Keywords
ultrasound - children - live stream - remote - ultrasound training
Introduction
Ultrasound (US) is an indispensable tool in diagnostics and interventions and for monitoring therapy success. Its advantages include noninvasiveness, absence of ionizing radiation, fast and broad availability, cost-effectiveness, and cutting-edge technology (microvascular imaging) providing the most advanced medical imaging [1]
[2]. US imaging is particularly suitable for use in children due to the fact that sedation is not required and the image resolution is excellent due to the slender body composition of children [3]
[4]. The use of point-of-care US (POCUS) in pediatric emergency departments demonstrates these advantages in acute, time-sensitive medical challenges [5]
[6]
[7]
[8] and efforts have been made to standardize recommendations for pediatric POCUS application as exemplified by the ESPNIC (European Society of Paediatric and Neonatal Intensive Care) evidence-based guidelines [9]. Examiner expertise is of utmost importance and different approaches to enhance US knowledge such as peer-assisted abdominal US teaching, training with US body part models, and task-trainer computer-based US simulation demonstrated the ability to improve US expertise [10]
[11]
[12]. Recently a nationally accredited pediatric-specific curriculum and training plan for POCUS application in the UK (CACTUS – Children’s ACuTe UltraSound) was published to address the lack of standardization of POCUS curricula, qualifications, and certification [13]. Further challenges and obstacles are new fields for POCUS application, i.e., ensuring POCUS application skills and addressing the shortage of certified instructors and on-site devices [3]
[4]
[7]
[9]
[13]
[14]
[15]
[16].
Remote US supervision appears to be a promising approach to address these POCUS challenges. Remote teaching has proven to be as effective as on-site teaching [17]
[18]
[19]
[20] and first feasibility studies simulated various clinical challenges for lung, cardiac, and pediatric POCUS involving physicians and prehospital staff [21]
[22]
[23]
[24]. These studies focused on technical feasibility, supervisor accessibility, expenditure of time, US functionality, and patient-self performance [21]
[22]
[25]
[26]. However, poor network quality resulting in prolonged and delayed exams, restriction to simple medical or trauma-related questions, and mandatory on-site attendance of an US expert [27] limit in part their overall significance.
In this study we analyze the general demand and technical feasibility of 24/7 remote US support at a tertiary university children’s hospital. Furthermore, we evaluated the impact on patient care and US education.
Materials and Methods
Patient Recruitment and Data Collection
This single-center study was conducted between October 2022 and January 2023 at a tertiary university children’s hospital. We included all US exams performed on outpatients of the central emergency department and on inpatients of the pediatric wards. The pediatric and neonatal intensive care units were excluded due to reduced accessibility to the specialized US device as a result of a longer distance to the US department. US exams performed during regular working hours were not part of this study design as on-site US supervisors are available and can immediately assist or take over US exams in the event of difficult medical questions and technical challenges.
Documentation of US exams was standardized and included the following parameters: name of on-site examiner, patient, date and time of exam, medical problem as reason for US exam, grading of urgency (emergency, urgent, and standard), success of exam (technical performance, achievement of definite diagnosis, duration of exam, clinical consequence (yes/no)) (Suppl. 1, 2, 3). Clinical consequences designated as “yes” were further defined as a direct consequence of the performed US exam and could be decisions to perform surgery (e.g., appendectomy) or an intervention (e.g., placement of a pleural drain), decisions regarding further diagnostics (e.g., other form of imaging), and decisions to restart or change a therapy (e.g., start antibiotic therapy).
The first four weeks of the study phase served as the “documentation period” to assess the demand for remote live US supervision. Examiners documented for each US exam whether live supervision would have been requested if available.
During the following eight weeks (referred to as the “supervision period”) examiners had the possibility to request remote supervision by a pediatric US expert for each US exam. The need for and the technical implementation of supervision, the name of the remote supervisor, and the satisfaction of on-site examiners and supervisors were documented.
Basic US expertise with proof of at least 700 US exams performed during the training period is a precondition for the acquisition of specialist certification in pediatrics in Germany. The physicians-on-duty taking part in this study were at least in their 5th year of residency after completion of a standardized 3-month US training period including about 2000 pediatric US exams performed under the supervision of certified pediatricians. Remote supervision was performed by five different senior pediatricians certified in pediatric ultrasonography by the German Society for US in Medicine (DEGUM). Three supervisors were certified as DEGUM level 1 with proof of certified training in pediatric sonography, e.g., by participation in a DEGUM-certified basic and advanced pediatric course, proof of 850 independently performed US exams including the brain, abdomen, and hips, and successful practical exam. Two supervisors were certified as DEGUM level 2 with proof of at least 3 years of experience in pediatric US, 1800 independently performed US exams including the brain, abdomen, and hips, and successful exam regarding teaching ability on the basis of lectures.
