PAUL H. MAYO and SUSANNA PRICE

Overview

Echocardiography provides intensivists with a means of rapidly assessing the anatomy and function of the heart in intensive care unit (ICU) patients with hemodynamic failure, thus guiding management. Since echocardiography is a key skill for frontline intensivists, developing effective training programs is essential to ensure that clinicians have competence in the field. This chapter discusses some issues related to training in critical care echocardiography (CCE) while considering the challenges from both the European and North American perspectives. Information in this chapter is relevant for two groups: for intensivists who seek to develop competence in CCE, it provides a guide for the process of training, and for intensivists who have the responsibility to train others to become proficient in CCE, it provides guidance for process development.

The North American Challenge

Roughly 6000 intensivists (at the attending level) in the United States need training in CCE. These frontline clinicians work on a full-time basis in the ICU and have the potential to use CCE as a primary bedside imaging modality. Some of these intensivists are faculty at fellowship programs and have the responsibility of training fellows in CCE. In the United States in 2011, 170 fellowship training programs under the specialty of internal medicine offered training in critical care medicine. These programs graduated 545 fellows with an additional 89 from anesthesiology-based critical care programs. CCE is an essential part of their training. For the individual fellow or attending intensivist, the question is how to become competent in CCE. At the system level, the challenge is how to provide training in CCE to many thousands of intensivists at both the fellow and attending levels.1–3

The European Challenge

Europe has 49 self-governing countries, 27 of which are member states of the European Union. The health care systems in each of these countries are different, as is the status of critical care itself, thus providing considerable challenges when considering the development of unified training programs. Accreditation in echocardiography at a European level is run by the European Association of Cardiovascular Imaging (formerly known as the European Association of Echocardiography) under the auspices of the European Society of Cardiology. Certification in intensive care medicine is provided at a national level. The European Society of Intensive Care Medicine, which aims to promote and coordinate activities, foster research and education, and provide recommendations for optimizing facilities in intensive care medicine, runs a diploma service in intensive care medicine but is not responsible for certification or accreditation. As in North America, for the individual intensivist in training the challenge is how to become competent in CCE. With the different systems that exist in Europe, the challenge of providing training has devolved to the individual nations. The role of regulatory bodies and relevant international societies is rather to provide guidance regarding the key skills and level of competence required in CCE for nations to be able to devise the most appropriate training program given the way that intensive care is structured in their own country.

International statements: Competence and training

The goal of training both for the individual and for the training system is competence; hence the latter must be explicitly defined. At an international level this was undertaken as a cooperative venture when a working group consisting of representatives from France and the United States coauthored a statement that defined competence in critical care ultrasonography.⁴ The document “American College of Chest Physicians/La Société de Réanimation de Langue Françoise Statement on Competence in Critical Care Ultrasonography” reviews the elements that define competence in CCE. At this point the statement on competence is commonly accepted as a guide that defines the goals of training for CCE.

The statement on competence defines basic-level and advanced-level CCE. Basic CCE comprises a number of standard views for assessment of cardiac function (parasternal long- and short-axis, apical four-chamber, long-axis subcostal, and longitudinal inferior vena cava views) to categorize and guide management of hemodynamic failure. Basic CCE includes the use of basic color Doppler techniques, but no additional type of Doppler measurement is included. Advanced CCE requires competence in standard cardiology-type echocardiography and includes additional elements that are applicable to critical care medicine, such as measurement of stroke volume and preload sensitivity, as well as estimation of left-sided filling pressure and lung ultrasonography. Training in advanced CCE requires a level of study identical to that for cardiology echocardiographers. It includes training in transesophageal echocardiography (TEE) when the equipment is available. Currently, most intensivists in the United States and many in Europe do not have access to TEE, although this is rapidly changing. Although competence in basic CCE is desirable for all intensivists, competence in advanced CCE is not needed by all. Some proportion of intensivists may desire training in advanced CCE, but what number is unknown.

The statement on competence clearly defines competence in CCE and is designed to be a “road map” for training. Following its writing, representatives from major critical care organizations from around the world met in Vienna in 2009 to develop guidelines for training in critical care ultrasonography. The resulting document titled “International Expert Statement on Training Standards for Critical Care Ultrasonography” represents the consensus of the working group. It addresses the question of how to become competent in both basic and advanced CCE.⁵

Regarding basic CCE, the Vienna group adopted the statement on competence as the foundation document that summarized the goals of training. For basic CCE, it was agreed that 10 hours of course work that combines lecture, didactic cases, and image interpretation constituted the minimum requirement for cognitive training in CCE. A minimum of 30 fully supervised studies was suggested as a goal for image acquisition training. Initial training could take place on normal subjects, but training should include scanning of patients in the ICU under supervision of a local expert. A logbook should be maintained to document scanning activity. Review of a comprehensive collection of images with abnormal findings should be required for training in image interpretation. Training in TEE remained an optional part of training in basic CCE. Regarding advanced CCE, it was suggested that 40 hours of course work, 150 transthoracic echocardiographic (TTE) studies, and 50 supervised TEE studies constituted the minimum requirement for training. Review of a comprehensive image collection, initial training on normal subjects, and bedside scanning under direct supervision of a local expert were also considered necessary to complete advanced CCE training. The Vienna group decided that a formal certification process was not required for basic CCE. Regarding advanced CCE, the group suggested that a formal certification process was required to ensure competence given the complexity of training and the need for recognition of a high skill level by colleagues and administrative entities.

