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A Survey of CEUS Education in Sonographer Training Programs: The Well-Opacified and Delineated Road Less Travelled, and Ready to be Taken

2020; Elsevier BV; Volume: 33; Issue: 9 Linguagem: Inglês

10.1016/j.echo.2020.07.010

1097-6795

Sharon L. Mulvagh, Carol Mitchell, Jennifer Bagley, Linda Feinstein, Pam Burgess, Jonathan R. Lindner, Andrej Lyshchik, Matthew Umland, Kathy Kelly, Beverly Gorman,

Cardiac Imaging and Diagnostics

Contrast enhanced ultrasound (CEUS) is a safe, portable, radiation-free imaging tool that produces high resolution, real-time images of the cardiovascular system, tumors, and organ blood vessels. When used during transthoracic echocardiography, CEUS can dramatically improve the detection of functional or structural abnormalities of the left and right ventricles, and enables detection and characterization of cardiac masses. Indeed, for over two decades contrast echocardiography has been considered an essential component for a modern echocardiography laboratory based on its ability to provide unique information that enhances diagnostic performance and reader confidence.1Lindner J.R. A practical approach to contrast echocardiography. American College of Cardiology.https://www.acc.org/latest-in-cardiology/articles/2017/07/10/09/17/a-practical-approach-to-contrast-echocardiographyDate accessed: June 3, 2020Google Scholar However, CEUS procedures are underutilized in clinical practice despite extensive evidence-based professional guidelines supporting appropriate use.2Porter T.R. Mulvagh S.L. Abdelmoneim S.S. Becher H. Belcik J.T. Bierig M. et al.Clinical applications of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography guidelines update.J Am Soc Echocardiogr. 2018; 31: 241-274Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar,3Porter T.R. Abdelmoneim S. Belcik J.T. McCulloch M.L. Mulvagh S.L. Olson J.J. et al.Guidelines for the cardiac sonographer in the performance of contrast echocardiography: a focused update from the American Society of Echocardiography.J Am Soc Echocardiogr. 2014; 27: 797-810Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar Several barriers to broader CEUS use have been proposed3Porter T.R. Abdelmoneim S. Belcik J.T. McCulloch M.L. Mulvagh S.L. Olson J.J. et al.Guidelines for the cardiac sonographer in the performance of contrast echocardiography: a focused update from the American Society of Echocardiography.J Am Soc Echocardiogr. 2014; 27: 797-810Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar including inconsistencies in sonographer training and the logistics of establishing intravenous access and administering approved, commercially available ultrasound enhancing agents (UEAs, sometimes also known as ultrasound contrast agents, or UCAs). The American Society of Echocardiography (ASE) guidelines1Lindner J.R. A practical approach to contrast echocardiography. American College of Cardiology.https://www.acc.org/latest-in-cardiology/articles/2017/07/10/09/17/a-practical-approach-to-contrast-echocardiographyDate accessed: June 3, 2020Google Scholar,2Porter T.R. Mulvagh S.L. Abdelmoneim S.S. Becher H. Belcik J.T. Bierig M. et al.Clinical applications of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography guidelines update.J Am Soc Echocardiogr. 2018; 31: 241-274Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar recommend sonographer-driven decision-making for contrast utilization, and endorse the placement of intravenous access and administration of contrast agents by trained sonographers who have demonstrated competency in these skills. Similarly, the International Contrast Ultrasound Society (ICUS) recommends adoption of scope of practice policies and procedures that permit qualified Diagnostic Medical or Cardiac Sonographers to gain peripheral venous access and administer ultrasound contrast agents when medically indicated, in order to assure equitable access to optimal care and avoid potential negative impact on patient care and outcomes, including unnecessary additional costs, delays, and exposure to ionizing radiation.4International Contrast Ultrasound Society (ICUS)Recommendation: role of qualified sonographers in CEUS.http://www.icus-society.org/wp-content/uploads/2018/08/ICUS-Policy-Statement_-Sonographer-Administration-of-CEUS82139072_8-c.pdfDate accessed: June 3, 2020Google Scholar In order to understand the current status of CEUS training opportunities for sonography students, the ICUS and ASE, in collaboration with the Intersocietal Accreditation Commission (IAC), American Institute of Ultrasound in Medicine (AIUM), Society of Diagnostic Medical Sonography (SDMS) and American Registry for Diagnostic Medical Sonography (ARDMS), undertook a survey of program directors of cardiac, vascular and general ultrasonography schools in the United States. The survey was composed of seven questions as listed in Table 1; three of the questions offered the option to select one response from of a listing of choices, while the remaining four questions offered binary response options (yes/no). Free-form answers were not possible in the survey design, beyond an explanation of “other” possible obstacles to implementing CEUS in their curriculum. The Survey Monkey (https://www.surveymonkey.com) tool was used to create the survey. Invitations to participate in the survey were emailed to approximately 227 program directors of ultrasonography schools.Table 1Survey questions and responsesQuestionnYes, %No, %Does your current curriculum include the practice of contrast enhanced ultrasound (CEUS)?