Elizabeth F. McIlwain, MHS, RCS, FASE, Chair, Council on Cardiovascular Sonography

In 2005 ASE published “Minimum Standards for the Cardiac Sonographer: A Position Paper.” This guideline addresses credentialing, formal education, technical competence, and continuing education for the sonographer. The ASE supports three primary areas in determining the competence of a sonographer:

• 1.
  

  A sonographer must be credentialed in the specialty in which he or she is working (adult echo, pediatric/congenital echo, vascular technology, etc).

  
  
• 2.
  

  Sonographers must demonstrate/document technical competence in the specialty(ies) in which they are working.

  
  
• 3.
  

  A sonographer must maintain his/her skills through continuing medical education.

So how are these standards applied to new hires in our labs? Assessing formal education pathway, credential, and continuing education status is straightforward. The new sonographer provides information regarding his or her education during the hiring process. New hires are usually required to present proof of a current cardiovascular ultrasound credential. Continuing education status can be assessed by reviewing proof of hours earned via a review of their CEU certificates or by presenting an active status of their cardiovascular ultrasound credentials. However, determining and maintaining technical competence is not quite so clear. How are we training, preparing, and mentoring one of the most valuable resources in the cardiovascular ultrasound lab—the sonographer?

This question has been asked on Connect@ASE several times over the years. The responses are always interesting and varied. The one constant is that a lab should have a process to orient a new sonographer (experienced or a new graduate) to the protocols of the lab and to ensure that the sonographer is competent in the skills and knowledge required to perform the procedures in the lab.

So what would an effective orientation process look like? I queried several of my “echo friends” (friends from large labs, small labs, hospital based, clinic based, academic based) and asked about their procedures for training new hires, I reviewed past discussions on Connect@ASE and I considered the information in the ASE guidelines related to quality and education ( http://asecho.org/qualityeducation/ ) as I attempted to answer the question of what should be considered when developing an orientation/training plan for a new hire. Length of time, method of training/evaluating, and competence determination seem to be the three main areas.

How long should an orientation period be? This could range from 2 weeks to 1 year. It is usually determined by the level of skill and experience of the sonographer, type of education, and the variety and complexity of procedures performed in the lab (transthoracic echo, transesophageal echo, stress echo, etc).

What training and evaluation methods should be used? Training methods typically include a review time, an observation period, and hands-on experience. During the review phase the “knobology” of the ultrasound system, the operation of the PACS system and the procedural protocol are reviewed. This is usually accomplished in a classroom type setting. Once the sonographer has been introduced to the basics of the department he or she move into some type of observation time. A new hire will observe another sonographer (usually a lead sonographer or an Advanced Cardiac Sonographer) performing daily procedures in the lab. This observation underscores the information he or she received during the review phase. At some point in time the sonographer begins performing studies and acquiring hands-on experience with the procedures and protocols of the lab. This hands-on time begins with the trainer in the room and progresses to a review of each study before the patient is released. As the sonographer demonstrates competence, he or she becomes more autonomous. The length of time for this training is definitely impacted by the level of experience of the new hire. Evaluation methods included observation, image and report review, and questioning.

How is competence determined? Determination of competence can be as simple as the sonographer demonstrating he or she can complete the lab protocol to a full review of several studies by the leadership team in the lab (lead sonographer, manager, physician, etc). One interesting idea is that of “mock” studies. This idea may be particularly useful with advanced applications such as left ventricular assist device turndowns, pacemaker optimizations, three-dimensional (3D) volume acquisitions, etc. Competence may also be determined in levels. A sonographer new to the lab could be deemed competent to perform transthoracic echocardiograms and then later go thru training and evaluation for other procedures (transesophageal echocardiograms, stress echocardiograms, etc).

One final thought to consider when developing an orientation plan is the introduction and training of new and/or advanced techniques (3D, speckle-tracking, interventional transesophageal echocardiography, ultrasound enhancement agents, focused echo procedures, etc). The landscape of the echo lab is in flux. New technologies, updated requirements, and general changes in how echocardiograms are ordered are a part of the daily routine. If new and amended procedures are to be effective, a plan for education and training of all sonographers in the lab needs to be in place. Orientation, training, and mentoring of sonographers should not cease when they are released from their probationary periods.

Ultrasound is a unique imaging modality because of its dependence on the technical skills and knowledge base of the sonographer performing the exam. It is important to ensure that the minimum standards for the cardiac sonographer with regard to credentialing, training/education, and competence are supported and maintained in our labs. An important aspect of this is the development of orientation processes that address these areas. If you have a formal orientation process in your lab, that is excellent, and I hope this information has led you to review it. If you do not have a formal orientation program I hope you will begin developing one now.

Special thanks to Deb Agler, Merri Bremmer, Hollie Carron, Karen Chin, Ken Horton, Peg Knoll, Becky Lindquist, Ray Musarra, Sue Philip, and Karen Zimmerman for sharing their experiences and insights on new hire training.