Point-of-care echocardiography in simulation-based education and assessment.

BACKGROUND: Emergency medicine milestones released by the Accreditation Council for Graduate Medical Education require residents to demonstrate competency in bedside ultrasound (US). The acquisition of these skills necessitates a combination of exposure to clinical pathology, hands-on US training, and feedback.
OBJECTIVES: We describe a novel simulation-based educational and assessment tool designed to evaluate emergency medicine residents' competency in point-of-care echocardiography for evaluation of a hypotensive patient with chest pain using bedside US.
METHODS: This was a cross-sectional study conducted at an academic medical center. A simulation-based module was developed to teach and assess the use of point-of-care echocardiography in the evaluation of the hypotensive patient. The focus of this module was sonographic imaging of cardiac pathology, and this focus was incorporated in all components of the session: asynchronous learning, didactic lecture, case-based learning, and hands-on stations.
RESULTS: A total of 52 residents with varying US experience participated in this study. Questions focused on knowledge assessment demonstrated improvement across the postgraduate year (PGY) of training. Objective standardized clinical examination evaluation demonstrated improvement between PGY I and PGY III; however, it was noted that there was a small dip in hands-on scanning skills during the PGY II. Clinical diagnosis and management skills also demonstrated incremental improvement across the PGY of training.
CONCLUSION: The 1-day, simulation-based US workshop was an effective educational and assessment tool at our institution.

Introduction

Determining the etiology of undifferentiated hypotension is a common diagnostic and therapeutic dilemma encountered by emergency physicians. Use of other imaging modalities is precluded in the case of an unstable hypotensive patient, making bedside ultrasound (US) invaluable. Bedside US can assist the emergency physician quickly make critical decisions that can alter a patient’s clinical course and ultimate outcome.1–3 A number of protocols have been developed guiding the use of bedside US in patients with undifferentiated hypotension.1,4–6

The Accreditation Council for Graduate Medical Education (ACGME) requires the use of US for diagnostic evaluation as a core competency milestone for emergency medicine (EM) residency training programs. Most accredited residency programs incorporate US training into the resident curriculum, though specific components and clinical time devoted to US training are highly variable among programs.7,8 Proctored US hands-on instruction and training modules have been shown to positively impact US training; however, to our knowledge, US-focused simulation-based training has not been studied before.9,10 This study evaluated a novel simulation-based US educational and assessment workshop.

Methods

Study design and setting

This was a single-center cross-sectional study conducted at an academic medical center. This study was reviewed and approved by the University of Arizona institutional review board authority. Written informed consent from participants was not required as per IRB. The study participants were 52 EM residents (postgraduate year [PGY]-I to PGY-III) with varying US experience. Participation in the study was voluntary. Data were collected from December 2013 to January 2014.

Education

A 1-day educational and assessment workshop focusing on simulation-based US training was integrated into the scheduled education day for EM residents. The focus of this workshop was sonographic imaging of cardiac pathology, which was incorporated during all components of the session, including a pre-workshop survey, objective structured clinical examination (OSCE), hands-on education station, simulation-based diagnostic session, and simulation-based management station (Table 1). Simulation of real clinical scenarios relevant to management of the hypotensive patient with chest pain was integrated into the workshop. Instructors for this course were Department of Emergency Medicine faculty and fellows with expertise in bedside US.

Table 1

Skills station descriptions

Focused cardiac US
Sonographic skills station	Learning objectives
Simulation-based focused echocardiography objective standardized clinical examination (30 min)	Evaluation of resident performance on a focused cardiac US.Cardiac evaluation in a hypotensive patient can be life saving. In this station, residents must perform a focused cardiac US for the following clinical scenario: “45 year old male with hx of heart disease presenting with hypotension. Vital signs: heart rate 129; blood pressure 100/70; respiratory rate 18; temperature 37.0 Celsius and pulse oximetry 99% on room air.”
Simulation-based diagnostics station (30 min)	How to review focused cardiac US images and clinical scenarios and offer a diagnosis.In this station, residents were provided focused cardiac US images, which demonstrated a variety of findings such as right ventricular dilatation, decreased cardiac function, wall motion abnormality, inferior vena cava evaluation, etc. After reviewing images, residents were asked to provide a diagnosis which best fit the video images and clinical scenarios.
Simulation-based clinical management station (30 min)	How to review focused cardiac US images and clinical scenarios and offer a management plan.In this station, residents were provided focused cardiac US images, which demonstrated a variety of findings such as right ventricular dilatation, decreased cardiac function, wall motion abnormality, etc. After reviewing images, residents were asked to provide management plans for the diagnoses, which best fit the images and clinical scenarios.
Review of the sonographic algorithm for hypotension (30 min)	How to approach an undifferentiated hypotensive patient.In this station, residents reviewed the high yield locations for focused US when evaluating a patient with unclear etiology for hypotension. During this session, emphasis was placed on focused cardiac evaluation, focused abdominal US, and focused thoracic US. Residents reviewed findings that would be associated with asystole, pulmonary embolisms, heart failure, tamponade physiology, dehydration, abdominal free fluid, aortic aneurysm, aortic dissection, pleural effusion, and pneumonia.

