Training guidelines for ultrasound: worldwide trends

Best Practice & Research Clinical Anaesthesiology 23 (2009) 363–373

Contents lists available at ScienceDirect

Best Practice & Research ClinicalAnaesthesiology

journal homepage: www.elsevier .com/locate/bean

11

Training guidelines for ultrasound: worldwide trends

Sean Bennett, Consultant in Cardiothoracic and Intensive Care Anaesthesia *

Department of Anaesthesia, Castle Hill Hospital, Cottingham, East Yorkshire, HU14 3LY, United Kingdom

Keywords:ultrasoundechocardiographyemergency medicinecritical care

* Tel.: þ1482 624196; Fax: þ1482 623026.E-mail address: [email protected]

1521-6896/$ – see front matter � 2009 Elsevier Ltdoi:10.1016/j.bpa.2009.08.001

Sound travels through objects that block light. Only very recentlyhas technology advanced enough to decipher ultrasound formedical use. Machines have become smaller, cheaper, moreversatile and more advanced than ever before. The medical use ofultrasound spreads across many fields so that traditional areas nolonger have a monopoly. With this comes the question of trainingdoctors. This has been done by various colleges and societiesworldwide. Some have been quicker to act than others. There alsoneeds to be an understanding of when broad experience andadvanced technical skills are required or when limited skills willdo. In addition, some procedures can be performed more safelywith ultrasound where the knowledge of ultrasound is not para-mount. This article covers current provision of training in echo-cardiography and ultrasound in areas relevant to anaesthetistswho are working in critical care (including accident and emer-gency) and complex surgery (mainly cardiac).

� 2009 Elsevier Ltd. All rights reserved.

Evolution of training in ultrasound

The ancient Greeks used a weighted rope to perform ‘sounding’ to measure the depth of water. The17th century scientist Robert Hooke noticed that sounds could be heard from the human body andsuggested that if we could visualise these sounds we could build up a picture of what lies inside. Thesewere concepts of distance and shape of objects. The first use of sound to detect objects was in militaryapplications of ‘A-mode’ scanning to detect submarines after World War I.

Piezoelectric materials were discovered by the Curie brothers in 1880, but it was the early 20th-century development of amplifiers that enabled the signals produced to be usefully displayed.

d. All rights reserved.

mailto:[email protected]

www.sciencedirect.com/science/journal/15216896

http://www.elsevier.com/locate/bean

S. Bennett / Best Practice & Research Clinical Anaesthesiology 23 (2009) 363–373364

In 1959, Professor Donald published the first paper on ultrasound ‘The investigation of abdominalmasses by ultrasound’ in the Lancet. A-scanning could differentiate cystic from solid tumours. By 1961,A-scanning was used to measure the head size of a foetus. Siemens produced the first commercialscanner in 1963, nicknamed the ‘dinosaurograph’, it had a single transducer in a tank of water. In the1970s and 1980s, the linear transducers were introduced, followed by phased arrays. Ultrasound use inindustry was now moving to applications in medicine, but the path was not defined.

In 1956, evidence appeared that foetuses exposed to X-rays could develop cancer. Ultrasound couldreplace X-rays and had a clear application.

There would be a progress in the use of ultrasound as devices became cheaper, smaller and moreintuitive. Older machines required an enormous amount of skill and knowledge, first to operate and thento interpret the signals produced. In addition, the machines were stationary, while the patient had to go tothe machine. Thus, ultrasound was competing with computed tomography (CT) and magnetic resonanceimaging (MRI) scanning.

During the 1980s, machines became portable and the advent of hand-held probes meant that allareas of the body could be explored. In addition, the transducer could be attached to an endoscope,allowing trans-oesophageal ultrasound/echocardiography (TOE).

Obstetrics had a niche, but radiologists were the first to incorporate ultrasound training into theirspecialist training programmes. The training approach was similar to the other training modalities–that is, to apply ultrasound technology to all areas of the body and understand the anatomy andpathology detected. This kept ultrasound away from individual specialties and optimised the use ofexpensive equipment. For the vast majority of studies, the patient still came to the machine.

Ultrasound and the heart or echocardiography required more advanced training than radiologycould provide, as part of general ultrasound, to realise its full potential. As such, echocardiographydeveloped as a specialist area of ultrasound. It was logical that cardiologist would embrace this asa special interest.

Various societies around the world now emerged to exploit the growing technology of ultrasoundand echocardiography: The Australasian Society for Ultrasound in Medicine (ASUM) in 1970, theAmerican Society of Echocardiography (ASE) in 1989, the Society of Radiologists in Ultrasound (SRU) in1990, the British Society of Echocardiography (BSE) in 1990 and the Consortium for the Accreditation ofSonographic Education (CASE) in 1993. In addition to these groups, there were societies with a specificaim within their educational portfolio (i.e., to learn TOE), notably these were the Society of Cardio-vascular Anesthetists in North America (SCA), the Association of Cardiothoracic Anaesthetists for theUK and Ireland (ACTA) and for Europe (EACTA). All these groups have certain common aims, that is, thedevelopment of training and standards in the use of medical ultrasound. Most comprise of doctors,sonographers and technicians. They work with other specialties to help them develop ultrasoundwhere it might be useful in their area of work. It has been a challenge for such bodies to stay ahead oftechnology so that statements concerning practice of ultrasound and accreditation remain contem-porary (e.g., the BSE working with the ACTA in the UK to establish an accreditation process for peri-operative cardiac surgery whilst being relevant to other practitioners of TOE).

