Recommended Standards

ED U/S is still in its infancy in Canada. It is therefore important that our credentialing mechanisms be rigorous. We must also seek to implant the highest standards of quality control and self-policing. CEUS therefore recommends that a physician attain the status of Independent Practitioner (IP) before being allowed to perform ED U/S without supervision.

To become an Independent Practitioner after having taken an introductory ED U/S course, a physician must complete 50 scans of each of the relevant areas. Definitions of an acceptable scan are:

• Heart: entire pericardium visualized to detect pericardial effusion and global activity
• Aorta: vessel visualized from subdiaphragmatic region to bifurcation in transverse view to measure diameter
• Abdomen: hepatorenal and splenorenal interfaces swept to detect free fluid; diaphragm visualized in LUQ
• Pelvis: Pelvis visualized to search for free fluid and uterus visualized to detect intrauterine pregnancy (IUP), defined as:
  1. Yolk sac or fetal pole visualized inside myometrium
  2. Bladder-uterine juxtaposition confirmed
  3. Myometrial mantle of 5 mm (minimum)

These scans can be verified by a CEUS Independent Practitioner or Master Instructor or a radiologist (see bylaws). All of these exams must be directly supervised and clearly positive or negative to count towards certification (indeterminate or inconclusive scans do not count). Upon completion of 50 determinate scans in each area, candidates must successfully pass written, visual and practical exams.

Non-IP's who are performing an exam without supervision can declare positives for the heart, aorta and abdomen. They can NOT declare positives for IUP. Positives declared by non-IP's in a STABLE patient must be confirmed by a formal imaging study as soon as possible. Positives declared in an UNSTABLE patient must be shown to the appropriate surgical consultant for consideration. Negative OR indeterminate scans declared by non-IP's must be documented as INDETERMINATE and the trainee must not draw any conclusions from said scan.

Once a trainee has completed the required 50 scans in the Cardiac, Aortic and Abdominal areas, they may complete their Obstetrical certification by submitting still or video images for later review by their trainer. Such images must show either an empty uterus or all three criteria of an IUP, and must clearly show bladder-uterine juxtaposition. On a still image, the uterine tissue must be clearly outlined and either show an endometrial stripe or all three criteria for an IUP. On a still image of an IUP the narrowest part of the myometrial mantle (which must be at least 5 mm) must be measured by electronic calipers and displayed on the archived or printed image.

It is not necessary to have a minimum number of positive scans during the certification process. The challenge of ED U/S is not image interpretation, because the recognition of true positives is relatively straightforward. Physicians are capable of doing this effectively after a brief introductory course.

The real challenge of ED U/S is image generation, developing the ability to get a clear image on the screen. The certification period serves primarily to ensure that physicians develop sound and effective technique. It also serves to ensure that independent practitioners thoroughly understand the need to reject any substandard image as being inconclusive, and to only declare a scan to be positive or negative when it is incontrovertibly so.

Each center should appoint an Independent Practitioner to act as local QA leader. It is strongly suggested that measures be put in place to proactively encourage excellence in both image generation and interpretation. These QA mechanisms can include direct observation, tape review and having Independent Practitioners actively involved in teaching (supervising >20 scans per area per year).

These standards are the most demanding of any in North America and quite possibly in the world. They were chosen to ensure that the use of ultrasound technology in Canadian Emergency Departments was of the highest calibre.

Physicians with significant prior experience in ED U/S are eligible for reduced training requirements. Such persons are invited to submit their CV to the board for consideration.