Basic critical care echocardiography: How many studies equate to competence? A pilot study using high fidelity echocardiography simulation

Abstract

Background: Assessment of competence in basic critical care echocardiography is complex. Competence relies on not only imaging accuracy but also interpretation and appropriate management decisions. The experience to achieve these skills, real-time, is likely more than required for imaging accuracy alone. We aimed to assess the feasibility of using simulation to assess number of studies required to attain competence in basic critical care echocardiography.

Methods: This is a prospective pilot study recruiting trainees at various degrees of experience in basic critical care echocardiography using experts as reference standard. We used high fidelity simulation to assess speed and accuracy using total time taken, total position difference and total angle difference across the basic acoustic windows. Interpretation and clinical application skills were assessed using a clinical scenario. 'Cut-off' values for number of studies required for competence were estimated.

Results: Twenty-seven trainees and eight experts were included. The subcostal view was achieved quickest by trainees (median 23 s, IQR 19-37). Eighty-seven percent of trainees did not achieve accuracy across all views; 81% achieved accuracy with the parasternal long axis and the least accurate was the parasternal short axis (44% of trainees). Fewer studies were required to be considered competent with imaging acquisition compared with competence in correct interpretation and integration (15 vs. 40 vs. 50, respectively).

Discussion: The use of echocardiography simulation to determine competence in basic critical care echocardiography is feasible. Competence in image acquisition appears to be achieved with less experience than correct interpretation and correct management decisions. Further studies are required.

Keywords: Critical care echocardiography; basic echo; competency; echo training; simulation.

Figure 1.

Imaging on echocardiography simulator: (a) Reference probe position (red) vs. trainee image acquisition (grey); (b) Reference vs. trainee probe position difference measured in term of total angle difference (pitch + roll + yaw) and distance difference (x + y + z); (c) Example of reference image; (d) Example of trainee image

Figure 2.

Image interpretation receiver operating curve (ROC): trainee imaging interpretation determined accurate if their image was both within 95% confidence interval of the expert group for both positional as well as orientation accuracy vs. a reference standard. From this data, ROC curves generated to determine the point of greatest specificity and sensitivity for accuracy in terms of number of focused cardiac ultrasound studies done to achieve ‘accurate imaging’.