STANDARDS OF CERTIFICATION

Transcription

1 STANDARDS OF CERTIFICATION CENTER OF CLINICAL ULTRASOUND (CECLUS) FACULTY OF HEALTH AARHUS UNIVERSITY medical science education implementation better patient care Thomas Fichtner Bendtsen Lars Bolvig 2012

2 2 Content 0. Introduction Background Training Recommendations Anaesthesiological ultrasound Introduction a. Anaesthesiological ultrasound airway a.1 Introduction a.2 Level a.3 Level a.4 Level b. Anaesthesiological ultrasound - pleura and lung b.1 Introduction b.2 Level b.3 Level b.4 Level c1. Anaesthesiological ultrasound - heart c1.1 Introduction c1.2 Level c1.3 Level c1.4 Level c1.5 Maintenance of Skills c2. Anaesthesiological ultrasound vascular access c2.1 Introduction c2.2 Level c2.3 Level c2.4 Level c2.5 Maintenance of Skills c3. Anaesthesiological ultrasound efast (extended Focused Assessment with Sonography in Trauma) c3. 1 Introduction c3.2 Level c3.3 Maintenance of Skills d. Anaesthesiological ultrasound nerve blocks d.1 Introduction d.2 Level d.3 Level d.4 Level Obstetric (fetal medicine) ultrasound Introduction Level Level

3 3 2.4 Level Maintenance of skills Gynecological ultrasound Introduction Level Level Level Maintenance of skills Endocrinological ultrasound Introduction Level Level Level Pediatric ultrasound Introduction c1. Pediatric FATE (focus assessed transthoracic echocardiography) c1.1 Introduction c1.2 Level c1.3 Level c1.4 Level c1.5 Maintenance of skills c2. Pediatric extended FAST (focused assessment with sonography in trauma) c2.1 Introduction c2.2 Level c3. Pediatric ultrasound guided vascular access c3.1 Introduction d. Pediatric neurology ultrasound d.1 Introduction d.2 Level d.3 Maintenance Oto-rhino-laryngeal ultrasound Introduction Level Level Level Maintenance of skills Orthopedic surgery ultrasound Introduction Level Level Level Maintenance of skills Rheumatological ultrasound Introduction Level Level

4 4 8.4 Level Maintenance of skills Infectious Diseases Ultrasound Introduction Cardiology Introduction Level Level Level Maintenance of Skills Lung Medicine Ultrasound Introduction Level Level Level Maintenance of skills Ultrasound in Surgical Gastroenterology Introduction Level Level Level Maintenance of skills Ultrasound of vascular surgery Introduction Level Level Level Maintenance of skills Ultrasound of neurology Introduction Level Level Level Maintenance of skills Ultrasound of general medicine Introduction Level Maintenance of skills Ultrasound of geriatric medicine Introduction Level Maintenance of skills Medical Gastroenterology Ultrasound Introduction Level Level Level

5 Maintenance of skills Contacts...213

6 0. Introduction 0.1 Background The increasing applications of ultrasound imaging throughout medical practice, together with the increasing availability of cheaper and smaller ultrasound scanners, mean that more medical personnel is using ultrasound equipment to perform and interpret ultrasound scans. Ultrasound has an enviable safety record to date. Various bodies, including scientific societies and manufacturers associations have made recommendations concerning the safe and prudent operation of ultrasound equipment, but, unlike imaging equipment, which makes use of ionizing radiation there is virtually no national or international regulation of ultrasound usage. The quality of clinical point-of-care (POC) ultrasound depends on the skill of the operator. To maximize the quality, safety and cost-effectiveness of a clinical ultrasound service and appropriately address the ethical and legal concerns of inadequately trained ultrasound operators, the personnel needs to be appropriately trained and to use equipment of appropriate quality. An appropriate level of training secures a safe and effective diagnostic, interventional or clinically focused ultrasound service. However, due to the complexity of issues involved, few have developed specialized national training schemes for clinical ultrasound and for instance echocardiography accreditation (through EAE, BSE or the ASE) does not reflect the requirements of the anesthesiologist and the ICU practitioner, as they contain heavy emphasis on valvular disease, little haemodynamic monitoring, and an absence of pathology in the critically ill. The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) has proposed minimal training requirements for the practice of medical ultrasound in Europe. The hospital and department managements must acknowledge the requirements to deliver training: the time commitment of the trainer and trainee, the provision of proper budgeting and funding, the content and practicability of the curriculum and the availability of trainers and training courses and provision of appropriate space and equipment. Training should be related to the specialist requirements of the trainee i.e. training should