As the membership of these bodies has grown, they have become more proactive in producingstatements about the scope of practice that is expected of its members, what standard needs to beachieved and how this is to be achieved. If everyone was starting from scratch, this would be relativelystraightforward. However, this is not the case; there has been a tendency among enthusiasts to gettrained and then set up training for others to follow. The idea being that training with specialty groupsis easier and should spread the benefits across the specialty. A curriculum is then established, which isfollowed by junior doctors, who then incorporate it into their training.

In 1996, ‘The task force for transoesophageal echocardiography,’ published ‘Practice guidelines forperioperative transoesophageal echocardiography’–a report by the American Society of Anesthesiol-ogists and the Society of Cardiovascular Anesthesiologists.1 This was followed by training guidelines in2002, ‘American Society of Echocardiography and Society of Cardiovascular Anesthesiology Task ForceGuidelines for Training in Peri-operative Echocardiography’ (Table 1).2 Both are available on the SCAwebsite (www.scahg.org).

In the UK, the established transthoracic echocardiography (TTE) accreditation was followed bya similar process for TOE in 2003 (Table 2).

http://www.scahg.org

Table 1Training for Transoesophageal Echocardiography USA (ASE/SCA). Exam is by the National Board of Echocardiography.

Basic During cardiac attachment or fellowship 150 cases (50 personally) 3PTEeXAMAdvanced 12 months in cardiac work þ150 cases (150 personally)

S. Bennett / Best Practice & Research Clinical Anaesthesiology 23 (2009) 363–373 365

The Cardiac Society of Australia and New Zealand published, ‘Recommendation for training andpractice of diagnostic perioperative TOE’, in 2004.3 The introduction states, ‘the importance ofguidelines will increase with the inevitable migration of echocardiography from the province ofcardiology and radiology to Emergency Medicine, Critical Care and Anaesthesia’.

In addition to the national societies producing guidelines, there have also been statements from otherglobal organisations. The World Health Organization (WHO) in 1998 produced a ‘technical report’ onultrasound, which stated what a physician should know versus a sonographer, and recommendeddifferent levels for training and equipment. The report discusses, ‘the urgent need to improve the trainingand clinical performance of physicians and allied health professionals who use ultrasound for diagnosticapplications’. It provides much detail in terms of curriculum and minimum standards and also points outthat ‘proper training programmes in ultrasonography only exist in a few affluent countries’.4

In 2004, the European Association of Cardiothoracic Anaesthetists (EACTA) started an accreditationprocess for TOE in collaboration with the European Association of Echocardiography (EAE).

The above account covers much of the English-speaking world plus Europe. It mainly concernsechocardiography. The standard set worldwide for accreditation in both TTE and TOE is similar, withsimilar processes involved. All have suggested a specific duration of time spent in an environmentregularly using echocardiography with a supervisor. All have numbers required for a logbook (between100 and 150) and all have an examination involving theory and interpretation of images. (In Australia,the American National Board Echocardiography examination or the completion of the PostgraduateDiploma of Perioperative and Critical Care Echocardiography (PGDipECHO) from the MelbourneUniversity is recognised). All agree that such a process is the minimum requirement for anyone whowants to go on to write reports, teach, do research or become regularly involved in making decisions inechocardiography. While this has been evolving in collaboration with cardiology, the cardiologists havecontinually reviewed how echocardiography training should be incorporated into cardiology trainingto ensure the highest standards of practice over the past 13 years (Table 3).5–7

The introduction of these processes was not without some difficulty. Some existing practitioners didnot accept the need to prove themselves by way of logbooks and examinations. However, the process isnow established and it is widely recognised that standards have improved. Ultrasound is rather uniqueas an investigative tool in that it is harmless. However, considerable harm can be caused by themisinterpretation of the information that can be obtained from the patient.

What about emergency medicine (EM) and critical care?

They have seen ultrasound emerging as a useful diagnostic and monitoring tool, but where do theygo for training? Both have needed the portability and multimodality of smaller systems to meet theirdemands. This now means that the doctors at the scene can obtain useful information and also morethan a simple two-dimensional (2-D) echo is available. Small machines now have several probes andfull ultrasound capability to undertake precise 2-D imaging, M-mode plus colour flow, continuous-wave and pulsed-wave Doppler. In addition, the heart, thorax, abdomen and vascular system can all beexamined. They now have a different problem to the one faced by cardiac anaesthesia 10 years ago.Then it was a clear-cut choice for TOE, whereas in non-cardiac surgery or critical care areas,

Table 2Perioperative TOE training UK (ACTA/BSE) and in Europe by EACTA/EAE.

