SCCM Resource Library-Point-of-Care Ultrasound in Critical Care: Credentialing Through Quality Assurance or Just Wing It?

Video Transcription

My name's Gil Allen. I am moderating the session. And I'd like to welcome you all to a session that we're titling Point of Care Ultrasound. What is it?  Credentialing Through Pathways or Just Wing It. I organized this session because I suspect that I, like many of you, are kind of struggling with the incredible rate  at which accessibility of bedside ultrasound has kind of outpaced our ability to manage it, both in terms of making sure that our providers are  proficient, making sure we have valid training pathways for our trainees, and even, to some extent, policing it at the bedside to make sure that clinical decision making is being  based upon reasonably good images and accurate interpretation. I often kind of use the term the wild west, the new wild west of critical care, because it's kind of become that.  And it's been an ornery beast to try and manage. Even in hospitals that have the infrastructure of quality assurance programming and whatnot.  So I've invited three speakers to talk today. I have Michael Lansbaugh from Intermountain Health, who is an active member of the Ultrasound Committee of SCCM,  oftentimes chairing many of our ultrasound training conferences and training programs. I have Leon Chen from Sloan Kettering. And Jose Gomez-Diaz will be here shortly.  He's actually at the Ultrasound Committee for SCCM. But he'll be closing off. So we're going to have three talks, 15 minutes. I'll ask you to let everybody finish their talk.  And then we'll try to leave all the questions to the end. I'm hoping this will generate a lot of good discussion. So I'll start off by introducing Michael Lansbaugh  from Intermountain Health. Thank you. Thank you. So my talk topic was whether we should let the old dogs give them a pass or whether we should make them commit to a higher bar here.  And so just to start, I'm going to disclose that I have no financial conflicts of interest, although there are probably some intellectual conflicts  of interest or intellectual biases here, in that I have made my career teaching ultrasound. And I think everyone should try to get quite a bit of education in ultrasound and echo.  And so I'm going to start here with that first comment here about old dogs. And so this is where that phrase came from. This is the book of husbandry by Anthony Fitzherbert,  a bunch of advice on how to plow and plant seeds and all of that. But the quote is, a dog must learn it when he is a whelp, or else it will not be, for it is hard to make an old dog  to stoop. And that is where that phrase came from. And so this is almost 500 years old bit of wisdom. And so the question here is, can you teach an old dog new tricks?  And the answer is, of course, yes. I think all of us know that we are not, although we can be somewhat crystalline in our thoughts  as we age, we are still capable of learning new things. This was a program that tried to teach adult or, I guess, advanced practitioners of critical care,  whether you're talking about ICU doctors or faculty or nurse practitioners. But I think the point here was that with a five-hour course  of education, five-hour course of hands-on training, there was a substantial improvement in competency and confidence with the advanced learners. And so the question isn't really,  can you teach an old dog new tricks? But the real question here is, if you're an old dog, is it worth it? And so I'm going to talk about some of the pros and cons  to whether or not we should credential. So one is it might have improved patient care, might reduce costs, and we might be able to supervise trainees.  But on the con for this, there's some controversial data about whether or not this actually improves outcomes. It may not actually save money.  And if you're an experienced clinician, you probably know how to manage a critically ill patient without ultrasound. And while it may be very useful for the person who's  just learning critical care, it may not be as useful to someone who already has a very good management practice. It also costs time and money.  And right now, there is a current dearth of infrastructure. And the other problem here is, if you learn ultrasound enough to practice it, that may not be enough to teach it.  If you want to teach ultrasound, you really have to have a higher bar if you're going to be expected to train your entire group or train a bunch of trainees.  So let's go first to that first question here. Will learning ultrasound improve patient care? So if you're going to say, I want a credential in this, let's say, is this worth it?  We should ask, is this skill actually worth improving patient care? Now, for procedural guidance, it seems pretty unequivocal that for thoracentesis, paracentesis,  and several other procedural guidance, it is definitely safer, it improves success, and it reduces harm. There are several professional society guidelines  that all recommend using ultrasound for procedural guidance. For vascular access as well, shorter time, greater success, fewer complications, and several societies  have all recommended this as well. However, when we talk about trying to change outcomes for more complicated management, point-of-care ultrasound may not actually improve outcomes.  So this is the SHOC-ED study, which was a study done in the emergency department two years ago, looking at patients who show up with hypotension.  And they applied this ultrasound protocol where they did a fairly good look at most of the major organs that might contribute to shock. And so they looked at the patients  when they rolled in, and again, at 60 minutes. And they looked at 30-day survival. There was no difference in their main outcome, which was 30-day survival, or in any other outcome  that we think might be relevant to this protocol. And so it didn't seem that it improved care. Another study that was done a little bit earlier suggested that it may not actually  reduce costs, which is another purported benefit of POCUS. In this case, there was a group of patients who showed up to the ED and got a point-of-care ultrasound protocol.  There was no difference in 30-day mortality. However, there was an increase in CT scans, increase in comprehensive echocardiography, and an increase in diagnostic thoracentesis.  It also may make more money for the hospital, which, depending on how your hospital or health care system is structured, may be a good thing or may be a bad thing.  So this may be increased costs for patients, or it may be increased revenue for the hospital. So they may view that as good or bad.  But I want to describe a program here with an emergency department that created, essentially, an automated point-of-care billing protocol. So as soon as someone decided they  wanted to take a look at a patient with the ultrasound, it would generate an automated report and bill. And it resulted in a seven-fold increase in revenue  with a huge amount of profit paying for itself very rapidly. And you say, great, that shows that we can be cost-solvent. But that means patients were charged an extra $350,000.  And so you can see here that, after this protocol, there was a big increase in billing. And one of the problems when we talk about cost savings  is what we really want to see is a reduction in unnecessary testing. If we talk about cost savings in that I did a necessary test,  but I just didn't bill for it, then that's not really much of a cost savings. And one of the other points here that I had made earlier is that perhaps old dogs are better Bayesians.  And so when I first started off in training, I don't know whether or not a patient might be fluid responsive or not. I don't have that sort of clinical instinct or experience  to really guide my management. Now that I have ultrasound skills, I still use them from time to time. But I also have better Bayesian approach. And so when I look at a patient, I  have a better pretest probability about whether or not they are fluid responsive or not. One example of that is, if the emergency department has  already given four liters in the past two hours, there's a pretty good chance that that patient is no longer going to be fluid responsive, irrespective of whatever test I do.  All right, so let's say we just assume that ultrasound is a benefit. And we're going to just put that aside, even though I've pointed out some of the controversies of ultrasound.  