Professional Documents
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POSITION PAPER
77
Journal of the American Society of Echocardiography
78 ASE Sonographer Training and Education Committee January 2001
cardiac sonographer. Specific goals of this revision lem-solving skills. The cardiac sonographer must
include the following: possess sophisticated cognitive skills and be profi-
• Define the role of the cardiac sonographer cient in the use of sonographic techniques to pro-
• Provide recommendations for educational path- duce accurate and appropriate anatomic and physio-
ways logic information for the physician to review for
• Provide recommendations for on-the-job orienta- diagnostic interpretation.
tion and continuing education. The cardiac sonographer is required to have a
Echocardiography includes the following comple- detailed understanding of cardiac and thoracic
mentary techniques: 2-dimensional echocardiographic anatomy, physiology, hemodynamics, embryology,
imaging, M-mode tracings derived from the 2-dimen- tomographic anatomy, and pathophysiology. This
sional image, continuous wave and pulsed wave knowledge base is a prerequisite to the understand-
Doppler flow velocity recordings, and color flow ing of echocardiographic data and quantitation of
Doppler imaging. Pharmacologic stress agents and derived parameters. The cardiac sonographer must
the performance of exercise are additional methods be able to recognize abnormalities, form a prelimi-
that expand the diagnostic capabilities of echocar- nary set of differential diagnoses, and extend the
diography. The use of contrast agents may be incor- scope of the examination to explore these possible
porated into any of these imaging modalities. pathologic conditions.
Additional techniques such as transesophageal, The cardiac sonographer should be able to obtain
intravascular, intracardiac, and intraoperative echo- pertinent clinical information from the patient, refer-
cardiography are primarily performed by a trained ring physician, and patient’s record, including cardiac-
physician.7,8 Despite this fact, it is recommended related physical findings and pertinent laboratory data,
that the cardiac sonographer have an understanding and to apply the necessary sonographic techniques to
of these techniques and their diagnostic value for the obtain comprehensive and diagnostic echocardio-
evaluation of cardiac anatomy, function, and hemo- graphic information. Failure to obtain and integrate
dynamics. such data may lead to an incomplete examination or
erroneous clinical interpretation of the echocardio-
gram—or both. A cardiac sonographer must be skilled
THE ROLE OF THE CARDIAC SONOGRAPHER in interacting with patients, which involves explaining
the procedure to the patient but not discussing the
The cardiac sonographer is an allied health practitioner clinical findings of the examination.
who, as the result of comprehensive, specialized edu- The cardiac sonographer must be skilled in select-
cation in the medical and technical aspects of diag- ing relevant echocardiographic data, making quanti-
nostic cardiac sonography, is qualified to perform tative calculations from these data, and communicat-
echocardiographic examinations in compliance with ing his or her impressions to the physician inter-
protocols and techniques, as outlined in Essentials preting the study. Although the performance, focus-
and Standards by the Intersocietal Commission for ing, and integration of the various components of the
the Accreditation of Echocardiographic Laboratories.9 echocardiographic examination require the cardiac
The primary role of the cardiac sonographer is to sonographer to be knowledgeable about cardiac
obtain diagnostic recordings of cardiac ultrasonogra- pathophysiology, its sequelae, and the techniques
phy images and Doppler hemodynamic data. The available for evaluating its severity, it is the responsi-
technique is extremely operator-dependant, and its bility of the physician, not of the cardiac sonograph-
optimal performance requires a highly skilled and er, to provide diagnostic clinical interpretations.