7 7 be modular. Within any one level of training it may be appropriate for a trainee to become proficient in some but not all of the individual modules and only undertake ultrasound practice in this/these areas. Except level one which contains the basic common trunk. Training should be given in departments which have a multidisciplinary (medical, surgical, radiological etc) philosophy, an adequate throughput of work, a trainer with experience and an interest in training in the module required, appropriate equipment and an active audit process. Regular appraisal should take place during the training period. At the end of a period of training a competency assessment form should be completed for each trainee, which will determine the area or areas in which they can practice independently. The responsibility to be adequately trained and to maintain those skills lies with the individual practising ultrasound. An assessment of competence is a reflection on the position at that moment in time and no more. Following training, regular and relevant continued medical education (CME)/continued professional development (CPD) should be undertaken and documented. It is the responsibility of the trainee to ensure that their practical skills are maintained by ensuring regular ultrasound clinics are undertaken and that there is an adequate range of pathology seen in their ultrasound practice. 0.2 Training Recommendations Training should consist of a theoretical module and practical modules of training. Theoretical Training Theoretical training should cover the physics of waves, sound waves and ultrasound, and ultrasound system controlled imaging, ultrasound user controlled imaging, image recording and reporting, sonographic image artefacts, sonoananatomy, sonopathology, and the relevance of other imaging modalities to ultrasound. This element of training may be best achieved by attending formal courses. Practical Training A curriculum for each module for the three levels of training has been developed incorporating a practical syllabus listing conditions which should be included in the experience of the trainee. In appropriate circumstances, a limited anatomical or modular

8 8 approach may also be acceptable if full competence in that area is demonstrated and future clinical practice is confined to that area alone. Practical experience should be gained under the guidance of a named trainer. The requirements for the different levels of training are as follows: Level 1 Practice at this level would usually require the following abilities: a. to perform common examinations safely and accurately b. to recognize and differentiate normal anatomy and pathology c. to diagnose common abnormalities within certain organ systems d. to perform appropriate interventions and clinically focused protocols e. to recognize when referral for a second opinion is indicated Within most medical specialties, the training requisite to this level of practice would be gained during conventional post-graduate specialist training programs. Different trainees will acquire the necessary skills at different rates and the end-point of the training program should be judged by an assessment of practical competence. Examinations/certification should encompass the full range of diagnostics/pathological conditions, interventions/procedures and clinically focused protocols listed in the modules. A log book listing the number and type of examinations undertaken by the trainee themselves should be kept. An illustrated log book of specific normal and abnormal findings may be appropriate for some modules. Training should usually be supervised by a level 2 practitioner. In certain circumstances it may be appropriate to delegate some of this supervision to an experienced level 1 practitioner with at least two years of regular practice. Level 2 This is an advanced level of practice and requires the following abilities: a. to accept and manage referrals from Level 1 practitioners b. to recognize and correctly diagnose almost all pathology within the relevant organ system

9 9 c. to perform all relevant ultrasound-guided invasive procedures d. to teach ultrasound to trainees and to Level 1 practitioners e. to conduct some research in ultrasound The training requisite to this level of practice would be gained during a period of subspecialty training, which may either be within or after the completion of a specialist training program. This requires at least one year of experience at level 1 with regular ultrasound clinics. A significant further number of examinations should have been undertaken in order to encompass the full range of conditions and procedures encountered in each module. A log book listing the numbers and types of examinations undertaken by the trainee should be maintained. An illustrated log book of specific normal and abnormal findings is appropriate. Supervision of training should be undertaken by someone who has achieved at least level 2 competence and has had at least two years experience at that level. Level 3 This is an expert level of practice, which involves the following abilities: a. to accept tertiary referrals from Level 1 and 2 practitioners b. to perform advanced (level 2) ultrasound examinations c. to perform advanced (level 2) ultrasound-guided invasive procedures d. to conduct substantial research in ultrasound e. to teach ultrasound at all levels f. to be aware of and to pursue developments in ultrasound This requires practitioners to spend a significant part of their time undertaking ultrasound examinations and/or teaching, research and development in the field of ultrasound. Continuing Medical Education (CME) and Professional Development (CPD) The minimum amount of on-going experience in ultrasound as outlined in each syllabus should be maintained.

10 10 CME/CPD should be undertaken which incorporates elements of ultrasound practice. Regular audit of the individual s ultrasound practice should be undertaken to demonstrate that the indications, performance and diagnostic quality of the service is satisfactory.

11 1. Anaesthesiological ultrasound 1.1 Introduction The curriculum of anaesthesiological ultrasound is 3-leveled and modular in order to relate the training to the specialist requirements of the trainee. Within any level of training it may be appropriate for a trainee to become proficient in some but not all of the individual modalities and only undertake ultrasound practice in this/these areas. Except level one which contains the basic common trunk for all specialists of anaesthesiology. The modalities of anaesthesiological ultrasound are: - airway - pleura/lung - heart - vascular access - efast - nerve blocks

12 12 1a. Anaesthesiological ultrasound airway 1a.1 Introduction This curriculum is intended for prespecialists and specialists of anaesthesiology who perform ultrasound guided Airway Management (UGAM). It includes standards for theoretical knowledge and practical skills. Introductory level Performance of supervised basic UGAM prior to Level 1 certification. Level 1 (basic) Performance of unsupervised basic UGAM. Basic UGAM: easy and effective ultrasound guided exams and procedures for airway management. Basic UGAM certification should be obtained by all specialists in anaesthesiology. It is recommended that all anaesthesiologists obtain Level 1 competence, preferably during their specialist training. At least Level 1 competence should be obtained by anyone performing UGAM unsupervised. Level 2 (advanced) Subspecialized anaesthesiologist who performs basic and advanced UGAM most working days. Advanced UGAM: all UGAM procedures beyond basic UGAM. Advanced UGRA certification is typically obtained by specialists in anaesthesiology subspecialized in anaesthesia for otorhinolaryngology. Level 3 (expert) Anaesthesiologists who performs basic and advanced UGAM every working day and most of the day, and who is active with science and teaching. Only very few anaesthesiologists obtain expert UGAM level. They are typically employed in a few university hospital centers.

