australasian society for ultrasound in medicine (asum) … · 2017. 12. 21. · an asum certificate...

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Australasian Society for Ultrasound in Medicine

P (61 2) 9438 2078 F (61 2) 9438 3686 E [email protected] W www.asum.com.au

ACN 001 679 161 ABN 64 001 679 161

Australasian Society for Ultrasound in Medicine (ASUM)

Certificate in Point of Care Ultrasound (Rheumatology)

(ACPoCUS)

CURRICULUM

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ACN 001 679 161 ABN 64 001 679 161

Table of Contents

Introduction: Who is the Australasian Society for Ultrasound in Medicine Certificate in Point of Care Ultrasound (Rheumatology) for?......………………………………………………….......

3

Capability Statements (CS)………………………………………………………………………….. 4 Overview of ACPoCUS (Rheumatology) Curriculum………………………………………….. 5

Core Units………………………………………................................................................ 5 Expected experiences and learning opportunities..………………………………………. 7

Clinical Supervisor requirements………………………………………………………………… 8 Assessments in simulation environments……………………………………………………… 9 CORE UNITS ACPoCUS (Rheumatology)……………………………………………………….. 10 Unit 1: Fundamentals of Ultrasound Practice………………………………………………….. 10

Aim……………………………………………………………………………………………… 10 Learning objectives…………………………………………………………………………... 10 Assessments………………………………………………………………………………….. 12 Resources/suggested learning activities…………………………………………………... 13

Unit 2: Needle Guidance Techniques…………………………………………………………….. 13 Aim……………………………………………………………………………………………… 14 Learning Objectives…………………………………………………………………………... 14 Core knowledge and skills to be achieved…………………………………………………. 14 Assessments………………………………………………………………………………….. 15 Resources/suggested learning activities…………………………………………………... 15

CORE CLINICAL UNITS……………………………………………………………………………... 15 Unit 3: Assessment of Upper Limb……………………………………………………………….. 15

Aim……………………………………………………………………………………………… 15 Learning Objectives………………………………………………………………………….. 16 Assessments………………………………………………………………………………….. 18 Resources/suggested learning activities…………………………………………………… 19

Unit 4: Unit 4: Assessment of Lower Limb……………………………………………………… 19 Aim……………………………………………………………………………………………… 19 Learning Objectives………………………………………………………………………….. 19 Assessments………………………………………………………………………………….. 22 Resources/suggested learning activities…………………………………………………… 23

Unit 5: Portfolio of Clinical Competence in PoCUS (Rheumatology)………………………. 23 Aim……………………………………………………………………………………………… 23 Requirements…………………………………………………………………………………. 23 Assessments………………………………………………………………………………….. 24 Final holistic clinical assessments………………………………………………………….. 24 Submission of completed Portfolio of Clinical Competence to ASUM for consideration of award of ACPoCUS………………………………………………………………………..

24

References…………………………………………………………………………………….. 25 APPENDIX 1…………………………………………………………………………………………… 26 Optional/additional clinical units……………………………………………………………………… 26 Additional Unit for ACPoCUS (Rheumatology)………………………………………………… 26

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Introduction: Who is the Australasian Society for Ultrasound in Medicine Certificate in Point

of Care Ultrasound (Rheumatology) for?

The Australasian Society for Ultrasound in Medicine (ASUM) is the peak body for setting and

maintaining standards for ultrasound practice in Australia and New Zealand. ASUM provides

credentials that certify practitioners as meeting the required standards based on the following

principles:

Maintenance of the highest standards of patient safety and confidence in the ultrasound

profession.

Only those practitioners who are suitably trained and qualified to practise in a competent

and ethical manner are credentialed to do so.

Risk to patient safety is minimised through robust, transparent, flexible and adaptable

processes of credentialing.

An ASUM Certificate in Point of Care Ultrasound (ACPoCUS) (Rheumatology) certified practitioner

utilises ultrasound for specifically focussed, diagnostic and/or procedural guidance purposes across

a range of core clinical applications as defined by the 2017 European League Against Rheumatism

(EULAR) standardised procedures for ultrasound imaging in rheumatology1.

The training, credentialing and scope of practice for ACPoCUS practitioners is of a separate and

different nature to the processes used to credential practitioners who perform what are often termed

“comprehensive” ultrasound examinations.

In recognition of the rapidly evolving and broadening use of ultrasound in point of care, focussed

clinical applications, ASUM credentialing provides:

processes that are, wherever possible, evidence-based and in accord with standards of

similar professional bodies and regulators;

a potential pathway for further development of knowledge, skills and research for

practitioners, along with advanced recognition of such further development;

a potential pathway for advocacy for Government recognition of the credentials obtained.

The ACPoCUS is designed for those practitioners who wish to demonstrate, through the certification

process, that they possess knowledge, skills and competence in the clinical application of focussed

ultrasound examinations, suitable to their clinical scope of practice. Practitioners would also be

expected to further develop and enhance their skills and knowledge, as applicable to their scope of

practice, and continue this development with further certification of additional and/or enhanced

skills.

Candidates for the ACPoCUS (Rheumatology) would usually be rheumatology specialists or other

specialists with a particular interest in, and area of practice of, treatment of disease and

inflammatory conditions of the muscles, joints, tendons, ligaments, soft tissues and bones of the

body and extremities.

Given the potentially wide range of possible clinical indications a practitioner may encounter, a

candidate is required to have access to a clinical supervisor/s who can advise and monitor the

candidate’s clinical knowledge and skill development, and ensure the practitioner only undertakes

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unsupervised ultrasound examinations once they have demonstrated advanced beginner level

competence2 for the specific application.

Candidates are expected to develop and demonstrate knowledge, skills and competence in the:

underpinning fundamental principles of ultrasound practice

sonographic/psychomotor skills required to produce a relevant and diagnostic examination (image acquisition)

ability to interpret (image interpretation) the ultrasound findings in the clinical context and

ability to communicate the clinical and ultrasound findings in a way that supports accurate, timely clinical management of the patient’s condition (clinical integration).

Capability Statements (CS)

The broad level knowledge, skill and abilities required of a practitioner awarded the ACPoCUS

includes, but is not limited to:

1. Use and care of ultrasound equipment including: underpinning theoretical knowledge of relevant physics and instrumentation; ultrasound bioeffects and safety issues.

