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Clinical competence and perceived confidence in certified registered nurse anesthetists: post thromboelastography (TEG) education

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Clinical competence and perceived confidence in certified registered nurse anesthetists: post thromboelastography (TEG) education

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Content Running head: THROMBOELASTOGRAPHY EDUCATION

Clinical Competence and Perceived Confidence in Certified Registered Nurse Anesthetists: Post
Thromboelastography (TEG) Education
by

Jeffrey Hua

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2021

THROMBOELASTOGRAPHY EDUCATION ii
Distribution of Work

The following manuscript was contributed to in equal parts by Marcus Pence, Jeffrey Hua,
and Fidel Garcia.

THROMBOELASTOGRAPHY EDUCATION iii
Dedication
On behalf of Marcus Pence, Jeffrey Hua, and Fidel Garcia, we would like to dedicate this
doctoral capstone on TEG education to the University of Southern California (USC) department
of nurse anesthesia and the Los Angeles County (LAC) + USC Medical Center certified
registered nurse anesthetists (CRNAs).
THROMBOELASTOGRAPHY EDUCATION iv
Acknowledgements
On behalf of Marcus Pence, Jeffrey Hua, and Fidel Garcia, we would like to acknowledge the
following individuals who played a critical role in the success of this doctoral capstone on TEG
education for the LAC+USC CRNAs:
Dr. Regalado Valerio, DNP, CRNA
- Dr. Elizabeth Bamgbose, PhD, CRNA
- Dr. Jeffrey R. Darna, DNP, CRNA, ACNP-BC
- Dr. Michele E. Gold, PhD, CRNA
- Dr. Charles Griffis, PhD, CRNA
- Dr. Amanda Goodrich, PhD
THROMBOELASTOGRAPHY EDUCATION v
Table of Contents
Distribution of Work ....................................................................................................................... ii
Dedication ...................................................................................................................................... iii
Acknowledgements ........................................................................................................................ iv
List of Tables ................................................................................................................................. vi
List of Figures ................................................................................................................................ vi
Abstract .......................................................................................................................................... vi
Chapter 1 ......................................................................................................................................... 1
Introduction ................................................................................................................................. 1
Research Question and Statement of Specific Aims ................................................................... 2
Background and Significance ...................................................................................................... 3

Chapter 2 ......................................................................................................................................... 5
Literature Review ........................................................................................................................ 5

Chapter 3 ....................................................................................................................................... 11
Methods ..................................................................................................................................... 11

Chapter 4 ....................................................................................................................................... 15
Statistical Methods .................................................................................................................... 15
Results ....................................................................................................................................... 15

Chapter 5 ....................................................................................................................................... 17
Discussion ................................................................................................................................. 17
Conclusion ................................................................................................................................. 17
Disclosures ................................................................................................................................ 18

References ..................................................................................................................................... 19
Appendices .................................................................................................................................... 26
Appendix A: Thromboelastography (TEG) Education Handout .............................................. 26
Appendix B: Demographics Survey .......................................................................................... 27
Appendix C: Pre-Test ................................................................................................................ 28
Appendix D: Post-Test .............................................................................................................. 29
THROMBOELASTOGRAPHY EDUCATION vi

List of Tables

Table 1. Participant Characteristics .............................................................................................. 22
Table 2. Answers to knowledge questions for pre- and posttests. ............................................... 23
Table 3. Scores for confidence questions for pre- and posttests. ................................................. 24

THROMBOELASTOGRAPHY EDUCATION vii
List of Figures
Figure 1. Logic Model for Thromboelastography Education ...................................................... 25

