|Year : 2013 | Volume
| Issue : 1 | Page : 18-23
Professional education, training and role of the cardiac sonographer in different countries
Irene Nicastro, Valentina Barletta, Lorenzo Conte, Iacopo Fabiani, Alessandro Morgantini, Giovanna Lastrucci, Vitantonio Di Bello
Department of Cardiac Thoracic and Vascular, University of Pisa, Pisa, Italy
|Date of Web Publication||10-Sep-2013|
Vitantonio Di Bello
Department of Cardiac Thoracic and Vascular, Via Paradisa, 2- 56124 Pisa
Source of Support: None, Conflict of Interest: None
Performing a good echocardiographic examination requires intensive training and highly qualified technical staff personnel, which, in many countries, is represented by the Cardiac Sonographer. Being an operator-dependent diagnostic method, a long debate has been held to help identifying the most appropriate curriculum for the training of this professional profile. Although guidelines for the education of the Cardiac Sonographers have been suggested by the American Society of Echocardiography (ASE) several years ago and many scientific publications have given credibility, trust and enhance to this professional profile in Italy, this figure is not yet recognized by the National Health System. It is encouraging that in the last decade, national authorities, such as the SIEC (Societΰ Italiana di Ecografia Cardiovascolare), have expressed interest in recognizing the Cardiac Sonographers as professionals in our country. Per their guidelines, the Cardiocirculatory Physiopathology Cardiovascular Perfusion technicians (TFCPCs) seem to be, among the professionals, the most suitable, due to their educational training and the role they play. Taking inspiration from the positive experience of this professional figure in the USA and in the Anglo Saxon countries, it could aims to be a valid support in terms of cost and quality for the Italian health system.
Keywords: ASE, digital lab, echocardiography, SIEC, sonographer
|How to cite this article:|
Nicastro I, Barletta V, Conte L, Fabiani I, Morgantini A, Lastrucci G, Bello VD. Professional education, training and role of the cardiac sonographer in different countries. J Cardiovasc Echography 2013;23:18-23
|How to cite this URL:|
Nicastro I, Barletta V, Conte L, Fabiani I, Morgantini A, Lastrucci G, Bello VD. Professional education, training and role of the cardiac sonographer in different countries. J Cardiovasc Echography [serial online] 2013 [cited 2020 Jun 2];23:18-23. Available from: http://www.jcecho.org/text.asp?2013/23/1/18/117981
| Who is the Cardiac Sonographer and What are its Responsabilities|| |
It is more than 40 years since echocardiography was first introduced as an instrumental examination for the diagnosis of many heart diseases. Transthoracic echocardiography is a non-invasive diagnostic technique, is easily accessible, and provided us with high performance results and real time information about the structure and the cardiovascular function. The Cardiac Sonographer has played a key role since the outset of this technique.  In literature, there are several scientific papers on this topic and they have been used to define the basis of minimum standards and recommended training courses for the formation of this professional profile. The Sonographer, in fact, has long been an unknown and unidentified figure. General medical practitioners, cardiologists and general health staff in different countries are still unaware of these professional skills. According to a report by the latest guidelines from the American Society of Echocardiography (ASE), the Cardiac Sonographer is a professional qualified to perform the echocardiographic examination in technical compliance with the guidelines and protocols laid down by 'Essentials and Standards of Intersocietal Commission for the Accreditation of Echocardiographic Laboratories (ICAEL).  In particular, the Cardiac Sonographer has the competence to perform non-invasive examination of the heart and great vessels using ultrasound imaging and Doppler technology. 
The primary role of the Cardiac Sonographer is to achieve good quality recordings of ultrasound cardiac images and hemodynamic Doppler data. The ultrasound technique is highly operator-dependent; therefore, an optimal performance requires careful training, good skills and experience of the operator. Hence, the cardiac Sonographer could play an extremely important role in the integrated process of acquisition, interpretation and subsequent reporting of the stored ultrasonic images.The Cardiac Sonographer must have good cognitive capacity, be proficient in ultrasound techniques, and produce accurate and appropriate anatomical and physiological information by the use of technology.
The Cardiac Sonographer has to be able to perform a standard echocardiographic test, select and focus the attention on the echoparameters relevant to the case by adapting the examination and optionally by amplifying on the individual problem, to allow a cardiologist the correct management of the patient. The physician reviewer, in fact, must receive all the information necessary to formulate a correct diagnosis.
