When the ASE and the American College of Emergency Physicians (ACEP) developed the consensus document on focused cardiac ultrasound (FOCUS), echocardiographers asked the question, “Should we embrace the performance of FOCUS echocardiograms by nonconventional ultrasound imagers”?
Emergency ultrasound performed by physicians other than echocardiographers is far from a new concept. The history of emergency ultrasound dates back to the 1980s. In the 1990s, the American College of Surgeons (ACS) established their Ultrasound Education Program, with the formal development of the National Ultrasound Faculty in 1998. The training of the Focused Assessment with Sonography for Trauma (FAST) examination is well-established, and the ACEP has developed guidelines and an imaging compendium which includes echocardiography.
The development of the FOCUS Consensus guidelines was a major step in defining the role of echocardiography in these settings, and an updated ASE document is nearing completion. The goals of this focused exam are limited: assessment of global cardiac systolic function, identification of ventricular enlargement or hypertrophy, assessment for pericardial effusion, estimation of intravascular volume status, or guidance/confirmation of emergency procedures (pericardiocentesis and pacemaker placement). Any other diagnosis that is incidentally made should be referred for cardiology consultation and/or comprehensive echocardiographic evaluation. FOCUS is performed by a physician trained in this examination and thus avoids the delays, costs, and specialized technical personnel that a time-sensitive or emergency performance of a comprehensive exam would entail. A determination of the need for emergent care or comprehensive echocardiographic examination can frequently be made from this limited assessment.
Point-of-care echocardiography makes sense not only for efficient healthcare delivery, but also for reducing healthcare costs. And the purpose of FOCUS is not to replace the comprehensive echocardiographic examination, but in some cases, to screen for its necessity. However, for an echocardiographer to embrace the performance and interpretation of even limited transthoracic echocardiograms by non-echocardiographers, it would be important to ensure these physicians are well-trained and competent. Toward this end, a collaborative effort among professional societies representing users of FOCUS is needed to develop specific echocardiography training programs similar to those of the American College of Cardiology and ASE, and competence examinations similar to those of the National Board of Echocardiography. The ACEP guidelines currently state, “For general emergency ultrasound competency, a minimum of 150 total emergency ultrasound examinations (with a range of 150–250 cases) is required, depending on the number of core applications being used.” In a center performing a large number of core applications (ie, trauma, pregnancy, abdominal aortic aneurysm, echocardiography, hepatobiliary system, urinary tract, deep venous thrombosis, soft tissue/musculoskeletal, thoracic) and procedures, the number of studies in each area may be less than 15. It would be difficult to accept such limited experience as sufficient training. In addition, the ACEP recommends “at least 10 hours of continuing medical educational credits pertaining to ultrasound activities per credentialing cycle (typically 2 years).” It is unlikely that one afternoon of CME a year could adequately enhance professional development and improve clinical care. The curriculum for FOCUS training as outlined by the ACEP ( Table 1 ) should be taught by physicians who have achieved the highest level of training; however, unlike the ACC and ASE guidelines, there are no “levels” of training defined. Finally, there are no certification examinations for emergency ultrasound, and determination of competence is left up to the program directors or local hospital credentialing committees without standardization. As stated in the ACEP guidelines, “Methods of determining competency include traditional testing, testing using simulator models, videotape review, observation of bedside skills, over-reading of images by experienced sonologists (expert physicians who perform and interpret ultrasound examinations), and monitoring of error rates through a quality assurance process.” But there is no guideline definition of an “expert physician.” The American Institute of Ultrasound in Medicine Training guidelines are more rigorous and closer to what might be acceptable minimum standards ( Table 2 ).
