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.
