The Role of Critical Care Specialty Societies in the Certification and Credentialing of Bedside Ultrasonography

2015 - 4 August – Post-Intensive Care Syndrome
Chaitanya Mandapakala, MD; Sarah Lee, MD, MPH
Two experts discuss critical care ultrasonography certification and credentialing.



The Society of Critical Care Medicine’s (SCCM’s) In-Training Section is dedicated to assisting and guiding trainees as they progress through training into independent practice. It also aims to foster career development following this transition. To further this mission, members contribute articles addressing emerging issues in critical care training and career development; these submissions are authored by in-training professionals under the guidance of a mentor. For additional information about the In-Training Section or this project, please contact Section Chair Utpal Bhalala, MD; Chair-elect Ashish Khanna, MD, FCCP; or Member-at-large Erik Vakil, MD.

Ultrasonography has come a long way as a medical diagnostic tool since its inception in the 1950s. With the development of real-time ultrasonography in the 1980s and advances in portability, cost effectiveness, and fast diagnostics, it has grown to become an essential tool for physicians and advanced care practitioners who treat critically ill patients.(1)

Studies have revealed the use of emergency bedside ultrasonography in a wide spectrum of situations, such as procedure guidance,(2) determination of cardiac activity,(3) evaluation of pericardial effusion(4) and assessing fluid responsiveness and hypotension,(5) deep vein thrombosis,(6) thoracoabdominal trauma,(7) and ectopic pregnancy.(8) Useful information can be obtained even from air containing organs such as lungs, which do not conduct ultrasound waves.(9)  With the increased safety and success of direct visual guidance of bedside diagnostic or therapeutic procedures, ultrasound guidance (i.e., placement of central venous catheters) has been recommended as the standard of care.(10)

Bedside critical care ultrasonography differs in important ways from the traditional ultrasonography performed by radiologists or echocardiography performed by cardiologists.(1) Its use starts with a specific question in a rapidly deteriorating patient that requires immediate interpretation and clinical decision-making. Repeated bedside ultrasonography is then performed to assess the changing status and to modulate treatment accordingly.

The biggest limiting factor to bedside critical care ultrasonography is that the quality and interpretation of the images are operator dependent. Sonographers, radiologists and cardiologists are certified and credentialed in their fields. Certification for bedside critical care ultrasonography is still emerging. To date, there is no critical care ultrasonography certification approved or provided by a member board of the American Board of Medical Specialties (ABMS).

In 1991, both the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) published position papers recognizing the utility of ultrasonography for patients in emergency situations.(11,12) In the mid-1990s, SAEM(13) and the American College of Surgeons (ACS) developed educational curricula to standardize bedside ultrasonography training.(14) In 1997, the ACS Board of Regents published a statement regarding verification of a surgeon’s ultrasonography qualifications.(15) In 2001, ACEP published the Emergency Ultrasound Guidelines, which were revised in 2008.(16) These guidelines pertain to the scope of practice and clinical indications for emergency ultrasonography.

In 2007, Critical Care Medicine published supplements that defined critical care ultrasonography and advanced critical care echocardiography (CCE).(17,18)  In 2009, the American College of Chest Physicians (CHEST) and the Société de Réanimation de Langue Française published their competency statement on critical care ultrasonography. This statement divided applications into general critical care ultrasound (GCCUS), basic critical care echocardiography and advanced critical care echocardiography.(19) In 2011, representatives of 12 critical care societies worldwide worked on a framework for organizing training targeted at GCCUS and basic and advanced CCE. They recommended that GCCUS and basic CCE training should be mandatory in the curriculum of intensive care unit providers, and each critical care society should support this training in its own country.(20)

The Society of Critical Care Medicine’s (SCCM’s) official statement provides recommendations for achieving and maintaining competence and credentialing in critical care ultrasonography with focused cardiac ultrasonography and advanced CCE.(21) It suggests that this can be achieved by either a fellowship-based pathway (for those in fellowship training) or a practice-based experience pathway (for practicing providers). However, a Web-based 2010 survey of program directors of American pulmonary critical care and critical care fellowship programs identified several barriers to critical care ultrasonography training in fellowship programs, including fellow turnover, insufficient faculty training, and perceived length of time required for echocardiography training.(22) Nevertheless, if this training is not captured in fellowship, there is less opportunity to receive it post-fellowship. A study of practicing emergency physicians in 2012 showed that physicians who completed training before 2001 were less likely to be credentialed than those trained after 2001. “Lacking hands-on experience” and “being too busy” were cited as the most common barriers to their credentialing.(23)

Currently, there is no widely accepted standard regarding need for certification for ultrasound or how to obtain certification if desired. In the future, there may be a requirement for certification that is linked to billing authority, especially with lobbying pressure from radiology or cardiology, but currently certification is not standard or offered by any specialty society or ABMS board. Organizations such as World Interactive Network Focused on Critical Ultrasound (WINFOCUS) are providing avenues for training in point-of-care ultrasonography around the world.(24) Societies such as SCCM and the American Thoracic Society provide training workshops at their annual meetings.(25,26) SCCM has created online modules that allow providers to practice their skills from the convenience of their homes and at their own pace to earn continuing medical education credit (Self-Directed Critical Care Ultrasound).(27) SCCM is now also offering critical care ultrasonography courses internationally.

