FOCUSED INTENSIVE CARE

ECHOCARDIOGRAPHY (FICE)

Accreditation Pack
Table of Contents
Introduction and Aims ...................................................................................... 3
Administration and "ownership" ....................................................................... 3
Evidence base ................................................................................................. 3
Relation to other training programmes and modules ....................................... 3
Summary of Process Requirements ................................................................ 4
Composition of FICE module: .......................................................................... 5
Appendix 1: FICE Curriculum ........................................................................ 11
Appendix 2: Summary of Training Record ..................................................... 15
Appendix 3: Supervised Cases Log ............................................................... 17
Appendix 4: Training Logbook ....................................................................... 18
Appendix 5: FICE Logbook form .................................................................... 20
Appendix 6: Triggered Assessment Evaluation ............................................. 21
Appendix 7: Policy on the Anonymisation of Patient Data (Summary of BSE
guidance) ....................................................................................................... 23
 Core Echo Module for Intensive Care Medicine

Introduction and Aims

Our aim is to put forward a relevant and achievable training pathway for
focused level echo aimed at general intensive care clinicians in the UK. It is
anticipated that the module could be completed during a 6-month block of
training in an appropriate unit. There will be many similarities to pathways in
other specialties and countries.
This document refers to focused adult transthoracic echocardiography, and
does not cover advanced, transoesophageal (TOE) or paediatric echo.

Administration and "ownership"

Development of the module was a joint Intensive Care Society (ICS) / British
Society of Echocardiography (BSE) project, and ongoing changes will
continue to have input from both societies. The ongoing administration will be
controlled by the ICS, including composition of committee and finances. This
will be reviewed in the future depending on integration of focused echo in the
FICM curriculum.

Evidence base
Multiple international studies have documented the utility of a focused or
limited transthoracic echo study in the management of acutely ill patients,
both within and without the Critical Care area1-4. Most of the studies have
been with modest numbers, and from units with particular expertise in echo,
but consensus statements from a number of international bodies have been
uniform in the call for implementation of basic level echo in critical care 5-8.

Relation to other training programmes and modules

There is considerable overlap and repetition with several other training
pathways in focused echo; many groups have already developed good
training structures. The aim of this module is to bring together the best areas
of these pathways in a format most applicable to ICM, rather than attempt to
create something new.
The College of Emergency Medicine (CEM) has defined levels of training in
place for ultrasound training; this level would be similar in many ways to the
echo / heart in cardiac arrest component of level 1 training.
The British Society for Echocardiography (BSE) has adopted Focused
Echocardiography in Emergency Life support (FEEL). Although there will be
many similarities with this programme, our focus will be on all critically ill
patients rather than the peri-arrest population.
Other excellent training documents and statements have been produced,
such as Focused Ultrasound and Echocardiography (FUSE), Focused
Assessment with Transthoracic Echo (FATE), Echo in Life Support (ELS) and
the recent round table consensus document from the ESICM5-8. The key
message and core elements of training are largely uniform across all these
documents. As the round table document reflects the expert views from 13
critical care societies across the world, we have tried to follow
recommendations from this group where possible.

Patient population
“Critically ill” refers to patients requiring level 2 or 3 care, but is not restricted
to those within the Intensive Care Unit. A focused echo study will have the
highest sensitivity in the sickest patients, and potentially less benefit in those
who have minimal organ dysfunction. It is anticipated that the vast majority of
cases collected for logbook should be on patients who have either
cardiovascular or respiratory support. Outpatient studies performed on stable
patients in the echo lab are generally not suitable as part of the logbook.

Summary of Process Requirements

 A fee will be charged to cover administration of the module of £30 for
Intensive Care Society members and £50 for non-members.
 You should address all queries regarding the FICE core module to:
FICE Administrator
The Intensive Care Society
Churchill House
35 Red Lion Square,
London WC1R 4SG
Tel: 0207 2804350 Fax: 0207 280 4369
Email: FICE@ics.ac.uk

 You should register and attend an approved basic echo workshop.

