled for three separate dates: February 13, 16 and 21, 2017. The educational offering was advertised by email and word of mouth. The NICU manager was helpful in facilitating dates and rooms for the lectures. In addition to the education lecture, a hands-on skills station allowed participants to use the ultrasound machine and practice ultrasound techniques. A phantom gel was made-out of gelatin, Metamucil, and elongated balloons that looked like blood vessels (see Appendix F) to allow the participants to practice scans and attempt central line placement with ultrasound. Some of the key barriers included the in-person lecture, which was difficult for some people to attend, inadequate time allotted for education to allow providers to feel adequately trained, and the scans not being done on live patients. A pre-/post course survey was developed using the University of Utah's RedCap program. The pre-/post course survey consisted of the same 15 questions. The first four questions focused on demographics such as gender, age, profession, and years of experience. Subsequent questions related to opinions about using point-of-care ultrasound, knowledge gained by attending lecture, comfort level using ultrasound, and education effectiveness. This survey was short and easy for participants to fill out. It was simple to input survey results into the RedCap program. The program analyzed the results and graphed the data as needed. The competency checklist was created for participants to help provide them a step-by-step approach NEONATAL ULTRASOUND FOR PROCEDURES 21 on how to use the ultrasound machine for central line placement. The participant demographics were as follows: 95% women; 30-39 years old (40%), 4049 years old (35%), > 50 years old (25%); Profession: NP (85%), RN (10%), and MD (5%); and years of experience 10-20 years (35%), > 20 years (30%), 5-10 years (25%), and 0-5 years (10%) (see Table 1 for survey results). In short, interest in ultrasound use, training adequacy, and comfort level improved. The main barrier in the pre-course survey was education/training whereas in the post-course survey comfort level was the main barrier. Most of the participants reported the main benefit of using ultrasound is to decrease central line insertion attempts. The questions related to basic ultrasound knowledge improved from pre-course survey to post-course survey. Many of the participants believed that more ultrasound courses are needed and would recommend this ultrasound course to others. In the end, the educational module was made very basic by focusing on the steps to use ultrasound, the ultrasound technique, and inserting central lines using ultrasound. Some of the barriers included difficulty with using ultrasound in neonates with their tiny anatomy, issues with privileging at the hospital level, convincing the neonatologists that ultrasound would be useful, and comfort level of NICU providers. One barrier was that the pre-/post course survey demographic questions were redundant. These questions could have been cut out from the postsurvey. The survey found that a one-hour educational module was not enough to help the participants feel completely comfortable using ultrasound. Using ultrasound for central lines is a skill that will require a great deal of practice by NICU providers. The educational module and evaluation results were presented to the NICU administration, including the nurse manager, NICU medical director, neonatologists and other nurse practitioners. There was some interest in starting an ultrasound program in the NICU, NEONATAL ULTRASOUND FOR PROCEDURES 22 although it involves a variety of specialties such as radiology, cardiology neonatology, etc. The initial steps are to find out what type of credentialing and privileging is required by the hospital. There are several different pathways in the hospital depending on the department. One department has their providers watch videos, attend simulation training, and perform a certain number of procedures on live patients. Another department uses the PICC Excellence program education. This program provides education via videos and checks competency via testing. Recommendations Many recommendations resulted from this project. First, using ultrasound is much more difficult on neonates than anticipated. This skill will take more education, training and practice. Future education should include practicing on live NICU patients if possible. This is the only way one will start to feel comfortable and become proficient in using ultrasound. One suggestion is to have NICU providers shadow a member of the IV team. The IV team uses point-of-care ultrasound frequently for central line procedures and has the expertise needed to teach NICU providers. Several training courses are needed for providers so