EDUCATION AND CLINICAL PRACTICE: ORIGINAL RESEARCH • Methodologic Quality of Guidelines for Training or Competence Processes for Basic Point-of-Care Echocardiography in Critical Care – A Systematic Review of the Literature

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EDUCATION AND CLINICAL PRACTICE: ORIGINAL RESEARCH • Methodologic Quality of Guidelines for Training or Competence Processes for Basic Point-of-Care Echocardiography in Critical Care – A Systematic Review of the Literature

Source: CHEST 2021; 160(2):616-623


Clinical practice guidelines are often described as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” However, the formulation of expert opinion guidelines may be associated with several sources of bias that could adversely affect the quality of the recommendations. In fact, an evaluation of clinical practice guidelines showed that guidelines published between 1985 and 1997 did not adhere well to established methodologic standards.

Point-of-care ultrasound (PoCUS) is defined as a diagnostic or procedural guidance ultrasound performed by clinicians to help guide patient management. The current pathways for PoCUS training, education and competence rely on expert guidelines issued by various national professional societies and organizations. No appraisal has been made to assess the methodologic quality of guidelines on basic critical care echocardiography (BCCE) education.

Therefore, the objective of this systematic review was to critically appraise the methodologic quality of such expert guidelines/recommendations on BCCE training and education.


The systematic review was performed on four databases (PubMed, OVID Embase, Clarivate Analytics Web of Science, and Google Scholar) using pre-defined search terms. The search was restricted to manuscripts published in the English language but not limited to time-period.

The review was performed by a multidisciplinary team of reviewers, including two intensivists with expertise in advanced PoCUS and BCCE training, a hospital scientist with expertise in advanced echocardiography, BCCE training, and research methodology, an experienced researcher, a BCCE trainee, a critical care nurse consultant sonographer with expertise in advanced echocardiography and BCCE training, and a public health expert. All the authors had experience in PoCUS education research.

The objective appraisal was performed by using the AGREE-II Critical Appraisal Tool for Clinical Practice Guidelines processes – a validated tool consists of 23 key items organized within six domains followed by two global rating items. For the objective appraisal, the reviewers assigned a numerical score ranging from 1 to 7 for all the items in the AGREE-II tool.


Out of 4,288 screened abstracts, 53 manuscripts were downloaded for further evaluation. Of these, 24 manuscripts fulfilled the inclusion criteria to be included in the analysis.

Relate to introductory BCCE courses, 11 guidelines (45.8%) recommended introductory courses to initiate BCCE training. However, very few provided clear details on the necessary training components, such as ultrasound physics (n = 6 [25%]), instrumentation (n = 5 [20.8%]), image acquisition theory (n = 6 [25%]), course curriculum (n = 5 [20.8%]), pre-course/postcourse testing (n = 1 [4.2%]), minimum duration of the course modules (n = 6 [25%]), or the qualifications of the trainers (n = 5 [20.8%]).

Relate to longitudinal competence programs, only eight guidelines (33.3%) gave clear details on the need for a longitudinal program to attain BCCE competence. Only few guidelines made clear recommendations for the structure of such programs, such as the need for trainees to scan real patients with clinical indications (n = 8 [33.3%]), maintaining a logbook to document findings (n = 14 [58.3%]), storing images for quality assurance (n = 9 [37.5%]), providing regular formative assessment sessions (n = 6 [25%]), or recommending a minimum number of scans to perform (n = 14 [58.3%]). Very few guidelines clearly detailed the determination of BCCE-competence, namely image acquisition competence criteria (n = 3 [12.5%]), image interpretation competence criteria (n = 2 [8.3%]), and credentialing/certification criteria (n = 3 [12.5%]).


In this first review which systematically assessed the methodologic quality of guidelines on training, competence, or credentialing processes for basic echocardiography in critical care, the authors demonstrated that very few guidelines reported adhering to the ideal processes for guideline formulation, such as adequate bias minimization strategies, ensuring representative stakeholder involvement, using systematic methods to search for and select the evidence, or appraising the strengths and limitations of the body of evidence.

Therefore, they concluded that the methodologic quality of guidelines on PoCUS education showed a widespread lack of adherence to systematic methods during guideline formulation. They believe that given this information, the impact of these methods on the validity of the recommendations needs to be evaluated in longitudinal studies on PoCUS competence education.

They also recommended that in the meantime, any future expert panel guidelines on this subject adhere to a systematic process of guideline formulation that includes the domains outlined in the AGREE-II appraisal tool.