13 13 Typical progression from Introductory level to Level 3 (1) Course pretest (2) Theory course of basic UGAM (3) Theory course posttest (4) Practical hands-on course of basic UGAM (2) Course exam in theory and practice of basic UGAM (3) Supervised procedures of basic UGAM (4) Level 1 certification of basic UGAM (5) Unsupervised maintenance of basic UGAM (6) Theory & practice course of advanced UGAM (7) Course exam of advanced UGAM (8) Supervised procedures of advanced UGAM (9) Level 2 certification of advanced UGAM - theory & practice (10) Level 3 certification of expert UGAM: Level 2 certified + minimum 500 basic and advanced UGAM procedures per year for at least two years + teaching experience within advanced UGAM + minimum three scientific publications about UGAM in peer reviewed papers (PhD level) 1a.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical Course A minimum of 20 hours theoretical and practical teaching is required preferably at the beginning of the training period. This should include: Wave, sound wave and ultrasound physics Ultrasound system controls Ultrasound user controls Ultrasound techniques Ergonomics Sterility Safety Administration (see Appendix 2) Sonoanatomy

14 14 Normal airway o tongue o thyroid and cricoid cartilages o cricothyroid membrane o thyroid rings o pretracheal soft tissue Normal pleura o lung sliding o lung pulse o diaphragm, lever, spleen, vertebral column Level 1 Competencies to be acquired To be able to: Perform a basic airway US exam US guided verification of endotracheal intubation US guided confirmation of endotracheal tube placement US guided localization of the cricothyroid membrane US guided cricothyrotomy US guided localization of the trachea Level 1 Theoretical & Practical Course The course content is equal to the Level 1 knowledge base and the Level 1 competencies to be acquired listed above. The course should be minimum 20 hours duration at the beginning of the training period. The theory course should include a pre- and a posttest. The entire course should be concluded with a course exam covering theory and practice. The practical sessions should be performed as Hands On Training (HOT): - HOT 1 o Basic UGAM views on normal models o Revision of normal findings - HOT 2 o Basic UGAM views on normal models or patients or sonosimulators o Revision of pathological findings (tutorial laptops)

15 15 - HOT 3 o Individual reappraisal with interactive in-depth training The course should be concluded with a course exam in theory and practice of basic UGAM: Theory (30 minutes, 25 MCQ) Practice (15 minutes, simulator or model) Proctored Level 1 practice Supervision and recommended number of exams: Within 3 months after the course, the trainee should collect a minimum of 50 UGAM exams under supervision: 25 fully supervised basic UGAM exams (TYPE A exams) + 25 autonomously collected (TYPE B exams, for later validation). The last 25 autonomously performed exams can be validated either by: a) physical delivery of the electronic logbook + digital clips/images on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the collection is completed; b) by internet sharing with a distant tutor. Training should usually be supervised by a level 2 practitioner. In certain circumstances it may be appropriate to delegate some of this supervision to an experienced level 1 practitioner with at least two years of regular practical experience. When local tutors are not available, the 25 TYPE A exams can be replaced by 25 autonomously collected exams and internet sharing with a distant tutor where the exams are uploaded and audited sequentially one-by-one (a dedicated area will be activated on the CECLUS channel, with reserved access to trainer s page matched with distance tutor). Lack of information on single cases, not allowing accurate judgement on trainees competence makes the case not valid for final certification. Documentation: All exams must be video recorded and archived in digital format and data collected in the electronic logbook (excel file). The documentation should record time spent, need for supervision and correction, and rating of sonoanatomic skill, imaging, image quality, and diagnostic performance. During the course of training the competency assessment sheet should be completed. Curriculum: An exam can be a real clinical UGAM exam or a simulated UGAM exam: Didactic cases (provided from local tutors and from distant tutors) should compensate for lack of an adequate number of cases on some types of less frequent abnormalities.