The big question here is, well, should we do formal credentialing, or should we just wing it? And I'm going to point out a study here to kind of underscore the argument  for formal credentialing. This was a study done by an educator, a cardiologist, who is very well known for doing point of care ultrasound teaching to internal medicine residents  and medical students. And he tested two different methods of teaching, conventional and a technology-aided approach, and showed that, man, after doing six months of training,  there was a huge increase in confidence. But there was also a big increase in false positive rates. And so these protocols are actually designed to avoid false positives.  And yet, despite that, medical students and residents ended up having a much higher false positive rate after six months of training.  And so even with this, there is the Dunning-Kruger effect here, where I'm sure many are familiar, where a little bit of knowledge can be very dangerous.  And the old joke goes that I tried to go to the Dunning-Kruger effect conference, but I couldn't find anybody to speak at the keynote address other than a couple of post-grads.  So the point here is you need to have some sort of competency to assure that you're not one of those people who is in that nadir of the Dunning-Kruger effect.  So let's say we've already decided ultrasound's beneficial, and we've decided that we should get credentialed. And this is what I think most people here are probably  interested in, how does an old dog get credentialed? So I'm going to talk first about basic critical care echo. And so this is a rubric designed by Dr. Susanna Price, who  is a cardiac intensivist, who has outlined these different levels of training. And if you look at basically every societal guideline that has been made since this point,  they all follow comparable to this. There's kind of an emergency, very basic level, and then a level one of being able to recognize  abnormal from normal and some common abnormalities. And so for basic critical care echo, what we're hoping for is level one in emergency. Now, there is no formal credentialing body  for that basic level. Now, some groups, for example, the emergency medicine disciplines will say, well, we expect every emergency medicine  doctor to have this by the end of training. And so that fixes the problem for at least all the people coming out of training, but that doesn't  fix the problem for those who have already finished. The basic ultrasound recommendations are still nebulous, as there is no accrediting body.  But there was a statement made about nine years ago suggesting maybe about 20 hours of CME, 10 in ultrasound, 10 in echo, and about 30 echoes performed.  And you have an expert supervisor who determines when you've attained competence, with no formal training or accreditation. More recently, the Society of Critical Care Medicine  has produced a statement that recommended, well, you should probably interpret maybe about 50 echoes, performed about 30, and here's some other procedures.  They recommend tailoring this to your specialty. And again, it's about the same in that you need an expert educator to supervise you and attest to whether or not you are good.  The curriculum should be tailored not only to specialty, but also to your level of experience in the fact that an attending is going to have different knowledge than a resident,  different knowledge than a medical student, but also should be tailored to what resources are available. For example, if there are no available patients  with tamponade because you end up dealing with patients who are primarily in an outpatient setting, you're not going to end up seeing too much of that.  If you end up dealing with mostly a cardiac ICU, you're probably not going to see as much trauma. This right here is just an example of a curriculum that was proposed.  And this gives you an idea. This is purely for how to deal with a traumatic assessment. And so I just want to give you an idea of the amount of complexity that's required,  even for this basic level. So it's a huge amount of work to try to design a basic education curriculum. But for a lot of people who want to accredit,  what we really need is to get to level two or three. And so this right here is a statement that was made by the American College of Cardiologists  that recommended certain levels for getting echocardiography certification. And so most cardiologists are at that level two. The ones who are running Echolab are level three.  And you can see there's an expectation of a significant amount of ECHOs performed. So the National Board of ECHO offers a competency exam in critical care ECHO. You need to pass it.  You need to be licensed. You need to have completed fellowship, or at least have a significant amount of critical care experience. You need to do about 20 hours of CME.  And you need to perform and interpret 150 ECHOs in the past three years that it's signed by a supervisor. Who's that supervisor?  Supervisor must be certified in comprehensive ECHO, critical care ECHO, or advanced perioperative ECHO. Or person has to be certified or a testament  of the comprehensive ECHO board and a recognized expert in the field of critical care ECHO, which is basically an allowance for an old boys club. So where can you find a supervisor?  As of today, I looked this morning, there are 456 people who have passed that critical care ECHO board. So a lot of people have passed it. It only came out a year ago, back in 2019.  But only 25 have actually certified. And only 16 are in the United States. So trying to find someone to mentor you is going to be quite challenging right now.  Although, the hope is that many of these testaments will complete their certification over the next year or two. This lack of instructors is the common problem  with all of the pathways to try to say, I want to get accredited. And if you look here in internal medicine, pediatric and med  peds residency programs, the most commonly cited reason for why there is no point of care ultrasound curriculum is the lack of a qualified instructor.  You can see this as well in a study looking at emergency room physicians that are in private practice, non-academic centers. The most common reason why emergency physicians were not  doing point of care ultrasound is the lack of training. About 70% of them said, there is no place where I can get good training. And you can see, again, in another study  here looking across specialties, that for a variety of pathologic causes that we might want to use ECHO, there was no training, competency, or credentialing.  So we see here there's a clear problem. And we don't really have a good solution. And one of the other problems is, even if I have an educator, there are several other costs.  So one is, I need to pay for an ultrasound machine, which, depending on whether you go with a handheld or a laptop style or a bigger system, can be anywhere from a couple  thousand to tens of thousands. And in some cases, with all of the probes and everything, can be in the $100,000 range. You'll need to have physical space.  You'll need to have computer software. You'll need to have storage space. You'll need to have IT support to manage this. You'll need to have people who can correct the problems when  you end up having an ultrasound that suddenly just gets lost and doesn't show up in your imaging system. You'll need to have, perhaps, an educator or a trainer.  This right here is an advanced cardiac sonographer who does some research with us. And we've also allowed him to help train some of the fellows at our institution.  You may need cardiology support. If you're just starting and you end up doing imaging in the middle of the night and you find what you think is a pulmonary embolism  and you need to call for cardiac support, they're going to be pretty upset if this call happens every night and it's always incorrect without the appropriate infrastructure.  You need to have a way for this to integrate into your electronic medical record because you're going to end up needing to document what happened.  And you're going to need some way of confirming that there's quality assurance. Now, the 2017 SCCM statement recommended that there should be some sort of quality  assurance for those who certify every two years or so. There is currently no or minimal support for anyone who wants to train adult learners.  And by adult, I mean people who are fully fledged, done with fellowship. This was a central theme of the Critical Care Ultrasound and Echo Summit that was in Park City, Utah,  here where we had several thought leaders in ultrasound discuss challenging problems that face critical care ultrasound education and research.  