The Intensive Care Society will provide a small number of courses,
however alternative courses (eg: FEEL) may be suitable. Please find a
complete list of approved courses on the ICS website.
The basic echo course should take place no more than 12 months prior
to the first logbook recorded scan; the course should be completed no
later than 12 months after the first log book recorded scan. Individual
exceptions may be considered for those who attended courses before
the inception of FICE, they should apply by email to the secretariat.
There should be no more than 12 months from the 1st to the last
 logbook scan. An extension to 18 months may be considered in
exceptional circumstances after review by FICE committee.
 Locate a mentor (list available on the ICS website)
 You must complete:
o 10 scans, with direct supervision
o Logbook with 50 cases (including above)
o Triggered Assessment
 Complete the Summary of Training document, to be signed by the
Mentor and supervisor, and submitted to the Intensive Care Society
Offices within 3 months of completing the final scan.
o Please note: Log books are NOT to be submitted to the
Intensive Care Society Offices.
o The deadline for submitting the Summary of Training
document is 3 months after the last date of collection of
cases. Failure to submit by this deadline will necessitate
repeating the entire process from the beginning.
o Extensions to this deadline may be granted only following
periods of maternity or extended sick leave or in exceptional
circumstances. Extension requests must be submitted in
writing to the secretariat before the original deadline. A
charge may be made for each request.
 A Certificate of Completion will be issued by the ICS.

Composition of FICE module:

1. Background knowledge
2. Initial hands-on instruction
3. Collection of suitable logbook of 50 cases
4. Review of all cases by mentor, acceptable agreement of findings
5. “Triggered assessment” of candidate performing a focused study
6. Formal “signoff” of completion of above to acceptable standard.

Phase 1
Background reading material and self-directed learning, suggested reading list
will be available on website.
e-learning module available via FICE website
Attend approved basic echo workshop

E-learning
This will be expanded upon in due course. The E- Learning module has now
been completed. This will be mandatory from 1 May 2014. Please click on the
link here http://www.e-lfh.org.uk/programmes/icu-echoultrasound/ A certificate
will be available to download once the module has been successfully
completed.
Course
Attend a pre-approved course on basic echocardiography. A list of approved
courses will be available on the Intensive Care Society website.

ICS will provide a minimum of one course per year to this end. Please see
the website for details of course dates.

Phase 2
Mentored session to ensure basic machine functions and ability to acquire
views
At least 1st 10 scans directly mentored to ensure suitable image acquisition,
this number may increase depending on individual skill acquisition. Some of
these scans may be collected on approved course.
Student performs and records a total of 50 focused echo exams (see below)
within a 12 month timescale from 1st to last scan
Attendance at departmental echo sessions encouraged when possible.
Each exam reported on focused echo logbook report form and images
archived.

Phase 3
50 exams and reports reviewed by ICU module mentor with focused echo
experience
Supervisor +/- mentor carry out triggered assessment
Should be at least 2 adequate views each study, and agreement with main
findings of mentor in majority of cases.
Completed “sign-off” sheet sent to ICS secretariat, certificate awarded for
successful completion.
Further logbook cases / training may be recommended if candidate fails to
demonstrate competence.

Definition of ICM Core echo module supervisor

Mentor
- The ICM echo unit mentor should have suitable experience and regular
practice in critical care echo. This could be defined by appropriate
accreditation (eg: BSE, CEM level 2, FEEL etc), logbook or by
agreement with BSE supervisor.
- They will be either a consultant in ICM, Anaesthesia, EM or an acute
medical specialty or a member of the BSE or ICS. Those without
regular ICM commitment must be members of either BSE or ICS.
- Responsible for the majority of the mentoring and review of trainee
scans
- Responsible for main “sign-off” of trainee logbook after review of scans
 - Must have the ability to refer to supervisor for difficult cases and advice
- Should have access to ongoing training from BSE accredited
supervisor depending on individual requirements
- Must retain logbook of personal cases

- It is anticipated that from 31st December 2014, all future mentors will
require at least FICE accreditation equivalence (by an abbreviated
process )

Supervisor
- Any practitioner with full BSE TTE or TOE accreditation, or equivalent.
- Supervisors wishing to explore “equivalence” should contact the
secretariat for details.
- Should ensure mentor has access to ongoing training depending on
individual needs
- Will sign-off trainee logbook as verification of ongoing relationship with
mentor
- Must perform “triggered assessment” of candidate with mentor towards
end of module
- Has the facility to review scans and accept further referral when
needed
- Is encouraged to participate in trainee teaching when possible
- Should facilitate mentor’s path to full BSE accreditation if appropriate

There should be a dedicated ultrasound machine of acceptable standard

(including image archiving) for transthoracic echo in each unit responsible for
training.