Abbreviations: US, ultrasound; min, minutes; hx, history.

Assessment

Resident assessment of these sonographic skills consisted of a 29-question multiple-choice online survey, five-item simulated visual diagnosis survey, five-item simulated imaging-based clinical management survey, and a simulated hands-on point-of-care echocardiography OSCE.

Data analysis

All analyses were performed using Stata 11 (StataCorp LP, College Station, TX, USA). Data were presented as mean values and percentages with 95% confidence intervals. Continuous variables were compared between the two groups (posttest versus 3-month posttest) using Student’s t-test and Wilcoxon signed-rank test. The statistical level of significance was set at P<0.05.

Results

A total of 52 residents with varying US experience participated in this study. Questions focused on knowledge assessment demonstrated consistent improvements across PGY of training. The average scores on the online knowledge-based survey were PGY I: 63% (standard deviation [SD] =10), PGY II: 70% (SD =7), and PGY III: 72% (SD =5). Seventy-one percent of the residents completed the clinical diagnosis and clinical management survey. Similar to the knowledge-based survey, the residents’ clinical diagnostic skills and clinical management skills also revealed incremental improvement across PGY of training. The average scores on the clinical diagnosis survey were PGY I: 78% (SD =22), PGY II: 77% (SD =27), and PGY III: 93% (SD =10). The average scores on the clinical management survey were PGY I: 62% (SD =19), PGY II: 62% (SD =19), and PGY III: 91% (SD =13). All 52 residents participated in the cardiac US OSCE. Interestingly, the OSCE evaluation demonstrated improvement between PGY I and PGY III; however, there was a small decrease in hands-on scanning skills during the PGY II. The average scores on the OSCE were PGY I: 78% (SD =7), PGY II: 74% (SD =8), and PGY III: 82% (SD =9).

Discussion

Numerous underlying pathologies can contribute to hypotension in a patient with chest pain. While cardiac echocardiography can provide valuable information, a comprehensive echo often cannot be obtained in these situations. Bedside US can provide invaluable information about overall cardiac contractility and wall motion abnormalities and identify pathology, such as pericardial tamponade or pericardial effusion, that may benefit from immediate intervention. Resuscitation without understanding of the underlying pathology can lead to poor outcomes and patient demise.

Current literature has demonstrated that, in addition to improving clinical outcomes, simulation-based learning in medicine has positive impact on learner performance, knowledge, and confidence.11,12 Delivering high-quality patient care while simultaneously providing optimal physician training is rarely possible, and simulation has emerged as a tool to reconcile this gap.13,14 The ACGME mandates US training as a core competency milestone for EM residents. Proctored hands-on simulation has been shown to positively impact resident knowledge retention.9 While EM residency programs provide some form of US training, a standardized curriculum does not exist and educational training is highly variable.7,15 Furthermore, a gold standard for milestone training or assessment has not been established.8

In this study, we developed and implemented a unique training system merging simulation-based milestone education and assessment. The assessment component was integrated into each station of this 2-hour workshop: technical skills were assessed with the OSCE, clinical diagnostic skills were assessed with video clips in the diagnosis station, and clinical management skills were assessed with two-step reasoning questions following each clinical management station (Table 1). To our knowledge, this is the first workshop to integrate numerous components of assessment with a focus on the EM US milestone recommendations.16

Our results demonstrate improvement in resident scores across successive PGY on the online survey and the clinical diagnosis and clinical management survey, as evidenced by the absolute average and narrowing of SDs. PGY III residents had the highest performance on the cardiac US OSCE. This would be expected as a higher PGY correlates with greater clinical experience and increased US exposure. This is similar to previous studies, which demonstrated greater scores among the most senior residents.17 In our investigation, PGY I residents scored higher on the cardiac OSCE than PGY II residents; this difference may be attributable to proximity to US rotation (at our institution, the interns have a dedicated 2-week US rotation).

Management of complex patients in the emergency setting requires prompt yet thoughtful evaluation. Providers must quickly and effectively process information from multiple facets to appropriately manage patients. Simulating stressful, intense environments allows residents to learn how to treat and evaluate high-risk conditions without increasing risk of harm to live patients, making simulation a valuable component of residency training.18–21

Limitations

This study is limited by its small sample size. The education and assessment curriculum was not pilot-tested or validated prior to implementation. Lastly, this study was not designed to assess overall impact of this simulation-based US workshop.

Conclusion

The 1-day, simulation-based US educational event was an effective educational and assessment tool at our institution.