Bridging the logistical gap between ultrasound enthusiasm and accreditation

Abstract

Point-of-care ultrasound is increasingly recognised as a valuable adjunct to patient care. Trainees in intensive care medicine are expected to accredit in focused intensive care echocardiography, but the availability of trained mentors and logistical/geographical factors make this difficult within the time constraints required. As a result, many trainees who are enthusiastic about point-of-care ultrasound find it difficult to achieve accreditation. We present a secure, web-based, multi-user system which mitigates many of these difficulties and allows for clinical mentorship to take place without geographical barriers, and at a time convenient for the participants.

Introduction

In the past decade, a number of point-of-care ultrasound (POCUS) accreditation schemes have been developed to encourage and facilitate the training of critical care clinicians in these skills. In the UK, schemes include Focused Intensive Care Echocardiography (FICE) accreditation, which provides a recognised structure for training, reporting and accreditation in echocardiography, and Core Ultrasound Skills in Intensive Care (CUSIC) accreditation which provides competency assessments for lung, abdominal and vascular ultrasound. These schemes require a minimum number of scans within a specified time period after undertaking an initial course, with critique and feedback from a qualified mentor. The trainee’s initial scans must be directly supervised by their mentor until basic competencies are met. Subsequent scans can be undertaken without direct supervision but these must be stored for review with the mentor. Current practice involves a trainee accumulating several scans then identifying a mutually available time slot to review these with their mentor. Barriers to this process can include the absence of a trained mentor at a trainee’s location, lack of shared time slots during the working day and trainees rotating to different sites whilst undergoing accreditation. These logistical issues can make accreditation challenging to achieve in the specified timeframe (Table 1).

Table 1.

Barriers to completing FICE/CUSIC accreditation.

No trained mentor at trainee location

Lack of shared time slots during work of day between mentor/trainee

Trainee rotating through different locations

Failure to complete requisite number of scans in specified timeframe

FICE: Focused Intensive Care Echocardiography; CUSIC: Core Ultrasound Skills in Intensive Care.

Methods

We have developed a free Hands On, Cloud Uploading Service for Point Of Care Ultrasound (HOCUS POCUS) web-based application at www.hocuspocus.org.uk which aims to solve some of the logistical problems with gaining accreditation.

In order to register an account, users must provide their name, e-mail address and professional body (e.g. General Medical Council) registration number. These data are collected only for the purposes of allowing users to identify each other (e.g. trainees identifying their mentor’s account) and to produce usable logbook reports for portfolio or accreditation purposes. All data are stored in an industry-standard MySQL (Oracle Corporation, Redwood Shores, CA) database, with full encryption and periodic off-site backups within the UK. Users may request deletion of their account and personal data at any time. The authors believe the site is therefore fully compliant with the European Parliament and Council Directive 95/46/EC.¹

The database is maintained by GR. No access by any other party is currently possible, for example as part of a research or audit project, and any such future access would require the consent of the site users.

Once the trainee and mentor have both created an account on the site and assigned their mentor/mentee relationship, trainees can enter the details required by the FICE and/or CUSIC schemes for each of their scans. Scan data are copied from the ultrasound device in the standardised DICOM file format. The scan clips are uploaded to an external, third-party online DICOM file-sharing service which is free to access (www.dicomlibrary.org). Each scan is then made available via hyperlink from the relevant case record on HOCUS POCUS: the website does not store the scan data itself.

There is no requirement to use the DICOM Library website, and users may link to scans they have uploaded to any available file-sharing service (e.g. Dropbox, Google Drive, iCloud Drive). However, we recommend this particular website for storing scan data as it provides robust anonymisation of DICOM files to prevent patient-identifiable information from being transmitted or stored. Anonymising DICOM scans is more difficult than it may first appear, as there is considerable heterogeneity between the outputs of different ultrasound hardware manufacturers in terms of where identifying information is encoded. In any instance, users must take care to ensure that patient confidentiality is protected and that they are in compliance with their local information governance policies.