Basic Advanced Accreditation

150 cases þ150 cases Logbook 125 cases (in 2 years)Basic knowledge

and viewsAble to study and report on wide rangeof conditions. Knowledge of TTE.

Exam theory plus case studies

Table 3Training for Echocardiography ASE (not intraoperative TOE) USA.

Level Training timemonths

Cumulative trainingtime months

Min No. TTEperformed

Min no. TTEinterpreted

TOEþ specialprocedures

1 3 3 75 150 Yes2 3 6 150 300 Yes3 6 12 300 750 Yes


transthoracic echocardiography can be used in many instances instead of TOE. Furthermore, earlyevidence showed that TOE made a difference in monitoring myocardial ischaemia, assessing repairedvalves and the diagnosis of cardiac effusion.8,9

Although there is a lot to learn for echocardiography, the patients typically exhibited a relativelynarrow range of pathologies. Even so perioperative TOE required knowledge of both diagnostic andmonitoring procedures. Who should be training and performing the TOE? The time spent in theoperating room gave the anaesthetists a clear advantage over the cardiologists.

The problem for the EM physician is the depth of knowledge in a wide range of specialties. He or shedoes not feel the need to become a fully proficient ultrasonographer in several specialties plus echo-cardiography using both TTE and TOE. However, anything could come through the door: obstetric,urology, vascular, trauma, abdominal, etc. For each of these specialties, there is a very comprehensivecurriculum published by the Royal College of Radiology10 in 2005. What was needed was to learn thebasic skills of ultrasound and then apply them to organs and vessels where relatively simple techniqueswould reveal important basic information using only a few simple measurements. This approachwould use the functions of the ultrasound machine that are more intuitive and therefore more likelythat the skills and information produced would be frequently re-enforced and reliable. Thus, 2-Dimaging with the use of M-mode for measuring dimensions and colour-flow Doppler for an opinion onvalve competency would provide useful ‘frontline’ information.

One approach is to look at it from the point of view of ‘time pressure’. This means that wherea condition could be life-threatening within a short time, usually bleeding, basic information on thepresence of fluid can be obtained with respect to many organs, including the heart. To this can be addedbasic ‘normal or abnormal’, which can be helpful particularly in cardiac. Non-life-threatening condi-tions can wait for the expertise to be available from within the hospital services. The danger in a broad-brush approach is that things will be missed. Especially if an early focused scan taken as normal is notfollowed up by a more expert scan, because the impression is that the patient has ‘been scanned’.However, an approach based on urgency outlines a curriculum which can be taught on a competency-based programme without the in-depth knowledge required for the pursuit of ultrasound as anindependent specialty. Indeed, many practical courses now run to accomplish this similarly to that ofAdvanced Trauma Life Support (ATLS) started in America in 1976. Such a document has been proposedby the Royal College of Emergency Medicine (RCEM) for Level 1 training11 and was published in 2006(Table 4).

Contemporary transthoracic echocardiography plus thorax scanning is taught in many countries in1 or 2 days as a practical skill termed ‘Focus Assessed Transthoracic Echocardiography’ (FATE).12 Thishas been designed for intensive care but could be used in emergency medicine. FATE does not explicitlyinclude pulmonary scanning (only pleural), which has become popular for detection of a pneumo-thorax. However, the same views can be used for this purpose. FATE does not cover many of the areasrequired for EM physician and therefore other courses such as ‘Focused Assessment with Sonographyfor Trauma’ (FAST) are also popular.13

Table 4Training in Ultrasound for Emergency Medicine RCEM (UK).

Level 1 50 cases (FASTþ vascular accessþ aortic aneurysm) Supervisorþ regular trainingLevel 2 (draft) 12 months practiceþ 3–5 cases per week Includes: urology, hepatic, vascular, cardiac, shock,

musc/skeletal, thorax, obsþgynae, paedsNo established accreditation. Only competency based.


What is FAST? It is trauma ultrasonography. It includes perihepatic, perisplenic, pelvis and peri-cardium scanning and, moreover, thoracic ultrasound primarily for haemothorax. The aim of FAST is toassist in the trauma or bleeding patient. The areas mentioned above are scanned for the detection offluid as an indication of bleeding rather than organ function. It is designed to compliment and notreplace ATLS and standard resuscitation. It does not include echocardiography or vascular access. So,has training for the EM physician fully evolved? Clearly not! The EM physician is looking for a curric-ulum which includes trauma plus a ‘banner’ approach to a range of pathological processes with clearlimits set on whether to act, observe or refer. This could come from an amalgamation of FATE, FAST,vascular access and defined areas from other specialties or it could come from a purpose writtencurriculum designed for EM by physicians with in-depth knowledge of EM and the full range ofultrasound. Such a process has started in the UK with the Level 1 Ultrasound Training Documentproduced by the RCEM11 and will be enhanced with the publication of the Level 2 training documentpublished in February 2009. Of note regarding echocardiography is that the RCEM has included TTE ona scenario basis and that TOE is not included (Table 5).