THROMBOELASTOGRAPHY EDUCATION viii
Abstract
Originally described in 1948 by Dr. Hellmut Harter, Thromboelastography (TEG)
provides a global assessment of coagulation function, clot formation, and dissolution in real time.
TEG technology performs an assessment of the viscoelastic strength of whole blood, allowing
for the production of a computer-generated tracing and quantitative assessment of clot formation
and breakdown. This study can be performed as a standard laboratory test, or as a point of care
test, with either option enabling the clinician to obtain valuable coagulation information within
15-20 minutes. Unlike standard coagulation tests, TEG is able to provide an assessment of
platelet function, which is critical for the identification of blood coagulation abnormalities and
management of blood coagulopathies. TEG guided blood component therapy has been shown to
reduce the incidence of bleeding, operating room length of stay (LOS), and postoperative LOS in
patients requiring intensive care (Dias, Sauaia, Achneck, Hartmann, & Moore., 2019). However,
despite the vast amount of research supporting TEG use, there is currently limited research
regarding TEG education, training, and clinician confidence. Furthermore, the correct
application and interpretation of TEG requires the individual performing the assessment to be
adequately trained, which is a limitation for institutions that do not have staff trained to utilize
TEG (Solomon, Collis, & Collins, 2012). Therefore, the two aims of this study are to address the
gap in literature on how to best educate CRNAs on the use of TEG, and to identify an
educational tool that could help improve clinician competence and perceived confidence of TEG
interpretation
THROMBOELASTOGRAPHY EDUCATION 1
Chapter 1
Introduction
Research has shown early identification of hemostatic pathology and targeted
management with thromboelastography (TEG) can decrease the number of blood products
transfused and the risk of surgical complications when compared to standard coagulation studies
(Fleming et al., 2017). TEG is a coagulation study providing global assessment of coagulation
function and clot formation. Standard coagulation tests (SCT), such as: partial thromboplastin
time (PTT), prothrombin time (PT), international normalized ratio (INR), and platelet (PLT)
count, provide valuable coagulation information but lack the ability to assess PLT function
(Collins, Macintyre, & Hewer, 2016). Unlike standard coagulation studies, TEG is able to
provide a whole blood coagulation assessment that includes PLT function, which is critical for
the identification of blood coagulation abnormalities (Collins et al., 2016). TEG has also been
found to have a high sensitivity for detecting fibrin formation and breakdown, which aids in the
early identification of perioperative dilutional coagulopathies and is essential for guiding the
blood administration provided by the anesthesia provider (Collins et al., 2016).
TEG guided blood component therapy (BCT) has been shown to decrease the average
number of blood products transfused in the perioperative period by as much as 40% in complex
cardiac surgery (Fleming et al., 2017). In addition, a recent systematic review found that TEG
guided BCT can improve patient outcomes by reducing the incidence of bleeding, operating
room length of stay (LOS), and reducing the LOS in patients requiring postoperative intensive
care (Dias, Sauaia, Achneck, Hartmann, & Moore., 2019). However, correct application and
interpretation of TEG requires the individual performing the assessment to be adequately trained,
THROMBOELASTOGRAPHY EDUCATION 2
which can be a limitation for institutions that do not have staff trained to utilize TEG (Solomon,
Collis, & Collins, 2012).
Research Question and Statement of Specific Aims
There is a large body of evidence supporting the use of TEG for the management and
prevention of blood coagulation disorders. However, despite the extensive amount of research
supporting TEG use, there is currently limited research regarding TEG education, training, and
clinician confidence. According to Morton, Galea, Uprichard, & Hudson (2018), TEG can
provide essential information for the coagulation management of a major trauma, but the lack of
clinician knowledge relating to its interpretation can hinder its use for providing targeted BCT.
In the observational study conducted by Morton et al. (2018), they found that after the
implementation of TEG in a major London trauma center, clinicians did not feel confident with
the interpretation of TEG, despite having received training prior to its use. The study found that
only eight of the 16 participants felt confident in interpreting TEG, and consequently only one
patient had their BCT guided by TEG out of the 16 trauma activations in which TEG was
employed (Morton et al., 2018).
In a study focused on implementation of point of care (POC) TEG in a level one trauma
center with no previous viscoelastic experienced providers, Wahlen, El-Menyar, Peralta, Al-
Thani (2018) showed the benefit of POC-TEG education. In this study, Wahlen et al. reported it
is possible to implement POC-TEG and it is a promising tool in guiding BCT as well as
managing patients with potential blood component coagulopathies. However, the study notes
that education is critical to POC-TEG implementation and that further research is needed on how
to educate providers on POC-TEG.
THROMBOELASTOGRAPHY EDUCATION 3
In order to contribute to the evidence regarding TEG education, the research question for
this project will explore: does TEG education have an impact on clinical competence and
perceived confidence in CRNAs regarding TEG interpretation, application, and clinical
management? Therefore, the two aims of this study are to address the gap in literature on how to
best educate CRNAs on the use of TEG, and to identify an educational tool that could help
improve clinician competence and perceived confidence of TEG interpretation. Clinician
confidence will be defined as an assurance in the care of anesthetized patients in coordination
with TEG utilization and interpretation along with being a potential leader in the area of TEG
education.
Background and Significance
TEG was developed in 1948 by Dr. Hellmut Hartert, initially to be used in clinical
research (Collins et al., 2016). TEG became available in the United States in the 1980s, when
the Haemoscope Corporation (Skokie Illinois, USA) applied the use of TEG in the clinical
setting, which has become the primary form of viscoelastic coagulation monitoring in the United
States (Othman & Kaur, 2017). The TEG coagulation test can be performed under POC and
provides information about viscoelastic changes occurring in the blood. The test involves taking
a small whole blood sample from the patient and activating a clot formation by adding kaolin,
which is a mineral that speeds up the clot formation. A small amount of whole blood is then
dispensed into a stationary cup inside the TEG device, which is then heated to 37 degrees Celsius
(Hellaby, 2012). A pin suspended from a torsion wire is then immersed within the stationary cup
that gently oscillates in a 4.5-degree arc. As clot formation begins to occur, the pin detects the
changes in viscoelastic strength and transmits the information to the torsion wire. The
information is then relayed to an electromechanical transducer that produces a computer-
THROMBOELASTOGRAPHY EDUCATION 4
generated graphical representation of the clotting strength, formation, and breakdown (Hellaby,
2012). The TEG coagulation assessment can take up to 40 minutes to complete; however, the
information about the clotting onset and clot strength can be obtained in five to ten minutes,
which is often the most vital information for the management of coagulopathies (Hellaby, 2012).
TEG primarily measures aspects of the clotting process and PLT function, aiding the
practitioner in distinguishing between surgical bleeding and underlying clotting disorders
(Hellaby, 2012). TEG data allows for the practitioner to guide transfusion therapy towards the
specific point in the coagulation phase, or at any signs of accelerated bleeding, and ultimately
target where the coagulation deficiency is. Once identified, hemostatic products are administered
accordingly (Fleming et al., 2017). Without TEG, transfusion therapy is less precise, empirically
guided, and there is no ability to determine if bleeding is surgical or due to coagulopathy, all of
which may put the patient at risk for unnecessary transfusion (Redfern et al., 2019).

