Faculty Bibliography

INTRODUCTION: Goal-directed echocardiography (GDE) is used to answer specific clinical questions that provide invaluable information to physicians managing a hemodynamically unstable patient. We studied perception and ability of house staff previously trained in GDE to accurately diagnose common causes of cardiac arrest during simulated advanced cardiac life support (ACLS); we compared their results with those of expert echocardiographers. METHODS: Eleven pulmonary and critical care medicine fellows, 7 emergency medicine residents, and 5 cardiologists board certified in echocardiography were enrolled. Baseline ability to acquire 4 transthoracic echocardiography views was assessed, and participants were exposed to 6 simulated cardiac arrests and were asked to perform a GDE during ACLS. House staff performance was compared with the performance of 5 expert echocardiographers. RESULTS: Average baseline and scenario views by house staff were of good or excellent quality 89% and 83% of the time, respectively. Expert average baseline and scenario views were always of good or excellent quality. House staff and experts made the correct diagnosis in 68% and 77% of cases, respectively. On average, participants required 1.5 pulse checks to make the correct diagnosis. Of house staff, 94% perceived this study as an accurate assessment of ability. CONCLUSIONS: In an ACLS-compliant manner, house staff are capable of diagnosing management-altering pathologies the majority of the time, and they reach similar diagnostic conclusions in the same amount of time as expert echocardiographers in a simulated cardiac arrest scenario.

PURPOSE: Goal-directed echocardiography (GDE) is used to answer specific clinical questions which can provide invaluable and timely information to the critical care physician. Studies that assess competency are lacking. We studied perception and ability of housestaff previously trained in GDE to accurately diagnose common causes of cardiac arrest during simulated cardiac arrest scenarios, and we compared them to expert echocardiographers. METHODS: 14 housestaff subjects with prior GDE training were enrolled. Subjects answered a pre-study questionnaire and had time to familiarize themselves with the transthoracic echocardiography simulator. A baseline assessment was conducted whereby subjects obtained four standard cardiac windows (parasternal long, parasternal short, subcostal, and apical four chamber). Subjects were exposed to six simulated cardiac arrest scenarios. They were given relevant clinical information and were asked to perform a GDE during pulse checks which lasted ten seconds. Three GDE attempts were allowed and if no diagnosis was offered, a final twenty second interval was allowed. Subjects were debriefed and filled out a post-study questionnaire. All echocardiography views were graded on a scale of zero to three. Subject performance was compared to the performance of three expert echocardiographers. RESULTS: 21% of subjects reported comfort using GDE independently, while 71% preferred attending oversight. Baseline and scenario views by subjects were of good quality 93% and 79% of the time, respectively. Expert baseline and scenario views were of good quality 100% of the time. Subjects and experts made the correct diagnosis in 68% and 72% of cases, respectively. On average, subjects and experts required 1.5 pulse checks for the correct diagnosis. 93% of subjects perceived this study as an accurate assessment of ability and felt more comfortable with GDE at its conclusion. CONCLUSIONS: Housestaff with prior GDE training reach similar diagnostic conclusions in the same amount of tim!

Rationale Current methods available to assess rapid response management skills are subjective and variable. High-fidelity simulation (HFS), however, allows for objective and standardized measurement of these skills. Physicians-in-training can undergo the same simulation and be scored against one another to determine their level of proficiency when leading a rapid response. We created a critical care simulation scenario and corresponding checklist assessment tool to measure specific behaviors related to effective management of a rapid response. Methods Forty-four second-year internal medicine residents underwent HFS of a critically-ill patient with pulseless electrical activity. The simulation was designed to elicit leadership qualities, communication skills, decision-making and resource management during a rapid response. A comprehensive checklist was developed from expert consultation that itemized behaviors as having been "well done," "partially done," or "not done." Video-recordings of simulations were reviewed by two independent raters, each of which underwent extensive training in checklist use prior to project initiation. Results Composite scores from both raters revealed that 39% (103/264) and 55% (243/440) of resident scores were "well done" for leadership and communication skills during the rapid response, respectively. Twenty-six percent (46/176) of scores were "well done" for decision-making and 42% (37/88) of scores were "well done" for resource utilization skills. Cronbach's Alpha analysis of internal consistency of composite "well done" scores was good, with a value of 0.869. Conclusions HFS with use of a corresponding checklist assessment tool is an objective and effective way in which to measure rapid response management skills. During our simulation, a minority of residents received "well done" scores for leadership, decision-making and resource utilization. This may reflect residents' discomfort when placed in a supervisory role during rapid responses, a paucity of exposure to such situations, or inadequate training in running rapid responses. In order to better educate physicians-in-training, a standardized and objective measurement tool must be used. Our checklist assessment tool demonstrates good internal consistency. Therefore, it can be used to objectively measure behaviors that exemplify organization and management of rapid responses