16 16 These should not be reported in the logbook but rather listed, indicated separately as part of exam final documentation. Sequential examinations on the same patients upon relevant clinical/therapeutical changes are encouraged; provided there s relevant change in the findings, they will be counted as individual cases. No more than 10% exams with normal findings are to be considered for the final certification Final Level 1 certification of basic UGAM Different trainees will acquire the necessary skills at different rates and the end point of the training programme should be judged by an assessment of competencies in the form of theoretical and practical certification. The theoretical and practical certification should encompass the full range of the Level 1 knowledge database and competencies to be acquired listed above. Theory (2 hours,100 MCQ) Practice (30 minutes, simulator or model) Areas of competence assessed during certification examination: Image generation Image acquisition Image interpretation Image administration Clinical and organizational thinking Tools that may be used for the assessment during certification examination: MCQs (overall theoretical assessment) Videoclip assessment (assessment of pathological clips interpretation and simulated clinical integration of findings) UGAM exam on a healthy volunteer (assessment of technical skills in machine setting, image acquisition and storage) UGAM on a real patient with relevant morbidity (overall practical assessment) Case discussion presented by the trainee

17 17 1a.3 Level 2 The training requisite to this level of practice would be gained during a period of subspecialty training, which may either be within or after the completion of a specialist training programme. The training should include a theoretical and practical course of at least 30 hours (see below) followed by a theoretical and practical examination and the trainee should read appropriate literature, scientific journals, and textbooks Competencies will have been acquired during training for level 1 practice which will then be refined by performing a minimum of 30 clinic sessions at a centre where supervision by someone with a Level 2 competence is available. Typically a Level 2 practitioner will have undertaken at least 500 ultrasound examinations within advanced UGAM before Level 2 certification. An electronic log book should be kept documenting a minimum of 50 exams which should include ideally all Level 2 competencies for advanced UGAM. An exam can be a real clinical UGAM exam or a simulated UGAM exam. A minimum of 25 exams have to be real clinical UGAM exams. The theoretical and practical certification should encompass the full range of procedures listed below. Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and Practical Course o new ultrasound modalities (eg. 3D and 4D ultrasound) o advanced sound and ultrasound physics o advanced ultrasound system machine controls o advanced ultrasound system user controls o advanced ultrasound techniques o advanced administration (teaching, documentation, organization) o advanced ultrasound artefacts o advanced UGAM o airway anatomy and sonoanatomy o complications o safety

18 18 Level 2 Competencies to be acquired o UGRA o exams of the tongue, oro-pharynx, hypo-pharynx, hyoid bone, larynx, vocal cords, cricothyroid membrane, cricoid cartilage, trachea, esophagus o prediction of difficult laryngoscopy in surgical patients o evaluation of pathology that may influence the choice of airway management technique (e.g. subglottic hemangiomas, laryngeal stenosis, laryngeal cysts, respiratory papillomatosis, pharyngeal pouch, various malignancies) o prediction of the appropriate diameter of endotracheal-, endobronchial-, or tracheostomy tube o localization of the trachea o localization of the cricothyroid membrane o confirmation of endotracheal tube placement 1a.4 Level 3 A level 3 practioner is likely to spend the majority of their time undertaking UGAM or teaching, research and development within their subspecialized field and will be an expert in this area. 1a.5 Maintenance of Skills Having been assessed as competent to practice there will be a need for continued professional development (CPD) and maintenance of practical skills. Recommended numbers of examinations to be performed annually to maintain skills at each level are given in the text. Practitioners should: include UGAM in their continued medical education (CME) audit their practice participate in multidisciplinary meetings keep up to date with relevant literature

19 19 1b. Anaesthesiological ultrasound - pleura and lung 1b.1 Introduction This curriculum is intended for prespecialists and specialists of anesthesiology who perform lung ultrasound (LUS). It includes standards for theoretical knowledge and practical skills. Introductory level Performance of supervised basic LUS prior to Level 1 certification. Level 1 (basic) Performance of unsupervised basic LUS. Basic LUS: easy and effective LUS for perioperative, emergency and critical care respiratory management. Basic LUS certification should be obtained by all specialists in anaesthesiology. It is recommended that all anaesthesiologists obtain Level 1 competence, preferably during their specialist training. At least Level 1 competence should be obtained by anyone performing basic LUS unsupervised. Level 2 (advanced) Subspecialized anaesthesiologist or critical care specialist who performs basic and advanced LUS most working days. Advanced LUS certification is typically obtained by specialists in anaesthesiology or intensive care medicine or lung medicine. Level 3 (expert) Expert who performs basic and advanced LUS every working day and most of the day, and who is active with science and teaching. Only very few clinical specialists obtain expert LUS level. They are typically employed in a few university hospital centers. Typical progression from Introduction Level to Level 3 (1) Course pretest (2) Theory course of basic LUS

20 20 (3) Theory course posttest (4) Practical hands-on course of basic LUS (2) Course exam in theory and practice of basic LUS (3) Supervised procedures of basic LUS (4) Level 1 certification of basic LUS (5) Unsupervised maintenance of basic LUS (6) Theory & practice course of advanced LUS (7) Course exam of advanced LUS (8) Supervised procedures of advanced LUS (9) Level 2 certification of advanced LUS - theory & practice (10) Level 3 certification of expert LUS: Level 2 certified + minimum 500 basic and advanced LUS procedures per year for at least two years + teaching experience within advanced LUS + minimum three scientific publications about LUS in peer reviewed papers (PhD level) 1b.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical Course Sound and ultrasound physics Ultrasound system machine controls Ultrasound system user controls Ultrasound techniques Ergonomics Sterility Safety Administration (see Appendix 2) Sonoanatomy Normal pleura o lung sliding o lung pulse o diaphragm, lever, spleen, vertebral column