All attending physicians received simulator-based training before the start of the study.
Standard US Exams
US exams were performed using an Aplio i800 (Canon Medical Systems) with transducers of different frequencies (i8CX1, I18LX5, I22LH8 and PVT712BT). A high-quality HDMI to USB 3.0 video encoder (Roland UVC-01) was attached to the US device to facilitate image live streaming with uncompressed 1080p HD at 60 FPS. This video capture device was connected to a laptop with high-resolution imaging including a 2560-by-1664 native resolution at 224 pixels per inch (MacBook Air M2 with 13.6-inch (diagonal) LED-backlit display) as shown in [Fig. 1]. The wireless local area network (WLAN) was used for image transmission. A virtual classroom software program designed for online education (Big Blue Button) ensured livestream imaging and continuous bilateral communication between supervisor and on-site examiner in a high-definition setting (1080p video mode, 1,920 by 1080 pixels). Regarding data safety, patient data were de-identified before the start of the livestream and the software program was password-protected. All images and documentation reports of US exams were stored automatically in the internal imaging system.
Fig. 1 Implementation of live- and remote-supervised pediatric ultrasound examination with combination of ultrasound device and attached laptop.
Questionnaire
An anonymous online evaluation (Lime Survey) among all attending physicians was conducted after completion of the study. The questionnaire contained 21 questions. Questions 1–7 pertained to the general level of training and the level of US experience. Questions 8–13 referred to personal confidence with regard to US expertise, particularly in on-duty situations. Questions 14–20 were related to the remote live supervision offered within this study and Question 21 addressed the need for instructional videos on various US topics. Further detailed information is depicted in Suppl. 4 and 5.
Patient data
We evaluated the age, sex, and discharge diagnosis of all patients.
Ethics
The local ethics committee approved the study. Written informed consent was not required, as de-identification during live streaming was part of the protocol. Before enrollment, all participants or their parents or legal guardians gave their oral informed consent.
Statistical analyses
The statistical tests were conducted using R-Studio (Version 2023.09.0 Build 463) and Instant Clue (Version 0.12.1). The raw ordinal data was transformed into the percentage of the respective group and was statistically analyzed using the Chi-square test with Yates' continuity correction if needed. The metric data was analyzed using an unpaired Student’s t-test. In both tests, p-values below 0.05 were considered significant.
Results
Pediatric cohorts
This study included 1247 inpatients (documentation period n=432; supervision period n=815) and 1704 patients in the central emergency department (CED) (documentation period n=528; supervision period n=1176). Oncological and pneumological diseases were the most frequent inpatient diagnoses. Diagnosis groups did not differ significantly (inpatients p=0.31 and CED p=0.99) between the two periods ([Table 1], Suppl. 6).
Table 1 Pediatric inpatient cohort.
