We sit on the cusp of the POCUS revolution! Though diagnostic ultrasound has been in clinical use for more than half a century, only in the past two decades has miniaturization and affordability put this technology within the grasp of clinicians at the bedside. Not since the stethoscope has the use of a clinical tool become so widespread. In contrast, while incorporating the stethoscope into everyday medicine occurred without a concerted effort toward standardization, POCUS is developing in the context of a worldwide medical community, with practice grounded in scientific evidence. Thus, POCUS education presents an expansive challenge – the task is made more difficult by unique constraints in the critical care setting and a current need for “back-training” of seasoned clinicians. In the last two years specifically, the COVID-19 pandemic has presented additional challenges to POCUS practice and education but also allowed for new insights into the application of modern educational tools. Even though we do not yet know the full impact of POCUS in the acute management of critically ill patients, there is a suggestion of benefit that is likely underestimated. As we navigate this era, there is no “one-size-fits-all” prescription for POCUS education – just as medical practice has shifted to individual-focused care, the same should be true for the training of clinicians in this critical skill. Below, we discuss several of the challenges and solutions we have encountered or expect to encounter in developing POCUS training in the critical care environment.

 

How to get started

 

1. Perform an internal needs assessment

 

A. Expertise, interest, and barriers

The specific needs of a given setting should set the agenda for POCUS training. Many different POCUS exams and curricula are described in the guidelines of major critical care societies. Early in such needs assessment, levels of trainee and faculty expertise will need to be assessed. Surveys and other methods for data gathering can also help identify potential ultrasound champions. An example of such an assessment tool is attached. Using data from such methods and referencing current guidelines, educators can then compile published curricula, courses, and other resources relevant to their training goals. Just as importantly, these assessments should elucidate barriers to training, such as ultrasound machine accessibility, storage and functionality, image storage, or countless other workflow issues that can hamper POCUS education. As learner groups annually change in composition and prior POCUS experience, serial needs assessment enables programs to better adapt their efforts to the variable needs of learners they encounter.

B. Distinguish between standardized curriculum and guidelines

As of 2022, the most recent comprehensive recommendations for critical care POCUS have been outlined by the European Society of Intensive Care Medicine (ESICM) to establish and maintain specific standards. Innumerable curricula and courses exist in live, virtual, or hybrid formats and vary based on the intended learners. Most major societies within Pulmonary and Critical Care Medicine offer such opportunities. These programs provide a content guide, but neither address a particular program’s requirements nor establish best practices for content delivery. In our view, a complete curriculum should be able to provide thorough practice-specific training at all levels of learner experience. What has become clear are the components of such a scaffold:

      • Didactics (with images and including ultrasound basics)
      • Image acquisition (either simulation, live, or both)
      • Image interpretation
      • Image review and feedback

 

2. Curriculum milestones

 

A. Basics, physics, knobology

Clinical ultrasound is based on principles of acoustic physics – understanding these is the first hurdle to developing POCUS skills. Following closely are concepts related to the operation of ultrasound machines, probe handling, and terminology used in image acquisition.  While seemingly mundane and often overlooked due to an enthusiasm for hands-on practice, these concepts are essential in the recognition of sonographic artifacts and image optimization. Overlooking them may lead to misdiagnosis. These skills are challenging to assess in a just-in-time fashion, especially in a critical care setting, and as such, they are often best taught en masse in a didactic format early on in POCUS education. Most professional societies have some online content available to their members. The Society of Point of Care Ultrasound (spocus.org) also has links to several online resources which may be helpful to individual learners or to the institution that may lack resources to create such content. As POCUS instruction becomes integrated into earlier stages of medical education, these basic topics may not require as much focus.

B. Technical skills: probe, machine and patient positioning

Many aspects of critical care require time-sensitive decision-making. These situations lend well to simulated learning, which allows a safe space to train in the practical aspects and refinement of image acquisition and interpretation. This is an important aspect of POCUS education as it enables timely and appropriate assessment in critically ill patient scenarios. Learning modules or sessions can be implemented within a fellowship, in collaboration with other divisions, out-sourced (courses, software, sim-models), or as a blend thereof. They should compound previously emphasized ultrasound basics and knobology.

Hands-on clinical practice in a proctored setting is a logical next step. It may begin with learners observing an advanced practitioner perform the exam, then mimicking the acquisition technique while receiving feedback. Learners may then perform the exam in the critical care setting while under supervision, and subsequently on their own. Review of image acquisition and interpretation can occur either in real-time during supervised learning or asynchronously. During technical skills instruction, at all stages of growth, creating a standard to emphasize exam appropriateness, acquisition, interpretation, and clinical integration is important.

C. Cognitive skills: Interpretation and technique formative assessment

Self-directed learning, participation in didactics, case-based learning, and quality improvement/assurance are all familiar concepts in medical education that can be applied to POCUS education. Primarily this can occur via a process that training programs are familiar with and using previously established guidelines [e.g., Society of Critical Care Medicine (SCCM), ESICM, American Society of Echocardiography (ASE)] as the basis for establishing competency. Collaboration within an institution may be needed and can utilize software such as QPath to asynchronously integrate feedback, from potentially multiple reviewers, while ensuring patient privacy.

