Toward an ultrasound curriculum for critical care medicine

Luca Neri, MD; Enrico Storti, MD; Daniel Lichtenstein, MD

Diagnostic ultrasound is a rap-idly developing imagingtechnology that can be foundin both industrialized and

developing countries. Recently, its point-of-care use has been investigated in anumber of primary, emergency, and crit-ical care applications (1–11). The rate atwhich bedside ultrasound use is spread-ing, and the continuing development ofnew applications, may outpace training ofadequate numbers of qualified users. Thispresents the risk of practicing under con-ditions of inappropriate training or qual-ity control. The lack of uniform and gen-erally accepted standards for training atthe international level compounds theproblem. The effectiveness of acquiring,interpreting, and incorporating real-timesonographic information into the critical

clinical decision-making process remainslargely operator-dependent. When appro-priate training and quality assurance isprovided, results can be highly accurateand reliable; standards for ultrasonogra-phy training are thus a prerequisite forprovision of high-quality “ultrasound-enhanced” services (12–16).

The scientific community has an urgentneed to provide guidelines for continuingultrasound education in critical care med-icine from medical school through to resi-dency, specialty training, and ongoingpractice. These guidelines are required tofacilitate standardization of physician com-petence and performance at local, national,and international levels. The EuropeanFederation of Societies for Ultrasound inMedicine and Biology has recently pro-posed minimal training requirements forthe practice of medical ultrasound, address-ing “the growing demand from many med-ical specialists in undertaking ultrasoundexaminations on patients [. . .] as a directextension of their clinical exam (17).” Sup-porting the strategy of other medical soci-eties and organizations, the European Fed-eration of Societies for Ultrasound inMedicine and Biology acknowledged thatultrasound can be fully embedded withinthe scope of practice of several nonimagingspecialties, provided they specify their own

educational pathways and guidelines. Todate, several educational and scientific bod-ies have produced specialty specific recom-mendations, protocols, and curricula fornonimaging medical professionals per-forming ultrasound (cardiac, vascular, gy-necologic, and obstetric specialists, and, toa lesser extent, gastroenterologists, sur-geons, urologists, and others).

However, there are no currently widelyacknowledged international guidelines, andonly a few scattered national examples existthat address ultrasound training for physi-cians, nurses, and paramedics performingultrasound examinations in emergency(18–23) and critical care (24, 25) settings.With regards to intensive and critical caremedicine, there are some outstanding ex-ceptions basically limited to echocardiogra-phy (transthoracic and transesophageal)(26–28) and a few interventional areas(drainages, vascular access, nerve blockage)(29–31). Critical care physicians, and par-ticularly general intensivists and anesthe-tists, provide critical and intensive care topatients whose problems relate to all ana-tomical regions. They manage complexmultisystem disease states and performmultiple interventional procedures through-out the body in a coordinated fashion. Anyultrasound curriculum or instructional de-sign should take into account this special-

From the General Intensive Care Unit “Bozza,”Niguarda Ca’ Granda Hospital, Milan, IT (LN, ES); Ser-vice de Reanimation Medicale, Paris-Ouest, HopitalAmbroise-Pare, Boulogne, FR (DL).

Dr. Lichtenstein has not disclosed any potentialconflicts of interest.

Address requests for reprints to: Luca Neri, MD,Niguarda Ca’ Granda Hospital, SSUEm 118-Milano,Milan, IT. E-mail: luca.neri@winfocus.org

Copyright © 2007 by the Society of Critical CareMedicine and Lippincott Williams & Wilkins

DOI: 10.1097/01.CCM.0000260680.16213.26

Accurate assessment and rapid decision-making are essentialto save lives and improve performance in critical care medicine.Real-time point-of-care ultrasound has become an invaluableadjunct to the clinical evaluation of critically ill and injuredpatients both for pre- and in-hospital situations. However, a highlevel of quality is necessary, guaranteed by appropriate educa-tion, experience, credentialing, quality control, continuing educa-tion, and professional development. Although educational recom-mendations have been proposed by a variety of nonimagingspecialties, to date they are still scattered and limited examplesof standards for critical and intensive care professionals. Thechallenge of providing adequate specialty-specific training, asencouraged by major medical societies, is made even more dif-ficult by the diversity of critical care ultrasound utilization byvarious subspecialties in a variety of settings and numerouscountries. In order to meet this educational challenge, a standard

core curriculum is presented in this manuscript. The proposedcurriculum is built on a competence, performance, and outcomes-based approach that is tailored to setting-specific training needsand prioritized according to critical problem-based pathways,rather than traditional organ-based systems. A multiple goal–oriented style fully addresses the specialty-specific approach ofcritical and intensive care professionals, who typically deal withdisease states in complex scenarios rather than individual organcomplaints. Because of the variation in the concept of whatconstitutes critical care worldwide, and the rate of change ofinformation and technology, this manuscript attempts to presenta learning system addressing a variety of needs for a rapidlychanging world. (Crit Care Med 2007; 35[Suppl.]:S290–S304)

KEY WORDS: point-of-care ultrasound; bedside ultrasound; crit-ical care; intensive care; ultrasound training; transversal compe-tencies; critical thinking

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ty-specific, rapidly evolving, critical care ap-proach—effectively abandoning “vertical”systematic organ-based training for a mul-tiple-goal, problem-based approach. Thismodel represents the core of a competency-based ultrasound instructional model, de-signed to impart not a simple body ofknowledge, but all the relevant skills andattitudes to improve patient outcomes andperformance at the individual and systemlevels. Whatever competency-based train-ing is undertaken, it has to be carefullytailored to the targeted audience’s needs,since critical care is delivered quite differ-ently throughout the world by medical andallied health providers in diverse settings(Tables 1 and 2).

Critical care professionals who per-form diagnostic ultrasound examinationsshould be credentialed through trainingprograms or institutions, requiring evi-dence of completed training and compe-tency requirements to meet the acceptedstandards in their area(s) of practice.Many small studies have looked at theefficacy of different instructional pro-grams for nonimaging specialists, lastingfrom a few hours (with some even self-taught using software on CD-ROM) todays to months. Almost all of theseshowed that short or minimal trainingwas effective for focused emergency-ultrasound indications, even in the handsof a relative novice (see bibliography inthe section about minimal require-ments).

The aforementioned educational stud-ies refer mostly to emergency medicineand surgical settings, whilst educationaldata strictly from critical care services arestill rare and essentially related to echo-cardiographic competencies (14, 15, 32–34), interventional procedures (35–37),and setting-specific training modules(e.g., prehospital emergency care, tacticalmedicine) (38–42). This shortage of datalargely reflects the current situation atthe world level, where few critical andintensive care services have definite on-going specialty-specific training pro-grams, credential systems, and quality-assurance plans for general ultrasounddevelopment.

The international standard core cur-riculum that we propose attempts to ad-dress this shortage of guidance, takinginto account previous and currentlyavailable recommendations, particularlythose from the World Health Organiza-tion (43, 44), European Federation of So-cieties for Ultrasound in Medicine andBiology (17), American College of Emer-

gency Physicians (ACEP) (18), AmericanCollege of Surgeons (ACS) (19), RoyalCollege of Radiologists (24), and WorldInteractive Network Focused on CriticalUltrasound (25). It also adds new ele-ments to the current debate.

A “transversal” approach to problemsand solutions, at different levels of ultra-sound practice, is consistent with themultiple-goal– directed, multisystem,time-dependent vision of critical careprofessionals, and actually refers to theirspecialty-specific competence. Neverthe-less, the variety of personnel and servicemodels for delivery of critical care in bothhospital and extra-hospital settings doesnot support any unique and specialty-specific model; rather, it calls for a com-petence- and performance-needs–basedapproach. This approach can be tailoredto various national and local training pro-grams and curricula. The continuing,rapid change of ultrasound technologyand critical care practice compels us toemphasize continuing education, ratherthan a rigid curriculum content.