2. Understanding and demonstration of psychomotor and other skills involved in producing and recognising an accurate and valid ultrasound examination and resultant data (the “sonographic process”).

3. Detailed anatomy, physiology and pathology as related to the ultrasound examinations relevant to the practitioner’s area of practice.

4. Accurate recognition and evaluation of sonographic appearances and information relevant to the practitioner’s specific area of practice including: normal anatomy; normal variants; artifacts; abnormalities.

5. Accurate critical analysis of information and ability to determine appropriate provisional diagnosis/diagnoses as a result of the ultrasound examination and in conjunction with other available clinical information as relevant.

6. Recognition of any limitations of the ultrasound examination and the effect of this on patient clinical management.

7. Ability to critically analyse findings and determine the need for further information such as: referral for more detailed ultrasound examination and diagnosis; other diagnostic tests; further clinical information; follow-up examinations.

8. Understanding of, and the ability to apply, any professional, ethical and legal issues that may be particularly relevant/unique to the ultrasound processes.

9. Understanding of, and commitment to, requirements for continuing professional development, especially as related to the use of ultrasound in their clinical practice.

10. Ability to communicate with patients/clients and colleagues in a manner that is timely, relevant and appropriate to the circumstances.

11. Ability to record ultrasound findings in the clinical record in a timely and accurate manner to facilitate appropriate continuity of patient care.

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ACN 001 679 161 ABN 64 001 679 161

Overview of ACPoCUS (Rheumatology) Curriculum

The ACPoCUS (Rheumatology) curriculum is focussed on assessment of clinical competence in the

core areas of the scope of practice. Much of the underpinning knowledge of anatomy, pathology

and clinical medicine relevant to the area of practice is assumed knowledge and this theoretical

knowledge base is not the focus of the assessments.

Candidates are expected to familiarise themselves with the requirements of the certification process

and the professional responsibilities of themselves and their supervisor/s prior to enrolment as a

candidate. To facilitate this Candidates are expected to read this curriculum document in

conjunction with the ACPoCUS Candidate’s Education and Clinical Experience Handbook and the

ACPoCUS Clinical Supervisor Handbook.

Core units

The ACPoCUS (Rheumatology) core units are:

Unit 1: Fundamentals of Ultrasound Practice

Unit 2: Needle Guidance Techniques

Unit 3: Assessment of Upper Limb

Unit 4: Assessment of Lower Limb

Unit 5: Portfolio of Clinical Competence in PoCUS (Rheumatology)

The EULAR standardised procedures1 advise the above areas as being core areas of clinical

ultrasound competence required by specialists using focussed ultrasound in clinical rheumatology

settings. Other areas may also be assessed, dependent on the practitioner’s scope of practice

including, but not limited to: peripheral nerves, salivary glands and vascular assessment.

Candidates are encouraged to undertake optional additional clinical units as applicable to their

scope of practice. Refer to Appendix 1 for information regarding additional/advanced units

available.

To be awarded an ASUM ACPoCUS (Rheumatology) a candidate must fulfil the following

requirements:

Step 1:

Enrol in ACPoCUS with ASUM

Nominate clinical supervisor/s for ASUM approval (refer to the Candidate’s Education and Clinical Experience Handbook and the Clinical Supervisor’s Handbook for details)

Commence ACPoCUS portfolio (refer to refer to the Candidate’s Education and Clinical Experience Handbook for details).

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Step 2:

Candidate identifies own learning needs and suitable educational opportunities, preferably in consultation with supervisor and/or other suitable advisor

Commence education and training in PoCUS

Commence recording examinations performed in simulation/training sessions on “model” patients in clinical record log (logbook) as part of the portfolio.

Step 3:

Have basic US skills, in relevant core clinical unit/s assessed as being at level of novice practitioner3 in simulation setting (Formative Assessment 1)

Achieve satisfactory result on Fundamentals of US Practice Quiz 1 (see separate definitions of quizzes in Unit 1: Fundamentals of Ultrasound Practice)

Commence clinical US examinations in clinical setting under supervision

Commence recording actual clinical examinations in clinical record log (logbook).

Step 4:

As skills and knowledge increase, undertake further education and training for increasing development and application of skills – learning needs identified by candidate in consultation with supervisor and/or other suitable advisor

Satisfactorily complete Fundamentals of US Practice Quizzes 2 and 3

Undertake education and training in the application of US techniques to needle/procedural guidance techniques.

Satisfactorily complete the following assessments in Unit 2: Needle Guidance Techniques: o Formative assessment of clinical skills (may be in simulated environment) o Summative assessment of clinical skills (may be in workplace or in a simulation

setting).

Step 5:

For each core clinical unit (Assessment of Upper limb, Assessment of Lower Limb) satisfactory completion of the following assessments is required:

o Formative assessment of clinical skills x 2 (see specific unit for requirements) o Summative assessment of clinical skills x 2 (see specific unit for requirements) o On-line interpretive, case-based scenario analysis quiz o Experience of specified type/number of cases as verified in clinical record log in the

portfolio.

Satisfactorily complete the final holistic on-line interpretive, case-based scenario analysis quiz to cover all core clinical areas of the ACPoCUS (that is: Assessment of Upper limb, Assessment of Lower Limb). The quiz is to assess that a candidate can satisfactorily demonstrate competence level skills in:

o image interpretation and o clinical integration of the ultrasound data.

Satisfactorily complete the final holistic summative clinical competence assessment (based on “global rating scale”3,4) of holistic clinical focussed/point of care ultrasound competence to include:

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o overall psychomotor and sonographic skill, including satisfactory use of equipment; o interpretation of ultrasound findings; o due regard for patient comfort and care at all times; o integration of ultrasound examination into patient clinical management; o demonstrated understanding of role and limitations of PoCUS; and o safe and appropriate clinical practice across the core clinical applications

(Assessment of Upper limb, Assessment of Lower Limb).

Step 6:

Submit Portfolio of Clinical Competence to ASUM for consideration of award of ACPoCUS

Portfolio to consist of:

o Evidence of attendance at relevant formal teaching and learning experiences o Clinical record log verifying required scan numbers/type for all core clinical units as

defined in the curriculum o Completed formative and summative assessments for Unit 2: Needle Guidance

Techniques, with the final summative assessment being at the Advanced Beginner2 level

o Completed formative and summative clinical assessments for each specified core clinical unit with final summative assessment for each core unit at “competent” level2

o Completed final holistic summative clinical competence assessment (global

rating scale3,4) by supervisor or other approved person at “competent” level2 o Evidence of satisfactory level of achievement of the following:

Fundamentals of US Practice quizzes x 3 Case-based scenario analysis quiz x 1 for each core clinical unit Final holistic on-line interpretive, case-based scenario analysis quiz.

