# Low Frequency, High Complexity: Assessing Skill Decay in Transesophageal Echocardiography Post-Simulation Training

## TL;DR

This study shows that skills in resuscitative transesophageal echocardiography decay over time but can be partially restored with spaced repetition.

## Contribution

The study quantifies skill decay in rTEE after simulation training and evaluates the effectiveness of spaced repetition.

## Key findings

- Skill decay was 41% after six months without practice.
- Spaced repetition reduced decay to 19% within a month.
- Hands-on image acquisition skills decayed less than name recall and probe manipulation.

## Abstract

Resuscitative transesophageal echo (rTEE) is a promising adjunct to cardiac arrest resuscitation. However, it is a high-acuity diagnostic tool that is rarely used in this setting and its safety establishment is limited because of low occurrence. High-acuity, low occurrence skills such as rTEE during cardiac arrest inevitably decay. In this study we examined the content and percentage of rTEE skill decay following simulation-based education (SBE).

Resuscitative TEE-naïve emergency physicians (EP) were trained using a combination of clinical exposure, web-based didactics, and monthly hands-on sessions with a high-fidelity rTEE simulator for four months. The COVID-19 pandemic created a natural wash-out phase where EPs did not perform any actual or SBE for six months after initial training. Unadvertised assessment of rTEE skill occurred at month 6 after rTEE training to test skill decay and at month 7 to determine the effect of spaced repetition. One year later, the EPs completed a questionnaire assessing rTEE comfort. Statistical measures were used to measure skill decay.

Seven EPs were individually evaluated in four domains: name recall; probe manipulation (rotation); probe manipulation (omniplane); and image acquisition adequacy. At the end of training, all participants reached a full proficiency score of 32. At month 6, the mean score was 19 of 32 (SD ±7), reflecting a 41% decay (95% confidence interval (CI) −54%, −27%; P < .001) for eight standard rTEE views. Following spaced repetition at month 7, the median score improved to 26 (IQR 23–30), representing a 19% decay (95% CI −35%, −4%; P < .02). For the three guideline-recommended views, the overall decay percentage was 26% (95% CI −36%, −16%; P < .001), although image acquisition skills did not show significant decay. Spaced repetition resulted in a 23% increase in mean scores (95% CI 9–37%), and the average time to obtain all eight rTEE views decreased from 7.3 minutes at month 6 to 5.7 minutes at month 7.

After focused, proficiency-based SBE in rTEE, hands-on image acquisition skills showed the least decay compared to name recall and probe manipulation. Spaced repetition mitigated decay over one month, although not back to baseline.