International consensus statement on training standards for advanced critical care echocardiography

Background

This expert panel statement is written in order to provide guidance to faculty and learners who are involved with training in advanced critical care echocardiography (CCE). For faculty, it defines explicitly how to design a training program; while for the learner it provides a guide to training that they should follow and expect from their faculty. This document is not meant to stand-alone, but is the continuation of two previous expert statements [1, 2]. Many of the participants who are part of the present working group were involved with preparation of these two prior publications. The reader should regard the three documents as part of a continued international effort to organize training in all aspects of critical care ultrasonography (CCUS), of which advanced CCE is one part.

In 2007, the Société de Réanimation de Langue Française and the American College of Chest Physicians convened an expert panel to develop a consensus statement designed to define competence in CCUS. The resulting statement established a standard definition of CCUS, including general CCUS (GCCUS), which includes elements of thoracic, vascular, abdominal ultrasonography, and basic and advanced CCE; and what the intensivist needed to achieve in order to be competent in the field [1]. That document, by design, set out the objectives of training, but provided no instruction on how to achieve competence. Its purpose was to establish the goals of training, and to subsequently develop recommendations as to how to proceed with training.

In 2009, the European Society of Intensive Care Medicine (ESICM) convened an expert panel to develop a consensus statement designed to establish standards for training in CCUS [2]. Eleven critical care societies from five continents sent representatives to the meeting and the resulting document, The International Expert Statement on Training Standards for Critical Care Ultrasonography, was subsequently endorsed by their critical care societies [2]. The training statement [2] used the competence statement [1] as its foundation document, and stated specifically that training in GCCUS and basic CCE should be a required part of critical care training. However, both working groups recognized that advanced CCE is different from basic CCE and needed a separate standard training document.

There are several reasons that advanced CCE, and therefore its training sequence, should be considered separately from GCCUS and basic CCE.

• 1. Advanced CCE is more complex and requires significantly more training time commitment than GCCUS and basic CCE do (Fig. 1). Accordingly, it cannot be integrated into general critical care training, but rather requires a dedicated training sequence.

  Fig. 1

  

  Advanced critical care echocardiography refers to a spectrum of echocardiographic techniques and skills (image acquisition, image interpretation, and clinical integration) that extend the competencies required for basic critical care echocardiography. Advanced critical care echocardiography relies on qualitative and quantitative assessment of cardiac structure and function with particular emphasis on hemodynamic monitoring and titration of care in the critically ill. Competence in critical care echocardiography occurs along a continuum. Competence to basic level may be achieved with a short period of training. Competence to advanced level requires a much longer period of training. Competence to expert level requires training and experience well beyond that needed for advanced level competence

• 2. Advanced CCE uses measurement techniques that have traditionally been performed by cardiologists, though their focus and use is often different from that of the cardiologist. The training sequence must be rigorous and include competence-based testing in order to assure professional credibility at the interface between the intensivist and the cardiologist. The training statement recommended that a formal certification process be developed to assure that the intensivist is technically and interpretively competent, which is not the case for either GCCUS or basic CCE.

• 3. While competence in GCCUS is regarded as a standard skill for the intensivist, advanced CCE is an optional skill that requires special training and additional competence.

Although the initial training statement provided some guidance for those interested in training in advanced CCE [2], the present expert statement presents a more detailed review of the subject. Panel members believe that the document is timely, as critical care programs offering organized training in the subject are not yet widespread. We hope to encourage international development of the field, by establishing a standard approach to training. This will help both faculty and learners to organize training, bring international academic credibility to the concept of advanced CCE training, and foster dissemination of a useful clinical tool.

Methods

The process, chaired by Prof. Vieillard-Baron and Dr. Mayo, started in May 2013 under the auspices of ESICM. Societies of critical care medicine involved in the development of training programs in CCUS were asked to designate experts as representatives (see Appendix). All participants in this expert panel are actively engaged in programs dedicated to training intensivists in advanced CCE and are recognized as experts in the field and/or who have special expertise in education design. Four aspects of training in advanced CCE were considered as especially relevant to the discussion. These were assigned to panel members, who wrote initial parts of the draft statement. Two panel members (AVB, PHM) were assigned to combine the parts and to edit a working draft document. This document was then submitted for review to all panel members on 15 September 2013 and edited through email exchange before the entire group met on 4 October 2013 in Paris. At the Paris meeting, the amended preliminary draft underwent systematic review by the entire group with subsequent discussion and debate leading to a consensus on all points. A final draft was edited by the two co-chairs and accepted without restriction by all members of the expert roundtable panel after separate review.