|
|
Study period
(12 weeks)
|
Documentation period
(4 weeks)
|
Supervision period
(8 weeks)
|
|
Patients
|
1247
|
432
|
815
|
|
Sex
|
m
f
|
54.4 % (n=678)
45.6 % (n=569)
|
56.5 % (n=244)
43.5 % (n=188)
|
53.3 % (n=434)
46.7 % (n=381)
|
|
Age (years)
|
6.6 ± 6.0 (5; 0–34)
|
6.3 ± 5.8 (4; 0–18)
|
6.6 ± 6.1 (5; 0–34)
|
|
Duration (days)
|
6.4 ±13.7 (3; 0–216)
|
6.4 ±15.1 (3; 0–202)
|
6.3 ±12.9 (3; 0–216)
|
|
Diagnosis
|
838
|
324
|
514
|
|
Oncology
|
22.8 % (n=191)
|
30.2 % (n=98)
|
18.1 % (n=93)
|
|
Pneumology
|
15.0 % (n=126)
|
16.0 % (n=52)
|
14.4 % (n=74)
|
|
Neurology
|
13.0 % (n=109)
|
14.2 % (n=46)
|
12.3 % (n=63)
|
|
Gastroenterology
|
11.5 % (n=96)
|
10.8 % (n=35)
|
11.9 % (n=61)
|
|
Neonatology
|
9.8 % (n=82)
|
7.4 % (n=24)
|
11.3 % (n=58)
|
|
Nephrology/urology
|
8.8 % (n=74)
|
8.0 % (n=26)
|
9.4 % (n=48)
|
|
Infectiology
|
5.3 % (n=44)
|
3.1 % (n=10)
|
6.6 % (n=34)
|
|
Cardiology
|
2.7 % (n=23)
|
2.5 % (n=8)
|
2.9 % (n=15)
|
|
Hematology
|
1.1 % (n=9)
|
1.5 % (n=5)
|
0.8 % (n=4)
|
|
Psychology
|
1.0 % (n=8)
|
0.6 % (n=2)
|
1.2 % (n=6)
|
|
Others (e.g., orthopedics, endocrinology)
|
9.1 % (n=76)
|
5.6 % (n=18)
|
11.3 % (n=58)
|
The main reasons for presentation to the CED were fever and discomfort with no significant differences between the analyzed time periods (52.8% vs. 47.4%) (Suppl. 6). CED patients were classified according to the Manchester Triage System (MTS) and the proportion of patients who proceeded to hospital admission was not statistically significantly different between the two periods (p=0.92 and p=0.969).
US exams in the documentation and supervision period
This study included a total of 108 US exams and the average number of US exams was equal between the documentation and supervision period (1.3 exams/day).
During the documentation period, the physicians on-duty indicated a desire for supervision support in 54.1% of all US examinations. The rate of supervision requests during the supervision period was 38% (27/71).
Supervised US exams required more time (14.4 min vs. 7.1 (without supervision) and 9.9 (documentation period) min; p<0.01 and p=0.08, respectively), were performed more frequently within the first 24 hours of presentation (70.4% vs. 56.8%, p=0.06), and were categorized more frequently as urgent (“emergency”; 22.2% vs. 2.3% and 10.8%; p<0.001) compared to non-supervised US exams. The proportion of exams performed at night was higher in the supervision period (28.2% vs. 16.2%; p=0.015) ([Table 2]).
Table 2 Ultrasound examinations regarding cohorts and implementation.
|
|
Documentation period
(4 weeks)
|
Supervision period
(without supervision)
|
Supervision period
(including supervision)
|
|
Ultrasound examinations
|
37
|
44
|
27
|
|
Sex
|
m
f
|
43.2 % (n=16)
56.8 % (n=21)
|
65.9 % (n=29)
34.1 % (n=15)
|
59.3 % (n=16)
40.7 % (n=11)
|
|
Age (years)
|
9.2 ± 5.6 (10.6; 0.1–17.4)
|
7.3 ± 5.5 (6.6; 0.1–18)
|
9.7 ± 6.2 (9.5; 0–17.9)
|
|
Duration (min)
|
9.9 ± 9.2 (7; 1–44)
|
7.1 ± 6.0 (5; 1–30)
|
14.4 ± 10.0 (13; 4–46)
|
|
Inpatients
Outpatients
|
56.8 % (n=21)
43.2 % (n=16)
|
65.9 % (n=29)
34.1 % (n=15)
|
77.8 % (n=21)
22.2 % (n=6)
|
|
Days
< 24 hours after presenting
|
3.2 ± 8.6 (0; 0–36)
87.1 % (n=30)
|
2.8 ± 8.1 (0; 0–46)
56.8 % (n=25)
|
4.8 ± 12.7 (0; 0–60)
70.4 % (n=19)
|
|
Working days
Saturday/Sunday/holiday
Nighttime (0–6)
|
37.8 % (n=14)
62.2 % (n=23)
16.2 % (n=6)
|
34.1 % (n=15)
65.9 % (n=29)
31.8 % (n=14)
|
55.6 % (n=15)
40.7 % (n=11)
22.2 % (n=6)
|
|
Emergency
Urgent
Not urgent
|
10.8 % (n=4)
54.1 % (n=20)
35.1 % (n=13)
|
2.3 % (n=1)
79.5 % (n=35)
18.2 % (n=8)
|
22.2 % (n=6)
66.7 % (n=18)
11.1 % (n=3)
|
|
Without ultrasound training
Ultrasound training received
Supervisor
|
8.1 % (n=3)
75.7 % (n=28)
16.2 % (n=6)
|
13.6 % (n=6)
59.1 % (n=26)
27.3 % (n=12)
|
0 % (n=0)
66.7 % (n=18)
33.3 % (n=9)
|
|
Supervision desired
|
|
Yes
Not
|
54.1 % (n=20)
45.9 % (n=17)
|
N/A
N/A
|
N/A
N/A
|
|