Some possible scenarios.

- Mentor has BSE full adult TTE / TOE / equivalent accreditation

o Supervisor not required, mentor can act as sole party. Links with
echo departments are strongly encouraged.

- Mentor has no echo qualifications, but considerable experience

and expertise.
Or
- Mentor has CEM level 2 echo competence / FEEL / FICE / other
qualification, but not full BSE.
o Ongoing link with supervisor required for governance. This may
be occasional (eg: once a month) supervised scanning to serve
as a “triggered assessment” of ability to obtain and interpret
basic echo images.
 - Mentor has enthusiasm, but limited skills and experience in ICM
echo.
o It is not possible to act as a mentor until further experience and
skills are acquired

These are only examples, and each department will have different
circumstances and challenges.

Focused study
Should generally only be carried out on patients meeting criteria for level 2
care or above. A maximum of 10 healthy volunteer scans are acceptable.
Patient details entered, ECG monitoring for capture. Images must be stored
At least 2 adequate views to be recorded.

5 views - Parasternal long axis

Parasternal short axis
Apical 4 chamber
Subcostal 4 chamber, including IVC view
Lung bases for evidence of fluid
Basic scanning modes only – 2D, freeze, calliper measurements
No use of M mode (except IVC collapse) colour-flow or other doppler. If these
are recorded for training purposes, conclusions must only be made from 2D
images.

Image quality (good / acceptable / poor) should be noted along with number of
views achieved.

Questions to be asked by each study (Answers can be yes / no / unsure)

Is the LV function significantly (ie: moderately / severely) impaired?
Is the LV dilated?
Is the RV dilated or severely impaired?
Is there pericardial fluid?
Is there evidence of hypovolaemia?
Is there pleural fluid?
Other comments can be made, and conclusion of study should be
related to clinical significance of findings.

Logbook report
Must not be entered in patient notes, nor should major treatment decisions be
made on unverified findings – this is a training logbook only
Logbooks and cases must be fully anonymised – please read the BSE Policy
on the Non-anonymisation of Patient data in appendix 14.
Should include clinical haemodynamics, and relevance of echo findings to
clinical scenario

This logbook is not to be submitted to the Intensive Care Society offices. A

Supervisor signature indicating completion of the logbook will suffice as
evidence when submitting completed training summary sheet.

Limitations
A focused study should not be carried out on stable patients to define or
diagnose ongoing chronic cardiac disease eg: stable valve disease,
ventricular hypertrophy or regional wall abnormalities not leading to acute
haemodynamic compromise. A full comprehensive departmental echo is still
the investigation of choice for many patients. Findings from the study must be
related to the clinical scenario, and may change with time and interventions. A
focused study is inappropriate to diagnose or exclude endocarditis. Critically ill
patients are often difficult to achieve good quality images, and it will not be
possible to achieve diagnostic studies on all patients. The temptation to over
interpret poor quality images must be avoided.

Definition of “competence”
Firm evidence is lacking, and training should fit into the existing modular ICM
training structure. The round table recommendations are that 30 scans are the
minimum number to achieve competence in image acquisition. We would
suggest 50 scans as a minimum number for the core module, to allow for
differing levels of skill acquisition. For some candidates, a further period of
training may be recommended. Completion of the module should normally be
possible within a 6 month time period.
1. Cholley BP, Vieillard-Baron A, Mebazaa A (2006) Echocardiography in the ICU: time for
widespread use! Intensive Care Med 32:9–10

2. Beaulieu Y (2007) Bedside echocardiography in the assessment of the critically ill. Crit
Care Med 35:S235–S249

3. Stanko LK, Jacobsohn E, Tam JW, De Wet CJ, Avidan M (2005). Transthoracic
echocardiography: impact on diagnosis and management in tertiary care intensive care units.

