Transesophageal echocardiography

Procedure 45 CLINICAL PRIVILEGE WHITE PAPER Transesophageal echocardiography Background Transesophageal echocardiography (TEE) is an ultrasound technique used to visualize the heart. A multi-crystal phased array or single crystal mechanical ultrasonic transducer is incorporated into a flexible gastroscope-like device. This arrangement allows the imaging transducer to be advanced into the esophagus, where it is positioned directly posterior to the heart. Cardiologists use TEE as a definitive diagnostic modality for a broad range of cardiovascular disorders, including suspected or proved diseases of the aorta. These diseases include aortic dissection, aneurysm, atherosclerosis, atrial pathology, infective endocarditis, prosthetic valve malfunction, and congenital abnormalities. Anesthesiologists also use TEE as a diagnostic monitoring technique inside the operating room and for preoperative and postoperative assessments outside the operating room. Even in nonoperative settings, anesthesiologists engaged in critical care medicine increasingly use TEE to evaluate and treat unstable patients in the intensive care unit. Involved specialists Cardiologists, surgeons, internists, anesthesiologists, neurologists, and emergency physicians. Positions of societies or academies ASE The American Society of Echocardiography (ASE) publishes Guidelines for Physician Training in Transesophageal Echocardiography. In this publication, the ASE states that TEE is one of a family of largely complementary echocardiographic techniques. In addition to TEE, these techniques include transthoracic M-mode, two-dimensional spectral Doppler, color flow Doppler imaging, and contrast echocardiography. Although TEE is unique in several important ways, the physician who uses TEE will also need to use many of the other foregoing echocardiographic modalities in evaluating the nature, A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006 1

extent, and significance of a variety of cardiac disorders. Therefore, a working familiarity with these related echocardiographic techniques is mandatory. Stress echocardiography and intravascular ultrasound are additional techniques that require special skills and training. Recommended background knowledge The physician who uses TEE to evaluate patients with suspected heart disease needs to have the following: 1. Substantial background and experience in general echocardiology as well as TEE 2. Thorough knowledge of cardiac disease and the hemodynamic alterations that characterize acquired and congenital disorders, and an understanding of the different diagnostic possibilities that require evaluation in a given clinical setting 3. Considerable understanding of ultrasonic image formation and Doppler assessment of intracardiac blood flow, tomographic cardiac anatomy and dynamics, the range of normal structural and functional findings, and the echocardiographic manifestations of a large number of cardiac disorders This background will help the physician performing and interpreting TEE studies to recognize pertinent abnormalities immediately, to document abnormal findings definitively when they are present, and to avoid false positive diagnoses. Training pathways Knowledge and experience in performing and interpreting TEE studies as well as in Level II general echocardiography and esophageal intubation can best be acquired during a formal period of cardiology fellowship training. Optimally, the training should be undertaken in an active echocardiographic laboratory, under the supervision of a fulltime physician director who has experience with all aspects of echocardiography and recognized expertise in TEE. Experience with probe passage, TEE examination technique, and interpretation of study findings should be accomplished in outpatient, critical care, and cardiac surgical settings be- 2 A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006

cause the clinical needs, hemodynamic variables, and technical and interpretive skills needed in these environments differ. The ASE believes that this experience is best achieved during a period of full-time training in echocardiography, and that the trainee should not be assigned conflicting clinical responsibilities during this training period. Note: While the ASE admits that it may be possible for a physician to perform and interpret TEE studies without becoming a fully trained cardiologist, the society does not advise that TEE procedures be performed or interpreted by a physician who has no special knowledge of cardiovascular disease. Recommended practical experience Training in the TEE examination needs to include practical experience in four different but intimately related areas: 1. Introduction of the TEE probe 2. Manipulation of the transducer 3. Optimization of instrument controls 4. Interpretation of the findings Recommended training components for developing and maintaining skills in TEE The ASE summarizes the components that are necessary for developing and maintaining proficiency in TEE in the following chart: Component Objective Duration General echocardiography, Level II Background needed for performance and interpretation 6 months or equivalent No. of cases (approx.) 300 Esophageal intubation TEE probe introduction Variable 25 TEE examination Skills in TEE performance and interpretation Variable 50 Ongoing education Maintenance of competence Variable 50 to 75 A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006 3

