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EAE RECOMMENDATIONS

European Association of Echocardiographyrecommendations for training, competence, and qualityimprovement in echocardiography

Bogdan A. Popescu (Chair)1*, Maria J. Andrade (Co-Chair)2, Luigi P. Badano3, Kevin F. Fox4,Frank A. Flachskampf5, Patrizio Lancellotti6, Albert Varga7, Rosa Sicari8, Arturo Evangelista9,Petros Nihoyannopoulos10, and Jose L. Zamorano11 on behalf of the European Association ofEchocardiography

Document Reviewers: Genevieve Derumeauxa, Jaroslaw D. Kasprzakb, and Jos R.T.C. Roelandtc

1‘Carol Davila’ University of Medicine and Pharmacy, ‘Prof. Dr. C.C. Iliescu’ Institute of Cardiovascular Diseases, Sos. Fundeni258, Sector 2, 022328, Bucharest, Romania; 2Department of Cardiology, Hospital de Santa Cruz, Carnaxide, Portugal;3Department of Cardiopulmonary Sciences, University Hospital ‘S. Maria della Misericordia’, Udine, Italy; 4Imperial College,London, UK; 5University of Erlangen, Erlangen, Germany; 6Department of Cardiology, University Hospital Sart Tilman, Liege,Belgium; 7Department of Medicine and Cardiology, University of Sciences, Szeged, Hungary; 8CNR, Institute of ClinicalPhysiology, Pisa, Italy; 9Hospital Vall d’Hebron, Barcelona, Spain; 10Hammersmith Hospital, NHLI, Imperial College, London,UK; 11Hospital Clinico San Carlos, Madrid, Spain

aInserm U886, Universite Claude Bernard, Lyon, France; bDepartment of Cardiology, Medical University of Lodz, Poland; andcDepartment of Cardiology, Thoraxcentre, Erasmus MC, Rotterdam, The Netherlands.

Received 5 September 2009; accepted after revision 10 September 2009

The main mission statement of the European Association of Echocardiography (EAE) is ‘to promoteexcellence in clinical diagnosis, research, technical development, and education in cardiovascular ultra-sound in Europe’. As competence and quality control issues are increasingly recognized by patients,physicians, and payers, the EAE has established recommendations for training, competence, andquality improvement in echocardiography. The purpose of this document is to provide the requirementsfor training and competence in echocardiography, to outline the principles of quality measurement, andto recommend a set of measures for improvement, with the ultimate goal of raising the standards ofechocardiographic practice in Europe.

KEYWORDSEchocardiography;

Recommendations;

Training;

Competence;

Quality

Introduction

Echocardiography has changed the practice of cardiovascu-lar medicine by improving prevention, diagnosis, and man-agement of various cardiovascular disorders. It is the mostcommonly used imaging modality in clinical cardiology,since it allows a comprehensive, immediate assessment ofcardiac and vascular anatomy and function. The availability,portability, non-invasive nature, and cost-effectiveness,together with the wealth of information it provides,render echocardiography the first-choice imaging techniquefor the diagnosis and follow-up of most heart diseases.1,2

During the last decades, echocardiography has enjoyedrapid technological developments, and at present, an impress-ive amount of information can be gathered from differentmodalities (M-mode, two- and three-dimensional, Doppler),approaches (transthoracic—TTE, transoesophageal—TEE,intravascular, epicardial), and applications (e.g. stress andcontrast echocardiography) used to study the heart.However, echocardiography remains largely an operator-dependent technique. A thorough knowledge of cardiovascularanatomy and pathophysiology together with appropriatetechnical skills is required to perform a comprehensive andclinically useful echocardiography study. The required knowl-edge and skill can only be gained through supervised educationand training in an appropriate environment. Previous* Corresponding author. Tel/Fax: þ40 21 3175227.

E-mail address: [email protected]

Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009.For permissions please email: [email protected].

European Journal of Echocardiography (2009) 10, 893–905doi:10.1093/ejechocard/jep151

publications, both from Europe3–5 and from the USA,6,7 havefocused on training requirements for clinical competence inechocardiography.

Purpose

The purpose of this document is to provide criteria fortraining, competence, and quality improvement in modernclinical echocardiography.

Document format

The present document released by the European Associationof Echocardiography (EAE) is developed in accordance withthe principles outlined in the European Society of Cardiology(ESC) Core Curriculum and is intended to complement it bygiving more details on specific, echocardiography-relatedissues.

The ESC Core Curriculum8 defines the different levels ofcompetence on several diagnostic techniques and statesthe level expected for a given area of subject matter.

Level I—experience on selecting the appropriate diagnosticmodality and interpreting results; this level does notinclude performing the technique (e.g. advanced methodsof imaging, such as cardiac magnetic resonance, CMR);Level II—practical experience, but not as independentoperator (the trainee has assisted in or performed theprocedure under the guidance of a supervisor);Level III—able to independently perform the procedureunaided (for the general cardiologist, this includes TTE).

Training

General aspects of training in echocardiography

Irrespective of the echocardiographic modality used, thereis a body of knowledge required by any person involved inperforming or reading echocardiograms. The basic knowl-edge required for competence in echocardiography is sum-marized in Table 1 and presented in detail in the EAE CoreSyllabus for echocardiographers.9

Knowledge of ultrasound physics and principles isparticularly important. Briefly, trainees should have knowl-edge of the properties of ultrasound waves, the elementsof an echo machine, echo image formation, and post-processing.8,9 The trainee should have knowledge of the set-tings and controls of the echo machine and be familiar withtypical artefacts and biological effects of ultrasound.Finally, the trainee should understand the principles ofDoppler echocardiography, being able to choose from thedifferent modalities (pulsed wave, continuous wave,colour, and tissue Doppler) those which apply for adequatemeasurements with specific clinical use.