Does the critical care physician need the same breadth and depth as the EM physician? Perhaps lessbreadth and more depth? In the intensive care unit, the patients are already selected and should havebeen evaluated in terms of trauma and active bleeding. Their needs are now on a different time scale andrequire cardiopulmonary monitoring as a priority. If information about, say, the urinary tract is required,this can be done by someone with expert knowledge of the specialty and provide far more accurateinformation than when performed by someone not qualified or not a regular practitioner in the field.Echocardiography for monitoring purposes does have some specific requirements that are not typicallypart of a standard examination. In addition, the operator will find more complex pathologies that areimportant rather than the simple question of heart function poised by the EM physician. Thus the criticalcare physician will require in-depth knowledge of echocardiography with familiarity in TTE and TOE. Anexample would be the patient who arrives conscious in the Accident and Emergency department butlater changes in consciousness level require intubation. The initial TTE shows ‘good left ventricular (LV)function’. The EM physician should document thickness of the intraventricular septum, which isthickened. The critical care physician needs more information. TTE may not clearly visualise theascending aorta, but TOE would reveal an aortic dissection in a few minutes. It would be inappropriate toperform a TOE in an unprotected airway but simple and safe on the intensive care unit. Another examplewould be obtaining a good short-axis view of the aortic valve with TTE in a febrile patient. However, thisis not always easy. The patient deteriorates and later, on intensive care, a TOE shows very simplya bicuspid aortic valve. The critical care physician does not need full training in TOE to identify this nordoes he or she need to understand the other associated abnormalities or scrutinise all the valves. Whatmatters is that this is an important finding that requires a full expert examination. A multidisciplinaryteam working in this can deliver the best care for the patients and find great job satisfaction.

Physicians in EM and critical care can be reassured by a document produced by the AmericanCollege of Cardiology Foundation (ACCF). This group, in collaboration with the ASE and others, madea critical appraisal of the use of echocardiography for a comprehensive list of indications. Intra-operative TOE was excluded, but all emergency work was included and of note was that the specific

Table 5Proposed level of competence for echocardiography in Intensive Care. Entry level training would be competencies, practicalcourses and direct assessment by local trainer. Level 1, would be more structured teaching, national courses, logbooks, super-visors, leading to national examination and accreditation. Level 2 achieved by accreditation in which greater experience isachieved with performance of specialized procedures, training level 1and research. Level 3, teaching all levels, development ofnew procedures and research.

Level 3 Accept referrals. Perform specialist examinationsand procedures.

Teachingþ research.

Level 2 Perform and interpretcomprehensive TTEþ TOE.

Diagnose most cardiac pathology. Teach level 1.

AccreditationLevel 1 Standard views TTEþ TOE. Normal v Abnormal. Recognize common pathology.Entry level Arrest/Shock situation. TTE only. FEEL/FATE.


scenarios mentioned in the Level 2 document produced by the RCEM were rated 8 or 9 (the highestscores). The relevant cases included were dyspnoea, heart failure, heart function post myocardialinfarction, haemodynamic instability and suspected aortic pathology.14

At present, physicians accredited in TOE (many of the cardiac anaesthetists) are able to provide theseskills on the cardiac intensive care. However, a curriculum specifically for the general intensive care andthe non-cardiac anaesthetist has not yet been produced by the societies. The closest is the documentproduced by the WINFOCUS (World Interactive Network Focused on Critical Ultrasound) and written byPrice.15 This is comprehensive and covers the needs of all the patients found on intensive care from thepoint of view of echocardiography, but other important elements of ultrasound are not included. TheIntensive Care Society has yet to incorporate this into their curriculum. The critical care physician wouldcertainly require other aspects of ultrasound as well and may find the echocardiography contained inthe WINFOCUS document too detailed. The document clearly defines levels of training and is useful(Table 2). These levels are more in step with other societies worldwide, for example, the AmericanCollege of Cardiology6, but not the same as those used by the RCEM. The BSE has published a ‘positionstatement’ in collaboration with WINFOCUS supporting the concept of a specific curriculum forintensive care physicians. They also include in the statement the value of competency-based courses asan entry level. The courses detailed are

‘FEEL’ – Focused Echo Evaluation in Life support;‘FATE’ – Focused Assessed Transthoracic Echocardiography; and‘FAST’ – Focused Assessed Sonography in Trauma.16

Other limited studies will emerge, such as HEARTscan (Haemodynamic Echocardiography Assess-ment in Real Time; see www.heartweb.com.au), which include basic valve assessment using 2-D andcolour-flow Doppler, in addition to basic haemodynamic assessment.

Should the training be limited to procedures or should full diagnostic scanning be taught?

