H22 How to teach ultrasound-guided peripheral nerve blocks to residents?

<h3></h3> <b>Regional anaesthesia (RA) plays an important role</b> in the success of most surgical procedures, providing multiple benefits.^{1 2} Its use is increasingly widespread, including outside the operating room.^{3 4} That is why RA is considered a core component of peri-operative care.^5-9 This importance of RA makes it <b>essential for residents to complete their anaesthesiology training programme?</b> by <b>mastering the knowledge and skills surrounding ultrasound guided regional anaesthesia (UGRA).</b>^10<b>-</b>14 This proficiency enables them to perform the main blocks used in daily clinical practice¹⁵ with quality and security, from which the greatest number of patients can benefit. Currently, there is no standardized educational approach to teaching UGRA in anaesthesiology training; only guidelines and recommendations are published in RA Fellowship programs.^{7 16} As UGRA and acute pain medicine are now considered essential knowledge and skills for anaesthesiologists, it is necessary to develop a standardized UGRA curriculum for residency training. This curriculum should be applicable to the majority of anaesthesiologists worldwide, improving the quality of training and nerve blocks for the benefit of patients. <b>The way of teaching has changed over the years.</b> We have moved from an <i><b>apprenticeship training model</b></i>^{17<i><b>-</b></i>19} based on ‘seeing and doing’ to directly performing the procedure on the patient in the clinical setting, often compromising patient safety. This traditional approach relied on time-based training without performance indicators and provided a limited number of procedure exposures. Additionally, the increased number of trainees has further challenged this model. Now, we are shifting towards a competency-based education (CBE) model.^18-23 CBE focuses on acquiring specific skills and competencies rather than completing a set number of hours. Trainees advance as they demonstrate mastery in key areas, allowing them to progress at their own pace and focus on areas that need improvement. Residency training programs worldwide are transitioning from time - or volume-based requirements to a CBE model with simulation-based education¹⁷. The principles of a CBE in RA are focused on defining<b> specific competencies,</b> developing<b> tailored learning pathways (individualized learning plans for residents)</b>²⁴ and <b>competency-based assessment.</b>^{16 25 26} The <b>UGRA core competencies</b> outlined by the ASRA-ESRA joint committee comprise six domains: patient care, medical knowledge, system-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism.¹⁷ The <b>Dreyfus Model of Skill Acquisition</b> is a framework that describes how learners progress through different stages of skill development, from novice to expert. This model is based on experiential learning, adaptation and judgment (figure 1). As residents gain experience, they advance through the different stages, becoming more adept at decision-making, problem-solving, and adapting to various clinical scenarios responding effectively. In the context of RA, <b>integrating the Dreyfus Model of Skill acquisition with competence-based education (CBE)</b> principles can provide a structured and effective approach to training anaesthesiology residents in UGRA, resulting in (figure 2): Progression learning through skill levels. Trainees advance from one step to the next after demonstrating the acquisition of specific competences according to defined objective proficiency benchmarks. Each step is accompanied by an assessment and feedback. Development of structured curriculum with specific definitions of learning objectives related to RA and assessment to document achievement of competencies. It is necessary to provide a mix of didactic education, hands–on training, simulation exercises and clinical experiences to support residents’ development. Continuous feedback and reflection on their performance, highlighting strengths and areas for improvement, as well as encouraging self–reflection and self–assessment to help residents monitor their progress and identify learning goals. Mastery–based progression. Residents advance to the next stage of the Dreyfus Model and take more complex challenges in RA once they demonstrate mastery of competencies at each level through assessment. Performance of successful UGRA requires theoretical knowledge and manual skills. According to CBE and Dreyfus integrated model, we can describe 4 stages of proficiency-based progression <b>(PBP) training programme for UGRA during anaesthesiology residency.</b> We describe competencies to achieve in the different stages/steps: First step Competences: KNOWLEDGE In this stage, didactic education should include: principles of ultrasonography, local anaesthetics, anatomy of peripheral nerve blocks (PNBs), applied anatomy to different surgery indications, understanding the role of RA as a core component of perioperative care and multimodal analgesia, indications and contraindications of common blocks, preparation for the block and management of RA complications. <b>Educational resources</b> for knowledge are textbooks, e-learning methods like video materials, and e-learning text. <b>Tools for knowledge assessment:</b> Multiple Choice Questions (MCQs), Short Answer Questions (SAQs), Case-Based Discussions (CBDs). Second Step Competences: SKILLS. Technical skills acquisition is very important in UGRA, and together with the vigilance of the anaesthesiologist, they are probably the most important component of patient safety during RA. In addition, high skill acquisition (proficiency) is associated with better outcomes. The specific interrelated skills required to perform UGRA are <b>image acquistion</b>, <b>anatomical interpretation</b>²⁸, <b>hand-needle-eye coordination</b> for precise alignment of the needle and ultrasound beam and accurate needle placement. Deliberate practice of component skills with feedback may accelerate the rate of skill acquisition.^{18 29} The most common errors made by residents during the learning of UGRA are related to skills acquisition. The first is the advancement of the needle when the tip is not visualized, followed by unintentional probe movement associated with poor ergonomics,³⁰ and failures in identifying the incorrect spread of local anaesthetic.