D. Defined levels of expertise

Recognizing those within a division with existing expertise should be a part of a needs assessment at any stage. This should include trainees with an interest and/or expertise. It may be necessary to collaborate with experts outside of a program or division, especially in a program’s early stages. Variability in prior education, training and self-directed learning may make any clear-cut delineation of expertise difficult. To scale, growing such expertise may need to be emphasized in addition to leveraging a robust quality assurance process. Ultimately, a needs assessment can better understand how this applies to individual programs. To further define expertise, pathways through CHEST (https://www.chestnet.org/learning/certificate-of-completion/critical-care-ultrasonography) and National Board of Echocardiography – specific for critical care echocardiography (https://echoboards.org/docs/CCEeXAM-Cert_App-2020.pdf) currently exist. A pathway through ESICM is reportedly under development.

 

3. Resource considerations

 

A. Capital

Device availability can reasonably be determined through a needs assessment. Having access to familiar and consistently available devices in a busy clinical environment is essential. The choice of device or devices and other associated software will depend upon needs assessment which should focus on financial and technological considerations, including safe handling of protected health information. Technology and miniaturization have made this process more complicated. Ultimately, weighing costs, accessibility, and capacity for image storage/review against the needs and practice workflow and POCUS education endeavors are important.

B. FTE

Curriculum development and coordination of instruction and assessment is a time-intensive process. Support for faculty efforts in this area is necessary. This may be sought from the hospital, clinical department or division, or from an affiliated academic institution. Additional effort is required to develop clinical workflows, ensure appropriate integration with the EHR, and maintain quality assurance and practice review.

 

4. Challenges and Suggested Solutions

 

A. Disparate learner/instructor schedules, generational learning style differences

Device availability can reasonably be determined through a needs assessment. Having access to familiar and consistently available devices in a busy clinical environment is essential. The choice of device or devices and other associated software will depend upon needs assessment which should focus on financial and technological considerations, including safe handling of protected health information. Technology and miniaturization have made this process more complicated. Ultimately, weighing costs, accessibility, and capacity for image storage/review against the needs and practice workflow and POCUS education endeavors are important.

      • Coordination between instructors and fellowship administration to ensure protected educational time for both the instructors and the learners
      • Software-based collaborative learning platforms
      • Self-directed learning
      • Individualized learning plans (an example is attached)
B. Variable learner skill levels
      • Define requisite prior knowledge based on societal guidelines and anticipated curriculum
      • Standardized learner assessment of knowledge and skill
      • Design curriculum to work from various pre-defined knowledge baselines
      • For learners or faculty with sufficient experience, offer fast-track to teaching or administrative roles
C. Unpredictable ICU environment
      • Intentionally scheduled instruction time separate from clinical time
      • Incorporate instruction time into clinical time, i.e., rounding
      • Ensure ease of image storage and review
      • Share cases and images through presentations at group conferences
D. Lack of clinical expertise in the pracctice
      • Define separate levels of expertise or ultrasound examination scope – see: Kirkpatrick, table 1
      • Collaborate with other departments (Emergency Medicine, Anesthesia, Cardiology, Radiology) or institutions
      • Hire faculty with ultrasound expertise
      • Provide faculty with educational time or CME funds for POCUS training

 

References

  1. Robba et al. 2021. Intensive Care Med. (ESICM recommendations)
  2. Olusanya et al. 2020. Journal of the Intensive Care Society.
  3. Weled et al. 2015. Crit Care Med.
  4. ACGME Program Requirements for Graduate Medical Education in Pulmonary Disease and Critical Care Medicine [IV.B.1.b).(2).(b).(xii), IV.B.1.c).(5).(a)]
  5. Wenger et al. 2020. J Clin Ultrasound.
  6. Kirkpatrick et al. 2020. J Am Soc Echocardiogr.
  7. Brady et al. 2021. Chest.
  8. Jackson et al. 2021. ATS Sch.

 

Phillip J. Gary, MD is a second-year Pulmonary and Critical Care fellow at Mayo Clinic in Rochester, MN. He received his medical degree from Drexel University College of Medicine and completed Internal Medicine residency and chief residency at Lankenau Medical Center. His interests include artificial intelligence applications in critical care research and medical education with a particular interest in ultrasound education.
Alex Vengerovsky, MD is an Intensivist at the University of Washington in Seattle, WA. He received his medical degree from New Jersey Medical School and completed Internal Medicine residency and Critical Care medicine fellowship at Mayo Clinic in Rochester, MN. His academic interests include point-of-care ultrasound and circulatory resuscitation. here
John G. Park, MD is an Associate Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at Mayo Clinic in Rochester, MN. He serves as the Associate Program Director for the Critical Care Medicine Fellowship program and leads the quality improvement programs for the Pulmonary, Critical Care, and Sleep Medicine fellowships.