To understand the ultrasound, physical principles and the knowledge of the equipment functioning is a prerequisite to obtain good data. For the cardiac sonographer, it is necessary also to learn the anatomy, the physiology, the hemodynamics and the pathophysiology of cardiac and thoracic surgery. These basic skills are an indispensable prerequisite for the interpretation of the obtained data, and the echocardiographic and Doppler parameters. The Cardiac of Sonographer work should always be supervised by a specialist who formulates a diagnosis and bears clinical responsibility.
The Cardiac Sonographer can assist the cardiologist at the moment of the examination, revision and reporting in order to provide useful interpretive and technical information. This cooperation is required to formulate the most accurate and comprehensive report. In transthoracic echocardiography, the Cardiac Sonographer should be able to optimize images even in difficult conditions that can occur in case of an immobilized patient.
The Cardiac Sonographer further performing trans-thoracic echocardiography and vascular ultrasound, is qualified to assist advanced echocardiographic procedures such as trans-oesophageal echocardiography, stress echocardiography and contrast echocardiography.
The cardiac sonographer should only be considered as a technician, and doesn't carry a healthcare competence, and hence cannot and should not be asked to do the tasks of registered nurses, such as, cannulating veins, infusing drugs or any other ways of assisting patients.
| Cardiac Sonographer: Recommended Training|| |
In 1992, the ASE published a report containing recommendations for the Sonographer training.  This report was subsequently resumed and updated in the guidelines for "Cardiac Sonographer Education: recommendations of the American Society of Echocardiography Sonographer training and education committee" in 2001.
A delineation of the training and a standardized core curriculum for the Cardiac Sonographer are both extremely important elements for the future and the increasing exploitation of this professional figure. Though the cardiac sonographer is recognized as a professional figure in the United States of America and Anglo-Saxon countries, it is still striving for its own professional place in Italy.
The ASE has endorsed several programs that are currently used for the training of Sonographers. In general, programs for Cardiac Sonographer training must provide teaching activity and a rigorous practical clinical training.
The educational program curriculum should include the following topics: Basic sciences (biology, physics, chemistry, statistics), cardiac anatomy and physiology, pathology and pathophysiology of heart failure, physical principles of ultrasound, basics of pharmacology, and what particularly concern echocardiographic technique, as probes and instrumentation, methods, applications, image quality, interpretation, medico-legal aspects, techniques of clinical research. , Clinical training should include a full time practical training of atleast 6 months duration. During this clinical training, the Cardiac Sonographer "student" should perform echocardiography on at least 40 patients per month (about 2 a day), using 2D techniques, M-mode and colour Doppler. For an optimal clinical formation, the student should extend the internship period to 12 months, in order to see a minimum of 480 patients under the supervision of the physician. The Cardiac Sonographer should also run and participate in the interpretation of 50 stress echo as part of their apprenticeship.  The ASE Sonographer Education and Training Committee hopes that the future Sonographers could complete their training in accredited and experienced facilities, as "high standards" in education are extremely important to ensure adequate quality in echocardiography.
| Continuing Education in Medicine|| |
The organisations responsible for accreditation have established for the Sonographer a "minimum number of hours required" for continuing medical education (CME) to develop their skills. Each Sonographer should meet the applicable procedure volume requirements and CME requirements first set in the ICAEL standards. Until April 2002, the ICAEL procedure volume standards require the performance of 300 resting transthoracic echocardiograms per year and 100 stress echocardiograms per year.  Therefore the Sonographer, individually, should feel be responsible and the community should be made aware of this update, as echocardiography is a fast-evolving method.
| Accreditation|| |
The ASE states that the minimum requirements of Sonographers skills should be accredited. However, the accreditation process is mandatory only in some countries. In Europe, there are no formal guidelines regarding and regulating the practice of trans-thoracic echocardiography, nor the obligation to be accredited. However, even in Europe there is a possibility, after passing an exam with the 'European Association of Echocardiography", to achieve voluntary "accreditation". 
European accreditation, however, is appointed exclusively to test the skills of each individual in performing and interpreting routine echocardiographic studies. The rights and responsibilities of the Sonographer are defined and established under national laws and regulations of each country. Even in England, where the Cardiac Sonographer (Cardiac physiologist) is an integral part of every echocardiography laboratory, the accreditation is not mandatory.
| Digital Echocardiography|| |
Digital storage and review is now the state of the art technological development in echocardiography, urging of practitioners to quickly move to all-digital laboratories.  In 2008, the European Association of Cardiovascular Imaging (EACVI, formerly EAE) has published the recommendations for standardization of performance, digital storage and reporting of echocardiographic studies, where the minimal standard acquisition protocol for transthoracic echocardiography is described with the minimum data sets required for each patient.  The identification of these data sets of quantitative and morphological variables for echocardiographic recording and report is essential, as already mentioned in 2002 in the ASE recommendations.  Hence accredited physicians, or sonographers in some countries, are responsible for the performance and quality of all echocardiographic studies conducted under their supervision. 