Maintenance of competence Physicians who perform and interpret TEE studies need to maintain ongoing continuing education in this field where technical improvements and innovations continue to modify techniques and broaden clinical applications. This education requires periodic attendance at postgraduate courses and workshops particularly those that focus on new developments. The maintenance of competence in TEE also requires the regular performance of TEE examinations, at a rate of approximately 50 to 75 cases per year, depending on complexity. The physician who does TEE studies less frequently will not be able to maintain his or her technical skills and will not be able to keep abreast of technical developments in the field. ASA, SCA Practice Guidelines for Perioperative Transesophageal Echocardiography is a report developed by a task force of the American Society of Anesthesiologists (ASA) and the Society of Cardiovascular Anesthesiologists (SCA). In this report, the task force states that anesthesiologists with basic training in perioperative TEE should be able to use TEE for indications that lie within the customary practice of anesthesiology. The task force realizes, however, that anesthesiologists with basic training occasionally will encounter unanticipated diagnostic issues that require the assistance of a physician with advanced TEE training. Also because it is essential for many intraoperative applications to obtain a definitive interpretation of the TEE examination at the time of surgery, the task force strongly recommends that anesthesiologists actively pursue collaboration with surgeons, cardiologists, or other physicians involved in a patient s care. Training pathways for residents in anesthesiology Introductory knowledge The task force recommends that all residents in anesthesiology acquire introductory knowledge in perioperative TEE. Every resident who completes the continuum of education in anesthesiology should understand how TEE can be safely and effectively used in essential perioperative applications. The training should include knowledge on the physical principles of echocardiographic imaging and blood flow measurements; two-dimensional echocardiographic anatomy of the heart and great vessels; and the perioperative indications, limitations, diagnostic capabilities, and risks of TEE. 4 A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006

Basic proficiency Residents in anesthesiology who wish to pursue basic training in perioperative TEE should acquire the cognitive and technical skills that will allow them to use TEE for indications that lie within the customary practice of anesthesiology. The training program should have an active perioperative TEE program. Although a physician can teach basic TEE skills with basic TEE proficiency, the training program should be under the guidance of, or in close collaboration with, a physician with advanced training in perioperative TEE. Basic cognitive skills include the following: 1. Knowledge of the physical principles of echocardiographic image formation and blood flow velocity measurement 2. Understanding the operation of the ultrasonographic instrument, including the function of all controls affecting the quality of data displayed 3. Knowledge of the equipment handling, infection control, and electrical safety recommendations associated with the use of TEE 4. Knowledge of the indications and the absolute and relative contraindications to the use of TEE 5. General knowledge of appropriate diagnostic modalities, especially transthoracic and epicardial echocardiography 6. Knowledge of the normal cardiovascular anatomy as visualized tomographically by TEE 7. Knowledge of commonly encountered blood flow velocity profiles as measured by Doppler echocardiography 8. Detailed knowledge of the echocardiographic presentations of myocardial ischemia and infarction 9. Detailed knowledge of echocardiographic presentation of normal and abnormal ventricular function 10. Detailed knowledge of the physiology and TEE presentation of air embolization 11. Knowledge of native valvular anatomy and function as displayed by TEE; knowledge of the major TEE manifestations of valve lesions and dysfunction and of the TEE techniques available for valve assessment 12. Knowledge of the principal TEE manifestations of cardiac masses, thrombi, and emboli; cardiomyopathies; pericardial effusions; and lesions of the great vessels Basic technical skills include the following: 1. Ability to operate the ultrasonograph, including controls affecting the quality of the displayed data A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006 5

2. Ability to safely perform a TEE-probe insertion in the anesthetized, tracheally intubated patient 3. Ability to perform a basic TEE examination 4. Ability to recognize major echocardiographic changes associated with myocardial ischemia and infarction 5. Ability to detect qualitative changes in ventricular function and hemodynamic status 6. Ability to recognize echocardiographic manifestations of air embolization 7. Ability to visualize cardiac valves in multiple views; ability to recognize gross valvular lesions and dysfunction 8. Ability to recognize large intracardiac masses and thrombi 9. Ability to detect large pericardial effusions 10. Ability to recognize common artifacts and pitfalls in TEE examinations 11. Ability to communicate the results of a TEE examination to the patient and to other health care professionals and to summarize these results cogently in the medical record Advanced proficiency Residents in anesthesiology who wish to attain an advanced level of training in perioperative TEE should acquire the cognitive and technical skills that will allow them to be able to exploit the full diagnostic potential of TEE in the perioperative period. The training should occur in cooperation with an established echocardiography service and the direct guidance of a physician with advanced proficiency in perioperative TEE. Credentialing and privileging According to the ASA/SCA task force, there are many organizations, most notably the American College of Surgeons, that are attempting to develop guidelines to assist hospitals in the granting of privileges. But these guidelines are primarily based on the recommendations of postgraduate training programs subjective experience. In view of this fact, the task force cannot justify the imposition of nationwide recommendations for the granting of initial privileges in perioperative TEE. However, it strongly supports requirements of continuous assessment of an individual s clinical performance using objective evidence as the basis for renewal of privileges. 6 A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006