THROMBOELASTOGRAPHY EDUCATION 5
Chapter 2
Literature Review
TEG has become a useful tool for anesthesia management in cardiac and liver surgeries,
trauma, and emergency settings; with improvement seen in several outcomes such as hospital
length of stay (LOS), blood transfusion requirements, and mortality (Dias et al., 2019).
In cardiac surgery, common complications include excessive bleeding, increased use of
allogenic blood products, and coagulopathy. Excessive bleeding has been described in 3 to 10%
of all patients undergoing cardiac surgery, with the most common cause being medical
coagulopathy. Postoperative bleeding and coagulopathy have been associated with increased
morbidity and mortality due to increased transfusion of allogeneic blood products, rate of
surgical re-exploration, thromboembolic events, intubation time, and LOS (Bolliger & Tanaka,
2017). Unfortunately, current SCTs are poor diagnostic tools of acute hemorrhage, such as in
post cardiopulmonary bypass, for several reasons. SCTs are regularly abnormal after cardiac
surgery due to reduced concentrations of prothrombotic coagulation factors but not thrombin
generation, and SCTs commonly have a long turn-around time of 30 to 90 minutes. POC
coagulation testing such as TEG on the other hand is ideal for diagnosing acute hemorrhage, as
TEG provides near simultaneous assessment of thrombocytopenia, coagulopathy, and
fibrinolysis allowing for a reduction in time before appropriate interventions are implemented
(Bolliger & Tanaka, 2017). In a systematic review by Bolliger & Tanaka (2013) there was
evidence of reduced bleeding, surgical re-exploration after cardiac surgery, lowered use of
allogenic blood products including decreased PLT and RBC transfusion, as well as a 40%
decrease in FFP administration. In addition, TEG use is associated with an improvement in
postoperative cardiac surgery LOS, where LOS is reduced by approximately 1.3 days (Redfern et
al., 2019).
THROMBOELASTOGRAPHY EDUCATION 6
In liver surgery, liver transplantation, and chronic liver disease, SCTs are not good
predictors of bleeding risk nor do they provide sufficient information to guide management
during bleeding episodes due to altered coagulopathy of patients in this population (Mallett,
Chowdary, & Burroughs, 2013). The concept of rebalanced hemostasis, where thrombin
generation in patients with liver disease is preserved, is an example where TEG incorporation
would be valuable for identifying and treating specific coagulation deficiencies. SCTs in this
instance would show prolonged PT, PTT, INR, and low PLT counts possibly resulting in
prophylactic allogenic blood transfusion, but viscoelastic tests such as TEG, would show that the
clotting process is maintained and transfusion is unnecessary (Mallett et al., 2013). In a
randomized controlled trial, De Pietri et al. (2016) found that in patients with cirrhosis or severe
coagulopathy, the overall use of blood products decreased by 16.7%, transfusion of FFP alone
decreased by 53.3%, and there was a significantly lower requirement of PLT in the TEG group,
28 units transfused, as compared to the control group which had 106 units transfused. In liver
transplant surgery, there are many difficulties of fluid management due to underlying
coagulopathies of cirrhosis, changing metabolism of coagulant factors in the prehepatic,
anhepatic, and neohepatic phase (Whiting & Dinardo, 2014). When comparing a non-monitored
group against a TEG monitored group in liver transplant surgery, there was a decrease in
erythrocyte and fresh frozen plasma transfusion with an increase in cryoprecipitate and platelet
transfusion indicating a more goal-oriented transfusion strategy (Whiting & Dinardo, 2014).
TEG provides dynamic and comprehensive information on hemostasis and clot formation, as
well as diagnosing hyperfibrinolysis, a common condition seen with cirrhosis, leading to a
significantly lower use of blood products and subsequent decrease in negative blood transfusion
effects such as allergic reactions, increased mortality, and LOS (De Pietri et al., 2016).
THROMBOELASTOGRAPHY EDUCATION 7
In trauma, approximately 25 to 35% of patients present with dysfunctional hemostasis or
coagulopathy, which is associated with increased morbidity and mortality (Karon, 2014). TEG
guided treatment has shown positive results in predicting and diagnosing early trauma induced
coagulopathy, reduced use of allogenic blood products, and improved outcomes (Dias et al.,
2019). Acute trauma coagulopathy is characterized by hyperfibrinolysis and systemic
anticoagulation, which if not recognized early with subsequent treatment may progress to trauma
induced coagulopathy, characterized by ongoing blood loss, hypothermia, and tissue acidosis
from hypoperfusion (Whiting & Dinardo, 2014). In trauma patients, the presence of
hyperfibrinolysis is associated with increased mortality, with recent literature, the CRASH-2
trial, concluding that early treatment with the antifibrinolytic medication tranexamic acid
improves survival in trauma patients (Whiting & Dinardo, 2014). Unfortunately, in the CRASH-
2 trial, patients did not have diagnostic tests for fibrinolysis, and viscoelastic tests such as TEG
are being incorporated into diagnosis and treatment algorithms to assist clinicians in identifying
an accurate patient coagulation profile and subsequent treatment interventions (Whiting &
Dinardo, 2014).
In a randomized controlled trial by Gonzalez et al. (2016) patients meeting criteria for
massive transfusion protocol were randomly assigned to a TEG group or SCT group and a
primary outcome of 28-day survival was measured. The TEG group 28-day survival was
significantly higher than the SCT group as 11 deaths occurred in the TEG group as compared to
20 in the SCT group. Other measures seen in the trial done by Gonzalez et al. (2016) included
hemorrhagic deaths, which occurred in 20% of patients in the SCTs group as compared to 8.9%
of patients in the TEG group. During the initial two hours of resuscitation, both SCT and TEG
groups required similar number of RBC units, but the TEG group required less FFP and PLT
THROMBOELASTOGRAPHY EDUCATION 8
units. There have been implications of platelet and plasma transfusion on the development of
organ dysfunction possibly explaining the more intensive care unit (ICU) and ventilator free days
seen in the TEG group. Overall, TEG guided BCT and TEG guided massive transfusion
protocol result in an improved survival rate at 28 days post injury, less hemorrhagic and early
deaths, and more intensive care unit free and ventilator free days (Gonzalez et al., 2016).
In emergency settings, TEG use demonstrated lowered rates of mortality within the first
six hours from emergency department arrival, and a greater probability of survival at 28 days
(Dias et al., 2019). In a study by Kashuk et al. (2012), TEG was implemented for the
management of patients arriving at the hospital at risk for trauma-induced coagulopathy and
demonstrated that mortality fell from 65% to 29% after TEG algorithm implementation. Similar
to other studies, the TEG group had a significantly lower FFP to RBC transfusion ratio at 3 hours
compared to the pre-TEG group suggesting that TEG is a useful tool for identifying coagulation
defects and guiding therapy to replace blood component deficiencies (Kashuk et al., 2012).
Future research is being done to expand TEG use to other populations such as obstetrics
and patients with hemophilia. In obstetrics, standard laboratory coagulation tests correlate very
poorly with blood loss in postpartum hemorrhage, and TEG could be very useful due to the
common occurrence of hyperfibrinolysis. Unfortunately, TEG testing in obstetrics would require
the 24-hour presence of trained personnel (Whiting & Dinardo, 2014). For patients with
hemophilia, current tests for hemophilia management quantify clotting factors in plasma, but
does not address the overall clot forming ability, which is problematic if inhibitors to clotting
factors are present (Whiting & Dinardo, 2014). The use of TEG for hemophilia patients may be
able to define an individual hemophiliac’s phenotype and provide objective response to treatment
THROMBOELASTOGRAPHY EDUCATION 9
rather than subjective data such as joint mobility or pain, which is the current standard of care
(Whiting & Dinardo, 2014).
Although TEG has many demonstrated potential benefits, it is not currently a standard of
care across many health care settings. One potential limitation is TEG use requires advanced
training and interpretation, which is not offered as part of the standard training curriculum.
According to Othman & Kaur (2017), TEG has received sufficient validity and has been shown
to be superior to SCTs, but standardization and training for TEG is a growing field. For proper
TEG interpretation, the clinician should understand TEG technique, tracing, and components,
along with terminology (Othman & Kaur, 2017). Current practice implications regarding TEG
include developing strategies to assist the CRNA in proper performance of a TEG test,
interpretation, clinical application, or development of therapeutic goals and transfusion
guidelines (Brazzel, 2013).
Initial TEG education includes TEG tracing (Appendix A), hemostasis phase, and
corresponding TEG parameters (Othman & Kaur, 2017). Critical TEG parameters, as depicted in
parentheses, and hemostasis phases are: reaction time (R), kinetic or clot formation time (K), rate
of clot strengthening (ɑ-angle), maximum strength of the developed clot or maximum amplitude
(MA), and percent lysis of clot at 30 minutes after MA (LY30) (Mallett et al., 2013). Clinician
confidence and understanding of TEG interpretation is imperative for advanced clinical
management and TEG guided transfusion therapy in patients with altered coagulopathy or
perioperative bleeding events (Collins et al, 2016).
Values provided by a TEG tracing can help guide the clinician in achieving early
identification of hematological pathologies that help guide blood transfusion therapy. There are
five values in particular clinicians use to guide their blood component therapy; these values are:
THROMBOELASTOGRAPHY EDUCATION 10
R-time, K-time, ɑ-angle, MA, LY30 (Walsh et al., 2016). The R time provides enzymatic
information regarding the clotting factors in the intrinsic and extrinsic pathway, similar to
conventional lab tests PT and PTT, which measures the reaction time to clot formation. A
prolonged R time greater than 7 minutes, can be interpreted as a deficiency in clotting factors,
thus indicating a need for fresh frozen plasma (Walsh et al., 2016). K-time along with ɑ-angle
measures the kinetics of clot formation, primarily fibrinogen activity, and to a lesser extent
platelet number, by determining the rate of clot formation. A low ɑ-angle, less than 45 degrees,
can alert the clinician of a low fibrinogen activity, thus indicating the need for cryoprecipitate
which contains fibrinogen (Walsh et al., 2016). MA provides information about the clot strength
by assessing the fibrin cross linking activity, measuring PLT number and function. A narrow
MA, <48 mm, is representative of a reduction in PLT cross linking, thus indicating a need for
PLT transfusion, desmopressin, or cryoprecipitate (Walsh et al., 2016). Lastly, LY30 provides
the percentage of clot lysis 30 minutes after MA has been achieved. An increase in LY30,
greater than 7.5%, is representative of fibrinolysis, thus alerting the clinician for the need to
administer an anti-fibrinolytic agent, such as tranexamic acid (Walsh et al., 2016).
Overall, TEG provides highly valuable and rapid coagulation information to assist the
clinician in properly determining diagnosis and treatment in a wide variety of patient populations
including emergency, trauma, cardiac surgery, and liver surgeries (Whiting & Dinardo, 2014).