Step 7 (Optional):

Candidates may choose to undertake optional additional clinical units suitable to their scope of practice needs.

These may be undertaken in conjunction with the core ACPoCUS units or at a later time.

All assessment requirements, as defined in the relevant description of the unit, must be met for optional additional clinical units.

Optional additional clinical units assessed as satisfactorily completed can be notated on the ASUM issued Certificate of Point of Care Ultrasound (Rheumatology).

Expected experiences and learning opportunities

ASUM recognises that practitioners will have widely varied clinical environments and scope of

practice needs, access to educational opportunities and preferred methods of learning. The

International Federation for Emergency Medicine3 defines the essential steps in PoCUS training as

1) initial introduction 2) gaining experience 3) achieving competence3. ASUM considers this model

appropriate for all areas of practice where PoCUS is used to contribute to patient management,

including rheumatology.

See Candidate’s Education and Clinical Experience Handbook for descriptions of “relevant” teaching and learning experiences See Candidate’s Education and Clinical Experience Handbook and the Clinical Supervisor Handbook for definition of “approved”

person

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Candidates are strongly encouraged to identify and undertake suitable formal education

opportunities prior to undertaking any ultrasound procedures in the clinical setting.

Candidates are strongly encouraged to undertake education and learning relating to the

Fundamentals of Ultrasound Practice, particularly the areas covered in section 1 of the content prior

to undertaking any ultrasound procedures in a clinical setting. Clinical record log (logbook)

entries for actual patients in clinical settings will not be accepted from any date recorded

prior to the satisfactory completion of the Fundamentals of Ultrasound Practice Quiz 1.

Candidates may wish to undertake courses provided by education providers who have been

endorsed by ASUM and listed on the ASUM website, or choose another educational opportunity

suitable to their needs, or arrange a structured education and training program to be conducted in

the workplace. For information on requirements of ASUM Endorsed Education Providers and

features to consider when choosing an education/training program refer to the Candidate’s

Education and Clinical Experience Handbook.

Candidates are strongly encouraged to identify on-going learning opportunities to undertake as their

skills and knowledge increase and they gain further experience.

Candidates should not view their introductory education/training sessions as providing them with

comprehensive skills and abilities. It is unlikely a candidate would be assessed as competent for

safe, unsupervised practice without the benefit of re-enforcement of the learning, and further skills

development, which come with on-going experiential learning and reflection.

Clinical supervision requirements

All ACPoCUS (Rheumatology) candidates must have access to clinical supervision during their

education and training. Candidates must nominate a suitable “Primary Clinical Supervisor” or a

combination of suitable persons to act jointly as “Primary Clinical Supervisory team” for the duration

of their candidature. The Primary Clinical Supervisor/s must be a currently practising practitioner

holding one of the following:

I. Fellowship of the Royal Australian and New Zealand College of Radiology (RANZCR) II. Diploma in Diagnostic Ultrasound (DDU) from ASUM

III. Certificate in Clinician Performed Ultrasound (CCPU) as issued by the ASUM in the relevant clinical area/s (ie rheumatology). The relevant CCPUs must have been obtained at least 2 years prior to undertaking the supervisor role and the supervisor must provide a statement regarding their on-going clinical experience in PoCUS since obtaining the CCPU

IV. An Accredited Medical Sonographer (AMS) with demonstrated experience in clinical teaching of sonographic skills, particularly for musculo-skeletal (MSK) applications and an in-depth knowledge and understanding of the underpinning principles of PoCUS applications. An AMS must be a part of a supervisory team with either one of the persons listed in points I, II and III or point V

V. An experienced specialist rheumatologist. If the rheumatologist does not hold a qualification as detailed in points I, II and III, they must be part of a supervisory team with a person with any of the qualifications listed in points I – IV above.

Further information regarding clinical supervisor requirements can be found in the Clinical

Supervisor Handbook.

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Note: In exceptional (only) circumstances where a suitable Primary Clinical Supervisor or Primary

Supervisory team with the above listed qualifications cannot be found or is otherwise not

appropriate, the ACPoCUS Certification Board may, at its discretion, accept another person as

clinical supervisor or a combination of supervisors with the appropriate expertise to provide

supervision.

Candidates, in consultation with their Primary Clinical Supervisor/s, may engage other experienced

and suitably credentialed practitioners (such as an Accredited Medical Sonographer - AMS) as a

member of the Primary Supervisory team to assist in appropriate teaching and competence

assessment within their scope of practice (for example scanning competence). All practitioners

involved in clinical supervision of a candidate who will be responsible for any assessment or

verification of practice must be approved by the ACPoCUS Certification Board prior to the

commencement of the clinical supervision.

Candidates should ensure that all nominated Clinical Supervisors have been provided with a copy

of this entire ACPoCUS (Rheumatology) curriculum document and the Clinical Supervisor

Handbook.

The Primary Clinical Supervisor/s must be in a position to be able to comment authoritatively and

objectively on the candidate's clinical practice and competence. The Primary Clinical Supervisor/s is

expected to be working predominantly within the candidate's usual workplace and be available for

direct access/advice when required.

All nominated supervisors must complete a Clinical Supervisor Form verifying that they agree to

undertake the supervision and have read and agreed to fulfil the Supervisor Responsibilities

(Clinical Supervisor Handbook).

It is the candidate’s responsibility to ensure the Clinical Supervisor Form/s is/are submitted to

ASUM at the beginning of their candidature. The ACPoCUS Certification Board will confirm with

the candidate and nominated supervisor/s if the nomination/s is/are acceptable to the ACPoCUS

Certification Board.

Any proposed changes to the arrangements for clinical supervision must be notified to the

ACPoCUS Certification Board for approval as soon as possible.

Assessments in simulation environments

Candidates may choose to have their formative and/or summative assessments undertaken in a

simulation environment (if within the specific requirements of the core unit). The simulation may be

in the workplace on “model” patients or may be in a purposeful education facility. Persons who

undertake the role of assessor only, and are not involved in an on-going clinical supervisor role, do

not need to be approved by the ACPoCUS Certification Board. Such assessors do need to meet

the professional background requirements, for supervisors, as detailed previously in this document.