Positions of other interested parties Saint Joseph Hospital, Lexington, KY According to Janet Guy, CMSC, medical staff coordinator at Saint Joseph Hospital in Lexington, KY, they have chosen the following TEE credentialing and privileging criteria for cardiologists and anesthesiologists. TEE cardiology criteria: Initial appointment: The applicant must show completion of a fellowship in cardiology or an approved course related to TEE performance and interpretation. A minimum of 25 TEE procedures must be evaluated by a qualified preceptor skilled in endoscopy to ensure appropriate intubation and associated anesthetic technique. Reappointment: The physician must be able to document that he or she has performed at least 10 procedures during the previous reappointment period. Anesthesiology criteria for intraoperative TEE monitoring Initial appointment: To be considered for Anesthesia Department TEE credentials, the applicant shall either have demonstrated competency during an approved residency program in anesthesia with a recommendation by the program director; or the applicant can provide documentation from a proctoring physician and evidence of training from a Society of Cardiovascular Anesthesiologists approved course. After documentation is received and confirmed, the Anesthesia Department will determine the applicant s initial TEE privilege level based on experience, national examination results, audited performance, and established Anesthesia Department TEE credential guidelines. Reappointment: The physician must be able to document that he or she has performed 100 procedures during the previous reappointment period. JCAHO The JCAHO has no formal position concerning the delineation of privileges for diagnostic angiography. However, its 1999 Comprehensive Accreditation Manual for Hospitals states (MS.5.4), Professional criteria... constitute the basis for granting initial or continuing medical staff membership and for granting initial, renewed, or revised clinical privileges. The Joint Commission further requires (MS.5.4.3) that the criteria at least A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006 7

Saint Joseph Hospital Department of Anesthesiology Transesophageal Echocardiograph Credentialing Guidelines Training Provisional Basic credentials Advanced training Advanced credentials Didactic SCA course (or other 20 hr. CME course) SCA course (or other 20 hr. CME course) SCA course (or other 20 hr. CME course) SCA course (or other 20 hr. CME course) SCA course (or other 20 hr. CME course) Exams 25 Probe insertions and complete exams 25 75 Complete Exams > 75 complete exams Basic plus 25 exams of advanced proficiency (valves, masses, pericardiectomy) >100 including 25 proctored exams at advanced proficiency Qualified proctor Basic or advanced Advanced None, in scope of practice Advanced or cardiologist None Appropriate cases Any, but trainee will not also provide anesthetic CABG, with EF <40%, age >60 years old, pt with high risk of ischemia CABG, with EF < 40%, age > 60 years old, pt with high risk of ischemia Basic plus advanced with an identified proctor available at all times Basic and advanced proficiency Scope of practice None Evaluate LV filing, global contractility, atheromatous aorta, recognize valvular pathology and abnormal structures, with proctor Evaluate LV filing, global contractility, atheromatous aorta, recognize valvular pathology and abnormal structures Advanced, and must have a proctor available at all times Advanced Interventions None None without proctor except manipulate LV filing and contractility Manipulate LV filing and contractility, recognize pathology and call for back-up from advanced or cardiology Basic, recognize pathology and call for back-up from advanced or cardiology All efforts made to contact a cardiologist for back-up prior to change in plan Continuing education 8 hr/2yr cycle CME in TEE 16 hr/2 yr cycle CME in TEE 16 hr/2 yr and pass perioperative TEE exam within 2 cycles of basic credential Recredential 50 cases per year + CME or pass exam 75 cases per year + CME or pass exam 75 cases per year + CME or pass exam Sources: Sandra Haigler, MD, Anesthesiologist; Sherry Tichenor, MSN, Assistant Vice President; Janet Guy, CMSC, Medical Staff Coordinator; Saint Joseph Hospital, Lexington, KY. 8 A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006

