American College of Cardiology

Quinones ET AL., ACC/AHA CLINICAL COMPETENCE STATEMENT ON ECHOCARDIOGRAPHY
J Am Coll Cardiol 2003;41:687-708

ACC/AHA Clinical Competence Statement on Echocardiography

A Report of the American College of Cardiology/American Heart
Association/American College of Physicians–American Society of Internal Medicine Task Force on Clinical Competence

Developed in Collaboration with the American Society of Echocardiography, the Society of Cardiovascular Anesthesiologists, and the Society of Pediatric Echocardiography

I. Introduction

This document is a revision of the 1990 ACP/ACC/AHA Clinical Competence in Adult Echocardiography.⁽¹⁾ The writing committee consisted of recognized experts in echocardiography representing the ACC, AHA, ACP-ASIM, American Society of Echocardiography (ASE), Society of Pediatric Echocardiography (SOPE), and the Society of Cardiovascular Anesthesiologists (SCA). The document has been approved for publication by the governing bodies of the ACC and the AHA, and endorsed by the ASE, SCA, and SOPE.

Purpose of this Clinical Competence Statement. Previous publications have focused on training requirements for clinical competence in echocardiography. The first recommendations were made in 1986 by Bethesda Conference 17: Adult Cardiology Training ⁽²⁾ and in 1987 by an expert panel of the ASE.⁽³⁾ They were followed by a previous version of the ACP/ACC/AHA physician clinical competence statement in 1990. These earlier recommendations were limited primarily to the practice of transthoracic echocardiography (TTE) in the adult patient. However, over the past 15 years echocardiography has evolved into a family of techniques (Table 1), each one with unique applications and its own set of cognitive skills and training requirements. Although the majority of these newer technologies were in their early phase of development in 1990, today they are used routinely in community hospitals all across the nation. In addition, the application of echocardiography in children and adults with congenital heart disease (CHD) has evolved into a highly specialized modality with its own set of cognitive skills and training requirements. Subspecialty societies such as the ASE have published recommendations for training and, in some cases, for competence in some of these newer techniques. In addition, guidelines for training in adult cardiovascular medicine in the form of a suggested core curriculum (COCATS) have included recommendations on training in echocardiography, first in 1995 and currently in a revised version.⁽⁴⁾ The recently formed National Board of Echocardiography (NBE) has also introduced guidelines for certification of special competence in adult echocardiography, which includes passing an examination in addition to specific training requirements. Separate certifications are granted for transesophageal echocardiography (TEE) and stress echocardiography. Recognizing the growths in technology and the increased complexity of echocardiography, the members of the ACC/AHA/ACP-ASIM Task Force on Clinical Competence commissioned this writing group to provide a new set of recommendations that recognize the different cognitive skills required for each of the new modalities and that address training, documentation and maintenance of competence.

Document Format. This document addresses competence in the performance and interpretation all the different modalities of echocardiography, including new applications of echocardiography in the operating room and the application of echocardiography in patients with complex CHD. The document also addresses the application of echocardiography using miniaturized hand-carried ultrasound instruments. For each of the applications, there will be a brief general overview, a discussion of the cognitive skills required and recommendations on training requirements, proof of competence, and maintenance of competence. Whenever possible, these recommendations will be linked to previously published recommendations made by specialty societies. In some situations, however, the writing group provides a set of recommendation that represent the consensus of this body of experts.

This document makes an important distinction between training requirements and documentation of competence. Training requirements represent the minimal training experience that is considered necessary to achieve the skills for performance at a particular level. It is recognized that training is highly individualized and some trainees may require higher volume and more hours of exposure to a particular technique. Proof of competence, on the other hand, consists of a set of requirements that provide some assurance that physicians have gained the expertise needed to perform according to recognized standards.

The sections on training requirements refer primarily to the training needed to achieve specific levels of expertise. Such training is expected to occur under the direct supervision of a qualified Level 3 or equivalent physician/teacher and for the most part, occurs during formal fellowship training in either cardiovascular medicine or cardiovascular anesthesiology. However, the document recognizes the fact that physicians trained prior to the development of these techniques may have properly learned their use while in practice. Thus, whenever possible, the document addressees training requirements and proof of competence for this group of physicians. Maintenance of competence requires the performance of a certain minimal volume of procedures and participation in continuing medical education (CME). This document recommends that physicians practicing echocardiography obtain a minimum of 5 hours per year of CME credits in echocardiography, as recommended recently by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL Newsletter 2001Vol 4; Issue 2; page 5).