Minimum Training Recommendations for the Practice of Medical Ultrasound in Europe

The 2 latest additions to the list of minimum training recommendations are published on the following pages. All 12 appendices are available at www.efsumb.org

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Appendix 10: Cranial Ultrasound in Infants

This syllabus is designed to include the whole of cranial ultrasound imaging in infants, not just the ultrasound skills needed on a neonatal intensive care unit. It does not include spinal ultrasound imaging.

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Level 1: Training and Practice

Practical training should involve at least one session per week over a period of no less than 3 months, with approximately five scans per session performed by the trainee (under supervision of an experienced practitioner).
By the end of Level 1 training the trainee should be able to recognise all main pathologies that need urgent assessment on a neonatal intensive care unit.
Different trainees will acquire the necessary skills at different rates, and the end point of the training program should be judged by assessment of competencies, rather than by numbers of scans performed alone. As a guide, a minimum of 200 scans should be undertaken if this is the first practical training module undertaken. For those who are already competent at ultrasound in other body areas a reduced number of scans may be needed to achieve competency.
Examinations should encompass all pathological conditions listed below.
A logbook listing the types of examinations undertaken should be kept.
An additional portfolio containing an illustrated description of 20 cases with which the trainee has been personally involved is a useful record of performance and achievement and a useful educational aid.
Training should be supervised either by a practitioner who has obtained at least Level 2 competence in cranial ultrasound, or by a Level 1 practitioner with at least 2 years' experience of Level 1 practice.
Trainees should attend an appropriate theoretical course and should read appropriate textbooks and literature.
During the course of training the competency assessment sheet should be completed as this will determine in which area or areas the trainee can practise independently

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Level 1: Knowledge Base

"Physics and technology, ultrasound techniques and administration (see Appendix 1)
"Issues of parental information and consent.
"Sectional and ultrasonic anatomy of the brain:
- Sagittal anatomy
- coronal anatomy
- basic transfontanal and near-field scanning
Pathology in relation to ultrasound:
- intracranial haemorrhage
- hypoxic ischaemic change (in full term and premature infants)
- ventricular dilatation
- common congenital malformations

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Level 1: Competencies to be acquired

To be able to:

- perform a thorough ultrasound examination of the brain in different scan planes
- recognise normal anatomy, common normal variants and varying appearances of normal anatomy with gestational age
- recognise varying presentations of pathological processes with gestational and post-natal age
- measure ventricular size and assess variation from normality
- assess obstructive hydrocephalus and monitor progression
- and describe intracranial haemorrhage and assess its extent
- recognise common congenital malformations and refer for appropriate further investigation
- recognise when other imaging modalities are more appropriate than ultrasound
- recognise abnormalities which need referral for scanning by a more experienced practitioner and/
- or further investigation

To be able to use ultrasound in the assessment of patients presenting with:

- prematurity
- fits/apnoea/collapse
- meningitis
- hydrocephalus
- asphyxia (full term and premature)
- other congenital abnormalities

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Level 2: Training and Practice

ractical training should involve at least 1 year of experience at Level 1 with a minimum of one session per week.
A significant number of further examinations should have been undertaken sufficient to encompass thefull range of conditions and procedures referred to below.
A logbook of all examinations undertaken should be kept.
Supervision of training should be by a practitioner who has achieved at least Level 2 competence in cranial ultrasound, has had at least 2 years' experience at that level, and who would normally be of a consultant or independent practitioner status.
A Level 2 practitioner will be able to accept referrals from Level 1 practitioners.

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Level 2: Knowledge Base

Sectional and ultrasonic anatomy

Cerebellum and posterior fossa structures
the basic use of Doppler ultrasound, including spectral, colour and power Doppler
further applications of cranial ultrasound
use of trans-axial ultrasound
assessment of cerebral perfusion

Pathology in relation to ultrasound

an understanding of the role of ultrasound in the context of cerebral asphyxia, abnormal head circumference, congenital abnormalities, non accidental injury and systemic disease

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Level 2: Competencies to be acquired

Competencies will have been gained during training for Level 1 practice, and then refined during a period of practice.
Vascular studies in asphyxia.
Role of ultrasound in the assessment of abnormal head circumference
Recognition of most identifiable congenital brain malformations.
Further assessment of antenatally suspected anomalies.
Identification and location of surface collections.
Appearances of non-accidental injury and the limitations of ultrasound assessment.
Intra-operative ultrasound as appropriate.
Infants with systemic disease (e.g., post-operative or paediatric intensive care).
Competency in reporting results and communicating them to the clinical teams in an appropriate way

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Level 3: Training and Practice

A Level 3 practitioner is likely to spend a significant proportion of his or her time undertaking cranial ultrasound, teaching, research and development and will be an 'expert' in this area.
Practical training should involve at least 2 years of experience at Level 2.
He or she will accept tertiary referrals from Level 1 and " practitioners and will perform specialised examinations.

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Maintenance of skills: All Levels

Having been assessed as competent to practice at Level 1, there will be a need for maintenance of practical skills, by continuing to perform regular ultrasound and update skills. Such further ultrasound practice may be intermittent, but no more that 3 months should elapse without the trainee using his ultrasound skills and sufficient examinations should be performed per year to maintain competency.
In independent practice, a medical practitioner scanning at level 1 should continue to perform at least 100 examinations per year should have regular meetings with imaging colleagues and should have a designated ultrasound practitioner of Level 2 experience or above designated as their mentor.