21 21 Sonopathology pneumothorax pleural effusion Level 1 Competencies to be acquired To be able to: Perform a basic lung US exam US guided pleural chest tube insertion Level 1 Theoretical & Practical Course The course content is equal to the Level 1 knowledge base and the Level 1 competencies to be acquired listed above. The course should be minimum 20 hours duration at the beginning of the training period. The theory course should include a pre- and a posttest. The entire course should be concluded with a course exam covering theory and practice. The practical sessions should be performed as Hands On Training (HOT): - HOT 1 o Basic LUS views on normal models o Revision of normal findings - HOT 2 o Basic LUS views on normal models or patients or sonosimulators o Revision of pathological findings (tutorial laptops) - HOT 3 o Individual reappraisal with interactive in-depth training The course should be concluded with a course exam in theory and practice of basic LUS: Theory (30 minutes, 25 MCQ) Practice (15 minutes, simulator or model) Proctored Level 1 practice Supervision and recommended number of exams: Within 3 months after the course, the trainee should collect a minimum of 100 LUS exams under supervision: 50 fully supervised basic LUS exams (TYPE A exams) + 50 autonomously collected (TYPE B

22 22 exams, for later validation). The last 50 autonomously performed exams can be validated either by: a) physical delivery of the electronic logbook + digital clips/images on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the collection is completed; b) by internet sharing with a distant tutor. Training should usually be supervised by a level 2 practitioner. In certain circumstances it may be appropriate to delegate some of this supervision to an experienced level 1 practitioner with at least two years of regular practical experience. When local tutors are not available, the 50 TYPE A exams can be replaced by 50 autonomously collected exams and internet sharing with a distant tutor where the exams are uploaded and audited sequentially one-by-one (a dedicated area will be activated on the CECLUS channel, with reserved access to trainer s page matched with distance tutor). Lack of information on single cases, not allowing accurate judgement on trainees competence makes the case not valid for final certification. Documentation: All exams must be video recorded and archived in digital format and data collected in the electronic logbook (excel file). The documentation should record time spent, need for supervision and correction, and rating of sonoanatomic skill, imaging, image quality, and diagnostic performance. During the course of training the competency assessment sheet should be completed. Curriculum: All the above mentioned pathology scenarios should be represented. An exam can be a real clinical LUS exam or a simulated LUS exam: Didactic cases (provided from local tutors and from distant tutors) should compensate for lack of an adequate number of cases on some types of less frequent abnormalities. These should not be reported in the logbook but rather listed, indicated separately as part of exam final documentation. Sequential examinations on the same patients upon relevant clinical/therapeutical changes are encouraged; provided there s relevant change in the findings, they will be counted as individual cases. No more than 10% exams with normal findings are to be considered for the final certification Final Level 1 certification of basic LUS Different trainees will acquire the necessary skills at different rates and the end point of the training programme should be judged by an assessment of competencies in the form of theoretical and practical certification. The theoretical and practical certification should

23 23 encompass the full range of the Level 1 knowledge database and competencies to be acquired listed above. Theory (2 hours,100 MCQ) Practice (30 minutes, simulator or model) Areas of competence assessed during certification examination: Image generation Image acquisition Image interpretation Image administration Clinical and organizational thinking Tools that may be used for the assessment during certification examination: MCQs (overall theoretical assessment) Videoclip assessment (assessment of pathological clips interpretation and simulated clinical integration of findings) LUS exam on a healthy volunteer (assessment of technical skills in machine setting, image acquisition and storage) LUS on a real patient with relevant morbidity (overall practical assessment) Case discussion presented by the trainee 1b.3 Level 2 The training requisite to this level of practice would be gained during a period of subspecialty training, which may either be within or after the completion of a specialist training programme. The training should include a theoretical and practical course of at least 30 hours (see below) followed by a theoretical and practical examination and the trainee should read appropriate literature, scientific journals, and textbooks Competencies will have been acquired during training for level 1 practice which will then be refined by performing a minimum of 30 clinic sessions at a centre where supervision by someone with a Level 2 competence is available.