The integration of the echocardiographic digital lab, where the cineloop and the echocardiographic images (sequence is precisely defined by the above mentioned protocols, with the cardiac sonographer profession, in the execution) of the echocardiographic examination, has demonstrated to be efficient for resource optimization. As shown in a paper published in 2009, the implementation of digital echocardiography, certified sonographer, and a miniaturized echo system allowed improvement of cost-effectiveness of the service provided by the echo-lab for inpatients, and avoided patients' discomfort derived from prolonged waiting time before and after the exam. 
| The European Scene: The Sonographer and England|| |
In the UK, the majority of echocardiograms are performed and reported by experienced cardiac physiologists. Cardiac physiologists (as called in the U.K. and Australia), or cardiovascular technologists and technicians (as called in the U.S.), assist physicians in diagnosing and treating medical conditions related to the human heart. A survey on transthoracic echocardiography practice in the UK published in 2007 showed that the cardiac physiologists performed echocardiograms in 98% of hospitals, and reported them in 88% of them. In terms of workload, cardiac physiologists performed and reported over 80% of all echocardiograms in 87% of hospitals. Just over half (57%) of these experienced technicians held a formal echocardiographic accreditation. Remarkably, only 22% of doctors who performed echocardiograms held such
an medical accreditation. There is no legal requirement to hold a recognized ultrasound qualification in order to practice as a sonographer in the UK.  In fact, even if most of the echocardiograms are performed by cardiac psysiologists, Cardiac Sonographers, as specific professional figure, are not currently State Registered in the United Kingdom. The anglo-saxon reality is very different from the Italian one, where, till today, the physician can exclusively perform and report the echocardiographic examinations.
| The Italian Reality and the Figure of the Circulatory Physio-Pathology and Cardiovascular Perfusion Technician|| |
In Italy, the Cardiac Sonographer professional figure is not yet recognized by the National Health Service. However, there is a huge interest for this professional position, which has already been included into the clinical routine of Anglo-Saxon and American cardiology laboratories. In the last decade, various professionals such as nurses, radiology technicians and Cardiocirculatory Physiopathology Cardiovascular Perfusion technicians, expressed their interest towards the profile of the Cardiac Sonographer.
Nevertheless, only the Cardiocirculatory Physiopathology Cardiovascular Perfusion technician (TFCPC) seems to have a technical-practical education, coherent, and almost comparable to the training courses offered and recommended for the Cardiac Sonographers training in the guidelines published by ASE in 2001. The Italian TFCPC has a strong similarity with the British cardiac physiologist.
During the three years of training, the TFCPC follows a teaching program in which courses of Cardiology, Cardiac Surgery, Cardiovascular Diseases, and Diagnostic Imaging are integrated with basic sciences such as chemistry, physics, computer science, statistics, biology, etc., and also performs the clinical training in hospital departments such as Cardiac Surgery, Cardiology, Hemodynamics and Arrythmology. After graduation, the education program can also be further deepened through the attainment of Masters, which, besides consolidating the already acquired knowledge, provides specific technical knowledge of echocardiography.
During this Master course, a period of over 500 hours of clinical training is planned, which aims to mature the practical skills, essential for the future Sonographer. The master title achievement takes place after passing a theoretical and practical examination, assuming the ability of the student to perform a basic echocardiographic and/or vascular exam, according to techniques M-mode, B-mode and colour Doppler.
There are several Master level courses for sonographers in Italy Currently. One of them has even brought staff from 77 Universities together, and is led by the University of Padua. Though rare, cardiac labs are present in Italy, and a Cardiocirculatory Physiopathology Cardiovascular Perfusion technician can work actively in the echo labs as Cardiac sonographers. A positive example is represented by the echo digital lab of the Cardiopulmonary Sciences Department of the University of Udine where, 2 physicians, 1 secretary and 3 cardiac sonographers work together in the echo lab as a team.
The implementation of the cardiac sonographer profession and digital labs shows several advantages. The presence of cardiac sonographers and the consequent possibility to assess imaging data separately from medical report (as in the echo digital lab) improves the lab efficiency, as the cardiologist can work on the report, while the technician continues to assess images, thus reducing the time periods of echocardiographs inactivity. Furthermore, the cardiologist can obtain higher quality reports in a shorter time, with a more accurate clinical implementation of the echo images. Hence, we have a reduction of the unit cost of echocardiographic examinations and the improvement of reports quality. 