THROMBOELASTOGRAPHY EDUCATION 11
Chapter 3
Methods
A literature search of reputable databases including PubMed, CINAHL, Google Scholar,
and Embase was performed to address the research question. Key search terms included:
“thromboelastography,” “TEG,” “surgery,” “coagulation testing,” “POC,” “acquired
coagulopathy,” “blood component therapy,” “systemic hemostatic agents,” “hemostatic
resuscitation,” “targeted pharmacologic therapy,” and “education.” The above key search terms
were also used to conduct a Medical Subject Headings (MeSH) search in these databases. The
inclusion criteria for literature review was material from peer-reviewed sources, published less
than 15 years prior, and incorporated all providers who use TEG in the clinical setting. Our
inclusion criteria carried a broad scope due to the focus upon education in the proposed study.
Articles reviewed included systematic analyses, literature reviews, randomized controlled trials,
retrospective studies, protocols, and teaching guides. Exclusion criteria for literature review
included non-reputable, non-peer reviewed sources. Literature included in the creation of
education was expanded beyond the criteria mentioned for literature review, as journal articles
were selected for information regarding TEG interpretation, clinical application, transfusion
management, and education, as well as gaps in knowledge. The purpose of expanding search
terms for one area of investigation was to allow researchers to build a foundation in the creation
of an evidence based educational in-service for practicing CRNAs.
The research team developed a logic model flow chart to guide the study execution,
which included inputs, outputs, assumptions, possible external factors, and outcomes (Figure 1).
Prior to implementation of the educational intervention, confirmation of non-human subject’s
research was obtained from USC’s institutional review board via iStar (IIR00002856). The
sample and targeted population for this study consisted of a convenience sample of CRNAs at
THROMBOELASTOGRAPHY EDUCATION 12
Los Angeles County (LAC) + University of Southern California (USC) Medical Center.
Inclusion and exclusion criteria were developed for the study population. The inclusion criteria
included any licensed practicing CRNA, while our exclusion criteria eliminated any health care
provider other than CRNA.
The research team provided an in-person pre and post-intervention survey (Appendix B,
C, D) assessing CRNA clinical competence of TEG and perceived confidence of TEG
application, interpretation, and clinical management. The research team presented an
educational intervention that was completed in the following sequence: pre-intervention survey,
educational intervention, and post-intervention survey utilizing REDCap software. The
educational program was led by members of the research group with the goal to improve CRNA
perceived confidence in TEG. The research team then compared the pre and post-intervention
surveys analyzing data regarding clinical competence and perceived confidence of TEG use.
The educational intervention followed a repeated measure design with all testing of
participant knowledge obtained via Research Electronic Data Capture (REDCap) protecting
participant identity and responses. CRNAs first completed the demographics portion of the
survey (Appendix B) followed immediately by the pretest (Appendix C). All information was
securely collected and stored electronically on REDCap via a private link provided by the
principal investigators and biostatistician. The REDCap link was accessed by a private
electronic device provided by the participants.
The pretest consisted of four multiple choice questions assessing the CRNA’s baseline
knowledge of specific TEG variables crucial to TEG interpretation. The variables that were
tested in these four questions were R time, alpha angle, K time, maximum amplitude (MA), and
lysis time 30 minutes (LY30). A fifth question (using a Likert scale) was included in the pretest
THROMBOELASTOGRAPHY EDUCATION 13
asking the CRNA to rate his or her confidence in implementing, applying and managing TEG in
the clinical setting from one (least confident) to ten (most confident).
The educational intervention consisted of a visual presentation adapted by the authors to
meet the needs of the sample audience, CRNAs, and presented the platform via PowerPoint
(PPT). The PPT presentation consisted of a brief introduction of TEG including advantages of
TEG testing to assess whole blood coagulation, platelet interaction, platelet function, and clot
breakdown. Next, a regular TEG tracing and corresponding values were introduced. The
definition of R time, K time, alpha angle, MA, and LY 30 were provided and located in the
corresponding region on the TEG tracing. Following the explanation of TEG values, a 94
second video demonstrating a TEG tracing being produced at an accelerated rate was shown
(KDMC Clinical Lab, 2019).
Following the video, a TEG tracing with corresponding TEG values (R time, K time,
alpha angle, MA, and LY30) were inserted over the corresponding areas of the tracing in a single
image (Whiting & Dinardo, 2014). Next examples of abnormal TEG tracings and potential
corresponding pathophysiology were provided (Whiting & Dinardo, 2014). The final portion of
the educational intervention consisted of presenting each CRNA participant with a physical copy
of the author compiled TEG Educational Handout.
The TEG Educational Handout consisted of three elements. First, a normalized TEG
tracing with TEG variables displayed over the corresponding area of the tracing was shown.
Second, seven TEG tracings that depict common coagulopathies accessible by TEG. Third, a
table compiled by the principal investigators listing TEG variables, the normal parameter of
those variables, and what part or component of the coagulation or fibrinolysis process they
measure.
THROMBOELASTOGRAPHY EDUCATION 14
The CRNA participants, with access to the TEG Educational Handout, then completed
the posttest (Appendix D). The posttest was a replication of the pretest with the addition of a
single question rating his or her confidence (using a Likert scale) in TEG implementation if
provided the TEG Education Handout.
There was one subject that did not complete the post-test, so that subject was removed
from analyses. The subjects were predominately male (61.5%) and under 40 years old (69.2%)
(Table 1). Most subjects were Caucasian (46.2%) followed by Asian (23.1%). All subjects
reported either having no prior clinical experience with TEG or they were not sure.

