Barriers to accreditation in point-of-care echocardiography for critical care: A Scottish perspective

Abstract

Point-of-care echocardiography accreditation is not mandated within the Faculty of Intensive Care Medicine (FICM) training curriculum, yet it is commonly utilised to aid clinical decision making in the intensive care unit. We designed a survey to assess barriers to accreditation in point-of-care echocardiography across Scottish critical care units. The majority (70.1%) of respondents were unaccredited, with the most common barrier (n = 102) being ‘lack of time with a mentor for supervised scanning’. This was amplified by the fact that only 25% of mentors received job planned time for scanning. Men were over-represented in those with accreditation, accounting for 61.4% of accredited clinicians, despite making up 51.0% of all respondents. In contrast, women represented 62.5% of unaccredited individuals who had undertaken at least one attempt at the process. We did not find a difference with other protected characteristics. This survey suggests that targeted support locally for those struggling to complete the process could address some of these concerns, and that further work needs to be taken to identify and address gender inequity in point of care echocardiography accreditation.

Introduction

For point-of-care echocardiography to be effective at the bedside, clinicians must be appropriately trained in its use ¹ ; yet many struggle to complete an accreditation process. ² A Scottish trainee survey suggested that ‘female sex, less than full-time training, and dual training with anaesthesia’, were all barriers to achieving accreditation. ³ Globally, in the point of care ultrasound (POCUS) community, there has been a drive to understand the extent of any gender inequities and to increase representation from women. ⁴

In the broader context of medical training in general, recent studies and surveys amongst healthcare professionals have demonstrated an imbalance in training opportunities, which could be attributed to prejudicial and discriminatory behaviours ⁵ ; due to this we felt it important to include questions on protected characteristics in our survey. We sought to characterise the experience of all critical care clinicians in Scotland, determining factors adversely impacting opportunities to train in point of care echocardiography.

Methods

A prospective survey aimed at all clinicians working in intensive care was designed and distributed to each intensive care unit across Scotland via email and social media. The survey asked questions on demographics, accreditation experience including barriers to success and clinical governance and quality control. Responses were streamed for those accredited and those unaccredited. All results were anonymised. After completion of the Research Ethics Committee tool, ⁶ no formal ethics approval was sought and participation was voluntary. The survey questions are presented in Appendix 1.

Results

One hundred and forty-seven people completed the survey, comprising 128 (87.1%) doctors and 19 (12.9%) Advanced Critical Care Practitioners (ACCPs). Forty-four (29.9%) had successfully gained accreditation, with Focused Ultrasound in Intensive Care (FUSIC) Heart (previously known as Focused Intensive Care Echocardiography (FICE)) the most common programme completed by 36 of those accredited (81.8%). Men represented 61.4% of those with a formal accreditation. Twenty-four (23.3%) of unaccredited respondents had at least one unsuccessful attempt, of these, 15 (62.5%) were women, one of whom was a less than full time clinician.

Thirteen percent of respondents were ‘less than full time clinicians’, and they accounted for 11% of those with an accreditation. We did not see a large difference in accredited and unaccredited respondents from participants based on their ethnicity, sexual orientation or whether they were living with a disability (see Appendix 2 for further results). Of the 44 participants accredited, 27 (61.3%) did this in under 12 months, therefore would not have required an extension.

Participants were asked to cite their top three barriers, and the most common was ‘finding time with a mentor to complete supervised scans’, followed by ‘finding time with a mentor to review unsupervised scans’. There were 28 mentors which represented 63.6% of those accredited, 7 of these had job planned time for this role (Table 1).

Table 1.

Key results summary.

Role	All (% of all respondents n = 147)	Accredited (% of all accredited, n = 44)	Unaccredited (% of those unaccredited, n = 103)
Consultant	61 (41.5)	29 (65.9)	32 (31.1)
Trainee	59 (40.1)	11 (25.0)	48 (46.6)
Fellow (all junior clinical fellows)	2 (1.4)	0 (0)	2 (2)
Speciality doctor	6 (4.1)	0 (0)	6 (5.7)
ACCP	19 (12.9)	4 (9.1)	15 (14.6)
Total	147 (100%)	44 (100%)	103 (100%)
Gender	All (% of all respondents)	Accredited (% of all accredited)	Unaccredited (% of those unaccredited)
Men	75 (51.0)	27 (61.4)	48 (46.6)
Women	68 (46.2)	15 (34.1)	53 (51.4)
Prefer not to say	4 (2.8)	2 (4.5)	2 (2)
Total	147 (100%)	44 (100%)	103 (100%)
Working pattern	All (% of all respondents n = 147)	Accredited (% of all accredited n = 44)	Unaccredited (% of those unaccredited n = 103)
Full time	128 (87.0)	39 (88.6)	89 (86.4)
Less than full time (LTFT)	19 (13.0)	5 (11.4)	14 (13.6)
Total	147 (100%)	44 (100%)	103 (100%)
Top 3 Barriers to accreditation			Total votes
1.	Time with mentor for supervised scans		102
2.	Time with mentor to review unsupervised scans		60
= 3.	Time for unsupervised scans		39
= 3.	Finding a mentor		39