Competence- and Problem-BasedTraining Solutions

Competence is composed of an indi-vidual’s knowledge, skill, and attitude toensure excellent performance and out-come in a certain situation, function, or

job. Over the last several years, severalsocieties and university boards, as well asquality-assurance bodies, have imple-mented educational projects based oncompetence, performance, and outcomesassessment to ensure that physicians areappropriately trained in the knowledgeand skills of their specialties. Also, inmany emergency and critical care medicinecurricula and job profiles, lists of genericprofessional tasks and duties are becomingreplaced with lists of core competenciesand outcome measures (45–47).

The successful diffusion of ultra-sound beyond traditional imaging spe-cialists to the critical care setting hasbeen driven by such a competence-based model. Current guidelines at-tempting to address the training needsof nonimaging specialist physicians inprimary, emergency, and critical caremedicine support a competence-basedapproach. However, many of them stillreflect the largely traditional systematicdiscipline-based use of ultrasound, withtraining and competencies split into or-gan- or system-based categories (17).Over the last decade, focused approachesarising from various emergency-medicineand trauma-surgery bodies have also devel-oped as modular goal-directed disease-based systems, highlighting subjects suchas hemoperitoneum, abdominal aortic an-eurysm, and hydronephrosis rather than

Table 1. Critical care ultrasound scenarios

In Hospital Out of Hospital

● Critical and intensive care service ● HEMS/EMS● Emergency department ● Mass casualty and disaster setting● Resuscitation room, trauma bay ● Austere and remote scenario● Operative room and perioperative area ● Peacekeeping and tactical field● Imaging department and other wards, etc. ● Scarce resource health setting, etc.

HEMS, helicopter emergency medical services; EMS, emergency medical services.

Table 2. Critical care ultrasound providers

Consultants or Physicians Temporarilyin Charge of the Critical Patient

(Major World Component)

PhysiciansSpecifically Trained

in CCMAllied Health

Personnel

● Emergency physicians ● General intensivists ● Nurses● Cardiologists, pneumologists, nephrologists ● General anesthetists ● Paramedics● Internists, gastroenterologists ● Critical and intensive

care subspecialties● Technicians

● Emergency/trauma surgeons, general surgeons ● Midwives [Assistants,remotely guided, ordirect providers]

● Cardiothoracic or vascular surgeons, urologists● Obstetricians and gynecologists, neonatologists,

pediatricians● Radiologists and imaging specialists, etc.

CCM, critical care medicine.

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organs or anatomical regions (18–21). Inresponse, this still evolving point-of-careperspective, recent multidisciplinary guide-lines, and even those curriculums devel-oped within radiologic bodies have startedto incorporate batches of “setting-specific”procedures for use in emergency depart-ments and intensive care units, includingdisease-based (aneurysm, hydronephrosis,peritoneal free fluid, etc.) and “problem-

based” (hypotensive-patient assessment)applications (24, 25).

While ultrasound education is ad-dressing this new problem-based trans-versal approach, actual practice and theresearch community already have movedfar ahead. The history of the acronymFAST is quite paradigmatic: born as afocused abdominal sonography fortrauma assessment (system-based), it

quickly shifted to focused assessmentwith sonography for/in trauma (problem-based) (48, 49). Now, it is being incorpo-rated into more elaborate protocols, suchas EFAST (extended FAST, to PTX assess-ment) (50), FASTER (FAST including ex-tremities and respiratory tract) (51), andFAST-ABCDE (FAST including airway-breathing-circulation-disabilities/deficitsand exposure) (Fig. 1; Tables 3 and 4).

Figure 1. Level 1 ultrasound competencies in trauma care: the FAST-ABCDE.

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The latter protocols extend the primarilyabdominal assessment of hemoperito-neum, initially to the chest (fluid andPTX) and later to the limbs (fractures andhematomas), while focusing on the prob-lems relevant to ABC/ABCDE surveys,and emphasizing a clinical transverse fo-cused assessment. Similarly, emergencypoint-of-care echocardiography (per-formed by noncardiologist providers),while initially limited to the subxyphoidview for pericardial fluid, has graduallyextended to evaluate abnormal motionand volumes status (16, 33, 52–54).

These are relatively new concepts forthe ultrasound community. While mostradiologists, cardiologists, and gynecolo-gists perform emergency ultrasound as-sessments daily, few of them will havescanned more than one or two anatomi-cal areas in the same patient, and proba-bly none more than three areas. In thefirst few minutes of the primary and sec-ondary assessments of the trauma pa-tient, a trained critical care physicianlooking for abnormal movements, air,and fluid collections could quickly gothrough airway, respiratory, cardiovascu-

lar, neurologic systems (or through skull,chest, abdomen, and limbs), getting acritical real-time insight to refine anddramatically improve diagnosis, treat-ments, and procedures.

Traditionally, most general ultrasoundcourses, after addressing physics and in-strumentation, move on to abdominal ap-plications, focusing first on the easiest andmost common (normal and abnormal)findings such as liver anatomy, cysts, andsteatosis. Ultrasound-guided proceduresand maneuvers are usually discussed onlyin advanced general modules. However, in

Table 3. Ultrasound (US) learning goals for the primary management of the critical patient (problem-based setting, ABCDE type, trauma and non-trauma,US basic level 1

Problem Ultrasound-Enhanced ABCDE Assessment Ultrasound-Enhanced Resuscitation

A Airway Airway● Airway: patency, spontaneous/manual lung ventilation ● Endotracheal intubation, other devices● Trachea: displacement, lesions/emphysema, adjacent

compressive hematomas/masses● Cricothyroidotomy and emergent tracheostomy

guidance● Stomach: endotracheal-tube displacement, prandial status

B Breathing Breathing● Lung, pleura, diaphragm: ● Needle aspiration: pneumothorax

— Absence/asymmetry of ventilation ● Tube thoracostomy: pneumothorax, hemothorax— Pneumothorax, emphysema subcutaneous ● Resuscitative thoracotomy: hemorrhage— Large pleural effusion/hemothorax— Pulmonary edema/interstitial congestion— Diaphragm lesions/dysfunction/paralysis

C Circulation Circulation● Cardiac/hemodynamic qualitative assessment: ● Defibrillation: recovery confirmation

— Asystolia confirmation, PEA vs. pseudo-PEA ● Pacing: mechanical capture, transvenous— Tamponade ● Evacuative pericardiocentesis— Severe left ventricular systolic dysfunction ● Evacuative pleurocentesis— Acute cor pulmonale ● Peripheral and central vascular puncture— Biventricular dysfunction ● Venous cutdown— Cardiac hypovolemic profile (severe) ● Intraosseous accessa

— Valvular gross lesions or intracardiac masses ● Diagnostic paracentesis/peritoneal lavage— Inferior vena cava (preload): size, variations, collapsibility

● Pericardial sac: fluid/hemorrhage, tamponade● Pleural space: fluid/hemorrhage● Peritoneal space fluid/hemorrhage● Retroperitoneal spaces: gross hematomas● Placenta: previa with vaginal bleeding, detachment● Veins: femoropopliteal and central deep vein thrombosis● Aorta: abdominal and proximal arch aneurysm

D Disability (neurologic status)● Optic nerve (cerebral hypertension): sheath enlargement● Neonatal/infant brain: hemorrhage● Pupils: size, symmetry, reactiveness (if not accessible)a

● Brain: cerebral midline shifta

● Cervical spine: gross displacementa

E Exposure Exposure● Full access to all anatomical areas ● Urinary catheterization● Preventing the misdiagnosis of life-threatening ABCDE lesions

and emerging complications● Nasogastric tube insertion● Further ABCDE procedures

F Additional assessments Additional treatments— ABCDE reassessment (if necessary) — Further ABCDE resuscitation— Secondary assessment (system- or problem-based) — Secondary assessment procedures— Intra-operative assessment — Intraoperative procedures— Intensive/subintensive care assessment — Intensive-care procedures— Definitive assessment — Definitive-care procedures— Follow-up (serial re-evaluations, monitoring) — Follow-up procedures

aTo be considered still under initial investigation.PEA, pulseless electrical activity.