they can feel confident using ultrasound and maintain competency for central line placement. There are many ways to provide education and training for point-of-care ultrasound. Several ultrasound videos that are available via YouTube provide basic ultrasound physiology education and skills. Different PowerPoint lectures can easily be accessed online. Ultrasound training programs such as the PICC Excellence program provides videos and tests. Lectures can be held in person or via the Web so that education can be more accessible to providers. Education and testing should be done on an annual basis to maintain competency. Another recommendation is to create a step-by-step guide to place on the ultrasound NEONATAL ULTRASOUND FOR PROCEDURES 23 machine to facilitate its use for the provider. This guide could list steps such as power on/off machine, input patient data, select correct transducer/probe, adjust depth control, adjust gain control, and scan. If providers are not frequently using the machine, this quick reference guide will help them get started and feel more comfortable using it. An ultrasound credentialing pathway should be established prior to implementing an ultrasound program in the NICU. Once there is a clear pathway, guidelines and protocols should be established for using ultrasound in the NICU. Future NNP students or those interested in using ultrasound can help establish these guidelines and protocols. They must work closely with the medical staff office to find out the specific requirements and recommendations that are needed. This recommend is something that can be done in the future because there is interest in using ultrasound. All the project results, recommendations, and key findings were presented at the DNP poster presentation on March 31, 2017 (see Appendix G). DNP Essentials The DNP essential this project focuses on is DNP Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking. An educational module is needed to get NICU practitioners comfortable using point-of-care ultrasound for procedures such as central line insertion. Once practitioners are comfortable using point-of-care ultrasound for procedures, quality improvement and policy changes can occur leading to improved patient care and outcomes. Fleming and Kim (2011) show that using point-of-care ultrasound for central line procedures lowers health care costs by decreasing the number of attempts and X-rays needed for line placement. It also decreases patient exposure to radiation (Fleming & Kim, 2011). This project will, it is hoped, increase the use of point-of-care ultrasound along the Wasatch Front NICU's and lead to more quality improvement projects and policy change. It is important for NEONATAL ULTRASOUND FOR PROCEDURES 24 DNP prepared practitioners to get involved in these types of projects to help advance and improve health care. Another DNP essential important to this project is DNP essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes. This project requires the involvement of many other disciplines such as nursing, medical staff, administration, radiology and cardiology to make it a success. Some disciplines such as radiology and/or cardiology may feel threatened that neonatology is encroaching upon their territory. The DNP-prepared provider will be able to effectively communicate and collaborate to bring all disciplines together. Conclusion Central lines are commonly placed in critically ill neonates during the first few weeks of life (Westergaard et al., 2013). Central line placement can be a very difficult procedure for small neonates and using point-of-care ultrasound at the bedside has the potential to decrease central line attempts and complications (Tang, 2014). Unfortunately, most NICU providers do not feel comfortable using point-of-care ultrasound because of their limited training and education (Evan et al., 2011). The main objective of this project was to create an educational module to help NICU providers become more familiar with using ultrasound for central line procedures. Initially, the idea was to create a module geared toward more in-depth education focusing on central line placement and manipulation of catheters. As the project progressed, it was quickly realized that more basic ultrasound education was needed to achieve an adequate comfort level among NICU providers. This is skill requires more education, practice, and training. Ultrasound education is the beginning step to implementing an ultrasound program in the NICU. Ultrasound usage can be expanded by future students, providers, or ultrasound NEONATAL ULTRASOUND FOR PROCEDURES 25 champions who want to become competent in using ultrasound for neonates. However, collaboration with many other pediatric subspecialties within the hospital, such as radiology, cardiology, anesthesiology, and