4. Orme RM, Oram MP, McKinstry CE (2009) Impact of echocardiography on patient

management in the intensive care unit: an audit of district general hospital practice. Br J
Anaesth102:340–344

5. Morris C, Bennett S, Burn S, Russell C, Jarman R, Swanevelder J for the NPOCUS critical
care echocardiography working group. Echocardiography in the intensive care unit: current
position, future directions. JICS April 2010

6. Jensen M, Sloth E, Larsen K, Schmidt M. Transthoracic echocardiography for

cardiopulmonary monitoring in intensive care. European Journal of Anaesthesiology 2004; 21:
700-707

7. Royse C, Seah J, Donelan L, Royse A. Point of care ultrasound for basic haemodynamic
assessment: novice compared with an expert operator. Anaesthesia 2006, 61:849

8. International expert statement on training standards for critical care ultrasonography.

Intensive Care Med (2011) 37:1077–1083

9. Manasia AR, Nagaraj HM, Kodali RB, Croft LB, Oropello JM, Kohli-Seth R, Leibowitz AB,
DelGiudice R, Hufanda JF, Benjamin E, Goldman ME (2005) Feasibility and potential clinical
utility of goal-directed transthoracic echocardiography performed by noncardiologist
intensivists using a small hand-carried device (SonoHeart) in critically ill patients. J
Cardiothorac Vasc Anesth 19:155–159

10. Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW (2009) Assessment of
left ventricular function by intensivists using hand-held echocardiography. Chest 135:1416–
1420

11. Price S, Via G, Sloth E, Guarracino F, Breitkreutz R, Catena E, Talmor D (2008)

Echocardiography practice, training and accreditation in the intensive care: document for the
World Interactive Network Focused on Critical Ultrasound (WINFOCUS). Cardiovasc
Ultrasound 6:49

12. Vignon P, Dugard A, Abraham J, Belcour D, Gondran G, Pepino F, Marin B, Francois B,

Gastinne H (2007) Focused training for goal-oriented hand-held echocardiography performed
by noncardiologist residents in the intensive care unit. Intensive Care Med 33:1795–1799
Appendix 1: FICE Curriculum
General Principles

Focused Intensive Care Echocardiography (FICE) is a valuable non-invasive

bedside technique to diagnose potentially reversible life threatening conditions
in patients that are acutely short of breath or haemodynamically unstable. This
curriculum details the knowledge, skills and attitudes required for competent
performance of FICE.

Features of Competent Performance

 Understands the technology and it’s limitations

 Uses focused echo in appropriate circumstances
 Reliably acquires images of adequate quality
 Correctly identifies normal and abnormal findings
 Integrates echo findings with clinical picture
 Documents findings in standard echo report
 Communicates findings with the clinical team
 Recognises when expert assistance or alternative investigation is
needed
 Follows infection control precautions
 Appreciates patient safety and comfort
 Safeguards confidential patient data
 Stores images for subsequent review

The curriculum is mapped to the relevant assessment tools as follows:

Assessment Tools
Full name Code
e-Learning E
Mentored Practice M
Logbook L
Triggered Assessment T

The curriculum is also mapped to the four domains of Good Medical Practice:

Domains of Good Medical Practice

Descriptor Domain
Knowledge, skills and performance 1
Safety and quality 2
Communication, partnership, 3
teamwork
Maintaining trust 4
Below is a detailed list of items which describe the knowledge, skills and attitudes which make up the above competences.

Domain 1: Imaging Physics & Instrumentation Assessment GMP

Knowledge
Properties of sound wave: amplitude, frequency, wavelength, propagation velocity E 1
Frequency range of sound waves used in diagnostic imaging E 1
Speed of sound in different media E 1
Behaviour of sound waves at interfaces between media E 1
Generation of ultrasound waves: the piezo-electric effect E 1
Design of the ultrasound transducer E 1
Structure of the ultrasound beam E 1
Principles of attenuation, scattering and reverberation E 1
Skills
Selects appropriate ultrasound transducer M, T 1
Uses conductive gel to aid transmission of ultrasound wave M, T 1
Correctly adjusts depth, gain and focus position L, M, T 1
Identifies common artefacts E, L, M, T 1, 2