Training in echocardiography should also include theability to communicate and report echocardiographyresults effectively to healthcare professionals and patientsand to cooperate with interventional cardiologists, electro-physiologists, anaesthesiologists and other physiciansinvolved in emergency medicine and intensive care, andcardiac surgeons.8,10

Over the last years, several echocardiography modalitieshave emerged, each one with specific applications requiringtheir own knowledge and skills and, therefore, training. Thisis the case for stress echocardiography, TEE, and intra-operative echocardiography, echocardiography in congenitalheart diseases (CHDs), contrast echocardiography, three-dimensional (3D) echocardiography, intracardiac and intra-vascular ultrasound.

In recent years, other non-invasive imaging modalities suchas nuclear imaging, CMR, and multi-slice computed tomogra-phy (MSCT) have witnessed a rapid development. Echocardio-graphers should be able to understand the strengths andweaknesses of each of these non-echo imaging modalitiesand to integrate them for better patient management.

Training duration

Recommendations for minimal training requirements(i.e. duration, number of cases) have been previouslypublished.3–7

This writing committee of the EAE recommends two levelsof expertise for training in echocardiography: basic andadvanced. The basic level is meant to be achieved byevery general cardiologist who uses echocardiography totake clinical decisions about patient management. Theadvanced level is addressed to cardiologists undertakingechocardiography as their main subspecialty, who shouldbe able to perform comprehensive echo examinations andprovide pertinent information, allowing other clinicians toaddress patient management.

For each level, minimal requirements for training durationand number of examinations performed are issued. As thereis little evidence base for required duration and number ofstudies, the figures mentioned in Table 2 represent a consen-sus view among the writing committee members, derivedfrom practical experience.

Although recommendations for training duration are usedto facilitate the organization of a focused training pro-gramme, the emphasis remains not on a specific durationof training, but on obtaining the required expertise.Although the number of echo studies in which a trainee par-ticipates is important, the case-mix of patients is equallyimportant and should cover the full range of cardiovasculardiseases (Table 3).

Table 1 Basic knowledge for competence in echocardiography

Ultrasound physics and biological effectsPrinciples of echocardiographic image formation and blood flow/

tissue velocity measurementsMachine settings and instrumentation handling for an optimal

image qualityNormal cardiovascular anatomy, including possible normal

variantsPathological changes in cardiovascular anatomy in different

disease statesNormal cardiovascular physiology and fluid dynamics of normal

blood flowPathological changes in blood flow in different disease statesIndications, contraindications, and appropriateness criteriaAlternative diagnostic techniques for any given situationPotential complications (e.g. for TEE, stress echo, and contrast

procedures)

B.A. Popescu et al.894

Table 3 Case-mix for basic-level training in transthoracic echocardiography

Cardiac disease/clinical scenario Knowledge and skills to be acquired

Valvular heart diseasesAortic stenosisAortic regurgitationMitral stenosisMitral regurgitationTricuspid stenosisTricuspid regurgitationPulmonary stenosisPulmonary regurgitationProsthetic valves

Display views for the diagnosisRecognition of diagnostic featuresEvaluation/quantification of severityDistinction between chronic and acute lesions (regurgitant lesions)Evaluation of the consequences on the size, geometry, and function of the cardiac chambersCriteria and timing for intervention, amenability for surgical repair, and suitability forpercutaneous interventionEchocardiographic (2D and Doppler) findings of normal function and malfunction of biological andmechanical valvesJudge the need for complementary diagnostic approachesDefine the need for regular follow-up studies

Ischaemic heart diseaseMyocardial infarctionIschaemic cardiomyopathy

Recognition of the signs and consequences of myocardial ischaemia and infarctionLocalize segmental wall motion abnormalities in a standardized formatEvaluation of infarct size and the amount of myocardium at riskEvaluation of global and regional LV systolic and diastolic functionDiagnose mechanical complications of MI and their haemodynamic consequencesRecognition of the prognostic implications of structural and functional parameters

CardiomyopathiesDilated cardiomyopathyMyocarditisHypertrophic cardiomyopathyRestrictive and infiltrativecardiomyopathies

Perform a complete M-mode, 2D, and Doppler examination which allows to establish the diagnosis,accurately quantify disease severity, and help to choose the proper therapeutical modalityMake the differential diagnosis of athlete’s heart vs. hypertrophic cardiomyopathyIdentify patients who are appropriate candidates for cardiac resynchronization therapy

Heart failureOutline echocardiographic features of cardiomyopathies, coronary heart disease, valvular heartdisease, myocarditis, constrictive pericarditis, pulmonary hypertension, and other conditionsassociated with heart failureIdentify causes of acute heart failureRecognize the prognostic implications of functional parametersRecognize typical complications in heart failure (spontaneous echo contrast and thrombusformation, pleural effusion, etc.)

HypertensionCalculation of LV mass, relative wall thickness, evaluation of LV geometryAssessment of LV systolic function and diastolic functionEstimation of LV filling pressures

Infective endocarditisEmergency echocardiographySimple CHDsCardiac tumours and massesSources of embolismPulmonary embolismPulmonary hypertensionDiseases of the aortaDiseases of the pericardiumNormal examinations Not more than one-third of total studies

Level III competence in general adult TTE as recommended in the ESC Core Curriculum for general cardiologists.8

Table 2 Training requirements to achieve basic and advanced level of competence

Echocardiographic technique Minimum number of examinationsperformed to become competent

Level ofcompetence

Minimum number of examinationsperformed/year to maintain competence

TTE 350 (basic) III Reasonable exposure750 (advanced) III 100a

TEE 75 (advanced) III 50Stress echocardiography 100 (advanced) III 100

Level III, ability to independently perform the procedure (unsupervised).aDetails from reference 32.

