Evaluation of the quality of transesophageal echocardiography images and verification of proficiency

Recommendations for Special Competency in Echocardiographic Guidance of Structural Heart Disease Interventions: From the American Society of Echocardiography

Transcatheter therapies for structural heart disease continue to grow at a rapid pace, and echocardiography is the primary imaging modality used to support such procedures. Transesophageal echocardiographic guidance of structural heart disease procedures must be performed by highly skilled echocardiographers who can provide rapid, accurate, and high-quality image acquisition and interpretation in real time. Training standards are needed to ensure that interventional echocardiographers have the necessary expertise to perform this complex task. This document provides guidance on all critical aspects of training for cardiology and anesthesiology trainees and postgraduate echocardiographers who plan to specialize in interventional echocardiography. Core competencies common to all transcatheter therapies are reviewed in addition to competencies for each specific transcatheter procedure. A core principle is that the length of interventional echocardiography training or achieved procedure volumes are less important than the demonstration of procedure-specific competencies within the milestone domains of knowledge, skill, and communication.

Transesophageal echocardiography simulation: A review of current technology

Transesophageal echocardiography (TEE) has experienced tremendous increase in interest and demand alongside the rapid growth of transcatheter structural cardiac interventions. TEE instruction prolongs the procedure, increasing the risk of probe malfunction from overheating and patient complications from prolonged sedation. Echocardiographic simulation programs have been developed to hone the procedural skills of novice operators in a time-unrestricted, low-pressure environment before they perform TEEs on real patients. Simulators likely benefit training in interventional TEE for the same reasons. We searched PubMed, basic Google, and Google Scholar for currently marketed TEE simulators, including foreign as well as US companies. We queried the vendors regarding features of the simulators that pertain to effective instructional design for diagnostic TEE. We also queried regarding the simulators' applicability to training in interventional TEE. The vendors' responses are reported here. In addition, we discuss the specific training needs for structural heart interventions, for which echocardiographic simulation could be a powerful educational tool. Lastly, we discuss the role of simulation for formative and summative assessment, and the advances required to improve training in complex procedures within the field of interventional echocardiography.

Three-Dimensional Transesophageal Echocardiography Simulator: New Learning Tool for Advanced Imaging Techniques

The use of intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) has grown exponentially in recent years. Three-dimensional TEE technology has evolved to allow for real-time display of 3D images and, thus, has become the standard of care for the evaluation of cardiac anatomy and function. Its use has provided a new dimension of clinical insight when managing patients for cardiac surgery or structural heart interventions. While the intraoperative utility of 3D TEE has expanded, there has been a slower advancement in the area of training and, specifically, simulator-based training in 3D TEE. This training is essential, as the skill set involved in acquiring 3D data sets differs from that of two-dimensional (2D) TEE and requires users to be able to appreciate how 3D anatomic display differs from that of tomographic cross-sectional 2D imaging. This added skill set requires mental reconstruction and spatial reorientation to appreciate the added elevational dimension in frustum-based imaging and is best achieved in a simulation environment rather than the busy operating room. In this review article, the authors evaluate the functionality of a 3D TEE simulator and how simulators such as this can establish preclinical proficiency in novices in the expanding area of advanced 3D TEE imaging.

Preclinical Proficiency-Based Model of Ultrasound Training

BACKGROUND

Graduate medical education is being transformed from a time-based training model to a competency-based training model. While the application of ultrasound in the perioperative arena has become an expected skill set for anesthesiologists, clinical exposure during training is intermittent and nongraduated without a structured program. We developed a formal structured perioperative ultrasound program to efficiently train first-year clinical anesthesia (CA-1) residents and evaluated its effectiveness quantitatively in the form of a proficiency index.

METHODS

In this prospective study, a multimodal perioperative ultrasound training program spread over 3 months was designed by experts at an accredited anesthesiology residency program to train the CA-1 residents. The training model was based on self-learning through web-based modules and instructor-based learning by performing perioperative ultrasound techniques on simulators and live models. The effectiveness of the program was evaluated by comparing the CA-1 residents who completed the training to graduating third-year clinical anesthesia (CA-3) residents who underwent the traditional ultrasound training in the residency program using a designed index called a "proficiency index." The proficiency index was composed of scores on a cognitive knowledge test (20%) and scores on an objective structured clinical examination (OSCE) to evaluate the workflow understanding (40%) and psychomotor skills (40%).

RESULTS

Sixteen CA-1 residents successfully completed the perioperative ultrasound training program and the subsequent evaluation with the proficiency index. The total duration of training was 60 hours of self-based learning and instructor-based learning. There was a significant improvement observed in the cognitive knowledge test scores for the CA-1 residents after the training program (pretest: 71% [0.141 ± 0.019]; posttest: 83% [0.165 ± 0.041]; P < .001). At the end of the program, the CA-1 residents achieved an average proficiency index that was not significantly different from the average proficiency index of graduating CA-3 residents who underwent traditional ultrasound training (CA-1: 0.803 ± 0.049; CA-3: 0.823 ± 0.063, P = .307).

CONCLUSIONS

Our results suggest that the implementation of a formal, structured curriculum allows CA-1 residents to achieve a level of proficiency in perioperative ultrasound applications before clinical exposure.

Learners and Luddites in the Twenty-first Century: Bringing Evidence-based Education to Anesthesiology

Anesthesiologists are both teachers and learners and alternate between these roles throughout their careers. However, few anesthesiologists have formal training in the methodologies and theories of education. Many anesthesiology educators often teach as they were taught and may not be taking advantage of current evidence in education to guide and optimize the way they teach and learn. This review describes the most up-to-date evidence in education for teaching knowledge, procedural skills, and professionalism. Methods such as active learning, spaced learning, interleaving, retrieval practice, e-learning, experiential learning, and the use of cognitive aids will be described. We made an effort to illustrate the best available evidence supporting educational practices while recognizing the inherent challenges in medical education research. Similar to implementing evidence in clinical practice in an attempt to improve patient outcomes, implementing an evidence-based approach to anesthesiology education may improve learning outcomes.