And the majority of the faculty attendees all said there was no infrastructure to train attending physicians despite an expectation to.  So even at institutions where they had expert educators, there was no infrastructure for these people to actually do. There were several novel approaches suggested,  although there was no consensus. Some suggested near peer education, which is have fellows train the attendings. And several people pointed out the potential conflicts with that.  There was also a potential argument for a teaching task force, which is basically just saying we're going to somehow expect people to fly all over the place  and train people with no money for it. So the big question here is, if you think that this is worth it, should you get credentialed? I would say, if you were a patient,  would you want to go to an institute where there was no critical care ultrasound? I think most of us would want that for our family members or for ourselves.  And so I would argue that, as far as making the commitment or giving a pass, which was the question posed to me, that everyone in intensive care should  be competent at basic ultrasound and echo. And by competent, I don't mean give them a pass. I mean commit to training. And by commit to training, I mean supervision  by an expert level clinician. Now, you can gain a lot of that training at a society course or at a local course that offers this. But I still think the problem here  is we need expert level clinicians which are currently absent in most programs. So the way forward is that we can't actually expect people to do what I just told them  unless we actually have institutions committing those resources. So we need to hire local expert trainers. We need to train people to go out and then educate the group.  And we need to coordinate with cardiology and echo labs who have some expertise to help advise and allow with quality assurance.  And the last thing is, until we have hospitals committing money and infrastructure to this, it's an unreasonable expectation to expect all of these old dogs to credential.  And with that, thank you.  Okay, good morning. My name is Leon Chen, and I am actually a nurse practitioner from Memorial Sloan Kettering Cancer Center Department of Anesthesiology and Critical Care Medicine.  And with that title, what I do is I actually train all the advanced practice providers within the department on point-of-care ultrasound.  So it's a little bit different, but I'll talk about our process and the challenges with  and then where we're at today and where we expect it to go from there. So I have no financial disclosure, except just like Dr. Lensbaugh, I imagine I have  intellectual disclosure, because the title of the talk is Credentialing Through QA Versus  Osmosis, and I am biased towards one, because I don't think you could learn it without proper structural training. You can't really learn by osmosis.  I'll briefly discuss what the current recommendation for point-of-care ultrasound training is and some literature on advanced practice provider POCUS training and competency.  That will be very, very short, because there aren't that much data on it, so you won't see much.  The benefit and challenges of APP POCUS program, which a lot of the problem shares with the physician training, including infrastructure, cost, faculty members.  And I'll talk about some of the future directions that I would like to see going forward. So I'm a big TV watcher, and if you're a TV watcher of a certain age, you'll be familiar  with the show ER, which is on TV all the time, if you have POP network, I think that's what the channel is.  And just the other day, I was watching it, and they had a scene where in M&M, people were just debating fiercely back and forth about the merits of Bessai ultrasound.  And then they were talking about whether or not it's actually useful. Now, we still might have the debate individually, but that was back in the 90s, where the question  isn't as clear. And even in the show, they said, we just started doing this a couple of years ago. I think it's beneficial. I don't think it's beneficial.  But most of the time, I think people could agree that nobody looks at critical care ultrasound or POCUS thinking that it's hocus pocus.  Since 2008, 2009, American College of Chest Physicians, alongside with our French critical care colleagues, came up with some basic consensus statement outlining some basic  studies that every single intensivist or people practicing intensive care should know how to perform.  And that includes thoracic, abdomen, vascular, in addition to procedural ultrasound. Of course, after that, there is Society of Critical Care Medicine's International Expert  Statement on Training Standards, which Dr. Lensbaugh outlined. There are basic outlines and format of how you should go about training, including training  environment, and then some of the minimal standards included. Of course, in 2016, Society of Critical Care Medicine also published a guideline for anybody  who is practicing critical care medicine. You should know what indication you have, which specific indication that you could use POCUS on, and what you should do with it.  So ultimately, the current recommendation is that there is benefit to POCUS in critical care.  There is a framework for how to go about training POCUS providers, intensivists, and assuming  all of these recommendations assume that you will take the recommendation and then train your practitioners and providers and provide them adequate tools to go ahead and perform  this exam. This is a little bit later. It's, again, a specific recommendation for achieving and maintenance of competency and  credential in critical care ultrasound and focused cardiac ultrasound and advanced critical care ECHO. Now, when we talk about POCUS, of course, there are different things.  This is all just basic exams, and we're not talking about advanced ECHO, which there is a separate credentialing body and there's an exam, and then you have to take a test for.  These recommendations for basic POCUS, it's very broad. Every society has to kind of adapt it into their own, and then different institutions  might adapt it further to train their providers.  Now, some of the difference is that American College of Chest Physicians' initial statement and the SECM, there's a subtle difference in language because the chest article actually  just talks about physician most of the time, and then the SECM guidelines, they kind of use the word provider.  So that kind of opens up for many more practitioners, including MPs and PAs. So if you go by the physician POCUS pathway, what they recommended was you could do one of two ways.  You could either do fellowship-based, so you have to be board-certified in a first internal medicine or other specialty, and then you do a subspecialty in critical care.  You do two years or one-year fellowship, and then by the time you finish, assuming that the fellowship has an ACGME-approved curriculum for ultrasound, and then you have a letter  supporting your competency, and then you are now competent. There's no test.  Now, the second way is for people who've practiced beyond, like before POCUS was part of their  training curriculum, and then you could learn by many other ways, like CME, practice with  a different experienced provider, or the fellow training, the attending, which again is problematic. But either way, you learn by experience.  So these two pathways, they're great for physicians. You have an outline, you have a framework. What about for MPs and PAs? Not quite, right?  You could do it by credentialing, you could do it by certification, you could do it by learning from others. It doesn't quite fit.  Now we do have advanced practice provider, critical care fellowships, but the ultrasound curriculum in each fellowship, it varies greatly.  Now we could go to CMEs, we could go take courses, but how do we actually maintain competency beyond that?  So those are some of the issues that these guidelines, that recommendation for training doesn't really apply to advanced practice providers in critical care.  So looking to American College of Emergency Physicians, they have been doing this a little bit longer.  So they actually have a policy statement for advanced practice provider point-of-care ultrasound guidelines.  And what they did was essentially saying all the APPs should follow the exact same training guideline for POCUS as their physician colleagues.  So when you graduate emergency medicine residency, you have to do 125 exams of various exams. And for that, you say, okay, now you're competent, great.  