Accreditation in transoesophageal echocardiography

S. J. Wright1, M. J. Barnard1, A. Smith1, B. Martin1, W. Aveling1, S. Anderson2, C. J. Broomhead3, C. Rathwell2, A. J. Crerar-Gilbert4, P. Quinton4, S. J. George5, G. Wright5 and Joint ACTA/BSE TOE Accreditation Committee

1 The Heart Hospital, London, UK 2 St Bartholomew’s Hospital, London, UK 3 The London Chest Hospital, London, UK 4 St George’s Hospital, London, UK 5 Harefield Hospital, London, UK

Editor—We were interested in the editorial by Swanevelder and colleagues1 describing the work of the Association of Cardiothoracic Anaesthetists (ACTA) and the British Society of Echocardiography (BSE) towards developing a UK accreditation process in perioperative transoesophageal echocardiography (TOE). In developing this examination, one of the main objectives of ACTA was to establish a credible and relevant accreditation examination comparable with that which exists in the USA (the National Board of Echocardiography Perioperative Transoesophageal Echocardiography examination). The BSE was approached by ACTA in the belief that a collaborative effort would give strength and credibility to the resulting accreditation process.

While we acknowledge the considerable time and effort expended by the authors and others on this task, we have serious reservations about the nature and content of the outlined accreditation process that has emerged. We recognize that compromises will be necessary in order to produce an outcome that accommodates the diverse backgrounds and practices of those using perioperative echo. However, we believe that the search for common ground has so distorted the original objective of establishing accreditation for perioperative TOE that it now has little relevance to anaesthetists.

Collaboration with other disciplines, such as those within the BSE, is welcome but not if it requires compromise on fundamental issues. Cardiologists and technicians generally rely on echo for diagnostic use, whereas anaesthetists use it predominantly for haemodynamic monitoring and confirmation of structural repair. We should not be worried if our echocardiography training and experience are different. Our skills are complementary to those of cardiologists—not identical or competitive. Clear differences in training and accreditation reflecting these backgrounds have been recognized by the American Society of Echocardiography (ASE)/Society of Cardiovascular Anesthesiologists (SCA) task force on training in perioperative echocardiography.2

We are certainly anxious about the BSE’s stated intention of acting as a guardian of echo standards of practice and of retaining the right to confer, deny and remove accreditation from individuals and institutions.3 4 For perioperative TOE, which is practiced primarily by anaesthetists, this self-regulatory role should be undertaken primarily by anaesthetists, who have a greater appreciation of the different priorities and practicalities of perioperative practice.

The logbook requirements of 150 cases over 18 months are neither realistic nor necessary. The number of TOE studies performed is not an indicator of the quality of those studies. Keeping a logbook should be encouraged and may be useful both in training and maintaining skills. Indeed, anaesthetic trainees are expected to keep logbooks during their training—but a precise number of cases in any specialty is not required as a condition of CCST. A reasonable number of total cases with appropriate mix of type and specialty is a sensible approach that is usually applied.

There are also real practical difficulties with the number of cases demanded. In total, 150 cases over 18 months represents the entire cardiac surgical workload of many anaesthetists, particularly if they also have non-cardiac or intensive care commitments. Few units in the UK have a TOE machine for each theatre; more commonly one machine may be shared between two to three theatres. Given this constraint on machine availability and realistic working conditions and practices, it is quite simply not feasible to perform a TOE examination for every single patient anaesthetized. Additionally, the case mix requirements need to be flexible. Not every anaesthetist will be able to provide the required number of cases of intracardiac masses and adult congenital heart disease. We believe that the logbook requirements should be removed entirely from the accreditation process. The most that is required (if anything) would be to indicate the average amount of experience that is expected from examination candidates—or that correlates with likely success.

