Welcome to this presentation on how to boost basic and advanced POCUS training in any institution. My name is Jane Chertow-Taylor. I am a physician assistant. I'm an assistant professor at the Physician Assistant Program at Baylor College of Medicine in Houston, Texas, and I serve clinically in the Department of Critical Care and Anesthesia at Baylor-St. Luke's Medical Center in the Texas Medical Center in the Division of Transplant Cardiovascular and Mechanical Circulatory Support. As far as disclosures, I have no relevant financial relationships to disclose. Our objectives for today are to briefly review different competency levels and what they mean, discuss the current environment and solutions in health care regarding POCUS, and then discuss how to boost POCUS at multiple levels. Where do we start? Before implementing interventions to boost basic and advanced ultrasound at your institution, it's important to do an assessment of the providers and the practice-based setting at your institution in particular. So we'll start with discussing briefly the competency levels that would be expected and then go deeper into what interventions can be put in place to boost the skills. When we talk about boosting POCUS at your institution, what we're actually talking about is the need to boost competency levels. So provider competency levels related to POCUS can be rated on a spectrum of novice to expert. Now, I want to bring your attention to the direction of the arrows from left to right. As you move to the right from the novice to expert stages, the skill sets below, which are not all-inclusive by any means, but you see that each skill set is additive on the prior level. So once you acquire the basic skills under novice, you don't disregard those. You continue to build on top to reach another level of mastery. Ultimately, a provider can be an expert at each level. You can be an expert at the novice level skill set. You can add on the skills that are advanced beginner and become an expert at that. This is important to note and to empower our providers to not try to tackle a whole mountain all at once to become an expert and often becoming discouraged, but to engage in each level and become proficient before they escalate to the next level. Providers within any institution are going to be at all different levels of competency, and you're going to have to implement multiple different methods to boost their competency levels. So in general, we understand that competence in the basic skills of image acquisition can be achieved with far less experience than perhaps saying the correct interpretation and management and then applying to mechanical circulatory support devices and adjustments of that. So when we talk about a novice level in general, we want the providers to understand how to utilize the equipment. So knobology, buttonology, the different modes, probe positioning to acquire basic images, and then the ability to obtain basic images. So for cardiac views, the top four parasternal long axis, parasternal short axis, apical four-chamber, subcostal four-chamber, and then also plural views and abdominal views. At this point, it's key that they can identify structures and then pick out abnormals versus normals. This will allow them to see obvious pathology. Now if they can't identify key structures, then they don't have the ability to understand that they have an accurate picture. Once you move more towards the advanced beginner, we expect that these providers can work to optimize their images better and interpret them without diagnostic errors as much. So understanding about echo artifacts, how to troubleshoot, and some of the common errors that they may encounter. It's also the time that they should be practicing some of the extended apical views, parasternal views, and suprasternal views that can be incorporated, especially in a patient that has difficult windows. Basic Doppler skills and assessment of the IBC general fluid status and starting to integrate these into their clinical exam and physical exam and other diagnostic measures to guide their patient care. Once you move towards a proficient level, we are integrating more skill sets such as pressure estimation, cardiac output, doing measurements such as MAPSI and TAPSI, being able to make inferences, measurements, etc., that allows them to evaluate ventricular function and valvular structure and function. This is a point at which we expect more ability to recognize right heart pathology and understanding if it's a cardiac or non-cardiac pathology, and looking at more advanced findings such as McConnell signs, septum physiology, and so forth. This skill level can be a spectrum that is blended, not necessarily just these skills listed in that column, but all of these can be integrated with patients that have maybe advanced mechanical circulatory support devices in place, and a proficient provider would have the ability to assess the device, correct positioning versus incorrect positioning, and more minute details and nuances of integrating their clinical findings to guide patient care. Moving towards the expert level, this may be as simple as using a transthoracic echoes to escalate care, whether that's inotropic or mechanical circulatory support in a patient that's decompensating. This may be patients that already have devices, and we're working to reposition in a patient that is decompensation, or possibly using them during weaning trials to predict the patient's ability to to have withdrawal of mechanical circulatory support, possibly to a lower level of support during weaning trials. The expert level is also where you could start integrating the ability to, one, perform TE and also integrate those findings into patient management. No one stage here is the most important. Each one is additive, so when we talk about the interventions to boost them, you need to have things in place at your institution that allow providers at these different levels to move to the next level and to allow them to