So if you're a PA or MP in the emergency room, go through the same training. I actually am friends with a couple of ER physicians who went through ultrasound fellowship  in EM, and then they actually trained alongside MPs and PAs who went through the exact same curriculum. Once they graduate, they are competent the same way.  And the leadership in EM ultrasound fellowship training, they actually are encouraged to incorporate MPs and PAs into the practice, train them the same way so that they have  the same outcome to ensure that whatever they're learning is on par with everybody else. So we don't have that for critical care society.  Critical care medicine doesn't have a policy statement on APPs practicing POCUS in critical care. I try to look for it. It's not there.  I try to find some data on training of MPs and PAs in POCUS. There's not much. I'll show you one.  This is one of the studies from Journal of Nurse Practitioners in 2018, and it is flawed, I can tell you, to say the least. So it's a very small study in one center.  And what they did was they took eight ICU MPs practicing a surgical ICU, and they excluded everybody who did not have previous experience with any type of ultrasound.  So they excluded those. So everybody in this cohort has some degree of training, whether it's somebody showed  them, you know, see one, do one, teach one, or just that they've seen a couple of exams done. And then they went through a short program.  They didn't really exactly describe what the program, they call it a kind of an information session. And then after that program, they went on to perform exams.  And then they're not doing full POCUS exams. All they're expected to do is capture images of inferior vena cava. And they had to interpret 50 images of inferior vena cava.  And then there's an overreader to kind of see whether or not the findings correlated. So what they found was that, yes, after a short training program, these eight ICU MPs  who already have experience in ultrasound are able to capture IVC images and interpret the images correctly with an overreader. So there was, how did they go about learning it?  They didn't really say. It's a lot of just kind of do it, they winged it, right? Essentially, for the study, they just winged it. So no structured training, obviously.  And I don't think that's the right path forward. So how do you actually get to competency for an APP? Again, different ways. You could do what that one center did.  You could learn by osmosis.  Teach them alongside, show them one, and then they will do one. Or you could do external CE courses.  So CME courses for SCCM, CHESS, a lot of other institutions have these type of training programs. They usually last from one to three days.  There's no way to maintain ongoing competency. Because again, after three days, they say, you learned these basic things, go ahead and perform exams.  How do we make sure that you still are competent? We can't. Certification pathway, it's available.  So CHESS obviously has a certificate of completion program that lasts about one year. So and then there are other institutions with certification programs.  But they're very, very expensive. And then a lot of MPs and PAs, our CEU money is not as much as our physician attending colleagues. So you simply can't afford it.  And then of course, there are more and more critical care APP fellowships out there. The last I counted is roughly 15, literally throughout the country.  And then, but only about 30%, 40% of them have any ultrasound training, structured ultrasound training.  And then they face the same problems in terms of infrastructure faculty as physician training.  So it's pretty treacherous road forward, but I'll give you an example what my institution we kind of did. And I'll give you our challenges and some of the ongoing problems we have.  So we, just like every other place that have a training program, we first had to find a physician faculty member who is an expert in sonography. And we did.  We found a home critical care attending who is competent at performing POCUS. And she had the time and willingness to teach all the other APPs.  We have secure money to find ultrasound because different centers obviously have different resources. But we have three ultrasound machines.  And then some of them, if they're in training, you obviously leave the unit short. And of course, beyond just the ultrasound machines, we have to get money for training  modules and also the staff. The training of the APP program lead, which ultimately is me. So I had to get trained first in ultrasound before I could help train others, because  our APP group is pretty big. Now, in terms of my time staffing the unit, that has to be decided by the leadership. And Memorial Stone Kettering is in New York City.  And as everything else in New York City, the space is always limited. So simulation space, a good space to actually allow people to do simulation and learning,  we did it in the basement at one point. So very, very tough to come by. In terms of the curriculum, we kind of followed what most of the recommendations said in terms  of providing online learning modules, didactic sessions, guided image interpretation. Then we just supervised hands-on exams.  And all the trainees have to provide an image portfolio similar to what CHESS and also ASAP has recommended. I think our final number is about 105 images of various exams.  And you have to have that portfolio reviewed by a faculty member. And then everything has to look good before you could go on to take a hands-on and a knowledge exam.  And if you've done all of that, you've completed a credentialing process in our institution and that you are competent in performing POCUS.  Now some of the other things we have to do is ongoing competency maintenance. So quality assurance of images, over-reading of the images.  We actually do collaborate with the cardiology department, who actually, that they actually help us train some of our APPs and some of the advanced echo images.  And we collaborate with them to the point that overnight, when we scan patients for tamponade, they're very happy to pick up the phone and answer our call and then over-read  it with us and make a determination. Billing is something that we're working on right now. Eventually we will hopefully bill for our exams.  So this is ultimately what a structure recommended by most society is. And we follow that as much as we can.  The benefits, I think, is the fact that having a structure and having everybody go through the same steps ensures competency.  You're always going to have people who are a little bit better scanners than others. You're always going to have better clinicians than others. And that just leaves it to talent.  Everybody goes through the same way. We ensure that everybody has the basic tools to go on to succeed. And at least we have documented competency.  And the standardization, I can't stress enough in terms of training. This is our advanced practice team. And it's a pretty big group.  So I'm actually pretty proud to say that out of roughly 40 people, we have about 80, 90% of them all trained, went through this program and trained in POCUS. Logistical challenges.  I think this is similar logistical challenges with every other institution that trains any type of provider. So image storage. So we went through several different systems.  The cost varies. And then some of them adapt better. Some of them we use we don't like and we kind of eventually gave up on. Image sharing.  How to securely do it and HIPAA compliant and without getting hacked. How do we store it in one system and send it to various places. That was a big to do.  And our information security system team is all over it. Training time and staffing. It's hard. So we train cohorts six to eight people at a time.  Again, we have a big service of 30, 40 MPs.  MPs and PAs. How do we actually staff the unit and make sure that everybody there are people actually watching the patient, taking care of patients while they're training.  So that took a lot of finagling. Faculty. Always a challenge. So we are training more and more capable APPs to help train other APPs.  But of course, we still have only one attending who does majority of the APP training in terms of POCUS. Overread and QA.  So as we have a bigger staff that is actually certified in POCUS, there's going to be more and more images.  It used to be me reading and then attending and reading all the images, but now it's obviously out of hand. So we can't actually physically do all of that. And documentation.  