Application selection

Every curriculum should include two mandatory applications (or module): the demonstration of how to generate and optimize an ultrasound image and demonstration of good practice in PoCUS which includes image quality assurance and competency assessments for the clinician. This forms the basis for training in all further applications. Mandatory core (or basic) applications are selected to complement local emergency medicine practice. Training bodies will consider disease prevalence, impact of disease, potential for patient benefit and resources when deciding what core applications to include. Optional enhanced (or advanced) applications are selected to encourage skill development and progression of PoCUS practice. Many PoCUS applications may be used by emergency physicians, and their non-inclusion in the core applications should not diminish their importance in practice.

All applications should be defined as diagnostic or procedural. Diagnostic applications can be single area applications (e.g., assessment of the abdominal aorta) or multiple area applications (e.g., shock assessment). Procedural applications should be selected for their ability to improve patient and procedural safety and efficiency. The curriculum describes each application in terms of what it is, potential benefits, equipment requirements, required knowledge of anatomy and pathology, as well as skills required.

Training methodology

Training in each application of PoCUS is divided into four stages: introduction, gaining experience, confirmation of competency, and skills maintenance.

Each application should be introduced by either delivery of recognized course material, online learning, modular learning, or by a combination of these methods. Further experience must be gained by a combination of scanning real patients with supervision (or proctoring), simulation, or by undertaking dedicated PoCUS fellowship training. It is recognized that learning curves vary for each individual and as such it is important that this stage optimizes the skills of image generation, recognition and clinical integration. Assessment of competency for each PoCUS application should be comprehensive and structured. A template global assessment form provides an assessment structure that includes task specific checklists, unique for each module, compiled using Delphi methodology amongst experts, and a global rating scale to assess good clinical practice (standard for all modules). Skills maintenance is essential and is achieved by continuous quality improvement methods. Hiatuses in performing a particular application may result in loss of skill. Peer review and audit has an important role in demonstrating continued competency. Keeping up to date with the latest medical research in this area is essential.

This process is summarized in Figure 1.

Figure 1 Essential components of an emergency PoCUS curriculum.

The anatomy of a PoCUS application

For each application it is important to understand what it is, when to use it, and why and how it is of benefit to EM practice. Hence the anatomy of each application needs to include details of what trainees will learn with regards to Knowledge, Skills, and Behaviour.

Demonstration of how to generate and optimize an image

It is imperative that trainees have a foundation in understanding how ultrasound works, safety issues, ergonomic considerations and how to operate and maintain the equipment. IFEM advocates that this topic is included as an application in its own right even though this is not a clinically directed module. Below is a general guide to the level of understanding expected:

Knowledge

• ∙ The basic components of an ultrasound system;

• ∙ Types of transducer and the production of ultrasound, with an emphasis on operator controlled variables;

• ∙ Use of ultrasound controls;

• ∙ Know the frequencies used in medical ultrasound and the effect on image quality and penetration;

• ∙ The interaction of ultrasound with tissue including biological effects;

• ∙ Safety issues in ultrasound;

• ∙ The basic principles of real time and Doppler ultrasound including color flow and power Doppler;

• ∙ The recognition and explanation of common artefacts;

• ∙ Image recording systems.

Skills

• ∙ Operation of the key machine controls;

• ∙ Transducer changing;

• ∙ Image manipulation and storage.

Behaviour

• ∙ Safe practice;

• ∙ Limitations of own skills;

• ∙ Integration of ultrasound findings with clinical assessment.

Demonstration of good practice in emergency ultrasound

Every user of ultrasound should embrace principles of good practice and governance or continuing quality improvement. IFEM advocates that this is included as an application in its own right even though this is not a clinically directed module. Below is a general guide to the level of understanding expected:

Knowledge

• ∙ Image recording, storing and filing;

• ∙ Reporting;

• ∙ Medico-legal aspects – outlining the responsibility to practise within specific levels of competence and the requirements for training;

• ∙ Consent issues;

• ∙ The value and role of departmental protocols;

• ∙ The resource implications of ultrasound use.

Skills

• ∙ Integrate PoCUS into departmental continuous quality improvement governance system

Behaviour

• ∙ Adherence to a rule-in philosophy (namely, that a focused ultrasound exam often rules-in a pathology but may be unable to rule it out due to a higher specificity than sensitivity of the application).

