IP2 Advanced Applications Credentialing

Transcription

1 IP2 Advanced Applications Credentialing Prepared for: Canadian Emergency Ultrasound Society Prepared by: Advanced Applications Committee Date: Oct, 2014 Proposal #: 6.0

2 Table of Contents Preamble... 3 Committee Membership... 4 IP2 Credentialing Process... 8 Overview Courses Apprenticeship Assessment of competence/examination Components of training Supervising physician Role of Sonographers Advanced Applications Streams IP2 Resuscitation Stream (Cardiac, Lung, IVC) IP2 Diagnostic Stream (Gallbladder, Renal/Bladder, DVT) PoCUS Needle Guidance (POCUSNG) Stream IP2 Musculoskeletal Stream (bones, joints) Table 1. AdApps Apprenticeship Requirements...20

3 Preamble With the growing interest in advanced bedside ultrasound applications, a number of members have asked CEUS to explore the development of an advanced application certification process. The Advanced Applications (AdApps) Committee, composed of members from coast to coast (and of wide-ranging backgrounds in clinician-performed ultrasound) has begun putting together a basic framework for such a process. This framework includes a series of parallel streams representing various clinical aspects of advanced bedside ultrasound. It is anticipated that trainees will be able to pursue certification, or IP2 status, in such areas as resuscitative, needle guidance, diagnostic, and musculoskeletal bedside ultrasound. Sincerely, Paul Olszynski, MD, MEd, CCFP (EM) (SK) Chair, AdApps Committee/Président, Comité AdApp

4 Committee Membership Dr. Martin Betz, (FRCP EM) Practiced emergency medicine for 25 years without using ultrasound, and the last 10 years, much more safely, using EDE. I teach EDE, EDE2 and EM residents, now in Toronto, previously in Saskatoon, Sudbury and the Middle East. Dr. Greg Hall MD BSc CCFP (EM) FCFP Assistant clinical professor McMaster university and director of ED ultrasound at Brantford General Hospital. CEUS Master instructor. Co-developer of the EDE 2 Course and co-author of Point-of-care ultrasound for Emergency Physicians. Director of EDE 3: Leading Edge Emergency Department Echo. Speaker at multiple conferences including CAEP Scientific Assembly, North York EM Update, UHN EM conference, Ottawa EM Conference. Interests: POCUS education, ultrasound technology. Dr. Ryan J. Henneberry MD, CCFP (EM), RDMS, Dip Sport Med Emergency Physician with interest in Point of Care Ultrasound (Director of Emergency Ultrasound, QEII HSC, Halifax) with a leadership role as Chair of the CAEP POCUS Committee. Other interests include sports medicine. He is an Assistant Professor of Medicine at Dalhousie University. Dr. Ben Ho, MD, CCFP (EM) Emergency Physician and CEUS Master Instructor. EDE 1 lecturer , EDE 2 co-developer, lecturer 2008-present, EDE 3 lecturer 2012, The EDE book chapter author - chapters thoracic, soft tissue. CEUS executive board: portfolio: standards , portfolio: Western Canada representative 2009-present. A few ongoing research projects so far - none submitted for publication yet. Nanaimo regional general hospital ED U/S director

5 Dr. David Kirschner, MD, (FRCP EM) An avid user and advocate for the continued development and integration of point of care ultrasound in the ED, he is pleased to be working with CEUS. He plans on continuing this work in the coming years as he practices in both pediatric and adult emergency departments. He is currently enrolled in the Ultrasound Leadership Academy. Dr. Jean-François Lanctôt MD, CCFP(EM) Dr Lanctôt is professor of medicine at McGill and Sherbrooke universities in Montreal, Canada. He is the co-founder of the EGLS course and he is the cocreator of the ios Application Shock Echo. He participated in establishing credentialing guidelines for advanced ultrasound in emergency medicine for the Association of Emergency Physicians of Quebec(AMUQ/ASMUQ). His main area of interest include resuscitation and critical care ultrasound. Dr. David Lewis MB BS FRCS FCEM CFEU PGDipSEM, Associate Professor Emergency Medicine - Dalhousie University, Ultrasound Program Director - Saint John Regional Hospital New Brunswick. Co-Director of the ECCU courses ( The ECCU courses are currently held in Saint John and Halifax, and have been running in the UK since Other than teaching core and advanced PoCUS, I have an interest in musculoskeletal ultrasound and sports medicine. Dr. Paul Olszynski, MD, MEd, CCFP (EM) Committee Chair Assistant Clinical Professor at the University of Saskatchewan. Director of Saskatoon Emergency Ultrasound Program. Interests include Clinician Performed Ultrasound, Medical Education, Simulation-based Medical Education. Currently undertaking study of CPU for SBO and Director of Undergraduate Ultrasound Education at the U of S.

