Gastroesophageal Balloon Tamponade Simulation-Based Mastery Learning Curriculum for Critical Care Fellows.

Abstract

Gastroesophageal balloon tamponade (GEBT) tube placement is a life-saving measure used as a bridge to definitive therapy in patients with variceal hemorrhage refractory to medical and endoscopic therapy. As a high-acuity low-occurrence (HALO) procedure, proficiency may not be achieved through clinical experience alone. Can a simulation-based mastery learning (SBML) curriculum improve competence with GEBT among pulmonary and critical care medicine (PCCM) fellows? Needs assessments were completed locally by University of Colorado PCCM fellows and nationally by PCCM and critical care medicine program directors to guide curriculum development, which resulted in a procedural training video, a large-group didactic session, and a small-group deliberate practice skills session using 3-dimensional printed gastroesophageal models. A simulation assessment checklist was developed using a Delphi process, and a minimum passing standard (MPS) was derived using the modified Angoff method. PCCM fellows participated in the curriculum, and a pretest-posttest design was used to evaluate the curricular impact on participant confidence, knowledge, and procedural skill. A subgroup of participants was reassessed at varying intervals to explore skill deterioration with time. A 23-item simulation assessment checklist with an MPS of 16 of 23 items correct was developed. Twenty-six PCCM fellows participated in the curriculum with significant improvement in confidence comparing performance before vs after curriculum intervention using a 5-point Likert scale ranging from 1 (not at all confident) to 5 (completely confident; median score, 4 vs 1; P < .01). Fellows demonstrated significant improvement in knowledge (82% vs 44% items correct; P < .01) on a 16-item questionnaire and on simulation assessment (20.4 vs 8.6 correct steps; P < .01). All participants achieved the MPS on posttesting. Follow-up assessments demonstrated skill deterioration: > 50% of participants no longer achieved the MPS at 6 months. This SBML curriculum was shown to improve learner confidence, knowledge, and procedural competence with GEBT and provides a curricular model for other HALO procedures. Skill deterioration was demonstrated after completing the curriculum, and methods to slow deterioration and reinforce proficiency warrant further investigation.