Practitioners should:

Include ultrasound in their ongoing CME
Audit their practice
Participate in multidisciplinary meetings
Keep up to date with relevant literature

(Tab: Appendix [10], see page XX)

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Maintenance of skills: All Levels

Having been assessed as competent to practice at Level 1, there will be a need for maintenance of practical skills, by continuing to perform regular ultrasound and update skills. Such further ultrasound practice may be intermittent, but no more that 3 months should elapse without the trainee using his ultrasound skills and sufficient examinations should be performed per year to maintain competency.
In independent practice, a medical practitioner scanning at level 1 should continue to perform at least 100 examinations per year should have regular meetings with imaging colleagues and should have a designated ultrasound practitioner of Level 2 experience or above designated as their mentor.

Practitioners should:

Include ultrasound in their ongoing CME
Audit their practice
Participate in multidisciplinary meetings
Keep up to date with relevant literature

(Tab: Appendix [10], see page XX)

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Appendix 11: THORACIC ULTRASOUND

This curriculum is intended for clinicians who perform diagnostic and therapeutic thoracic ultrasound. It includes standards for theoretical knowledge and practical skills. At least level 1 competence should be obtained by anyone performing thoracic scans unsupervised

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Level 1

It is recommended that the trainee should observe 25 thoracic ultrasound examinations and perform (under supervision) at least 100 examinations on normal patients, 50 ultrasound examinations on patients with pleural effusions and 25 thoracocenteses
A minimum of 200 examinations in total are required to acquire the necessary skills; the end point of the training programme should be judged by an assessment of competencies
Examinations should encompass the full range of pathological conditions listed below.
A logbook listing the types of examinations undertaken should be kept.
Training should be supervised either by someone who has obtained at least Level 2 competence in thoracic ultrasound or by a Level 1 practitioner with at least 2 years' experience of Level 1 practice.
Trainees should attend an appropriate theoretical course (at least 15 hrs) and should read appropriate textbooks and literature.
During the course of training the competency assessment sheet should be completed as this will determine in which area(s) the trainee can practise independently.

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Knowledge Base

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Physics and technology, ultrasound techniques and administration Approaches to:

chest wall
pleural space
lung (direct intercostal, abdominal)
mediastinum ( suprasternal, right and left parasternal, posterior paravertebral, supraclavicular, subcostal - approaches)

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Sectional and ultrasonic anatomy

right and left hemidiaphragms
heart
superior and anterior mediastinum (with great vessels and oesophagus)
liver and spleen
chest wall
supraclavicular region
rib and intercostal spaces

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Pathology in relation to ultrasound

pleural effusion
pleural thickening
pneumothorax
chest wall abnormalities
detection of pulmonary lung consolidation ( inflammation, atelectasis, embolism, neoplasm)
paralysed hemidiaphragm
pericardial effusion

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Competencies to be Acquired To be able to:

Recognize the normal anatomy of pleura and diaphragm
Identify the heart, great mediastinum vessels, liver and spleen
Recognize pleural effusion, including the different echogenic patterns
Recognize pleural thickening and its differentiation from pleural fluid
Detection of pulmonary consolidation (inflammation, atelectasis, embolism, neoplasm)
Estimate the quantity of pleural fluid
Perform guided thoracocentesis

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Level 2

Practical training should involve at least 1 year of experience at Level 1 with a minimum of two examinations performed per week.
A further 300 examinations should be undertaken in order to encompass the full range of conditions and procedures listed below.
Supervision of training should be undertaken by someone who has achieved at least Level 2 competence in thoracic ultrasound, has had at least 2 years' experience at that level.
A Level 2 practitioner will be able to accept referrals from Level 1 practitioners.

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Knowledge Base

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Sectional and ultrasonic anatomy

a full understanding of thoracic and diaphragmatic anatomy

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Pathology in relation to ultrasound

"more detailed understanding of pleural disease ( differentiation of pleural thickening including diagnosis of pleural masses)
"differentiation/characterisation of peripheral pulmonary consolidation, lung abscesses and sequestration
differentiation of mediastinal masses ( solid vs. cystic vs. vascular)

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Competencies to be Acquired To be able to:

Perform a comprehensive ultrasound examination of the thorax
Use Doppler ultrasound, including colour and power Doppler in the study of pulmonary , pleural or mediastinal lesions
knowledge about the use if contrast agents
Undertake diagnostic interventional procedures including lung, pleural, mediastinal and supraclavicular nodal biopsy
Perform special therapeutic percutaneous US guided procedures such as catheter drainage of pleural effusion, pleurodesis and instillation of fibrinolytic agents
Recognise abnormalities which are outside his/her experience and refer to a more experienced ultrasound professional.

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Level 3

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Training and Practice

A Level 3 practitioner should spend the majority of their time undertaking thoracic ultrasound or teaching, research and development and will be an 'expert' in this area

He/she will perform special examinations at the leading edge of ultrasound practice (e.g. endoscopic ultrasound including endobronchial examinations)
He/she will accept tertiary referrals from Level 1 and 2 practitioners and will perform specialised examinations (e.g. the use of intravascular contrast agents in evaluating malignancy or pulmonary infarction) as well as performing advanced ultrasound-guided invasive procedures.

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Maintenance of Skills: All Levels

Having been assessed as competent to practise there will be a need for continued medical education (CME) and continued professional development and maintenance of practical skills.
A chest physician specialist will need to continue to perform ultrasound scans throughout the remainder of the training programme. Such further ultrasound practice may be intermittent, but no more than 3 months should elapse without the trainee using his/her scanning skills.
A medical practitioner scanning at Level 1 should perform at least 100 ultrasound examinations per year and have regular meetings with ultrasound /radiological colleagues

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Practitioners should:

include ultrasound in their ongoing CME
audit their practice
participate in multidisciplinary meetings
participate in basic, advanced or/and postgraduate thoracic ultrasound courses
keep up to date with relevant literature