General considerations

Advanced CCE may be defined as any aspect of echocardiography that has utility to the intensivist. While it shares with cardiology the same imaging device, transducer, the image interpretation methods, and much of the same knowledge base and standard views, it differs in many ways from cardiology-based echocardiography. First, it is performed by the intensivist at the bedside of the patient during the active process of diagnosis and management of cardiovascular instability, so the clinician decides what component of the examination is relevant within the clinical context. Thus, the examination may be as complete as the cardiology-type examination; or it may be as limited as needed to aid in diagnosis and management (e.g., measurement of the stroke volume, right ventricular dysfunction, or assessment of left atrial pressure). Accordingly, its use is guided by the clinical diagnostic and therapeutic question. Secondly, while the cardiologist and the intensivist both use the examination to identify a diagnosis, the intensivist also integrates the findings into an immediate clinical management plan in ways that are different from the consultative cardiology echocardiographer.

Beyond determining diagnosis and initial management strategy, the intensivist uses advanced CCE as a hemodynamic monitoring tool by performing sequential examinations on patients on mechanical ventilation to assess the efficacy and tolerance of therapeutic changes. The intensivist must have similar skill at diagnosis of cardiac dysfunction as the cardiologist, but must have the training to use echocardiography as a sequential assessment tool. The cognitive base outlined in this document for advanced CCE emphasizes the importance of training in both the diagnostic and the hemodynamic monitoring aspects of the technique. Unlike the cardiologist, the intensivist with training in advanced CCE also has, by definition, competence in GCCUS; given that competence in GCCUS should be a standard part of critical care training. Skill at GCCUS is complementary to advanced CCE.

Not all intensivists need training in advanced CCE. Basic CCE is a very useful tool for the intensivist to guide in the diagnosis and management of the patient with hemodynamic insufficiency. All critical care doctors should be competent in basic CCE, but intensive care unit management will benefit if some proportion of these doctors are also trained in advanced CCE.

In approaching training in advanced CCE, faculty and learners will address the following four questions:

• (A) Competence in image acquisition and interpretation. What are the required echocardiographic views?

• (B) Competence in the cognitive base. What constitutes the cognitive base in cardiovascular physiology and echocardiographic interpretation?

• (C) Training requires specific requirements and methods of training. What are these?

• (D) Training is designed to result in competence. How is competency determined and certified?

The purpose of this statement is to answer these questions and to thereby present faculty and learners with a useful framework for training.

Part A: what are the required echocardiographic views for training in advanced CCE?

Competence in advanced CCE requires that the clinician be adequately trained in both image acquisition and image interpretation. It follows that this document must set out a defined minimal set of echocardiographic views deemed necessary to accomplish those goals. Clearly, more views and their interpretation can be added to the CCE examination as clinical conditions demand. A major goal of advanced CCE training is mastery of image acquisition and image interpretation of these views. This section will define the image set for transthoracic (TTE) and transesophageal echocardiography (TEE) that is a required element of training and competence in advanced CCE. Both TTE and TEE are mandatory parts of advanced CCE training.

• 1. Competence in image acquisition and interpretation of the two-dimensional (2D) TTE views with associated Doppler measurements listed in Table 1.

  Table 1 Two-dimensional transthoracic echocardiography views and associated Doppler measurements required for competence in image acquisition and interpretation

• 2. Competence in image acquisition and interpretation of the two-dimensional (2D) TEE views with associated Doppler measurements listed in Table 2.

  Table 2 Two-dimensional transesophageal echocardiographic views with associated Doppler measurements required for competence in image acquisition and interpretation

The main differences, advantages, and disadvantages of TTE and TEE are summarized in Table 3. While TTE is widely available, some intensive care units do not have yet TEE capability. In this case, training in TEE image acquisition may be provided in cooperation with cardiac anesthesiology and cardiologists.

Table 3 Advantages and disadvantages of transthoracic (TTE) and transesophageal echocardiography (TEE)

Part B: what is the cognitive base required for training in advanced critical care echocardiography?