pertain to evidence of current licensure, relevant training or experience, current competence, and ability to perform the privileges requested. While the JCAHO does not require hospitals to use any specific method in delineating clinical privileges, it does require such privileges to be hospital-specific and based on an individual s demonstrated current competence (MS.5.15). It further requires (MS.5.15.1 MS.5.15.1.3) privileges to be related to an individual s documented experience in categories of treatment areas or procedures, the results of treatment, and the conclusions drawn from organization performance improvement activities when available. CRC draft criteria Minimum threshold criteria for requesting TEE privileges The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this practice area. Education: MD or DO Minimal formal training: The applicant must demonstrate successful completion of an approved residency or fellowship training program that provides the necessary cognitive and technical skills required to perform TEE. Required previous experience: The applicant must demonstrate that he or she has successfully performed at least 50 to 75 TEE procedures in the last 12 months. In no instance should privileges to perform TEE be granted to individuals who are not considered fully competent in complementary echocardiography techniques. Note: A letter of reference must come from the director of the applicant s residency or fellowship program. Or a letter of reference should come from the applicant s chief of cardiology or chief of anesthesiology at the institution where the applicant last practiced. Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanisms. Applicants must demonstrate that they have maintained competence by having performed at least 50 to 75 TEE procedures in the past 12 months. A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006 9

In addition, continuing medical education related to TEE should be required. For more information For more information regarding TEE, contact: American Society of Anesthesiologists 520 North Northwest Highway Park Ridge, IL 60068-2573 Telephone: 847/825-5586 Fax: 847/825-1692 Web site: www.asahq.org American Society of Echocardiography 4101 Lake Boone Trail, Suite 201 Raleigh, NC 27607 Telephone: 919/787-5181 Fax: 919/787-4916 10 A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006

Privilege request form Transesophageal echocardiography In order to be eligible to request clinical privileges for transesophageal echocardiography, a physician must meet the following minimum threshold criteria: Education: MD or DO Minimal formal training: The applicant must demonstrate successful completion of an approved residency or fellowship training program that provides the necessary cognitive and technical skills required to perform TEE. Required previous experience: The applicant must demonstrate that he or she has successfully performed at least 50 to 75 TEE procedures in the last 12 months. In no instance should privileges to perform TEE be granted to individuals who are not considered fully competent in complementary echocardiography techniques. References: A letter of reference must come from the director of the applicant s residency or fellowship program. Or a letter of reference should come from the applicant s chief of cardiology or chief of anesthesiology at the institution where the applicant last practiced. Reappointment: Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanisms. Applicants must demonstrate that they have maintained competence by having performed at least 50 to 75 TEE procedures in the past 12 months. In addition, continuing medical education related to TEE should be required. I understand that by making this request I am bound by the applicable bylaws or policies of the hospital and hereby stipulate that I meet the minimum threshold criteria of this request. Physician s signature: Typed or printed name: Date: A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006 11

Clinical Privilege White Papers Advisory Board Publisher/Vice President: Suzanne Perney, sperney@opuscomm.com Executive Editor: Jay Z. Kumar jkumar@opuscomm.com Managing Editor: Mary Beth Florentine, mbflorentine@opuscomm.com Contributing editor: Hugh P. Greeley Chair, The Greeley Company James F. Callahan, DPA Executive vice president and CEO American Society of Addiction Medicine Chevy Chase, MD Sharon Fujikawa, PhD Clinical professor, Dept. of Neurology University of California, Irvine Medical Center Orange, CA John N. Kabalin, Md, FACS Urologist/Laser surgeon Scottsbluff Urology Associates Scottsbluff, NE John E. Krettek Jr., MD, PhD Neurological surgeon Vice president for medical affairs Missouri Baptist Medical Center St. Louis, MO Michael R. Milner, MMS, PA-C Senior physician assistant consultant Phoenix Indian Medical Center Phoenix, AZ Richard Sheff, MD Senior consultant The Greeley Company Marblehead, MA Herman Williams, MD Senior consultant The Greeley Company Marblehead, MA The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 1999 Opus Communications, Marblehead, MA 01945. 12 A supplement to Briefings on Credentialing 781/639-1872 Criteria reviewed 2006