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critical care, undifferentiated problems areprimarily approached according to theABCDE or the “head-to-toes” sequencebased on physiologic priority. The abdomenis an important region to examine sono-graphically, but not before the airway, lungs,and heart. Free fluid is a major finding todetect, but not before assessing criticalfunction or movement (heart and pleuralmotion) or for intrapleural air (pneumo-thorax). Performance- and outcome-basedintroductory ultrasound training should al-

ways follow the same pathways and priori-ties, encompassing easy and “critical” find-ings in the real order of importance.Recently, an increasing number of focusedapplications directed at the airway, lung,heart, head, and limbs have been shown tobe feasible and accurate in the hands ofadequately trained emergency and criticalcare physicians. New, fully developed AB-CDE and head-to-toes management ap-proaches should be strongly recommendedin any ultrasound training for emergency

and critical care professionals (Fig. 1; Ta-bles 3 and 4).

Levels of Proficiency

We propose three consecutive levels ofproficiency, as generally acknowledged bya growing international consensus: level1 (general: common and focused), level 2(comprehensive: specialized and subspe-cialized), level 3 (expert: cutting edge in

Table 4. Ultrasound learning goals for the secondary management of the critical patient (system-based setting, head-to-toes type, trauma and non-trauma,US advanced level 1)

System Ultrasound-Enhanced “Head-to-Toes” Assessment Ultrasound-Enhanced Treatment

Head/neck ● Skull/facial bones: fractures ● Eventual ABCDE procedural support● Maxillary sinus: hemosinus, sinusitis ● Pre-/intra-/post-operative (general, orthopedic,

cardiovascular, thoracic, neurologic, obstetricand gynecologic surgery)

● Eye: gross lesions● Transcranial Doppler: focused findings● Soft tissues: hematomas, septic lesions, foreign bodies ● Soft-tissue collections diagnostic/evacuative

drainages, foreign-body detection/extraction● Limbs: arthrocentesis, fracture alignment,

basic loco-regional anesthesia

Thorax ● Lung: interstitial syndromes, contusions, neonatal respiratory diseases,acute respiratory distress syndrome

● Rib, sternum, and clavicle: fractures● Heart performance/filling state (semiquantitative/simple quantitative

assessment):— Overall heart chambers, abnormal dimensions— Left ventricular function “visual” and “measured” (fractional

shortening, fractional area change)— Gross preload estimation of left ventricle and of whole heart— Right ventricular function— Pulmonary embolism cardiac findings— Gross valvular dysfunction— Suspected infective endocarditis— “Contrast enhanced echocardiography” for suboptimal chamber

imaging (optional)● Soft tissues: hematomas, septic lesions, foreign bodies

Abdomen ● Liver, spleen: gross lesions/hematomas● Gallbladder: cholecystitis, hydrops, gross cholelithiasis● Kidney: gross lesions/hematomas, gross urolithiasis, hydronephrosis● Diaphragm: gross lesions, dysfunction/paralysis● Peritoneum: pneumoperitoneum● Intestinal tract: ileum, ischemia, appendicitis, abscesses/trapped

collections● Pre-/retroperitoneum: gross hematomas● Aorta: gross aneurysmatic dissection/rupture● Caval vein/iliac: thrombosis● Bladder: gross calcula/sediment/coagula, distension, retention, catheter

balloon● Perineum: hematomas, acute scrotum (trauma, inflammation, torsion)● Uterus: intrauterine pregnancy, fetal/placental/amniotic basic

assessment● Soft tissues: hematomas, septic lesions, foreign bodies

Limb ● Diaphysis (fractures)● Joints (fluid)● Soft tissue (gross hematomas, abscesses, muscle lesions)

Further assessment ● Further ABCDE re-evaluation ● Definitive care procedures● Eventual problem-based secondary assessment: cardiac arrest, shock/

hypotension, dyspnea/hypoxemia/thoracic pain, coma/focalsigns/headache, acute abdomen, abdominal/lumbar/pelvic/limb pain,oligoanuria, sepsis, fever of unknown origin, multiple organ failure,obstetric and gynecologic issues, etc.

● Intensive care procedures● Eventual ABCDE resuscitation

● Intensive- and subintensive-care assessment● Follow-up

— Serial re-evaluations— Continuous monitoring (intensive/subintensive care, transport to

other units/hospitals)

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clinical application, research, and educa-tion) (17). Each level has at least twosublevels, basic and advanced. A basiclevel 1 (BL1) curriculum would be ABCDEtraining in trauma and nontrauma car-diopulmonary arrest, shock/hypotension,dyspnea/hypoxemia, and coma/neuro-logic signs. The advanced level 1 (AL1)student also would learn to use the head-to-toes protocol and to evaluate addi-tional critical syndromes, such as acuteabdomen, cardiac failure, oligoanuria,chest/abdominal/lumbar/pelvic pain, ob-stetrics and gynecology issues, etc. Level2 competencies would be more special-ized, targeted toward clusters of profes-sionals or departments; they would belearned and credentialed during specificadditional modules. Level 3 expertise de-notes experts with significant experienceand specific educational responsibilities.Modular subspecialty instructional in-sights should be available to begin, inte-grate, support, and maintain competenceat all levels.

These standard core competencieswould have a high level of definition, par-ticularly at level 1. They could be thebasis for any ultrasound curriculum, in-cluding introductory courses, proctoredpractice, credentialing and accreditation,continuing education and professionaldevelopment, quality assurance, and de-velopment planning. Proficiency goals,integrated with the supporting educa-tional science topics, are the basis for thetraining program and accreditation pro-cesses targeted to trainers (instructors)and course directors. Focused modular(or multimodular) approaches to organs,systems, diseases, or problem-based setsof competencies are also acceptable, pro-vided that full competence in the targetedarea(s) is demonstrated and future clini-cal practice is confined to those field(s)alone.

Levels of Ultrasound Practice inIntensive and Critical Care

Three consecutive levels of training,experience, and proficiency are outlinedboth for providers and instructors: gen-eral, comprehensive, and expert ultra-sound in critical care medicine (respec-tively, USCCM levels 1, 2, and 3). Two orthree further sublevels for each level ofexpertise are identified as single-applica-tion, basic, and advanced, as follows:

● Level 1: General (set of common, fo-cused competencies)

— Single-application competent [US-CL1]

— Basic (ABCDE-conformed) [US-BL1]

— Advanced (problem- and system-based) [US-AL1]

● Level 2: Comprehensive (set of specific,thorough competencies)— Basic (specialized, problem-based)

[US-BL2]— Advanced (subspecialized, system-

based) [US-AL2]● Level 3: Expert (high expertise in clin-

ical usage, research, and/or teaching)— Basic (specialized, problem-based)

[US-BL3]— Advanced (subspecialized, system-

based) [US-AL3]