Competency in the cognitive base is one of the three essential elements of advanced CCE along with mastery of image acquisition and subsequent image interpretation. The unique cognitive base permits the intensivist to apply the results of the imaging study to the clinical situation for purposes of immediate diagnosis and management. The goal is for the intensivist to integrate echocardiography into the care of the patient with cardiopulmonary failure. It follows that training in the cognitive base of advanced CCE should emphasize clinical applications that are specific to the management of the critically ill and unstable patients.

• 1. Specialty training in critical care medicine is a requirement for training in advanced CCE. Implicit to specialty training in critical care medicine is comprehensive knowledge of cardiopulmonary physiology as related to the critically ill patient. With this background, the intensivist may productively combine their general knowledge of critical care with a specific knowledge of advanced CCE. The interface between knowledge of essential aspects of pathophysiological function and advanced CCE is a key component of the cognitive base.

• 2. Intensivists are uniquely qualified to use advanced CCE owing to the nature of their clinical work, which regularly includes ongoing bedside diagnosis and management of hemodynamic and respiratory failure. Knowledge of a wide variety of pathophysiological processes peculiar to critical care medicine where echocardiography may be productively integrated into the care plan is important. The training sequence for advanced CCE must provide competence in the cognitive base relevant to a wide variety of clinical applications of echocardiography (Table 4) and to key clinical questions relevant to advanced CCE (Table 5).

  Table 4 Clinical applications of advanced critical care echocardiography

  Table 5 Relevant clinical questions addressed with advanced CCE in patients with cardiopulmonary compromise

Part C: what are the specific methods and requirements of training in advanced CCE?

The design of an effective training program requires identification and deployment of effective methods of training that may differ according to faculty preference, local resource availability, and learner preference. The challenge in creating an effective local training program is compounded by a paucity of literature on the subject. In addition to a review of methods of training, the training program must include some specific requirements of milestones that need to be achieved by the learner.

• 1. Training in advanced CCE must be supervised by expert faculty. The faculty must be skilled in and recognized by the critical care community as an expert in advanced CCE, preferably with formal certification by a national level authority. As certification at national level is not yet widely available, the alternative is recognition by critical care societies established at a national or international level. Recognition by private or local groups is not sufficient. The expert faculty assumes responsibility for the development of a local training program that provides training in image acquisition, image interpretation, and the cognitive base. The responsible faculty must be a critical care specialist who may choose to partner with colleagues in cardiology and cardiac anesthesiology in developing the training sequence. An example of requirements for expert faculty designation is presented in Table 6.

  Table 6 Requirements for expert faculty designation to provide training in advanced critical care echocardiography in France

• 2. A minimum of 100 full TTE studies is required as part of training in advanced CCE. Although there is no definitive literature on the subject, this minimum number is supported by the experience of all the experts involved in this document. It represents a reasonable balance between the need to achieve competence and the time required for training. By comparison, the American Society of Echocardiography has recommended 150 TTE studies for level 2 competence [3]. The studies must be personally performed by the learner. Initially, studies may be performed on normal subjects, but the majority of studies must be performed on patients. A full image set (as outlined in part A) must be obtained for each study and interpreted by the learner. A proportion of the TTE studies must be performed under the direct supervision of faculty, particularly at the beginning of training. Subsequent studies may be performed without direct supervision. Each full TTE study requires recording of the relevant images and a formal interpretation of the image set with review by expert faculty. Elements that are required for the study report are summarized in Table 7. If the learner is judged not to be competent following 100 studies, the expert faculty may require further training in image acquisition.

  Table 7 Elements that are required in the written transthoracic and transesophageal echocardiography study report

• 3. A minimum of 35 full TEE studies is required as part of training in advanced CCE. This minimum number is based on a well-conducted trial [4]. A significant proportion of these studies should be performed in critically ill patients. The studies must be personally performed by the learner under the direct supervision of the expert faculty and must include the process of patient selection, the introduction and manipulation of the probe, and the preparation of the final report. A full image set (as outlined in part A) must be obtained for each study and interpreted by the learner. Each full TEE study requires recording of the relevant images and a formal interpretation of the image set with review by the faculty. Elements that are required for the study report are summarized in Table 7. If the learner is judged not to be competent following 35 studies, the expert faculty may require further training in image acquisition. A validated scoring system for assessment of competence in hemodynamic monitoring using TEE is proposed in Table 8. Examinations performed with miniaturized TEE probes are not counted in the requirement for 35 full TEE studies. These probes have limited imaging capabilities compared to standard TEE probes, so they cannot be considered as counting for training in advanced CCE.