Supervision helpful
|
|
Clinical perspective
Yes
No
|
N/A
N/A
|
N/A
N/A
|
100 % (n=27)
0 % (n=0)
|
|
Training perspective
Yes
No
|
N/A
N/A
|
N/A
N/A
|
88.9 % (n=24)
11.1 % (n=3)
|
The main reasons for initiating a POCUS exam were pain and/or swelling in a specific area of the body (abdomen, thorax, neck, genitals), abnormal blood and urine parameters (kidney and/or liver enzymes, blood gas analysis, urine analysis), traumatic injury, or surgical procedure. Abdominal US exams were most frequent (43.3–68.9%). In almost half of the POCUS exams, a suspected pathology was excluded (42.6–50.0%) as presented in Suppl. 7. Pathological US findings were most frequently related to the gastrointestinal system (18.5–28.0%; in particular gastroenteritis, appendicitis, liver anomalies). Supervised US exams included a higher proportion of specific request areas and partly findings such as the kidney (20%; focal nephritis, renal transplant perfusion, chronic kidney failure, nephrolithiasis, urinary tract disorder), cervical area (10%; parotitis, lymphadenitis, exclusion abscess cervical region), testis (6.7%; epididymitis, testicular torsion), and lung (6.7%; pneumonia and pleural effusion) (Suppl. 7; [Fig. 2], [Fig. 3], [Fig. 4], [Fig. 5]; [Video 1]).
Fig. 2 5-month-old boy with deterioration of his general condition and unclear hepatopathy. Supervised ultrasound examination reveals unclear mass at the upper pole of the right kidney. Microvascular imaging unmasks the area with markedly reduced perfusion compared to the regular corticomedullary perfusion pattern of the rest of the renal parenchyma. Differentially, the diagnosis of focal nephritis was initially made. Under antibiotic therapy, no sonographic improvement was seen in the course, and after heminephrectomy and histological evaluation, the diagnosis of juvenile xanthogranuloma with systemic involvement was made.
Fig. 3
a+b 13-year-old girl with cramp-like abdominal pain. Supervised ultrasound examination reveals a thickened appendix with a diameter of 8 mm (see black arrow) with an echo-rich surrounding reaction (cross-sectional and longitudinal view). After appendectomy, the diagnosis of acute ulcero-phlegmonous appendicitis and periappendicitis was confirmed histologically.
Fig. 4 11-year-old girl with intermittent abdominal pain. Supervised ultrasound examination reveals a 4 mm long stone at the lower pole of the left kidney with a slight acoustic shadow on the B-scan and characteristic twinkling phenomenon on Doppler sonography. In the further course, the diagnosis of cystinuria was made.
Fig. 5 6-year-old boy with significant swelling of the left neck. The underlying disease is known to be an aggressive fibromatosis (desmoid type) of the abdominal wall. Supervised ultrasound examination reveals an enlarged and clearly hyperperfused anechoic lymph node in the sense of lymphadenitis. Under antibiotic therapy, there was rapid improvement.
Video sequence associated with [
Fig. 2] showing evidence of reduced perfusion of the unclear mass at the upper pole of the right kidney.Video 1
In 25 of 27 (92.6%) supervised US exams, a diagnosis was confirmed or ruled out by the on-site examiner and the supervisor without subsequent revision by other investigators (Suppl. 8).
Clinical consequences after an US exam leading to a surgical (e.g., appendectomy, orchidopexy, vascular revision) or interventional procedure (e.g., bladder catheterization, kidney biopsy, stone removal, pleural drainage) evolved in 22 of 117 (18.8%) cases and were similar in both periods and not increased in supervised exams (17.9–20.0%, p=0.17). However, initiation or change of drug therapy (mainly antibiotics and laxative drugs) was lower in non-supervised compared to supervised US exams and during the documentation period (11.6% vs. 25.7% and 33.3%, p=0.018 and p<0.001, respectively). Details are listed in Suppl. 7.