Core clinical applications

In general, core clinical PoCUS applications:

• ∙ Are simple to learn, perform and interpret;

• ∙ Are rapid to perform;

• ∙ Answer simple questions, ideally with binary (yes/no) answers;

• ∙ Allow learners to consolidate key ultrasound skills, which provide a solid foundation to their practice;

• ∙ Have significant impact in the area/region being practiced due to burden of disease, local resources or mortality/morbidity considerations.

Examples of recommended core applications include:

• ∙ Basic cardiac

  • ○ Is the heart beating normally?

  • ○ Is there pericardial fluid?

  • ○ Is there an enlarged right ventricle?

  • ○ Is the left ventricle enlarged?

• ∙ Basic trauma/E-FAST

  • ○ Is there free fluid in the pleural/pericardial/peritoneal space?

  • ○ Is there a pneumothorax?

• ∙ Simple assessment of fluid status

  • ○ Is the inferior vena cava (IVC) full or empty?

• ∙ Looking for sites of bleeding

  • ○ Is there an abdominal aortic aneurysm?

• ∙ Simple lung assessment

  • ○ Is there a pneumothorax?

  • ○ Is there pleural fluid?

• ∙ Simple early pregnancy assessment

  • ○ Is there an intra-uterine pregnancy?

• ∙ Simple venous occlusive assessment

  • ○ Is there an occlusive above-knee DVT?

• ∙ Simple procedure guidance

  • ○ Peripheral and central line insertion

Enhanced clinical applications

In general, enhanced PoCUS applications are those that:

• ∙ Are more difficult to learn, perform and interpret;

• ∙ Require prior proficiency in a related more basic core application;

• ∙ Answer more complex questions;

• ∙ Or, they may be simple to learn but have less impact in the area/region being practiced due to different burdens of disease, local resources or mortality/morbidity considerations.

Examples of enhanced applications include:

• ∙ Intermediate and advanced echocardiography

  • ○ Is there valvular disease?

  • ○ Is there a segmental wall motion abnormality in the left ventricle?

• ∙ Advanced trauma

  • ○ Is there solid organ injury?

• ∙ Advanced Lung

  • ○ Are the lungs wet or dry?

  • ○ Is there consolidation?

  • ○ Is there pleural thickening?

• ∙ Comprehensive venous occlusive assessment

  • ○ Is there a below-knee DVT?

Choosing and defining what applications should be included

Principles that can be used when deciding which applications to include as core or enhanced include:consideration for local patterns of disease (e.g., if diagnosis of pleural fluid is required frequently, ensure that this is included in the curriculum in addition to peritoneal and pericardial fluid); and complimenting the skills of the provider, and accommodating their needs (e.g., emergency physicians may not need to learn obstetric applications in some health care systems, whereas in other systems this may be the single most important application).

Applications can be divided by Organ System, Disease System and Procedure Type, and then by Core and Enhanced knowledge. Facilitating a “building-block” approach to PoCUS education by building enhanced applications on the skills learned with core applications.

As such, a beginner may become competent in scanning a particular organ system for simple but important pathology (e.g., pericardial effusion), while an advanced user may develop competency to scan the same organ system for other more complex pathology (valvular pathology). A comprehensive table of applications and suggested curriculum content is provided in Supplementary Table 1.

Training

This section of the curriculum provides an overview of the three essential training steps required for PoCUS for any specific application, namely: initial introduction, gaining experience and achieving competency (see Figure 2). Formalizing these steps into a well-structured training programme improves long term learning outcomes. The final make up of a specific region’s training programme and curriculum will be influenced by local factors/logistics and should therefore be flexible in order to optimally incorporate the three basic learning steps.

Figure 2 Essential Steps in PoCUS Training

Initial introduction

The initial introduction is the first contact session between trainer and trainee, which should focus on the providing the core knowledge of the application, demonstration of the skill and the first time practice under trainer supervision. The formal introductory course is most commonly used but should include reading materials such as online learning, video resources. Simulation or other variations may be used due to local resource and logistical challenges. Recommended teaching formats include:

• ∙ Short lectures,

• ∙ Demonstrations,

• ∙ Hands on skills teaching,

• ∙ Simulation sessions,

• ∙ Open and closed discussions,

• ∙ Passive and interactive web based learning,

• ∙ Practical scanning on real patients.