Horses for courses

Ultrasound has shown itself to be useful in a wide variety of settings and traditional, long, courseknowledge training is not appropriate in all settings. The philosophy is different. In cardiologya complete understanding of cardiac disease is the primary position and then an awareness of whereechocardiography assists in diagnosis and follow-up of the disease. To get the most out of the ultrasoundmeans that all its modalities need to be understood and used regularly. However, just being a cardiol-ogist does not mean that the skills required for echocardiography are intuitive. An echo-accreditedcardiologist will not have the knowledge or skills to detect abdominal fluid or safely place a central veincatheter under ultrasound guidance.

Therefore, training should also be possible for limited procedures as determined in a writtencurriculum relevant to the specialty. Not only can abnormalities be detected earlier but also procedurescan be performed more safely. For example, pleural fluid can be detected at volumes of 250 ml andpleural drains can be inserted more accurately, avoiding the life-threatening complications seen byclumsy insertion.17

Similarly with vascular access, lines can be placed more precisely using ultrasound, which, in turn,reduces complications. Here an in-depth knowledge of head and neck disease may be unnecessary. Theoperator uses a simple feature of ultrasound to assist in a procedure. A procedure that he or she mayalready be an expert at performing but can reduce complication rates even further with ultrasound.18

Nerve blocks have always been an art rather than a science. Traditionally, we have used superficiallandmarks to identify deep, delicate nerves. We have used electric shocks to help, although this isunpleasant for the patient. Currently, the nerves can be visualised using 2-D ultrasound and high-frequency probes. The needle can be seen approaching and smaller volumes of local anaesthetic can beused to establish better neurological blockade, with lower complication rates. Again, the operator doesnot need in-depth knowledge of the nervous system. The ultrasound is a guide and is not a diagnostic.

http://www.heartweb.com.au


Nevertheless, because the physician may have been doing hundreds of procedures a year, he or sheremains the expert, perhaps even more so.

The physicians need to have a good understanding of the machinery and physics related to their areaof interest. Once learned, these basic skills can be applied to other procedures as well, with the correctprocedural training. Thus, once image formation and acquisition are understood, this applies to allapplications. For example, learning about long- and short-axis views and left/right orientation are coreconcepts in 2-D ultrasound that can be applied to vascular access and nerve blocks in any area of the body.

The above examples are of procedures in essentially normal tissue. It may be complicated when theneedle placement or drainage itself becomes diagnostic. Here an understanding of the disease anda differential diagnosis are important and ultrasound may provide an important part of the informa-tion. For example, drainage of a pancreatic cyst would be inappropriate for someone who only learnedvascular access and knows little about the anatomy of the pancreas. For these reasons, it is crucial thatphysicians work within a clearly defined curriculum.

Knowledge-based versus caseload training

Knowledge without experience is no more useful than experience without knowledge. Both arerequired, and this follows on from the discussion in the above section and that of the procedural anddiagnostic training in ultrasound scanning. Cardiologists felt threatened when cardiac anaesthetistsbegan gaining proficiency in TOE. They felt that their special skill could not just be passed ontoanaesthetists, that this is not an anaesthetic territory and felt it even harder to accept that somecardiologists who were not actually qualified in echocardiography were being exposed. The responsefrom the cardiac anaesthetists was as follows:

1. We all are qualified with the same medical degree. Knowledge cannot be monopolised by a few.2. The operating room is indeed the anaesthetists’ territory.3. There was no intention to expose the cardiologist, but only to set a standard in TOE that would

benefit as many patients as possible within a given sphere of echocardiography. It is acceptable ifthis sphere was what the cardiologists were able and willing to offer, otherwise it needed to betaken up by those who could deliver it.

In so doing, some of the aspects of echocardiography were defined as advanced, requiring inter-vention above the level normally acquired by cardiac anaesthetists. Whereas other aspects, forexample, weaning-off cardiopulmonary bypass would rapidly become an area in which the cardiacanaesthetist would be the expert. Logically, the accreditation process set by ACTA/BSE for TOE involvesequal amounts of examination time spent on theory and case reporting. Nevertheless, experience isrequired and this is tested in a logbook with an appropriate case-mix.

The RCEM have, as mentioned above, define the Level 1 curriculum for their trainees. It includesa limited amount of knowledge relating to ultrasound physics and anatomy. It lists all the organsneeding to be recognised and also indicates the presence of fluid. This amount of knowledge can betested during competency assessment. The number of competencies is not very large, and therefore allcompetencies can be directly assessed during the training period. The trainee is required to keepa logbook and record 50 cases (20 FAST, 20 abdominal aortic aneurysms and 10 vascular access). Thenumbers are not absolutely rigid, neither is the number of ‘normal scans’. There is also a requirement towork with a qualified sonographer on a regular basis. There is a restricted number of scan views anda narrow range of abnormalities investigated, such as ‘fluid or no fluid,’ ‘vessel or no vessel,’ indicatingthat the scope of practice is extremely limited. It can be properly assessed in terms of the safe conductof the examination and the successful completion of an ultrasound-guided procedure. This would notbe true in echocardiography, as it would involve testing the candidate in many pathological situations.Therefore, these competencies are incorporated into the EM training programmes for trainees andexisting specialists can obtain certification from any of the recognised courses.