identify that they can have the ability to move to different levels. Oftentimes, we're in institutions where none of this has been implemented before, and we're the first provider to do so, so there may be multiple barriers to overcome. With the rapid growth and development of interest in POCUS and the ability to use it at the bedside to provide timely patient care, we currently are living in an environment where there are different POCUS training courses, both institutional and national and international based. There's inconsistencies amongst training before providers start implementing their skills on their own and different levels of mastery. There's definitely overlaps in training, and as we spoke previously, there's barriers to this within the healthcare system, so this in turn leads to delays in advancing skills for providers. To overcome the barriers to implementing POCUS and boosting POCUS within your institution, we really have to look at a multidisciplinary approach. Now, that's kind of a catch-all term in healthcare these days, but what do I mean by this? You need to pool your resources, evaluate what equipment you currently have, ultrasounds, how you can share them within departments, units, and different teams until more resources can be obtained. You need to evaluate your staff and in what areas they work and who is there during day shift and night shift, given that the ability to use POCUS and boost it at the bedside requires a skill that's available 24-7 to truly make an impact on patient care. You need to harness knowledge from providers in all different phases of care to enhance the education process to make POCUS more impactful. You need to engage administrative support. Ultimately, you're going to need the administrative support and staffing to make a difference in your everyday clinical operations so that POCUS can be effectively implemented and providers have the time and support to move from very basic novice skills to the expert level. Boosting POCUS in any setting has to start very early. Medical schools and physician assistant schools, nurse practitioner schools, and EMS are still in the process of integrating POCUS training, but the sooner we can implement this in the academic centers, the sooner we can have providers coming into the clinical arena that have a baseline knowledge of POCUS so that they can then quickly build on those skills. Now, how can we do this within academic centers so that it benefits all settings? You know, rural settings, critical access settings, community locations, outpatient clinics, inpatient units, rehab, etc. The best way to do this is to start with the students, right? These students are going through a didactic curriculum, a clinical curriculum, and then they're spreading out to all different sites when they go into practice. So we can give them tools to be successful early on, right? Part of this may be ensuring that every student has access to a handheld device, at least for certain clinical rotations, or supplying preceptors as a perk in exchange for precepting students a type of handheld ultrasound device that they can use during their teaching. Every institution or hospital may not be able to provide the funds immediately for a preceptor to start implementing ultrasound and boost it within their institution, but this is kind of a backwards way of getting ultrasound into areas that didn't previously have it until you can get the administrative support for ultrasound. So for students in their didactic curriculum, you can integrate ultrasound teaching as you teach systems, right? So during the CB unit, teach the cardiac ultrasound exam. During the pulmonary unit, teach the pleural exam, GI, the abdominal exam, and so forth. And then as they go into their clinical year, you really want to have a putting it all together workshop so that they can practice their POCUS. Now along with all these skills, you have to teach students and let them understand that this is just one tool in their toolbox. They still have to learn the clinical medicine portion and how to treat patients, but along the way, they can start building their confidence of handling an ultrasound probe and acquiring images and so forth like we talked about for the novice basic skill for POCUS. Now this would require faculty time, some type of quality review process, a checkoff system, and acquired amount of documented scans on passports as they progress through their clinical rotations. But this kind of education is preventative and additive in the way that as these students spread out to different clinical settings across the nation, that they can bring POCUS to those institutions and we will boost the use of it much quicker than just for every individual provider that is currently employed and working in a healthcare setting today. Depending on your institution and clinical practice setting, there may be many providers that didn't receive that kind of POCUS training in their schooling, or as was my case, had been in practice for a while where ultrasounds weren't present in every unit, and when they were, they were mostly used for procedural guidance, not necessarily guiding bedside clinical management, or maybe they came from an institution where there was not a large emphasis on POCUS. In either situation, it's helpful to implement a critical care echocardiography program that is inclusive for all providers within your institution. The multi-pronged approach that we took at our institution was to implement multiple layers of workshops, tangibles that reinforce the topics taught in the workshops, and then OSCEs for skills verification. For the first layer, you want to implement a foundational ultrasound skills workshop that allows you to level the playing field amongst your providers. So you would start with a program that reviewed all of the basic skills first. One of the best ways to do this is to have short lecture didactics regarding each view, and then have participants rotate through hands-on stations so that