24 24 Typically a Level 2 practitioner will have undertaken at least 500 ultrasound examinations within advanced LUS before Level 2 certification. An electronic log book should be kept documenting a minimum of 50 exams which should include ideally all Level 2 competencies for advanced LUS. An exam can be a real clinical LUS exam or a simulated LUS exam. A minimum of 25 exams have to be real clinical LUS exams. The theoretical and practical certification should encompass the full range of procedures listed below. Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and Practical Course o new ultrasound modalities (eg. image fusion and 4D ultrasound) o advanced sound and ultrasound physics o advanced ultrasound system machine controls o advanced ultrasound system user controls o advanced ultrasound techniques o advanced administration (teaching, documentation, organization) o advanced ultrasound artefacts o advanced LUS o anatomy and sonoanatomy o pathology and sonopathology o complications o safety Level 2 Competencies to be acquired o LUS o diagnose pneumothorax o diagnose pleural effusion o diagnose rib fractures o diagnose interstitial syndrome o diagnose lung edema o diagnose ARDS

25 25 o diagnose interstitial lung disease o diagnose respiratory distress syndrome o diagnose lung consolidation o diagnose pneumonia o diagnose lung embolus o diagnose lung tumour o diagnose atelectasis (compression, obstruction) o examination of acute, severe respiratory insufficiency with the BLUE (Bedside Lung Ultrasound in Emergency) protocol o control of lung ventilation after intubation 1b.4 Level 3 A level 3 practioner is likely to spend the majority of their time undertaking LUS or teaching, research and development within their subspecialized field and will be an expert in this area. 1b.5 Maintenance of Skills Having been assessed as competent to practice there will be a need for continued professional development (CPD) and maintenance of practical skills. Recommended numbers of examinations to be performed annually to maintain skills at each level Level 1: the practitioner should perform at least 100 basic LUS exams each year. Level 2: the practitioner should perform at least 200 basic and advanced LUS exams each year. Level 3: the practitioner should perform at least 400 basic and advanced LUS exams each year. Practitioners should: include LUS in their continued medical education (CME) audit their practice participate in multidisciplinary meetings keep up to date with relevant literature

26 26 1c1. Anaesthesiological ultrasound - heart 1c1.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of prespecialists and specialists of anaesthesiology who perform focused cardiac ultrasound also called FATE (focus assessed transthoracic echocardiography). The FATE curriculum includes standards for theoretical knowledge and practical skills. Introductory level (pre-certification) Performance of supervised basic FATE prior to Level 1 certification. Level 1 (basic) certification Performance of unsupervised basic FATE. Basic FATE is easy and effective basic assessment of haemodynamics with ultrasound. Basic FATE certification should be obtained by all clinical specialists assessing potentially acute or critically ill patients. It is especially recommended that all anaesthesiologists obtain Level 1 FATE competence, preferably prior to or during their specialist training. At least Level 1 competence should be obtained by anyone performing basic FATE unsupervised. Level 2 (advanced) certification Subspecialized clinical specialist who performs focused cardiac assessment with ultrasound most working days. Advanced FATE is typically obtained by specialists in anaesthesiology subspecialized in anaesthesia for cardiothoracic surgery or intensive care medicine or emergency medicine. Level 3 (expert) certification Clinical specialists who perform basic and advanced FATE every working day and most of the day, and who are active with FATE related science and teaching. Only very few clinical specialists employing FATE obtain the expert FATE level 3 certification. They are typically employed in university hospital centers.

27 27 Typical progression from Introductory level to Level 3 (1) Theory course pretest (2) Theory course of basic FATE (3) Theory course posttest (4) Practical hands-on course of basic FATE (2) Course exam in theory and practice of basic FATE (3) Proctored practice (supervised procedures) of basic FATE (4) Level 1 certification of basic FATE (5) Unsupervised maintenance of basic FATE (6) Theory & practice course of advanced FATE (7) Course exam of advanced FATE (8) Supervised procedures of advanced FATE (9) Level 2 certification of advanced FATE - theory & practice (10) Level 3 certification of expert FATE: Level 2 certified + minimum 500 basic and advanced FATE exams per year for at least two years + teaching experience within advanced FATE + minimum three FATE related scientific publications in peer reviewed papers (PhD level) 1c1.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical Course Wave, sound and ultrasound physics Ultrasound system machine controls Ultrasound system user controls Ultrasound techniques - B mode (2D brightness mode) - M mode (motion mode) - Power Doppler - Pulsed wave Doppler - Continous wave Doppler Ergonomics

28 28 Sterility Safety Administration Implementation of a focused echocardiography program Sonoanatomy basic TTE (transthoracic echocardiography) 2D views o subcostal 4-chamber o apical 4-chamber o parasternal long axis o parasternal short axis at the following levels: aortic valve (base) mitral leaflet tips papillary muscles Cardiac function systolic ventricular function diastolic ventricular function ejection fraction fractional shortening mitral septal separation mitral annular plane systolic excursion (MAPSE) tricuspid annular plane systolic excursion (TAPSE) LV dimensions (2D and M-mode) Septal thickness at end diastole Cavity size at the end diastole Posterior wall thickness at end diastole Cavity size at end systole Aortic root dimension Left atrial dimension Sonopathology Basic cardiac chamber dysfunction o dilated left atrium o dilated left ventricle