Each level of proficiency encompassesgeneral problem-based profiles (such asUS-BL1, US-AL1, US-BL2, and US-BL3,consistent with transversal or multipleuses in critical care). Levels 2 and 3 alsoencompass system-based subspecialtypractices (e.g., echocardiography for in-tensivists at US-AL2 and US-AL3). Thoseprofessionals who undertake to masterspecific ultrasound-assisted tasks can beacknowledged as having level 1 expertisein a single application (e.g., internal jug-ular vascular access, as US-CL1). Creden-tialed, competent physicians and boardsshould always directly supervise trainees’or residents’ performance until outcomemeasures certify them as independent,competent operators at a certain level. Atpresent, strictly defined boundaries be-tween the three main steps are difficult toprecisely define, and this schema shouldbe regarded as an overview to compre-hend the different levels of practice.These main three categories are drawnand adapted from the World Health Or-ganization (44), and recent EuropeanFederation of Societies for Ultrasound inMedicine and Biology (17) and Royal Col-lege of Radiologists (24) guidelines ad-dressing medical and surgical practice, aswell as most of the actual echocardio-graphic or cardiology societies’ recom-mendations. Levels I, II, and III, as re-ported in ACEP guidelines, refer to thetrainee’s learning process through didac-tics, proctored experience, and creden-tialing (18); similarly, the ACS creden-tials three levels respectively for courseattendance, competence acquisition, andinstructor status (19). Both of the lattertwo categorizations could be functionallyincorporated into any level of the overallgrading system.

Training Program Models

Competence-, performance-, outcome-,and problem-based multistep modulartraining appears to be the most feasible andeffective instructional pathway, comparedwith an organ-based curriculum. Accord-ing to the training needs of the target au-dience, two kinds of instructional programsare highlighted:

● Standard: general-purpose training(including specialty-specific, subspe-cialty, or monothematic standardizedmodules).

● Needs-based: customized training(fully tailored to specific demands orsystem-needs analysis).

Considering the entire spectrum ofspecialty-specific USCCM, possible stan-dard and customized training and cre-dentialing pathways could be further dif-ferentiated and arranged as follows:

● Standard sequence: to achieve USCCMstandard certification as a provider.— Level 1, general training, basic and

advanced modules for providers(US-BL1 and US-AL1).

— Level 2, comprehensive training,basic and advanced modules forproviders (US-BL2 and US-AL2).

— Level 3, expert training, basic andadvanced modules for providers(US-BL3 and US-AL3).

● Instructor modules: credentials for in-struction at provider level or lower.

● Refresh modules: accelerated coursestructure to renew lapsed certification.

● Customized sequences: special coursesfor a variety of purposes.— Single-application credentials, as dis-

cussed previously, giving a specializedUS-CL1 rating that could be promotedto US-BL1 with completion of the en-tire basic course structure. A variety ofUS-CL1 ratings would be available, onefor each appropriate specialized usageof ultrasound.

— Non-standard credentialing: For thosewith previous formal or informal train-ing, experience, and proficiency—whohave nonetheless accumulated a set ofcompetencies—this category of train-ing might be made available to accel-erate their credentialing. This categoryrecognizes those who have learned ontheir own, or in some other fashionthat lacks documentation, and canprove their competence if provided theopportunity for an appropriate evalua-tion and acknowledgment by the ap-propriate boards.

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Educational Module Structure

Particularly at level 1, each module re-quires candidates to attend an introductorycourse and workshop with didactic andpractical components. They will performand record a requisite number of proctoredexaminations, and pass a final exit exami-nation designed to assess these competen-cies:

1) Introductory workshop (prerequisiteto parts 2 and 3)a) Theoretical sessions (knowledge

base)— Methods: didactic sessions.— Tools: multimedia lectures, in-

teractive cases, syllabi, text-books, video, web-based andcomputer-assisted learning, etc.

— Precourse training (printed orelectronic/online format).

b) Practical sessions (core skills andattitudes)— Methods: demonstrations and

hands-on training.— Tools: practical work-stations on

patients, models, or simulators.2) Proctored practice (sets of minimal

requirements)a) Logging supervised scanning, with

real-time reviewb) Logging independent scanning,

with delayed or remote over-reading

3) Credentialing evaluation (parts 1 and2 must be completed beforehand)a) Introductory workshop and proc-

tored practice documentation

b) Case studies, research, and thera-peutic-plan presentation

c) Multiple-choice test and video in-terpretation

d) Competence-based practical examon simulated or real patients

e) Theory and practical teaching sim-ulations (only for instructors)

Several studies and recommendationsaddressing emergency and critical care–medicine educational needs highlight theeffectiveness of such a sequence. However,study-time and repetition quotas remain indispute. Previously suggested figures haveranged from 2 hrs to 40 hrs of introductorylectures, and from 10 mins to 40 hrs ofhands-on training. The number of recom-mended practice scans has ranged from 15to 50 per applications, and from three to600 total examinations, depending most onprocedural type and targeted goals, con-tents, structure, duration, and audience(17–26, 31–38, 42–44, 55–77). Consideringthe documents and experiences reported inthe provided bibliography, we defined andsuggested several detailed study-time andrepetition quotas (Tables 5 and 6)

Recommended LearningContent

Standard Competencies. The standardcompetencies (see http://ccmjournal.com/pt/re/ccm/toc.00003246-200705001-00000.htm ) represent the general theoreticaland practical basis of any standard and cus-tomized training in critical care ultra-sonography, encompassing main ultra-

sound functions and responsibilities suchas image generation, acquisition, interpre-tation and administration, clinical deci-sion-making, problem-solving, and devel-opmental planning. The outlined skills aregrouped systematically according to themain categories of functions and responsi-bilities. General and specific sets of stan-dard competencies should be further tai-lored to the targeted audience and thetraining goals, organizing the content ac-cording to different outcome- and problem-based priority settings.

Outcome-Based Categories. Criticalcare ultrasound training or curriculashould be shaped and developed in rela-tion to specifically targeted outcome cat-egories, such as technical, clinical, orga-nizational, and social effectiveness.Technical effectiveness refers to the fea-sibility and consistency of the applied im-aging technology, and the adequacy andaccuracy of machines and providers inperforming image generation, acquisi-tion, interpretation, and administration.The set of associated core competenciesshould enable the provider to effectivelyhandle ultrasound equipment, scanningprocedures, sonographic semeiotics, aswell as administrative, legal, and ethicalissues. Each ultrasound-training curric-ula must encompass and assess technicaloutcome-related competencies. Clinicaleffectiveness is consistent with the im-pact on clinical outcome measures, de-pending on the accurate and timely in-corporation of the sonographicinformation into clinical management.

Table 5. Requirements for ultrasound in critical care medicine (USCCM) credentialing

Standard Specialty-Specific MinimalRequirements for

USCCM Credentials

Prerequisite for Admission to Credentialing CompetenceAssessment

Prerequisites for Maintenance of Credentials After CompetenceAssessment

Formal CourseTiming

Preliminary Practice (Proctored) ContinuingPractice

Annual Exams

Refresh orRevalidationFrequency

ContinuingEducation Quality AssuranceExams Period

Level 1—general Audits, updates(literature,technology),meetings &congresses,professionaldevelopment, etc.

Supervision, over-reads, goldstandardstesting, patientoutcomereview,developmentplans, etc.

Single-competence[US-CL1]

1 day (8 hrs) 15–30 1–3 months 15–30 2 yrs

25–50 25–50

Basic [US-BL1] 2 days (16 hrs) 200 3–6 months 100 2 yrs

Advanced [US-AL1] 3 days (24 hrs) 300 6–12 months 200 2 yrs

Level 2—comprehensive

Specialized [US-BL2] 5 days (40 hrs) 800 (cumulative) 1 yr (at level 1) 300 3 yrsSubspecialized

[US-AL2]Discipline-

specificDiscipline-

specificDiscipline-

specificDiscipline-

specificDiscipline-

specificLevel 3—Expert

Specialized [US-BL3] Optional 2000 (cumulative) 3 yrs (at level 2) 500 5 yrsSubspecialized

[US-AL3]Discipline-

specificDiscipline-

specificDiscipline-

specificDiscipline-

specificDiscipline-

specific

US, ultrasound; CL, single-competence level; BL, basic level; AL, advanced level.

