Ultrasound Training in CCM Programs

Enyo Ablordeppey, MD, MPH

Enyo AblordeppeyWhat’s new in critical care ultrasound training?
Everyone acknowledges that ultrasound training in critical care programs is important. But exactly how one does this is challenging to conceptualize. We are not talking about just occasionally using ultrasound or learning a little during rounds aka “informal teaching”, but developing educational pathways that allow critical care medicine providers to become as comfortable utilizing point of care ultrasound (POCUS) as they are with the ventilator or vasopressors. No one is arguing the importance of POCUS, rather what is the best way to educate and train fellows in critical care ultrasound (CCUS) well enough that they gain the confidence to utilize it daily and make decisions regarding patient care.

Where do we begin?
We begin first by understanding who isn’t using it and why. Despite mounting evidence suggesting that POCUS improves patient safety during procedures, enhances rapid decision-making, and assists in diagnostic capabilities,1-3 a national survey of program directors demonstrates that most critical care medicine fellowship programs do not offer “formal” training in focused critical care ultrasound.4 Only limited model curriculums exist for teaching and implementing focused CCUS in the ICU.5,6 It’s also important to note that because critical care medicine have providers from diverse backgrounds who have variable background experience with POCUS, developing the most effective training is challenging.

What does “formal” ultrasound training mean? That’s an area open to interpretation. Do workshops, lectures, and rotations count? There are no guidelines listed for this description. Not surprising then, there are deficiencies in ultrasound training in critical care fellowship programs. Thus, groups like the American College of Chest Physicians (ACCP)2, the American Society of Echocardiography (ASE), and the American College of Emergency Physicians (ACEP)7 have produced guidelines to highlight important aspects of critical care ultrasound training. While these guidelines are great, implementing POCUS training has been limited by multiple barriers, such as available protected didactic time, brief length of training programs, lack of faculty proficiency in ultrasound, financial constraints, and political/administrative concerns.4,8

So, we begin by trying to bridge these barriers in POCUS training and daily utilization in the ICU. Let’s review the prominent five barriers listed: 1. Available protected didactic time. This is the most important aspect of POCUS training. Since time is a constant, increasing time for POCUS may mean decreasing time for something else. How do we get around this barrier? You don’t. It takes time to learn POCUS just like any other diagnostic or procedural process in medicine. Without the time to incorporate it, fellowship programs suffer, repeating the same ineffective training. Reviewing the most recent survey of CCUS education, very few programs had mandatory or optional rotations or a specific curriculum. And less than half even had formal lectures or hands-on ultrasound sessions. This could be an easily addressed gap. Training programs need more time to provide didactic education in POCUS. 2. Brief length of training programs. Anybody advocating longer training periods? I doubt it. Perhaps instead of lengthening training, programs can incorporate structured ultrasound training into the existing curriculums by starting with ultrasound lectures and hands-on courses. 3. Lack of faculty proficiency. That makes sense; fellows in training need the support of their faculty to gain ultrasound expertise. In addition, faculty proficiency might encourage more diagnostic interventions by POCUS, which could lead to daily ultrasound utilization. This is challenging. However, program options are two-fold - both focus on recruitment of new faculty that have this additional POCUS training and/or focus efforts on current faculty development in this arena. 4. Financial constraints. It’s true that ultrasound education has an expense, for example, equipment costs, workshop costs, and the cost of protected faculty time. But education has a cost. Programs have to be willing to see the value of the financial investment of POCUS training for their fellows and their patients. 5. Political/administrative concerns. These may be harder encounters for programs to battle, but conflicts have to be fought for change to occur. What is the overarching theme in these barriers? Every program needs a dedicated POCUS champion to develop solutions to meet individual ultrasound education program needs.

How do we begin?
We begin by looking at emergency medicine, which was the first group to really define and establish national competencies for POCUS in the emergency department. Although a long battle, nearly all emergency medicine residency programs offer “formal” ultrasound training with the support of their accreditation body. The Accreditation Council of Graduate Medical Education (ACGME) now requires that an ultrasound machine be available in critical care fellowship training programs.9 So, step 1 is to obtain a dedicated ultrasound machine. Step 2, I believe, is to train, train, train to establish competency, both at the faculty and fellowship level. This is the longest step and requires a dedicated person or team to maintain a level training field, as POCUS is a rapidly developing field embraced by multiple medical specialties. There are multiple online and published resources that are available for individuals or groups in learning and teaching POCUS. Step 3 is curriculum development and implementation, as seen in Figure 1.

