Point-of-Care Cardiac Ultrasound Training Programme: Experience from the University Hospital Hradec Králové

Point-of-care ultrasound examinations performed by physicians of different specialties are a rapidly growing phenomenon, which has led to a worldwide effort to create a standardised approach to ultrasound examination training. The implementation of emergency echocardiography by noncardiologists is mainly aimed at the standardisation of the procedure, a structured training system, and an agreement on competencies. This article summarises the current training programmes for nonechocardiographers at the University Hospital in Hradec Králové. In cooperation with cardiologists specialised in cardiac ultrasound (ECHO), an extended acute echo protocol dedicated to emergency department physicians was developed and validated in daily practice. According to our retrospective evaluation, after one year of clinical practice, we can confirm that point-of-care ultrasound examinations performed using the standardised limited echo protocol are safe and accurate. The observed concordance with comprehensive ECHO was 78%. This trial is registered with NCT05306730.


Introduction
Point-of-care ultrasonography (POCUS) is defned as the acquisition, interpretation, and immediate clinical integration of ultrasonographic imaging performed by acute care clinicians at the patient's bedside rather than by a radiologist or cardiologist [1,2].With the increasing quality and availability of ultrasound equipment, POCUS is being more widely performed by a variety of specialists [3].Despite the growth in the importance and presumed benefts of POCUS, there is no comprehensive and generally accepted consensus on the required level of investigation at the time of writing this article [1,[4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20].Te absence of a training programme and the introduction of this diagnostic method without clearly defned examination protocols and rules for its use led the Joint Commission on Accreditation of Healthcare Organizations and the Emergency Care Research Institute to identify the adoption of POCUS as a major health technology hazard in 2020 [21].In the same year, a statement on the need for structured educational programmes for POCUS was published by the Ultrasound Working Group of the European Federation of Internal Medicine [22].Additionally, in 2020, the American Society of Echocardiography stated that to ensure high-quality care, cardiologists should be involved in the education and direct training of clinicians who perform cardiac ultrasonography [23].With reference to Dr. Kimura's original work, the diferent levels of cardiac ultrasound examination are described according to the extent of the examination [23,24].Te defnition of these terms is essential to defne a universal POCUS training programme for use across diferent specialties (internal medicine, emergency medicine, intensive care, anaesthesia, etc.).Cardiac ultrasound categories are shown in Table 1.Te fndings of cardiac POCUS should always be evaluated in the context of a comprehensive examination with the awareness of the potential for misinterpretation in view of the known limitations of this method (time constraints, limited patient examinability, examiner experience, etc.) [12,19,25,26].In 2013, the European Association of Cardiovascular Imaging (EACVI) recommended following the ABCD approach when performing emergency echocardiography, which is shown in Table 2 [25,27].

Cardiac POCUS Training Programme in the University Hospital Hradec Králové
In 2020, on the initiative of the physicians of the First Internal Cardiology Clinic and the physicians of the Emergency Medicine Department, a pilot training programme for limited echocardiography was launched for physicians without cardiology qualifcations.Te British Society of Echocardiography (BSE) Level 1 protocol was chosen as the echocardiography training scope, extended by apical twoand three-chamber views and measurement of the tricuspid valve gradient for pulmonary hypertension estimation and the ascending aortic dimension.Color Doppler of the aortic and mitral valves from parasternal long and short axis views and the mitral valve from apical views was also added.Tis protocol was chosen to cover major abnormalities of the right and left ventricles and aortic, mitral, and tricuspid valves to assess pulmonary hypertension and pericardial efusion.It may also raise suspicion of a dissection of the ascending aorta.Te protocol also includes a lung ultrasound (see Figure 1) [28] to assess the most signifcant pulmonary diseases.Te ultrasound training programme consists of the following steps.

2.1.
Step One: Basic Echocardiography Introduction-Teoretical Course.Physicians who had not previously received systematic training in any form of ultrasonography were ofered participation in the training programme.
A three-hour introductory seminar is provided to introduce students to the principles of focused ultrasound examination and the required echocardiography protocol.Te theoretical training includes a presentation of possible pathological fndings on lung ultrasound and their place in the overall examination protocol.For theoretical preparation, a basic textbook on echocardiography is recommended (e.g., Echo Made Easy or Point of Care Ultrasound [29,30]).
Following the introduction, trainees under the guidance of a cardiologist learn how to operate the ultrasound machine to optimise the projection display and archive individual recordings.

Step Two: Training in Clinical Practice. Te actual clinical training takes place at the Department of Emergency
Medicine and the Department of Noninvasive Cardiology of the First Department of Internal Medicine.Under the supervision of trainers, who are board-certifed cardiologists with many years of experience in echocardiography, trainees perform an ultrasound examination of the heart according to a defned protocol.Individual digital images are archived in a central repository.A structured record of each examination is stored in the hospital information system.
Te duration of this phase can vary, and it is necessary for trainees to become familiar with the most common pathologies required for the logbook.Te minimum period of clinical training is three months.