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CORE UNITS ACPoCUS (Rheumatology)

Unit 1: Fundamentals of Ultrasound Practice

Rationale

The acquisition and interpretation of ultrasound images requires a sound understanding of the underlying physical principles of ultrasound, the interaction of ultrasound with tissue and related limitations. It is equally important to know how misleading information (artifacts) can result from the scanning process, how artifacts are minimised and the typical appearances of commonly encountered artifacts.

It is also important to understand the technical features of the equipment, how appropriate

equipment is selected for a given examination, how the settings are optimised to ensure useful

information is acquired and the terminology used to describe the findings.

All practitioners using ultrasound techniques are responsible for ensuring they have adequate and

up-to-date knowledge of the image acquisition and interpretation process and associated legal and

ethical requirements, including recognition of the philosophy of focussed (point of care) ultrasound

applications, its integration into clinical management and its limitations.

Aim

The candidate demonstrates knowledge and competent application of the physical principles and

instrumentation of ultrasound, and the broad professional, ethical and legal principles relevant to

focussed (point of care) ultrasound practice. The candidate can relate the fundamental principles to

the validity and clinical utility of the information obtained.

Candidates please note: ASUM provides an on-line tutorial which has been specifically designed

to assist candidates in their learning and preparation for the Unit 1: Fundamentals of Ultrasound

Practice quizzes. All candidates are strongly encouraged to undertake the on-line tutorial prior to

attempting the quizzes.

Learning objectives

Section 1 (relates to Quiz 1)

Physical principles of ultrasound

The candidate can describe:

the wave nature of ultrasound and its propagation through tissue

the reflection and scattering of ultrasound and how these relate to acoustic impedance

the concept of attenuation, its mechanisms and factors affecting it

refraction of ultrasound

the concept of pulsed ultrasound.

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Imaging Principles and Technology

The candidate can describe the:

pulse-echo principle and how it is used in B-mode and M-mode ultrasound imaging

purpose and function of a transducer, including methods and importance of focussing

concept of an ultrasound beam and the importance of controlling beam width

major types of transducer and the factors affecting the choice of transducer for a specific application

concept of slice thickness

major aspects of image quality

principal image artifacts and their impact on image quality and clinical utility.

Image/Data Collection and Optimisation

The candidate can:

describe a range of techniques to ensure the best quality examination is obtained including: patient positioning and breathing; systematic scanning techniques.

describe and apply a range of probe manipulation techniques to produce an accurate, valid and efficient examination.

recognise standard scan planes, image orientation and associated terminology used in relevant ultrasound applications and be aware of common variations used in particular fields (for example, intracavity scanning and cardiac ultrasound).

apply equipment controls to optimise the quality of the images/data produced including: power; time gain compensation (TGC); gain; focus; depth and zoom; accurate measurements.

describe the underpinning philosophy and limitations of focussed (point of care) ultrasound examinations in the clinical setting.


Doppler Principles and Instrumentation

The candidate can describe the:

basic principles of the Doppler effect and describe how it is used in ultrasound diagnosis

basics principles of operation of continuous wave and pulsed Doppler instrumentation

major elements of the Doppler spectral display

basic principles of colour Doppler, including power (amplitude) mode

the principal Doppler artifacts and how they can be identified and/or eliminated.

Good ultrasound practice

The candidate can:

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ACN 001 679 161 ABN 64 001 679 161

describe the principles of adequate documentation of ultrasound images and data

accurately apply standard terminology used to describe ultrasound appearances

describe general principles of care and maintenance of equipment

describe and apply principles of infection control in the use of ultrasound and its associated equipment

explain and apply informed consent processes, particularly for invasive examinations

demonstrate due regard for patient comfort and care at all times

demonstrate satisfactory communication skills with patients and other practitioners regarding the ultrasound examination and its role in patient management, including limitations of the examination/procedure.


The candidate can:

demonstrate an understanding of the potential impact of bioeffects and biohazards in ultrasound scanning

define the parameters used to describe patient exposure to ultrasound

explain practical approaches to reducing risk as published in relevant professional body policies.

New and Evolving Techniques

The candidate will understand the basic principles of a range of new technologies including:

contrast agents

tissue and contrast harmonic imaging

spatial compound scanning

three-dimensional (3D) scanning.

Assessments

Three quizzes directly related to Sections 1, 2 and 3 as detailed above must be satisfactorily

completed. The “satisfactory” level for each quiz is 80% or greater.

Quiz 1: Twenty multiple choice questions (MCQ) related to Section 1

Quiz 2: Twenty MCQ related to Section 2

Quiz 3: Ten MCQ related to Section 3.

Quizzes will be available on-line and “at-call” and will be time-limited. Candidates may undertake

the quizzes when they believe they are ready and have received a “log-in” code from ASUM for the

purpose.

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Quiz 1 must be satisfactorily completed prior to undertaking clinical ultrasound examinations on

actual patients in a clinical setting and recording these in the clinical record log. Any clinical

examinations on actual patients in a clinical setting which pre-date successful completion of Quiz 1

will not be accepted as meeting the clinical record log requirements.

Scans performed in a simulation setting, or on “model” patients for training purposes, may be

recorded in the clinical record log prior to the satisfactory completion of Quiz 1.

Quizzes 2 and 3 should be completed at an appropriate time, in line with on-going development of

skills and clinical experience, as determined by the candidate and preferably in consultation with

their supervisor/s. All quizzes must be satisfactorily completed to be eligible for the award of the

ACPoCUS.

Access to each quiz will be time-limited. If any quiz is not satisfactorily completed the quiz must be

attempted again. Candidates must note that questions will be randomly assigned from a database

of questions. Re-attempting the quiz may result in a different set and/or order of questions

presented.

Following two unsuccessful attempts at any given quiz the candidate may be required to

demonstrate attendance at, or completion of, an ASUM endorsed formal education and learning

experience/program before being able to attempt the relevant quiz again.

If a candidate remains unsuccessful after two further attempts at a given quiz, ASUM reserves the

right to require evidence of additional remedial learning prior to further attempts, or to cancel the

candidate’s enrolment.

Resources/suggested learning activities (to be fleshed out)

Gill, Robert (2012) The Physics and Technology of Diagnostic Ultrasound: A Practitioner’s Guide.

High Frequency Publishing. ISBN 9780987292100.