So we ran into some of the issues, documentation. The people who actually first learned POCUS, they were afraid to document the findings  because they felt like they were overstepping their training.  We're not radiologists. We're not cardiologists. Why are we making these POCUS documentations?  It took a change in mindset, a lot of education to actually tell them it's not any different when you document a finding from auscultation.  You're using it to make a clinical judgment, and then this is something that you should put in the books. You can't just hide it away.  And our eventual goal for quality assurance is 10% of all of our POCUS exams will be overread and make sure that their quality is maintained.  There should be proper documentation for every single POCUS exam performed by an APP. And what the guideline says, you should have maybe a committee of people overreading it  and then give it a score. We haven't gotten to that point yet because that just takes a lot of manpower.  Some of the future directions, in my mind, you could do it one of several ways. One is more likely than the other.  So I'll talk about the one that I don't think will happen anytime soon. Which is incorporating POCUS training into a MP or PA school curriculum.  You're starting to see more and more MS schools do that, part of their anatomy and physiology to kind of help them learn ultrasound, at least expose them to it beforehand.  For MP and PA school, I know that there are some PA schools that are already starting to do that. But MP schools, I'm a faculty for one MP school. There's a lot of challenges.  There's a lot of challenges with buy-in and equipment and money and all of that. What's more feasible, in my mind, is to actually standardize a structure for POCUS training  in APP critical care fellowships. There are more and more going around, and I think that's a trend.  You're going to see more and more critical care APP fellowships as a whole because people realize that there is a demand for them.  And then how to go about creating a curriculum and requiring every single APP fellowship to have a curriculum for POCUS.  That would depend on a lot of other issues like faculty costs. But I think it's something worthwhile that the program directors of various APP fellowships  should consider and institute eventually. So with that, thank you for your time. Just like to briefly introduce our last speaker. It's Dr. Jose Diaz Gomez from Mayo.  He's a former chair of the Ultrasound Committee for the SCCM and a former chair of the Ultrasound Training Program for SCCM.  He's going to talk today about quality assurance and point-of-care ultrasound, really how we can deliver it and how do we find the time.  As you've heard our last two speakers actually just touch on, it's all right. Thank you, Gil. So whenever I'm associated with Dr. Lanzba, I know there is a real challenge, you know,  coming up and he wants me to share with you basically how we can deliver point-of-care ultrasound with high quality and how we find the time.  Let's see if I'm able to answer those two questions, at least one. So I will try just to see, show you the perspective of what high-quality service in ultrasound means.  I will make emphasis on the assessment of competent-based medical education and then the value of the rubrics I have used in the past, some experiences here in the United  States and elsewhere, and finally, what is my vision, what's going to happen in the future. So by definition, when we talk about quality assurance, it should be a systematic process  ensuring that that information obtained by ultrasound is timely, is appropriate and accurate.  So it's easy to say that, but to achieve that goal, you're going to understand that it's a really serious process on that. And you have to monitor that activity continuously.  And not only that, you have to realize that the life of many individuals are, you know, they're probably the main reason we want this high quality.  In my current practice at Texas Heart, there are in general three, four patients with impella,  probably five to four, you know, four to five patients on ECMO and probably half a dozen transplant patients. You might imagine the high-stakes situation in that setting.  So what we do is to be focused on the process, not the individual. So if something goes wrong, oh, this guy, he doesn't have the skills.  Well, one second, why don't understand how you select a patient to apply ultrasonography, how the study was performed, who interpreted it, how it was interpreted.  There was a report. And ultimately, that will actually translate in potential outcome. That should be the mindset, okay, from the engineering standpoint.  So the steps to develop a high-quality service are the following. You need to understand how to select the patients.  So if my scope of practice is a critical care echocardiography, why a patient that has been having dyspnea for six months come to me and I will try to use the tool for that  patient population. That's not the case. I'm talking about patients that are in a daily basis in the ICU. So this is very important.  So depending on which echocardiography is taking care of those patients, then you apply that. Second, study performance.  I will do a lot of emphasis there because you need to rely on your equipment. You need to have that accurate sonography. That's the reason it's italics.  And italics, I will make emphasis on that, how to record those studies. We need to save those. Why? Because we can do then an evaluation subsequently.  And then finally, our report should be concise, very clear, and everybody should be able to understand that.  So as a study performance is concerned, you got to make sure that you have equipment that is reliable, that anytime you're going to use it, it's ready, and it will give you high  quality images. So how much do you trust your transducer? You know, you just cannot have a program where the equipment is not actually adequate for what you do.  Then you need to make sure that that equipment is well-maintained. And in a daily basis, you got to make sure if there is any problem, any deficiency has to be reported and fixed.  Right now, I just, you know, since last year when I joined Texas Heart, I was telling my best friend here, Dr. Castillo, say, listen, I don't like the settings, and we need to  call a biomed and making sure that the machines were running properly. That's the first, very first step.  So everybody here has to understand that if you don't have good quality assurance, that will undermine the diagnostic quality of the ultrasonography examination and expose that  operator to many risks, to do misdiagnosis, to do the wrong call. And that goes actually along the health of that patient.  So let's go back to one of the most respected, he's one of the top 10 psychologists in the history of the United States.  And this professor at Harvard in the 70s, actually, he was working on how the companies were selecting people based on tests.  He was the one, the first one who proposed that it should be based on demonstrated competency.  Then after that, pretty much the World Health Organization on the 70s to the 80s were creating, oh no, we need to make sure we have competency-based medical education.  And that's when there were two terms that were coming up, competency and proficiency. The difference between the two, the competence is just the entry level that probably you  were able to do it once, okay? But to be a master, you need to become a proficient individual in ultrasonography.  And this is very important because there are people who just do a procedure once, oh, I'm good at it. Well, wait a second, are you sure? How you can assess?  Well, the fact is this, we don't have any standardized, objective, quantitative method to actually assess competence in diagnostic ultrasonography.  That doesn't exist, and that's a problem because you don't have a tool to assess something that is really serious, which will be the tools that we have so far available.  Let's go, let's review it. So in this assessment of competence, we have, it's like pretty much a functional analysis  of the occupational roles, and we want those occupational roles to see how affect the outcomes, okay?  And that's what they are doing right now on simulation and education in general. So among all these assessment tools that we have, the most, probably the most valuable  so far are the checklist, simulation, and models. And after that, 360 evaluations. That's when subjectivity is coming here because, hey, I like the guy or I don't like the guy.  It's not the guy, it's good at it. Most of the time, these evaluations become a little bit subjective.  