European Association of Echocardiography recommendations 895

For this reason, it is recommended that fellows keep a logbook documenting their direct involvement in echo studies,including specific diagnoses of patients they have examined.

Basic level

A trainee with a basic level of expertise should be able toindependently perform a general TTE examination (level IIIin TTE) according to the recommendations for stan-dardization of performance, digital storage, and reportingpublished by the EAE.10

The trainee should acquire sufficient knowledge and tech-nical ability to be able to answer common clinical questionsand to be helpful in urgent clinical situations.

A 6-month full-time training fellowship in echocardiogra-phy is the minimum recommended training period toachieve the basic level of expertise in TTE. Training timeshould be time-tabled and protected. If this period doesnot allow the trainee to achieve the required number ofexaminations or a well-balanced mix of pathology, the train-ing period should be extended.

During training for the basic level, the number of TTEexaminations performed by a trainee should be at least350.8 This portfolio must be completed within the 6-monthperiod of continuous training. It should include an appropri-ate case-mix as described in Table 3.

It is expected that after successful completion of thistraining level, a trainee should be able to undertake andpass the EAE accreditation examination in TTE. Traineeswill be exposed to TEE and stress echocardiography examin-ations, being able to understand the indications, contraindi-cations, strengths, and weaknesses of these techniques(level I competence). However, they will not be requiredto perform these techniques by themselves.

Thus, the recommended basic-level training correspondsto level III competence in general adult TTE and to level Icompetence in TEE and stress echocardiography.

Advanced level

The advanced-level training in echocardiography is reservedfor trainees who already have the basic level, but who wantto engage in more complex TTE studies and to become fullycompetent (level III) in: special TTE procedures, such as 3Decho, contrast echo, or echocardiography during interven-tional procedures, and also to be able to perform TEE andstress echocardiography independently.

Examples of TTE examinations that require special exper-tise and would be outside the competence of a general car-diologist with only basic echo training are: thecomprehensive haemodynamic evaluation of patients withcomplex valve disease (including full quantitation), theassessment of patients referred for cardiac resynchroniza-tion therapy, and the performance of more complex TTEprocedures (e.g. deformation imaging, detection of subclini-cal disease including cardiomyopathies, eligibility for percu-taneous valve implantation).

The advanced level of training is aimed at acquiring inde-pendence in performing and interpreting TEE studies—minimum 75 independently performed; stress echostudies—minimum 100 independently performed (Table 2).

Competence at an advanced level implies an additionaltraining period in echocardiography of at least 6 months

and performance of 750 TTE studies, beyond those reservedfor the basic level (Table 2).

This higher level of dedicated training should be acquiredin echocardiography laboratories fulfilling the EAE rec-ommendations for advanced accreditation.11

The competence levels for echo practitioners are summar-ized in Table 4.

Training programme

The trainee in echocardiography should follow a structuredtraining programme to address the learning objectives.The training programme should include practical training,theoretical educational activities, and ideally researchactivities. It has to be comprehensive and should include,apart from acquiring knowledge and skills, development ofappropriate behaviours and attitudes.8 For consistency, itis recommended that the programme is completed in asingle accredited centre able to cover the trainingrequirements.

During the training period, trainees should regularlyattend departmental meetings reviewing topics, presenting,and discussing difficult cases, indications, results,procedure-related complications, and comparisons withother modalities (including cardiac catheterization andheart surgery). The trainee should attend at least once ayear a national and/or international accredited echocardio-graphy meeting. It is strongly recommended that the traineeis involved in the research projects of the laboratory.

Self-assessment needs to be emphasized, and web-basedonline educational programmes and products will play animportant role in a fellow’s overall learning experienceduring and after training. The trainee should have sufficientbackground knowledge for each level of training and mustcomplete the required number of echo studies.

Training centres

The EAE has published standards for laboratory accredita-tion in TTE, TEE, and stress echocardiography.11 These rec-ommendations consider two levels of laboratoryaccreditation: standard and advanced, depending on theservices provided, staffing, equipment resources, andother organizational and internal criteria judged as essential

Table 4 Summary of competence levels for echocardiographicpractitioners

Basic echocardiography(corresponds to ESC CoreCurriculum requirements forgeneral training forcardiologists)

Level III competence ingeneral adult TTELevel I competence in TEELevel I competence instress echocardiography

Advanced echocardiography(appropriate for cardiologistswith subspecialty interest inechocardiography)

Level III competence ingeneral adult TTELevel III competence incomplex adult TTELevel III competence inTEELevel III competence instress echocardiography

ESC, European Society of Cardiology; TTE, transthoracic echocardiogra-phy; TEE, transoesophageal echocardiography.


to guarantee suitability for competitive training andresearch.

The echocardiography laboratories in which training isundertaken should fulfil the EAE recommendations, prefer-ably those for an advanced level.11 In particular, the com-mitment of training staff is vital for training quality. Thetrainer should be available to supervise, criticize, andcorrect the performance and interpretation of echostudies and to promote the active participation of traineesin research activities. Furthermore, the training centreshould organize regular educational activities on a weeklybasis.

A training echo laboratory may be autonomous or integratedina cardiac imaging department or in a cardiology department.The presence of a coronary care unit, of other non-invasiveimaging modalities (e.g. nuclear cardiology, CMR, MSCT), aswell as different subspecialties (e.g. interventional cardiology,electrophysiology, cardiac surgery) in the same institutionallows the trainee to be exposed to a full range of techniquesand to relate and confront the echo findings with those pro-vided by complementary techniques.