THROMBOELASTOGRAPHY EDUCATION 15
Chapter 4
Statistical Methods
Statistical analysis was performed by a biostatistician using the Stata software, version
15.1 (Stata Corp., College Station, Texas). Each of the four knowledge questions were given one
point if they were correct and zero points if they were incorrect or the subject indicated "not
sure". One-sided Exact McNemars tests were used to compare pre- and posttests for each
question. A total score was calculated for each person by adding the number of correct scores for
each question. A one-sided Wilcoxon Signed Rank test was used to test the difference in total
score between pre- and posttests. For the question asking about confidence, a One-sided
Wilcoxon Signed Rank test was used to compare confidence scores between pre- and posttests.
P-values less than 0.0-5 were considered statistically significant.
Results
There was a statistically significant improvement in test score between the pre- and
posttests for all of the four knowledge questions: "What does R-time identify?", "What two
variables best measure fibrinogen?", " What variable measures the percent of clot breakdown
after maximum clot formation has been achieved?", and " What can low maximum amplitude
(MA) value signify?" (p = 0.008, 0.001, 0.004, and 0.031 respectively) (Table 2).
Prior to implementation of the educational intervention only 39% of subjects were able to
correctly define R-time, with 50% answering "Not Sure", whereas, after the intervention, 92% of
subjects were able to correctly define R-time. Only 15% of subjects were able to identify the two
variables that best measure fibrinogen prior to the intervention, with 50% answering "Not Sure",
whereas, 92% of subjects answered this correctly after the intervention. Prior to the intervention,
23% of subjects correctly answered LY30 when asked which variable measures the percent of
THROMBOELASTOGRAPHY EDUCATION 16
clot breakdown after maximum clot formation has been achieved, with 46% answering "Not
Sure", whereas, after the intervention, 85% of subjects were able to correctly. Lastly, 39% of
subjects correctly identified what low maximum amplitude (MA) value can signify prior to the
intervention and this number increased to 77% after the intervention.
There was also a statistically significant improvement in the total scores of all four
questions between the pre- and posttests (p = 0.001) (Table 2). The median total score for the
four knowledge questions combined prior to the intervention was 1 (IQR: 1-3), whereas after the
intervention, the median total correct was 4 (IQR: 3-4).
Confidence in the ability to implement, apply, and manage TEG in a clinical setting also
statistically significantly improved (p = 0.001). On a scale of 1 – 10, where 1 equals not
confident and 10 equals very confident, the median score went from 1 (IQR: 1-2) prior to the
intervention to 7 (IQR: 5-9) after the intervention (Table 3). After the intervention, subjects were
asked to score, on a scale of 1 – 10, their confidence in implementing, applying, and managing
TEG in the clinical setting if provided a visual aid/interpretation guideline, where 1 equals not
confident and 10 equals very confident. The median score for this was a 10 (IQR: 6-10)