²⁷ It is recommended that these skills be acquired first in a <b>simulation</b> environment before being applied in clinical practice.^{17 29} Third and fourth Step: CLINICAL PRACTICE. The final step involves performing UGRA blocks in the clinical environment, on patients, under supervision and feedback. Supervision will gradually decrease until residents demonstrate, after assessment, the acquisition of all competencies in the clinical practice. Other tasks and skills can be learned through clinical experience, such as using an aseptic technique, marking of block site, monitoring of vital signs and patient comfort, providing informed consent, management of complex patients or complications, explaining post-procedure care and multidisciplinary of postoperative care. A key aspect of PBP programs is <b>assessment</b> to demonstrate competency in the curricular goals, although there is no standard tool for assessing UGRA competency.^{21,31,23,32,33,21,28,34,35,36,37,38,39} Task-specific checklists are the most reliable form of assessment and can be used in simulation and clinical settings. Example checklist tasks include¹¹: visualizing key landmarks, identifying nerves/plexus, confirming normal anatomy or recognizing variations, maintaining an aseptic technique, following the needle in real time, identifying the correct pattern of local anaesthetic spread and following safety guidelines. Other assessment tools include: <i>Global Rating Scores,</i> Quality-compromising behaviours (QCB), <i>Direct observation of procedural skills (DOPS), Cumulative sum scoring (CUSUM), Key Performance Indicators</i><i> (KPIs) or new technologies like tracking motion devices (digits/arms/eye gaz</i>⁴⁰<i>, 360-degree video, augmented and virtual reality.</i> <b>Simulation-based education and training (SBET)</b>^{17<b>,</b>41<b>,</b>42<b>,</b>43<b>,</b>44<b>,</b>45} is an essential component of an UGRA teaching curriculum and plays a primary role in competency-based learning in the preclinical phase^16,35, although it is only partially or poorly implemented in many countries, including Europe⁴². Simulation is useful for training both <b>technical</b> (understanding devices operations, imagine optimization, image interpretation, visualization of needle insertion and of LA.) and <b>non-technical skills</b> (leadership, communication, team working, situation awareness and decision-making). SBET offers several advantages over traditional training methods: it allows safe and ethical learning without risk or consequences for patients. This provides the opportunity for repetitive practice in a safe environment, creates low-stress learning conditions without time pressure. Additionally, it offers individualized expert feedback, increases trainees’ self-confidence (which improves problem solving in the clinical practice and reduces the likelihood of complications), shortens the learning curve and achieves long-term retention of skills. All of these benefits ultimately improve clinical competency, block success, and patient safety. Debriefing and feedback have been identified as the most important aspects of simulation-based learning. There are diverse simulation modalities with different applications in regional anaesthesia training (table 1). Simulation, artificial intelligence and new technologies³⁵ play an increasingly important role in the field of RA.⁴⁶ There are several high-quality websites and online resources dedicated to teaching regional anaesthesia, each offering a range of educational materials, including tutorials, videos, guidelines, applications and interactive modules to enhance knowledge and skills in regional anaesthesia. Machine learning systems for RA have been incorporated in recent years as artificial intelligence-based devices for ultrasound image interpretation^{18,47,48,49,50}, and other wearable devices for needle tasking⁴⁷, virtual^35,51 and augmented reality⁵²,⁵³. Randomized control trials are still missing for application of AI-guided UGRA in clinical anaesthetic practice^47,54. To sum up, the ASRA-ESRA-UK guidelines suggest the implementation of a PBP training and assessment in UGRA to enhance quality of training and quality of nerve blocks, thereby improving patient outcomes^20,17. Through a combination of didactic education, hands-on clinical experience and continuous assessment, residents can achieve proficiency and confidence in UGRA, an essential area of anaesthesiology. Foundation training should be aimed at the learning and deliberate practice of a <b>small number of versatile techniques that cover the vast majority of surgical procedures</b>^26<b>,</b>28<i> (Plan A</i>¹⁵<i>: interscalene, axillary, femoral, adductor canal, sciatic in the popliteal fossa, erector spinae plane and rectus sheath blocks).</i> This approach ensures patient access to reliable and safe RA. Competence in more advanced blocks should be acquired during an advanced fellowship in regional anaesthesia. Training to competence in the preclinical setting using simulation has become and essential part of the learning process, as well as the continuous assessment of competence acquisition rather than the volume of practice. Residents will require more than the established minimum number to become proficient in regional anaesthesia and periodic retraining is necessary to consolidate and maintain proficiency in technical skills introduced during training^17,55. Certainly, it’s imperative to be familiar with all the educational sources and evaluation tools. Based on our resources, we should prioritize those that are most reproducible in our environment, utilizing a competence-based model of teaching. There continues to be controversial issues such as curricular goals (like which peripheral blocks and how many), universal assessment tools for achieving competences in UGRA, limited access to simulation to train in preclinical setting, and understanding if knowledge and technical skills are transferable. Future work should focus on standardizing the UGRA curriculum and determining the most effective teaching and assessment methodologies for achieving competencies in UGRA. 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