Editorial II
Ultrasound imaging by anaesthetists: training and accreditation issues
The use of ultrasound imaging is increasing in anaesthesia, critical care and pain management. Many departments will have purchased ultrasound devices, either from charitable funds, or from capital funding to comply with NICE Guidance relating to central venous access.1 However, I suspect that most departments will not have any formalized training programmes, or systems of accreditation. There is little specific guidance from the Royal College of Anaesthetists, or other relevant organizations, regarding the necessary equipment, knowledge base, skills or practical experience that are required before using such technology independently. A notable exception is echocardiography. The Association of Cardiothoracic Anaesthetists, in combination with British Society of Echocardiography, have a published syllabus, stated competencies and a new exam (www.bsecho.org). Other specialties are facing similar issues of ultrasound teaching and accreditation, for example obstetrics and gynaecology, A & E, musculoskeletal services and vascular surgery. There are clinical pressures to use ultrasound to improve diagnostic and interventional procedures. Alternatively there may be financial incentives for clinicians to adopt ultrasound as a fee generating procedure in the private sector. A summary of relevant electronic resources are listed (Table 1).
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In the future, procedures such as central venous catheterization, arterial access, diagnosis of pleural collections, echocardiography, regional nerve blocks and other techniques are likely to be performed routinely by anaesthetists using ultrasound (Table 2). Despite the large number of positive publications in the literature and NICE recommendations, the availability of appropriate equipment and personnel skilled in its use remain patchy in anaesthesia and intensive care practice in the UK. Operator inexperience or the use of unsuitable equipment, particularly in the more challenging patient, may increase rather than decrease complications.2
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As with other computer driven devices, each year ultrasound machines get smaller, cheaper, easier to use and more powerful in terms of image quality. Different clinical applications require varying techniques, ultrasound machines and more specifically probes. Small devices specifically designed for vascular access are generally unsuitable for other applications, for example pleural ultrasonography and drainage. In order to perform vascular access, pleural drainage and limited transthoracic cardiac ultrasound, two or three different probes are required, together with a more expensive multi-purpose machine. The addition of transoesophageal echocardiography (TOE) requires very expensive probes and machines. Vascular access and nerve blockade use similar probes, but the resolution required for imaging smaller nerve bundles demand higher specification and more expensive devices for optimal practice.3 There is a danger that the important issues of equipment maintenance, calibration and replacement/upgrading are ignored when departments other than radiology make a one off purchase. In the UK, the Royal College of Radiologists (RCR) has issued guidance in this area (www.rcr.ac.uk).
The issue of image storage has been largely ignored to date in this context, a position which is unlikely to be tenable in the future. Currently, the majority of use has been as an aid to existing interventional procedures, which would have been performed whether ultrasound was available or not. However, there is an element of diagnosis in all cases, even if this is not the primary aim, for example, during venous access, finding a thrombosed central vein would lead to a requirement to consider more formal imaging, and the need for short or long term anticoagulation. It is not sufficient just to move to a new puncture site and ignore this relevant finding. All scans of the heart, lungs and pleura are performed for diagnostic purposes and the consequences of inaccurate diagnoses are obvious. Indications for echocardiography are well known and examinations range from a limited assessment taking 2–5 min to a full examination of all views with associated measurements taking upwards of 20–30 min. Thoracic imaging is rapidly evolving to include assessment of the size and nature of pleural effusions, the detection of pneumothorax, peripheral pulmonary emboli and other lung pathology.4 5
Images of both normal and abnormal anatomy, plus interventions should be saved in a retrievable format. It would be difficult to defend allegations of misdiagnosis, or complications if no images are recorded but acquired images are very dependent on the skill of the operator. Machines purchased by anaesthetic departments may not include a suitable printer or video recorder, in order to save costs. Modern ultrasound devices are effectively personal computers and can download still or moving images to another computer. However, it requires organization to regularly store such data in a secure area, with a method allowing retrieval up to years later, along with obvious issues of data protection. A range of storage options are available; varying from small thermal printer paper printouts which degrade quickly over time to a fully integrated hospital wide picture archiving computer system.
The speed of acquisition of ultrasound skills outside radiology is starting to be assessed.6–8 It is recognized in the training of radiologists that certain individuals find learning such three dimensional skills easier than others, but formal documentation of such findings are scarce. There are interesting challenges and studies for those with an interest in education and teaching. Parallels with other skills such as fibreoptic intubation exist, where initial usage was confined to a few enthusiasts who subsequently taught others. The physical basis of ultrasound imaging,9 the practicalities of usage and various safety issues are not covered in any depth, in the current FRCA examinations. Courses currently available for anaesthetists tend to be short, based on theoretical classroom teaching, ultrasound anatomy on volunteers and the use of agar ‘phantoms’ to teach needle visualization. There is usually no formal accreditation of attained skills. Alternatively, there are longer courses modelled on training for radiographers, spanning many months either full or part time, with formal accreditation (www.bmus.org) but these are probably impractical, in terms of time commitment, for most full time clinicians.
