Methods: This was a prospective validation study of an objective QA scale for lung ultrasound (LUS) in the emergency department. We identified the first 100 LUS performed in normal clinical practice in the year 2020. Four reviewers at an urban academic center who were either emergency ultrasound fellowship-trained or current fellows with at least six months of QA experience scored each study, resulting in a total of 400. The primary outcome was the level of agreement between the reviewers. Our secondary outcome was the variability of the scores given to the studies. For the agreement between reviewers, we computed the intraclass correlation coefficient (ICC) based on a two-way random-effect model with a single rater for each grading scale. We generated 10,000 bootstrapped ICCs to construct 95% confidence intervals (CI) for both grading systems. A two-sided one-sample t-test was used to determine whether there were differences in the bootstrapped ICCs between the two grading systems.

Results: The ICC between reviewers was 0.552 (95% CI 0.40–0.68) for the ACEP grading scale and 0.703 (95% CI 0.59–0.79) for the novel grading scale (P < 0.001), indicating significantly more interobserver agreement using the novel scale compared to the ACEP scale. The variance of scores was similar (0.93 and 0.92 for the novel and ACEP scales, respectively).

Conclusion: We found an increased interobserver agreement between reviewers when using the novel, organ-specific scale when compared with the ACEP grading scale. Increased consistency in feedback based on objective criteria directed to the specific, targeted organ provides an opportunity to enhance learner education and satisfaction with their ultrasound education.

Introduction: Transesophageal echocardiography (TEE) is a well-established method of evaluatingcardiac pathology. It has many advantages over transthoracic echocardiography (TTE), including theability to image the heart during active cardiopulmonary resuscitation. This prospective simulation studyaims to evaluate the ability of emergency medicine (EM) residents to learn TEE image acquisitiontechniques and demonstrate those techniques to identify common pathologic causes of cardiac arrest.

Methods: This was a prospective educational cohort study with 40 EM residents from two participatingacademic medical centers who underwent an educational model and testing protocol. All participantswere tested across six cases, including two normals, pericardial tamponade, acute myocardial infarction(MI), ventricular fibrillation (VF), and asystole presented in random order. Primary endpoints were correctidentification of the cardiac pathology, if any, and time to sonographic diagnosis. Calculated endpointsincluded sensitivity, specificity, and positive and negative predictive values for emergency physician (EP)-performed TEE. We calculated a kappa statistic to determine the degree of inter-rater reliability.

Results: Forty EM residents completed both the educational module and testing protocol. This resultedin a total of 80 normal TEE studies and 160 pathologic TEE studies. Our calculations for the abilityto diagnose life-threatening cardiac pathology by EPs in a high-fidelity TEE simulation resulted in asensitivity of 98%, specificity of 99%, positive likelihood ratio of 78.0, and negative likelihood ratio of0.025. The average time to diagnose each objective structured clinical examination case was as follows:normal A in 35 seconds, normal B in 31 seconds, asystole in 13 seconds, tamponade in 14 seconds,acute MI in 22 seconds, and VF in 12 seconds. Inter-rater reliability between participants was extremelyhigh, resulting in a kappa coefficient across all cases of 0.95.

Conclusion: EM residents can rapidly perform TEE studies in a simulated cardiac arrest environmentwith a high degree of precision and accuracy. Performance of TEE studies on human patients in cardiacarrest is the next logical step to determine if our simulation data hold true in clinical practice. [West JEmerg Med. 2017;18(5)830-834.]