BTS has just published Training Standards for Thoracic Ultrasound (TUS). How was this new project conceived?
This is an exciting new document produced by BTS in response to a call from the pleural community to update TUS training. TUS practice and TUS training is, in the majority, delivered by respiratory physicians, yet we still follow the Royal College of Radiologists’ guidance. Alongside this, other point of care ultrasound curricula are evolving and hence the pleural community proposed that respiratory physicians, through BTS, develop our own training standard. The BTS Board of Trustees and the Joint Royal Colleges of Physicians Training Board (JRCPTB) Specialist Advisory Committee (SAC) for respiratory medicine reviewed and approved the proposal for the production of a training standard in thoracic ultrasound.
At the time I was fortunate to be chair of the BTS Education and Training Committee and was asked to chair the writing group.
Who was involved in developing the standards?
It was important that the writing group had a wide membership to ensure that the training standard is relevant, comprehensive, robust and deliverable. The group therefore included representatives of the Respiratory SAC, members of the BTS Pleural Diseases Specialist Advisory Group (BTS Pleural SAG), respiratory physicians with an interest in pleural disease (including pleural leads from specialist centres and from a district general hospital) a pleural nurse specialist, respiratory specialty trainees, a representative from the British Society of Thoracic Imaging (BSTI) and a co-author of the Focused Acute Medicine Ultrasound (FAMUS) curriculum from the Society of Acute Medicine.
How did the writing group determine the scope of the standards?
In 2018, members of the BTS Pleural SAG published a paper outlining an aspirational model for the safe and effective provision of pleural medicine services in the UK (1). We used this as a basis for initial discussion and from here, as a group, agreed the content and format of the BTS standard.
Drafts were presented in subsequent years at pleural SAG open meetings at the BTS Winter Meeting and regularly at the RCP respiratory SAC meetings, providing us with important feedback. The final version was then presented to and approved by the Respiratory SAC, as well as BTS Board.
An important decision at the outset was to ensure the focus of the document was on training in TUS. We did not cover procedural training, pleural service provision, and nor did we include competency frameworks. TUS in acute respiratory failure is also excluded as this is addressed in other curricula.
It seems that TUS has evolved significantly in recent years and transitioned more closely into respiratory care. As a respiratory consultant, how do you think this area of medicine has changed?
Things have certainly changed (for the better) following the National Patient Safety Alert in 2008 and bedside TUS at the time of intervention for pleural fluid is now a mandatory requirement (2). Pleural sub-specialty work has increased significantly over the last 15-20 years with increasing uptake of local anaesthetic thoracoscopy and the development of pleural services. This has, however brought challenges to service provision out of hours and training.
How has this change impacted training? How is training organised at the moment?
The training curriculum used at the moment is the Royal College of Radiologists (RCR) “Focused” and “Level 1” TUS for trainees, and “Level 2” for trainers, adopted by the JRCPTB Respiratory Medicine Curriculum.
We have been hearing for a while now that the rigid requirements for respiratory trainees to attend appropriate lists to gain experience and the required number of scans, could be impractical and difficult to deliver. Work by Andrew Stanton and others clearly showed that the majority of TUS and TUS training is performed by respiratory physicians, rather than radiology (3). It was probably therefore overdue that we should develop a training process best suited those delivering TUS and those needing to learn.
Given this backdrop, what did the writing group set out to produce?
As a group we felt it was important to create a single document detailing the training standards that was practical, deliverable and inclusive. We have adopted progressive training tools called Entrustable Professional Activites (EPAs) or, as they will be named in JRCPTB curricula, Capabilities in Practice (CiPs). These allow a more flexible accumulation of experience on an ad hoc basis as well as on pleural lists, fitting in with how many pleural procedures are done on a day to day basis across the UK.
An exciting new development in this TUS training standard is the introduction of an “Emergency” level TUS. The aim here is to help with the provision of safe out of hours (OOH) TUS in the exceptionally rare situation that an intervention is required in this setting. The vision is that this will help trusts formulate robust OOH plans for TUS and allow a more present and permanent workforce (e.g. critical care outreach nurse practitioners, advanced care nurse practitioners, physician associates, emergency medicine and intensive care medicine teams) to deliver TUS in these emergency settings. Importantly TUS competence does not impart procedural competence, but can help this be delivered alongside someone competent to make management decisions and undertake the procedure. As you can imagine this section stimulated the most discussion, but we hope we have produced a balanced and deliverable option.
Central to the document is also the critical notion that TUS is to be used alongside clinical information, complementary imaging modalities (plain radiography and CT) and thoracic radiology. It is about helping all of us to use TUS effectively and safely alongside our other skills and resources to ensure our patients receive the best care, diagnosis and treatment.
Who do you anticipate reading the document?
I would expect a broad range of professionals to be interested in this publication. The Training Standard addresses the provision of acute or emergency pleural ultrasound and will therefore be relevant to providers of both acute and out of hours medical care.
We hope that in addition to respiratory teams, acute medical and intensive care consultants, advanced nurse practitioners, physician associates and specialty trainees in general and acute medicine, looking to develop TUS skills will all find the standards useful. We have also referenced other USS training programmes such as FAMUS and CUSIC and how these will feed into this pathway.
Can you tell us the key element of the standards?
There are 3 key inclusions:
- The assessment of normal and abnormal anatomy including normal lung, pleural fluid in infection and malignancy, and pulmonary infection.
- The establishment and maintenance of TUS competencies.
- Description of a practical and achievable structure for the provision of TUS training across secondary and tertiary healthcare settings.
Readers will find details on:
- Entrustable Professional Activity/Capabilities in Practice
- Operator Levels
- Maintenance of Competency
- Applicability to other specialities and allied health professions
Figures and tables are included to summaries the primary and advanced operator pathways.
How do think this publication will impact TUS training?
Our aim is that this document will bring further clarity to TUS training alongside the other point of care curricula we have already mentioned. Importantly we had the support of the Respiratory SAC when writing this document, and that changes and updates to the respiratory curriculum will be aligned to the standards.
We are also keen that this document provides a TUS training structure for other professionals such as physicians associates and nurse practitioners as pleural services broaden their teams.
We acknowledge in the document that the oversight of TUS training and those practitioners in a trust who are signed off to practice at the different levels, will fall to pleural mentors and/or pleural leads. Whilst this brings a more robust governance to TUS provision, it will also require time and we hope the training standard will help provide a stimulus for this time to be included in job planning.
References:
- Evison M, Blyth KG, Bhatnagar R, et al Providing safe and effective pleural medicine services in the UK: an aspirational statement from UK pleural physicians BMJ Open Respiratory Research 2018;5:e000307. doi: 10.1136/bmjresp-2018-000307
- NPSA Alert 1 May 2008. Chest drains: risks associated with the insertion of chest drains. NPSA/2008/RRR003.
- Stanton AE, Evison M, Roberts M, et al. Training opportunities in thoracic ultrasound for respiratory trainees: are current guidelines practical? BMJ Open Respiratory Research 2019;6:e000390. doi:10.1136/bmjresp-2018-000390