CORE CERTIFICATION

It is important that our credentialing mechanisms be rigorous. We must also seek to implant the highest standards of quality control and self-policing. CEUS therefore recommends that a physician attain the status of Independent Practitioner (IP) before being allowed to perform Point-of-Care-Ultrasound (POCUS) without supervision.

As CEUS is now adding certification tracks for many advanced applications we have now designated the four basic (and still most important) indications as the Core track.

To become a Core Independent Practitioner one must have taken a CEUS approved introductory POCUS course, and then complete 50 determinate scans of in each of the Core POCUS Applications. (Clinicians working outside of the emergency department may not require certification in all of these applications and may be eligible to become a Limited Core IP).

Definitions of an acceptable scan are:

  • Heart: entire inferior pericardium visualized to detect pericardial effusion and global activity
  • Aorta: vessel visualized from subdiaphragmatic region to bifurcation in transverse view to measure diameter
  • Abdomen: hepatorenal and splenorenal interfaces swept to detect free fluid; diaphragm visualized in LUQ
  • Pelvis: Pelvis visualized to search for free fluid and uterus visualized to detect intrauterine pregnancy (IUP), defined as:
    1. Yolk sac or <<fetal pole with fetal cardiac activity>> visualized inside myometrium
    2. Bladder-uterine juxtaposition confirmed
    3. Myometrial mantle of 5 mm (minimum)

These scans can be verified by a CEUS Core Independent Practitioner, Core Master Instructor, or a radiologist. A cardiologist can supervise cardiac scans. All of these exams must be directly supervised and clearly positive or negative to count towards certification (indeterminate or inconclusive scans do not count). Upon completion of 50 determinate scans in each area, candidates must successfully pass written, visual and practical exams.

Non-IP's who are performing an exam without supervision can declare positives for the heart, aorta and abdomen. They can NOT declare positives for IUP. Positives declared by non-IP's in a STABLE patient must be confirmed by a elective imaging study as soon as possible. Positives declared in an UNSTABLE patient must be shown to the appropriate surgical consultant for consideration. Negative OR indeterminate scans declared by non-IP's must be documented as INDETERMINATE and the trainee must not draw any conclusions from said scan.

Once a trainee has completed the required 50 scans in the Cardiac, Aortic and Abdominal areas, they may complete their Obstetrical certification by submitting still or video images for later review by their trainer. Such images must show either an empty uterus or all three criteria of an IUP, and must clearly show bladder-uterine juxtaposition. On a still image, the uterine tissue must be clearly outlined and either show an endometrial stripe or all three criteria for an IUP. On a still image of an IUP the narrowest part of the myometrial mantle (which must be at least 5 mm) must be measured by electronic calipers and displayed on the archived or printed image.

It is not necessary to have a minimum number of positive scans during the certification process. The challenge of POCUS is not image interpretation, because the recognition of true positives is relatively straightforward. Physicians are capable of doing this effectively after a brief introductory course.

The real challenge of POCUS is image generation, developing the ability to get a clear image on the screen. The certification period serves primarily to ensure that physicians develop sound and effective technique. It also serves to ensure that independent practitioners thoroughly understand the need to reject any substandard image as being inconclusive, and to only declare a scan to be positive or negative when it is incontrovertibly so.

After all scan number requirements have been met, a Basic IP Candidate must complete and pass the CEUS Core Examination series.

CEUS recommends specific documentation standards once you are a Core IP.

Each center should appoint a Core Independent Practitioner to act as local QA leader. It is strongly suggested that measures be put in place to proactively encourage excellence in both image generation and interpretation. These QA mechanisms can include direct observation, tape review and having Independent Practitioners actively involved in teaching (supervising >20 scans per area per year).

These standards are the most demanding of any in North America and quite possibly in the world. They were chosen to ensure that the use of ultrasound technology in Canada was of the highest calibre.

Physicians with significant prior experience in POCUS are eligible for reduced training requirements and can challenge the Core Certification process.