  Table 8 Proposed scoring system to test competency in TEE hemodynamic evaluation in mechanically ventilated patients. From [5]

• 4. Both TTE and TEE simulators may be used in order to facilitate skill acquisition, particularly at the beginning of training. Studies performed on simulators are not taken into account in the 100 TTE and 35 TEE required for qualification.

• 5. The expert faculty is responsible for the design and implementation of the local training program. Methods of training for the cognitive base include case-based teaching, internet-based methods, formal conferences, study of articles and textbooks, and attendance at organized courses. If training faculty chooses to design a course in advanced CCE that is required of all learners, the suggested duration of the course time is approximately 40 h. As there is considerable overlap in the knowledge base required for cardiology and advanced CCE, modern textbooks on echocardiography for cardiologists are an excellent resource for the intensivist learner for some part of the cognitive base. Many of these textbooks have useful image files that can be retrieved from an online repository in coordination with the text content. The learner should have full mastery of standard cardiology textbook content with the exception of chapters related to complex congenital heart disease and stress echocardiography. However, standard cardiology textbooks do not cover many topics that are part of advanced CCE. For this part of the cognitive base, the learner must access articles and the few textbooks on the subject that are currently available. A comprehensive list of key articles that are relevant to training in advanced CCE is given in an online supplement.

• 6. Training in image interpretation requires that the learner reviews a large number of studies. Some proportion of image interpretation training must occur under the direct supervision of an expert reader. Although there are many ways of accomplishing this, initially partnership with the cardiology service where the learner spends time in a cardiology reading room reviewing a large number of studies may prove useful. It is not reasonable to expect that each learner will encounter all important abnormal findings either in the reading room or during their image acquisition training. Therefore, a comprehensive panel of abnormal images with their clinical scenarios must be reviewed with supervisory faculty. Abnormal images and their clinical scenarios may be presented in interactive lecture format or through internet-based methods and should include both TTE and TEE cases. There is no specific requirement for number of images that need to be reviewed, beyond that the number should exceed many hundreds.

Part D: training is designed to result in competence. How is it determined that training has resulted in competence?

Competence is the combination of knowledge, skills, and behavior required to perform a specific function in an adequate and well-qualified manner. As this document is focused on developing explicit recommendations regarding training in advanced CCE, defining competency is important.

There are two general approaches to determine whether a learner has achieved competence in advanced CCE. One method is that the learner acquires skill at image acquisition, image interpretation, and cognitive knowledge of the field under the supervision of knowledgeable faculty within the context of residency or fellowship training or as an attending physician if there is local faculty support in their hospital. This approach may include a requirement that there be a certain number of image sets performed and interpreted, and may include some formal course work. After some amount of training, the learner is designated by their trainers as being competent to perform advanced CCE. The advantage of this method is its informality and simplicity of administration. As a credit to its efficacy, a generation of advanced critical care echocardiographers has been trained in this way. The disadvantages of this method are that there is no formal assessment of skill that encompasses the key components of competence: image acquisition, image interpretation, and cognitive base, there is an intrinsic conflict of interest when the trainer is responsible for final assessment of competence, and it may be difficult to assure the competence of the trainer.

The alternative approach to determine whether a learner has achieved competence is to require competency-based testing at the end of the training period. With this method, the training program follows the specific requirements that have been presented in this document regarding image acquisition, image interpretation, and cognitive base. The expert panel members recognize that methods of training in advanced CCE will differ to some extent between countries. However, at the end of training, the learner should undergo formal evaluation of their skill with a summative test of skill. If they have fulfilled the training requirements and performed adequately on the comprehensive test, they are recognized as being competent. We recommend that formal assessment of competence should be a required component of training in advanced CCE.

Requirements for competency based testing

• 1. At the completion of training, the learner must successfully complete and pass an examination that includes assessment of image acquisition, image interpretation, and cognitive base for advanced CCE in order to be deemed competent. No candidate may take the examination until they fulfilled all parts of training as described in this statement. This includes a formal statement by the expert faculty that the candidate has successfully completed training.