Advice on training is available from the RCR, who have recently upgraded their document ‘Ultrasound Training Recommendations for Medical and Surgical specialties’ (2005) (www.rcr.ac.uk). This accepts that there is a clinical need for ultrasound services to be provided by non-radiologists. However, there is a caution that training of medical non-radiologists should be adequately funded, and it is emphasized that the use of ultrasound remains highly operator-dependent, despite technological advances. It states that operators are ethically and legally vulnerable if they have not been adequately trained, or use inappropriate equipment. Training requirements are divided into three levels of competency (Table 3). Emphasis is given to theoretical knowledge, practical supervision in the classroom and clinical situation, a named supervisor, formalized assessment, accreditation and revalidation. Most interested practicing anaesthetists are likely to be operating at Level 1 with some practice at Level 2. More specialized areas, like perioperative TOE or complex nerve blocks, might be considered to be within Level 3. It can be debated just how much experience is required for competence at the various levels and within individual anatomical areas of practice. Specified numbers of examinations, both supervised and unsupervised, are listed and run into the hundreds, in order to gain adequate experience of common clinical findings.
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The relevance of the above guidance for anaesthesia, critical care and pain management can be debated. Recommendations are made for urological, gynaecological, gastrointestinal, vascular, breast, thoracic, focused emergency, intensive care and musculoskeletal ultrasound. There is no specific reference to anaesthesia, or pain management. A problem for anaesthetists is that practice is not limited to a single organ system such as vascular. Anaesthetists perform multiple interventional procedures around the body which would require significant knowledge of ultrasound anatomy and techniques if it is to be used. In the intensive care section peripheral nerve anatomy is listed in the knowledge base of skills, as is the use of ultrasound to guide regional anaesthesia. Some areas discussed under the musculoskeletal section would be potentially of interest to the pain specialist, for example, the recognition of nerve entrapment syndromes and other musculoskeletal ultrasound findings, both in health and disease. The syllabus for ultrasound training in critical care is comprehensive, including examinations of the retroperitoneal and peritoneal spaces, the abdominal aorta and upper urinary tract. Basic thoracic and cardiac ultrasound and focused emergency imaging (for bleeding or other fluid collections) are useful starting points for those with an interest.
The practical implications of training large numbers of junior and senior anaesthetists in such skills is formidable, particularly as most have no background in ultrasound techniques. In Leeds, we have approximately 200 consultants and trainees, none of whom, to my knowledge, have any formal accredition in ultrasound use, other than cardiothoracic anaesthetists with echocardiography training. We have attached warning notices on ultrasound machines to try and discourage inexperienced users from having a go. Basic training on applied physics, imaging principles and devices is interchangeable between different areas of practice. The role of laboratory simulators ranging from agar phantoms for needle visualization to computer driven simulators for applied anatomy is evolving.10 11
Radiology departments have problems in maintaining training experience for their own doctors and radiographers, before meeting diverse demands from multiple other specialties. The significant demands, including time commitment, of such programmed training has been demonstrated in obstetrics (www.rcog.org.uk). There are obvious cost pressures in training time, teaching and equipment, which will have to be carried by anaesthetic departments if such techniques are to become mainstream practice.
The RCR recommendations provide useful generic guidance, which will I believe need further refining in years ahead. It would seem sensible for the Colleges and specialist Societies to update these guidelines together in the future. In the meantime clinicians need to be aware of their obligations to ensure that their own knowledge and competencies in these areas are adequate.
Leeds, UK
E-mail: andy.bodenham{at}leedsth.nhs.uk
Acknowledgments
I would like to thank colleagues in anaesthesia, intensive care medicine and radiology for their constructive comments on this editorial.
References
1 National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for central venous catheters (NICE technology appraisal, No. 49). London: NICE. 2002;London NICE
2 Grebenik CR, Boyce A, Sinclair ME, et al. NICE guidelines for central venous catheterization in children. Is the evidence base sufficient? Br J Anaesth 2004; 92:827–30
3 Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth 2005; 94:7–17
4 Beaulieu Y and Marik PE. Bedside ultrasonography in the ICU. Part 1. Chest 2005; 128:881–95
5 Beaulieu Y and Marik PE. Bedside ultrasonography in the ICU. Part 2. Chest 2005; 128:1766–81
6 McCarter FD, Luchette FA, Molloy M, et al. Institutional and individual learning curves for focused abdominal ultrasound for trauma: cumulative sum analysis. Ann Surg 2000; 231:689–700[Medline]
7 Gracias VH, Frankel HL, Gupta R, et al. Defining the learning curve for the Focused Abdominal Sonogram for Trauma (FAST) examination: implications for credentialing. Am Surg 2001; 67:364–8[Medline]
8 Sites-Brian D, Gallagher JD, Cravero J, et al. Learning curve associated with a simulated ultrasound-guided interventional task by inexperienced anesthesia residents. Reg Anesth Pain Med 2004; 29:544–8[CrossRef][Web of Science][Medline]
9 Kremkau FW. Diagnostic Ultrasound: Principles and Instruments 2002; 7th edn Philadelphia WB Saunders
10 Nizard J, Duyme M, Ville Y. Teaching ultrasound-guided invasive procedures in fetal medicine: learning curves with and without an electronic guidance system. Ultrasound Obstet Gynecol 2002; 19:274–7[Medline]
11 Schafhalter-Zoppoth I, McCulloch CE, Gray AT. Ultrasound visibility of needles for regional nerve block: an in vitro study. Reg Anesth Pain Med 2004; 29:480–9[CrossRef][Web of Science][Medline]
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