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Organizational and social effectivenessrefers to the ability of managing improve-ment and development plans, as well asimpacting organizational and social sys-tems at different levels (departmental, lo-cal, regional, national, international). Alllevels of effectiveness and the overall per-

formance are quite consistent with the“transversal competencies” of the criticalcare physician and would be further en-hanced by a point-of-care team-centeredpractice.

Setting-Specific Training Needs. Theoutlined standard outcomes and compe-

tencies are developed to meet the com-mon demands of the critical care physi-cian. Nevertheless, looking from a broadperspective to the variety of critical carescenarios throughout the world, we no-tice several different approaches and pro-viders within similar settings in different

Table 6. Level 1 basic and advanced minimal requirements

Basic and Advanced Level 1 of Sonography (US-BL1 and US-AL1) in Intensive and Critical Care Medicine

Structure and Sequence Recommended Subcomponents Recommended Minimal Requirements

Introductory course Theory Didactical content or e-learningPrecourse training Formal classes or computer/web-based learningDidactic sessions Lectures, interactive cases

Ratio of students/faculty � maximum 30–40:1Contents: see US-BL1 and US-AL1 theory syllabus

Practical Applications on real or simulated patients, simulatorsDemonstrations and hands-on training Ratio students/tutor/machine/model � maximum 5:1:1:1

Contents: see US-BL1 and US-AL1 practical syllabusCourse duration: 2 days (16 hrs) US-BL1, 3 days (24 hrs) US-AL1Ratio practical/theory: 1:1 or more

Proctored practice Technical Exams/key competence: 15–30 or 25–50, 1–3 per monthClinical Exams/module (US-BL1): 200/3–6 monthsOrganizational Exams/module (US-AL1): 300/6–12 months

Supervised and independent practicalperformance

Review: real time (�30%) and delayedFrequency: 5–10 exams/week; inactivity �1 monthClinically indicated: at least 50%Pathologic finding: at least 10–20%Logbook (at least 5–10% illustrated)Applications on real or simulated patients, simulatorsContents: see US-BL1 and US-AL1 practical syllabusInvolvement in research, education, quality assurance, planning

Credentialing evaluation Presentations 3 relevant logged cases (plus illustrations, follow-up)— Competence-based Case-study reports 1 study to be proposed or published— Modular assessment Research study 1 plan (or component) to be presented— Continuing process Development planning 1 simulated or real session (only for instructors)

TeachingTheory test Required overall performance: �75%

Multiple-choice test 25–50 questions/3–5 answers eachVideo interpretation 5–10 pathologic video clips

Practical test Required modular performance: 100%Competence-based practical exam Application on real or simulated patients/scenarios

Administration Inventory of assessed/credentialed competenciesModular competence-assessment sheet Temporary validity (see prerequisite for maintenance)Prerequisite for admission Introductory workshop: 100% attendancePrerequisite for maintenance Practice: minimal requirements to be achieved

Annual numeric goals of practice (minimum, logbook)Periodic refresh/revalidation, CME/CPD, quality assurance

Table 7. Point-of-care critical ultrasound modalities

Modality Function and Goals Targeted Patients

Primary ultrasound ● PHC-conformed ultrasound practice, for developingessential, acceptable, accessible, and sustainablehealthcare systems

● Communities accessing scarce resource health services withno referral systems and significant socioeconomicconstraints

Triage ultrasound ● Secondary field triage, for improving treatment andevacuation priority scoring

● Large number of injured patients in mass or disaster events

Screening ultrasound ● Primary or secondary screening, for improvingdiagnostic workup

● Patients with subacute or uncertain clinical presentations

Emergency ultrasound ● Primary emergency assessment, for improvingemergency care (including procedural guidance)

● Patients with acute or emergency clinical presentations

Observational ultrasound ● Secondary serial evaluation for monitoring focusedparameters (and/or detecting emerging complications)

● Stable patients under observation, with uncertain diagnosisor prognosis, after initial full assessment

Intensive ultrasound ● Screening, emergency, and observational ultrasoundperformed in those with critical multisystem illness

● Selected critically ill patients requiring intensive assessment,monitoring, and treatment

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countries. After a literature review andcritical appraisal, we identified point-of-care ultrasound-delivery formats that, ir-respective of country or scenario, presentsimilar objectives and requirements interms of funding, equipment, education,and organization (Table 7). At one ex-treme of this set of modalities, we find“primary” ultrasound providers, trying toserve hundreds of thousands of patients,with very scarce resources, thus targetingpublic health (e.g., the prevention of fe-tal-maternal disorders in developingcountries’ rural areas). At the other endof the scale, “intensive care” providers aretotally focused on small clusters of criti-cally ill patients, targeting individual vitalfunctions and providing very costly inten-sive care (e.g., the trauma patient assistedby highly specialized units).

In relation to providers, scenarios (Ta-ble 1 and Table 2), and modalities (Table7), the standard and core competenciesshould be further shaped for specific set-tings and clinical needs.

Problem-Based andSystem-Based ManagementPriorities

A multiple-goal problem-based ap-proach represents the main criteria toprioritize ultrasound core competenciesthroughout any critical care specialty-specific training program. Overall, criti-cal care performance is typically orientedtoward complex disease states rather thansingle organs, calling for an accurate andtimely transversal approach to multiplesystems, rather than a comprehensive ex-amination of a single anatomical region.Particularly for undifferentiated and unex-pected scenarios, management strategiesbecome largely dependent on ABCDE-typepriority settings, focusing on life-threaten-ing problems first. The basic ultrasoundapplications, performed by level 1 basicproviders, should be effectively organizedand prioritized according to an AdvancedCardiac Life Support/Advanced TraumaLife Support–style primary survey of theundifferentiated/unstable states such ascardiac arrest, dyspnea, shock, and coma,both in injured and uninjured patients.Sonographic serial re-evaluations or con-tinuous monitoring should also be incor-porated into the clinical follow-up pro-cess.

Further advanced and comprehensiveapplications should then be continued, ac-cording to a system-based (head-to-toes–like) or problem-based (ABCDE-like) sec-

ondary survey, by level 1 advancedproviders (Fig. 1; Tables 3 and 4). In anyphase, specific clinical markers or informa-tion could change the priority settings,suggesting specific pathways or a movestraight to level 2 and level 3 procedures, oreven a restart of the ABCDE protocol atstep A. The whole primary and secondarymanagement should lead the patient to de-finitive care, after an eventual operativeand/or intensive care phase. To provide anexample of clinical and sonographic point-of-care integration, we describe the thor-ough ultrasound-enhanced critical man-agement cycle (USCMC) in trauma care:the extended FAST protocol with ultra-sound fully integrated with ABCDE andhead-to-toes assessment, treatment, andfollowup (Fig. 1). The sonographic applica-tions listed would represent both the com-petencies and the learning goals required atadvanced level 1 practice.

The overall inventory of critical care–ultrasound competencies should be pri-oritized and arranged throughout the dif-ferent educational steps, consistent withthe planned levels of certification.