THROMBOELASTOGRAPHY EDUCATION 17
Chapter 5
Discussion
This study revealed that a TEG specific education intervention was effective and CRNA
participants showed statistically significant improvement in both knowledge and confidence
questions. Strengths of the study include being a novel study regarding TEG education in the
CRNA population along with creation of a TEG cognitive aid that can improve CRNA
confidence with TEG interpretation. An additional strength to this study is the high completion
rate and low attrition rate (92.8%) for the intervention, with 13 out of 14 CRNAs at LAC
completing pre and posttests. Limitations of the study include relatively small sample size,
convenience sampling (single center study), and use of a non-validated education tool. For data
collection, the study participants completed a pre and posttest survey that the authors of the study
created which had not been previously validated, because to our knowledge, there are no
validated TEG education tests or cognitive aids available.
Further studies should focus on expanding the sample size of CRNA participants and
reassessing the validity of the TEG educational handout. Repeated educational sessions with the
TEG education handout outside of this study will improve the validity of our results. Future
studies can also include other disciplines of the health care team other than CRNAs to further
determine generalizability including but not limited to student registered nurse anesthesiologists.
Conclusion
TEG plays a valuable role with application in many clinical fields, particularly in the
management of coagulopathy or acquired coagulopathy disorders, massive hemorrhage, cardiac
or liver surgery, and surgical or trauma patients (Othman & Kaur, 2017). The advantage of TEG
to monitor the entire clotting process at the bedside, providing the CRNA with valuable
THROMBOELASTOGRAPHY EDUCATION 18
treatment information will further expand the clinical use of TEG throughout the healthcare
environment. However, introducing TEG, a new technical piece of equipment, to CRNAs who
already manage a crowded ecosystem of machines, devices, and tests is challenging and will
dramatically affect the efficacy of TEG. A significant criticism of TEG use is having untrained
or inexperienced providers operating the machine, which often leads to inconsistent results
interpretation (Walsh et al., 2016). This study accepts the strong evidence for the use of TEG in
producing better patient outcomes but acknowledges that CRNAs must have confidence in their
ability to interpret, apply, and manage the findings that TEG provides. Studying how CRNAs
can gain confidence in their ability to utilize TEG may ultimately lead to further use of TEG in
hospitals throughout the country by removing barriers to its use and encouraging anesthesia
providers to utilize it in their patient care. Future research should focus on gaps in literature such
as effective TEG education for CRNAs and creating a validated education tool. This study aims
to better prepare CRNAs for the use of TEG in the clinical setting by improving provider
confidence through education and use of TEG interpretation guidelines and visual aids.
Disclosures
The authors of this study have no conflicts of interest to disclose, no relationship with
TEG manufacturers, nor do we have any financial interest in corporations that produce TEG
equipment.

