The speed of ultrasound

Smaller, more capable and cheaper ultrasound machines have resulted in this imaging modality moving out of the imaging departments and into the hands of clinicians. This has allowed improvements in diagnosis and procedural performance, but comes with the challenges of training and accreditation. The Australian Society of Ultrasound in Medicine (ASUM) has responded to these by creating the CCPU, which is now being revised and enhanced to incorporate an e-learning platform, writes ASUM’s Tanya Carleton, Dr Adrian Goudie, Dr Justin Bowra and Annie Gibbins.
“ In 2012 DOHA awarded ASUM a grant to develop the training, education and qualification of POCUS practitioners.”
The use of ultrasound has undergone dramatic changes in the last decade as a result of technological advances. As the cost and size of ultrasound machines have decreased, the ability to perform diagnostic quality ultrasound has spread rapidly. Ultrasound is now widely available outside imaging departments and is being performed by an ever growing range of specialties. This use is generally limited in scope to answering specific clinical questions or guiding procedures and is referred to as clinician performed or ‘point of care’ ultrasound (POCUS). Many specialist colleges and societies now include ultrasound in their training (for example, emergency medicine, critical care and anaesthesia). Many also recommend ultrasound for the guidance of procedures (e.g. Australian College for Emergency Medicine for central vascular access, and the Thoracic Society of Australasia for chest drains, etc.), as shown in figure 1.
With any changes in practice there are challenges in education and credentialing. ASUM has recognised and responded to these challenges by developing, in concert with expert clinician users, a Certificate of Clinician Performed Ultrasound (CCPU). This qualification is open to doctors who use ultrasound to perform procedures or answer limited clinical questions, as demonstrated in figures 2 and 3. It should be noted that the CCPU is not a specialist imaging qualification (ASUM provides the Diploma of Diagnostic Ultrasound (DDU) for those practitioners who wish to practice specialist imaging).
The Department of Health and Aging (DOHA) has recognised the importance of clinician performed ultrasound and is examining its financial implications. Currently, there are no separate Medicare items for clinician performed ultrasound (although some procedures now require ultrasound guidance). In 2012 DOHA awarded ASUM a grant to develop the training, education and qualification of POCUS practitioners. This grant has allowed ASUM to develop its existing curriculum for education and training and to establish an e-learning platform to meet the needs of POCUS practitioners. The CCPU has developed benchmark standards of education that include: Low instructor:student ratios (1:5), low machine:student ratios (1:5), and the requirement of a clinicians’ involvement in course design and practical training. Experience is gained via performing and recording ultrasound scans in a logbook and training assessments, culminating in a competence assessment prior to being awarded the CCPU. More recent developments include the addition of e-logbooks and changes to ASUM’s logbook assessment system that will speed up logbook processing.
Post qualification competence is maintained with ongoing practice requirements and a CPD system. The ASUM CCPU is a modular qualification. That is, each clinician enrols in those units that most suit their practice. For instance, a Neonatologist will enrol in the neonatal units, while an emergency physician might enrol in a number of different units such as Basic Echocardiography in Life Support and Extended Focused Assessment with Sonography for Trauma (EFAST). Table 1 lists all the ASUM CCPU units currently available, while additional units have been proposed for development.

Table 1.
The complete list of ASUM CCPU units

Abdominal Aortic Aneurysm (AAA)

Above the Knee Deep Vein Thrombosis (DVT)

Acute Scrotum

Advanced Clinician Performed Neonatal Ultrasound

Advanced Early Pregnancy

Basic Early Pregnancy

Basic Echocardiography in Life Support

Basic Gynaecology

Basic Monitoring the Fetus (2nd & 3rd Trimester)

Biliary

Breast

Endocrine

Extended Focused Abdominal Scan for Trauma E-FAST (Trauma)

Hepatic

Introduction to Clinician Performed Neonatal Ultrasound

Lung

Musculoskeletal (MSK)

Physics & Image Optimisation

Pleural Effusion

Rapid Cardiac Assessment (RCA)

Renal Hydronephrosis & Calculi

Rheumatology

Vascular Access

Figure 1.
Real time US guidance improves the safety of bedside procedures. Ascitic tap with needle arrowed.
Figure 2.
Ectopic pregnancy diagnosed in the emergency department allowed direct transfer to hospital with O&G services.
Figure 3.
Diagnosis of dilated cardiomyopathy with apical thrombus in a young breathless patient allowed early appropriate referral.
“CPD opportunities will facilitate the career development of ultrasound professionals within the framework of correct Standards of practice.”
Figure 4.
Dr Sue Campbell-Westerway teaching scanning skills to midwives in Indonesia.
All candidates are required to complete a physics and image optimisation unit to ensure basic principles are well known. In general, each unit consists of:

• An introductory course: Usually 1-2 days, consisting of lectures and practical training sessions.