Ideally, there should be joint educational programmesthat rotate fellows who are training in cardiovascular medi-cine, among echocardiography, nuclear cardiology, CMR, andCT, if these are available.12 The echo laboratory should col-laborate closely with both non-invasive and invasive servicesbecause these approaches are complementary rather thancompetitive.

Transthoracic echocardiography in adult patients

In order to use this powerful technique adequately, criteriafor appropriateness have been published,13 with rec-ommended strengths of indication for specific clinicalscenarios.

As operator dependence is an important issue for echocar-diography, the trainee needs to understand, acquire, anddocument all the standard imaging planes as rec-ommended.10 However, limiting the examination to stan-dard imaging planes may sometimes lead to overlookingimportant pathological findings and/or to reporting inaccur-ate data. It is therefore essential that the echocardiogra-pher is able to adapt the examination on the basis of liveinterpretation of encountered findings. The trainer has akey role in teaching a trainee how to use the transducerappropriately and to understand what represents optimaldata acquisition and technical quality for the individualpatient.

Specific training and competence recommendationsfor special procedures

Transoesophageal echocardiographyTEE provides an excellent window to the heart and greatvessels. The detailed indications, contraindications, risks,and potential complications of TEE have been published indedicated documents14,15 and are beyond the scope of thisdocument.

In order to achieve the advanced level III of competencein TEE, a minimum number of 75 TEE studies performedunsupervised is recommended.

To be eligible for accreditation in TEE by the EAE, docu-mentation within a year of 75 TEE cases for candidatesholding TTE accreditation, and of 125 for those not holding

TTE accreditation, is required. National accreditation orEAE accreditation is required for physicians independentlyperforming and reporting TEE studies.

The specific knowledge and skills required to becomecompetent in safely performing and reporting TEE studiesare mentioned in Table 5.

Ideally, training in TEE should also include exposure tointra-operative TEE (see what follows) and to interventionalTEE. Interventional TEE (e.g. closure of atrial septaldefects, percutaneous mitral balloon valvuloplasty, and per-cutaneous valve implantation) requires a thorough knowl-edge of each particular procedure and its potentialproblems.

Table 5 Knowledge and skills required for competence intransoesophageal echocardiography

KnowledgeBasic general knowledge related to echocardiography (Table 1)Strengths and weaknesses of TEE for a given indicationDifferential benefit compared with other imaging techniques,

in particular TTE and other tomographic techniquesIndications, contraindications, risks, and complications of the

TEE procedureInfection control measures and electrical safety issues related

to the use of TEETechniques and risks of local anaesthesia and sedation;

pharmacology of involved drugsAnatomy of the upper gastrointestinal tract with special

emphasis on potential problems and hazards duringoesophageal intubation

Knowledge of normal and abnormal cardiovascular anatomy onTEE, and of the typical cross-sections used

Ability to communicate examination results to the patient andto other healthcare professionals

SkillsAbility to perform a complete TTE examinationAbility to obtain a focused history of upper gastrointestinal

disordersOperation of the TEE probe and biteguard, including

manipulation of the probe tip and change in imaging planeorientation

Ability to operate the echo machine, including all controlsaffecting image quality

Techniques of oesophageal intubation (both in ventilated andnon-ventilated patients) including sedation techniques,appropriate monitoring, readiness of supportive equipment

Proficiency in cardiopulmonary resuscitationManipulating the probe to generate the necessary imaging

cross-sections for answering specific clinical questionsFamiliarity with obtaining typical sets of imaging and other

data (cross-sections, Doppler data, and others) to beobtained during TEE for specific indications (e.g. search forcardiac source of embolism, prosthetic valve dysfunction,etc.), including intravenous right heart contrast injectionfor shunt detection

Ability to recognize anomalies of cardiac structure andfunction as imaged by TEE, and to recognize artefacts

Ability to perform qualitative and quantitative analyses of theechocardiographic data

Ability to produce a logical and comprehensive written reportof the echocardiographic findings, including the possibleclinical implications

Competence in disinfecting the probe and detecting technicaldefects, in particular in electrical insulation


Intra-operative transoesophageal echocardiographyIntra-operative echocardiography refers to applications ofechocardiography in patients undergoing surgery, whereasperi-operative echocardiography refers to applications ofechocardiography performed during the early post-operativeperiod. Nowadays, these examinations are performed mainlythrough the TEE approach, although epicardial techniquescontinue to have a role during surgery in specific cases.

Intra-operative echocardiography relies on most of theecho modalities used in the non-surgical setting, so pre-viously mentioned requirements for training andcompetence in TEE apply here as well. In addition,intra-operative TEE requires understanding the particularchallenges of the operating theatre environment, takinginto account the variable haemodynamics of patients onand off cardiac bypass, discussing the findings with the sur-geons in an adequate manner, and understanding the surgi-cal procedures including their potential complications,which often require special knowledge of local techniquesand vocabulary. The indications for intra(peri)-operativeTEE have been previously published.16 Results of surgerymay be evaluated by echocardiography, and additional surgi-cal therapy may be performed if deemed necessary on thebasis of the echo results.

In many European countries, the intra-operative TEEstudies are performed by anaesthesiologists with specialtraining in TEE.