THROMBOELASTOGRAPHY EDUCATION 19
References
Bolliger, D., & Tanaka, K. A. (2013). Roles of thromboelastography and thromboelastometry for
patient blood management in cardiac surgery. Transfusion Medicine Reviews, 27(4),
213–220. https://doi.org/10.1016/j.tmrv.2013.08.004
Bolliger, D., & Tanaka, K. A. (2017). Point-of-Care Coagulation Testing in Cardiac Surgery.
Seminars in Thrombosis and Hemostasis, 43(4), 386–396.
https://doi.org/10.1055/s-0037-1599153
Brazzel, C. (2013). Thromboelastography-guided transfusion therapy in the trauma patient.
AANA Journal, 81(2), 127–132.
Collins, S., Macintyre, C., & Hewer, I. (2016). Thromboelastography: Clinical Application,
Interpretation, and Transfusion Management. AANA Journal, 84(2), 129–135.
De Pietri, L., Bianchini, M., Montalti, R., De Maria, N., Di Maira, T., Begliomini, B., … Villa,
E. (2016). Thromboelastography-guided blood product use before invasive procedures in
cirrhosis with severe coagulopathy: A randomized, controlled trial. Hepatology, 63(2),
566–573. https://doi.org/10.1002/hep.28148
Dias, J. D., Sauaia, A., Achneck, H. E., Hartmann, J., & Moore, E. E. (2019).
Thromboelastography‐guided therapy improves patient blood management and certain
clinical outcomes in elective cardiac and liver surgery and emergency resuscitation: a
systematic review and analysis. Journal of Thrombosis and Haemostasis.
https://doi.org/10.1111/jth.14447
Fleming, K., Redfern, R.E., March, R.L., Bobulski, N., Kuehne, M., Chen, J.T., Moront, M.
(2017). TEG-Directed Transfusion in Complex Cardiac Surgery: Impact on Blood
Product Usage. The Journal of Extra-Corporeal Technology, 49(4), 283-290.
Gonzalez, E., Moore, E. E., Moore, H. B., Chapman, M. P., Chin, T. L., Ghasabyan, A., …
THROMBOELASTOGRAPHY EDUCATION 20
Sauaia, A. (2015). Goal-directed Hemostatic Resuscitation of Trauma-induced
Coagulopathy. Annals of Surgery, 263(6), 1051–1059.
https://doi.org/10.1097/sla.0000000000001608
Hellaby, M. (2012). Thromboelastography: a point-of-care test of coagulation efficiency.
Technic: The Journal of Operating Department Practice, 3(2), 14–16.
Karon, B. S. (2014). Why is everyone so excited about thromboelastography (TEG)? Clinica
Chimica Acta, 436, 143–148. https://doi.org/10.1016/j.cca.2014.05.013
Kashuk, J. L., Moore, E. E., Wohlauer, M., Johnson, J. L., Pezold, M., Lawrence, J., … Sauaia,
A. (2012). Initial experiences with point-of-care rapid thromboelastography for
management of life-threatening postinjury coagulopathy. Transfusion, 52(1), 23–33.
https://doi.org/10.1111/j.1537-2995.2011.03264.x
Kane, L. C., Woodward, C. S., Husain, S. A., & Frei-Jones, M. J. (2015). Thromboelastography -
Does it impact blood component transfusion in pediatric heart surgery? Journal of
Surgical Research, 200(1), 21–27. https://doi.org/10.1016/j.jss.2015.07.011
KDMC Clinical Lab. (November 6, 2019) TEG tracing animation [video file]. retrieved from
https://www.youtube.com/watch?v=gJwU7g0mn8M&feature=emb_logo
Mallett, S. V, Chowdary, P., & Burroughs, A. K. (2013). Clinical utility of viscoelastic tests of
coagulation in patients with liver disease. Liver International: Official Journal of the
International Association for the Study of the Liver, 33(7), 961–974.
https://doi.org/10.1111/liv.12158
Morton, S., Galea, J., Uprichard, J., & Hudson, A. (2018). The practicalities and barriers of using
TEG6s in code red traumas: an observational study in one London major trauma centre.
Canadian Journal of Emergency Medicine, 0(0), 1–4.
https://doi.org/10.1017/cem.2018.426
THROMBOELASTOGRAPHY EDUCATION 21
Othman, M., & Kaur, H. (2017). Thromboelastography (TEG). In E. J. Favaloro & G. Lippi
(Eds.), Hemostasis and Thrombosis: Methods and Protocols (pp. 533–543). New York,
NY: Springer New York. https://doi.org/10.1007/978-1-4939-7196-1_39
Redfern, R. E., Fleming, K., March, R. L., Bobulski, N., Kuehne, M., Chen, J. T., & Moront, M.
(2019). Thrombelastography-Directed Transfusion in Cardiac Surgery: Impact on
Postoperative Outcomes. The Annals of Thoracic Surgery.
https://doi.org/10.1016/j.athoracsur.2019.01.018
Sankarankutty, A., Nascimento, B., da Luz, L. T., & Rizoli, S. (2012). TEG® and ROTEM® in
trauma: Similar test but different results? World Journal of Emergency Surgery, 7(Suppl
1), S3. https://doi.org/10.1186/1749-7922-7-S1-S3
Solomon, C., Collis, R., & Collins, P. (2012). Haemostatic monitoring during postpartum
haemorrhage and implications for management. British Journal of Anaesthesia,109(6),
851-863. doi:10.1093/bja/aes361
Wahlen, B. M., El-Menyar, A., Peralta, R., & Al-Thani, H. (2018). World Academic Council of
Emergency Medicine Experience Document: Implementation of Point-of-Care
Thromboelastography at an Academic Emergency and Trauma Center. Journal of
Emergencies, Trauma and Shock. Mumbai: Medknow Publications.
https://doi.org/10.4103/JETS.JETS_134_17
Walsh, M., Fritz, S., Hake, D., Son, M., Greve, S., Jbara, M., Castellino, F. J. (2016). Targeted
Thromboelastographic (TEG) Blood Component and Pharmacologic Hemostatic Therapy
in Traumatic and Acquired Coagulopathy. Current Drug Targets,17(8), 954-970.
Whiting, D., & DiNardo, J. A. (2014). TEG and ROTEM: Technology and clinical applications.
American Journal of Hematology, 89(2), 228–232. https://doi.org/10.1002/ajh.23599
THROMBOELASTOGRAPHY EDUCATION 22

Table 1. Participant Characteristics
Characteristic
All
(N=14)
Complete
(N=13)
Gender, N (%)
Female 4 (28.6) 4 (30.8)
Male 9 (64.3) 8 (61.5)
Prefer not to answer 1 (7.1) 1 (7.7)
Age group, N (%)
25-39 10 (71.4) 9 (69.2)
40 to 59 2 (14.3) 2 (15.4)
60 + 2 (14.3) 2 (15.4)
Race or Ethnicity, N (%)
Caucasian 6 (42.9) 6 (46.2)
Hispanic/Latino 2 (14.3) 1 (7.7)
Asian/Asian American 3 (21.4) 3 (23.1)
Other 2 (14.3) 2 (15.4)
Prefer not to answer 1 (7.1) 1 (7.7)
Years of experience as a CRNA, N (%)
0-2 years 6 (42.9) 6 (46.2)
3-4 years 4 (28.6) 3 (23.1)
5-9 years 1 (7.1) 1 (7.7)
10 years + 3 (21.4) 3 (23.1)
Prior clinical experience with TEG?, N
(%)

No
12 (85.7) 11 (84.6)
Not sure
2 (14.3) 2 (15.4)

THROMBOELASTOGRAPHY EDUCATION 23

Table 2. Answers to knowledge questions for pre- and posttests.
Pretest
only
Completed both tests
Test questions
Pretest Posttest p-value
What does R-time identify?, N (%)