they can practice in real time with instructor feedback. Some of the tips that were helpful during this is, one, to allow the students to have the most hands-on probe time. The second was to use models, perhaps, that have a background in ultrasonography so that they can give real-time feedback to the student on pressure and position of their probe and how to optimize their images. The third key feature here is to make sure your workshops are inclusive of all providers. Patients don't choose their location when they have a medical emergency, right? So to really boost POCUS usage in your institution, providers should be offered this opportunity to attend workshops regardless of whether they work in the critical care arena, emergency medicine, pre-hospital, or inpatient services, hospital services, rehab, et cetera, and regardless of whether they are an advanced practice provider or a resident fellow or attending. Once you've established a baseline level of training for your providers, or perhaps if they're at a more advanced stage, provide advanced teaching at their level, you can start to build your workshops and small groups based off of that. Depending on the level of competencies the providers at your institution are at, you can really customize this to your providers and build workshops and small group activities that cover these topics that progress so the providers can move from the far left of the competencies, the novice, towards the expert levels of care. Now within your institution, you may not always have an expert to teach, perhaps resuscitative TE, but this is where it's key to network through your society so that you can bring in guest lecturers that can help facilitate the process, and then as your providers in your institution become more comfortable and confident and experienced in these skills, they can give back to your ultrasound program by teaching the skills to fellow colleagues. The second layer to reinforcing topics taught during ultrasound workshops and small groups to really expand POCUS usage within your institution is to provide some kind of tangible. In the upper left corner here, I have just a pictorial of a echocardiography small cheat, a pocket-sized book that can be carried around as providers learn these images and what they're expected to look for. In the bottom corner, I have some FATE ultrasound training cards that you can print and laminate and providers can carry in their pocket and wipe down and clean, of course, if they are getting ultrasound jelly on them, and little tip sheets that include common measurements and how to obtain them so that providers can help build their confidence and practice these skills and have a ready-made reference, even if they don't perform ultrasound every day in their clinical setting. We've also gone as far as to blow these up into full-page sizes and laminate them and attach them to our ultrasound machines so that they have easy access to them right there. Now, it's not just a cheat sheet for providers as they're becoming more proficient, but even the ones that are proficient can pull those sheets up at the bedside and show other learners what you would expect to see in certain views and what you're looking for compared to what's actually going onto the screen to help their learning process. Some of the other ways we've started integrating ultrasound earlier on is when providers first come into our service, they receive an orientation and lectures and so forth, but to go ahead and include ultrasound topics and common views and give them a handbook that they can study that's applicable to the patient population that they're going to see the most in their units. Now, there's a multitude of ideas out there, but the main point is to have something tangible that they can carry and reference very easily. You can do this on a smart device too, but ultimately having the hard copies seems to be most effective, especially in times of emergency and wanting to utilize POCUS. The third layer of OSSI really correlates back to having a quality assurance process. So, objective structured clinical examinations allow an opportunity for providers to demonstrate their confidence and their clinical POCUS skills and even integration of these skills in some standardized scenarios. You can assign a skilled ultrasound trainer to evaluate the OSSIs to maintain consistency, but we've done that in a multitude of ways. Here at Baylor College of Medicine, we have a simulation lab where we'll have our providers come in and round through quarterly so that they can test off like this. You can also have it in more of a hospital setting where the providers rotate through stations and demonstrate through a check-off process. As you start layering in these trainings and workshops, it's important to really also promote an ecocentric culture within your institution. So, what do I mean by this? There's many times where we can go to conferences or trainings and be all pumped up and engaged to implement some new skills, but the reality is when you go back to your clinical setting in bedside, there's not always the time, the support, or the energy to include new skills even though they may benefit patient care, right? So, this can be as simple as all providers engaging and promoting the ultrasound usage. So, for maybe more beginner providers, encouraging them to bring the ultrasound to the bedside when they go to evaluate an episodic problem. That way they can start correlating their ultrasound findings with what they're already seeing clinically when they do hemodynamic assessments. Or this could be as simple as when a provider is able to acquire images and determine abnormal pathology for the senior expert member to inquire further of, okay, now let's do this measurement or do this measurement to support our findings. It takes a whole team, not just one individual, but definitely one provider can serve to promote an ecocentric culture within your institution. As far as assessment tools, in support of having an