medical staff, will have to occur. Specific criteria need to be defined for using point-of-care ultrasound at the bedside in the NICU. In summary, this project has important implications for NICU providers who care for neonates with central lines. This project has improved the comfort level of NICU providers using point-of-care ultrasound to assist in central line procedures. It is hoped it will lead to implementation of point-of-care ultrasound in NICUs along the Wasatch Front. NEONATAL ULTRASOUND FOR PROCEDURES 26 References Ades, A., Sable, C., Cummings, S., Cross, R., Markle, B., & Martin, G. (2003). Echocardiographic evaluation of umbilical venous catheter placement. Journal of Perinatology, 23(1), 24-28. Aouad-Maroun, M., Raphael, C.K., Sayyid, S.K., Farah, F., & Akl, E.A. (2016). Ultrasoundguided arterial cannulation for paediatrics (Review). Cochrane Database of Systemic Reviews, 2016 (9), 1-52. Doi: 10.1002/14651858.CD011364.pub2 Bajaj, L. (2017). Arterial puncture and cannulation in children. Retrieved from http://www.uptodate.com/contents/arterial-puncture-and-cannulation-inchildren#subscribeMessage. Burdjalov, V., Srinivasan, P., Baumgart, S., & Spitzer, A. R. (2002). Handheld, portable ultrasound in the neonatal intensive care nursery: a new, inexpensive tool for the rapid diagnosis of common neonatal problems. Journal of Perinatology, 22(6), 478-483. Eisen, L.A., Narasimhan, M., Berger, J.S., Mayo, P.H., Rosen, M.J., & Schneider, R.F. (2006). Mechanical complications of central venous catheters. Journal of Intensive Care Medicine. 21(1), 40-46. El-Khuffash, A. F., & McNamara, P. J. (2011). Neonatologist-performed functional echocardiography in the neonatal intensive care unit. Seminars in Fetal & Neonatal Medicine, 16(1), 50-60. Engel, C., Silva, C., Baker, K., & Goodman, T. R. (2012). Underutilized ultrasound applications in the neonatal intensive care unit. Ultrasound Quarterly, 28(4), 299-304. Evans, N., Gournay, V., Cabanas, F., Kluckow, M., Leone, T., Groves, A., et al. (2011). Pointof-care ultrasound in the neonatal intensive care unit: International perspectives. Seminars in Fetal & Neonatal Medicine, 16(1), 61-68. NEONATAL ULTRASOUND FOR PROCEDURES 27 Fidler, H. L. (2011). The use of bedside ultrasonography for PICC placement and insertion. Advances in Neonatal Care, 11(1), 52-53. Fleming, S. E., & Kim, J. H. (2011). Ultrasound-guided umbilical catheter insertion in neonates. Journal of Perinatology, 31(5), 344-349. Harabor, A., & Soraisham, A. (2014). Rates of intracardiac umbilical venous catheter placement in neonates. Journal of Ultrasound in Medicine, 33(9), 1557-1561. Keller, J.M. (1987). Development and use of the ARCS Model of Motivational Design. Retrieved from http://ocw.metu.edu.tr/pluginfile.php/8620/mod_resource/content/1/Keller%20Developm ent%20%20Use%20of%20ARCS.pdf Lichtenstein, D., van Hooland, S., Elbers, P., & Malbrain, M. L. (2014). Ten good reasons to practice ultrasound in critical care. Anaesthesiology Intensive Therapy, 46(5), 323-335. Liteplo, A., Noble, V., & Atkinson, P. (2012). My patient has no blood pressure: point-of-care ultrasound in the hypotensive patient - FAST and RELIABLE. Ultrasound, 20(1), 64-68. Main, S., Jarman, R. D., Richards, S., & Connolly, J. (2010). Education and service delivery: Improved patient management with point-of-care ultrasound. Ultrasound, 18(4), 201-204 204. Moore, C.L., Copel, J.A. (2011). Point-of-care ultrasonography. New England Journal of Medicine, 364, 749-757. Nguyen, J., Cascione, M., & Noori, S. (2016). Analysis of lawsuits related to point-of-care ultrasonography in neonatology and pediatric subspecialties. Journal of Perinatology, 36, 784-786. NEONATAL ULTRASOUND FOR PROCEDURES 28 Nichols, I. & Doellman, D. (2007). Pediatric peripherally inserted central catheter placement: application of ultrasound technology. Journal of Infusion Nursing. 30(6), 351-356. Rowe, V.L. (2016). Arterial line placement. Retrieved from http://emedicine.medscape.com/article/1999586-overview#a4. Stokowski G., Steele D., & Wilson D. (2009). The use of ultrasound to improve practice and reduce complication rates in peripherally inserted central catheter insertions: Final report of investigation. Journal of Infusion Nursing. 32(3), 145-155. Tang, L., Wang, F., Li, Y., Zhao, L, Xi, H. Guo, Z….. (2014). Ultrasound guidance for radial arterial catheterization: An updated meta-analysis of randomized controlled trials. