Transesophageal Echocardiography in the Emergency Department: Development of a Validated Checklist for Training

Although the use of transesophageal echocardiography (TEE) may improve cardiac arrest management, emergency physicians (EPs) may have insufficient clinical practice opportunities to become competent in TEE. Standardized checklists, such as those used in simulation-based mastery learning (SBML), improve trainee performance for rarely performed procedures. To date, there is no validated checklist for performing point-of-care (POC) TEE in the emergency department setting. The objective of this project was to develop and validate an SBML checklist containing the critical actions for performing POC TEE that can be used for procedural skills training.

This was a multiphase study that began with a three-round modified Delphi to develop the checklist and ended with pre-post assessment. After checklist development, aspects of reliability were measured by piloting the checklist as part of an SBML training program. A previously validated survey was used to assess pre- and post-training confidence in using TEE.

The final checklist consisted of 43 items across 7 sections. The minimum passing score (MPS) was set at 83% and the panel deemed 4 actions as critical to patient safety. There was near-perfect inter-rater agreement among all raters with a Gwet's AC1 of 0.99 (95% CI 0.98-1.00) for the full checklist. All EPs that participated in training met the MPS, with a mean score of 97.0% (95% CI 95.0-100%). Median confidence using TEE improved after SBML (23 to 80, p < 0.0001). The post-training confidence for trainees who had prior TEE experience was not significantly different compared to trainees without prior TEE experience (86 vs. 75, p = 0.142).

We have developed a novel POC TEE SBML checklist and present validity evidence for the checklist. When using the SBML checklist for TEE training, pretraining confidence was higher among participants with prior TEE experience, but post-training confidence equalized between participants with and without prior TEE experience.