Level 1—General Practice

General Requirements. Point-of-careultrasound practice, at this level, wouldusually require general competence ingenerating, acquiring, interpreting, andadministrating common and focusedsonographic findings (17, 24) to incorpo-rate them into decision-making algo-rithms and enhance clinical performanceand outcomes in the following circum-stances:

— Triage, diagnostic, monitoring, ther-apeutic assessments: CPR-ABCDE,dyspnea/hypoxemia, chest pain,shock/hypotension, coma/neurologicfocal signs, acute abdomen, abdomi-nal/lumbar/pelvic pain, oligoanuria/dysuria, fever of unknown origin,systemic inflammatory response syn-drome/sepsis/multiple-organ dysfunc-tion syndrome, FAST and extendeduses, with additional focus on abdom-inal trauma, thoracic trauma, limbtrauma, head trauma, ocular trauma,hemodynamics, cardiac failure, pul-monary embolism/deep vein throm-bosis, cervical-cranial (including fo-cused transcranial Doppler), softtissues, ventilated patient, obstetricsand gynecology, pediatrics, geriatrics.

— Procedural guidance: Endotrachealintubation, cricothyroidotomy, tra-

cheostomy, thoracostomy/needle as-piration, pericardiocentesis, pleuro-centesis, paracentesis, vascular access(central and peripheral veins, periph-eral arteries), intraosseous access, de-fibrillation, cardiac pacing, urinarycatheterization, naso-gastric tube in-sertion, nerve blockage (basics), for-eign-body detection and removal, ab-scess/hematoma drainage.

Level 1 ultrasound providers shoulddemonstrate the following general com-petencies:

a: perform common examinations safelyand accurately (image generation andacquisition).

b: describe, recognize, and differentiatenormal anatomy and function; diag-nose common abnormalities withinorgans and systems (image interpreta-tion).

c: manage examinations and documenta-tion according to administrative, med-ical, and legal duties.

d: integrate sonographic informationinto clinical decision-making algo-rithms, including interrelationshipwith other imaging techniques and re-ferral criteria (clinical image integra-tion).

e: incorporate scanning information intointerventional procedures, increasingaccuracy, effectiveness, and safety (ul-trasound procedural guidance).

f: manage quality-assurance and devel-opment plans, enhancing point-of-careultrasound practice, education, tech-nology, and research, to impact orga-nizational and social outcomes (ultra-sound development plans).

g: teach ultrasound to level 1 trainees (iflevel 1 instructor competency is at-tained).

Within most medical specialties, thistraining could be accomplished duringpostgraduate practice-based pathways orconventional specialist training. In orderto enhance and facilitate learning out-comes, general level 1 competenciesshould be differentiated into at least twolevels of training and proficiency, accord-ing to relevance, prevalence, scientific ev-idence, and ease of learning: basic andadvanced level 1 (US-BL1 and US-AL1)proficiency.

Training and Practice● Trainees should acquire an appropriate

body of knowledge.● The level 1 basic module consists of a

2-day (16-hr) course (50% lectures and

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interactive cases, 50% demonstrationsand hands-on practice). The level 1 ad-vanced module could be a 3-day (24-hr) course (same theoretical/practicalratio). Level 1 monothematic modules,particularly single-application formatcourses, are usually well covered by1-day (8-hr) workshops.

● Numerous educational methods canbe used to present the theory com-ponent including lectures, interac-tive cases, syllabi, textbooks, video,and web-based and computer-as-sisted learning. Precourse learning,reassessed at the beginning of themodule, could partially replace thecognitive component. Introductoryhands-on experience within a labora-tory setting could involve scanningof live models or patients, objectivestructured clinical examinations, andcomputer simulations.

● Postcourse practical training shouldinvolve carrying out regular proctoredultrasound examinations in criticalcare units or services, or alternativelyin emergency and imaging depart-ments.

● Examinations should encompass thefull range of pathologic states and pro-cedures listed in the practical syllabus.

● A minimum number of scanning pro-cedures, in each specific area of inter-est, should be performed.

● Most of the organ/disease-based pri-mary applications, outlined in the level1 syllabus (see http://ccmjournal.com/pt/re/ccm/toc.00003246-200705001-00000.htm), would generally require25 exams to 50 exams each (e.g., pleu-ral space/effusion, lower extremityvein/thrombosis, abdominal aorta/aneurysm), even if accuracy for severalspecific findings and signs would begenerally acquired with less practice(heart motion, sliding-lung sign, ve-nous compressibility, etc.).

● Provided that trainees are clinically ex-perienced and credentialed, some addi-tional scanning could be adequate foreffective sonographic integration incritical states management (e.g., dys-pnea/hypoxemia, shock/hypotension,coma) or procedural guidance (e.g.,vascular-line insertions, tracheal intu-bations).

● As a recommendation, a certain por-tion of logged exams should be clini-cally indicated (�50%) and should bepositive (�10–20%); the rest could beperformed on normal organs/systemsor simulated patients.

● Considering submodular training, afew dozen proctored examinationscould credential trainees for one ortwo applications (e.g., FAST exam andvascular access). Proportionally, sev-eral hundred scans should be requiredfor fulfilling complete modules, whichencompass �30–40 key competencies.Fortunately, learning outcomes signif-icantly improve with practice exten-sion and learning curves overlap, thusthe full basic and advanced level 1competencies would likely require 200and 300 overall examinations, respec-tively, appropriately distributed amongthe different applications.

● Approximately 5–10 examinations per-formed by the trainee per week couldrepresent a realistic reference for ac-quiring, retaining, and developingskills over the whole training period(3–6 and 6–12 months, respectively,for basic and advanced level 1).

● Examinations could be performed assupervised scanning with real-time re-viewing, or independent scanning withdelayed or remote overreading of therecorded documentation. At least 20%of initial and 10% of final scanningwould be best practiced under directsupervision.

● A personal logbook should be kept list-ing the types of examinations under-taken. Trainees should record patientdemographics, examination details,findings, and adequacy of interpreta-tion.

● An additional logbook containing anillustrated description of at least 20different cases in which the trainee hasbeen personally involved may be a use-ful adjunct.

● During the course of training, a com-petency-assessment sheet should becompleted, because this will determinethe area or areas in which a traineecould practice independently.

● The entire practical experience should begained under the support of a recognizedtrainer; the supervisor should be eithersomeone who has obtained at least level 2certification or a level 1 practitioner withat least 2 yrs of experience.

Physicians with extensive ultrasoundexperience, who currently employ point-of-care ultrasound in their clinical prac-tice, may, at the discretion of appropriateboards, undergo the credentialing exam-ination without attending the instruc-tional workshop or logging proctoredstudies.

Core Competencies. A detailed practi-cal and theoretical syllabus for level 1practice is outlined in this section, en-compassing common and focused appli-cations in critical care medicine both forbasic and advanced practices. Minimal re-quirements for skill acquisitions and re-tention are recommended, even thoughdifferent trainees will acquire and main-tain the necessary abilities at differentrates and the end-point of the trainingprogram should be determined by a spe-cific final assessment for each module.The core competencies are listed system-atically according to their technical (im-age generation, acquisition, interpreta-tion, and administration), clinical(decision-making and enhancement) rel-evance. The technical abilities—embrac-ing management of ultrasound instru-mentation, techniques, and semeiotics—are listed first, as they represent the firstmandatory step for any further effectiveclinical performance. To avoid redun-dancy, we described them according to anorgan- and disease-based scheme. How-ever, we still emphasize that during thetheory and practical training itself, thissystem-based layout should be reshapedaccording to problem-based ABCDE andsystem-based head-to-toes pathways,where technical skills should always bepresented and learned as part of inte-grated clinical decision-making.