29 29 o dilated right atrium o dilated right ventricle o hypertrophy left ventricle Mesothelial cavities o pericardial effusion basic US diagnosis of cardiac tamponade US guided pericardiocentesis Pedunculated masses Endocarditis and the valves Hypovolemia Level 1 Competencies to be acquired To be able to perform a basic FATE exam: Perform echocardiographic examinations safely and accurately and acquire all standard views To recognise and differentiate between normal anatomy/physiology and pathology To diagnose common abnormalities within the cardiovascular system To recognize when a referral for a second opinion is indicated To understand the relationship between echocardiographic imaging and other diagnostic imaging techniques Perform focused point-of-care echocardiographic hemodynamic monitoring of patient response to interventions and diagnostics: o Ventricular function Systolic function and wall motion abnormalities Diastolic function o Hypovolemia and volume responsiveness o Tamponade and pericardial disease o The sepsis syndromes o Effects of preload and afterload and assessment of filling status o Acute cor pulmonale o Hypoxemia o Complications of acute MI

30 30 o Chest trauma o Assessment of shock o Peri-resuscitation o Failure to wean from mechanical ventilation o Hemodynamic measurements Level 1 Theoretical & Practical Course The course content is equal to the Level 1 knowledge base and the Level 1 competencies to be acquired listed above. The course should be minimum 20 hours duration at the beginning of the training period. The theory course should include a pre- and a posttest. The entire course should be concluded with a course exam covering theory and practice. The practical sessions should be performed as Hands On Training (HOT): - HOT 1 o Basic TTE views on normal models o Revision of normal findings - HOT 2 o Basic TTE views on normal models or patients or sonosimulators o Revision of pathological findings (tutorial laptops) - HOT 3 - Individual reappraisal with interactive in-depth training The course should be concluded with a course exam in theory and practice of basic FATE: Theory (30 minutes, 25 MCQ) Practice (15 minutes, simulator or model) Proctored Level 1 practice Supervision and recommended number of exams: Within 3 months after the course, the trainee should collect a minimum of 25 basic FATE exams under supervision: 25 fully supervised basic FATE exams (TYPE A exams) + 25 autonomously collected (TYPE B exams, for later validation). The last 25 autonomously performed exams can be validated either by: a) physical delivery of the electronic logbook + digital clips/images on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the collection is completed; b) by internet sharing with a distant tutor. Training should

31 31 usually be supervised by a level 2 practitioner. In certain circumstances it may be appropriate to delegate some of this supervision to an experienced level 1 practitioner with at least two years of regular practical experience. When local tutors are not available, the 25 TYPE A exams can be replaced by 25 autonomously collected exams and internet sharing with a distant tutor where the exams are uploaded and audited sequentially one-by-one (a dedicated area will be activated on the CECLUS channel, with reserved access to trainer s page matched with distance tutor). Lack of information on single cases, not allowing accurate judgement on trainees competence makes the case not valid for final certification. Documentation: All exams must be video recorded and archived in digital format and data collected in the electronic logbook (excel file). The documentation should record time spent, need for supervision and correction, and rating of sonoanatomic skill, imaging, image quality, and diagnostic performance. During the course of training the competency assessment sheet should be completed. Curriculum: All the above mentioned pathology scenarios should be represented. An exam can be a real clinical UVS exam or a simulated UVS exam: Didactic cases (provided from local tutors and from distant tutors) should compensate for lack of an adequate number of cases on some types of less frequent abnormalities. These should not be reported in the logbook but rather listed, indicated separately as part of exam final documentation. Sequential examinations on the same patients upon relevant clinical/therapeutical changes are encouraged; provided there s relevant change in the findings, they will be counted as individual cases. No more than 10% exams with normal findings are to be considered for the final certification. Final Level 1 certification of basic FATE Different trainees will acquire the necessary skills at different rates and the end point of the training programme should be judged by an assessment of competencies in the form of theoretical and practical certification. The theoretical and practical certification should encompass the full range of the Level 1 knowledge database and competencies to be acquired listed above. Theory (2 hours,100 MCQ) Practice (30 minutes, simulator or model)

32 32 Areas of competence assessed during examination: Image generation Image acquisition Image interpretation Image administration Clinical and organizational thinking Tools that may be used for the assessment during examination: MCQs (overall theoretical assessment) Videoclip assessment (assessment of pathological clips interpretation and simulated clinical integration of findings) TTE on a healthy volunteer (assessment of technical skills in machine setting, image acquisition and storage) TTE on a real critical or cardially morbid patient (overall practical assessment, including ECHO-guided patient management) Case discussion presented by the trainee 1c1.3 Level 2 Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and Practical Course o new ultrasound modalities (eg. 4D ultrasound and image fusion) o contrast agents o advanced sound and ultrasound physics o advanced ultrasound system machine controls o advanced ultrasound system user controls o advanced ultrasound techniques o advanced administration (teaching, documentation, organization) o advanced ultrasound artefacts o advanced FATE: o systolic function preload (Frank-Starling's law) afterload (LaPlace's law)