Stress echocardiographyThe EAE has recently published an expert consensus state-ment on stress echocardiography.17 The document presentsin detail the different types of stressors and protocols tobe used, the indications and contraindications for eachtype of stress, the diagnostic criteria and prognostic valueof stress echo findings, and the possible complications andadverse events.17

It is not reasonable to begin using stress echocardiographywithout a complete training in TTE, and holding national orEAE accreditation in TTE is highly recommended. The basicskills required for imaging the heart under resting conditionsdo not differ substantially from those required for imagingthe same heart from the same views during stress.However, it has been shown that the interpretation ofstress echo tests by an echocardiographer without specifictraining in stress echo severely underestimates the diagnos-tic potential of the technique.18 To build the learning curveand reach a plateau of diagnostic accuracy, examination of100 stress echocardiography studies was found to beadequate.18

The EAE recommendation is to perform at least 100examinations under the supervision of an expert reader ina high-volume laboratory, ideally with the possibility ofangiographic verification, before starting stress echocardio-graphy on a routine basis.17

To acquire intra-reader diagnostic power and to reduceinter-reader variability, there is no substitute for jointreading stress echo studies with an expert echocardiogra-pher.19 The use of digital images instead of videotapesmay improve agreement,20 although reproducibility isusually poor in patients with resting images of borderlinequality. In patients with a difficult acoustic window, nativesecond harmonic imaging21 and the use of contrast agentshelp improve accuracy and reduce variability.22,23 Trainees

must also learn and understand the safety aspects of stressecho and the importance of appropriately trained staff.

To achieve a versatile diagnostic approach enabling toaddress individual patient needs, it is important tobecome familiar with all types of stressors (pharmacologicaland exercise). However, since difficulty in performance,reading, and safety varies according to patients’ character-istics, type of stress, and protocol used, it is recommendedto begin with those easier and safer and then progress to themore technically demanding and with higher risk.17

Trainees must also understand that for a given diagnosticaccuracy, every observer has his/her own ‘sensitivity/speci-ficity curve’, depending on whether images are aggressivelyor conservatively interpreted as abnormal and so it is impor-tant to use optimal consensus criteria for reading stress echostudies.17,24

The training requirements for competence in stress echo-cardiography are mentioned in Table 2, and the staffrequirements of the stress echo laboratory are presentedin Table 6.17,25,26

Echocardiography for adults with congenital heart diseaseEchocardiography has become the first-choice non-invasivetool in the diagnosis and serial evaluation of infants, chil-dren, and adults with CHD.

To perform TTE in patients with suspected or known CHD,practitioners must know the protocol of standardized analy-sis, crucial when acquiring sequential data.27

The appropriate views, measurements, and the awarenessof possible co-existence of multiple pathologies are all partof training. In adults with poor-quality transthoracic imagesor in instances where better definition of anatomy or flowdynamics is needed, TEE or saline contrast may be helpful.The trainee should have appropriate knowledge of the indi-cations for TEE and contrast studies.

In addition, the limitations of echocardiography and thecomplementary role of other imaging techniques (e.g.

Table 6 Staff requirements for stress echocardiography

Training requirements for performance and interpretation ofstress echocardiographyUnderstanding the basic principles, indications, applications,

and technical limitations of echocardiographyLevel III training in TTESpecialized training in stress echocardiography with

performance and interpretation of 100 or more stress studiesunder appropriate supervision by an echocardiographer withlevel III of competence in stress echocardiography

Maintenance of competence in stress echocardiographyPerformance and interpretation of 100 or more stress studies

per yearParticipation in continuing medical education in

echocardiographyAt least two persons are required to record and monitor stress

echo studies. One should be qualified in advanced lifesupport, the other in basic life support. A nurse should

always be present to support the physician performing the testIf the study is performed by a sonographer/technician, a

physician with expertise in both echocardiography andresuscitation should be always attending in case a life-threatening complication occurs


assessment by CMR of right ventricular size and function)have to be known. Adult cardiologists with basic trainingin echo (level III in general TTE) should be able to recognizebenign developmental variants and common congenitalheart defects (e.g. isolated atrial and ventricular septaldefects, patent ductus arteriosus, isolated congenitalvalve disease, subaortic membrane, coarctaction of theaorta, transposition of great arteries, tetralogy of Fallot,Ebstein’s anomaly, persistent left superior vena cava),define the need and appropriate frequency of follow-upstudies, and evaluate the need for surgical or percutaneousintervention.

Contrast echocardiographyAgitated saline has been used for a long time as an echo con-trast agent (e.g. to assess for the presence, size, and func-tional relevance of an inter-atrial shunt in patients withsuspected patent foramen ovale). The introduction of trans-pulmonary intravenous contrast agents has improved theassessment of LV structure and function.

The EAE has recently published recommendations for theclinical use of contrast echocardiography.23 The documentdescribes in detail the characteristics of currently availablecontrast agents, the contrast imaging modalities, the indi-cations, clinical efficacy, and the safety of contrast agentsused in echocardiography.

Before using contrast agents, physicians and sonographersmust have acquired basic training and preferably alsoaccreditation in TTE. Those planning to use contrastagents during stress echocardiography must be accreditedor at least must have undergone appropriate training instress echocardiography. Beyond training in resting andstress echo techniques, the use of contrast agents requiresa level of experience acquired under appropriate supervi-sion. Everyone involved in contrast echocardiographyshould be competent in the administration of contrastagents, should know the indications and contraindications,and should be able to manage adverse events.23 Experiencewith contrast agents for LV opacification is a prerequisite formoving on to the assessment of myocardial perfusion.

Competence

Requirements for competence in different echocardiographytechniques, together with the minimal training require-ments, have been discussed in the previous section. Thissection presents the general principles of assessing compe-tence, maintaining competence, and the current status ofthe EAE accreditation and re-accreditation for variousecho modalities.