The high demand for echocardiographic examinations, and the strong positive European experience represented by England, has aroused a deep interest in the topic, even by some national boards such as the Italian Society of Cardiovascular Echography (SIEC). It is very important to emphasize that the SIEC has included within its program, among the objectives to be achieved, the following aims:
- A way to establish the professional figure of the Sonographer;
- A document about the Sonographer in Italy;
- An area dedicated to Sonographer in the SIEC;
- A training program (Bachelor, Master, company certification).
This "new" professional figure could be a valuable support for the National Health System (SSN) in terms of cost/ quality, helping to resolve the problem of long waiting lists that currently affect the implementation of this diagnostic test. One of the barriers that prevent the diffusion of the cardiac sonographers in Italy is the plethora of cardiologists that can execute cardiovascular echography in labs and ward, making less urgent the need of a technician beside them. The opposite happens in the Anglo-Saxon countries where the cardiac sonographer is a diffuse profession.
| A Look Ahead: The United States and 'ACS'|| |
Cardiovascular sonography is rapidly growing in the medical field, thanks to recent advancements in the vascular and sonography technology.
There are several options in the U.S.A. for those seeking a degree in cardiovascular sonography including:
- Associate's Degree - This is the most common degree obtained in cardiovascular sonography. The two-year degree program focuses on the core courses of the first year for the student. In the second year, the focus shifts towards a specialization and clinical studies. After obtaining the degree, most go into the work force and continue to receive on-site training from an employing hospital or clinic.
- Certification - While certification in cardiovascular sonography is not technically required, it helps to achieve higher professional standards. There are two options available for certification. One is the Registered Cardiac Sonographer certification offered by Cardiovascular Credentialing International, and the other is a Registered Diagnostic Cardiac Sonographer certification offered by the American Registry of Diagnostic Medical Sonographers.
- Bachelor's Degree - Though a cardiovascular sonography bachelor's degree is less common than the associate's, more number of schools are offering students the opportunity to obtain the bachelor's degree, which gives more training within a focus, and more opportunities for clinical classes to obtain hands on experience.
- Master's Degree - There are specific masters in Cardiovascular Sonography. These special programs are designed to prepare students for entry-level positions in the field of cardiovascular technology, but it is for those who already hold bachelor's degrees. Students take a series of courses as well as attend on-campus lectures integrated with hands-on training in the ultrasound lab.
In the U.S., in addition to being recognized and operating in the clinical routine, the figure of the Cardiac Sonographer is already framed in a more complex and structured position. A recent report aims to identify the potential of Cardiac Sonographers in reaching advanced operational levels. 
The Advanced Cardiovascular Sonographer (ACS), would be assigned the task of instructing less experienced Cardiac Sonographers on more sophisticated echocardiographic technologies, and the newer methods of analysis and validating and incorporating them in daily practise. Further, they need to ensure that all echocardiographic parameters required based on patient history, have been obtained, to review studies and images acquired during the echocardiographic examination, and assist the Sonographer in case any additional projections or parameters are needed.
It is important, however, not to confuse qualitative echocardiographic assessment and the drafting of the final report, because, although the ACS is designated to play an important role during the review of preliminary examination, and, if necessary, assisting the Cardiac Sonographer of a lower level, the responsibility of the final report nonetheless lies on the specialist. ,
The ACS would promote the advancement and integration in clinical routine of more sophisticated ultrasonographic methods, thus improving the quality of Echolab, and ensuring a better service to the patients.
| Conclusions|| |
The Cardiac Sonographer is a figure with a professional profile and with skills now well established in many countries. The recognition and integration into daily clinical practice of Sonographers, could lead, even in Italy, to an overall improvement in performance offered by public and private echocardiographic laboratories.
The improvement could be achieved in terms of reduced downtime and waiting lists for echocardiography and increased efficiency, with a significant reduction in unit cost of the examination itself (due to reduced cost of personnel performing the echocardiogram and better use of resources).
Thus, in our report, we have aimed to make the medical professionals and health employees aware about the responsibilities and the potential of this professional figure, and also to reflect on the comparison of this figure with already existing professions in Italy, in the Anglo-Saxon countries and in the US.
| Acknowledgements|| |
Thanks to Dr. Giovanna Lastrucci for editorial assistance.
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