With regard to the inclusion of transthoracic echo (TTE), we acknowledge that following vociferous objections from many UK anaesthetists the profile of TTE interpretation in the TOE examination has been considerably reduced compared with the earliest proposals. We accept that TTE can be extremely valuable in perioperative diagnosis and decision making (primarily on ITU), but we would dispute that practical competence in TTE is in any way necessary for competent execution of TOE. Many anaesthetists practice predominantly in the operating theatre with little if any participation in intensive care. It follows that those who do use TTE do so variably and at very different levels. The proposal that up to 100 transthoracic studies may be included in a logbook submission for TOE accreditation is wholly inappropriate; it allows transthoracic echocardiographers with little actual TOE experience to gain recognition in this skill. This does not prevent those who are interested in developing their TTE skills and knowledge from doing so and certifying their skills in the TTE accreditation examination already in existence. Transthoracic echo does not need to be included in the TOE examination questions nor training guidelines. It is simply not part of a TOE accreditation process.

We are practising cardiac anaesthetists, and some amongst us have perhaps the longest experience of perioperative TOE in the UK. We reiterate our respect and acknowledgement of the individual contributions made to this difficult and cumbersome process. Nevertheless, we would ask the editorial authors to reflect on the needs and aspirations of ordinary cardiac anaesthetists and the conditions in which we practice. We would urge them to join us in seeking an accreditation process that is relevant for practising cardiac anaesthetists. To do otherwise risks widespread rejection of the scheme. Most anaesthetists in the UK will be interested and willing to participate in an accreditation process that accredits what they actually do. They do perioperative TOE and want an accreditation in perioperative TOE. We believe that our concerns are shared by many in the field—and would urge them to express their views if this is the case. Our primary motive is to improve perioperative care of the cardiac surgical patient. We lack confidence that the proposed accreditation process is the best means of achieving that goal. Unless substantial modifications are made to the current proposals, we do not intend to participate in the UK accreditation scheme. We will either evaluate the forthcoming European Society of Cardiology initiative or continue with the well-established North American scheme.

S. J. Wright1

M. J. Barnard1

A. Smith1

B. Martin1

W. Aveling1

S. Anderson2

C. J. Broomhead3

C. Rathwell2

A. J. Crerar-Gilbert4

P. Quinton4

1The Heart Hospital, London, UK

2St Bartholomew’s Hospital, London, UK

3The London Chest Hospital, London, UK

4St George’s Hospital, London, UK

Editor—The recent ACTA/BSE statement1 outlining accreditation in transoesophageal echocardiography in the UK represents a lost opportunity for the British cardiac anaesthetic community.

The ACTA/BSE statement has quoted extensively from recent literature that confirms that routine intraoperative TOE has a significant positive impact on the outcome of cardiac surgery. Recent evidence, as quoted, is compelling, such that ‘immediate’ access to intraoperative TOE should be a standard of care in modern cardiac anaesthesia. The days of waiting for an expert to arrive, make a quick diagnosis and leave should be confined to the past. Whether the echocardiographer is a cardiologist, radiologist, or anaesthetist is largely immaterial, providing they possess a clear understanding of the surgery, the bypass procedure, theatre procedures, and the implications and influence of anaesthesia, drugs, and fluids administered (or lost). They quote their own survey results of only 11% (of 53%) of UK intraoperative echocardiography being performed by anaesthetists with accreditation, but it is difficult to see how this number will increase with the stringent conditions they recommend to access accreditation. In fact, it is sure to fall if requirements of ‘150 cases, 18 month duration, and BSE appointed supervisor’ are mandatory. A standard of ‘immediately accessible 24 h intraoperative echo’ will become more remote.

Whilst the joint ACTA/BSE statement has acknowledged the work of our American colleagues they have, incredibly, eschewed the development of the special expertise of perioperative echocardiography and have stated the aim of accreditation to be ‘designed to encompass the needs of every specialty using TOE...’. Echocardiography itself is becoming a family of modalities with separate and common agenda.5 Neither is it relevant to the practising DGH cardiologist to know the latest suture techniques in valve repair, or the influence of anaesthetic drugs and fluids on the image, nor for the perioperative echocardiographer to recognize every rarity in echocardiography. The result is similar to the ASE statement of 1992,6 which so disenfranchised anesthesiologists in the USA, that the perioperative route was initiated by the SCA7 in 1995. Allegations of quality are belied by the real benefits to patients of routine use of intraoperative echocardiography, as quoted.