well-educated person who can continuously inte- The cardiac sonographer should work under the
grate known clinical information, ultrasonographic supervision of physicians trained to a Level 3 status
image content, and related physiologic data to tailor or by Training Level 2 physicians who themselves are
the examination to ensure that it is comprehensive under the supervision of a Training Level 3 physi-
and accurate. Continuous application of the princi- cian.8 The supervising physician should be available
ples of ultrasound physics and instrumentation dur- for assistance in the performance of the examination
ing the examination is requisite to obtain optimal when it is technically difficult, confusing, or nondi-
data. Accordingly, the cardiac sonographer must agnostic or when ancillary techniques or interven-
assume significant responsibility for the examination tions are needed. The cardiac sonographer should
and therefore must exercise independent judgment, participate with the supervising physician in the
apply knowledge of clinical cardiology, and use prob- interpretive review of the examination to provide
Journal of the American Society of Echocardiography
Volume 14 Number 1 ASE Sonographer Training and Education Committee 79
input in the evaluation of data and to contribute rel- includes determination of the following anatomic
evant technical information.This collaborative, coop- features:
erative effort is necessary to ensure that the diag- • Thoracoabdominal situs
nostic information obtained and reported will be as • Cardiac position
complete as possible. It is also essential for quality • Atrial situs
assurance, as recommended by the Intersocietal • Atrioventricular connection
Commission for the Accreditation of Echocardi- • Ventricular morphology
ography Laboratories (ICAEL).9 • Ventriculoarterial connection
The cardiac sonographer must have a complete • Great vessel relation.
understanding of the physical principles of ultra- The pediatric sonographer must also have an under-
sound, the operation of diagnostic instruments, standing of surgical procedures for the repair or par-
and the bioeffects of ultrasound. He or she should tial repair of congenital heart disease and the various
be responsible for obtaining routine periodic qual- modifications encountered for different congenital
ity assurance and safety checks on the ultrasonog- disorders.10 Knowledge of the 3 major categories of
raphy equipment. The sonographer also should be corrective procedures (total correction, partial cor-
cognizant of patient exposure to ultrasonic energy rection, and palliation) and the variations encoun-
and its effects on human tissue systems to ensure tered is vital when performing pediatric echocardi-
patient safety without sacrificing examination ography. It should be within the skills of all cardiac
quality. sonographers to provide appropriate studies to the
The nature of the patient population mandates physician for the diagnosis of simple forms of con-
that the cardiac sonographer be qualified to perform genital heart disease, such as atrial and ventricular
cardiopulmonary resuscitation. septal defects. Evaluation of complex forms of con-
genital heart disease should be performed by a car-
Specialty Practice diac sonographer with specialty training as a pedi-
Adult transthoracic echocardiography. The car- atric cardiac sonographer, as described later in this
diac sonographer must have a broad understanding article.
of cardiovascular diseases and noncardiac illnesses Transesophageal echocardiography. The role of
that complicate cardiac pathology and pathophysi- the cardiac sonographer in the performance of the
ologic findings in the adult patient population. In transesophageal echocardiography examination is
addition, a broad understanding of the manifesta- usually limited to manipulation of the controls on
tions of congenital heart disease in the adult popu- the ultrasonography system. An understanding of
lation is essential.The ability to adapt the examina- the standard views, the order in which they are ob-
tion to optimize imaging when body habitus tained, and the potential complications of the exam-
and/or immobility present technical limitations is ination are important aspects of the sonographer’s
important when performing adult transthoracic participation in the procedure. The sonographer
echocardiography. The cardiac sonographer must may be involved in preparing the patient, which
also have an understanding of the expected out- involves explaining the procedure, obtaining in-
comes and potential complications of surgical and formed consent, and spraying local anesthesia into
nonsurgical cardiac interventions, know the man- the oropharynx to establish topical anesthesia and
ner in which each affects the anatomy and physi- suppress the gag reflex. Monitoring the hemody-
ology, and be able to tailor the examination accord- namic status of the patient is required of all person-
ingly. nel involved with the procedure. Knowledge of ster-
Pediatric transthoracic echocardiography. Evalua- ile technique and the surgical environment is
tion of the pediatric patient with congenital heart required when performing transesophageal echo-
disease requires specialty training in the embryonic cardiography procedures in the operating room.