Domain 2: Cardiac Anatomy and Pathophysiology Assessment GMP

Knowledge
Echo anatomy: cardiac chambers/valves/great vessels/pericardium E 1
Coronary anatomy relevant to blood supply of the myocardium E 1
Typical size of cardiac chambers and great vessels E 1
Temporal relationship of the electrocardiogram (ECG) to myocardial contraction and valve movement E 1
Components of systolic function: wall motion and wall thickening E 1
Normal patterns of inferior vena cava (IVC) movement E 1
Effect of spontaneous and positive pressure ventilation on the cardiac cycle and IVC movement E 1
Effect of vasoactive drugs on cardiac physiology E 1
Causes of: left ventricular dilatation, right ventricular dilatation, systolic dysfunction, regional wall motion abnormalities, E 1
pulmonary hypertension, aortic dilatation / dissection, pericardial and pleural collections
Skills
Recognises cardiac structures: chambers/valves/great vessels/pericardium L, M, T 1
Identifies walls of left ventricle (LV) and territories of coronary arteries L, M, T 1
Uses ECG to determine phase of the cardiac cycle L, M, T 1

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Domain 3: Image Acquisition and Interprétation Assessment GMP
Knowledge
Movements of transducer and orientation with respect to screen E 1
Echo windows and standard views E 1
Findings in:
Left ventricular dilatation: left ventricle end diastolic diameter (LVEDD) > 6cm E 1
Right ventricular dilatation: right ventricle (RV) greater than 2/3rds the length of the left ventricle E 1
Ventricular dysfunction: reduction in wall motion and thickening E 1
Regional wall motion abnormalities: regional reduction in wall motion and thickening E 1
Pulmonary Hypertension: RV dilatation, ‘D’ shaped deformity of septum, paradoxical septal motion E 1
Hypovolemia: IVC collapse with respiratory cycle, approximation of papillary muscles during systole E 1
Aortic pathology: aortic dilatation or dissection flap E 1
Pericardial collection: collection in pericardial space, distinction from pleural collection E 1
Pleural Collection: collection in pleural space, distinction from pericardial collection E 1
Skills
Reliably acquires standard views L, M, T 1, 2
Comments on whether image is adequate or not L, M, T 1, 2
Correctly identifies normal and abnormal findings L, M, T 1, 2
Interprets echo findings with respect to cardio-respiratory support at time of imaging L, M, T 1, 2
Correlates echo findings with clinical picture and takes appropriate action / inaction L, M, T 1, 2
Repeats focused echo after intervention L, M, T 1, 2

Domain 4: Patient Safety and Governance Assessment GMP

Knowledge
Indications and limitations of focused echo E 1, 2
Relationship between conduct of peri-arrest echo and the Advanced Life Support (ALS) alogorithm E 1, 2
Format of standard echo report E 1
Indications for immediate expert assistance, subsequent comprehensive echo by accredited practitioner or need for E 1, 2
alternative investigation
Importance of entering patient information, capturing images and uploading study to appropriate archiving system E 1, 2
Need to quality assure echo reports E 1, 2
Relevance of Data Protection Act to image storage E 1, 2, 4
Infection control precautions E 1, 2, 4

13
Potential hazardous biological effects of ultrasound: heating/resonance E 1, 2, 4
Need to provide patient explanation relevant to the clinical setting E 3, 4
Skills
Performs focused echo in appropriate circumstances and in ALS compliant manner M, L 1, 2
When needed seeks expert assistance in a timely fashion L, M, T 1, 2, 4
Enters patients details and saves studies L, M, T 1, 2
Accurately documents findings using standard reporting structure L, M, T 1, 2, 3
Takes appropriate infection control procedures M, T 1, 2, 4
Attitudes
Communicates findings with clinical team L, M 3
Considers patient comfort during procedure M, T 3, 4
Seeks regular hands on tuition and review of their echo reports L, M 2,4

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Appendix 2: Summary of Training Record
Focused Intensive Care Echocardiography
Trainee Information
Name
GMC number
Hospital(s) at which FICE
module completed

Name of FICE approved

Mentor

Name of Supervisor

Summary of Training

Component Date Signature

Phase 1
FICE basic knowledge base
completed (please circle) E-
learning/ Other
Please summarise in space below:

FICE Approved Course

Venue:
Date:
Organiser
Phase 2
Supervised cases
Phase 3
Triggered Assessment
Completed logbook

Date of completion
________________________

15
 Mentor: ________________________

Supervisor (if applicable): ________________________

16
Appendix 3: Supervised Cases Log
Focused Intensive Care Echocardiography
Directly Supervised Cases
Case Brief description Date Mentor’s comments Mentor’s signature

1
2
3
4
5
6
7
8
9
10

17
Appendix 4: Training Logbook
Case Brief description Date Mentor’s comments Mentor’s initials
(when required)
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

18
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

19
Appendix 5: FICE Logbook form
Patient Details / Cross reference Date:

Operator:

(Any documents leaving clinical area must be Image quality (

anonymised)
Haemodynamics: Good
Acceptable
Poor

Circle U/A –Unable to assess

Is the LV function significantly YES NO U/A
impaired?
Notes:

Is the LV dilated? YES NO U/A

Notes:

Is the RV dilated or severely impaired? YES NO U/A

Notes:

Is there pericardial fluid? YES NO U/A

Notes:

Is there evidence of hypovolaemia?? YES YES NO U/A

Notes:

Is there pleural fluid? YES NO U/A

Notes:

Other comments:

Conclusion and clinical significance:

Is expert referral required? Y N

Signed: Counter signed:

This is a training report only, and should not be used to influence clinical management without 20
expert verification
Appendix 6: Triggered Assessment Evaluation
Before using this document, a trainee should have completed the following steps:

1. Nominated a FICE-approved mentor and supervisor

2. Gained an comprehensive understanding of the following theoretical and practical competencies, as detailed
in the curriculum
a. Ultrasound imaging physics and instrumentation
b. Cardiac anatomy and physiology
c. Image acquisition and interpretation
d. Patient safety and governance
3. Attended a FICE-approved course
4. Carried out 10 mentored scans
5. Completed a logbook of at least 50 scans

Within each of the following Medical assessors comments recorded during the Competent?
three sections, the learner assessment (please initial)
must:
1. Preparation for the scan
Greets the patient
appropriately and identify the
patient with the notes
Confirms that the indication for
the procedure is within own
competency
Positions the patient correctly
Demonstrates appropriate
attitude and professional
manner

2. The scan
Sets up the equipment
acceptably, including ECG
Probe selection, handling and
scanning technique
Acquisition of the best possible
image using depth, gain and
focus
Demonstrates all views
available
Identifies pericardium and
describes any pericardial
effusion
Describes LV dimensions
Describes overall LV systolic
function
Comments on evidence of
hypovolaemia
Comments on right ventricular
dimensions
Describes right ventricular
function

21
 Identifies IVC in longitudinal
section
Assesses IVC diameter and
collapsibility/distensibilty

Scan completed within

appropriate timescale

Scan clips saved

3. Post scan
Informs the patient if
appropriate

Records findings

Overall performance, recording

and interpretation of scan
satisfactory (Essential
competence)

Certified as complete by (Mentor) ______________________

Countersigned by Supervisor ______________________

(if applicable)
Date Completed ______________________

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Appendix 7: Policy on the Anonymisation of Patient Data (Summary of BSE guidance)

The duty of confidentiality arises out of the common law of confidentiality, professional obligations
and also staff employment contracts. Breach of confidence may lead to disciplinary measures,
bring into question professional reputation and possibly result in legal proceedings.

Guidance is provided to NHS staff in the ‘NHS Code of Practice on Confidentiality’ (November
2003).
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasse
t/dh_4069254.pdf

Patient information that can identify individual patients is confidential and must not be used or
disclosed. In contrast, anonymised information is not confidential and may be used.

Key identifiable information includes:

Patient’s name, address, full post code, date of birth;

NHS number and local identifiable codes;
Anything else that may be used to identify a patient directly or indirectly. For example, rare
diseases, drug treatment or statistical analyses which have very small numbers within a small
population may allow individuals to be identified.

Anonymisation requires the removal of such information from all reports and images.

Guidance to candidates submitting Logbooks and Cases for Accreditation

The NHS Code of Practice on confidentiality means that evidence submitted for the practical part
of the Accreditation process must have all patient identification removed.

23