© 2015, Wiley Periodicals, Inc. DOI: 10.1111/echo.12887
Echocardiography
ORIGINAL INVESTIGATIONS
Training Program for Cardiology Residents to Perform Focused Cardiac Ultrasound Examination with Portable Device Vicente N. Siqueira, M.D., Frederico J. N. Mancuso, M.D., Orlando Campos, M.D., Angelo A. De Paola, M.D., Antonio C. Carvalho, M.D., and Valdir A. Moises, M.D. Cardiology Department, Paulista School of Medicine, Federal University of S~ ao Paulo, Brazil
Introduction: Training requirements for general cardiologists without echocardiographic expertise to perform focused cardiac ultrasound (FCU) with portable devices have not yet been defined. The objective of this study was to evaluate a training program to instruct cardiology residents to perform FCU with a hand-carried device (HCD) in different clinical settings. Methods: Twelve cardiology residents were subjected to a 50-question test, 4 lectures on basic echocardiography and imaging interpretation, the supervised interpretation of 50 echocardiograms and performance of 30 exams using HCD. After this period, they repeated the written test and were administered a practical test comprising 30 exams each (360 patients) in different clinical settings. They reported on 15 parameters and a final diagnosis; their findings were compared to the HCD exam of a specialist in echocardiography. Results: The proportion of correct answers on the theoretical test was higher after training (86%) than before (51%; P = 0.001). The agreement was substantial among the 15 parameters analyzed (kappa ranging from 0.615 to 0.891; P < 0.001). The percentage of correct interpretation was lower for abnormal (75%) than normal (95%) items, for valve abnormalities (85%) compared to other items (92%) and for graded scale (87%) than for dichotomous (95%) items (P < 0.0001, for all). For the final diagnoses, the kappa value was higher than 0.941 (P < 0.001; 95% CI [0.914, 0.955]). Conclusion: The training proposed enabled residents to perform FCU with HCD, and their findings were in good agreement with those of a cardiologist specialized in echocardiography. (Echocardiography 2015;32:1455–1462) Key words: hand-carried ultrasound device, cardiology residents, echocardiography, focused cardiac ultrasound Different types of portable ultrasound devices have been validated for use in cardiology to assess various clinical conditions.1–3 They have shown reliability in analyzing two-dimensional (2D) images, such as cardiac chamber size, left ventricular hypertrophy and function, and pericardial effusion.4–7 Because portable ultrasound devices are easy to carry and simple to use, they may be employed for focused cardiac ultrasound (FCU), potentially reducing the need for regular echocardiograms, lowering costs and helping clinicians with their clinical decision making processes.8,9 For the appropriate use of these devices and to avoid misdiagnosis, professionals who are not specialized in echocardiography should have adequate training.10–12 General instructions, including theoretical and practical training to capacitate physicians to perform cardiac ultrasound Address for correspondence and reprint requests: Vicente N. Siqueira, Rua Napole~ao de Barros, 75 – 2o andar, CEP 04024002 – S~ ao Paulo, SP, Brazil. Fax: 55 11 55725462; E-mail: [email protected]
examinations to achieve specific objectives, have been published, but they do not indicate specific requirements.13,14 Different types of training have been proposed that vary according to the clinical application and duration.15–19 The capabilities of portable ultrasound devices and their potential availability and clinical application suggest their value to general cardiologists for the assessment of cardiological conditions in clinical practice. Thus, hands-on training is needed to obtain adequate images to recognize the most common cardiac abnormalities. The aim of this study was to evaluate a training program for cardiology residents to perform focused cardiac ultrasound with a hand-carried device (HCD) for general application in cardiology. Methods: Residents and Training Program: We included cardiology residents who had already completed a residency in internal medicine without previous experience in cardiac 1455
Siqueira, et al.