Proof of competence: accreditation

Although in theory completion of an appropriate trainingprogramme should ensure competence, all systems need tohave additional checks. Furthermore, individual compe-tence cannot be distinguished from the competence of theteam and facilities around them. This link is illustratedboth in the fact that laboratories applying for EAE accredita-tion must have evidence that their sonographers are accre-dited11 and equally in the fact that the American system foraccreditation of echo laboratories requires submittedsamples of each individual’s work as part of the

assessment.28 Therefore, the assessment of competencerequires evaluation of the knowledge and skill of the individ-ual, and the echo laboratory within which they work.

Proof of individual competence

Competence requires assessment that the candidate hasappropriate knowledge, skills, and attitudes6,8 and ismeasured in a combination of three ways:

(a) evidence (statements or testimonials) by trainers andsupervisors;

(b) knowledge-based assessments (examinations);(c) evidence of practical ability (log books and practical

assessment).

(a) Letters of reference and simple verification of subspe-cialty training may not be adequate substitutes for indepen-dent evaluation of an echocardiographer’s skill andexpertise. The ideal way of assessing the competence ofan individual is by direct observation while performing theexamination, using the directly observed procedural skillsassessment.29

Therefore, the importance of trainers and supervisorscannot be underestimated. The supervisor should holdnational and/or EAE accreditation and would usually bethe director of the laboratory in which training wasundertaken.

At the end of the training, the supervisor will be asked tostate (testify) that the candidate has

(i) undergone a programme of training;(ii) achieved appropriate competence.

(b) As a method of assessment, examinations are muchcriticized and do indeed have many faults. They mainlytest factual knowledge. However, they are widely accepted,validated, and very widely used in assessment processes.

In echocardiography, questions should test theoreticalknowledge and also the interpretation of images shown tothe candidates. Images can be collated within a case study(most useful for TTE) or shown as single independentimages (method used for TEE).

Therefore, as part of the assessment of competency usedto award EAE accreditation, candidates will undertake amultiple choice question examination:

(i) 100 items testing theoretical knowledge;(ii) 50 items testing the ability to interpret images from

echo studies.

Although the examination has a projected pass mark, it isappropriate that this can be adjusted by the examinationcommittee after each examination on the basis of a combi-nation of methods including benchmarking against a panel ofexperts and benchmarking against cohorts of candidates(who tend to have a consistent range of competence)derived from item response statistics.

The examination should be constantly revised andevaluated.30,31

(c) The very practical nature of echocardiography meansthat a practical element to assessment is necessary.Although this could be entirely provided by the supervisor’s


statement/testimonial (American NBE/CCI/ARDMS system),there are strong arguments for including it in the assessmentprocess (the EAE accreditation process).

A log book allows the assessors to review the range ofwork undertaken by the trainee and by analysis (grading)of reports achieve an assessment. An additional or alterna-tive approach is to ask the candidate to submit samples oftheir work electronically on a disc or via the web. Thismust be done within local data-protection regulations. Thestudies can again be graded. In both cases, it is importantthat grading is objective and reproducible and this requirestraining and quality control processes to be in place.

The practical element for EAE accreditation consists ofsubmission of a log book of cases (250 for TTE, 125 forTEE, unless candidate already has TTE accreditation where75 suffice, 250 for CHD echocardiography) performed bythe candidate within a 12-month period after passing thewritten examination. The case-mix is proscribed to coverthe range of pathologies normally seen.

Previously, a random sample of 15 cases drawn from thelog book were graded by two examiners. However, an elec-tronic log book has been introduced for TTE in 2009 and isplanned for TEE in 2010. This involves submission of sixstudies covering a range of key pathologies and a fullrange of echocardiographic views and modalities. The candi-date uploads the studies into the web-based system at theHeart House (still frames and clips, properly anonymized)together with his reports for those studies. This electroniclog book is then marked by independent EAE graders.32

In combination, the supervisor’s statement, completion ofthe written examination, and practical log book provideevidence of competence and the award of accreditation bythe EAE.

Maintenance of individual competence

Re-accreditationOngoing competence cannot be assumed in the practice ofechocardiography. Its practical nature and the constantdevelopment of new techniques require ongoing practiceand learning to maintain competence. This is an importantaspect of quality control in echocardiography.

Numbers alone may be a poor guide, but there is no otherpracticable system short of asking practitioners to retakeknowledge-based and practical assessments at regular inter-vals. Most systems for re-accreditation combine require-ments for ongoing practice with the obtaining of creditsfor continuing education through attendance at relevantmeetings or other continuing learning activities.28,32

Further inclusion of a requirement to participate in aquality control (assurance) programme is included withinsome systems. Health systems where physicians largelyreport studies performed by sonographers may distinguishbetween the numbers of studies reported and studies per-formed for ongoing competence.

Although award of EAE accreditation is valid for 5 years,re-accreditation requires evidence of continuing practice(statement from laboratory head or assistant) and also evi-dence of CME activity (e.g. certificates of attendance).

The basic requirements for EAE re-accreditation in TTEare:

† 250 studies per year and 40 h of CME (high-volume appli-cants), or

† 100 studies per year and 50 h of CME (low-volumeapplicants).32

Laboratory accreditationIn determining the quality of an echocardiographic labora-tory, criteria have been established. There are large pro-grammes for laboratory accreditation in Europe11,32 andthe USA.28 The main areas assessed are:

† facilities (environment and equipment);† work flow;† education and training;† quality assurance.

Separate criteria exist for TTE, TEE, and stress echocar-diography, and the EAE system has two levels, standardand advanced, the latter applicable to laboratories offeringinternationally recognized training and research.

In summary, the EAE requires candidates to undertake asupervised programme of training in a suitable echo labora-tory and to demonstrate knowledge through a written exam-ination and skill through submission of a log book of echostudy reports.

Quality improvement

Despite the fact that ensuring a high level of quality hasbecome an important issue for patients, physicians, andpayers, relatively limited attention has been focused onmeasures of quality control and quality improvement inechocardiography.