6 Dr. Laurie Robichaud, MD Resident/PGY4 at the Royal College EM program at McGill University. She is currently enrolled as a fellow in the Ultrasound Leadership Academy for Emergency Ultrasound. Her interests include PoCUS education, resuscitation, and research. Dr. Joel Turner, MD, MSc, FRCP Former Program Director of the Royal College EM program at McGill, and is the inaugural Fellowship Director of the EM ultrasound fellowship at McGill. Working at the Jewish General Hospital, he is an instructor of the EDE2, and EDE3 courses, and is a CEUS Master Instructor. He has authored chapters in the EDE book (DVT, ocular) as well as in a recent volume of the EM Clinics of North America (thoracic). He also helped initiate the development a CEUS training site in Doha, Qatar. Dr. Maxime Valois MD, CCFP(EM) Assistant professor of medicine at Montreal, McGill and Sherbrooke universities in Montreal, Canada. He was director of a CEUS training center in Montreal until December He is the co-founder of the EGLS course and he is the co-creator of the ios Application Shock Echo. He is also a professor of the Ultrasound Leadership Academy and participated in reviewing the credentialing guidelines for advanced ultrasound in emergency medicine for the Association of Emergency Physicians of Quebec(AMUQ/ASMUQ). His main area of interest include resuscitation and critical care ultrasound. Dr. Michael Woo MD Emergency Physician and Trauma Team Leader at the Ottawa Hospital and an Associate Professor with the Departments of Emergency Medicine and Family Medicine at the University of Ottawa. Received training in ultrasound at the Ottawa Hospital and obtained his American Registry for Diagnostic Medical Sonography certification in Director for both the Emergency Medicine Ultrasonography program and Point-of-Care Ultrasonography

7 (Emergency Medicine) Fellowship. Continues to combine his passion for education with clinical sonography with national and international speaking engagements and maintaining an active research program.

8 IP2 Credentialing Process Overview In keeping with the credentialing process established by CEUS for IP1, the IP2 streams will require a combination of course attendance, supervised apprenticeship and final examination. 1. Courses Trainees pursuing CEUS credentials in IP2 streams must first complete a CEUS recognized introductory course on the relevant application. 2. Apprenticeship Having completed an introductory course in advanced applications, trainees will be asked to formally register for apprenticeship in any of the four IP2 streams (Resuscitation, Needle-Guidance, Diagnostic, and Musculoskeletal). Each stream document sets out minimum standards for the number of scans that must be completed prior to a competency assessment/examination. Apprenticeships must be supervised. Half of all apprenticeship scans must be obtained under direct supervision of an IP2 instructor. In order to ensure a solid understanding of clinical integration, the remaining required scans must be submitted in the form of a training portfolio that consists of recorded clips as well as accompanying documentation that explains patient presentation, image interpretation and subsequent proposed integration of findings into clinical care. This portfolio must then be submitted to the supervising instructor for review and determination of adequacy of scans. It is expected that trainees encounter both negative and positive pathology during their apprenticeship. While this may be difficult to capture under direct supervision, it is expected that upon completion of the required number of scans, trainees will have documented at least 1 of each of the relevant pathologies for that scan/indication.

9 Once a trainee has completed the required number of scans (50% determinate under direct supervision, 50 % determinate and adequate scans in portfolio), then a competence assessment can be initiated. Apprenticeship should last no longer than 18 months. 3. Assessment of Competence/Examination This final component of apprenticeship will include an online examination, a visual exam completed with an IP2 instructor, and a bedside practical assessment. Upon successful completion of each component, the trainee will be granted IP2 status within the given IP2 stream. 4. Components of training Directly supervised dynamic scans on live human models Reviews of recorded dynamic scans on live human models Written examination in MCQ format can be done on-line or in person Visual exam done with direct supervisor either in person or via internet conferencing 5. Instructor/ Master Instructor IP2 An IP2 clinician can assist other trainees with the case portfolio component of their apprenticeship (by helping ensure that trainees record adequate clips of their cases), and thus taking on the role of instructor. Once an IP2 clinician has assisted 5 other trainees with their portfolios, he/she is eligible for Master Instructor apprenticeship on the recommendation of another IP2 Master Instructor. Master Instructor apprenticeship includes 2 components: a course based bedside-instruction component (at a course recognized by CEUS) and attendance at an IP2 teaching course.