Onset of clot formation (correct)
6 (42.9) 5 (38.5) 12 (92.3) 0.008
Onset of fibrinolysis
1 (7.1) 1 (7.7) 0 (0.0)
Not sure
7 (50.0) 7 (53.8) 1 (7.7)
What two variables best measure
fibrinogen?, N (%)

Maximum amplitude and LY30 2 (14.3) 2 (15.4) 0 (0.0)
R time and K time 3 (21.4) 2 (15.4) 0 (0.0)
Alpha angle and K time (correct) 2 (14.3) 2 (15.4) 12 (92.3) 0.001
Not sure 7 (50.0) 7 (53.8) 1 (7.7)
What variable measures the percent of clot
breakdown after maximum clot formation
has been achieved?, N (%)

Maximum amplitude (MA)
4 (28.6) 3 (23.1) 1 (7.7)
LY30 (correct)
3 (21.4) 3 (23.1) 11 (84.6) 0.004
R time
1 (7.1) 1 (7.7) 0 (0.0)
Not sure
6 (42.9) 6 (46.2) 1 (7.7)
What can low maximum amplitude (MA)
value signify?, N (%)

Hypercoagulability 3 (21.4) 2 (15.4) 2 (15.4)
Decreased platelet function, or number
(correct)
5 (35.7) 5 (38.5) 10 (76.9) 0.031
Fibrinolysis
1 (7.1) 1 (7.7) 0 (0.0)
Not sure
5 (35.7) 5 (38.5) 1 (7.7)
Total Correct out of 4, Med (IQR)
1 (0 -
2)
1 (0 - 2) 4 (3 - 4) 0.001

THROMBOELASTOGRAPHY EDUCATION 24
Table 3. Scores for confidence questions for pre- and posttests.

Pretes
t only
Complete
Confidence questions
Pretest Posttest
p-
value
On a scale of 1-10, how confident do you feel in
implementing, applying, and managing TEG in the
clinical setting? (1 = not confident and 10 = very
confident), Med (IQR)
1 (1,
2)
1 (1, 2) 7 (5, 9) 0.001
1, N (%)
9
(64.3)
8 (61.5) 1 (7.7)
0.008
2
2
(14.3)
2 (15.4) 0 (0.0)
3 0 (0.0) 0 (0.0) 1 (7.7)
4 0 (0.0) 0 (0.0) 1 (7.7)
5 0 (0.0) 0 (0.0) 1 (7.7)
6 0 (0.0) 0 (0.0) 1 (7.7)
7 0 (0.0) 0 (0.0) 2 (15.4)
8 1 (7.1) 1 (7.7) 2 (15.4)
9 0 (0.0) 0 (0.0) 1 (7.7)
10
2
(14.3)
2 (15.4) 3 (23.1)
On a scale of 1-10, how confident do you feel in
implementing, applying, and managing TEG in the
clinical setting if provided a visual aid/interpretation
guideline? (1 = not confident and 10 = very
confident), Med (IQR)
10 (6, 10) N/A
1, N (%) - - 1 (7.7)
2 0 (0.0)
3 - - 1 (7.7)
4 - - 1 (7.7)
5 0 (0.0)
6 - - 1 (7.7)
7 0 (0.0)
8 0 (0.0)
9 - - 2 (15.4)
10 - - 7 (53.8)
THROMBOELASTOGRAPHY EDUCATION 25

Figure 1. Logic Model for Thromboelastography Education

THROMBOELASTOGRAPHY EDUCATION 26
Appendices
Appendix A: Thromboelastography (TEG) Education Handout
THROMBOELASTOGRAPHY EDUCATION 27
Appendix B: Demographics Survey

THROMBOELASTOGRAPHY EDUCATION 28
Appendix C: Pre-Test
THROMBOELASTOGRAPHY EDUCATION 29
Appendix D: Post-Test

Abstract (if available)

Abstract Originally described in 1948 by Dr. Hellmut Harter, Thromboelastography (TEG) provides a global assessment of coagulation function, clot formation, and dissolution in real time. TEG technology performs an assessment of the viscoelastic strength of whole blood, allowing for the production of a computer‐generated tracing and quantitative assessment of clot formation and breakdown. This study can be performed as a standard laboratory test, or as a point of care test, with either option enabling the clinician to obtain valuable coagulation information within 15-20 minutes. Unlike standard coagulation tests, TEG is able to provide an assessment of platelet function, which is critical for the identification of blood coagulation abnormalities and management of blood coagulopathies. TEG guided blood component therapy has been shown to reduce the incidence of bleeding, operating room length of stay (LOS), and postoperative LOS in patients requiring intensive care (Dias, Sauaia, Achneck, Hartmann, & Moore, 2019). However, despite the vast amount of research supporting TEG use, there is currently limited research regarding TEG education, training, and clinician confidence. Furthermore, the correct application and interpretation of TEG requires the individual performing the assessment to be adequately trained, which is a limitation for institutions that do not have staff trained to utilize TEG (Solomon, Collis, & Collins, 2012). Therefore, the two aims of this study are to address the gap in literature on how to best educate CRNAs on the use of TEG, and to identify an educational tool that could help improve clinician competence and perceived confidence of TEG interpretation.

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Asset Metadata

Creator Hua, Jeffrey (author)

Core Title Clinical competence and perceived confidence in certified registered nurse anesthetists: post thromboelastography (TEG) education

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Publication Date 05/30/2020

Defense Date 05/29/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag anesthesia,coagulation,CRNA,OAI-PMH Harvest,TEG,thromboelastography

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Valerio, Regalado (committee chair), Bamgbose, Elizabeth (committee member), Darna, Jeffrey (committee member)

Creator Email jeffreth@usc.edu,jhua1029@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-314845

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