Emergency. 2017; 5 (1): e70 BR I E F RE P O RT An Echocardiography Training Program for Improving the Left Ventricular Function Interpretation in Emergency Department; a Brief Report Mary Jacob1, Hamid Shokoohi1∗, Fabith Moideen2, Amelia Pousson1, Keith Boniface1 1. Department of Emergency Medicine, George Washington University, Washington DC. USA. 2. Department of Emergency Medicine, Baby Memorial Hospital, Calicut, Kerala, India. shokoohi@gwu.edu (corresponding author) Received: April 2017; Accepted: June 2017; Published online: 15 June 2017 Abstract: Introduction: Focused training in transthoracic echocardiography enables emergency physicians (EPs) to accu- rately estimate the left ventricular function. This study aimed to evaluate the efficacy of a brief training program utilizing standardized echocardiography video clips in this regard. Methods: A before and after design was used to determine the efficacy of a 1 hour echocardiography training program using PowerPoint presentation and standardized echocardiography video clips illustrating normal and abnormal left ventricular ejection fraction (LVEF) as well as video clips emphasizing the measurement of mitral valve E-point septal separation (EPSS). Pre- and post-test evaluation used unique video clips and asked trainees to estimate LVEF and EPSS based on the viewed video clips. Results: 21 EPs with no prior experience with the echocardiographic technical methods completed this study. The EPs had very limited prior echocardiographic training. The mean score on the cate- gorization of LVEF estimation improved from 4.9 (95% CI: 4.1-5.6) to 7.6 (95%CI: 7-8.3) out of a possible 10 score (p<0.0001). Categorization of EPSS improved from 4.1 (95% CI: 3.1-5.1) to 8.1 (95% CI: 7.6- 8.7) after education (p<0.0001). Conclusion: The results of this study demonstrate a statistically significant improvement of EPs’ ability to categorize left ventricular function as normal or depressed, after a short lecture utilizing a commer- cially available DVD of standardized echocardiography clips. Keywords: Echocardiography; ultrasonography; ventricular Function, Left; educational techniques © Copyright (2017) Shahid Beheshti University of Medical Sciences Cite this article as: Jacob M, Shokoohi H, Moideen F, Pousson A, Boniface K. Pan vs. An Echocardiography Training Program for Improving the Left Ventricular Function Interpretation in Emergency Department; a Brief Report . 2017; 5(1): e70. 1. Introduction A ssessment of left ventricular function by point-of-care echocardiography is of particular importance in dif- ferentiating the causes of some presentation such as hypotension and dyspnea in emergency department. Re- search has demonstrated that focused training in transtho- racic echocardiography enables EPs to accurately classify left ventricular ejection fraction (LVEF) as normal, depressed, or severely depressed (1, 2). Over 20 years ago, Plummer et al published their sentinel paper on the impact of point-of- care echocardiography in the evaluation of penetrating car- ∗Corresponding Author: Hamid Shokoohi; 2120 L Street NW, Suite 450, Washington, DC 20037. Tel: 202 741 2911 Fax: 202 741-2921 E-mail: shokoohi@gwu.edu diac trauma (3). Since that time, focused clinician-performed echocardiography has been found to be useful in the assess- ment of patients with cardiac arrest, suspected massive pul- monary embolism, and hypotension (4, 5). There are sev- eral technique for echocardiographic evaluation of LVEF, in- cluding Simpson’s rule, wall motion index, and subjective visual estimation. McGowan et al. performing a system- atic review found that none of the three mentioned methods had superiority to others in estimation of LVEF (6). Simp- son’s method requires significant experience, and can often be limited by technically suboptimal examinations with in- distinct endocardial borders. However, visual estimation of LVEF is a commonly employed technique and correlates well with ventriculography (7). Mitral valve E-point septal sep- aration (EPSS), is another easy-to-obtain echocardiographic parameter that correlates inversely with LVEF. EPSS is mea- sured as the minimal distance between the anterior mitral This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com M. Jacob et al. 2 valve leaflet and the interventricular septum in the paraster- nal long view during diastole using M-Mode on echocardiog- raphy. Secko et al. showed that junior EPs could obtain EPSS measurements that correlated with visual estimates of LVEF (8). We created a training program in point-of-care echocar- diography utilizing echocardiography video clips