In subjects where the scope of the use of ultrasound is wider but still contained within onespecialty, it is still possible to have a rigorous competency- and knowledge-based training and


assessment. For example, the RCOG are in the process of discontinuing their diploma course inobstetric ultrasound for a modular system. The new system would have five modules (two basic andthree intermediate) – each module with a separate curriculum, logbook and assessment tool. Earlier,the time spent on performing ultrasound and the numbers of cases seen were important criteria.Now the emphasis is on detailing cases and demonstrating that the procedure can be carried outproperly, including the knowledge outlined in the specific curriculum. The new system appearsthorough and should work well. It is however difficult to find any evidence that one system is betterthan the other. Although societies such as the RCOG have used different systems they have not runparallel systems and subsequently had a blinded assessor to determine which systems producesa better-trained physician.

In 2000, Mandavia published a study regarding the possibility of teaching ultrasound techniques, ina focused manner, to EM physicians of all grades. The study included 80 subjects who received a 2-daycourse: the first day covering ultrasound theory and the second day on learning competencies. Thecurriculum focused mainly on FAST plus FATE. All the trainees were assessed and followed up for 10months. The results showed that focussed ultrasound training had a high degree of success.19 However,non-focused training where large numbers of case experience (at least 200) are required did not havesimilar success rates.20

It is important to note that while many institutes promote and train EM physicians in the use ofultrasound, ASE recommends that, as in training guidelines for non-cardiac ultrasonography, inde-pendent competence in echocardiography (Level 2) including a minimum of 6 months of echocardi-ography education with 300 studies should be the standard.21 This is contrary to the earlierrecommendation by Mateer who had proposed 40 h of instruction and 150 cases, with up to 50 beingcardiac.22 Although this is currently outdated, the official position of the ASE has not changed.

In summary, where one is teaching the use of ultrasound-guided procedures, a set number of casestested directly seems appropriate. As knowledge of the acquired data becomes more important todetermine the management, knowledge-based training plus case records or logbooks become moreimportant. In both instances, having a detailed curriculum to work from is crucial.

Certification and accreditation

Certification is a statement (often on a piece of paper) of a fact (e.g., ‘This is to certify that Dr Smithcompleted 15 hours of training in ultrasound.’) while accreditation is an official recognition. To beaccredited is to be ‘generally accepted, having guaranteed quality.’ Thus the body or society that awardsthe ‘accreditation’ is giving a seal of approval of a certain standard for which the society itself isa recognised authority. This is very important for public confidence. It serves no purpose having anunrecognised society issuing spurious accreditation. The recognised authority is most likely to berepresented by experts in the field with national or international standing. The accreditation issued isthe end of a process, which included curriculum, training and assessment. However, this does not meanthat other bodies cannot help with various parts, particularly the training. This is very helpful indiversifying teaching and making the subject more widely available (e.g., CASE). They do not write thecurriculum or issue accreditation. Their role is to ensure that the universities involved in ultrasoundtraining meet an acceptable standard.

Accreditation implies more than just an examination and, as discussed above, ultrasound andechocardiography require assessment in several fields. This is done by balancing between examinationof theory, practical assessment and experience by logbooks and a case-mix. The balance depends on theparticular area of work. It sets a standard that has been deemed to be safe and practicable. It allowsphysicians in the field to set their sights and work towards a goal that will inevitably make them betterat their practice than they were before. It is essential for doctors in training before they can be allowed touse ultrasound. In most specialties, the process of accreditation for existing specialists is voluntary,which allows specialist to opt out of ultrasound and work in an environment where ultrasound ishandled by specialists. Some specialties have incorporated ultrasound training into the junior doctor’score training curriculum. This surely is the way ahead in all areas where ultrasound or echocardiographyis thought to be an integral part of the specialist’s armamentarium. Once accredited, it is rare forphysicians to complain about the extra burden because of the evident improvement in working practice.


Does this mean that for every procedure within anaesthesia that requires ultrasound or echocar-diography, there should be a separate accreditation? No, but there should be appropriate training,competency and knowledge assessment. Do we need accreditation at all? Yes. A survey in 2004 showedthat, in the UK, all cardiac units were using or had access to TOE. A survey of all 122 EM trainingprogrammes in America had a 78% response rate and showed that 95% were actively teaching ultra-sound, mostly FAST.23 This scale of activity needs standards. As in EM, it is not difficult for the college todecide what procedures are relevant and should be a part of training for all, which can then be assessedas they qualify. In anaesthesia, this should currently include ultrasound-guided venous access24 andnerve blockade. As technology advances, other competencies could be added to training, such aspreoperative assessment of LV function or a heart murmur using a hand-held device. More complexareas of ultrasound procedures should then be defined as outside of the general anaesthetic practiceand be defined within other specialties or sub-specialties. This would include the use of ultrasound onintensive care and TOE for cardiac anaesthesia. Defined areas are not only important for the specificprocedure but it also clarifies that something is ‘not to be done’ if appropriate training has not beenacquired. This may all sound a little pedantic and earlier when procedures were introduced (e.g., theSwan–Ganz catheter) there was no specific certification for its use. This is true but if use of right heartcatheters had been restricted to those qualified to do so then there may have been more benefit andless complications for patients.25

