Echocardiography Practice, Training and Accreditation in the ICU: WINFOCUS

Abstract and Introduction

Abstract

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described.

Obtaining competence in ICU echocardiography may be achieved in different ways – either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level – obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs.

1.0 Introduction

The application of echocardiography in the critically ill has been well-recognized for several years, principally in patients following cardiac surgery. The use of this technique is presently expanding to include diagnosis and monitoring on the general intensive care unit (ICU). Further, as echocardiography is an evolving technology with broadening applications throughout medical and surgical practice, and equipment is becoming cheaper, more portable and more widely available, it is inevitable and appropriate that medical practitioners other than cardiologists and echocardiographers should seek to develop skills in the performance of ICU echocardiography.

Currently there are no specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice. Despite this, many are recommending that echocardiography should be incorporated into ICU training programs due to its ability to positively impact on patient management. However, due to the complexity of issues involved, few have developed specialized national training schemes for ICU echocardiography and echocardiography accreditation (through EAE, BSE or the ASE) does not reflect the requirements of the ICU practitioner, as they contain heavy emphasis on valvular disease, little haemodynamic monitoring, and an absence of pathology in the critically ill. The World Interactive Network Focused on Critical UltraSound (WINFOCUS, http://www.winfocus.org) is a scientific society committed to the development of high-quality ultrasound in the emergency and ICU setting, including echocardiography. This document has been prepared from recommendations published by the Royal College of Radiologists, and British Society of echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with input from established practitioners of ICU echocardiography to provide guidance to individual physicians (and also to inform program directors, the relevant echocardiographic and intensive care societies, hospital administrators and health care policy makers) of the requirements involved in the development of skills in echocardiography in the ICU setting. Although the authors recognise that ICU clinicians may use ultrasound to image other organ systems, for the purposes of clarity these recommendations are limited to training and accreditation in echocardiography. Recommendations for training of non-radiologists in the imaging of other organ systems exist, and WINFOCUS projects already include systematic development of a comprehensive ultrasound curriculum for the intensivist and critical care physician.