The American approach has generated worldwide interest and stimulation for perioperative echocardiography and fostered the education and standards of the surgical, cardiological and anaesthetic communities. Few appointments to a consultant (attending) post in cardiac anaesthesia in the USA are possible without certification in echocardiography, and immediate availability of intraoperative echo is part of the cardiac surgical process, an enviable position. The committee must justify why they have dismissed these considerable achievements of our American colleagues, and pursued a course that is less accessible to our anaesthetic community. Whilst the recommended training for the SCA/ASE includes 150–300 cases, the crucial difference is that this is not an exclusion criteria, and no time factor is imposed. This allows many practicing anaesthetists to gain the necessary accreditation without cripplingly unattainable commitments to undertake routine echocardiography in an exercise of number crunching.

There has been recognition that a basic and an advanced level may be required.2 The examination proposed in this Editorial3 is neither basic (or accessible to a majority of potential users) nor is it advanced in perioperative echocardiography. A flawed process (with inadequate consultation of lead practitioners of perioperative echocardiography) combined with a confused objective of the joint BSE/ACTA committee has led to an irrelevant result for the majority of practising perioperative echocardiographers, and does not serve the ACTA community. As the current directors of the oldest course for intraoperative echocardiography in the UK, we will, unfortunately, have to continue to recommend the National Board of Echocardiographers (NBE) (American) examination in perioperative echocardiography, as the appropriate accreditation for our students. The opportunity of a British solution appears to be lost, unless there is a significant overhaul, and we will either await an enlightened EACTA strategy or continue to rely on our American colleagues.

S. J. George

G. Wright

Harefield Hospital, London, UK

Editor—We acknowledge the debate that Wright and colleagues, and George and Wright, bring to the Joint ACTA/BSE accreditation process for transoesophageal echocardiography. However, the UK process is designed to meet the needs of practising cardiac anaesthetists as well as cardiologists, technicians and others involved with transoesophageal echocardiography. It was developed over 3 yr, in consultation with the ACTA membership and EACTA representatives, and with the support of the ACTA and BSE Councils.

The accreditation process reflects the experience of the NBE, borne of collaboration between anaesthetists and cardiologists. The syllabus is of similar breadth and is relevant to the diagnosis and monitoring of conditions seen in perioperative echocardiography. We adopted logbook and supervisor based accreditation as a method of ensuring competency in practice as well as in theory. The NBE has also recently developed a separate board certification process to ‘recognize significant practice experience’ in the candidates who have passed their written examination.

The number of studies required for the logbook was chosen from the minimum recommended by the SCA/ASE training guidelines. We recognize the difficulty some practitioners may have in achieving this in 18 months and will keep it under review. However, we hope that a challenging target may encourage serious engagement with echocardiography and be seen as an advantage. The first logbook to be submitted by an anaesthetist was completed in a period of only 4 months.

We have in preparation a report of the outcomes of the pilot examination held in October 2003 and the candidates’ questionnaire following it. We hope to submit this for publication in the near future.

J. Swanevelder

Leicester, UK

On behalf of the Joint ACTA/BSE TOE Accreditation Committee

References

1 Swanevelder J, Kneeshaw J, Chambers J, et al. Accreditation in transoesophageal echocardiography: statement from the Association of Cardiothoracic Anaesthesists and the British Society of Echocardiography Joint TOE Accreditation Committee. Br J Anaesth 2003; 91: 469–71[Free Full Text]

2 Cahalan MK, Abel M, Goldman M, et al. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists Task Force Guidelines for training in perioperative echocardiography. Anesth Analg 2002; 94: 1384–8[Free Full Text]

3 Leech G. The BSE: from club to professional society. British Society of Echocardiography Newsletter, July 2003; 45: 8

4 Rimington H. Behind the Scenes. British Society of Echocardiography Newsletter, July 2003; 45: 10

5 Thys DM. Clinical competence in Echocardiography. Anesth Analg 2003; 97: 313–22[Free Full Text]

6 Pearlman AS, Gardin JM, Martin RP, et al. Guidelines for physician training in transesophageal echocardiography: recommendations of the American Society of Echocardiography Committee for Physician Training in Echocardiography. J Am Soc Echocardiogr 1992; 5: 187–94[Medline]

7 Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 1996; 84: 986–1006[ISI][Medline]