10 6. Role of Sonographers Sonographers and Echosonographers can offer trainees excellent guidance in image generation (within their respective scopes). Such guidance may prove to shorten the total number of attempts required to generate the specified determinate views/scans for a given indication. As such, trainees can seek out guidance/supervision from sonographers for the portfolio portion of their apprenticeship. This should be arranged at a local level with considerations for remuneration being addressed independently of CEUS.

11 Advanced Applications Streams Resuscitation Diagnostic Needle Guidance Musculoskeletal

12 IP2 Resuscitation Stream (Cardiac, Lung, IVC) I. CARDIAC a) Views: Parasternal Long Axis (PSL/PLAX) Parasternal Short Axis (PSS/PSAX) Apical 4 Chamber (A4C) Subxiphoid (SX) b) Image Generation Requirements: 50 supervised determinate scans of each of the three views with minimum 25 directly supervised, 25 recorded and reviewed in the applicants portfolio. c) Pathology: - PCE - LV dilation - RV dilation - LV failure Each pathology should be demonstrated at least once within the 50 scans. d) Determinate Scans: - PSL: Correctly identify midpoint of LV, MV and AV imaged, EPSS correctly identified (>1cm or <1cm), LV imaged in longest and widest orientation, Aortic root & Descending aorta visulaized - PSS: Assessment of LV contraction at level of papillary muscles, assessment of RV strain and septal bowing - A4C: All 4 chambers imaged in widest, longest view, Vertical orientation of septum, TV and MV imaged e) Clinical scenario management correctly incorporate findings of: - LV failure and LV dilation in shock and dyspneic patient - Hyperdynamic/empty LV in shock patient - RV dilation in shock and dyspneic patient II. Inferior Vena Cava (IVC) a) Views: Longitudinal and transverse intrahepatic IVC b) Image Generation Requirements: 10 supervised determinate scans, Minimum of 5 directly supervised, 5 recorded and reviewed The above applies to each of the patient states: spontaneously breathing patients (10 scans) and intubated (10 scans). c) Pathology: - Normovolemic nonintubated patient IVC respiratory variation

13 - Obstructive shock or failure, nonintubated patient - Hypovolemic shock, nonintubated patient - Hypovolemic shock, intubated patient d) Determinate Scans: - demonstrate IVC s imaged in long axis and short axis in widest diameter - identify intrahepatic course of IVC and correct measurement technique - correctly position measurement markers for IVC diameter e) Clinical Scenario Management - correctly incorporate images for following scenarios: - flat/collapsing IVC in shock and dyspneic patient - distended IVC in shock and dyspneic patient - positive IVC in positive pressure ventilated shock patient III. Lung/Pleura a) Views: - Intercostal pleura in longitudinal, - Longitudinal view of diaphragm - supradiaphragmatic lung in sitting patient b) Image Generation Requirements - 20 intercostal pleural and supradiaphragmatic views with minimum of 10 directly supervised scans - Should include view of pleura and deeper lung tissue over anterior, lateral, and posterior aspects of lung in supine patient c) Pathology - Pneumothorax: - Interstitial fluid - Pleural Effusion d) Determinate Scans: - longitudinal image of lung pleura in three intercostal spaces - correctly identify on video recording or live patient: pleural line, pleural slide, ribs and rib shadow, true comet tails, A-lines - Cardiac lung point, liver lung point, spleen lung point - Demonstrate how to image least dependant region of lung in supine patient and follow pleura laterally to reach potential lung point - Images demonstrate definitive views of pleura, A-lines, ribs in longitudinal orientation - Images of lung bases demonstrate definitive views of diaphragm and supradiaphragmatic lung

14 - Identify A-lines, B-lines, lung consolidation, pleural effusion, air bronchograms, atelectasis e) Clinical Scenario Management- Demonstrate how to incorporate findings into clinical scenarios including: - Normal lung with high clinical suspicion of pneumothorax - Spontaneous pneumothorax - Patient with lack of lung slide due to other pathology such as pleurodesis - CHF with significant B-lines - Pneumonia with consolidation - Dyspneic patient with normal lung findings - Dyspneic patient with large pleural effusion and dyspnea - Shock patient with cardiac failure and lung edema