ASUM on-line module (name to be included when revised edition available)

Available via the author’s website https://ultrasoundbook.net

ASUM Endorsed Education Providers’ training courses

ASUM’s annual “DDU Physics Seminar” (see ASUM website for details).

Unit 2: Needle Guidance Techniques

Rationale

The role of ultrasound scanning in focussed (point of care) clinical settings includes both diagnostic

aims and procedural guidance purposes1. Procedural guidance using ultrasound scanning can

improve patient safety and procedural efficiency1 if performed by appropriately trained and

competent practitioners.

ASUM believes all practitioners performing focussed (point of care) ultrasound examinations should

have a foundational level of knowledge and skill in the use of ultrasound guidance, and knowledge

https://ultrasoundbook.net/

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of how ultrasound guidance can be used to improve the efficiency and effectiveness of

interventional procedures.

Equally important is for practitioners to be aware of the limitations of the techniques and their own

ability to perform ultrasound guided interventional procedures safely and efficiently. Practitioners

must only undertake ultrasound guided clinical interventions IF it is within their scope of practice

and competence level. Practitioners have an obligation not to undertake procedures in which they

are not competent.

ASUM recognises that not all practitioners will use ultrasound guidance of interventional procedures

in their practice. However, ASUM believes it is important that the foundational concepts, principles

and basic skills required are demonstrated by all candidates prior to the award of an ACPoCUS.

Aim

The candidate demonstrates foundational knowledge, and advanced beginner2 level application, of

the principles of ultrasound guidance of interventional procedures in focussed (point of care)

ultrasound practice.

Learning Objectives

The candidate can:

describe the general principles of the common methods used for ultrasound guidance for interventional procedures

demonstrate fundamental psychomotor and technical skills in using ultrasound to satisfactorily guide simple interventional procedures

describe and apply principles of infection control, according to the ASUM/ACIPC 2017 Guidelines for Reprocessing Ultrasound Transducers (ASUM website), in the use of ultrasound and its associated equipment for guidance of interventional procedures.

Core knowledge and skills to be achieved

Ultrasound guidance methods and principles:

o free-hand techniques following needle path determination with ultrasound imaging o ultrasound real-time guided techniques o technique guided by purpose designed guidance devices

Infection control:

o infection control related to ultrasound equipment

Skills:

o coordination of psychomotor skills to perform imaging and needle/device insertion simultaneously

o apply sonographic principles to optimise ultrasound imaging to enhance accuracy and clarity of image guidance

o use ultrasound guidance techniques to insert needle/device accurately and efficiently to area of interest

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o apply correct and safe infection control processes to ensure risk of procedure related infection/contamination is as low as reasonably achievable (ALARA)

Assessments

Formative competence assessment (may be in a simulation or clinical setting).

Summative competence assessment (may be in simulation or clinical setting).

For the summative assessment to be deemed satisfactory, the candidate must be assessed as

meeting the level of Advanced Beginner2.

Resources/suggested learning activities


Clinical training

CORE CLINICAL UNITS

Rationale

The main purpose of focussed (point of care) ultrasound examinations in the rheumatology clinical

setting is to provide easily obtained, valid information of the patient’s current clinical problem to

inform and allow timely clinical management decisions. Ultrasound guided procedures for the

purpose of biopsy, therapeutic or diagnostic fluid aspiration and/or injections can lead to enhanced

patient safety and therapeutic and diagnostic outcomes.

The role of focussed ultrasound examinations is to answer a specific, clinical question to assist the

clinician in deciding on appropriate further clinical management, or to guide diagnostic or

therapeutic invasive procedures. The ultrasound information/data should be used to “rule in” or “rule

out” the possible diagnosis and, if the findings are equivocal, the clinician will have to consider the

need for other diagnostic and/or management strategies.

Unit 3: Assessment of Upper Limb

Aim

The candidate demonstrates skill in obtaining valid and efficient ultrasound data in the assessment

of the joints, bones and soft tissues of the upper limb to answer the specific clinical question and/or

guide the invasive procedure. The candidate can recognise when the findings are positive, negative

or equivocal and use this assessment to enhance the clinical management of the patient.

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Learning objectives

The candidate can:

describe the clinical questions, related to the upper limb which may typically be addressed using focussed point of care ultrasound scanning, as described in relevant and contemporary peer-reviewed literature or relevant published protocols or standards of practice

demonstrate the technical (sonographic) ability to acquire a satisfactory ultrasound examination which is suitable to answer the clinical question, including any dynamic assessments of movement and/or applicable measurements

describe the diagnostic criteria, as described in relevant and contemporary peer-reviewed literature or relevant published protocols or standards of practice, for ultrasound findings which would support a positive, negative or equivocal diagnosis

describe the limitations of ultrasound in assessing the upper limb in a PoCUS context

demonstrate the ability to interpret the ultrasound data to determine if the findings support a positive, negative or equivocal answer to the specific clinical question

demonstrate the ability to determine the appropriate on-going patient management as a result of the ultrasound findings in conjunction with other clinical information

demonstrate the knowledge and psychomotor skills to effectively and efficiently use ultrasound to guide invasive procedures to enhance patient safety and outcomes

demonstrate the ability to describe and adequately document the ultrasound findings in the patient’s clinical record in such a way as to facilitate satisfactory continuity of care of the patient.

Expected standards of practice (Upper limb)

Key clinical questions addressed in PoCUS contexts:

o Which are the relevant joints, bones or soft tissue structures affected? o Is there evidence of abnormal fluid collection/s? o Is there evidence of abnormal bone surfaces/structure? o Is there evidence of inflammation, disruption or rupture of tendons and/or ligaments? o Is there evidence of thickening, inflammation or other abnormality of the synovium? o Is there any evidence of calcification, soft tissue masses or other abnormal space occupying

lesions in the area of interest? o Is there evidence of abnormal movement of structures on dynamic imaging? o What are the measurements of the relevant findings? o What is the clinical relevance of the findings and/or measurement/s? o Are there any other findings which may support another differential diagnosis which may

explain the patient presentation?