∗1535446Does your program have interest in adding curriculum on CEUS?1498614Does your curriculum train students on IV insertion?ˆ1481882Does your program “certify” students on IV insertion?141595n, number of respondents.Tabled 1Components%nKnowledge of ultrasound agent composition8968Patient selection for ultrasound enhancing agents (clinical indications)6852Contrast agent safety6852Guidelines on CEUS5139Contrast-specific US machine settings4736Methods for contrast storage, preparation, administration4232Live demonstration of CEUS1411n, number of respondents; respondents chose all that applied, so answers do not add to 100%.∗For those answering NO to having CEUS in the curriculum, what are the obstacles to implementation? (N = 68 responses). Open table in a new tab Tabled 1Obstacles%nCurrent educators do not have sufficient expertise7249Lack of teaching resources6846Assumptions that CEUS training will be provided during “internships”2618Time limitations in the current curriculum (no space)2416Other†Other: Majority (70%) reason: “lack of use in area”.1913Perceived lack of importance of CEUS by those who plan curriculum107Lack of interest from past trainees64∗For those answering that their program trains students in IV insertion (N = 24 responses).† Other: Majority (70%) reason: “lack of use in area”. Open table in a new tab Tabled 1Type of training%nDidactic9222Simulation on phantoms6716Instruction on live models215 Open table in a new tab Open table in a new tab n, number of respondents. n, number of respondents; respondents chose all that applied, so answers do not add to 100%. ∗For those answering NO to having CEUS in the curriculum, what are the obstacles to implementation? (N = 68 responses). ∗For those answering that their program trains students in IV insertion (N = 24 responses). There was a high response to the survey with 153 respondents (67% response rate). Fifty four percent of the respondents stated that they currently offer some CEUS training, generally limited to didactic training. Only 18% of respondents offer training on IV insertion, of whom 21% include instruction on live models and 67% on phantoms. In addition, only 5% of sonography programs certify their students on IV insertion. Almost half of respondents indicated they have inadequate resources to include CEUS training in their curriculum, due to one or more of the following reasons: current educators do not have sufficient expertise to provide CEUS education (72%), lack of teaching resources (68%), assumptions that CEUS training will be provided during “internships” (26%), time limitations in current curriculum (24%), perceived lack of importance of CEUS by those who plan curriculum (10%), and lack of interest from past trainees (6%). 13% of all respondents indicated that CEUS is not being used clinically in their area. Despite these deficits, 86% of all respondents stated that they are interested in adding CEUS curriculum to their programs. Survey results are detailed in Table 1. These survey results reflect a clear need for providing enhanced, scalable CEUS educational resources for sonography programs in order to help future sonographers understand basic and advanced CEUS skills and better participate in coordinated care teams. To that end, the six organizations that collaborated on the survey have now formed a Joint Task Force on CEUS Curriculum in Sonographer Schools, with the goal of gathering existing curricular materials and developing further resources for sonographer training programs. Current educational resources are posted on the websites of both ICUS and ASE, and additional educational materials will be made freely available to all sonography school program directors for use as CEUS curriculum modules. In addition, the ASE is working to develop a curriculum for sonography school program directors that will focus on CEUS for echocardiography. These materials will include learner objectives and learning modules with slides and post-activity knowledge-based tests, and sample competency forms to be used (i) in scan labs for practice on an IV arm mannequin, and (ii) for competency evaluations on live volunteers or with patients (depending upon program policies). These efforts are consistent with Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer52013-2015 by the participating organizations as a “jointwork”. Society of Diagnostic Medical Sonography. Scope of practice and clinical standards for the diagnostic medical sonographer April 13, 