15 IP2 Diagnostic Stream (Gallbladder, Renal/Bladder, DVT) I. Gallbladder a) Views: - Both long and short axis views of gallbladder using subcostal, lateral, and intercostal approach - use of supine and left lateral positioning b) Image Generation Requirements: total 40 determinate gallbladder scans with minimum 20 directly supervised c) Pathology - Cholelithiasis - Cholecystitis - Choledocolithiasis d) Determinate Scans: - Identification of Exclamation Mark sign: portal vein, MLF, gallbaldder - gallbladder visualized in long and short from fundus to gallbladder neck - identification of portal triad - identification of gallstones - identification of wall +/- thickening - identification of peri-cholecystic fluid - identification of enlarged gallbladder - Wall-Echo-Shadow sign (WES) e) Clinical Scenario management - gallbladder in setting of biliary colic - gallbladder in setting of cholecystitis - gallbladder in setting of pancreatitis - inflamed gallbladder in setting of critically ill patient (acalculus cholecystitis) - GB and CBD in setting of jaundice II. Renal a) Views: - Left and right Kidney in long and short axis (using lateral view) - Bladder in transverse and long b) Image generation: - Renal: 20 (10 directly supervised) - Bladder: 5 (3 directly supervised) c) Pathology

16 - Hydronephrosis: Mild, moderate, severe - Hydroureter: proximal (UPJ) and distal (UVJ) - Calyx rupture - Pyelonephritis - distended bladder d) Determinate Scans: - Visualization of kidneys in longest axis - clear view of renal pelvis and proximal ureter - correct localization of bladder trigone - evidence of proper visualization for possible ureteric jets e) Clinical Scenario Management - Assessment of kidneys in setting of renal colic - identification of nephrolithiasis - role of renal scan in patient presenting with new onset flank pain (r/o AAA and assess for hydronephrosis) - further imaging following identification of hydronephrosis (unilateral vs bilateral) - hydronephrosis in setting of sepsis - estimation of bladder volume in?retention? - confirmation of catheter placement - Assessing hydro in the hypovolemic patient III. Deep Venous Thrombosis- 2 area/multipoint assessment a) Views (both left and right): - Transverse view of common femoral vein and its proximal branches - Transverse view of popliteal vein and their branches b) Image generation: 40 limbs (20 under direct supervision) c) Pathology - Femoral thrombus - Greater Saphenous thrombus - Popliteal thrombus - Identification of cellulitis or ruptured baker s cyst d) Determinate Scans: - clear identification of common femoral vein and other structures/vascular bundle - appropriate use of multi-point compression in both areas - saphenous-femoral confluence - common-deep femoral branch and distally several cms - popliteal fossa from adductor canal to trifurcation - clear identification of popliteal artery and vein with appropriate depth of field

17 e) Clinical Scenario Management - identification of DVT in setting of patient in obstructive shock - identification of DVT in swollen leg - identification of negative study in difficult scan/patient

18 IP2 PoCUS Needle Guidance (POCUSNG) Stream This document provides guidance on the process of acquiring recognized competency in PoCUSNG the ability to safely manipulate a needle under ultrasound guidance to the target with precision. Attaining this competency does not imply competency in any particular procedure. Needle Guidance a) Views: There are a growing number of procedures in emergency medicine and other medical specialties that have been shown to be both safer and frequently more effective when performed under ultrasound guidance. Commonly performed procedures where there is strong evidence for the benefit of using ultrasound guidance include, but are not limited to: - Central venous line placement - Peripheral venous line placement - Thoracentesis - Pericardiocentesis - Paracentesis - Peripheral nerve blocks - Supra-pubic catheter placement - Fracture hematoma block - Foreign body localization - Joint aspiration / injection b) Image generation: The underlying principles that determine PoCUSNG competency in the above procedures are: - An ability to recognize the ultrasound appearance of the target and surrounding structures. - An ability to safely manipulate a needle under ultrasound guidance to the target with precision and utilizing appropriate aseptic technique. - Directly observed PoCUSNG using simulator/phantom At least 10 successful attempts c) Pathology - identification of needle tip - interpretation of artifacts related to needle guidance - set up of sterile technique for procedure d) Image adequacy/competence: done under supervision of instructor* *The above components of competency achievement in PoCUSNG may all be acquired at the course, depending on its format. Alternatively the assessment of competency can be performed at a later date via local assessment.

