Integrating graduated didactics into training reduces the time required to build skill in focused cardiac ultrasound

Introduction: Focused cardiac ultrasound (FoCUS) has become a widely used tool for the point of care evaluation of basic cardiac pathology, and there is a growing need for efficient and consistent training in this modality.... [ view full abstract ]

Introduction:
Focused cardiac ultrasound (FoCUS) has become a widely used tool for the point of care evaluation of basic cardiac pathology, and there is a growing need for efficient and consistent training in this modality. We developed a self-directed, simulator-based curriculum that includes a graduated, integrative approach to learning FoCUS and allows for more efficient acquisition of technical and cognitive skill.

Methods:
Fifteen nurse practitioners and resident physicians completed a FoCUS curriculum using simulator technology to scan a mannequin with a mock transducer. Training was presented in a stepwise fashion, beginning with instruction on the technical acquisition of standard cardiac views through practice capturing these views in a normal heart. This was followed by instruction on the focused assessment of selected cardiac structures for the diagnosis of basic pathology, again integrated with practice in assessing these structures by scanning the mannequin to obtain and interpret pathologic images. Thus, didactic instruction on echocardiography was gradually presented in the context of image acquisition and image interpretation. Learners were then asked to apply the skill they had acquired in image acquisition and interpretation to complete three undifferentiated practice cases, obtaining all standard views and analyzing the pathology. The curriculum was self-directed, and learners were allowed to freely move between practice modules as desired. They were provided with additional cases to scan ad libitum.
Six of the learners completed a pre-test on the simulator and nine completed a pre-test on a standardized patient. All learners completed a post-test comprised of three simulator test cases, obtaining and interpreting images in each case. Psychomotor (technical) skill in image acquisition was assessed in terms of the angle deviation between the plane of the learner-acquired image and the anatomically correct plane for the specified view. The angle deviation metric was provided immediately to the learner as visual and numeric feedback as each image was acquired throughout training, while all test cases were completed without any feedback on image accuracy. Cognitive skill in image interpretation was assessed through multiple choice questions on pathologic findings.
The time to complete the curriculum and the angle deviation and image interpretation score after training were compared between the new graduated curriculum and a previously validated curriculum in which all didactic instruction on echocardiography was presented before the practice scanning in the traditional, lecture-before-hands-on-practice format. Change in psychomotor and cognitive skill was also compared for the subset who took the simulator pre-test.

Results:
The average time to completion decreased from 8.0 ± 2.5 hours using the traditional curriculum to 4.6 ± 2.0 hours using the new curriculum (p < 0.0001). After training psychomotor skill by mean angle deviation was similar in the new vs. traditional curriculum (26 ± 15 vs. 36 ± 24 degrees, p=0.11), as was cognitive skill (65 ± 15 vs 71 ± 8%, p=0.16). Learners who took the simulator pre-test showed a similar decrease in angle deviation (-40 ± 32 vs. -47 ± 33 degrees, p=0.33) and a similar improvement in cognitive skill (20 ± 31 vs. 27 ± 21%, p=0.52) after completing the new vs. traditional curriculum.

Discussion:
In comparison to a previously validated traditional curriculum, a new curriculum developed to specifically instruct learners in a stepwise fashion provided an equally effective but more efficient means of teaching psychomotor and cognitive skills in FoCUS. This curriculum maintains the ability to teach FoCUS in a self-directed manner and provides an improved method in efficiently and consistently training practitioners.