Level 2—ComprehensivePractice

General Requirements. Point-of-careultrasound practice, at this level, wouldusually require specialized competenciesin acquiring, interpreting, and incorpo-rating specific and comprehensive sono-graphic imaging into decision-makingalgorithms, to enhance clinical perfor-mance and outcomes. Level 2 of practicein critical care medicine is a specialty-specific level of ultrasound proficiencyderived from the depth and length of ex-perience, ideally augmented by specificcore knowledge and skills. We are notgoing to highlight detailed syllabi for thislevel, since we feel that further experi-ence, data, and consensus should bereached to accurately identify the level 2core competencies of the general criticalcare specialist. Level 2 usually refers tothe ability to provide comprehensive ul-trasound examinations over an organ or abody system. This is a concept that fitswell within an organ or system-based spe-cialty (e.g., cardiology, gynecology, gas-

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troenterology), where a level 2 practitio-ner performs complete (not just focused)examinations over a targeted organ sys-tem. However, critical care does not dealwith isolated organs or systems. Thepathophysiology of the critically ill con-sists of scenarios involving symptoms andsigns. We would strongly suggest empha-sizing clinical approaches in level 2 fo-cusing on the comprehensive assessmentand management of these states ratherthan organs (e.g., hypoxia, hypovolemia,coma, sepsis rather than lung, heart, ves-sels, and liver). Before defining the prob-lem-based comprehensive and transversalcompetencies characterizing level 2 ofpractice in critical care, the level 1 clin-ical profile should be further defined andvalidated. Currently, we recommend pro-moting the development of collateralsystem-based level 2 subspecializations,to strengthen critical care physician per-formance in certain functions (e.g.,transthoracic/transesophageal echocardi-ography for hemodynamic assessmentand management). Because of the diffi-culties in maintaining proficiency andcredentials for several advanced skills atthe same time, each trainee should planand perform only a few subspecializedmodular level 2 upgrades, eventuallyaiming for level 3 in the targeted fields.Such modules should not encompass ap-plications requiring training and con-tinuing education that would be too dif-ficult for the practitioner to sustain. Forexample, certain echo-lab skills, callingfor several hundred annual examinationsto retain credentials, may be appropriatefor a cardiologist, but not for a generalintensive care practice.

Given these considerations, we pro-pose that level 2 credentialing require atleast 1 yr of experience at level 1, withregular ultrasound practice to guaranteean increased comprehensive ability inmanaging the set of level 1 clinical indi-cations and applications. Level 2 ultra-sound providers should then demonstratethe following competencies (17, 24):

a: to accept and manage referrals fromlevel 1 practitioners.

b: to perform disease-based or problem-based specific examinations safely andaccurately (image generation and ac-quisition).

c: to describe, recognize, differentiate,and assess correctly almost all normaland pathologic sonographic patternswithin one or more relevant organs,systems, syndromes, or clinical proce-

dures (image interpretation, proce-dural guidance).

d: to acquire and manage more specificand comprehensive sonographic infor-mation, to achieve more effectively theclinical and organizational goals out-lined at level 1 practice.

e: to teach ultrasound to level 1 and 2trainees provided that level 1 and 2instructor competency is formally ac-knowledged.

f: to conduct research in critical caremedicine ultrasound applications.

Monothematic subspecialized mod-ules should also be recommended to en-hance or increase the basic skill inven-tory of the critical care physician. Typicalexamples would be training focused onechocardiography (including transesoph-ageal), vascular ultrasound, or gastroin-testinal ultrasound, or on procedures,such as regional anesthesia, vascular ac-cess, airway management, etc. Specificmodules could also highlight setting-related competencies, such as those con-sistent with perioperative or prehospitalcritical care functions and responsibili-ties. In the cluster of the level 2 subspe-cialized providers, we should also includethe radiologists trained as sonologists,since their comprehensive competence isusually focused on the abdomen andsome procedural application, and less of-ten the other systems relevant to criticalcare (such as vascular, cardiac, airway).Subspecialized categories of level 2 com-prehensive proficiency in CCM shouldalso be attributed to other imaging spe-cialists (e.g., gastroenterologist, cardiolo-gist, gynecologists), or to the technicianstrained and certified in specific areassuch as echocardiography and vascularultrasound.

Training and Practice● At level 2, trainees should further ex-

tend the body of knowledge encom-passed at level 1.

● Additional practical training should in-clude at least 1 yr of experience at level1, with regular ultrasound practice incritical care services, or alternativelyin emergency and imaging depart-ments.

● A further 300 examinations should beundertaken to encompass the fullrange of pathologic conditions andpractical procedures listed in the level1 program.

● Approximately 5–10 examinations perweek could represent a valuable refer-ence for acquiring, retaining, and de-

veloping further skills over the wholetraining period (12 months).

● A logbook listing the numbers andtypes of examinations undertaken bythe trainee should be maintained, asduring level 1 training.

● A further illustrated logbook of specificnormal and abnormal findings shouldbe kept, detailing 20 different casesexamined by the trainee, which may beuseful to document further progres-sion of training. Bibliographic refer-ences of supporting ultrasound theoryor practice should be attached, as well.

● Examinations should be reviewed orundergo other quality assurance(cross-checking with other imagingexaminations, discharge report, follow-up, etc.).

● The end-point of the level 2 trainingprogram will be judged by a formalassessment of competencies, wheredocumentation of practice and, even-tually, educational and research activ-ity, should be produced, too.

● The full practical experience should begained under the support of a recog-nized supervisor; this role should beundertaken by someone who hasachieved at least level 2 competence,has had at least 2 yrs of experience atthat level, and would normally be ofconsultant status.

● Trainers, trainees, and training centersshould continuously undergo quality-assurance programs to keep the wholesystem (and each instructional compo-nent) accredited.

● Imaging specialists and experts alreadypracticing in specific areas (acknowl-edgeable at the 2nd and 3rd level)should still formalize areas of compe-tence and meet quality-assurance andcontinuing-development requirementsfor undertaking USCCM-teachingroles.

Core Competencies. Whether thetrainee’s professional development planincludes subspecialty training, the teach-ing modules could be based on the se-quence of the level 1 modules andadapted to the appropriate contents: in-troductory course (1–3 days), proctoredpractice (3–12 months), final assessmentof competencies, and credentialing. Aminimum number of proctored andlogged scanning procedures in each mod-ule area should be recommended, to-gether with educational and researchtasks, before final credentialing. Echocar-diographic training for intensivists can be

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acknowledged as level 2 training (or in-troductory to it), and is already availablein some countries such as France, Bel-gium, the United States, Canada, Den-mark, Australia, India, and Italy) (78). Inan increasing number of countries,courses on U.S.-guided vascular accessare available. In most, practical trainingis nonstandardized and focused only onperipheral and internal-jugular-vein ap-proaches, consistent with a level 1 stan-dard. A comprehensive level 2 approachwould require more in-depth training,encompassing all the venous-access tech-niques over all anatomical areas. Ad-vanced courses on multiple regional an-esthesia techniques are increasinglyavailable, too (particularly in Germany,Austria, and North America). Nearly all ofthe other ongoing experiences targetingcritical care practitioners throughout theworld are striving to develop “focused”ultrasound at level 1. As for specialty-specific level 2, the subspecialty level 2training experiences (with the exceptionof echocardiography) still require furtherdata before being definitely incorporatedinto a formal evidence-based curriculumwith a detailed syllabus.