The statement on competence was detailed, whereas the statement on training was synoptic. As an example, the number of studies required for training was only a suggested target because the evidence was insufficient to make more definitive recommendations. Hence the goal was to establish a broad standard to permit flexibility in the design of training programs for a variety of medical cultures. The training statement did establish that basic-level CCE and general critical care ultrasound should be a required part of the training of every intensivist. Since publication of the training statement, Vignon et al reported on a program to train house staff in basic CCE.⁶ The results supported the recommendations of the statement on training. Regarding advanced CCE, Charron et al reported that competence in TEE requires approximately 30 studies under supervision, a number that is less than the 50 suggested in the training statement.⁷ Furthermore, these numbers are significantly lower than recommended by European certifying bodies in echocardiography (Table 61-1). In the United Kingdom, the British Society of Echocardiography has developed an accreditation process for CCE that requires the same standards (and number of studies) as for standard TTE accreditation.

Represented at the Vienna meeting were four professional societies from North America: the American College of Chest Physicians (ACCP), American Thoracic Society (ATS), Canadian Critical Care Society (CCCS), and Society of Critical Care Medicine (SCCM). The SCCM did not formally endorse the final document, but its representatives were involved in the roundtable discussions. The international accrediting bodies in echocardiography were not represented; however, it is reasonable to assume that the statement on competence and the training statement are widely recognized by intensivists as the present standard in North America and Europe.

Training programs, certification, and accreditation

Even though the two statements are useful in planning a training program, competence in CCE is not ensured. Poorly designed didactic programs, lack of skilled bedside trainers, and a focus on number rather quality of studies performed may all work against achievement of competence. A well-defined process of training does not guarantee competence. An alternative approach is to emphasize competency-based testing at the completion of training. Although this may exist at the local level in fellowship programs, no competency-based testing has yet been widely accepted in either North America or Europe at a national level.

To avoid conflict of interest, a meaningful certification program should be designed by an agency that is completely independent of the training system. In the United States, the authorities responsible for developing the highest standard of certification are not likely to be interested in developing a high-level certification program for basic CCE given that it applies to a relatively small number of physicians. In the United Kingdom, a national program does exist for basic echocardiography as an entry level for all acute practitioners. This was a joint venture between the Resuscitation Council and the British Society of Echocardiography; it was not limited to CCE but linked to advanced life support. Basic CCE is only one skill of a larger skill set intrinsic to critical care medicine. Although it is perceived that certification in basic CCE is necessary, this implies a need for certification in other aspects of critical care medicine that are of higher risk and complexity, such as airway management and vascular access. It could be argued that basic CCE should be bundled into other important aspects of critical care practice that do not require individual certification. However, these discussions are possibly irrelevant since in the future, the inevitable adoption of basic universal ultrasound training as part of undergraduate medicine will make requirements for this basic level of echocardiography training for intensivists irrelevant (see Chapters 57, 60, and 62).

Across Europe and North America, accreditation (which has legal, financial, and interdisciplinary and intradisciplinary implications) is reserved for full echocardiography training—that is, the level at which one is able to practice independently and perform a fully comprehensive study. It is not competency based per se; however, each trainee completing the accreditation process has a mentor who supervised the training and certified that the trainee is of a sufficient standard (and has undertaken the logbook studies). In the United States, there is no means for intensivists to achieve high-level certification in advanced CCE because the National Board of Echocardiography (NBE) does not issue certification in echocardiography to noncardiologists. However, it allows any licensed physician to take the echocardiography boards, including intensivists. Many cardiologists have decided not to take the echocardiography boards, so they cannot receive certification in echocardiography by the NBE. Cardiologists who decide to not take the echocardiography boards may still demonstrate competence in echocardiography. This pathway is described in a statement by the major cardiology societies.⁸ Intensivists may also satisfy the competence requirements, and if they do, they are competent in echocardiography to an equal extent as cardiologists. One approach is for the intensivist to satisfy the requirements for competence and to pass the echocardiography boards. Passing this challenging examination demonstrates to cardiology colleagues that the intensivist has mastery of the subject. In Europe, clinicians who wish to practice echocardiography (irrespective of their underlying specialty) and cardiac physiologists are encouraged to achieve accreditation in echocardiography. Indeed, the initial British Society of Echocardiography TTE accreditation process was devised for echocardiographic physiologists and has only recently been adopted by cardiologists as a demonstration of the minimal level of competence needed to be an independent echocardiography practitioner. Moreover, accreditation is available for primary care practitioners, and in the United Kingdom a critical care accreditation process exists; however, it currently includes only TTE. TEE accreditation was largely developed in response to the recognition that the majority of TEE studies are currently undertaken by cardiovascular anesthesiologists. Thus, accreditation processes were developed in the United Kingdom and Europe in conjunction with the relevant cardiothoracic anesthesia societies.

Final thoughts

Conclusion

The statements on competence and training standards serve as useful guides in CCE training. In the United States it will become a uniform standard only when the ACGME requires CCE training as part of fellowship training. In Europe, as with cardiology (for which accreditation by the European Association of Cardiovascular Imaging is required only by those subspecializing in echocardiography), it is likely that intensivists who wish to practice advanced echocardiography will obtain appropriate national or international accreditation. Whether a specific accreditation process for CCE will be developed at the European level remains uncertain.

By contrast, basic CCE should be achievable by all intensivists, and although attending-level intensivists may find it difficult to obtain training in CCE in their own hospital, the professional societies offer courses to remedy this situation. It is hoped that in the future, basic ultrasound will be incorporated into the medical student curriculum. Thus current challenges in basic CCE training will not exist (see Chapter 60).

Pearls and highlights

References