Once the trainee is happy with the details entered, they can electronically “sign” the record. From this point, the scans are available for their mentor to view at their leisure from anywhere with an internet connection. The mentor may then add their own comments and answer questions posed by the trainee before indicating whether or not the scan is acceptable for accreditation purposes and adding their own electronic signature to this effect.

This method also allows the possibility of “face-to-face” discussions over encrypted video-conferencing software such as Skype™ (S.A.R.L, Luxembourg) or FaceTime™ (Apple, Cupertino, US) whilst ultrasound clips are being viewed simultaneously by the trainee and mentor. This provides the possibility of real-time discussion and education without geographic constraints. The scan links can also be securely shared with others and so provide an easy route for mentors to seek second opinions or encourage shared learning amongst their peers or with other trainees.

Scans signed by both users are then available to view in the trainee's electronic logbook, which contains the same information as required by the paper logbooks for FICE and CUSIC accreditation. The website is also able to generate a PDF version of the logbook for printing, which includes QR codes allowing third-party verification (e.g. by accreditation scheme administrators) of the electronic signatures (Figure 1).

Figure 1.

Focused Intensive Care Echocardiography (FICE) paper logbook form (left), web-based data capture form (centre) and PDF logbook entry (right).

Results

Initial work by BA and JB to produce an electronic version of the FICE/CUSIC logbooks took the form of a shared spreadsheet using Microsoft OneDrive.² The shared form required the same information as the FICE and CUSIC paper forms and therefore did not require any more time or effort to complete and in fact was less laborious. However, as a single document shared between two parties, it lacked many of the features required of a robust multi-user system.

Further development of a bespoke web-based portfolio system by one of the authors (GR) has greatly improved the user interface and added important facilities such as user access control, a dashboard summarising progress towards accreditation and generation of logbook and summary reports (Figure 2) in PDF format.

Figure 2.

PDF logbook summary report.

Using HOCUS POCUS, his supervisor (BA) has been able to review, discuss and approve scans for JB despite being based at a hospital over a 2 h round trip away and located in a separate training Deanery.

At present, the database holds 17 FICE, 16 CUSIC (pleural) and 6 CUSIC (abdominal) scans, with this number expected to increase significantly as more users register for an account.

During this pilot phase of development, we undertook a simple survey of our 19 registered users; 83% of the respondents strongly agreed that HOCUS POCUS is easier to use than paper forms, with 100% of respondents agreeing or strongly agreeing that the site is well designed and intuitive to use. Reflecting their unequal distribution across hospitals, two-thirds of the respondents agreed that there are problems matching mentors with trainees, while the remaining third reported no problems locally. All respondents agreed or strongly agreed that HOCUS POCUS will make it easier for trainees to achieve accreditation.

Security

Attention was given to security and confidentiality issues throughout this process and all patient-identifiable information are removed from all files prior to use. No patient-identifiable data are stored by the website, which is hosted in a secure data centre in London (Telehouse™, Docklands, UK). All traffic to and from the website are protected with industry-standard SSL encryption. User accounts are created after an e-mail verification process and all user passwords are stored in an encrypted format which is not retrievable by the authors. Access to individual scan data, logbooks and user information is restricted by a permission-based user-level access control system. All data are additionally backed up with encryption to an offsite facility daily.

This project was undertaken with the input of our Trust’s Information Governance Officer to ensure adherence with confidentiality requirements.

Discussion

There is significant enthusiasm for gaining ultrasound experience, but this does not always translate into accreditation, with trainees citing lack of access to mentors and scheduling conflicts as factors.³ We hope that HOCUS POCUS may mitigate some of these difficulties and make it easier for trainees to gain accreditation.

There is already a significant financial burden on intensive care trainees, and the authors have agreed to make the website free to use, albeit with no warranty to users.

Further development is needed to support CUSIC vascular scans, and support for the triggered assessments required by accreditation schemes is planned. To reduce dependency on an external provider, the authors would prefer scan images to be hosted directly on the site but there are multiple technical and legal hurdles to overcome before this is possible.

HOCUS POCUS is still in its infancy and requires further testing to ensure it meets the needs of its users and the accreditation schemes. We welcome any feedback and/or criticism.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.