That's the reason nowadays simulation is taking a really crucial role in the training of ultrasonography, and I will show you why.  When you do TTE simulation, okay, for the learner, for the person who is just learning, you actually can distinct different levels of learning and styles.  And not only that, I will show you a simulator that was guiding you, hey, you need to correct your angle to have a good image.  So right away, the learner is understanding what his error is. And then, because the person will be doing it again and again, that retention will go  to a different level with mentorship. So here we go. This is a friend of mine, I met this person three years ago at a meeting at American Society of Echocardiography.  She's a full professor, NIH-granted cardiologist. Very nice individual and very smart. And she shared with me this technology. This is a simulator that she has.  You have here two images. This is an optimal view and not that optimal view, the epical four-chamber view. You see here that there is red and there is this green.  So it's showing here the angle, how the learner needs to correct the angle in order to obtain the good image.  So imagine how simulation is empowering that learner to learn a skill not having even a mentor beside him or her. So here we go.  Once again, just tilting, rotating a little bit the probe here is correcting that angle and is making an image that was not that great in a great one.  So this is the current simulation, state-of-the-art, and the paper was published, you know, a year ago.  So you can see here how the angle deviation is corrected after the training, okay? So that's for actually the trainee and for the trainer.  For me, if I'm the mentor, I'm the person, I'm the proctor, I will be able to use this if I want to hire people. I have done actually in the past.  We have actually selected a candidate, put a situation. This is the simulator and what would you do?  And that's the reason simulation probably right now if you want quality assurance, it should be that desirable tool to utilize.  And now that I'm exposed to a higher volume of patients with cardiothoracic disease, you can see here how volume matters. So you have two groups here, physicians and sonographers.  There are no physicians. Just obtaining the views and see how these people, these sonographer nurses, were doing an average more than 300 to 500 studies.  And when you have this high volume, that was associated with less angle error. This is important to have that practice, okay?  So to become an accredited sonographer, what you need is to have those attributes, okay? You have your logbook and then you decide, okay, what would be my outcomes? What I want?  Oh, I want to make sure my patient is not in shock for an hour. I need to realize what kind of shock you are treating. What would be the assessment criteria?  Then you go and say, okay, any patient that decreases their blood pressure by less, let's say more than 20% baseline will do this.  You have to define teaching and learning activities and then you have an assessment time and finally the strategy. That's when governance come into place.  You had the equipment, but you need governance. Then you need to navigate now the political situation in every single institution. So one tool I'm being using lately is the rubrics.  So the rubrics are these forms that you can assess anything you want and you are actually grading it. And the good thing here is that it becomes more objective.  Let's say, okay, look at the RSS in here, the image quality or whether it was able to recognize the sonography landmarks or even the documentation.  So if the person does a good job doing image quality but doesn't document really well, that's not good because if something bad happens and they will try to review documentation  for a peer review and the documentation is not there, then there is a problem there. So because of that reason, rubrics are becoming a more useful tool and there are rubrics for  everything. You can see here then how the rubrics help the trainee to have those performance indicators.  You have a score, okay, and for me, for the trainer, I am focused on those aims. This is what I want you to achieve and it facilitates the evaluation process.  And it really works on a small group size. So these are the advantages. You can have different degrees of performance so it's more objective, it's quantitative  and you can provide feedback, what was wrong. The disadvantage is that when you have large groups, it becomes a little cumbersome and requires assistance.  So this is an example, another example you have here, the novice, what you're expecting  with the novice, okay, how do you assess the patient, what were the settings, the preparation, even the professionalism, how they were dressed. All these things matter.  I mean, I'm very strict when a fellow is examining, for instance, a female patient and be very professional, cover her, applying the gel, all these things matter.  So you can decide, you use whatever rubric you want and by the way, I don't have any conflict of interest but you go to iRubric.com and you will see all these examples there.  This is another one for transclinical Doppler, okay. So once again, rubrics are a valuable tool to quantify performance.  So how would you handle human errors that you detect during quality assurance? Well, pretty much, you really need to identify those dimensions of care and the focus will  be remembered on the process and the patient and what is the direct echocardiography product.  No on the professional, the individual, leave that for the last thing you're going to be concerned about.  You need to review the process and how all these echocardiography product was actually put in place, okay.  And then, this is probably the most painful part, how are you going to have the monitoring system to make sure that you are following this process very closely and I will show  you an example in the end. So the American Medical Association stated that, you know, ultrasound imaging is within  the scope of practice of physicians with training in technology and the physician should qualify  for prevent if they possess appropriate training as specified by their respective specialty association. So this is back, you know, 20 years ago.  So 20 years ago, we knew that we were empowered on ultrasonography. We're just catching up. But our profession allows us to use this tool and we need to be good at it.  So this is just a personal experience I have, you know, a few years back. What I did was, I was interested, if I invest, if I implement a system where my advanced  practice providers have some competency, I don't know it will be proficient or not at that point, but at least I wanted them to be competent, then what would be the difference  if they are assessing a patient in shock versus a really well-trained, strong intensivist? So that's what we did.  And what we found is that actually, the only difference was that we, the intensivist, we were faster in obtaining the proper diagnosis.  But the concordance on the diagnosis for shock was at the 85%, 85%. So 85, 8 out of 10 times, we actually put, we covered the pumps. They didn't know what the drips were running.  They just were coming to do an assessment with the echo. And then they were out of the room. And then after that, the intensivist will come, do the same.  And I have the sonographer, a sonographer, comparing the interpretation in both. So I did that a few years back. So I implemented a curriculum in six phases.  And number one was have that didactic for four hours. Then I did a well lab with the, you know, big heart so they understand really well how  the ultrasound beam travels through the heart. And then sometimes people are intimidated when you have, you know, okay, he's my boss,  whatever, then the cardiac sonographer invest a little bit of money in that. And they were scanning with a cardiac sonographer for six months period. And then we did simulation.  Then after that, we did that interpretation at the bedside with the patients. And finally, a cognitive, you know, test that it was no different between physicians and APPs.  Other people thinking bigger in the healthcare system, I like this publication from the UK  where this individual put actually as a patient-centered approach with echocardiography. You can see here echo quality, how it can be consistent, how we can educate and how  we can actually satisfy the customer. And you can see all this is patient-centered, another concept.  And the last one is this experience in credentialing point-of-care ultrasonography in Australia. And once again, remember what I told you about the governance.  