from pa- tients with known LVEF. In this method the trainees were taught to focus on the anterior mitral valve’s motion relative to the septum. The aim of this study was to evaluate the effi- cacy of this brief educational training program in improving LVEF and EPSS interpretation by EPs. 2. Methods 2.1. Study design and setting A before and after design was used to determine the effi- cacy of a brief educational echocardiography training pro- gram on interpretation of left ventricular function with re- gards to LVEF and EPSS. The study was conducted in two ur- ban adult academic Emergency Departments in Baby Memo- rial and Malabar Institute of Medical Sciences (MIMS) Hospi- tals in Calicut, Kerala, India. Data were collected during the academic year of 2014-2015. The George Washington (GW ) University Institutional Review Board approved the study, and letters of support were obtained from the two partici- pating hospitals in India. Both hospitals gave written per- mission for the study and reviewed the institutional review board forms prior to study commencement. The study inves- tigators were two attending EPs and one senior resident from an ACGME approved Emergency Medicine residency training program. No patients were involved and informed consent was obtained from the EPs involved in the study. 2.2. Participants The study population was the emergency physicians in post graduate training at the mentioned Hospitals. All emergency physicians in-training were included in the study and medi- cal students and faculty in practice were excluded. 2.3. Outcomes The primary goal of this study was to determine the efficacy of a brief educational training program utilizing standard- ized echocardiography video clips in improving EPs’ skills in categorizing LVEF as normal (>50%), depressed (30-50%), or severely depressed (<30%) based upon a single parasternal long axis view. The secondary goal was to classify EPSS as normal (< 8 mm) or increased (≥ 8 mm) based on B-mode images. 2.4. Intervention The EPs’ training intervention for estimating LVEF and EPSS consisted of a 1 hour didactic by the senior level emer- Figure 1: An M-mode ultrasound scan through the distal- Most as- pect of the anterior leaflet of the mitral valve to trace the movement of the anterior MV leaflet through the cardiac cycle. The E and A points of each diastole are visible as asymmetric humps during each diastole. gency medicine resident who had previously completed a two-week ultrasound rotation and had undergone dedicated 2 hour echocardiography training with experienced emer- gency ultrasonographers. The course utilized materials con- sisting of a PowerPoint presentation and a number of stan- dardized video clips illustrating normal and abnormal LVEF as well as video clips emphasizing the measurement of EPSS. The echocardiography video clips were part of a com- mercially available DVD with patients who had undergone contemporaneous radionuclide ventriculography, giving the LVEF. By utilizing a series of standardized examples of a wide range of ejection fractions, the training period was able to be compressed. The EPSS from the video clips was esti- mated from the B-mode images using calipers by the GW ul- trasound quality assessment team led by an ultrasound fel- lowship trained attending. EPSS measurements of > 8 mm indicate poor left ventricular function (figure1). The EPs completed a 10 question pre-test and post-test using stan- dardized video clips of parasternal long axis view to estimate LVEF and EPSS based on these video clips from patients with known ejection fraction. Each correct answer earned 1 point and inappropriate ones zero point. The pre- and post-test clips, as well as the video clips in the PowerPoint presenta- tion, were all different from one another but had the same number of normal, depressed, and severely depressed LVEF videos clips. The pre- and post- tests also reported a survey of broad demographics (year of training, prior ultrasound train- ing, self-reported confidence in echocardiographic interpre- tation, prior echocardiograms training, and using ultrasound in last month). No personal identifiers were collected in this study. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2017; 5 (1): e70 2.5. Statistical analysis Sample size was determined by the class size of interna- tional EPs. Data were analyzed Using Stata version 10.1 and presented as number (%) or mean ± standard devia- tion. A paired samples t-test was used to compare two related means. A p-value of less than 0.05 considered significant. 