2015.https://www.sdms.org/about/who-we-are/scope-of-practiceDate accessed: May 20, 2020Google Scholar published in 2015 and developed by representatives from 16 professional organizations. The document supports appropriate education and training so that the sonographer is able to start an IV and administer contrast according to facility protocol (p.4).52013-2015 by the participating organizations as a “jointwork”. Society of Diagnostic Medical Sonography. Scope of practice and clinical standards for the diagnostic medical sonographer April 13, 2015.https://www.sdms.org/about/who-we-are/scope-of-practiceDate accessed: May 20, 2020Google Scholar It also demonstrates that the current scope of practice already includes that sonographers establish intravenous access and administer UEAs. We note that as professional societies develop curricular materials and participate in writing scope of practice documents for sonographers, they also provide feedback to the Commission on Accreditation of Allied Health Education Programs (CAAHEP) Committees on Accreditation. These committees promulgate, review and revise the educational Standards and Guidelines for entry-level sonographers and other health care practitioners. Current CAAHEP Standards and Guidelines for cardiovascular technology (CVT) adult echocardiography recommend,6Commission on Accreditation of Allied Health Education ProgramsStandards and Guidelines for the Accreditation of Educational Programs in Cardiovascular Technology. Commission on Accreditation of Allied Health Education Programs 2016.https://www.caahep.org/CAAHEP/media/CAAHEP-Documents/CVTStandards2015.pdfDate accessed: May 20, 2020Google Scholar, 7Joint Review Committee on Education in Diagnostic Medical SonographyNational Education Curriculum.http://wwwjrcdmsorg/nechtmDate accessed: May 20, 2020Google Scholar, 8Ehler D. Carney D.K. Dempsey A.L. Rigling R. Kraft C. Witt S.A. et al.Guidelines for cardiac sonographer education: recommendations of the American Society of Echocardiograpjy sonographer Training and education Committee.J Am Soc Echocardiogr. 2001; 14: 77-84Abstract Full Text PDF PubMed Scopus (75) Google Scholar and diagnostic medical sonography (DMS) cardiac and pediatric cardiac learning concentrations9Commission on Accreditation of Allied Health Education Programs Standards and Guidelines for the accreditation of Educational Programs in Diagnostic Medical SonographyCommission on Accreditation of Allied Health Education Programs 2011.https://www.caahep.org/CAAHEP/media/CAAHEP-Documents/DMSStandards.pdfDate accessed: May 20, 2020Google Scholar require, that accredited programs teach the appropriate use of CEUS, applications, indications, limitations, and technique. It is recommended that curricular documents have content including: types of CEUS, instrumentation settings, physical interactions, artifacts, patient monitoring, and side effects.7Joint Review Committee on Education in Diagnostic Medical SonographyNational Education Curriculum.http://wwwjrcdmsorg/nechtmDate accessed: May 20, 2020Google Scholar These efforts could benefit from additional statements regarding (i) training and competency to establish intravenous access, administer contrast, and demonstrate proficiency in performance of an echocardiogram with CEUS, (ii) emphasis on collaborative life-long learning for maintenance and augmentation of CEUS skillset as new applications evolve, and (iii) operational team-based workflow where physicians and sonographers work jointly to achieve appropriate use of UEA. It is our collective mission to improve CEUS education for current and future generations of sonographers, so that they may be able to best serve patients by providing optimal echocardiographic and body ultrasound imaging consistent with applicable guidelines. The collaborative Joint Task Force on CEUS Curriculum in Sonographer Schools aims to provide the tools to facilitate this mission.Sharon L. Mulvagh, MD, FASE, Department of Medicine, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada and Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Carol Mitchell, PhD, ACS, RDMS, RDCS, RVT, RT(R), FASE, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin; Jennifer Bagley, MPH, RDMS, RVT, FAIUM, FSDMS, Department of Medical Imaging Radiation Sciences, The College of Allied Health, The University of Oklahoma Health Sciences Center-Schusterman Campus, Tulsa, Oklahoma; Linda Feinstein, JD, Dentons US LLP, Chicago, Illinois; Pam Burgess, BS, ACS, RDCS, RDMS, RVT, FASE, Cardiac Ultrasound Lab, Wake Forest Baptist Health, Winston-Salem, North Carolina; Jonathan R. Lindner, MD, FASE, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Andrej Lyshchik, MD, PhD, FAIUM, FSRU, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Matthew Umland, ACS, RDCS, FASE, Aurora Healthcare, Milwaukee, Wisconsin; Kathy Kelly, MA, MS, American Registry for Diagnostic Medical Sonography (ARDMS), Rockville, Maryland; Beverly Gorman, RDCS, Intersocietal Accreditation Commission (IAC), Elliott City, Maryland.