Gaining experience

Gaining experience should be based on the use of an ultrasound machine on actual patients if possible. The key features of this phase are focused around optimizing the trainee’s skill in:

• ∙ Image acquisition,

• ∙ Image interpretation,

• ∙ Clinical integration.

Image acquisition

We recommend supervision by a clinician trained in PoCUS or by a sonographer while gaining experience in image acquisition. There is no universal number of scans required to achieve competency, as this is operator and situation dependent and may range from 10 to 50 or more scans per application. Accumulation of experience in PoCUS in general is likely to improve skills globally, in addition to gaining experience specific to each particular application. Alternatives to proctored scanning include scanning patients who are undergoing diagnostic imaging (computed tomography scan, formal echocardiogram, or any other imaging test). There are services that will review images for new clinicians for a fee and offer remote mentoring via web based image portals. The increasing wireless capabilities of ultrasound machines mean that images can be transmitted in real time and several studies have demonstrated that streaming to web based interactive portals like Skype, FaceTime, etc. can be ways of getting image feedback and mentoring even if a local expert is not available in one’s own practice environment. However, one must be mindful of not breaching patient confidentiality and adhering to local information governance arrangements.

Finally, there are increasing numbers of simulators that can provide opportunities for practice – especially for scans that are invasive and involve some discomfort to the patient (i.e. transesophageal echocardiography or transvaginal sonography) it may be to the novice scanner’s advantage to practice initially on a simulator.

Image interpretation

Gaining experience interpreting images is part of the process of learning how to obtain a good image. The immediate feedback of formal diagnostic imaging for the patient and the new clinician sonographer can help to confirm initial image interpretation made at the bedside and a new clinician sonographer can gain experience and confidence by utilizing formal diagnostic imaging in the early phase of their training as a check. There are also increasing numbers of on-line and web-based image banks where new clinician sonographer can practice their interpretation skills [see Supplementary Table 1]. Some websites and portals have competency assessment tests that the new clinician sonographer can take to provide evidence to their practice governing board or hospital administration as evidence of their growing competency.

Clinical integration

The trainee should be able to apply the findings of the application to clinical practice. It is essential to understand the clinical question or circumstance. It is also necessary to be familiar with the quoted accuracies in the medical literature as this provides a greater understanding of the limitations or strengths of the application. For example:

• ∙ Highly sensitive tests are good at ruling out pathology (e.g., seeing a normal calibre abdominal aorta from the proximal aspect to the distal bifurcation effectively rules out an abdominal aortic aneurysm);

• ∙ Highly specific tests are good at ruling in pathology (e.g., seeing free intra-peritoneal fluid during a focused assessment with sonography scan (FAST) effectively confirms free fluid is present).

Achieving competency

The final phase is assessment to determine if the PoCUS trainee has achieved competence in performing, interpreting and incorporating the application. There are various methods available to assess competence. Current evidence supports the use of a task specific checklist (unique to each module) and a global rating scale (good clinical practice) irrespective of the assessment method chosen. The curriculum template assessment forms can be adapted and incorporated into local curricula and assessment processes.

These provide the opportunity for local facilities to adapt PoCUS assessment process to their local needs, allowing comprehensive competency assessment and quality assurance.

The assessment tools provided include 2 components (shown in Table 1 and Table 2):

1. 1. Task specific checklists, unique for each module. These should be be compiled using a Delphi methodology amongst experts for a specific ultrasound module.

2. 2. Global rating scale to assess good clinical practice (standard for all modules).

Table 1 Example of image demonstration tasks required for FAST examination

* Adapted with permission from College of Emergency Medicine Emergency Medicine Ultrasound Core (Level 1) competency Workplace Based Triggered Assessment – 2010, Adapted from de Cossart and Fish 2005©

Table 2 Example of global assessment for a PoCUS application

^* Endorsed by the International Federation for Emergency Medicine; Adapted with permission from College of Emergency Medicine Emergency Medicine Ultrasound Core (Level 1) competency Workplace Based Triggered Assessment – 2010, Adapted from de Cossart and Fish 2005©

IFEM recognizes the variation in current methods of certification and credentialing internationally. The application-specific competency based assessment process recommended here provides a flexible yet standardized approach to skills assessment. IFEM does not provide direct certification of competency, rather it supports local assessment in keeping with agreed applications, standards and skill sets. Further examples of assessment documentation can be found in Appendix B.