Design of a Workshop for Focused Transesophageal Echocardiography During Noncardiac Surgery in Nurse Anesthesia Education

Abstract

Objective: The use of transesophageal echocardiography (TEE) by certified registered nurse anesthetists (CRNAs) during noncardiac surgery is relatively uncommon despite its unique potential to diagnose causes of hemodynamic instability. To address this problem, educational endeavors designed to provide practical TEE skills to CRNAs are needed. The aim of the current study was to evaluate the feasibility, acceptability, efficacy, and utility of a 2-day focused TEE workshop in nurse anesthesia education that employed a protocol involving a limited number of views and used goal-directed, qualitative assessments of critical physiologic parameters.

Methods: This was a prospective, observational study involving 14 second-year nurse anesthesia students. The cohort was evaluated following completion of this workshop by simulator-based testing involving hypothetical clinical scenarios, and this test data was analyzed according to the percent successful acquisition and interpretation of TEE views to determine immediate objective teaching efficacy. The acceptability, perceived efficacy, and perceived utility of the workshop were assessed by online survey, and survey responses were qualitative and quantitative in nature.

Results: Participants acquired appropriate TEE views associated with clinical scenarios 99% of the time and correctly interpreted the pathology in those views 93% of the time. Participants uniformly perceived significant educational value in this workshop and intend to incorporate TEE in their future clinical practice.

Conclusions: A 2-day workshop to teach focused TEE to nurse anesthesia trainees directed by a streamlined protocol is feasible, acceptable, and perceived as useful by participants, and provides practical experience and entry-level competency in this point-of-care ultrasound modality.

Keywords: TEE workshop; focused echocardiography; noncardiac surgery; nurse anesthesia education; transesophageal echocardiography.

Figure 1.

Miller's pyramid for clinical assessment. Higher levels of the pyramid model are associated with increasing professional competence which can be assessed by different means. For example, “knows” can be evaluated by multiple choice questions, “knows how” by oral examination, “shows” by simulation, and “does” by clinical interactions.

Figure 2.

Simulator screenshots of the 4 views used in the focused transesophageal echocardiographic protocol: (A) transgastric midpapillary short axis; (B) midesophageal 4 chamber; (C) midesophageal 2 chamber; and (D) midesophageal long axis views. Abbreviations: Ao, aorta; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

Figure 3.

Curriculum for the didactic sessions I and II of the workshop. Abbreviations: LVOT, left ventricular outflow tract; SAX, short axis; SWMAs, segmental wall motion abnormalities; TEE, transesophageal echocardiography.

Figure 4.

Transesophageal echocardiography simulator. Trainer includes mannequin torso, probe, and laptop with a split screen demonstrating simultaneous ultrasound and augmented reality displays. External motion tracker is not shown. See text for details. Photo by CAE Healthcare with permission.

Figure 5.

Focused transesophageal echocardiography algorithm. Abbreviations: LV, left ventricle; LVEDV, left ventricular end diastolic volume; LVESV, left ventricular end systolic volume; RV, right ventricle; SWMA, segmental wall motion abnormality; TEE, transesophageal echocardiography; TG MP SAX, transgastric midpapillary short axis view.