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222952/ Westergaard, B., Classen, V., & Walther-Larsen, S. (2013). Peripherally inserted central catheters in infants and children - indications, techniques, complications and clinical recommendations. Acta Anaesthesiologica Scandinavica, 57(3), 278-287. Wu, S.Y., Ling, Q., Cao, L.H., Wang, J. Xu, M.X., Zeng, W.A. (2013). Real-time twodimensional ultrasound guidance for central venous cannulation: A meta-analysis. Retrieved from http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1918693 Young, M.P. (2014). Complications of central venous catheters and their prevention. UpToDate. Retrieved from http://www.uptodate.com.ezproxy.lib.utah.edu/contents/complications-ofcentral-venous-catheters-andtheirprevention?source=machineLearning&search=central+line+complications&selected Title=1%7E150§ionRank=1&anchor=H10#H10 NEONATAL ULTRASOUND FOR PROCEDURES Appendix A 29 NEONATAL ULTRASOUND FOR PROCEDURES 30 NEONATAL ULTRASOUND FOR PROCEDURES 31 NEONATAL ULTRASOUND FOR PROCEDURES 32 NEONATAL ULTRASOUND FOR PROCEDURES 33 NEONATAL ULTRASOUND FOR PROCEDURES Appendix B 34 NEONATAL ULTRASOUND FOR PROCEDURES 35 NEONATAL ULTRASOUND FOR PROCEDURES 36 NEONATAL ULTRASOUND FOR PROCEDURES 37 NEONATAL ULTRASOUND FOR PROCEDURES 38 NEONATAL ULTRASOUND FOR PROCEDURES 39 NEONATAL ULTRASOUND FOR PROCEDURES 40 NEONATAL ULTRASOUND FOR PROCEDURES 41 NEONATAL ULTRASOUND FOR PROCEDURES 42 NEONATAL ULTRASOUND FOR PROCEDURES 43 NEONATAL ULTRASOUND FOR PROCEDURES 44 NEONATAL ULTRASOUND FOR PROCEDURES 45 NEONATAL ULTRASOUND FOR PROCEDURES 46 NEONATAL ULTRASOUND FOR PROCEDURES Appendix C 47 NEONATAL ULTRASOUND FOR PROCEDURES 48 Appendix D NAME____________________________ DATE______________________ NICU Competency Check List for Ultrasound Guided Vascular Access Placement Turn on/off ultrasound Input patient information _______ _______ Choose correct probe for procedure _______ Describe how the screen indicator relates to the probe indicator _______ Demonstrate proper placement of hand position using probe _______ Determine ultrasound 2D mode for vessels identification _______ Adjust depth and gain for image acquisition _______ Describe the difference between a vein and artery on ultrasound _______ Access vessel using short axis (transverse) technique _______ Access vessel using long (longitudinal) axis technique _______ Demonstrate directionality of color Doppler flow _______ Demonstrate how to use Pulsed-Wave Doppler to detect pulsatile flow _______ NEONATAL ULTRASOUND FOR PROCEDURES Appendix E 49 NEONATAL ULTRASOUND FOR PROCEDURES 50 NEONATAL ULTRASOUND FOR PROCEDURES 51 Appendix F Philippe Jeanty, MD, PhD; Thao Jeanty. Inner Vision Women's Ultrasound, Nashville, Tennessee, USA. A recipe from Thao & Philippe's Kitchen! Step 1: the base Ingredients in the following proportions, in the total volume desired, are stirred until completely dissolved: • 250 mL (approximately 1 cup) boiling water, • 25 g of unflavored gelatin (about 3 packets of Knox brand gelatin), (flavored gelatin is ok too, it smells great but is more expensive, and we will reserve it for the 3rd layer below) • 10 g (a heaping tablespoon) of sugar-free psyllium hydrophilic mucilloid fiber (brand name: sugar-free Metamucil). Talcum powder can also be used but it tends to settle more. • Pour in a large container (more will follow so plan to not fill the container now. We used plastic salad bowls like this NEONATAL ULTRASOUND FOR PROCEDURES 52 Stir it every now and then (about every 20 min) until it starts to thicken. Otherwise the fibers will settle in the bottom. When it starts to thicken, stop stirring, to not "break" the structure and introduce air bubbles (NO air bubbles at all of course!) Let it congeal for a few hours in a refrigerator at 6°C. It should be really firm and jiggle when set. This is the schematic of what we have with the first layer in orange. Step 2: the inclusions While the first layer is congealing, prepare the "inclusions". We bought a bunch of small balloons like these: NEONATAL ULTRASOUND FOR PROCEDURES 53 Put some of the same mixture as above (without the Metamucil) so they appear echofree to make "cysts". Prepare a smaller batch of mixture, and fill the balloon with a funnel. The balloon should be about 2-4 cm). You can also fill a few balloons with a higher amount of Metamucil (triple it) to create more echogenic balloons) To mimic "femurs" we simply took some drinking straws that we cut in exact numbers such as 20, 30, 40 and 50 mm. The exact numbers are so that when the students scan we know that values such as 37 mm are not well measured. These "femurs" will fill with gel in the next step when they get embedded. To mimic "vessels", use rubber tubing (not plastic as these are too hard to puncture). Old Foley catheters are good too if you can recover some. To be really fancy, these can be filled with the same gelatine mixture (no Metamucil) with food colorant (so that we can test that the students aspirate color in their "puncture". Again let the gel solidify in the whole tubing before cutting it in 10-15 cm segments. NEONATAL ULTRASOUND FOR PROCEDURES 54 This is the schematic