• 
  Practical experience phase:
  
  
  
  • Logbook completion: A required number of scans (including some abnormal cases) must be recorded and signed off by a suitably qualified assessor.
  
  
  • Two formative (can include assessor feedback) assessments.
  
  
  
  


• Final assessment by an approved assessor.


• Recertification: Every five years. A combination of logbook requirements and continuing education.

ASUM plans to enhance the CCPU structure by developing online materials that will include online assessments of knowledge and image interpretation (in addition to but not replacing practical assessments).
The Certificate of Allied Health Performed Ultrasound is being developed to meet the needs of Allied Health professionals.
ASUM recognises that many allied health practitioners use ultrasound as part of their daily practice, and in some cases ultrasound has become the standard of care for their counterparts overseas. Examples include midwives who use ultrasound to monitor fetal wellbeing (see figure 4), vascular access nurses who perform central venous canulation and PICC (Peripherally Inserted Central Catheter) line insertion, and defence force medics who assess wounded personnel in the field. To meet their needs, steps are underway to create a parallel qualification, the Certificate of Allied Health Ultrasound.
ASUM’s e-Learning portal ‘myASUM’ will have ultrasound resources for all specialties and experience levels!
ASUM is also developing an e-Learning ‘myASUM’ portal to serve the entire ultrasound community. Continuing Professional Development (CPD) points will be offered to members through learning materials such as case studies with still and video images, lecture presentations, links to AJUM and other journals and more. A core aim of ‘myASUM’ is to encourage the correct use of ultrasound imaging equipment and promote benchmark Standards of Practice by featuring resources for practitioners at every level of their training and career in ultrasound. Resources will range from the basics of ultrasound through simpler learning cases to advanced cases for experienced practitioners. CPD opportunities will facilitate the career development of ultrasound professionals within the framework of correct Standards of Practice. The new e-learning content is due to for public release in late August.
Other Growth at ASUM
ASUM is encouraging and developing a number of special interest groups covering the diverse range of ultrasound use, for example a group that will explore expansion of clinician ultrasound education to medical students. Interested parties are encouraged to contact ASUM at ccpu@asum.com.au or visit the website at www.asum.com.au.
Tanya Carleton
Med (Hons), Grad Dip TCM, BSc (Business Admin)
ASUM Education Project Manager
Tanya Carleton is the Education Project Manager at the Australasian Society for Ultrasound in Medicine (ASUM). She is an internationally experienced adult education professional with over 15 years of experience in the healthcare and education sectors. Tanya is currently working with the ASUM team to develop ASUM’s Certificate of Clinician Performed Ultrasound (CCPU).
Dr Adrian Goudie
MBBS, FACEM, DDU
ASUM President
Dr Adrian Goudie is an Emergency Physician at Fremantle Hospital and King Edward Hospital for Women, in Western Australia. He completed his emergency training in Perth before working in Australia, South Africa and the UK, where he began training in ultrasound and echocardiography. His research interests include the use of ultrasound in critical illness and the role of focussed ultrasound in emergency management. He is regularly involved in ultrasound training and education for critical care doctors. He currently chairs the Ultrasound Subcommittee of the Australasian College for Emergency Medicine and is President of the Australasian Society for Ultrasound in Medicine Council and member of the CCPU committee.
Dr Justin Bowra
MBBS, FACEM, CCPU
ASUM CCPU Board Chair
Dr Justin Bowra is a practising senior emergency physician who has been performing bedside ultrasound since 1999. He is the author of Emergency Ultrasound Made Easy (Churchill Livingstone), a member of the ACEM ultrasound committee and the ASUM CCPU Certification Board, and is a foundation member of WINFOCUS (World Interactive Network of Focused Ultrasound). He founded the world’s first training program in nurse-performed trauma ultrasound at Liverpool Hospital (Sydney). He runs the emergency ultrasound programs at Sydney Adventist and Royal North Shore Hospitals.
Annie Gibbins
MEd, Grad Dip Ed, BHlth Sc
ASUM Chief Executive Officer
Annie Gibbins has been the CEO of the Australasian Society for Ultrasound in Medicine since May 2011. She has 25 years experience within the health and education sector and has extensive experience providing high-level advice, leadership and direction in both the public and private spheres. Annie holds a Master of Education (VET), Graduate Diploma of Adult and Vocational Education, Cert IV in Assessment and Workplace Training and Bachelor of Nursing.