2.3.
Step Tree: Te Final Assessment.Te formal examination takes place in the presence of two cardiologists with extensive echocardiography experience, one holding EACVI accreditation in adult transthoracic echocardiography and the other being profcient in emergency medicine.
Te examination consists of an independently performed echocardiographic examination as per protocol under the supervision of examiners who assess the quality and completeness of the study.Te candidate makes a report based on acquired images, which is scrutinised for accuracy and guidance for the next management of the patient.In the second part, the candidate is presented with a randomly selected echo study based on the protocol.Correct interpretation of the fndings is marked.
In the case of a positive evaluation by both examiners, the trainees receive a certifcate on the successful completion of the course.Based on this, the candidates' personal work competencies are extended by independently performing and reporting on emergency cardiac ultrasound examinations.
To maintain examination quality and competence, a minimum of ffty examinations per year must be documented, and once per year, a four-hour stay at the echo department under the supervision of the supervisor is required to formally verify the maintenance of examination quality.All examinations must be recorded in the hospital information system.

Effectiveness of the Training Programme: Experience after One Year of Practice
In 2022, a total of 560 patients were examined in the emergency department using the limited echocardiography protocol by a noncardiologist who had successfully completed the training programme.Of these, 111 were admitted to the hospital.Full echocardiography examination was recommended by the physician performing the basic echo study in all cases and performed in 69 (62%) of the patients.In this group, the results of both scans were compared with the focus on left and right ventricle dimensions, left ventricle global and regional function, ascending aorta dimension, pulmonary hypertension, signifcant valvular abnormality and assessment of pericardial space, and inferior vena cava dimension assessment.4 Emergency Medicine International fndings resulting in incorrect clinical management.Te comparison was limited by the fact that the mean time diference between basic and comprehensive echo studies was 4.2 days (median 2 days), and the clinical status of some patients varied by hours.We can, however, conclude in retrospect that concordance was found for 78% of the patients examined.In 15 cases (the remaining 22%), a discrepancy was found (1 case of overestimated aorta dimension, 2 cases of overestimated LV function, 1 case of underestimated LV function, 1 case of undescribed PK dilatation, 3 cases of undescribed pulmonary hypertension, 1 case of overestimated and 1 case of underestimated valvular lesion, 1 case of undescribed tricuspid annuloplasty ring, 1 case of suspected LV thrombus that was not confrmed, and 1 case of an undescribed regional wall motion abnormality).Of note, none of these discrepancies would have changed or infuenced the therapeutic management of the patients.

Discussion
POCUS is not defned by the scope of the examination but by the conditions under which the examination is performed and the level of expertise of the examining physician.We believe that it is good practice to teach cardiac POCUS to physicians with a wider range of specialties to ensure safe and confdent use of this examination method in clinical practice.Te scope of the actual examination must always be adapted to the clinical condition of the patient; this is the essence of POCUS.Compared to the established multiday courses for POCUS, the limited echocardiography training programme at the University Hospital Hradec Králové is time-consuming and requires the accessibility of the echocardiography department facilities and the availability of specialist physicians to consult with the candidate regarding their ultrasound fndings.

Limitation of the Analysis.
Te main limitation of this analysis is the fact that the analysed subgroup consisted only of hospitalised patients.Tis may have led to underestimating errors in patients who were discharged due to an unrecognised echocardiographic fnding.Tis limitation will be addressed by the ENDEMIC study.Another limitation is the delay of the supervision examination (4.2 days), during which some fndings could have spontaneously resolved (transient systolic dysfunction, etc.).

Conclusion
Our experience confrms that the concept of sonography training enables physicians of diferent specialties to perform standardised ultrasound examinations that, according to our retrospective evaluation, are accurate and reproducible and meet the requirements for safe use according to the ABCD approach.However, high accuracy alone does not justify the cost of a training programme, and there is currently little to no evidence of the clinical beneft of POCUS echocardiography by noncardiologists.To overcome this lack of evidence in patients with chest pain, the prospective, randomised ENDEMIC trial (NCT05306730) was initiated.
Publication of the study results is anticipated in mid-2024.
suspicious Verifcation of ultrasound fndings in the context of clinical and other paraclinical investigations (C) Comprehensiveness Do as complete examination as suitable (D) Double R-record, review Te study should be recorded and reviewed Source: Neskovic AN, Hagendorf A, Lancellotti P, et al.Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations.Eur Heart J Cardiovasc Imaging.2013; 14 (1): 1-11.
Te study was approved by the local ethics committee.Te main focus was the revelation of unrecognised aortic dilatation, unrecognised or misrecognised signifcant left ventricular dysfunction (left ventricle ejection fraction <40% or focal akinesis), right ventricular dilatation, pulmonary hypertension, signifcant valvular regurgitation, incorrect assessment of the pericardium and inferior vena cava, or any other missed signifcant 2 Emergency Medicine International CCE, critical care echocardiography; POCUS, point-of-care ultrasound; UAPE, ultrasound-assisted physical examination; FOCUS, focused cardiac ultrasound.Source: Kimura BJ.Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside.Heart 2017; 103: 987-994.