186 Low Frequency, High Complexity: Skill Retention Following Proficiency-Based Transesophageal Echocardiography Simulation Training

Abstract

Focused transesophageal echocardiography (TEE) is now recommended during cardiac arrest in the emergency department. Implementation of TEE in cardiac arrest management requires additional training for a relatively low frequency and high complexity procedure. Thus, focused TEE curricula requires high proficiency retention rates to succeed. Retention rates of newly acquired TEE knowledge and skill after high fidelity simulation in emergency physicians (EMPs) are unknown. This study’s primary objective was to determine retention of TEE proficiency. This is an observational study at an academic medical center of TEE naïve EMP faculty using high fidelity TEE simulation. EMP were trained in TEE using web-based didactics and monthly hands-on sessions with a TEE simulator (HeartWorks®) for 4 months. Skills were assessed monthly via direct observation from a TEE expert until proficiency was achieved. Proficiency was defined as the ability to name, describe, and obtain 8 hands-on TEE images during the monthly examinations. The COVID-19 pandemic created a natural wash-out phase where EMPs did not perform any actual or simulated TEE for 6 months after initial TEE training. Unadvertised assessment of TEE skill occurred at months 7 and 8 after initial TEE training to test skill decay. During the assessment, EMPs had two attempts to recall the name of each TEE view, describe probe manipulation needed to achieve the view, and then obtain each view on the TEE simulator. No memory aids, discussion, or feedback were provided during the assessment. Time to obtain all 8 TEE views on the simulator was measured. This analysis is limited to the three most critical TEE views in cardiac arrest: midesophageal 4 chamber (4Ch), midesophageal long axis (LAX), and transgastric left ventricular short axis (TG). Seven EMP were evaluated individually at both 7 and 8 months after initial training. At month 7, correct name recall of the 3 views (4Ch, LAX, TG) was 71%, 57%, and 86% respectively. Correct probe manipulation description of the 3 views (4Ch, LAX, TG) was 86%, 29% and 29%. On the simulator, all three views were obtained by all participants on the first attempt. The average time to obtain all 8 TEE views was 7.3 minutes and 4.6 minutes during the first and second attempts, respectively. During the 8th month assessment, correct name recall of the 3 views (4Ch, LAX, TG) was 100%, 71%, and 100% respectively. Correct probe manipulation description of the 3 views (4Ch, LAX, TG) were 100%, 71%, and 86%. On the hands-on simulator, the three views (4Ch, LAX, TG) were correctly obtained 100%, 86%, and 100% on the first attempt and all participants obtained all three views correctly on the second attempt. The average time to obtain all 8 TEE views was 5.7 minutes and 4.0 minutes during the first and second attempts respectively. Focused, proficiency-based training on a TEE simulator results in durable skills after 6 months. Hands-on image acquisition skills were retained at a greater rate than the names of each view or probe manipulation recall. Time to obtain TEE views decreases over time as participants continued testing on the TEE simulator. These findings can inform curriculum design as widespread utilization of TEE increases.