3. Results: 32 EPs were enrolled in the post graduate EM training pro- grams, among them 21 EPs (65.62%) were available and par- ticipated in both pre- and post-tests. The baseline character- istics of EPs and their previous experiences with ultrasound is summarized in Table 1. The EPs had very limited prior echocardiographic training aside from the cardiac view of the Focused Assessment with Sonography in Trauma (FAST) ex- amination. The mean score on the categorization of LVEF es- timation improved from 4.9 (95% CI: 4.1-5.6) to 7.6 (95%CI: 7-8.3) out of a possible 10 score (p< 0.0001). Categorization of EPSS improved from 4.1 (95% CI: 3.1-5.1) to 8.1 (95% CI: 7.6- 8.7) after education (p<0.0001) (Figure 2). 4. Discussion The results of this study demonstrate a statistically signifi- cant improvement of EPs’ ability to categorize left ventricular function as normal or depressed, after a short lecture utiliz- ing a commercially available DVD of standardized echocar- diography clips. LVEF and EPSS are important data points in critical care and emergency medicine decision-making. Vi- sual estimation skills in this regard typically are gained via many hours of experience at the bedside. In this study, a Table 1: Demographic characteristic of participants Characteristics No (%) Year of Training 1 8 (38.09) 2 7 (33.33) 3 3 (14.28) Not reported 3 (14.28) Prior ultrasound training Yes 10 (47.61) No 8 (38.09) Not reported 3 (14.28) Ultrasound use in last month Non-user 5 (23.80) User 13 (61.90) Not reported 3 (14.28) Comfort level Not at all 5 (23.80) Somewhat 12 (57.14) Very 2 (9.52) Not reported 2 (9.52) senior emergency medicine resident with skills in focused echocardiography successfully taught a group of EPs visual estimation of LVEF and EPSS using a brief training program comprised of commercially available, standardized echocar- diography clips, with an emphasis on the motion of the ante- rior leaflet of the mitral valve as a teaching tool. The abil- ity of EPs to accurately categorize LVEF has been demon- strated in the past, utilizing an extended period of time with hands-on scanning, both in the echocardiography lab as well as in the ED. Moore et al evaluated the ability of EPs with fo- cused training in echocardiography to determine left ventric- ular function of hypotensive emergency department patients compared to a blinded cardiologist reviewing the echocar- diogram acquired by the EP (1). Training was accomplished with a combination of didactics (six hours of videotaped in- struction), time in the echocardiography laboratory under supervision of a cardiologist (greater than ten hours), and completion of complete echocardiogram study reviewed for adequacy by a cardiologist prior to beginning patient enroll- ment. Weighted kappa for the categorization of LVEF by EPs and cardiology in this study was 0.61 (95% CI 0.39-0.83) and the length of time required for completion of the echocardio- gram was 17.5 +/- 10.8 minutes (range 4-45 minutes). The authors state in their discussion, however, that the majority of the time was spent taking M-mode measurements, bor- der tracing, and capturing adequate views for printing, and they estimate that they could complete a five-view echocar- diogram in less than five minutes focusing on LVEF. Randazzo et al. studied visual estimation of LVEF in an ED popula- tion as well (2). The investigators undertook additional train- ing in limited echocardiography (three hours of didactics, re- view of normal and abnormal echocardiograms, and 5 proc- tored exams on patients who were not enrolled in the study) and compared EP LVEF category with that of a complete echocardiogram performed by cardiology. Weighted kappa for the categorization of LVEF by EPs and cardiology was Figure 2: LVEF and EPSS interpretation before and after video- based module training (p < 0.0001 for both measurements). LVEF=left ventricular ejection fraction; EPSS=end point septal sep- aration. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com M. Jacob et al. 4 0.71 (95% CI 0.53-0.89). Subgroup analysis revealed the high- est agreement (92.3%) between EPs and formal echocardio- grams within the normal LVEF category, followed by 70.4% agreement in the poor LVEF category and only 47.8% in the moderate LVEF category. This study is the first to demon- strate that a didactic session utilizing standardized echocar- diography clips from patients with known LVEF can lead to improved accuracy in the determination of systolic function. Improving EP echocardiographic interpretation skills can be beneficial by rapidly identifying those patients with abnor- mal systolic function, utilizing the motion of the anterior leaflet of the mitral valve as a tool to more accurately as- sess LVEF. This study also evaluated the use of a single view echocardiogram as a physical exam adjunct in distinguishing cardiogenic from non-cardiogenic dyspnea based on ejec- tion fraction (EF) by using a depressed EF as a marker for congestive heart failure as well as EPSS as a tool for left ven- tricular function delineation. 