Questionnaire
Demographics
58 physicians completed the questionnaire. All supervisors and 25% of senior pediatric physicians, but only 5.3% of pediatric specialists and none of the residents were DEGUM level 1 certified.
Supervisors and residents during/after US rotation (40% and 33.3 %, respectively) attended a certified US course by DEGUM more frequently than pediatric specialists (0%) and residents waiting for US rotation and senior pediatric physicians (each 6.3%) (Suppl. 9).
US exams
All supervisors, 15.8% of pediatric specialists, and 37.6% of senior pediatric physicians performed US exams at least several times (defined as ≥ 3 US exams) a week, whereas 58.3% of residents before US rotation and 37.5% of senior pediatric physicians did not perform US on a regular basis.
All supervisors but only 12.1% of the remaining cohort of attending physicians indicated that they felt confident performing pediatric US exams without supervision. Confidence was higher among physicians performing US routinely (≥ 3 times/week (40% vs. 3.7%/ 0% [performed less frequently/never]).
None of the supervisors but a total of 32.8% of the other participants postponed US exams due to a lack of time and a higher percentage of them performed US less frequently (80.8%) and “nearly never” (66.6 %). Uncertainty about missing pathological findings led to US exam postponements among 39.7% of all examiners. There was again a higher percentage of US examiners performing US less frequently, an absence of DEGUM 1 level, and an absence of US rotation ([Table 3]).
Table 3 Survey results regarding ultrasound examinations.
|
Independent performance of US examinations
|
Percentage
|
|
Almost daily
|
8.6% (n=5/58)
|
|
Several times a week (≥ 3 US exams/week)
|
17.2% (n=10/58)
|
|
Never
|
25.9% (n=15/58)
|
|
Several times a year (≥10 US exams/year)
|
20.7% (n=12/58)
|
|
Several times a month (≥3 US exams/month)
|
25.9% (n=15/58)
|
|
Not specified
|
1.7% (n=1/58)
|
|
Feel comfortable enough for pediatric ultrasound examination
|
|
Almost always
|
12.1% (n=7/58)
|
|
No
|
19.0% (n=11/58)
|
|
Rarely, frequently (> 50% of cases) support desired
|
15.5% (n=9/58)
|
|
Sometimes, sometimes (30–50% of cases) support desired
|
31.0% (n=18/58)
|
|
Frequently, occasionally (<20% of cases) support desired
|
22.4% (n=13/58)
|
|
Familiar with the technical applications of the US device
|
|
Completely true
|
8.6% (n=5/58)
|
|
Tends not to apply; I am often uncertain
|
12.0% (n=7/58)
|
|
Applies to basic applications
|
41.4% (n=24/58)
|
|
Applies to most applications
|
27.6% (n=16/58)
|
|
Does not apply at all
|
10.3% (n=6/58)
|
|
Postponement of US examination due to lack of time
|
|
Very frequently (every shift)
|
5.2% (n=3/58)
|
|
Frequently (every 2nd to 3rd shift)
|
25.9% (n=15/58)
|
|
Sometimes (every 4th to 5th shift)
|
24.1% (n=14/58)
|
|
Rarely (less often than every 5th shift)
|
13.8% (n=8/58)
|
|
Never
|
6.9% (n=4/58)
|
|
Not specified
|
24.1% (n=14/58)
|
|
Postponement of US examination due to a lack of US experience
|
|
Very frequently (every shift)
|
6.9% (n=4/58)
|
|
Frequently (every 2nd to 3rd shift)
|
12.1% (n=7/58)
|
|
Sometimes (every 4th to 5th shift)
|
20.7% (n=12/58)
|
|
Rarely (Less often than every 5th shift)
|
27.6% (n=16/58)
|
|
Never
|
15.5% (n=9/58)
|
|
Not specified
|
17.2% (n=10/58)
|
|
Postponement of US examination due to uncertainty and concern about overlooking a pathological finding
|
|
Very frequently (every shift)
|
8.6% (n=5/58)
|
|
Frequently (every 2nd to 3rd shift)
|
12.1% (n=7/58)
|
|
Sometimes (every 4th to 5th shift)
|
19.0% (n=11/58)
|
|
Rarely (less often than every 5th shift)
|
24.1% (n=14/58)
|
|
Never
|
19.0% (n=11/58)
|
|
Not specified
|
17.2% (n=10/58)
|
|
Supervising support by physician with ultrasound experience desired
|
|
Very frequently (every shift)
|
20.7% (n=12/58)
|
|
Frequently (every 2nd to 3rd shift)
|
34.5% (n=20/58)
|
|
Sometimes (every 4th to 5th shift)
|
12.1% (n=7/58)
|
|
Rarely (less often than every 5th shift)
|
17.2% (n=10/58)
|
|
Never
|
1.7% (n=1/58)
|
|
Not specified
|
13.8% (n=8/58)
|
US supervision
All supervised US exams were classified as decisively helpful to confirm diagnosis and nearly all of them (88.9 %) for training purposes ([Table 2]). All physicians supported further continuation of supervised US exams (Suppl. 10). There were no concerns among on-site examiners regarding technical implementation, expectations of the remote supervisor, time-consuming US exams during on-duty shift, and disturbing the supervisor at night. Supervisors assessed practical implementation by on-site pediatricians as very good in all cases and the connection quality of all supervised exams was rated as acceptable (Suppl. 8). A majority of the participating physicians (Suppl. 11) supported the development of short educational videos.