19 IP2 Musculoskeletal Stream (bones, joints) I Fractures a) Views: 2 views of long bones in 2 planes, perpendicular to each other. Single view of sternum, ribs, and clavicle. b) Image generation: - 30 scans, with a minimum 10 scans of the distal radius, and a minimum 10 scans of other sites scans must be directly supervised, the remaining can be recorded and reviewed in portfolio. c) Pathology: i. Upper Extremity - Distal radius fracture (Smiths, Colles) - Humeral head - Boxer s fracture ii. Lower Extremity - Femoral shaft - Lateral/medial malleolus - 5th metatarsal iii. Other Fractures of sternum, ribs, clavicle d) Determinate Scans - Clear identification of the displacement of the cortex, - Ability to identify the amount and direction of cortical displacement, angulation if present e) Clinical Scenario - Identification of fractures following traumatic injuries, - To be able to integrate findings on ultrasound with radiography (as needed), - to use POCUS to measure adequacy of closed reduction (if performed) II. Dislocations a) Views: Posterior view of the shoulder at the level of the scapula, assessing the position of the humeral head.

20 b) Image Generation Requirements: - 6 supervised scans, with a minimum 3 which must be directly supervised, the remaining can be recorded and reviewed in portfolio. c) Pathology: - Anterior Shoulder dislocation - Posterior Shoulder dislocation d) Determinate Scans: - Clear identification of the displacement (anterior or posterior) of the humeral head with respect to the glenoid/scapula. e) Clinical Scenario - Identification of dislocation following traumatic injuries, seizure, etc., - To be able to integrate findings on ultrasound with radiography (as needed), - to use POCUS to measure adequacy of closed reduction (if performed). To provide US guidance for hematoma block. III. Joints Elbow, wrist, hip, knee, ankle a) Views: - Longitudinal and transverse views of the elbow, knee and ankle joints. Single, longitudinal views of the wrist and hip. b) Image Generation Requirements: - 20 determinate scans. A minimum of 10 scans must be directly supervised, the remaining can be recorded and reviewed in portfolio. c) Pathology: - Joint effusion d) Determinate Scans: Clear identification of articular area and ability to identify the presence or absence of a joint effusion. To differentiate a small effusion from the articular cartilage. e) Clinical Scenario - Identify presence or absence of a joint effusion in a patient presenting with swollen joint. - Identify the depth of the effusion (if present). - To provide surface landmarks to aid in the aspiration of the joint of effusion.

21 Table 1. CEUS AdApps Image Generation Requirements for IP2 Apprenticeship Advanced EDUS Applications Cardiac PLAX, PSAX, A4C, SX IVC- (spont. breathing or ventilated) Number of examinations* 50 (25 directly supervised) 10 (5 directly supervised) Positives** One of each of the following: PCE, RV Dilation, LV Failure, Hyperdynamic LV N/A Lung/Pleura 20 (10 directly supervised) Gallbladder 40 (Hepatobilliary) (20 directly supervised) Renal 20 (10 directly supervised) Bladder 5 (3 directly superivised) DVT 40 limbs (20 directly supervised) Needle Guidance Fractures 10 procedures (all supervised on simulators or in practice) 30 scans (10 directly supervised) Dislocations 6 (3 directly supervised) Joints 20 scans (10 directly supervised) Pneumothorax, Interstitial fluid, Pleural effusion Cholelothiasis, Cholecystitis, Mild, moderate and severe hydronephrosis N/A Thrombus in: Femoral vein, Greater Saph. Vein, popliteal vein, Venous access, fluid aspiration, nerve block Long bone fractures, Boxer s fracture, Smiths/Colles, Sternum Anterior and Posterior shoulder dislocation Joint effusion of elbow, knee, ankle, hip * Scans should be performed on a range of patient types (age, body habitus) with at least half being done on patients >50 yoa. ** If a specific positive scan has not been encountered during apprenticeship, the trainee should access a video library or simulated case and review it prior to challenging the exam. All positives (pathologies) must have been either encountered or at least reviewed by video prior to challenging the credentialing examination.