University of Toronto Interdepartmental Division of Critical Care Medicine
Toronto, Ontario

Program Director: Andrew Steel, MD
Program Type: Critical Care Medicine
Abstract Authors: Alberto Goffi, MD, Warren Luksun, MD, Ghislaine Douflé, MD, Simon Abrahamson, MD

BACKGROUND
The use of Point of Care Ultrasonography (POCUS) has increased dramatically in critical care medicine. Although many organizations provide training standards and guidelines, increased research is needed to refine training requirements. We developed an expanded, multi-system POCUS program to meet these clinical and academic needs.

Our clinical programs include medical, surgical, and subspecialty (cardiovascular, neurosurgical, trauma, ECLS, solid organ/heme transplantation) patients, and, as such, we planned to develop advanced ultrasound modules involving these areas.

One hurdle faced by our program is 5 geographically separate sites. This necessitated developing tools for remote quality control, case reporting, and feedback.

METHODS - EDUCATION
For the past five years, using evidence and guideline based standards for training, we have developed a ultrasound curriculum that incorporates multi-system point of care ultrasonography (Table 1). The current structure includes a Basic (Year 1) and an Advanced (Year 2) program. Both Basic and Advanced programs are longitudinal with concurrent evaluation (Table 2).

Varied educational modalities were incorporated to improve trainee satisfaction and performance. Fundamental theory is taught via didactic lectures and pre-readings. Subsequent skills and knowledge are acquired in hands-on sessions with simulation and standardized patients. Group sessions are provided for image interpretation and bedside technical skills.

Written and performance based examinations are utilized. Multiple choice/short answer exams and script concordance testing are used to evaluate diagnostic and therapeutic integration of ultrasound findings compared to practitioners and experts.

Off-the-shelf, publically available solutions are used to submit saved clips. Portfolio evaluation is conducted by physicians with formal training/certification in echocardiography or POCUS.

RESULTS
This is the fifth year of our program, and 26 fellows are participating this year. Four months into this year’s curriculum, we have completed the introductory workshops and lectures on lung ultrasound and focused cardiac ultrasound (basic left and right ventricular function, pericardium, and fluid responsiveness assessments). Lecture, small group, and workshop attendance exceeds 90%. More than 50% of trainees have uploaded clips and reports for the portfolios.

During the second half of the year, we will focus on image interpretation and bedside and simulated acquisition (supervised and self-regulated). In addition to baseline knowledge testing, trainees have undergone two rounds of script concordance assessment.

We will conduct the certification exam in April 2015. We will use examination results and analysis of portfolios to develop learning curves and understand gains made by trainees.

CONCLUSIONS
Development of a multi-system, point-of-care ultrasonography educational program can be done with a concurrent research program. In addition to entry level ultrasound skills, this program offers a unique opportunity to develop an expanded skillset, including transcranial doppler, optic nerve ultrasound, transthoracic echocardiography, biliary ultrasound, and genito-urinary ultrasound.

The biggest barrier to implementation has been the high ratio of fellows to trained attendings. We will continue to build online content in the form of lectures, cases, exams, and portfolio submission to allow for increased distance supervision, sustainability, and transferability.

Future direction includes collaborating with World Interactive Network Focused On Critical Ultrasound (WINFOCUS) for certification. Accumulated evaluation data can be used to inform future training not only in our institution but also at others. We are specifically interested in the changes in judgment with script concordance test methodology exhibited by trainees as they progress through their fellowship.

Table 1: Components of Basic (Year 1) Program and Advanced (Year 2) Program

Table 2: Longitudinal Curriculum and Evaluation

APPENDIX 1