US Training in CCM Programs
Figure 1. Steps to program development

Steps to developing a POCUS program

  1. Obtain a dedicated ultrasound machine.
  2. Find and groom a POCUS champion aka “dedicated person”.
  3. Obtain institutional buy-in and commitment for program development.
  4. Implement a POCUS curriculum and measure outcomes.

Tips for the champion role

  1. Become an “expert” (advanced ultrasound education), if not already performed, including emergency ultrasound fellowship training, national courses, and workshops.
  2. Train their department/group in POCUS.
  3. Perform quality assurance and address machine maintenance concerns.
  4. Be supported with time and funding by their hospital/department to perform POCUS.
  5. Find allies to support POCUS education and develop collaborations with other ultrasound-focused specialties, such as radiology and cardiology.
  6. Understand the long-term initiative of POCUS training. Structured POCUS training in a fellowship-training program is a strong advantage during program recruitment.

The WashU way?
At Washington University in St Louis, our approach to providing critical care ultrasound training started in 2013 and is multidisciplinary and robust. It’s not perfect, but we believe that it addresses the biggest barriers to program incorporation of POCUS in the critical care environment. We acknowledge that our curriculum was developed after review of the literature, discussions with other ultrasound experts that created structured CCUS training programs, and curriculum support programs like the ACEP teaching fellowship where our curriculum was reviewed. We have identified a POCUS champion in CCUS who coordinates all aspects of POCUS training for all of our critical care fellows. In addition, we have established a critical care ultrasound taskforce that is made up of ICU faculty who are ultrasound advocates and champions in their perspective ICUs. These allies are important to unify the concept of POCUS in critical care medicine and serve as faculty educators and advocates who provide daily POCUS training during patient care management. Finally, we have developed an educational pathway and curriculum for POCUS training during the fellowship-training program, which includes the following:

  1. Pre-fellowship POCUS quiz.
  2. Annual five-hour basic critical care ultrasound course in August (ultrasound topics: lung, cardiac, abdomen, vascular access).
  3. Annual five-hour advanced critical care ultrasound course in March (Advanced quantitative cardiac, RUSH exam, TEE, pericardiocentesis).
  4. 4-week critical care ultrasound rotation: fellowship supported elective rotation with goals of standardizing critical care ultrasound education with daily patient scanning and didactic simulation. Rotation is modeled to define rotation competency after obtaining at least 20 complete RUSH (rapid ultrasonography in shock and hypotension) exams and completion of asynchronous curriculum training modules. Additional training includes advanced TTE training depending on interest and prerequisite ultrasound knowledge.
  5. Post elective written quiz pass rate of > 75%.
  6. SonoSim® simulator online focused modules.
  7. Monthly ultrasound case rounds (open to all critical care fellows and faculty).
  8. Structured POCUS lectures series (at least 8 faculty presented ultrasound lectures per acad. calendar).

What are the National Standards?
I get asked that question a lot. There are certainly increasing expert opinions about what critical care ultrasound means and what it should encompass. Unfortunately, because of the multidisciplinary nature of critical care medicine, each society has guidelines about components and measurements of critical care ultrasound competency. I offer two examples below. The ACCP offers critical care ultrasound certificate of training for those who like having the national recognition, documentation, and competency standardization of ultrasound training. Other societies have supported guidelines of competency assessment, including SCCM where the ultrasound certification task force created guidelines to provide guidance to both providers and hospitals in the process of credentialing in critical care ultrasound and advanced critical care echocardiography.10 The Canadians have also published guidelines for CCUS training.11 Finally, there should be a principal national consideration of whether POCUS should be labeled as a knowledge and skill set required for the general critical care intensivist, similar to intubation and mechanical ventilation management, or if it should be a separate specialty skill that requires additional training and proof of completion. My opinion is that basic POCUS should be an expected competency of critical care training programs. Advanced ultrasound studies, such as quantitative point of care cardiac examinations, likely need additional specialty training and documentation.