Minimum expected ultrasound data acquisition/protocols:

Preparation

o Prepare clinical environment o Prepare patient, including informed consent o Select and prepare ultrasound and ancillary equipment o Enter patient data into ultrasound equipment

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ACN 001 679 161 ABN 64 001 679 161

Image acquisition

o Acquire and optimise ultrasound images/data, including correct probe choice and use of “stand-off” material if required

o Identify relevant anatomical features and landmarks following determination of clinical area of interest

o Continuous real-time imaging of the area/s of interest to include related bones, joints, tendons, ligaments, muscles, synovium and other soft tissues as relevant

o Real-time imaging of dynamic movements of anatomical features if necessary o Measurement of any areas of interest, such as tendon thickness, or if abnormality found,

area/structure measured in 2 orthogonal planes o Apply Doppler techniques as required to demonstrate areas of inflammatory change or to

distinguish vascular structures o Identify and respond to ultrasound artifacts, if required, to improve diagnostic quality of

images/data o If performing a guided invasive procedure follow all protocols as described in Core Unit 2

Needle Guidance Techniques

Minimal recorded images/ultrasound data

The following are the required minimal images to be recorded, unless the patient’s clinical situation

(for example an unstable trauma patient) renders this impracticable and/or unsafe. In this situation,

the practitioner should record whatever images are obtainable, in the time available, to answer the

clinical question without allowing the ultrasound examination to interfere with ongoing medical

treatment.

If local protocols recommend more recorded images/data for a particular examination then these

should be adhered to.

o Representative images of relevant anatomical landmarks and areas of clinical significance in at least two orthogonal planes, preferably with major landmarks annotated

o Measurements of any abnormal findings in two orthogonal planes if possible o If available short video or cine-loop of relevant dynamic movement o If performing a guided invasive procedure, record at least two images in orthogonal planes

to demonstrate needle position. During the procedure and post-procedure images may be required, depending on the procedure, to verify the outcome.

Sonographic appearances of expected positive, negative and equivocal findings

o Describe ultrasound appearances, of the relevant anatomy/area of interest, using correct sonographic terminology, including the appearances consistent with:

o Synovial thickening o Synovial fluid/effusion o Bone erosion o Tenosynovitis o Tendinopathy o Tendon rupture o Ligament tear o Masses: ganglion, tendon nodule, calcification o Bursitis o Impingement features on dynamic assessment

o Identify and describe conclusive findings, positive or negative

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ACN 001 679 161 ABN 64 001 679 161

o Identify limitations of examination or relevance of equivocal findings

Integration of ultrasound findings with clinical information

o Describe relevance of ultrasound findings correlated to clinical presentation and other data o Evaluate findings for monitoring purposes: disease activity/progression/regression

o Integrate information with ongoing clinical management of patient

Post examination

o Ensure examination and findings adequately recorded in patient clinical record o Clean ultrasound equipment safely and correctly o Store ultrasound equipment safely and correctly o If guided invasive procedure performed, adhere to applicable infection control guidelines.

Assessments

Assessments for clinical units are focussed on the candidate demonstrating the knowledge, skill and

ability to perform an accurate, valid, efficient, and clinically relevant ultrasound examination which

has the potential to have a positive impact on patient clinical management.

Candidates are expected to develop a solid foundation of key ultrasound knowledge and skills and

apply these to clinical practice in a guided, supervised, incremental fashion. As their experience

builds, candidates may wish to undertake further formal training and education to further develop

and enhance their skills.

To be awarded an ACPoCUS (Rheumatology) a candidate must, amongst other items as described

in this curriculum, successfully meet the specific requirements of Unit 3: Assessment of Upper Limb.

The successful completion and documentation of the following assessments in Assessment of

Upper Limb is required:

o Two (2) formative assessments of clinical skills, specifically related to the assessment of the upper limb (may be in simulated environments). The two assessments are to be of joints in different parts of the upper limb ie NOT two joints in the hand.

o Two (2) summative assessments of clinical skills, specifically related to the assessment of the upper limb (must be in workplace or on models with pathology if in a simulation setting). The two assessments are to be of joints in different parts of the upper limb ie NOT two joints in the hand.

o One (1) ASUM on-line interpretive, case-based scenario analysis quiz, specifically related to the assessment of the upper limb.

Notes:

o The formative and summative assessments are not to be of the same two joint areas. There must be at least one formative or summative assessment of each of the hand (metacarpals/phalanges), wrist, elbow and shoulder.

o The summative assessments must be undertaken after no less than 50% and then 90% of the clinical record log requirements for upper limb cases have been met.

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ACN 001 679 161 ABN 64 001 679 161

Experience of specified type/number of cases as verified in clinical record log (logbook).

For Assessment of Upper Limb, candidates must demonstrate, in their verified clinical record log,

that they have personally performed:

a minimum of 40 ultrasound scans of each of the: (This gives a total of 120 for upper limb – current CCPU is 50 shoulder, 30 hand/wrist and 20 elbow – total 100 plus 25 guided injections across all limb numbers)

o shoulder o elbow o hand/wrist

of the 40 scans for each area, at least 50% (20 scans) must have been performed in an actual clinical setting and

at least 10 cases must have involved an ultrasound guided procedure at least 25% (10 scans) must have had verified positive findings.

For full details and other clinical record log requirements refer the Candidate’s Education and

Clinical Experience Handbook.

Resources/suggested learning activities (to be fleshed out)


Clinical training

ASUM Standards of practice documents

? key references to be provided by Certification Board specialists

Unit 4: Assessment of Lower Limb

Aim

The candidate demonstrates skill in obtaining valid and efficient ultrasound data in the assessment

of the joints, bones and soft tissues of the lower limb to answer the specific clinical question and/or

guide the invasive procedure. The candidate can recognise when the findings are positive, negative

or equivocal and use this assessment to enhance the clinical management of the patient.

Learning objectives

The candidate can:

describe the clinical questions, related to the lower limb which may typically be addressed using focussed point of care ultrasound scanning, as described in relevant and contemporary peer-reviewed literature or relevant published protocols or standards of practice

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ACN 001 679 161 ABN 64 001 679 161

demonstrate the technical (sonographic) ability to acquire a satisfactory ultrasound examination which is suitable to answer the clinical question, including any dynamic assessments of movement and/or applicable measurements

describe the diagnostic criteria, as described in relevant and contemporary peer-reviewed literature or relevant published protocols or standards of practice, for ultrasound findings which would support a positive, negative or equivocal diagnosis

describe the limitations of ultrasound in assessing the lower limb in a PoCUS context

demonstrate the ability to interpret the ultrasound data to determine if the findings support a positive, negative or equivocal answer to the specific clinical question

demonstrate the ability to determine the appropriate on-going patient management as a result of the ultrasound findings in conjunction with other clinical information

demonstrate the knowledge and psychomotor skills to effectively and efficiently use ultrasound to guide invasive procedures to enhance patient safety and outcomes

demonstrate the ability to describe and adequately document the ultrasound findings in the patient’s clinical record in such a way as to facilitate satisfactory continuity of care of the patient.