So put the, analyze a problem, and then develop those policies, have the proper resources, make sure they have documentation, and finally implementing the program.  And look at how simple they were. Everybody I'm pretty sure, every single ICU, trainees, APPs, attendants, they know how to do vascular access. You get comfortable.  And then after that, hey, let's do some E-FAST. They are not going right away on echo, and then do some echo, and then here, try upper quadrant ultrasound, DVT, and renal.  So if you take a look, these are the views they were asking for, those views. That was pretty much what defined the competency. And this was the rubric they were using, see?  So very simple, but it took them six years to develop all this. So in 2011, they were doing an average 500 studies. By 2016, 4,000.  Imagine the right percentage of diagnosis, the rescue echoes they did. Imagine even the billing for those that like, you know, to impress the administration. So good experience.  In the end, it was all about having the quality audit, having that feedback. But look at this here.  Ongoing education, one-to-one training, clinical scanning, competency assessment, credentialing maintenance.  All, once again, you need the equipment, you need the governance, and you have the collective learning.  So this is the example I was telling you, and the reason I'm bringing it is because it's not coming from critical care. It's coming from the hospital world, from hospital medicine.  So what they do, they implemented a committee of review point-of-care ultrasound, and basically each one, they are doing like a sample 10%.  Each case is reviewed by two physicians in the committee, the hospitalist, and then with a cardiologist or a radiologist. And here we go. That's the way they provide the feedback.  So there are hospitals doing this already. That's the kind of process we want in place to review what we do.  And as biased as I can be to be a member of the SCCM, I have here Gil and Mike Lanspa beside me because they know we really have been working really hard the last five years  on half our own protocols. I have to say we have tried to identify that entry point for the eco-passionate people, and the easy, it comes from only doing that sub-coastal view.  Just put in a sub-coastal view. That's the entry point. And then we go to the stars. For those, and once again, I don't have any royalties, but the new ultrasound test  book, I was one of the editors. Mike was one of our contributors as well. And we put together an algorithm. It's sequential. It's methodic.  And we believe that will be the way we should be doing echocardiography. But ultimately, I'm part of the committee that actually does this exam to become  critical care board certified. And to me, in one slide, I want to put together an entry point. Those that become a little bit more passionate, more ambitious, do a full exam.  And those who want to be leaders in the future, they should go to a certification pathway. Because what this drive is only one thing, excellence.  And there is nothing wrong about that. Do everybody has to do this in the society? No. But we need at least a few folks doing this pathway so the quality  insurance in the end will be much higher. So the last thing for the future, look at what's happening right now. This paper is from the cardiology side.  And they are trying to, it's kind of neat. Because right now, you do a study. And this was your study. And now you will be receiving a graphic report.  They are telling you, please ensure the pulse cursor is at the left tips. Thank you. They're telling you what you did wrong during the study after you have completed.  And this one, you see, you did a great job imaging this patient. And they give you some feedback. So that's what is coming up. And it's kind of neat.  I mean, it's good to know how we actually will become better. This is software. Of course, there will be some investment you have to be here.  But it's all going in the right direction to have higher quality. So this is the problem. This takes time. You know, doing this takes time. And sometimes we don't have the time.  So for the second question is, I just need to remind these. They will always have excuse to say, no, I cannot do it. There is just not enough time. There is not enough money.  I'm not getting reimbursed for this. I just don't know how to do this. Or say, present this lecture, but I don't have the skills. No, I just can't change.  I'm happy with the way I'm doing it. I'm not ready for that yet. I'm too junior. And this is not going to work. Of course, there is always excuse.  Honestly, I have been busy as I can be. But I'm one of those individuals when I have less time. For some reason, I become a little bit more creative.  And I ended up doing a decent job, at least. But I'm not going to give up on a tool that's so tremendously powerful. And I have saved so many lives.  And now, I think we have spent time on education to go to the next level, which is create the evidence. With that, I think simple overall strategy is to be practical,  multi-professional, multi-specialty involvement. Okay, team up with respiratory therapies, nurses, nurse practitioners, you know, be methodical.  That's the reason those algorithms help you out. Document what you're doing. Don't feel embarrassed to share with others what you have done,  nothing wrong, and then publish what you found. We need to publish that. With that, I just want to thank you for the opportunity for being here. We've gone a little bit over.  But if anybody has any questions, we could probably at least stimulate some discussion for a few minutes here. Can you come to the microphone?  So, I'm Fraser McKay. I work at Leahy, just outside of Boston, as both an intensivist and an emergency physician, which is what I am.  I wonder if there's, any of you are aware of requirements via the ACGME for fellowships, so that number, 150 scans in ASAP.  The reason why the debate in emergency medicine stopped is because the ACGME and the Board of Emergency Medicine made it required that in order  to graduate residency, you had to have 150 scans. And that was the thing, having gone through this just a few years after that decision occurred.  That was the thing that made everyone in emergency medicine get on the same page, that made all the, quote, old dogs learn new tricks.  You couldn't teach residents unless you had this credential. So, I was just wondering if you had opinions on that as to whether or not the ACGME  and accrediting bodies are moving toward a requirement. Thanks. So, yes, thanks. I think that is a great point.  And the emergency medicine groups have been a lot more experienced in this, kind of led the cause.  The big challenge is still there's a lot of people that are in non-teaching institutions that don't have access to this.  But I can at least attest for internal medicine, as of now, the pulmonary critical care or internal medicine critical care still doesn't have much more than just an expectation  of, well, you should do a couple of thoracentesis and paracentesis, and you should probably be able to use echo or ultrasound for procedural guidance.  But there's no current recommendation. And as we all know, these are large bureaucracies that are slow to change. I do think that the path forward is to mandate that.  But I would say for at least internal medicine, med-peds, and pediatrics, it seems that there is insufficient infrastructure at this time to try to mandate that with adult learners.  The majority of internal medicine programs don't even have an expert educator. Thank you. I think that the other tricky part is that numbers don't necessarily equal quality.  And we have, you know, I can guarantee most all my critical care fellows are probably completing 120 bedside exams, but they're not uploading them every time to QPATH for me  to be overlooking and providing real-time feedback. So this is the issue. The 150 number is actually higher than the European has been asking for.  What we intend with the critical care certification is to make sure there is a proctor that is assuring that quality. So because in the end, in the certification process,  the person who is applying for the certification might be audited. And that's the reason right now the whole emphasis is to have the first, you know,  group of proctors that actually can review those studies.  I think we'll need to clear the room for the next session. If anyone wants to ask questions of me, we'll be right outside.  Yes, excellent point. Thanks, yeah.