of what we have with the first layer in orange, and the inclusion (in blue) on top of it Step 3: anchoring the inclusions Most likely all these inclusion will float, so they need to be anchored on the base. To do that the easiest is to place them on the base in Step 1 (when it has congealed) then fill a layer the thickness of the largest inclusion, and let that second layer congeal. When the balloons have congealed, cut the "knot" off so that the "lesion" looks cleaner delineated. Place the cut section "below" as much as possible. We tried anchoring with unfolded paper clips, but they created lots of artifacts when scanning and did not anchor very well. When pouring the second layer, enter the cut straws ("femurs") at an angle so that they fill with the liquid gel. The inclusions will progressively "float" to the top of the second layer, so make it as thin as possible (certainly no thicker then the largest inclusion): Let the phantom congeal, and very delicately stir the layer to prevent too much sedimentation of the fibers. Step 4: Finishing layer Finally one more layer, about 5-8 cm thick, is mixed and poured over the second (and already NEONATAL ULTRASOUND FOR PROCEDURES 55 congealed layer) to form the "near field" when scanning. Here flavored gelatin is good as it will "hide" the inclusions better so that the students cannot see what they are trying to scan. We did not add any antiseptic (such as cholorox) into the mixture and it will last 2 weeks in the refrigerator (we did not try longer and it may very well last longer). NEONATAL ULTRASOUND FOR PROCEDURES 56 Table 1 Survey questions Gender Pre-Survey Results (n=20) Post Survey Results (n=20) Female 95% Female 95% Age Male 20-29 y.o. 5% 0% Male 20-29 y.o. 5% 0% 30-39 y.o. 40% 30-39 y.o. 40% 40-49 y.o. 35% 40-49 y.o. 35% >50 y.o. NP 25% 85% >50 y.o. NP 25% 85% RN 10% RN 10% Profession MD/DO Years of experience MD/DO 5% Other 0-5 years 0% Other 10% 0-5 years 0% 10% 5-10 years 25% 5-10 years 25% 10-20 years 35% 10-20 years 35% 30% >20 years 75% Strongly agree 30% 80% 20% Agree 20% >20 years I am interested in using point- Strongly agree of-care ultrasound for central line procedures in neonates Agree (PAL, PICC, UVC, UAC). Neutral Disagree My training and/or education on using point-of-care ultrasound for central line procedures is adequate. 5% Strongly disagree Strongly agree 5% Neutral 0% 0% 0% 0% 10% Disagree Strongly disagree Strongly agree 0% 10% Agree 5% Agree 35% Neutral 10% Neutral Disagree 20% Disagree 20% Strongly disagree 55% Strongly disagree 10% 5% NEONATAL ULTRASOUND FOR PROCEDURES What is the main barrier limiting you from using point-of-care ultrasound in your practice? Education/training 65% Education/training Equipment availability 20% Equipment availability Comfort level Comfort level Medical liability What do you think the greatest benefit to using point-of-care ultrasound for central line procedures is? 57 15% 0% Medical liability 55% 5% 35% 0% Limited research showing benefit 0% Limited research showing benefit 0% Physician resistance 0% Physician resistance 0% Other Decreased insertion attempts 0% 0% 65% Other Decreased insertion attempts 90% 0% Decreased procedure time 10% Decreased procedure time Decreased manipulation of Decreased manipulation of catheter 5% catheter 0% Decrease malposition of Decrease malposition of catheter 25% catheter 0% What is the best ultrasound probe to use for central line procedures? The blue and red colors on the ultrasound screen indicate the difference between an artery and vein. I am comfortable using pointof-care ultrasound for central line procedures in neonates. Other Low frequency 0% 30% Other Low frequency Medium frequency 45% Medium frequency High frequency True 25% High frequency 60% True 75% 5% False 40% 95% False Strongly agree 0% 20% 5% Strongly agree 0% 5% Agree 5% Agree 25% Neutral 15% Neutral 45% Disagree 40% Disagree 20% Strongly disagree 60% Strongly disagree 5% NEONATAL ULTRASOUND FOR PROCEDURES Point-of-care ultrasound can improve quality of care in neonates. A point-of-care ultrasound course for central line procedures in neonates is needed in my practice. Strongly agree 70% Agree 25% Agree Comments/suggestions Strongly agree 75% 25% Neutral 5% Neutral 5% Disagree 0% 0% Disagree Strongly disagree Strongly agree 0% 55% Agree 35% Agree Neutral 10% Neutral Disagree I would recommend this education module to others. 58 0% Strongly disagree Strongly agree Disagree Strongly disagree Strongly agree 0% 65% Strongly disagree Strongly agree Agree 20% Agree Neutral 15% Neutral 0% 75% 20% 5% 0% 0% 80% 20% 0% Disagree 0% Disagree 0% Strongly disagree 0% Strongly disagree 0% Great information, will need lots of practice!! Very informative and useful, would highly recommend NEONATAL ULTRASOUND FOR PROCEDURES Appendix G 59