Accreditation includes re-accreditation, which is equally important. It sets a minimum standardrequired to continue to work in the field and has be shown to be effective.26

Of course, it is not just the individual who needs to be accredited. The institute also requires a levelthat allows the individual to practice safely and keeps a record of the individual and collectiveperformance of the practicing physicians. Thus, record keeping, academic meetings and peer review ofcases provide maintenance and improvement of skills, whilst the public are reassured that standardsare maintained. In the UK, this role is provided by CASE, the societies and the royal colleges. In America,it is the governing society and universities often backed by medical companies who insist on this typeof accreditation and quality assurance.

Future trends

The expanding use and application of ultrasound will continue, with further reduction in the sizeand cost of the equipment and technology, which will make ultrasound more user-friendly andintuitive. Matrix scanners and 3-D or 4-D imaging are a reality. It will be as common to see a physicianincluding ultrasound whilst assessing a patient, as it is now to see a stethoscope. In addition, a muchwider range of procedures will be ultrasound guided. Medicine advances in some general directions,such as cleaner drugs so that adverse reactions are less common and therapeutic effects are moreprecise. Similarly, interventions, both medical and surgical, are becoming less invasive. As proceduresbecome less invasive with less complications and quicker recovery, it becomes important thatanaesthesia develops likewise. This means reducing all anaesthetic complications. Althoughthese seemed less important and rarer compared with surgery, ultrasound will provide the means toimprove on this. The most common complication with the Swan–Ganz catheter was at insertion.25 Atthe same time, the patients being anaesthetised are older and sicker. In cardiac surgery, aortic valvescan be replaced and mitral valves repaired percutaneously. The patients are often selected because theyare too sick for open surgery. They still require anaesthesia, and the most non-invasive way to monitorboth the procedure and the heart is with TOE. Such developments suggest a bright future for TOE.27

Where TOE may have been considered an add-on less than 10 years ago, now some procedures wouldnot start without TOE. Echocardiography and ultrasound are driving the physiological limits of certainprocedures. Ultrasound-guided nerve blockade will become the norm opening a range of procedures,particularly in orthopaedics, with the expectation of minimal physiological disturbance in veryfrail patients.

In non-cardiac surgery, echocardiography and ultrasound have been slow to appear. This will notonly change but there is also an opportunity here – that is to properly control and assess the impact ofall types of ultrasound in non-cardiac surgery. Yet again, the cardiac risk profile is increasing in thispopulation and many areas of surgery now have a higher mortality than cardiac surgery.


Ultrasound has always been a part of physics taught at school. A few medical schools are teachingultrasound as an optional module, but very few have it as a core topic. This will soon change. Soon,medical students will approach postgraduate ultrasound in the same manner they approach surgerytoday, building on their knowledge of anatomy.

In summary, the advent of cheaper, smaller, more versatile machines and higher definition imageshas created an explosion of applications of ultrasound no longer confined to traditional fields such asradiology and cardiology. It is important to control this technology while allowing its use for the benefitof patients. This means adherence to a defined curriculum and strict training. In perioperative echo-cardiography, accreditation has been established in the America, Australia, Europe and the UK. Thisrequires knowledge-based and logbook training.

Competency-based training is appropriate for defined areas such as FATE and FEEL. In areas relevantto anaesthesia, the educational body that defines the process is identified on a worldwide basis.

Ultrasound techniques in emergency medicine have developed as machines have become moremobile. Here, less knowledge, about specific organs, but more organs require scanning. Competencytesting is the norm. Many courses exist worldwide but concerns remain about important decisionsbeing made with no formal accreditation. The RCEM recommends ultrasound training for all juniordoctors.

Critical care training has not defined a diagnostic curriculum due the problems of depth ofknowledge and the difficulty in acquiring and maintaining skills. WINFOCUS has published a proposal,which may be adopted in the UK.

Procedures such as vascular access can be taught as a competency. General ultrasound trainingshould become part of medical school training.

However, gaps remain in setting curricula and ensuring good practice. Furthermore, the intro-duction of ultrasound should be controlled and studied. Hard evidence for improved standards of careis scarce.

Conflict of interest

The author has no conflict of interest either financial or personal that may have affected the contentof this article.

References

1. The task force for transoesophageal echocardiography. Practice guidelines for perioperative transoesophageal echocar-diography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists.Anesthesiology 1996; 84(4): 986–1006.