Level 3—Expert Practice

General Requirements. Level 3 practi-tioners are expected to spend a significantpart of their time undertaking ultrasoundexaminations, teaching, researching, anddeveloping new ultrasound knowledge.They are therefore regarded as expert inthis area. They will be able to performspecialized examinations at the cuttingedge of ultrasound practice and will beactively involved in developing innovativeultrasound applications within criticalcare. Generally, this very advanced levelof practice would involve the followingabilities (17, 24):

a: to accept tertiary referrals from level 1and 2 practitioners

b: to perform specialized ultrasound ex-aminations

c: to perform advanced ultrasound-guided invasive procedures

d: to conduct substantial research in ul-trasound

e: to teach, mentor, and supervise ultra-sound practitioner at all levels

f: to be aware of and to pursue new de-velopments in clinical ultrasound

In a developed and formalized trainingsystem, level 3 experts should have spenta continuous period devoted to specialty

or subspecialty-specific ultrasound train-ing in critical care, being mentored andsupervised by other level 3 practitioners.Unfortunately, at the moment, we arestill far from having a critical mass ofexperts in ultrasound to set up and main-tain such a system. If we look at criticalcare ultrasound subspecialties, we wouldfind several level 3 experts practicing andpublishing data throughout the world.Some are intensivists or anesthesiolo-gists, expert in specific ultrasound fields,such as echocardiography or interven-tional applications. More frequently, theyare experts belonging to other medical orsurgical specialties who frequently per-form “organ-based” ultrasound examina-tions in critical care services; they arephysicians temporarily in charge of thecritical patient, or consultants making orrecommending clinical decisions accord-ingly (cardiologists, gastroenterologists,internists, vascular surgeons, nephrolo-gists, urologists, gynecologists, etc.).However, if we look at critical care ultra-sound as a transversal multidisciplinarytool, throughout the world we would findjust a few critical care physicians practic-ing multiorgan and multisystem ultra-sound at level 3 (1).

Maintenance of Skills

At all levels, after having been assessedas competent to practice, the physicianwill need continuing education and pro-fessional development, because of thenatural decay of infrequently performedcompetencies and to keep pace with thecontinuous development of technologyand procedures (Table 4).

● In medical practice, a critical care phy-sician performing ultrasound shouldcontinue to perform at least 100 and200 examinations per year respectivelyat basic and advanced level 1, 300 peryear at level 2, and 500 per year at level3. Level 1 trainees should continue topractice ultrasound throughout theirtraining with no �1 month elapsingwithout using ultrasound skills.

● Credentialed physicians should alsohold regular meetings with imagingspecialists and peers, and should keepa named experienced sonographicpractitioner as a mentor.

● They should also include ultrasound intheir continuing medical education,audit their practice, participate in mul-tidisciplinary team meetings and con-ferences, and keep up to date with rel-

evant literature and technologydevelopment.

● Finally, at all levels, while implement-ing a training program, quality shouldbe guaranteed. Providers, students, in-structors, and training centers shouldcontinuously undergo quality-assur-ance processes, which assess technicaland clinical performance throughmethods such as supervision, over-reads, gold-standards testing, or pa-tient-outcome review within depart-mental ultrasound plans.

A Training System Approach Matrix.The outlined critical care ultrasound cur-ricula aim to strengthen the basis forconsensus around standards of ultra-sound performance and education in crit-ical care. Nevertheless, any systematicand international approach to the mattershould consider the huge variety of inter-pretations of the critical care conceptthroughout the world, as well as the ac-tual and potential differences among allthe critical care ultrasound services andproviders. In addition to standardizedmodels, we should also focus on the bestmethods to design and implement trainingthat meets any specific local, regional, ornational demand. A performance-basedneeds analysis, incorporated into a systemapproach to training and development, isprobably the most widely acceptedemerging instructional model, able tomeet specific requirements and goals inview of a performance-management pro-cess (79). Training and development re-fers to an ongoing process set up mostlyto address workforce performance gaps;i.e., education required to meet perfor-mance standards of completeness and ac-curacy for a defined task or set of tasks(function, role, job). The performancegap is effectively indicated by the perfor-mance appraisal, which includes evalua-tion of all activities ensuring that organi-zation, department, service, andindividual goals are consistently beingmet in an effective and efficient manner.

Constructing a training program sys-tematically involves a sequence of dy-namic steps that can be grouped into fiveiterative phases: a) needs analysis (as-sessing organizational goals, perfor-mance standards and gaps, workforceneeds for competence, learning objec-tives); b) training model design; c)courseware development; d) course im-plementation and conduction; and e)continuing evaluation and improvementthroughout all of the phases. The steps in

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each phase should not be thought of asconcrete in nature. Depending on start-ing points and variables, one step doesnot have to be completed before the nextone is started. Every training project willdevelop its own rhythm and flow. Theoutlined approach is not to be considereda mechanical, linear, or algorithmic pro-cedure, but rather an exploratory prob-lem-solving technique that uses analysesand evaluation feedback to provide cus-tomized performance-based training anddevelopment solutions.

CONCLUSION

In the future, the accurate assessmentof critical disease states and the safe guid-ance of interventional procedures is likelyto be routinely performed by critical andintensive care physicians using ultra-sound. A qualified level of practice—asverified through education, credentials,experience, and continuing medical edu-cation and professional development—isnecessary to allow for the provision of asafe and effective ultrasound service. Al-though scientific and educational bodies,particularly for the critical care subspe-cialty areas, have recently made somerecommendations, there are still onlyscattered examples of educational stan-dards for general-purpose applications.This article strives to address this gap, bysuggesting detailed performance andcompetence-based educational recom-mendations, acceptable at an interna-tional level, to facilitate the incorporationof the emerging point-of-care ultrasoundusage into critical care practice.

Given the nature of the critically illpatient, these recommendations cannotbe conclusive for all patients and careproviders, but are intended to further theongoing international debate on the ed-ucational and proficiency requirementsnecessary for the appropriate use of ul-trasound in critical care. We perceive thatthe critical care community will easilyaccept the rationale regarding the level 1of general practice, which encompassesthe most common applications for thecritical ABCDE and head-to-toes manage-ment processes. More complex will be therecognition of newer subspecialty areas ofcritical care encompassing higher levelsof ultrasound practice (in concert withechocardiography) and adopting the“transversal” profile of the level 2 (com-prehensive) and level 3 (expert) ultra-sound providers. Regardless, the increas-ing availability of portable and affordable

technology, together with the rationalgoal-directed simplification of competen-cies and applications, represent a tremen-dous opportunity for the highly sophisti-cated ICUs of the industrialized world, aswell as for the essential critical care ser-vices of the less developed nations. Thereis a huge educational challenge ahead ofus. At the conclusion of this article, pri-marily intended to define standard refer-ences for an international ultrasoundcurriculum, we must still underline thelimit of any stiffly standardized contentand model, and rather emphasize thevalue of any system process that enables aversatile and easily updated continuing-training solution.

To achieve a universal approach to ul-trasound education in critical care, amulticentric educational study has beenundertaken to apply the described andfuture curriculum models throughoutseveral dozen countries over the next fewyears (“Continuing Medical Education forUltrasound in Critical Care Medicine,”CME USCCM Project, accessed at: http://www.winfocus.org/usccm) (25). Whiletesting and refining goals, contents, andmethods, we aim to gather and empoweran interactive worldwide network, able toprovide gradual consensus and evidence-based recommendations, and test the fea-sibility of a certification and quality-assurance international developmentplan.

The advice contained in this docu-ment draws partially on the documentspublished by eminent boards and institu-tions. Particularly, we wish to acknowl-edge the contributions of the UnitedKingdom Royal College of Radiologists,the European Federation of Societies forUltrasound in Medicine and Biology, theAmerican College of Emergency Physi-cians, the American College of Surgeons,the World Health Organization, and theWINFOCUS (World Interactive NetworkFocused on Critical UltraSound) studygroups. In addition, we would like tothank colleagues in intensive and crit-ical care medicine, anesthesia, emer-gency medicine, emergency surgery, ra-diology, and ultrasound-imagingspecialties for their constructive com-ments on this article and their eventualparticipation in the “CME USCCM” in-ternational study.

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