Discussion
Remote live US supervision was demonstrated to be feasible without any technical restrictions and valuable to train and support physicians at all experience levels particularly in the out-of-hour context and it may have an impact on the improvement of US diagnostics even in the case of critical pediatric challenges in tertiary hospitals.
There is only limited pediatric experience in remote US supervision. Whitney et al. reported remote pediatric emergency US by an on-site and a remote US expert instantly evaluating downloaded US video clips. However, this and further remote studies demonstrated limitations such as a lack of availability of supervision experts, reduced effectiveness in prehospital settings, and insufficient frame rates per second during the video [21]
[23]
[25]
[27]. Therefore, our study design relied on WLAN, 24/7 support, and multiple US supervisors.
The survey results and the high rate of supervised US exams strongly indicated the high demand for the assistance of on-site pediatricians. Lack of personal experience and time and concerns regarding potentially missed pathologies were frequent worries in our and other studies [7] and led to 81% of pediatricians postponing US exams.
The higher proportion of emergency cases and requests within the first 24 hours of presentation related to more specific exams underline the importance of supervised US exams. Although supervised US exams, as in other studies [21], lasted significantly longer, possibly due to complex medical requests, additional use of advanced technologies, and simultaneous US training, on-site pediatricians did not consider the exam duration to be a potential barrier. The 24/7 remote live supervision option might have led to an increased rate of nighttime US exams in the supervision period, which might potentially accelerate the time to diagnosis.
Remote assistance supported various pediatric POCUS challenges and included state-of-the art US techniques such as microvascular imaging for the detection of focal nephritis or evidence of adequate perfusion after kidney or liver transplantation, which have not yet been included in POCUS curricula [9]
[13]
[24]
[25]
[27]. New applications can facilitate and alter medical decisions as demonstrated in a study about the use of pediatric lung POCUS instead of chest radiography leading to a reduction of X-ray exams but also to an increase in antibiotic therapy as US was highly sensitive to detect lung consolidations [28]. Our evaluation did not increase the number of surgical or interventional procedures but reduced modifications of drug therapy and admission rates during the supervision period.
Our study demonstrated no difficulties regarding the implementation of instructions and expectations of the supervisors probably due to the monocentric study design and the higher rate of participating on-site examiners with intensive pre-study on-site US teaching (50%) compared to other studies displaying difficulties implementing supervisor instructions [14]
[22]
[25]. A potential future multicenter approach for remote live US supervision may further emphasize the need for certified pediatric POCUS curricula, training plans, and accreditation processes as already started by the ESPNIC in guideline recommendations and in the UK as part of the CACTUS training [5]
[6]
[8]
[9]
[13]
[14].
Limitations
The study design includes important limitations such as short study duration, unicentric approach, and limited number of US exams. Neonatology and pediatric intensive care and US exams during working hours were excluded. Randomization regarding patient cohorts or examiner experience was not applied. A multicenter approach as previously discussed might be more challenging due to variations of technical equipment, on-site examiner US experience, and pediatric cohorts.
Conclusion
Remote live US supervision is feasible and effective even in the case of various, complex pediatric challenges, even outside regular working hours. It helps to overcome the main obstacles like the shortage of qualified instructors and also provides simultaneous US teaching and diagnosis of acute medical demands. Further multicentric studies focusing on patient-centered outcome measures are important to establish and implement algorithms for the daily routine.