• 2. Determination of skill at image acquisition is the responsibility of local expert faculty. Design of the structured training program includes the responsibility to develop summative competence-based testing of skill at image acquisition. This may include testing of image acquisition using a simulator, especially for TEE. Testing of image interpretation and cognitive elements should be standardized at the national level or international level by national bodies or critical care societies, and use secure computer-based testing methods that are typical of board-style examinations. The results of the examination may be incorporated into a formal national level certification process, as recommended in the Vienna statement [2].

• 3. Completion of training and competency-based testing designates the intensivist as being competent in advanced CCE as a clinical skill. This designation is binary, and implies no hierarchy of competence.

Conclusion

This international expert statement on training standards for advanced CCE serves to provide guidance to faculty and learners who are engaged in advanced CCE training. The document establishes specific requirements to guide expert faculty who are tasked with the development of structured training programs that provide mastery of image acquisition, image interpretation, and the cognitive base. In the future, it should be adapted by national authorities or critical care medicine societies to establish their own certification process according to specific national requirements.

Appendix: colleges and societies involved in the statement with their representatives

• European Society of Intensive Care Medicine (ESICM): Drs. Philippe Vignon, Frances Colreavy, Jean-Luc Canivet, Daniel De Backer, Bernard Cholley. Dr. Maggiorini represented the educational and training committee of the ESICM.

• American College of Chest Physicians (ACCP): Drs. Paul Mayo, Seth Koenig.

• American Thoracic Society (ATS): Drs. Michael Pinsky, Antoine Vieillard-Baron.

• French Society of Intensive Care Medicine (SRLF): Dr. Michel Slama.

• Hong Kong College of Anaesthesiologists (Board of Intensive Care): Dr. Gordon Choi

• Hong Kong Society of Critical Care Medicine: Dr. Gordon Choi.

• Asia Pacific Association of Critical Care Medicine (APACCM): Drs. Anthony McLean, Gordon Choi.

• Canadian Critical Care Society: Drs. Yanick Beaulieu, Rob Arntfield.

• College of Intensive Care Medicine of Australian and New Zealand: Drs. Anthony McLean, Gordon Choi.

Expert Round Table on Echocardiography in ICU:

Antoine Vieillard-Baron, MD, PhD, Medical-surgical ICU, Université Versailles Saint Quentin en Yvelines, Hôpital Ambroise Paré, Assistance Publique des Hôpitaux de Paris. No conflict of interest.

Paul H. Mayo, MD, Long Island Jewish Medical Center, Hofstra North Shore LIJ School of Medicine Hempstead NY, USA. No conflict of interest.

Philippe Vignon, MD, PhD, Medical-surgical ICU, Teaching hospital of Limoges, Limoges, 87000, France. No conflict of interest.

Bernard Cholley, MD, PhD, Service d’Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (AP-HP); and Université Paris Descartes, Sorbonne Paris Cité. No conflict of interest.

Michel Slama, MD PhD, FACCP, FAHA, Unité de réanimation médicale, service de néphrologie, CHU Sud Amiens 80090, France. No conflict of interest.

Michael R. Pinsky, MD, Dr hc, University of Pittsburgh, Pittsburgh, PA, USA. No conflict of interest.

Anthony McLean, MD, Professor and Head Intensive Care Medicine Nepean Hospital, Perth; University of Sydney, Australia. No conflict of interest.

Gordon Choi, MD, Department of Anaesthesia and Intensive, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong. No conflict of interest.

Yanick Beaulieu, MD, Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Québec, Canada. No conflict of interest.

Dr. R Arntfield, MD, London Health Sciences Centre, Western University, London, Ontario, Canada. No conflict of interest.

S. Koenig MD, Long Island Jewish Medical Center, Hofstra North Shore LIJ School of Medicine, Hempstead NY, USA. No conflict of interest.

F. Colreavy, MD, Department of Intensive Care, Mater Misercordiae Hospital, Eccles Street, Dublin 7, Ireland. No conflict of interest.

J.L. Canivet, MD, PhD, Head of Clinic, Department of General Intensive Care, CHU de Liège University Hospital of Liège, Liège, Belgium. No conflict of interest.

Daniel De Backer, MD, PhD, Department of Intensive Care Medicine, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium. No conflict of interest.