ultrasound and who agreed to participate in this prospective and nonrandomized study. The Institutional Research Ethical Committee approved the study. The training consisted of lectures and practice. Initially, there were four 50-minute classes that included topics such as ultrasound imaging and basic Doppler principles, heart anatomy and acoustic windows, chamber size measurements and function, valve morphology and dynamics, pericardial effusion evaluation, the indications and limitations of all echocardiographic techniques, and finally, an interpretation and discussion of normal and abnormal echocardiographic images. The practical training included the observation of complete echocardiograms of regularly scheduled patients evaluated at the echocardiographic laboratory. All of these exams were performed by a cardiologist who was specialized in echocardiography (cardiologist) with experience equivalent to level 3 of the American Society of Echocardiography.20 For other 30 patients who were also evaluated at the echocardiography laboratory, after complete echocardiographic examination with conventional equipment, the cardiologist oriented the resident to obtain imaging planes and to recognize normal and abnormal cardiac structures and functional parameters with the portable ultrasound system (Fig. 1). The training was carried out over 30 days and incorporated into the regular activities of the resident. The residents were trained to analyze 15 parameters (Table I). Furthermore, they were trained to define one single diagnosis that was potentially responsible for the clinical status of each patient or that was clinically relevant. Echocardiography and Interpretation: The resident and cardiologist performed the cardiac ultrasound examinations with a Sonosite Elite or Sonosite Micromax echocardiographic system (SonoSite Inc., Bothell, WA, USA) with a 4-MHz transducer. Only 2D and color flow imaging were used. Learning Assessment: Before and after training, the residents responded to a 24-question test with a total of 50 items. The complete test included 20 theoretical questions with 40 items and four questions with 10 items pertaining to image interpretation (8 video clips and 2 still images). After the training period, an assessment of practical skills was conducted, which included performance assessments for 30 exams of adult patients with a portable system in the following settings: emergency department, cardiac intensive care unit, cardiac ward, and outpatient clinic (Fig. 1). A brief report, including the 15 items and the final diag1456
Figure 1. Protocol flowchart: Sequence of evaluations and training. FCU = focus cardiac ultrasound.
nosis as described above, was prepared specifically for the training and evaluation process. The report prepared by the resident was compared to that produced by the cardiologist. The resident and cardiologist were blinded to one another’s performance and report. The report of the cardiologist was based on images that were also obtained with the portable ultrasound system immediately after the exam performed by the resident. We measured the duration (in min.) of the exam performed by the cardiologist and the resident. The exam performed by the cardiologist was determined inconclusive for a final diagnosis when a fundamental chamber or structure could not be visualized, and the same strategy was used for the 15 items. If the resident could not visualize one item or did not address it in the report, the interpretation was considered incorrect. Statistical Analysis: The categorical data were described as a percentage, and the quantitative variables were reported
Training to Perform Focused Cardiac Ultrasound
TABLE I Parameters Evaluated in Each Structure by Focused Cardiac Ultrasound and Dichotomous or Graded Scale Classification Structure Left atrium Left ventricle
Right atrium Right ventricle Aortic root Tricuspid valve Mitral valve Aortic valve Pericardium
Parameter
Classification
Size Size Thickness Systolic function RWMA Size Size Systolic function Size Regurgitation Calcification Regurgitation Calcification Regurgitation Effusion
Normal or dilatation (mild, moderate, or severe) Normal or dilatation (mild, moderate, or severe) Normal or hypertrophy (mild, moderate, or severe) Normal or dysfunction (mild, moderate, or severe) Normal or abnormal Normal or dilatation Normal or dilatation Normal or abnormal Normal or dilatation None or mild, moderate, or severe None or mild, moderate, or severe None or mild, moderate, or severe None or mild, moderate, or severe None or mild, moderate, or severe None or mild, moderate, or severe
RWMA = regional wall-motion abnormality.