33 33 contractility (intrinsic myocardial function) ejection fraction (eyeballing, calculation with M-mode) hemodynamic parameters (cardiac output (CO) with pulsed wave Doppler (PWD)) o diastolic function compliance and relaxation of the left ventricle using transmitral flow curve visualized with PWD estimating inotropic effect and/or volume effect o pericardial effusion o pleural effusion o pathology (lung embolus, acute coronary syndrome, papillary muscle rupture, septic shock, chest trauma, complicated AMI, cardiac tamponade, pulmonary oedema (cardiogenic and non-cardiogenic), weaning failure from mechanical ventilation, ARDS, acute valvular dysfunction) o valvular stenosis using pressure gradients (continuous wave Doppler - CWD) o insufficiency jets (valvular insufficiency) and atrial septal defect and ventricular septal defect using colour flow Doppler (CFD) o assessment of wall thickness and chamber dimensions in M-mode o assessment of bi-ventricular function o application of extended FATE views subcostal vena cava apical 2-chamber view apical long-axis view apical 5-chamber view parasternal short axis mitral plane view parasternal aorta short axis view o diastolic left ventricular function o Doppler (continuous wave, pulsed wave) o Measurement of cardiac filling pressures o Measurement of cardiac output and pulmonary artery pressure

34 34 Level 2 Competencies to be acquired Competencies will have been gained during training for Level 1 practice and then refined during a period of practice To be able to: o advanced FATE o perform the advanced FATE protocol o estimate chamber dimensions and left ventricular diameter (M-mode) o estimated contractility (systolic function) of both ventricles o estimate fractional shortening (FS) and ejection fraction (EF) with M-mode of the left ventricle o estimated cardiac output of left ventricle with continuous wave Doppler o gauge mitral annular plane systolic excursion (MAPSE) o gauge mitral septal separation (MSS) o gauge tricuspid annular plane systolic excursion (TAPSE) o visualize transmitral flow with PWD o identify important pathology, e.g. left ventricular dilatation, left ventricular hypertrophy, hypovolemia, left atrial dilatation, right ventricular dilatation, pericardial effusion, pleural effusion, anatomical defects. o detect valvular stenosis and/or insufficiency using CWD and CFD. o correlate sonographic findings to clinical context. o Color Doppler mapping o Quantitative spectral Doppler Pulsed Doppler Continous wave Doppler o TDI (Tissue Doppler Imaging) The training should include a theoretical and practical course of at least 30 hours (see below) followed by a theoretical and practical examination and the trainee should read appropriate literature, scientific journals, and textbooks Competencies will have been acquired during training for level 1 practice which will then be refined by performing a minimum of 30 clinical sessions at a centre where supervision by someone with a Level 2 competence is available.

35 35 Typically a Level 2 practitioner will have undertaken at least 800 ultrasound examinations within advanced FATE before Level 2 certification. An electronic log book should be kept documenting a minimum of 50 procedures which should include ideally all Level 2 competencies for advanced FATE. The theoretical and practical certification should encompass the full range of sonopathology listed above. 1c1.4 Level 3 A Level 3 practioner is likely to spend the majority of their time undertaking FATE or teaching, research and development within their subspecialized field and will be an expert in this area. 1c1.5 Maintenance of Skills Having been assessed as competent to practice there will be a need for continued professional development (CPD) and maintenance of practical skills. Recommended numbers of examinations to be performed annually to maintain skills at each level Level 1: the practitioner should perform at least 100 basic UVS exams each year. Level 2: the practitioner should perform at least 200 basic and advanced UVS exams each year. Level 3: the practitioner should perform at least 400 basic and advanced UVS exams each year. Practitioners should: include FATE in their continued medical education (CME) audit their practice participate in multidisciplinary meetings keep up to date with relevant literature

36 36 Certification for physicians already holding national/international TTE certifications Physicians holding national or international echocardiography accreditation are considered technically competent in the execution of a Focused Echo exam. Their clinical competence in image integration into the critical or acute cardiac patient management should though be certified by provision of minimum 30 documented exams (Logbook) + exam on a critical patient + case discussion

37 1c2. Anaesthesiological ultrasound vascular access 1c2.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of prespecialist and specialist anesthesiologists who perform ultrasound guided vascular access (UGVA). UGVA includes standards for theoretical knowledge and practical skills. Introductory level (pre-certification) Performance of supervised basic UGVA prior to Level 1 certification. Level 1 (basic) UGVA certification Performance of unsupervised basic UGVA. Basic UGVA certification should be obtained by all specialists of anesthesiology, preferably prior to or during their specialist training. At least Level 1 competence should be obtained by anyone performing basic UGVA unsupervised. Level 2 (advanced) UGVA certification Subspecialized specialist of anaesthesiology who performs basic and advanced UGVA most working days. Level 3 (expert) UGVA certification Subspecialized experts of anaesthesiology who perform basic and advanced UGVA every working day, and who are active with UGVA related science and teaching. Only very few anaesthesiologists employing UGVA obtain the expert UGVA level 3 certification if any. They would typically be employed in a few university hospital centers. Typical progression from introductory level to Level 3 (1) Theory course pretest (2) Theory course of basic UGVA (3) Theory course posttest (4) Practical hands-on course of basic UGVA