Discussion

Point of care echocardiography increasingly plays a role in critical care decision making, with 61 (41% of the total) of our respondents performing echocardiography in critical care on a ‘more than weekly’ basis. Despite this, it is not currently mandated in the Faculty of Intensive Care Medicine curriculum for intensivists in training.

Studies have already shown a considerable number of clinicians may use echocardiography at the bedside, despite lacking accreditation. ² This may present a patient safety issue, as well as generating clinical governance concerns.

As far as we are aware, this is the largest survey on this issue within Scotland. Workforce data ⁷ from the period showed 227 critical care consultants, 71 non-consultant doctors not in training posts, 82 doctors in training posts and 64 Advanced Critical Care Practitioners (ACCPs) demonstrating a 26%, 11%, 72% and a 29% response rate respectively. A limitation of our survey is therefore that there was an imbalanced response across these staff groups which could lead to bias in the results towards the experience of doctors in training posts.

In the accredited cohort, the majority were men (61.4% vs 34.1% women) despite a more even split in all survey respondents (51.0% men vs 46.2% women). Women were overrepresented in the group of unaccredited respondents requiring multiple attempts to accredit (62.5%) with only one of these individuals training Less Than Full Time (LTFT). Although survey numbers are small, meaning robust multivariate analysis would not be appropriate, these figures suggest at least in Scotland that fewer women complete the accreditation process. This appears to be outside concerns relating to LTFT work.

More work is required to explore and confirm the gender imbalance seen in Scotland’s accredited clinicians. A 2023 study by Olson et al. looking at procedural training in critical care, demonstrated that gender disparities may prevail in unstructured training environments. Focus groups suggested that men were better at ‘self-advocacy’. Interestingly, the gender disparity was not appreciated at another institution where a structured learning programme in procedural skills was delivered. ⁸ Tzamaras et al. ⁹ performed a simulation-based experiment with surgical residents showing women were less confident in their abilities in central venous catheterisation insertion, despite demonstrating a comparable level of technical skills to men. Pearce et al ¹⁰ demonstrated in an Australasian survey of anaesthesia residents that men completed more procedures and rated themselves at a higher level of competence than the women.

Formal incorporation of the FUSIC Heart training into the ICM curriculum may provide the structured access to mitigate concerns regarding inequity of training opportunities, but this is not without its own challenges. It would place additional requirements on intensivists in training, trainers, institutions and the FUSIC committee overseeing accreditation. Moreover, it would still exclude non training doctors and ACCPs. A suggested compromise could be use of structured local programmes to support learners who have difficulties completing the process, for example, multiple unsuccessful attempts or minimal time left to completion. It is important to note, that the FUSIC Heart committee already offer logbook extensions to support learners who may need more time, where they can demonstrate mitigations against skill fade between training scans.

A limitation of our survey was due to comparatively small numbers based on the estimated critical care workforce, we were unable to draw conclusions on barriers relating to ethnicity, sexual orientation or disability.

A further limitation is that we did not fully explore reasons for failed accreditation although 16 (11%) acknowledged that they ‘ran out of time’ during the attempt. We do not know how many failed to certify based on an unsuccessful triggered assessment. We also did not collect data on supervisor numbers, which would be a limitation on the number of triggered assessments that could be performed.

The rotational element of medical training creates a challenge in fulfilling FUSIC heart requirements, with doctors-in-training accounting for 68% of failed accreditation attempts versus 40% of all survey respondents.

In conclusion, performing focused echocardiography is a complex skill which is increasingly expected and highly valued, yet not formally included within the ICM training programme. There are several barriers consistently identified within Scotland which need to be addressed if we are to see an increase in trained clinicians. Making point-of-care ultrasound training part of the ICM curriculum in the UK could promote equity of training opportunities and prompt the allocation of resources in this area, however this needs to be balanced against the existing demands on the POCUS and critical care community.