Here is the ACCP critical care ultrasound certificate program requirements:

  1. Complete Online Learning Module: Bedside Ultrasound in Critical Care CAE Online.
  2. Attend Critical Care Ultrasonography: Essence in Critical Care & Integration into Clinical Practice.
    • Complete online portfolio (submission of 102 ultrasound video clips for review by faculty):
      • Abdominal: 16 exams, with a minimum of 4 with a positive finding
      • Cardiac: 50 exams, with a minimum of 10 with a positive finding
      • Pulmonary/Pleural: 12 exams, with a minimum of 4 with a positive finding
      • Vascular (DVT): 24 exams, with minimum of 3 with a positive finding
  3. Pass a Final Comprehensive Assessment.

Here are the Canadian recommendations for CCUS training and competency:

US Training in CCM Programs2

Figure 2. Proposed CCUS training pathway11: CCE Critical care echocardiography; GCCUS General critical care ultrasound; QA Quality assurance

Future direction?
The future looks bright for POCUS in the critical care environment. Thanks to emergency medicine for paving the way for POCUS in the ED, which has guided many institutional and national pathways for critical care ultrasound proposed training curriculums. Ultimately, the culture of ultrasound in the ICU has to change. The days of occasionally grabbing the ultrasound for some cases and procedures without realizing its true value as a diagnostic modality worthy of archiving, documentation and billing in the critical care environment are over. More training programs are training their fellows and faculty in POCUS and need the administrative structure to achieve full implementation. Future direction might include assessments of which training curriculums are most effective to retain ultrasound knowledge/skills/comfort, promote ultrasound utilization, and determine if this increased utilization of POCUS translates into meaningful patient care improvement and clinical relevant outcomes.

References

  1. Ablordeppey EA DA, Beyer AB, Theodoro DL, et al. Diagnostic accuracy of central venous catheter confirmation by bedside ultrasound versus chest radiography in critically ill patients: A systematic review and meta-analysis. Crit Care Med. 2017 Apr;45(4):715-724.
  2. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009 Apr;135(4):1050-1060. doi: 10.1378/chest.08-2305. Epub 2009 Feb 2.
  3. Neri L, Storti E, Lichtenstein D. Toward an ultrasound curriculum for critical care medicine. Crit Care Med. 2007 May;35(5 Suppl):S290-S304.
  4. Eisen LA, Leung S, Gallagher AE, et al. Barriers to ultrasound training in critical care medicine fellowships: a survey of program directors. Crit Care Med. 2010 Oct;38(10):1978-1983.
  5. Killu K, Coba V, Mendez M, et al. Model point-of-care ultrasound curriculum in an intensive care unit fellowship program and its impact on patient management. Crit Care Res Pract. 2014;2014:934796.
  6. Fagley RE, Haney MF, Beraud AS, et al. Critical care basic ultrasound learning goals for American anesthesiology critical care trainees: recommendations from an expert group. Anesth Analg. 2015 May;120(5):1041-1053.
  7. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010 Dec;23(12):1225-1230.
  8. Mosier JM, Malo J, Stolz LA, et al. Critical care ultrasound training: a survey of US fellowship directors. J Crit Care. 2014 Aug;29(4):645-649.
  9. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in critical care medicine. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/142_critical_care_int_med_2016.pdf. Approved October 1, 2011. Revised July 1, 2015 and July 1, 2016. Accessed July 5, 2017.
  10. Pustavoitau A, Blaivas M, Brown SM, et al. From the Ultrasound Certification Task Force on behalf of the Society of Critical Care Medicine: Recommendations for achieving and maintaining competence and credentialing in critical care ultrasound with focused cardiac ultrasound and advanced critical care echocardiography. Society of Critical Care Medicine. http://journals.lww.com/ccmjournal/Documents/Critical%20Care%20Ultrasound.pdf. Accessed July 5, 2017.
  11. Arntfield R, Millington S, Ainsworth C, et al. Canadian recommendations for critical care ultrasound training and competency. Can Respir J. 2014 Nove/Dec;21(6):341-345.

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