Critical care societies are playing a crucial role in providing standardized training modules in critical care ultrasonography, which could facilitate hospitals’ credentialing pathways for trainees and practicing critical care providers. As ultrasonography becomes ubiquitous and accepted as a standard of care, consensus regarding this training should occur across disciplines to maintain quality. More opportunities are needed for providers out of training to learn these new skills in a convenient, cost-effective way without compromising the integrity of the certification and credentialing process.

References:

1. Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med. 2007 May; 35(5 Suppl):S126-S130.
2. Nicolaou S, Talsky A, Khashoggi K, Venu V. Ultrasound-guided interventional radiology in critical care. Crit Care Med. 2007 May;35(5 Suppl):S186-S197.
3. Salen P, Melniker L, Chooljian C, et al. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med. 2005 Jul;23(4):459-462.
4. Tayal VS, Beatty MA, Marx JA, Tomaszewski CA, Thomason MH. FAST (focused assessment with sonography in trauma) accurate for cardiac and intraperitoneal injury in penetrating anterior chest trauma. J Ultrasound Med. 2004 Apr;23(4):467-472.
5. Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med. 2004 Aug;32(8):1798-1800.
6. Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011 Mar;139(3):538-542.
7. Ma OJ, Mateer JR, Ogata M, Kefer MP, Wittmann D, Aprahamian C. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma. 1995 Jun;38(6):879-885.
8. Durham B, Lane B, Burbridge L, Balasubramaniam S. Pelvic ultrasound performed by emergency physicians for the detection of ectopic pregnancy in complicated first-trimester pregnancies. Ann Emerg Med. 1997 Mar;29(3):338-347.
9. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008 Jul;134(1):117-125.
10. Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE, Foster B. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med. 2002 Aug;9(8):800-805.
11. American College of Emergency Physicians. Policy statement: Ultrasound use for emergency patients, June 1991. Updated 1997 and 2001 as: Use of ultrasound imaging by emergency physicians. Available at: http://www.acep.org/webportal/PracticeResources/PolicyStatements/ Accessed February 27, 2015.
12. Society for Academic Emergency Medicine: Ultrasound Position Statement, 1991. Available at: http://www.saem.org. Accessed February 25, 2015.
13. Mateer J, Plummer D, Heller M, et al. Model curriculum for physician training in emergency ultrasonography. Ann Emerg Med. 1994 Jan;23:95-102.
14. [No authors listed.] Approval of courses in new skills. Bull Am Coll Surg. 1998 Mar;83(3):35-36.
15. [No authors listed.] Statement on ultrasound examinations by surgeons. Committee on Emerging Surgical Technologies and Education, American College of Surgeons. Bull Am Coll Surg. 1998 Jun;83(6):37-40.
16. American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg Med. 2009 Apr;53(4):550-570.
17. Kirkpatrick AW, Blaivas M, Sustic A, Chun R, Beaulieu Y, Breitkreutz R. Focused application of ultrasound in critical care medicine. Crit Care Med. 2008;2008 Feb;36(2):654-655.
18. Porembka DT, Hoit BD, eds. Echocardiography in intensive care medicine. Crit Care Med. 2007;35(8 Suppl):S309-S433.
19. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009 Apr;135(4):1050-1060.
20. Expert Round Table on Ultrasound in ICU. International expert statement on training standards for critical care ultrasonography. Intensive Care Med. 2011 Jul;37(7):1077-1083.
21. Official Statement of the Society of Critical Care Medicine: Recommendations for Achieving and Maintaining Competence and Credentialing in Critical Care Ultrasound with Focused Cardiac Ultrasound and Advanced Critical Care Echocardiography. Available at http://journals.lww.com/ccmjournal/Documents/Critical%20Care%20Ultrasound.pdf. Accessed February 27, 2015.
22. Eisen LA, Leung S, Gallagher AE, Kvetan V. Barriers to ultrasound training in critical care medicine fellowships: a survey of program directors. Crit Care Med. 2010 Oct;38(10):1978-1983.
23. Nelson BP, Mahesri J, Huang A. Barriers to credentialing emergency physicians in ultrasound use. Crit Ultrasound J. 2012;4(Suppl 1):A11.
24. Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012 Apr;38(4):577-591.
25. Society of Critical Care Medicine. Critical Care Ultrasound. http://www.sccm.org/Education-Center/Ultrasound/Pages/Fundamentals.aspx. Accessed March 1, 2015.
26. American Thoracic Society. 2015 Postgraduate Courses. http://conference.thoracic.org/2015/program/postgraduate-courses/. Accessed March 1, 2015.
27. Society of Critical Care Medicine. Self-Directed Critical Care Ultrasound. http://www.sccm.org/Education-Center/Ultrasound/Pages/Self-Directed-Critical-Care-Ultrasound.aspx. Accessed March 1, 2015.