*2. Cahalan MK, Abel M, Goldman M et al. American Society of Echocardiography and Society of Cardiovascular Anesthesi-ology Task Force guidelines for training in perioperative echocardiography. Anesthesia and Analgesia 2002; 94: 1384–1388.

3. Available from: www.anzca.edu.ac/professional document PS46; 2004.4. Training in diagnostic ultrasound: essentials, principles and standards. Report of WHO study group. Technical Report

Series, 875 ISBN:13 9789241208758.5. Pearlmann AS, Gardin JM, Martin RP et al. Guidelines for optimal Physician training in echocardiography. Recommen-

dations of American Society Echocardiography committee for physician training in echocardiography. The AmericanJournal of Cardiology 1987; 60: 158–163.

*6. Quinones MA, Douglas PS, Foster E et al. ACC/AHA clinical competence statement on echocardiography. Journal of theAmerican College of Cardiology 2003; 41(4): 687–707.

*7. Ryan T, Armstrong FW & Khandheria BK. Task force 4. Training in echocardiography. Journal of the American College ofCardiology 2008; 51(3): 361–367.

8. Thys D. Echocardiography and anesthesiology successes and challenges. Anesthesiology 2001; 95(6): 1313–1314.9. Leung J, O’Kelly B, Browner W et al. Prognostic Importance of postbypass regional wall-motion abnormalities in patients

undergoing coronary artery bypass graft surgery. Anesthesiology 1989; 71(1): 16–25.*10. Ultrasound training recommendations for medical and surgical specialties. London: Royal College of Radiologists. Available

from: http://www.rcr.ac.uk.*11. College of Emergency Medicine Ultrasound Sub-committee. Training in ultrasound in emergency medicine- Level 1.

Available from: www.collemergencymed.ac.uk; 2006.*12. Jensen MD, Sloth E, Larsen KM et al. Transthoracic echocardiography for cardiopulmonary monitoring in intensive care.

European Journal of Anaesthesia 2004; 21: 700–707.13. Kirkpatrick AW, Sirois M, Laupland KB et al. Hand-held sonography for detecting post-traumatic pneumothoraces: the

extended focused assessment with sonography for trauma (FAST). Journal of Trauma 2004; 57: 288–295.

http://www.anzca.edu.ac/professional document PS46

http://www.rcr.ac.uk

http://www.collemergencymed.ac.uk


*14. Douglas PS, Khandheria B, Raymond F et al. Appropriateness criteria for transthoracic and transoesophageal echocardi-ography. Journal of the American College of Cardiology 2007; 50: 187–204.

*15. Price S, Via G, Sloth E et al. WINFOCUS ECHO-ICU Group. Echocardiography practice, training and accreditation in theintensive care. Cardiovascular Ultrasound 2008; 6: 49–177.

16. Collaborative Working Group of the British Society of Echocardiography. Position statement: echocardiography in thecritically ill. Journal of Intensive Care Society 2008; 9(2): 197–198.

17. Capper SJ, Ross JJ, Sandstrom E et al. Transoesophageal echocardiography for the detection and quantification of pleuralfluid in cardiac surgical patients. British Journal of Anaesthesia 2007; 98: 442–446.

18. Bodenham A. Can you justify not using ultrasound guided central venous access. Critical Care 2006; 10: 175.*19. Mandavia DP, Aragona J, Chan L et al. Ultrasound training for emergency physicians-a prospective study. Academic

Emergency Medicine 2000; 7(9): 1008–1014.20. Hertzberg BS, Kliewer MA, Bowie JD et al. Physician training requirements in sonography: how many cases are needed for

competence? American Journal of Roentgenology 2000; 174(5): 1221–1227.21. Stewart WJ, Douglas PS, Sagar K et al. Echocardiography in emergency medicine: a policy statement by the American

Society of Echocardiography and the American College of Cardiology. Journal of the American Society of Echocardiography1999; 12: 82–84.

22. Mateer J, Plummer D, Heller M et al. Model curriculum for physician training emergency ultrasonography. Annals ofEmergency Medicine 1994; 23: 95–102.

23. Counselman FL, Sanders A, Slovis CM et al. The status of bedside ultrasonography training in emergency medicine resi-dency programs. Academic Emergency Medicine 2003; 10(1): 37–42.

24. Bodenham A. Ultrasound imaging by anaesthetists: training and accreditation issues. British Journal of Anaesthesia 2006;96: 414–417.

25. Harvey S, Harrison DA, Singer M et al. Assessment of the clinical effectiveness of the pulmonary artery catheter; a rand-omised controlled trial. Lancet 2005; 366: 472–477.

*26. Abuhamad AZ, Benacerraf BR, Woletz P et al. The accreditation of ultrasound practices. Impact on compliance withminimum performance guidelines. Journal of Ultrasound in Medicine 2003; 23: 1023–1029.

27. Shernan S. Perioperative echocardiography; past, present and future. The American Journal of Social Psychiatry 2008; 21(2).pp. 25A–26A.

Documents

Training guidelines for ultrasound: worldwide trends