5. Limitations There were a number of limitations in this study. This study took place in its entirety in the classroom setting, and as such the EPs did not acquire the images themselves. Image inter- pretation is a separate skill set than image acquisition, and both facets of point-of-care ultrasound are critical to arriving at the correct diagnosis. In addition, EPSS is traditionally a measurement made from M-mode. This training session em- phasized the concepts of anterior mitral valve leaflet motion relative to the septum that is at the core of the M-mode EPSS measurement, and these concepts can be applied in real time during B-mode imaging as a component of visual estimation. Also, the use of a solitary view of the heart can be deceiving when estimating LVEF in the presence of regional wall mo- tion abnormalities. The video clips used in this study were older images from a commercially available digital resource. However, this did not appear to limit the EPs’ interpretation of images. The study did not seek to differentiate the incre- mental increase in diagnostic accuracy of LVEF determina- tion with EPSS compared to without teaching EPSS, as the sample size was too small to allow two comparison groups. Finally, this study did not test long-term retention, which would be the next step in the evaluation of video-based train- ing program as an adjunct to international EPs’ ultrasound training. 6. Conclusion The results of this study demonstrate a statistically signifi- cant improvement of EPs’ ability to categorize left ventricular function as normal or depressed, after a short lecture utiliz- ing a commercially available DVD of standardized echocar- diography clips. 7. Appendix 7.1. Acknowledgements The authors wish to thank the faculty at MIMS and the Baby memorial hospitals in Calicut for providing opportunity to conduct this research. We are grateful for the academic sup- port of Dr. Dr.Venugopalan Poovathum Parambil. 7.2. Author contribution All authors substantially contributed to this work. M.J., H.S. and K.B. designed the experiment. M.J. and F.M. conducted the observations at the site. M.J. and H.S assembled input data, and conducted statistical analysis. M.J. drafted the first manuscript and all authors discussed the results and impli- cations and commented on the manuscript at all stages. 7.3. Funding No funding or support to declare. 7.4. Conflict of interest The authors declare that they have no competing interests. The authors do not have a financial interest or relationship to disclose regarding this research project. References 1. Moore CL, Rose GA, Tayal VS, Sullivan DM, Arrowood JA, Kline JA. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med. 2002;9(3):186-93. 2. Randazzo MR, Snoey ER, Levitt MA, Binder K. Accuracy of emergency physician assessment of left ventricular ejec- tion fraction and central venous pressure using echocar- diography. Acad Emerg Med. 2003;10(9):973-7. 3. Plummer D, Brunette D, Asinger R, Ruiz E. Emergency de- partment echocardiography improves outcome in pene- trating cardiac injury. Ann Emerg Med. 1992;21(6):709-12. 4. Salen P, Melniker L, Chooljian C, Rose JS, Alteveer J, Reed J, et al. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? The American journal of emer- gency medicine. 2005;23(4):459-62. 5. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emer- gency department echocardiogram. Acad Emerg Med. 2001;8(6):616-21. 6. McGowan JH, Cleland JG. Reliability of reporting left ven- tricular systolic function by echocardiography: a system- atic review of 3 methods. Am Heart J. 2003;146(3):388-97. 7. Cheitlin MD, Alpert JS, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, et al. ACC/AHA guidelines for This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 5 Emergency. 2017; 5 (1): e70 the clinical application of echocardiography. Circulation. 1997;95(6):1686-744. 8. Secko MA, Lazar JM, Salciccioli LA, Stone MB. Can Junior Emergency Physicians Use E-Point Septal Separation to Accurately Estimate Left Ventricular Function in Acutely Dyspneic Patients? Acad Emerg Med. 2011;18(11):1223-6. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com Introduction Methods Results: Discussion Limitations Conclusion Appendix References