Video Summary

The session titled "Point of Care Ultrasound: What is it? Credentialing Through Pathways or Just Wing It?" discussed the challenges surrounding the accessibility and management of bedside ultrasound in healthcare. The session emphasized the need for valid training pathways and the importance of ensuring providers are proficient and competent in ultrasound. The session included talks from experts in the field, who discussed the benefits and challenges of implementing credentialing programs for ultrasound training. They highlighted the need for infrastructure, resources, and expert trainers to support formal credentialing. The speakers also emphasized the importance of quality assurance and monitoring in ultrasound practice to ensure accurate interpretation and clinical decision making. They discussed the use of rubrics and simulation as effective tools for training and assessing competency. The session concluded with a discussion on future directions, including incorporating ultrasound training into advanced practice provider fellowships and the development of standardized pathways for ultrasound training. The speakers agreed that everyone in intensive care should be competent at basic ultrasound and echo, but acknowledged the challenges in providing the necessary education and training. They stressed the importance of investing in infrastructure, resources, and expert trainers to ensure high-quality ultrasound practice.

Asset Subtitle

Procedures, Professional Development and Education, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Explain the current challenges in defining ultrasound and echocardiography proficiency for more senior established critical care providers
Describe options available to senior level critical care providers to overcome the current challenges regarding ultrasound and echocardiography proficiency
Review what other institutions are doing to formalize their ultrasound curriculum for critical care
Apply formalized evaluation programs to ensure ongoing quality assurance of point-of-care ultrasound providers

Credentialing the Old Dogs: Make the Commitment or Give Them a Pass?

Michael J. Lanspa

Training Our Professionals: Credentialing Through Quality Assurance Versus Passive Osmosis

Leon Chen

Quality Assurance in Point-of-Care Ultrasound: How Can We Deliver, and How Do We Find the Time?

Jose L. Diaz-Gomez

Meta Tag

Content Type Presentation

Knowledge Area Procedures

Knowledge Area Professional Development and Education

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Point of Care

Tag Echocardiography

Tag Economics

Tag Cardiothoracic Critical Care

Year 2020

Keywords

Point of Care Ultrasound

Credentialing

Pathways

Bedside Ultrasound

Healthcare

Training

Competency

Quality Assurance

Simulation

Ultrasound Practice

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