Delivering training in ICM ultrasound - the UK way
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Presented at International Fluid Academy Meeting 2015 - Antwerp, Belgium
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Delivering training in ICM ultrasound - the UK way
- 2. Background The use of point-of-care US on the ICU is expanding Numerous courses but lack Formal accreditation Integration into national training programme
- 3. DEVELOP A COMPREHENSIVE COMPETENCY-BASED TRAINING PROGRAMME IN POINT-OF-CARE ULTRASOUND ON THE ICU
- 4. Core Ultrasound Skills in Intensive Care (CUSIC) PHASE 1: Initial theoretical and practical training E-learning Course PHASE 2: Supervised practice until competence demonstrated in acquiring and saving images PHASE 3: Mentored practice with completion of log book demonstrating knowledge of an appropriate range of pathology PHASE 4: Completion of competency assessments within the range of practice
- 7. ECHOCARDIOGRAPHY Focused Intensive Care Echocardiography (British Society of Echocardiography) 10 scans under direct supervision Logbook with 50 (suitable) cases Triggered assessment
- 8. LUNG BLU protocol 50 scans (no more than 10 normal) Ultrasound-guided pleural aspiration and drainage Triggered assessment
- 9. ABDOMINAL Recognition of US appearance of bowel liver spleen Kidneys (eFAST and AAA) Assessment and drainage of ascites
- 10. VASCULAR Real-time Short and long axis No minimum number CVC Sites Internal Jugular Femoral (Subclavian)
- 12. Discussion Clearly defined goals, competencies and timeframe Standardisation of training & reporting tools Governance Quality Control Projects and Research Collaborations Limitations/Challenges Inaugural year Resources and sustainability – time, expertise
- 13. Further information/reading Expert Round Table on Ultrasound in ICU, Cholley B et al (2011) International expert statement on training standards for critical care ultrasonography. Intensive Care Med 37:1077–1083 Intensive Care Society UK CUSIC Accreditation - http://www.ics.ac.uk/ics- homepage/accreditation-modules/cusic-accreditation/ Online resources #POCUS - twitter Oxford Point-of Care Ultrasound Programme avkwong@mac.com, graham_n_barker@hotmail.com @avkwong
Editor's Notes
- Broadly speaking, CUSIC is delivered in several phases. This is a concept that is mirrored in several other practical procedures. Phase 1 – you need to arm yourself with the knowledge. This knowledge can be obtained through reading books and attending courses. In the UK we have an online module that I will show you later. It covers the basic physics of ultrasound and other principles. This then allows for more time at the course for hands on scan time. For those of you who have been on courses, I’m sure you’ll agree that’s usually the most sort after part. Phase 2 – supervised practice with a mentor or supervisor on real patients. It is important that the bulk of learning takes place by the bedside on the ICU and not an outpatient clinic. Goes back to the point of being relevant. There are challenges to scanning pts on the ICU. They are not as easily repositioned as pts in clinic. Please note that being to able to store the images is also highlighter. This is crucial for the governance side of things not just during the learning phase but in actual clinical practice. Phase 3 – practice, practice, practice. Or rather mentored practice. There is nothing quite like learning a skill with a master guiding you. Personally, I can’t tell you how useful it was to have an expert guide me through the process. Tilt the probe this way, rotate it that way, why didn’t you optimise the gain etc….. Phase 4 – an assessment of the skills obtained.
- So why are we talking about this. Well because US as a medical tool has expanded well beyond the remits of radiologists. Even on the ICU it is no longer the area of a few enthuasiast. It has evolved into an essential tool for all clinicians. There is literally no limit to what we can scan. Heart Lung Abdomen Vascular
- So this is the website I was talking about, although its run by NHS England. Its an online learning resources with an assessment at the end. This is compulsory for all colleagues seeking CUSIC accreditation or FICE Echo accreditation in the UK.
- The echocardiography component is called FICE or focussed intensive care echocardiography. This accreditation was developed with help and input from the british society of echocardiography and thus our cardiology colleagues. That’s a picture of the accreditation pack which is available free online. It requires the course. It requires 10 scans under direct supervision and then a logbook of 50 scans. Everyone learns at a different pace so these are minimum numbers. There is then a triggered assessment. So you might say that how can anyone be competent after just 50 scans. I’ve got several answers to this – it’s the quality of teaching, its does have an assessment at the end but perhaps most importantly, its about asking the right questions..
- Lung US based on the BLU protocol. 50 scans minimum Diagnostics but also procedural. A simple decision tree that is utilised. In the UK, there are various ways of delivering this module. In my institution we have a hybrid of out-patient clinics, elective procedural lists and unit activity. We work very closely with our colleagues in respiratory medicine and believe that it offers the best of all the worlds
- The abdominal module. The basic CUSIC syllabus includes scans of the bowel liver spleen and kidneys. I’m sure you can see how useful it is to rule out hydronephrosis without relying on your radiology colleagues. My hospital is also a major trauma and vascular centre so FAST scanning and AAA scans are also taught although this is outside of CUSIC. The interventional aspect of the module is the drainage of ascites
- Finally, the vascular module. This essentially deals with US guided vascular access – arterial, peripheral and central venous (IJ and Femoral). US guided subclavian access is optional and not core. As an anaesthetist by background, I was already very comfortable with this skill. I also believe that the long-axis view, being able to see the entire length of the needle including the tip, is the gold standard.
- At the end of all this, you get this form is submitted to the ICS which then reviews it and you get your accreditation. There is an expectation that once accredited, you are suppose to actively maintain your skills and keep a continuing professional development diary.