Expected standards of practice (Lower limb)

Key clinical questions addressed in PoCUS contexts:

o Which are the relevant joints, bones or soft tissue structures affected? o Is there evidence of abnormal fluid collection/s? o Is there evidence of abnormal bone surfaces/structure? o Is there evidence of inflammation, disruption or rupture of tendons and/or ligaments? o Is there evidence of thickening, inflammation or other abnormality of the synovium? o Is there any evidence of calcification, soft tissue masses or other abnormal space occupying

lesions in the area of interest? o Is there evidence of abnormal movement of structures on dynamic imaging? o What are the measurements of the relevant findings? o What is the clinical relevance of the findings and/or measurement/s? o Are there any other findings which may support another differential diagnosis which may

explain the patient presentation?

Minimum expected ultrasound data acquisition/protocols:

Preparation

o Prepare clinical environment o Prepare patient, including informed consent o Select and prepare ultrasound and ancillary equipment o Enter patient data into ultrasound equipment

Image acquisition

o Acquire and optimise ultrasound images/data, including correct probe choice and use of “stand-off” material if required

o Identify relevant anatomical features and landmarks following determination of clinical area of interest

o Continuous real-time imaging of the area/s of interest to include related bones, joints, tendons, ligaments, muscles, synovium and other soft tissues as relevant

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ACN 001 679 161 ABN 64 001 679 161

o Real-time imaging of dynamic movements of anatomical features if necessary o Measurement of any areas of interest, such as tendon thickness, or if abnormality found,

area/structure measured in 2 orthogonal planes o Apply Doppler techniques as required to demonstrate areas of inflammatory change or to

distinguish vascular structures o Identify and respond to ultrasound artifacts, if required, to improve diagnostic quality of

images/data o If performing a guided invasive procedure follow all protocols as described in Core Unit 2

Needle Guidance Techniques

Minimal recorded images/ultrasound data

The following are the required minimal images to be recorded, unless the patient’s clinical situation

(for example an unstable trauma patient) renders this impracticable and/or unsafe. In this situation,

the practitioner should record whatever images are obtainable, in the time available, to answer the

clinical question without allowing the ultrasound examination to interfere with ongoing medical

treatment.

If local protocols recommend more recorded images/data for a particular examination then these

should be adhered to.

o Representative images of relevant anatomical landmarks and areas of clinical significance in at least two orthogonal planes, preferably with major landmarks annotated

o Measurements of any abnormal findings in two orthogonal planes if possible o If available short video or cine-loop of relevant dynamic movement o If performing a guided invasive procedure, record at least two images in orthogonal planes

to demonstrate needle position. During the procedure and post-procedure images may be required, depending on the procedure, to verify the outcome.

Sonographic appearances of expected positive, negative and equivocal findings

o Describe ultrasound appearances, of the relevant anatomy/area of interest, using correct sonographic terminology, including the appearances consistent with:

o Synovial thickening o Synovial fluid/effusion o Bone erosion o Tenosynovitis o Tendinopathy o Tendon rupture o Ligament tear o Masses: ganglion, tendon nodule, calcification o Bursitis o Impingement features on dynamic assessment

o Identify and describe conclusive findings, positive or negative o Identify limitations of examination or relevance of equivocal findings

Integration of ultrasound findings with clinical information

o Describe relevance of ultrasound findings correlated to clinical presentation and other data

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ACN 001 679 161 ABN 64 001 679 161

o Evaluate findings for monitoring purposes: disease activity/progression/regression o Integrate information with ongoing clinical management of patient

Post examination

o Ensure examination and findings adequately recorded in patient clinical record o Clean ultrasound equipment safely and correctly o Store ultrasound equipment safely and correctly o If guided invasive procedure performed, adhere to applicable infection control guidelines.

Assessments

Assessments for clinical units are focussed on the candidate demonstrating the knowledge, skill and

ability to perform an accurate, valid, efficient, and clinically relevant ultrasound examination which

has the potential to have a positive impact on patient clinical management.

Candidates are expected to develop a solid foundation of key ultrasound knowledge and skills and

apply these to clinical practice in a guided, supervised, incremental fashion. As their experience

builds, candidates may wish to undertake further formal training and education to further develop

and enhance their skills.

To be awarded an ACPoCUS (Rheumatology) a candidate must, amongst other items as described

in this curriculum, successfully meet the specific requirements of Unit 4: Assessment of Lower Limb.

The successful completion and documentation of the following assessments in Assessment of

Lower Limb is required:

o Two (2) formative assessments of clinical skills, specifically related to the assessment of the lower limb (may be in simulated environments). The two assessments are to be of joints in different parts of the lower limb ie NOT two joints in the foot

o Two (2) summative assessments of clinical skills, specifically related to the assessment of the lower limb (must be in workplace or on models with pathology if in a simulation setting). The two assessments are to be of joints in different parts of the lower limb ie NOT two joints in the foot

o One (1) ASUM on-line interpretive, case-based scenario analysis quiz, specifically related to the assessment of the lower limb

Note:

o The formative and summative assessments are not to be of the same two joint areas. There must be at least one formative or summative assessment of each of the foot, ankle, knee and hip.

o The summative assessments must be undertaken after no less than 50% and then 90% of the clinical record log requirements for lower limb cases have been met.

Experience of specified type/number of cases as verified in clinical record log.

For Assessment of Lower Limb, candidates must demonstrate, in their verified clinical record log,

that they have personally performed:

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ACN 001 679 161 ABN 64 001 679 161

a minimum of 40 ultrasound scans of each of the: (This gives a total of 120 for lower limb – current CCPU is 20 hips, 20 knees and 60 foot/ankle – total 100 plus 25 guided injections across all limb numbers)

o hip o knee o foot/ankle

of the 40 scans for each area, at least 50% (20 scans) must have been performed in an actual clinical setting and

at least 10 cases must have involved an ultrasound guided procedure at least 25% (10 scans) must have had verified positive findings.

For full details and other clinical record log (logbook) requirements refer to the ACPoCUS

Candidate’s Education and Clinical Experience Handbook.