ecocentric culture, it is helpful to have a checklist, right? These are the generally accepted views. This is how you will obtain the views, and this is measurements that we're looking for to be documented before we make patient care decisions. Having consistency amongst your group with a checklist like this will help build confidence in your provider skills amongst other multidisciplinary teams maybe that are helping care for your patient. Now, there's multiple ways to verify findings, right? You can escalate the images to a senior, maybe expert ultrasonographer within your provider group for verification. You can order a formal study and correlate the findings on your POCUS to the official radiology read or cardiology read, or you can share images to cardiologists, anesthesiologists, et cetera, so that they can also verify findings. The more this is done, the more confidence will be built into the provider's findings. Now, another layer to this is that as you have providers utilizing POCUS in your units, you can require them to document that they performed a set predetermined minimum number of each kind of study, and then also of each view, and then also require a minimum quantity with accurate diagnoses before they are cleared to make patient management decisions independently. This doesn't mean that all providers can't still do the POCUS, right? They can get the POCUS, acquire the images, make determinations, and then escalate to their supervising or more expert member until they are cleared through this documentation method. Regardless of how your institution decides to go about this, and it is multi-layers and it takes a lot of time and effort, but remember we do it because it only takes one saved life to embrace a greater good, right? It only takes one provider walking by a bedside or bringing an ultrasound to the bedside to make a difference in a patient's outcome. So, really make it an effort to embrace bi-institutional efforts for training, right? Get together with academic centers, with local affiliations, with other hospitals, and pool your resources to create trainings like this. As patient volumes go up, it may be more difficult with less staff to do all of these kind of bedside exams, but really embrace this environment and allow for it to show you what limitations your team has and even yourself as a provider, and then that can really help guide what future trainings and workshops that need to be provided within your institution. As always, when we implement a new tool in our clinician toolbox, we want to be good stewards, right? So, definitely focus on using POCUS for the right indication, right interpretation, right integration, and encourage other providers within your institution to do this as well. Boosting POCUS definitely takes an ongoing effort, right? You need to plan for having continual skill refinements. One of the key ways we do that at our institution is having a quarterly simulation skills labs. This allows providers that are already established and moving through their competency levels to come and practice their skills in a controlled setting and with feedback from other members that have been identified as experts. We really look to our staff and try to identify individuals and providers that have a passion for POCUS and encourage their participation in other national trainings and certification advancements so that they can come back to the group and help support the train-the-trainer method, but also to continually grow the usage of POCUS within our critical care setting. Another thing you can do is have a POCUS mentorship program where you pair a advanced beginner or proficient or expert with somebody that is maybe novice or advanced beginner so that they can guide them through their process as they're growing as a provider using POCUS. Another thing you can do is develop a journal club so providers can do image acquisition and then de-identify it and save them for review and discussion amongst a group, which can then lead into other discussions of what other evaluations we could do or measurements we could do and teaching of those skills so that you can continually boost people to the next level. If you're not at facilities that maybe have access to all these resources or maybe not a number of faculty to help do this, you can definitely look at devices that have technology or AI that can help teach to optimize the images within the device or maybe obtain measurements. That way you can corroborate your findings and supplement your self-training. There's devices such as the Cosmos, Philips has one, some integrated telehealth ultrasounds that can be helpful. Within your institutions, you should also look at partnerships. Historically, ultrasonographers would do an ultrasound and send it to the radiologist for a read or to a cardiologist or anesthesiologist that did TEEs. As you're developing in your group skills in doing this, whether it is TEE or transthoracic echo, look at those partnerships that you can have for cardiologists, anesthesiologists, and so forth to come and speak to your group or maybe review some images so that they can also develop a confidence in your team and how you're utilizing POCUS at the bedside. Another thing that's very helpful here is to very clearly document in the patient's chart when POCUS is done and your exact measurements and your findings before you document your patient management decisions. That allows them also to have confidence in your decision-making ability, which when you're integrating POCUS into new clinical settings, you need that support from the multidisciplinary team. Thank you for your time. I hope you were able to learn something that you can bring back to your institution. Integrating POCUS in different clinical settings is an ever-evolving process, so please don't hesitate to reach out if you have any other questions. Thank you.

Point-of-care ultrasound

POCUS training

Provider competency

Ultrasound training

Multidisciplinary approach

Ecocentric culture