development of the heart, lungs, and circulation. Stress echocardiography. Stress echocardiography
Knowledge of the incidence, causes, inheritance pat- is one of the more challenging techniques used in
terns, and pathologic consequences of congenital cardiac ultrasonography laboratories. The cardiac
cardiac malformations is also required. Cardiac sonog- sonographer should have extensive experience in
raphy in the pediatric population requires the ability the evaluation of patients with ischemic heart dis-
to evaluate the cardiac status by using a logical and ease and a thorough understanding of wall motion
systematic approach to analyze the heart and related abnormalities and the corresponding coronary artery
structures segmentally. This segmental approach perfusion regions. It is essential that the cardiac sonog-
Journal of the American Society of Echocardiography
80 ASE Sonographer Training and Education Committee January 2001
rapher record and capture 2-dimensional views to currently being used to educate cardiac sonogra-
ensure visualization of left ventricular segments sup- phers: programs dedicated to cardiac diagnostic
plied by each of the 3 coronary artery distributions. ultrasonography, those offering cardiac and general
Doppler echocardiography may be used in selected diagnostic ultrasonography, and those focused
patients during and/or after stress.The sonographer toward cardiovascular technology. The ASE recom-
must be familiar with the use of specialized digital mends that institutions with such educational pro-
echocardiography equipment necessary to optimal- grams provide a standardized curriculum to pro-
ly display high-resolution images of the left ventric- mote uniform quality for the education of the car-
ular endocardial borders. The cardiac sonographer diac sonographer. The curriculum should include
should be adept at using digital image acquisition comprehensive and rigorous didactic instruction
systems to effectively record representative images as well as a supervised clinical internship of at
during pharmacologic and supine bicycle stress least 6 months.
examinations and immediately after stress in tread- The curricular guidelines below assume successful
mill, bicycle, and pharmacologic examinations. Ex- completion of prerequisites for undertaking sonog-
pertise is necessary to acquire high-quality images rapher education, including comprehensive college-
within 60 to 90 seconds after exercise termination. level courses in the following areas:
Contrast echocardiography. Contrast echocardi- • Anatomy and physiology
ography consists of intravenous or intra-arterial • Pathophysiology
injection of sterile microbubble agents to enhance • Algebra and trigonometry
detection of blood flow within or between cardiac • Basic sciences (eg, biology, chemistry, and physics,
chambers or to improve the definition of cardiac tar- to provide the foundation necessary to under-
get information. The supervising physician and/or stand more advanced concepts).
the cardiac sonographer determine whether con- The student cardiac sonographer should complete
trast injection is indicated. Because of the ever- an educational program that consists of at least 12
evolving advancements in the use of contrast agents months of full-time echocardiography education.The
in echocardiography, it is increasingly important curriculum should consist of competency-based aca-
that sonographers maintain a high level of expertise demic, laboratory, and clinical experience. Hands-on
in contrast administration and imaging techniques. imaging time in the laboratory and clinical setting is
The sonographer will determine which views to essential.An additional 6 months (minimum) of clin-
image during contrast injection and the timing of ical instruction in a primary pediatric setting is rec-
the injection for optimal visualization. A thorough ommended for comprehensive training in pediatric
understanding of the physical principles of ultra- echocardiography.
sound is required, including its various effects on Providing quality education is a complex task. It
microbubbles and the manner in which ultrasono- requires a substantial commitment on the part of
graphic control settings can be optimized with those doing the educating to provide the level of
regard to attenuation, harmonic imaging, and bubble rigor and types of educational experiences neces-
destruction. Sonographers involved in the establish- sary to ensure competence and a professional level
ment of intravenous access and contrast administra- of practice. Although suggested numbers of hours
tion should have appropriate training and certifica- and cases are given in these ASE guidelines, it is
tion. important to recognize that several variables are
inherent to the education process, including but not
limited to the background of the persons being edu-
RECOMMENDED EDUCATIONAL PATHWAY cated, the educators’ experience and interests in
FOR THE CARDIAC SONOGRAPHER teaching, and the professional standards practiced by
the institution. Many factors contribute significantly
The education and credentialing of cardiac sonogra- to the quality and effectiveness of any program,
phers are extremely important to the future of the including the following:
field to ensure the appropriate professional status of • Qualification and competency admission/accep-
competent practitioners and to enhance the stan- tance criteria
dards of practice in echocardiography.These criteria • Intellectual level of textbooks
in turn enhance the quality and cost-effectiveness of • Pedagogic approach (which must include formal