Principles of quality measurement

At present, quality assessment of echocardiography servicesin Europe occurs almost exclusively through voluntaryaccreditation. Both the American Society of Echocardiogra-phy, through the Intersocietal Commission for the Accredita-tion of Echocardiographic Laboratories,28 and the EAE haveintroduced accreditation both for individuals30–32 and forechocardiographic laboratories.11,32 However, it is clearthat quality measurement and monitoring are neededbeyond accreditation because accreditation typicallyreflects conditions during a snapshot in time and it wouldbe desirable to implement continuous monitoring forquality control and improvement.33

Assessing quality in echocardiography

The first step is to create specific quality measures.34 TheEAE model consists of four distinct domains which may influ-ence clinical outcome: patients’ selection, study perform-ance, interpretation, and reporting (Figure 1). Laboratoryinfrastructure (logistics, equipment, staffing) and organiz-ation (procedures and protocols) influence and supportthese four domains.

† The first step to a high-quality echocardiographic serviceis to ensure appropriate patient selection for a particularecho modality on the basis of evidence or consensus that


it is reasonable, cost-effective, will affect patient man-agement, and will lead to clinical benefit.

† The second step is study performance using adequateequipment,11 accredited sonographers and phys-icians,11,31 to obtain complete and accurate informationrelated to the clinical questions.10 All the studies needto be recorded, ideally in digital format.10

† Images and tracings are assessed qualitatively and quanti-tatively in an accurate way.

† Finally, a report should be timely issued in a clear,concise, and clinically oriented manner in order toaddress further patient management and ultimatelyimprove outcome. Study and previous report archivingand retrieval procedures are part of the latter step.

Quality measures are proposed for each step of the frame-work depicted in Figure 1 (Table 7).

Patient selectionThe continuous expansion of clinical applications of echocar-diography together with continued technical improvementshas led to an explosive increase in the number of echostudies performed. In order to identify patients who wouldbenefit most from echocardiography, guidelines listing theindications for which echocardiography may be consideredappropriate have been published.13 Since most studies areperformed solely in response to the referring physician’srequest without any previous discussion with the cardiologistwho analyses and reports the study, educational effortsshould be made to increase referring physician awarenessabout the existing guidelines. To help referring physiciansto make appropriate requests and to collect data for moni-toring study indications, it would be useful to developspecific order forms. Feedback to referring physiciansabout their study ordering behaviour should also beprovided.

Although it requires some work and adequate data collec-tion, optimizing and monitoring patient selection are impor-tant because of their impact on downstream testing, skillmaintenance, procedures, and costs.

Study performance and patient’s safetyHigh-quality image acquisition and study completenessdepend on specific protocols which optimize the likelihoodthat an echo study is complete and accurate.10 Adheringto such recommendations and monitoring accuracy, comple-teness, and overall quality of echo studies could be useful

tools for evaluating the quality of echo services (Table 7).Factors such as the incidence of complications during TEEor stress echo studies or the percentage of unsuccessfulintubation in attempted TEE studies are indicators to beused for assessing patient’s safety. Training and accredita-tion of sonographers and/or cardiologists who performecho studies are also important quality indicators.However, accreditation of individual echocardiographersalone cannot guarantee high-quality echo studies. It is alsonecessary to have adequate echo systems, management,and organization, and this underpins the EAE’s establish-ment of procedures for both individual and laboratoryaccreditation.32

Study interpretationThe EAE has developed procedures to assess competencefor standard adult TTE and TEE, as well as for CHDechocardiography.32

However, high-quality study interpretation is not guaran-teed by the existence of accredited echocardiographers.High-quality echo laboratories should provide evidence ofboth accuracy and reproducibility of echo studies’ interpret-ation (Table 7). There are different approaches to assessaccuracy in echocardiography: random re-reporting ofstudies; comparison of echo results with those obtainedusing other imaging modalities; analysis of computerizeddatabases35; reviewing a master set of cases by eachreader of the laboratory.36

Reproducibility should be assessed by measuring intra-and inter-reader variability of the most critical parameters[i.e. left ventricular (LV) ejection fraction and/or volumes,transaortic gradients, valve areas].

Laboratories may choose to develop a master set of caseswith the most frequent diagnoses to calibrate interpret-ations and reduce inter-reader variability.

In summary, it is important that routine periodical checksof accuracy and reproducibility are undertaken to confirmthat reasonable standards for both are met.

ReportingA high-quality echo report should be accurate, complete,and answer unambiguously the clinical question for whichthe study was requested. It should also be easy to under-stand by the referring physician. The minimal data set ofparameters that should be contained in a high-qualityecho report has been published by the EAE.10 In addition,the EAE has listed measurements and morphological

Figure 1 Framework for assessing quality in echocardiography and its influence on patient management. The proposed model consists offour main domains which may influence clinical outcome. Laboratory infrastructure and organization support the whole echocardiographyprocess.