Appendix 1

Survey questions

1. What is your role? (If medical background to question 2, if nursing or AHP to question 3)

2. What is your training background? (the training programme you are currently in or have most recently completed)

3. How would you describe your working pattern?

4. What is your gender?

5. How would you describe your ethnicity?

6. How would you describe your sexual orientation?

7. Do you consider yourself to have a disability?

8. Please indicate what your experience has been of critical care echo? (if accredited directed to question 9, if not accredited directed to question 13)

9. Which accreditation process did you complete?

10. How long did the accreditation process take from registration until accreditation? (for most recent successful attempt if >1 attempt).

11. How many attempts did your accreditation take (an attempt is beginning the accreditation process, e.g. registering, attending a course or beginning a logbook)

12. Are you a mentor or supervisor?

13. How often are you performing critical care echo? (when working in ICU; if answer is ‘never’ then directed to question 20)

14. Do you document your echo reports in patients notes?

15. Do you keep a personal logbook of your scans?

16. How do you maintain your echo skills? (tick all that apply)

17. Do you complete any quantitative assessment?

18. Which of the following measurements are you confident to obtain? (tick all that apply)

19. How confident are you in your echo practice?

20. What do you think your top three barriers to accreditation in critical care echo are? (select up to three options)

21. Would you be interested in transoesophageal echocardiography?

22. Please add any other comments about your experience of critical care echo.

Appendix 2.

Further results table for demographics and job roles (excluding those presented in main article).

Role	All (% of all respondents n = 147)	Accredited (% of all accredited, n = 44)	Not accredited (% of those not accredited, n = 103)
Consultant	61 (41.5)	29 (65.9)	32 (31.1)
Trainee	59 (40.1)	11 (25.0)	48 (46.6)
Fellow (all junior clinical fellows)	2 (1.4)	0 (0)	2 (2)
Speciality doctor	6 (4.1)	0 (0)	6 (5.7)
ACCP	19 (12.9)	4 (9.1)	15 (14.6)
Critical care nurse	0 (0)	0 (0)	0 (0)
Total	147 (100%)	44 (100%)	103 (100%)
Training background if medical	All (% of all medical respondents n = 120)	Accredited (% of all accredited, n = 38)	Not accredited (% of those not accredited, n = 82)
Dual ICM/Anaesthetics	52 (43.3)	26 (68.4)	26 (31.7)
Dual ICM/EM	5 (4.1)	1 (2.6)	4 (4.9)
Dual ICM/AM/Resp/Renal	1 (0.8)	1 (2.6)	0 (0)
Single ICM	8 (6.7)	1 (2.6)	7 (8.5)
Single anaesthetics	44 (36.7)	9 (23.7)	35 (42.7)
ACCS	6 (5)	0 (0)	6 (7.3)
Foundation	2 (1.7)	0	2 (2.4)
Paediatrics	2 (1.7)	0	2 (2.4)
Ethnicity	All (% of all respondents n = 147)	Accredited (% of all accredited, n = 44)	Not accredited (% of those not accredited, n = 103)
Asian or Asian British	9 (6)	2 (4.5)	7 (6.7)
Arab	2 (1.4)	1 (2.3)	1 (0.9)
Black	0	0	0
White	125 (85.0)	36 (81.8)	89 (86.4)
Mixed	2 (1.4)	0 (0)	2 (1.9)
Prefer not to say	7 (5)	4 (10)	3 (2.0)
Other/free text response	2 (1.4)	1 (2.3)	1 (0.9)
Sexual orientation	All (% of all respondents n = 147)	Accredited (% of all accredited, n = 44)	Not accredited (% of those not accredited, n = 103)
Heterosexual/straight	123 (83.5)	36 (81.9)	87 (84.5)
Gay, lesbian, homosexual	8 (5)	1 (2.2)	7 (6.8)
Bisexual	2 (1)	0 (0)	2 (1.9)
Prefer not to say	13 (9)	7 (15.9)	6 (5.8)
Other/free text response	1 (0.5)	0 (0)	1 (1.0)
Disability	All (% of all respondents n = 147)	Accredited (% of all accredited, n = 44)	Not accredited (% of those not accredited, n = 103)
Yes	3 (2)	2 (5)	1 (9.7)
No	136 (93)	38 (86)	98 (95)
Prefer not to say	6 (4)	3 (9)	3 (2.9)
Other/free text response	2 (1)	0 (0)	2 (1.9)