patient care. exercises to promote critical thinking and inte-
The ASE recognizes that several pathways are gration of materials)
Journal of the American Society of Echocardiography
Volume 14 Number 1 ASE Sonographer Training and Education Committee 81
tion be conducted in an environment in which a graduated cardiac sonographer and the institution
broad educational experience can be obtained. that hires the new graduate must be aware of the
Quality education of cardiac sonographers is need for a comprehensive orientation process to
extremely important to the future of the field familiarize the sonographer with all aspects of the
because it enhances the standards of practice in echocardiography laboratory and the institution.The
echocardiography. The ASE recommends that car- orientation period should last a minimum of 6
diac sonographer students consider entering pro- months and ideally should consist of 9 months of
grams that have been awarded accreditation by the direct supervision under one or more members of
CAAHEP, JRC-CVT, or JRC-DMS. Although specific the technical staff and/or the technical director. All
guidelines for approval are found in the CAAHEP’s clinical studies should be supervised. It is recom-
standards and guidelines documents, 2,3 such an mended that every echocardiography laboratory
environment should optimally contain the follow- have in place clearly defined protocols for every
ing: examination type performed.9 The newly graduated
• A broad spectrum of cardiovascular medicine to cardiac sonographer should be proficient at per-
provide the full breadth of cardiovascular diag- forming all examinations according to the defined
nostic procedures protocols. The sophisticated and rapidly evolving
• Comprehensive patient evaluation and care nature of technology in echocardiography demands
• Exposure to preoperative and postoperative car- an advanced level of understanding from the cardiac
diac surgery patients sonographer. Familiarization with all equipment used
• A patient population that encompasses the full in the echocardiography laboratory, including emer-
disease spectrum, from neonatal cardiovascular gency equipment, is a vital part of the cardiac sonog-
abnormalities to cardiac abnormalities of the rapher’s orientation.
elderly, and includes patients who present with a Each echocardiography laboratory and institution
variety of other medical and pediatric illnesses should have written policies and procedures for pro-
that may or may not influence cardiovascular vision of patient care.The cardiac sonographer grad-
dynamics uate should also be familiar with all policies and pro-
• A variety of ultrasonographic imaging modalities cedures before completing an orientation period.
for use in training, including M-mode, 2-dimen- Interaction between the cardiac sonographer and
sional, Doppler (continuous wave, pulsed wave, the medical staff/director is another aspect of the
color flow, tissue velocity), harmonics, and ad- echocardiography laboratory that varies from institu-
vanced automated imaging techniques as part of tion to institution. It is important that the roles and
the ultrasonography equipment responsibilities for communication be clearly defined
• Competent practitioners in echocardiography, and understood by the newly employed cardiac
including physicians, cardiac sonographers, and sonographer.
specialists in the fields of ultrasound physics
Continuing Education
and instrumentation, anatomy, physiology, and
pathology The credentialing and accreditation bodies for the
• An echocardiography laboratory that performs practice of cardiac sonography mandate accumula-
and interprets a minimum of 100 echocardio- tion of specified credits in continuing education.
grams per month. With additional developments in specialized proce-
The ASE Sonographer Education and Training Com- dures and technologies, it is recommended that the
mittee recommends that the teaching program and cardiac sonographer stay current in the field of
the educational environment be evaluated annually echocardiography because these and other new pro-
to ensure that the established curricula reflect state- cedures become a part of everyday practice.The cre-
of-the-art practice in echocardiography. dentialing organizations for cardiac sonography have
established minimum continuing medical education
hour requirements to maintain active status. The
RECOMMENDED PRACTICE ORIENTATION FOR ICAEL requires that each technical staff member
THE CARDIAC SONOGRAPHER earn 30 hours of echocardiography-related continu-
ing medical education over a 3-year period for the
The operator-dependent nature of echocardiography laboratory to be granted and to maintain accredita-
dictates that the cardiac sonographer assume signifi- tion.9 It is important for individual sonographers to
cant responsibility for the examination. The newly take responsibility for their own education. Institu-
Journal of the American Society of Echocardiography
Volume 14 Number 1 ASE Sonographer Training and Education Committee 83
St. Vrain JA, Skelly AC, Waggoner AD, et al. Multiskilling phy and the professionalization of cardiac sonographers. J Am
and multicredentialing of the health professional: role of Soc Echocardiogr 1999;12:335-42.
the cardiac sonographer. J Am Soc Echocardiogr 1998;11:
Report of the National Commission on Allied Health (Work-
272-4.
place Relationship Committee). J Allied Health 1996;25:31-
Waggoner AD, Skelly AC. The profession of cardiac sonogra- 69.
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