Resources/suggested learning activities


Clinical training

ASUM Standards of practice documents

? key references to be provided by Certification Board specialists

Unit 5: Portfolio of Clinical Competence in PoCUS (Rheumatology)

Rationale

The award of an ACPoCUS (Rheumatology) is based on a candidate demonstrating a level of

competence2 in the core clinical applications1 of ultrasound appropriate to the clinical scope of

practice.

Overall competence as a practitioner of PoCUS in rheumatology is determined, by ASUM, by

assessment of multiple items of evidence related to the core knowledge, skills and abilities required

to use ultrasound safely, efficiently and in a way that enhances patient clinical management.

Aim

The aim of the Portfolio of Clinical Competence unit is for the candidate to be eligible for certification

as a PoCUS (Rheumatology) practitioner through submission of a portfolio of evidence verifying

that they meet the Capability Statements for ACPoCUS (Rheumatology).

Requirements

The candidate develops and maintains a portfolio of evidence throughout their education and

training in PoCUS.

On completion of all the required assessments, including those previously detailed in this curriculum

document and the final holistic clinical assessments detailed below, the candidate submits the

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ACN 001 679 161 ABN 64 001 679 161

portfolio of evidence and seeks the award of the Certificate in Point of Care Ultrasound

(Rheumatology) (ACPoCUS).

Final holistic clinical assessments:

Final holistic on-line interpretive, case-based scenario analysis quiz to cover all core clinical areas of the ACPoCUS Rheumatology (that is: Assessment of Upper Limb, Assessment of Lower Limb). The quiz is to assess that a candidate can satisfactorily demonstrate competent level skills in:

o image interpretation and o clinical integration of the ultrasound data.

Final holistic summative clinical competence assessment (based on “global rating scale”3,4) of clinical focussed/point of care ultrasound at the level of competence2 to include:

o overall psychomotor and sonographic skill, including satisfactory use of equipment; o due regard for patient comfort and care at all times; o interpretation of ultrasound findings; o integration of ultrasound examination into patient clinical management; o demonstrated understanding of role and limitations of PoCUS; and o safe and appropriate clinical practice across the core clinical applications

(Assessment of Upper Limb, Assessment of Lower Limb).

Submission of completed Portfolio of Clinical Competence to ASUM for consideration of award of ACPoCUS. Portfolio to consist of

o Evidence of attendance at relevant formal teaching and learning experiences o Clinical record log verifying required scan numbers/type for all core clinical units as

defined in the curriculum o Completed formative and summative assessments for Unit 2: Needle Guidance

Techniques, with the final summative assessment being at the Advanced Beginner2 level

o Completed formative and summative clinical assessments for each specified core clinical unit with final summative assessment for each core clinical unit at “competent” level2

o Completed final holistic summative clinical competence assessment (global

rating scale3,4) by supervisor or other approved person at “competent” level2 o Evidence of satisfactory level of achievement of the following:

Fundamentals of US Practice quizzes x 3 Case-based scenario analysis quiz x 1 for each core clinical unit Final holistic on-line interpretive, case-based scenario analysis quiz

See Candidate’s Education and Clinical Experience Handbook for descriptions of “relevant” teaching and learning experiences See Candidate’s Education and Clinical Experience Handbook and the Clinical Supervisor Handbook for definition of “approved” person

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ACN 001 679 161 ABN 64 001 679 161

Following the submission of the Portfolio of Clinical Competence, the ASUM Certification Board will

review the submission and determine if the candidate has fulfilled the requirements for the award of

ASUM Certificate in Point of Care Ultrasound (Rheumatology).

Where there are significant discrepancies in the level of achievement/competence in any area of

assessment, ASUM reserves the right to require the candidate to undergo additional assessment

prior to determining the final outcome. Additional assessments may be further competence

assessment/s undertaken by independent, ASUM appointed assessors and/or the candidate may

be asked to present for a case-based oral assessment.

Further, where there are significant discrepancies in the level of achievement/competence in any

area of assessment, and the candidate is unable to demonstrate recent (previous 2-3 years)

attendance at relevant ASUM endorsed formal teaching and learning programs, ASUM reserves the

right to require the candidate to undergo additional education at a relevant ASUM endorsed (or

specified) formal teaching and learning program prior to submitting further assessments for

consideration.

References:

1. Möller I, Janta I, Backhaus M, Ohrndorf S, Bong DA, Martinoli C, et al. The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology. Ann Rheum Dis 2017, Aug 16

2. Khan K, Ramachandran S. Conceptual framework for performance assessment: Competency, competence and performance in the context of assessments in healthcare--deciphering the terminology. Med Teach 2012;34(11):920-8

3. Atkinson P, Bowra J, Lambert M, Lamprecht H, Noble V, Jarman B. International federation for emergency medicine point of care ultrasound curriculum. CJEM 2015, Mar;17(2):161-70

4. Ilgen JS, Ma IW, Hatala R, Cook DA. A systematic review of validity evidence for checklists versus global rating scales in simulation-based assessment. Med Educ 2015, Feb;49(2):161-73

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ACN 001 679 161 ABN 64 001 679 161

APPENDIX 1

OPTIONAL/ADDITIONAL CLINICAL UNITS

ASUM offers a range of optional, additional clinical units that candidates may wish to receive

certification for, along with the ACPoCUS core units. As the available units may be subject to

change from time to time, the current list (available on the ASUM website) should be reviewed by

candidates to determine their needs.

Key points regarding additional/optional units are:

Candidates may choose to undertake additional clinical units suitable to their scope of practice needs.

These may be undertaken in conjunction with the core ACPoCUS units or at a later time.

All assessment requirements, as for core clinical units, must be met for additional clinical units.

Additional clinical units assessed as satisfactorily completed can be notated on the ASUM issued

Certificate of Point of Care Ultrasound (Rheumatology). If undertaken in conjunction with the core

ACPoCUS units the additional units will be added to the ASUM issued Certificate. If additional units

are completed at a later time the candidate can apply to ASUM to have their Certificate re-issued

with the updated information notated on the ASUM issued Certificate.

Additional units for ACPoCUS (Rheumatology) as at January 2018

?? are these appropriate

? others

1. Lung assessment 2. Soft tissue assessment 3. Nerve blocks (peripheral) 4. Nerve blocks (central)

australasian society for ultrasound in medicine (asum) … · 2017. 12. 21. · an asum certificate...

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