using descriptive statistics. The paired t-test was used to compare the results of the written test before and after training, t-test for exam duration, and the kappa test was conducted to analyze the agreement between the resident and cardiologist for the 15 parameters and the final diagnosis.21 Sensitivity, specificity, and accuracy were used to analyze the performance of the resident on the exam in the identification of the normal or abnormal parameters according to attending cardiologist’s interpretation. The chisquare and Fisher’s exact test were used to identify whether the percentage of correct interpretation of the 15 items by the resident was different across the various settings, between the normal and abnormal items, between valve abnormalities and all other items, and between dichotomous and graded scale items. A P-value of
Echocardiography
ORIGINAL INVESTIGATIONS
Training Program for Cardiology Residents to Perform Focused Cardiac Ultrasound Examination with Portable Device Vicente N. Siqueira, M.D., Frederico J. N. Mancuso, M.D., Orlando Campos, M.D., Angelo A. De Paola, M.D., Antonio C. Carvalho, M.D., and Valdir A. Moises, M.D. Cardiology Department, Paulista School of Medicine, Federal University of S~ ao Paulo, Brazil
Introduction: Training requirements for general cardiologists without echocardiographic expertise to perform focused cardiac ultrasound (FCU) with portable devices have not yet been defined. The objective of this study was to evaluate a training program to instruct cardiology residents to perform FCU with a hand-carried device (HCD) in different clinical settings. Methods: Twelve cardiology residents were subjected to a 50-question test, 4 lectures on basic echocardiography and imaging interpretation, the supervised interpretation of 50 echocardiograms and performance of 30 exams using HCD. After this period, they repeated the written test and were administered a practical test comprising 30 exams each (360 patients) in different clinical settings. They reported on 15 parameters and a final diagnosis; their findings were compared to the HCD exam of a specialist in echocardiography. Results: The proportion of correct answers on the theoretical test was higher after training (86%) than before (51%; P = 0.001). The agreement was substantial among the 15 parameters analyzed (kappa ranging from 0.615 to 0.891; P < 0.001). The percentage of correct interpretation was lower for abnormal (75%) than normal (95%) items, for valve abnormalities (85%) compared to other items (92%) and for graded scale (87%) than for dichotomous (95%) items (P < 0.0001, for all). For the final diagnoses, the kappa value was higher than 0.941 (P < 0.001; 95% CI [0.914, 0.955]). Conclusion: The training proposed enabled residents to perform FCU with HCD, and their findings were in good agreement with those of a cardiologist specialized in echocardiography. (Echocardiography 2015;32:1455–1462) Key words: hand-carried ultrasound device, cardiology residents, echocardiography, focused cardiac ultrasound Different types of portable ultrasound devices have been validated for use in cardiology to assess various clinical conditions.1–3 They have shown reliability in analyzing two-dimensional (2D) images, such as cardiac chamber size, left ventricular hypertrophy and function, and pericardial effusion.4–7 Because portable ultrasound devices are easy to carry and simple to use, they may be employed for focused cardiac ultrasound (FCU), potentially reducing the need for regular echocardiograms, lowering costs and helping clinicians with their clinical decision making processes.8,9 For the appropriate use of these devices and to avoid misdiagnosis, professionals who are not specialized in echocardiography should have adequate training.10–12 General instructions, including theoretical and practical training to capacitate physicians to perform cardiac ultrasound Address for correspondence and reprint requests: Vicente N. Siqueira, Rua Napole~ao de Barros, 75 – 2o andar, CEP 04024002 – S~ ao Paulo, SP, Brazil. Fax: 55 11 55725462; E-mail: [email protected]
examinations to achieve specific objectives, have been published, but they do not indicate specific requirements.13,14 Different types of training have been proposed that vary according to the clinical application and duration.15–19 The capabilities of portable ultrasound devices and their potential availability and clinical application suggest their value to general cardiologists for the assessment of cardiological conditions in clinical practice. Thus, hands-on training is needed to obtain adequate images to recognize the most common cardiac abnormalities. The aim of this study was to evaluate a training program for cardiology residents to perform focused cardiac ultrasound with a hand-carried device (HCD) for general application in cardiology. Methods: Residents and Training Program: We included cardiology residents who had already completed a residency in internal medicine without previous experience in cardiac 1455
Siqueira, et al.
