title: Institutional and individual learning curves for focused abdominal ultrasound for trauma: cumulative sum analysis.
abstract: OBJECTIVE
  To evaluate both institutional and individual learning curves with focused abdominal ultrasound for trauma (FAST) by analyzing the incidence of diagnostic inaccuracies as a function of examiner experience for a group of trauma surgeons performing the study in the setting of an urban level I trauma center.
  
  
  BACKGROUND
  Trauma surgeons are routinely using FAST to evaluate patients with blunt trauma for hemoperitoneum. The volume of experience required for practicing trauma surgeons to be able to perform this examination with a reproducible level of accuracy has not been fully defined.
  
  
  METHODS
  The authors reviewed prospectively gathered data for all patients undergoing FAST for blunt trauma during a 30-month period. All FAST interpretations were validated by at least one of four methods: computed tomography, diagnostic peritoneal lavage, celiotomy, or serial clinical evaluations. Cumulative sum (CUSUM) analysis was used to describe the learning curves for each individual surgeon at target accuracy rates of 85%, 90%, and 95% and for the institution as a whole at target examination accuracy rates of 85%, 90%, 95%, and 98%.
  
  
  RESULTS
  Five trauma surgeons performed 546 FAST examinations during the study period. CUSUM analysis of the aggregate experience revealed that the examiners as a group exceeded 90% accuracy at the outset of clinical examination. The level of accuracy did not improve with either increased frequency of performance or total examination experience. The accuracy rates observed for each trauma surgeon ranged from 87% to 98%. The surgeon with the highest accuracy rate performed the fewest examinations. No practitioner demonstrated improved accuracy with increased experience.
  
  
  CONCLUSIONS
  Trauma surgeons who are newly trained in the use of FAST can achieve an overall accuracy rate of at least 90% from the outset of clinical experience with this modality. Interexaminer variations in accuracy rates, which are observed above this level of performance, are probably related more to issues surrounding patient selection and inherent limitations of the examination in certain populations than to practitioner errors in the performance or interpretation of the study.
authors.affiliation: Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
authors.forename: F D
authors.initials: FD
authors.lastname: McCarter
authors.forename: F A
authors.initials: FA
authors.lastname: Luchette
authors.forename: M
authors.initials: M
authors.lastname: Molloy
authors.forename: J M
authors.initials: JM
authors.lastname: Hurst
authors.forename: K
authors.initials: K
authors.lastname: Davis
authors.forename: J A
authors.initials: JA
authors.lastname: Johannigman
authors.forename: S B
authors.initials: SB
authors.lastname: Frame
authors.forename: J E
authors.initials: JE
authors.lastname: Fischer
mesh_terms: D000007:Abdominal Injuries / Q000000981:diagnostic imaging*; D000328:Adult; D003951:Diagnostic Errors; D004502:Education, Medical, Continuing; D005260:Female; D006465:Hemoperitoneum / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D014193:Trauma Centers; D014463:Ultrasonography / Q000379:methods; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging*