Effectiveness of Simulation-Based Training on Transesophageal Echocardiography Learning

The SIMULATOR Randomized Clinical Trial

Théo Pezel, MD1,2,3Julien Dreyfus, MD4Basile Mouhat, MD5; et al

JAMA Cardiol. Published online January 11, 2023.

IMPORTANCE:  Evidence is scarce on the effectiveness of simulation-based training in transesophageal echocardiography (TEE).

OBJECTIVE:  To assess the effectiveness of simulation-based teaching vs traditional teaching of TEE knowledge and skills of cardiology fellows.

DESIGN, SETTING, AND PARTICIPANTS:  Between November 2020 and November 2021, all consecutive cardiology fellows inexperienced in TEE from 42 French university centers were randomized (1:1; n = 324) into 2 groups with or without simulation support.

MAIN OUTCOMES AND MEASURES:  The co-primary outcomes were the scores in the final theoretical and practical tests 3 months after the training. TEE duration and the fellows’ self-assessment of their proficiency were also assessed.

RESULTS: While the theoretical and practical test scores were similar between the 2 groups (324 participants; 62.6% male; mean age, 26.4 years) before the training (33.0 [SD, 16.3] points vs 32.5 [SD, 18.5] points; P = .80 and 44.2 [SD, 25.5] points vs 46.1 [SD, 26.1] points; P = .51, respectively), the fellows in the simulation group (n = 162; 50%) displayed higher theoretical test and practical test scores after the training than those in the traditional group (n = 162; 50%) (47.2% [SD, 15.6%] vs 38.3% [SD, 19.8%]; P < .001 and 74.5% [SD, 17.7%] vs 59.0% [SD, 25.1%]; P < .001, respectively). Subgroup analyses showed that the effectiveness of the simulation training was even greater when performed at the beginning of the fellowship (ie, 2 years or less of training) (theoretical test: an increase of 11.9 points; 95% CI, 7.2-16.7 vs an increase of 4.25 points; 95% CI, −1.05 to 9.5; P = .03; practical test: an increase of 24.9 points; 95% CI, 18.5-31.0 vs an increase of 10.1 points; 95% CI, 3.9-16.0; P < .001). After the training, the duration to perform a complete TEE was significantly lower in the simulation group than in the traditional group ( 8.3 [SD, 1.4] minutes vs 9.4 [SD, 1.2] minutes; P < .001, respectively). Additionally, fellows in the simulation group felt more ready and more confident about performing a TEE alone after the training (mean score, 3.0; 95% CI, 2.9-3.2 vs mean score, 1.7; 95% CI, 1.4-1.9; P < .001 and mean score, 3.3; 95% CI, 3.1-3.5 vs mean score, 2.4; 95% CI, 2.1-2.6; P < .001, respectively).

CONCLUSIONS AND RELEVANCE: Simulation-based teaching of TEE showed a significant improvement in the knowledge, skills, and self-assessment of proficiency of cardiology fellows, as well as a reduction in the amount of time needed to complete the examination. These results should encourage further investigation of clinical performance and patient benefits of TEE simulation training.

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Simulation‑Based Training on Basic Obstetrics and Gynecology Ultrasound Skills During COVID Pandemic

Yerra, A.K., Jogi, S., Emmadisetty, S. et al.

The Journal of Obstetrics and Gynecology of India

Jan 7, 2023

BACKGROUND: COVID-19 pandemic led to an alarming rise in sickness absenteeism among the radiologists. Anticipating a continued shortage of experienced radiologists in future COVID waves, it is essential to train the medical professionals in basic skills related to ultrasonography to enable them to perform basic Obstetrics and Gynecology (OG) scans safely in emergencies. Virtual reality simulation training is an alternative to conventional ultrasound training.

METHODS: A cross-sectional study was conducted during 8-day-long workshop to identify the trainees’ basic, after training knowledge and skills in OG ultrasound and to document their perceptions of the training. Statistical analysis was done using descriptive statistics (percentages and mean standard deviations) and paired t test for comparisons.

RESULTS: A total of 80 health care professionals underwent ultrasound simulation training. It was found that the post-test score in the knowledge domain, instrument handling, basic gynecological skills, and first-trimester antenatal ultrasound skills in the practical domain was signifcantly higher than the pre-test score (P-value

CONCLUSION: The study showed that ultrasound-based simulation can provide a realistic setting for training and assessment of novices in learning basic skills.

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EACVI SIMULATOR-online study: Evaluation of Transoesophageal Echocardiography Knowledge and Skills of Young Cardiologists

Théo Pezel, Augustin Coisne, Błażej Michalski, Hatem Soliman, Nina Ajmone, Robin Nijveldt, Ivan Stankovic, Erwan Donal, Joost van der Maaten, Constantinos Papadopoulos,

Thor Edvardsen, Denisa Muraru, Steffen E Petersen, Bernard Cosyns.

European Heart Journal – Cardiovascular Imaging (2022) 00, 1–8.

AIMS: To assess the level of transesophageal echocardiography (TOE) knowledge and skills of young cardiologists.

METHODS AND RESULTS: A European Association of Cardiovascular Imaging (EACVI) online study using the first fully virtual simulation-based software was conducted in two periods (9–12 December 2021 and 10–13 April 2022). All young cardiologists eligible to participate (< 0.001). Prior participation to a TOE simulation-based training session, a higher number of TOE exams performed per week, and EACVI certification for TOE were independently associated with a higher global score (all P<0.001)

CONCLUSION: Online evaluation of young cardiologists around the world showed a relatively low level of TOE skills and knowledge. Prior participation to a TOE simulation-based training session, a higher number of TOE exams performed per week, and the EACVI certification for TOE were independently associated with a higher global score.

Read more https://doi.org/10.1093/ehjci/jeac195

Rational and Design of the SIMULATOR Study: A Multicentre Randomized Study to Assess the Impact of SIMULation-bAsed Training on Transoesophageal echocardiOgraphy leaRning for Cardiology Residents

Théo Pezel, Anne Bernard, Yoan Lavie Badi8, Julien Dreyfus, Etienne Audureau, Yohann Bohbot, Damien Fard, Arnaud Hubert, Lee S. Nguyen, Cécile Monteil, Loïc Bière, Florent Le Ven, Marjorie Canu, Sophie Ribeyrolles, Baptiste Mion, Basile Mouhat, Baptiste Bazire, Charles Fauvel, Julien Ternacle, Jennifer Cautela, Théo Cambet, Thierry Le Tourneau, Erwan Donal, Stéphane Lafitte, Nicolas Mansencal and Augustin Coisne

INTRODUCTION: Simulation-based training in transesophageal echocardiography (TEE) seems promising. However, data are limited to non-randomized or single-center studies. To assess the impact of simulation-based vs. traditional teaching on TEE knowledge and performance for medical residents in cardiology. Pezel et al. SIMULATOR Study: TEE Simulation Training.

MATERIALS AND METHODS: Nationwide prospective randomized multicenter study involving 43 centers throughout France allowing for the inclusion of >70% of all French cardiology residents. All cardiology residents naive from TEE will be included. Randomization with stratification by center will allocate residents to either a control group receiving theoretical knowledge by e-learning only, or to an intervention group receiving two simulation-based training sessions on a TEE simulator in addition.

RESULTS: All residents will undergo both a theoretical test (0–100 points) and a practical test on a TEE simulator (0–100 points) before and 3 months after the training. Satisfaction will be assessed by a 5-points Likert scale. The primary outcomes will be to compare the scores in the final theoretical and practical tests between the two groups, 3 months after the completion of the training.

CONCLUSION: Data regarding simulation-based learning in TEE are limited to nonrandomized or single-center studies. The randomized multicenter SIMULATOR study will assess the impact of simulation-based vs. traditional teaching on TEE knowledge and performance for medical residents in cardiology, and whether such an educational program should be proposed in first line for TEE teaching.

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Does the virtual simulation training improve the learning of pelvic ultrasound performed in gynecological emergencies?

Legendre G, Beaudoux G., Descamps P., Bouet P.

Ultrasound In Obstetrics & Gynecology , Volume 54, Issue S1. October 2019

OBJECTIVES: To compare the contribution of training using virtual simulation with theoretical instruction alone in the learning of pelvic ultrasound for gynecological emergencies in non‐experienced students.

METHODS: A unicentre randomised controlled trial was conducted. The participants were students in the last year of medical studies during their internship in the obstetrics and gynecology department at the University Hospital Center of Angers. Twenty participants were randomised to a 1:1 ratio in the training group and control group of 10 students each. All participants received a two hours theoretical course on the physical basis of ultrasound, the use of probes, as well as the basic principles of an trans‐vaginal ultrasound examination centreed on the different standardised images to be given to gynecologic emergencies. For the training group an additional 20‐minute pelvic ultrasound training on a trans‐vaginal virtual simulator was performed. The participants were evaluated on images taken from patients consulting our gynecological emergencies centre. The pictures evaluated were sagittal and coronal sections of the uterus, left and right ovarian sections and a Morrison pouch view. The primary outcome was based on picture quality scores described by Salomon et al. with the French Society for the Improvement of Ultrasound Practices (SFAPE) and by Popowski et al. for Standardisation Acute Female Echography (SAFE). Secondaries outcomes focused on the general ultrasound skills and the duration of acquisition of the pictures.

RESULTS: The mean SFAPE and SAFE scores were significantly higher in the training group than in the control group (14.5 ± 3.1, p = 0.046 and 10.1 ± 2.08, p = 0.016, respectively).

CONCLUSIONS: After a very short training session, using virtual simulation, inexperienced students produce proper pictures for the management of gynecological emergencies and better quality ultrasound pictures than students trained only theoretically.

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Developing and Gathering Validity Evidence for a Simulation-Based Test of Competencies in Lung Ultrasound

Pietersen PI1,2,3, Konge L4, Graumann O5,6, Nielsen BU7, Laursen CB8,5

Regional Center for Technical Simulation, Region of Southern Denmark, Odense, Department of Respiratory Medicine, Odense University Hospital, Odense, Institute for Clinical Research, University of Southern Denmark, Odense, Copenhagen Academy for Medical Education and Simulation, Central Region of Denmark, Copenhagen, Denmark. Institute for Clinical Research, University of Southern Denmark, Odense, Denmark. Department of Radiology, Odense University Hospital, Odense, Denmark. Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark. Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark.

BACKGROUND: Clinical lung ultrasound (LUS) is a fast bedside diagnostic tool which can assist clinicians in decisions regarding the treatment and monitoring of patients with respiratory symptoms. LUS training and education differ widely, and is often done in a clinical setting, with potential risks for patients if decisions are made based on the wrong interpretations. No clear guidelines or recommendations for objective and standardized assessment of LUS skills exist, and those that do are often based on a fixed time-frame or an arbitrary number of examinations performed; this does not ensure adequate competencies.

OBJECTIVES: The study aimed to develop and gather validity evidence for a practical, simulation-based test in LUS.

METHODS: Nine cases were developed in collaboration with Surgical Science Healthcare, representing the most common diagnosis and sonographic findings in patients with respiratory symptoms. Thirty-six participants with different levels of competence in LUS, completed the test. The participants were divided into groups, i.e., novices, intermediates, and experienced, according to their experience with LUS, the number of examinations they had performed, and any research they had conducted. Their answers were used for item analyses.

RESULTS: The intraclass correlation coefficient, Cronbachs’ α, was 0.69 summarized, and there was a statistically significant difference (p < 0.001) between the novices and the trained participants (intermediates and experienced). A pass/fail score of 16 points was calculated according to the contrasting-groups method.

CONCLUSION: We developed a test for the assessment of clinical competencies in LUS. The test proved solid validity evidence, and a pass/fail standard without any false-negatives, and only 2 explained false-positives.

Training Pulmonary/Critical Care Fellows in Advanced Critical Care Transesophageal Echocardiography: A Simulator Based Training Project

Astha Chichra, MD; Seth Koenig, MD; Viera Lakticova, MD; Mangala Narasimhan, DO; Paul Mayo, MD

Chest. 2015;148(4_MeetingAbstracts):455A. doi:10.1378/chest.2280908

Sunday, October 25, 2015 at 04:30 PM – 05:30 PM

PURPOSE: Critical care transesophageal echocardiography (cTEE) is an important component of advanced critical care echocardiography. Experiential training in cTEE requires greater than 30 real case patients to achieve competence1. The effectiveness of high fidelity TEE simulator (simulator) training to achieve competence is unknown. We studied the effectiveness of using a simulator to train pulmonary/critical care medicine fellows (fellows) in cTEE image acquisition and interpretation.

METHODS: We trained 12 fellows with no experience in cTEE using a simulator. Using a standardized cTEE image acquisition format, trainees performed 14 complete studies, with image acquisition testing on the 15th study. We used a validated system for scoring the operative and interpretive skills of the trainees 2. Once competent on the simulator1, they performed cTEEs under direct attending supervision on patients. Each patient cTEE was graded using the same scoring system as for the simulator. Successful training outcome was defined as a score of >35/401.

RESULTS: Twelve fellows received training with the simulator, consisting of a 3 hour training period. All fellows achieved perfect performance in image acquisition on the simulator at the 15th cTEE study. Eight fellows have further performed at least 5 patient cTEEs. Six fellows achieved a score of >35/40 on their first patient cTEE. The other 2 fellows required an average of 3 studies to achieve a score >35/40.

CONCLUSIONS: Training fellows to perform cTEE using a simulator is effective and may reduce the number of real patient cTEEs needed for training purposes.

CLINICAL IMPLICATIONS: Simulator training can accelerate the training curve for cTEE in fellows. Further studies need to be performed in order to establish the minimum number of cTEEs to be performed to achieve competency. References: 1.Charron, C et al. Number of supervised studies required to reach competence in advanced critical care transesophageal echocardiography.Intensive care medicine (2013): 1-6. 2. 2.Charron, C et al. Validation of a skills assessment scoring system for transesophageal echocardiographic monitoring of hemodynamics. Intensive care medicine 33.10 (2007): 1712-1718.

DISCLOSURE: The following authors have nothing to disclose: Astha Chichra, Seth Koenig, Viera Lakticova, Mangala Narasimhan, Paul Mayo

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