In this special guest blog post, Dr Adrian Wong discusses the challenges surrounding the introduction and implementation of a new technology in healthcare, bedside ultrasonography.
The application of ultrasound beyond the realms of the Radiology department is well and truly established. Ultrasound has evolved into an indispensable tool in the physicians’ armament – providing diagnostic, monitoring and procedural guidance within a neat package. Acute physicians, ED doctors, anaesthetists and critical care physicians have all embraced ultrasound as an essential part of their role.
The key to utilizing ultrasound successfully, in the hands of such a diverse group of specialties, lies in asking the right questions. Hence the development of focused examinations. Focused echocardiography is probably the best example of the use of ultrasound, permitting non-cardiologists to answer questions immediately relevant to their area of practice. The ability to confidently rule out (or in) pericardial tamponade in cardiac arrest or pneumothorax in trauma is pivotal in patient management. A word of caution though, as POCUS examinations are usually performed in a time-sensitive environment, getting it wrong can have significant repercussions. Urban legends such as a patient being thrombolysed because the LV was mistaken for the RV or a ‘leaking AAA’ taken straight to theatre only to reveal a normal caliber aorta are whispered in corridors as a reminder to the budding POCUSologist.
The proven clinical benefits of point-of-care ultrasonography has led to ongoing expansion of its role into uncharted areas. Whilst obviously exciting, this raises the issue of training and competency (to perform, interpret and act upon results). How best to become competent in ultrasonography makes for interesting and sometimes divisive conversation.
Reflecting on personal experience, my interest in POCUS coincided with the launch of CUSIC (Core Ultrasound Skills in Intensive Care), the UK’s own POCUS programme. A handful of centres in the UK offered fellowships with qualified trainers and suitable training opportunities. Apart from the guidance of experienced colleagues, my training was supplemented with online FOAMed resources. Videos recorded and shared (available free of charge) by esteemed teams of individuals such as @5minsono and @ultrasoundpod were instrumental in my professional development. Since then, the number of courses and fellowships available have continued to expand. I now help run our department’s POCUS fellowship and hence the issue of training is never far from my mind.
When one considers all the possible modules under the umbrella term of point-of-care ultrasound (POCUS) e.g. echocardiography, abdominal, etc. the concept of training and competency becomes even more nebulous. There are numerous POCUS accreditation programmes available from a variety of bodies. The ACCP, ESICM and ICS (UK) have developed their own programmes, all of which contain some overlapping similarities. As adult learners have different styles of learning, there is no single best way to learn the skill of POCUS.
As an example, the BSE (British Society of Echocardiography) accreditation for critical care requires a theoretical and practical examination with a logbook of 250 appropriate cases. In contrast, FICE (Focused Intensive Care Echocardiography) accreditation requires attendance at a course, a logbook of 50 cases and a triggered assessment. These two accreditations obviously differ in their resulting skillsets and breadth of clinical scanning experience, but this highlights the variation in training requirements for the module of echocardiography in critical care. Furthermore, BSE requires a regular logbook of cases to maintain accreditation, whereas no formal processes are currently in place to maintain FICE accreditation. In practice, any clinician with BSE or FICE accreditation is able to perform day-to-day echocardiography in an intensive care setting (although awareness of one’s own limitations is crucial in more complex cases).
Generally speaking, all the accreditation programmes are divided into theoretical knowledge and practical skills.
The theoretical component is generally comprised of basic physics, anatomy and a description of textbook views and pathology. A diagnostic algorithm is also introduced. This component can be delivered online or in person at courses. Each has its advantages and drawbacks.
Arguably the more important component of training is the practical aspect. This is where a face-to-face course/apprenticeship provides a useful starting point. Having an expert guide you through the scan – how to position the patient, adjust probe orientation etc is invaluable.
After the course, the accreditation systems available diverge. The UK’s POCUS accreditation (CUSIC) requires a specified number of scans in the presence of a mentor. It is the expectation of this programme that the supervised scans are performed until a minimum number has been achieved, thereafter triggering an assessment phase. Such an apprenticeship model is labour-intensive compared to other programmes which perhaps requires the uploading of scans onto an online logbook for review.
A recent survey of ESICM members showed that the main barrier to attaining POCUS training is the lack of trainers (personal communication). If there are insufficient trainers, the rollout of training and assessment will be limited / delayed. As mentioned above, an online platform (with minimal face-to-face interaction) is certainly one way of tackling the problem of a limited trainer base. But does this approach cheat the learner of the invaluable mentorship process? How do we ensure that the end product is a confident and competent physician which will ultimately benefit patients?
There is a need to improve access to trainers and this inevitably means increasing their numbers. In the UK, the number of ‘training the trainers’ courses has increased but is still rather limited and does not match demand. There is a danger of rushing these trainers through the process without the necessary checks in place. This benefits no one, least of all the patients.
Having completed the accreditation process, like the rest of medicine, the learning process does not stop. Without a universally agreed method of maintaining accreditation across various POCUS programmes, there is naturally concern that once accreditation is gained, physicians fail to maintain their skillset for example due to a lack of time or inadequate exposure to clinical variety.
Accepting that publication bias exists, the literature is full of manuscripts which demonstrate that learning the skill of ultrasound is not difficult. Their conclusion is often along the lines of “it takes X months for a complete novice to learn and attain a 95% agreement rate with scans performed by experts”. Such feasibility studies often hint at the potential of ultrasound to improve patient outcomes (without being able to confirm this), further adding to the feeding frenzy of colleagues wanting to learn and develop POCUS skills.
Underlying all these training principles and crucial for future development is a matching governance structure. How images are stored, indexed, reported and reviewed all need to be planned before training programmes launch locally.
In summary, there is a variety of accreditation programmes available. They vary in:
- The modules covered
- What is actually required in the modules
- How training is delivered – face-to-face vs distance learning
- The number of scans/logbook requirements
- The assessment process
- The reaccreditation/maintenance of competency process
In conclusion, when learning and performing POCUS, self-awareness is crucial. Being aware of one’s own limitations and indeed, the limitations of the scan being performed is of paramount importance. Putting your hand up and admitting that you need help or more expert opinion is a sign of strength not weakness. With that awareness firmly in place, go out there and learn!
Expert Round Table on Ultrasound in ICU. Intensive Care Med. 2011 Jul;37(7):1077-83. Epub 2011 May 26 – International expert statement on training standards for critical care ultrasonography
United Kingdom’s Accreditation Programme, Syllabus and Logbook (FREE)
POCUS – http://www.ics.ac.uk/ics-homepage/accreditation-modules/cusic-accreditation/
ECHO – http://www.ics.ac.uk/ics-homepage/accreditation-modules/focused-intensive-care-echo-fice/
ESICM European Diploma in Echocardiography – http://www.esicm.org/education/edec
International consensus statement on training standards for advanced critical care echocardiography – http://icmjournal.esicm.org/Journals/abstract.html?doi=10.1007/s00134-014-3228-5
ACCP Critical Care Ultrasonography accreditation – http://www.chestnet.org/Education/Advanced-Clinical-Training/Certificate-of-Completion-Program/Critical-Care-Ultrasonography