ultrasound and who agreed to participate in this prospective and nonrandomized study. The Institutional Research Ethical Committee approved the study. The training consisted of lectures and practice. Initially, there were four 50-minute classes that included topics such as ultrasound imaging and basic Doppler principles, heart anatomy and acoustic windows, chamber size measurements and function, valve morphology and dynamics, pericardial effusion evaluation, the indications and limitations of all echocardiographic techniques, and finally, an interpretation and discussion of normal and abnormal echocardiographic images. The practical training included the observation of complete echocardiograms of regularly scheduled patients evaluated at the echocardiographic laboratory. All of these exams were performed by a cardiologist who was specialized in echocardiography (cardiologist) with experience equivalent to level 3 of the American Society of Echocardiography.20 For other 30 patients who were also evaluated at the echocardiography laboratory, after complete echocardiographic examination with conventional equipment, the cardiologist oriented the resident to obtain imaging planes and to recognize normal and abnormal cardiac structures and functional parameters with the portable ultrasound system (Fig. 1). The training was carried out over 30 days and incorporated into the regular activities of the resident. The residents were trained to analyze 15 parameters (Table I). Furthermore, they were trained to define one single diagnosis that was potentially responsible for the clinical status of each patient or that was clinically relevant. Echocardiography and Interpretation: The resident and cardiologist performed the cardiac ultrasound examinations with a Sonosite Elite or Sonosite Micromax echocardiographic system (SonoSite Inc., Bothell, WA, USA) with a 4-MHz transducer. Only 2D and color flow imaging were used. Learning Assessment: Before and after training, the residents responded to a 24-question test with a total of 50 items. The complete test included 20 theoretical questions with 40 items and four questions with 10 items pertaining to image interpretation (8 video clips and 2 still images). After the training period, an assessment of practical skills was conducted, which included performance assessments for 30 exams of adult patients with a portable system in the following settings: emergency department, cardiac intensive care unit, cardiac ward, and outpatient clinic (Fig. 1). A brief report, including the 15 items and the final diag1456
Figure 1. Protocol flowchart: Sequence of evaluations and training. FCU = focus cardiac ultrasound.
nosis as described above, was prepared specifically for the training and evaluation process. The report prepared by the resident was compared to that produced by the cardiologist. The resident and cardiologist were blinded to one another’s performance and report. The report of the cardiologist was based on images that were also obtained with the portable ultrasound system immediately after the exam performed by the resident. We measured the duration (in min.) of the exam performed by the cardiologist and the resident. The exam performed by the cardiologist was determined inconclusive for a final diagnosis when a fundamental chamber or structure could not be visualized, and the same strategy was used for the 15 items. If the resident could not visualize one item or did not address it in the report, the interpretation was considered incorrect. Statistical Analysis: The categorical data were described as a percentage, and the quantitative variables were reported
Training to Perform Focused Cardiac Ultrasound
TABLE I Parameters Evaluated in Each Structure by Focused Cardiac Ultrasound and Dichotomous or Graded Scale Classification Structure Left atrium Left ventricle
Right atrium Right ventricle Aortic root Tricuspid valve Mitral valve Aortic valve Pericardium
Parameter
Classification
Size Size Thickness Systolic function RWMA Size Size Systolic function Size Regurgitation Calcification Regurgitation Calcification Regurgitation Effusion
Normal or dilatation (mild, moderate, or severe) Normal or dilatation (mild, moderate, or severe) Normal or hypertrophy (mild, moderate, or severe) Normal or dysfunction (mild, moderate, or severe) Normal or abnormal Normal or dilatation Normal or dilatation Normal or abnormal Normal or dilatation None or mild, moderate, or severe None or mild, moderate, or severe None or mild, moderate, or severe None or mild, moderate, or severe None or mild, moderate, or severe None or mild, moderate, or severe
RWMA = regional wall-motion abnormality.
using descriptive statistics. The paired t-test was used to compare the results of the written test before and after training, t-test for exam duration, and the kappa test was conducted to analyze the agreement between the resident and cardiologist for the 15 parameters and the final diagnosis.21 Sensitivity, specificity, and accuracy were used to analyze the performance of the resident on the exam in the identification of the normal or abnormal parameters according to attending cardiologist’s interpretation. The chisquare and Fisher’s exact test were used to identify whether the percentage of correct interpretation of the 15 items by the resident was different across the various settings, between the normal and abnormal items, between valve abnormalities and all other items, and between dichotomous and graded scale items. A P-value of