Table 7 Action items and quality measures in the ‘dimensions of care’ framework for echocardiography

Step Quality goals Action items Quality measures

Laboratoryinfrastructure

Ensure baseline standards forequipment and staff proficiency

† Apply for standard laboratory accreditation11

† EAE and/or national certification for both sonographers andphysicians

† Aim for advanced laboratory accreditation for stress echoand TEE11

† Monitor number of studies performed/reported by eachsonographer/physician

† Percentage of echo studies performed by certified sonographers† Percentage of echo studies performed/reported by certified

physicians† CME credits for both sonographers and clinicians

Patient selection Appropriateness † Introduce appropriateness criteria for TTE, TEE, and stressechocardiography

† Develop specific study order forms to help referring cliniciansin selecting appropriate indications

† Monitor case-mix of echo studies

† Percentage studies meeting appropriateness criteria† Percentage of in- and out-patient studies reported as normal

Study performance Diagnostic quality studies † Adopt EAE recommendations for standardization ofperformance, digital storage, and reporting ofechocardiographic studies10

† Adopt EAE recommendations for stress echo17

† Adopt EAE recommendations for TEE14

† Ensure adequate time for each echo modality11

† Develop specific protocols for the use of contrast

† Number of studies reviewed monthly for completeness by theclinical and/or technical head of the laboratory

† Percentage of complete studies according to EAErecommendations10

† Percentage of non-interpretable studies† Number of studies performed/interpreted daily by each

sonographer/physician† Percentage of studies performed with the use of contrast

Patient safety – Monitoring in- and out-patient waiting list– Develop specific time-frame for performing echo study

according to the clinical priority– Monitoring major complications of stress echo (death, acute

myocardial infarction, major arrhythmias) and of TEE

– Percentage of patient who were studied within the pre-definedtime-frame set for each clinical priority

– Percentage of patients with documented signed informedconsent prior to TEE or stress echo

– Percentage of unsuccessful intubations in patients in whom TEEwas attempted

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Study interpretation Accuracy † Adopt existing standards for measuring and interpreting echostudies10,37

† Compare results with other imaging techniques or withsurgical findings

† Adopt digital archiving of images and data10

† Percentage of patients with an explicit clinical indication to echo† Percentage of patients with abnormal stress echo and normal

coronary arteries at coronary angiography† Bias and limits of agreement of LV volumes vs. cardiac MR or

nuclear† Bias and limits of agreement of transaortic gradients with

cardiac catheterization† Number of studies reviewed monthly for interpretation by the

clinical head of the laboratory

Reproducibility – Develop procedures for determining intra- and inter-readervariability of reporting physicians

– Intra- and inter-reader reproducibility of LV ejection fraction– Intra- and inter-reader reproducibility of aortic/prosthetic

effective orifice area

Reporting Completeness † Develop computerized software for structured reporting forall echo modalities10

† Adopt minimal data sets for comprehensive reporting of echostudies10

† Percentage of reports meeting requirements of the minimal dataset for reporting10

† Percentage of reports in which the clinical indication for thestudy has been clearly stated

† Percentage of reports in which a comparison with previousstudies (when available) has been provided

Timelines – Define procedures to provide timely report to referringphysicians

Improved patient care(outcomes)

Satisfaction † Develop customer satisfaction assessment tools † Percentage of patients/referring physicians reporting asatisfaction score above a pre-determined value

† Percentage of patients referred to cardiac scintigraphy after adefinitively positive or negative stress echo for coronary arterydisease

Impact on clinical management – Develop methods for measuring patient outcomes and impacton medical decision making

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descriptors of cardiovascular structures that should be usedto develop structured reporting databases.10 Once suchdatabases are in place, monitoring the quality of reportingcan be easily performed by measuring the percentage ofreports containing essential parameters for a given clinicalcondition.

Finally, reports should be transmitted to referring phys-icians on time. Reports from routine studies should usuallybe issued on the day of the examination. For urgent orin-patient studies, at least a preliminary report shouldusually be issued immediately, and timelines standardsshould be developed for particular clinical situations (i.e.high-risk findings should be promptly notified to the refer-ring physician).11

Implementation of quality-improvementrecommendations

The essence of improving the quality of an echo laboratoryis that all professionals involved in the process of producingan echo study (cardiologists, sonographers, nurses, adminis-trative personnel, managers, and other healthcare pro-fessionals) work as a team. The aim of such a team is toidentify and analyse problems using objective measures ofquality performance (Table 7), develop possible solutions,test effective applications of such solutions, and implementchanges. It would be useless to have only the head of theecho laboratory involved in the quality-improvementprocess.

One of the main difficulties to start a quality-improvementprogramme is the concern about how to handle humanerrors detected during quality assessment. It should bepointed out that the purpose of any quality-improvementprogramme is not to find faults, but rather to identifydimensions of care which need improvement. The focusshould always be on the patient and the echocardiographicproduct, and not on identifying professional errors.However, to increase adherence to the programme, it ismandatory to prepare mechanisms allowing correction oferrors without exposing participant professionals to liability.

Another important obstacle to overcome when starting aquality-improvement programme is adequate resourceavailability. Collecting the various measures needed tomonitor the process requires expertise, time, and moneyand cannot be done without an adequate database whichincorporates quality-measurement parameters (e.g. properordering information, clinical priority class, type ofmachine used, standardized reporting). Constructing suchinformation systems is costly. External review, particularlyif core laboratory or expert panels are involved, may costeven more.

Therefore, it is mandatory for every quality-improvementprogramme to share the importance of such a process withlocal hospital managers who should agree to invest in pro-cedures aimed at improving patient care.

One possible approach is detailed below:

† After having obtained adequate resources to run aquality-improvement programme, divide all professionalsworking in the echo laboratory into task groups for analy-sis of specific components of the framework depicted inFigure 1.

† Start by analysing simple parameters (e.g. caseload, car-diologist, and sonographer qualifications) and reviewingthe various recommendations listed in this document.

† Next, task groups should be organized to assess thevarious components of the framework. During this step,methods and quality measures should be tested tomonitor the different areas within each dimension andspecific problems should be identified.

† Following this process, suggest and test solutions to pro-blems and implement those which have been provedeffective over time.

As the technology used in echocardiography evolves andthe scope of applications changes and increases, the rec-ommendations included in this document will need furtherrevision and updating.

Conflict of interest: none declared.

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