A survey of United Kingdom intensive care echocardiography provision

Introduction

In the United Kingdom (UK), transthoracic echocardiography provision is provided predominantly by specialist cardiac physiologists. ¹ A comprehensive accreditation is a requirement for independent scanning and reporting of a full transthoracic data set including two-dimensional assessment as well as colour, continuous, pulse wave and tissue doppler assessment. In 2014/15, the number of cardiac physiologists in the UK was approximately 3000. Consequently, the availability of the comprehensive echocardiography service is predominantly confined to in-hours (i.e. weekdays) only.^2,3

In 2012, the Intensive Care Society pioneered the UK’s inaugural program in the form of Focused Intensive Care Echocardiography (FICE). Focused accreditation is based on two-dimensional assessment and limited quantification measurements. Thus, there is a lower time commitment for both accreditation and maintenance of skill set. with a conservative estimate placing the number of current Focused Ultrasound in Intensive Care (FUSIC) Heart accredited practitioners at over 2000 (Marcus Peck, 2023, personal communication).

The provision of echocardiography, in particular out of hours, is of vital importance to the process of donor heart assessment in transplantation. This piece of work lead by National Health Service Blood & Transplant (NHSBT) with representation from cardiology, intensive care, paediatric, cardiothoracic surgery and focused echo, looked to assess the current deliverability of comprehensive and focused donor echocardiography in UK Intensive Care Units (ICUs).

Methods

We initiated the process by establishing a widely representative group of UK stakeholders from cardiology, intensive care, paediatric, cardiothoracic surgery and focused echocardiography under the umbrella of NHSBT.

Through a modified Delphi approach, we developed a national survey pertaining to key information, such as the number of echocardiography-trained personnel available, the type and timing of the imaging technique, and equipment availability in intensive care unit establishments. The full survey questions are listed in Supplemental Appendix 1.

Through use of Survey Monkey^® we prospectively surveyed every UK intensive care unit over a period of 5 months, from March to July 2022. The survey was circulated via email to each hospital organ donation lead via the regional clinical leads of organ donation.

Results

The survey collected responses from 95 centres across the UK, representing various hospital types. These include district hospitals, tertiary hospitals, trauma centres, transplant centres, neurosurgical units, cardiac units, and paediatric units, for a total of 44% of 217 ⁴ adult ICUs and 19% of 27 ⁵ paediatric ICUs nationwide (Table 1).

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Table 1.

Availability of point-of-care ultrasound machines with echocardiography capability and focused accredited staff in the intensive care unit.

Category		n	Percentage
ICU with ultrasound		93	98
ICU without ultrasound		2	2
ICU with ultrasound remote viewing ability		49	52
ICU without ultrasound with remote viewing ability		46	48
Median number of echo capable ultrasound machines per ICU		2 (IQR 2, 3)
Availability of focused echo accredited staff in the ICU
Categories of staff with focused echo accreditation	Consultants	Registrar/Fellow	Allied Health Care	Others
Total number from 95 ICU	343	137	31	8
Median number of personnel per ICU	3	1	0	0

ICU: intensive care unit; IQR: inter quartile range.

In total, 519 focused accredited personnel in intensive care units in the UK were identified in this study, 343 consultants, 137 registrars and 39 Allied health professionals. Each ICU had median 4 (IQR 2, 6) personal with 3 (IQR 2, 5) consultants and 1 (IQR 0, 2) registrar trained in focused echocardiography. Only five units reported they had no accredited personnel. Approximately 51% of reporting centres had a designated ICU echocardiography lead.

Regarding comprehensive echocardiograms, 48% of respondents reported obtaining them within 6 h during normal working hours, dropping to 11% outside of normal hours. Over half (53%) indicated more than 24 h would be needed outside regular hours (Table 2).

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Table 2.

Comprehensive and focused echocardiography time delay in 95 Intensive care units.

Time of day	In hours	Out of hours	In hours	Out of hours
Duration	Focused echo responses (%)		Comprehensive echo responses (%)
Within 6 h	57 (60)	19 (20)	46 (48)	10 (11)
6–12 h	19 (20)	19 (20)	19 (20)	14 (115)
12–24 h	13 (14)	27 (28)	17 (18)	21 (22)
More than 24 h	6 (6)	30 (32)	13 (14)	50 (53)
Total	95 (100)	95 (100)	95 (100)	95 (100)

In comparing time frames for obtaining focused echocardiograms, 60% of respondents (n = 57) indicated that focused echocardiogram can be acquired within 6 h during normal working hours. Outside of normal working hours, this percentage dropped to 20% (n = 19), while 32% (n = 30) indicated that obtaining a focused echocardiogram would require more than 24 h to obtain.

Regarding equipment, 98% of units reported having point-of-care ultrasound machines, median 2 (IQR 2, 3) machines per ICU, all with echocardiographic capabilities. However, only 52% have remote viewing capability for echocardiogram images.

Discussion

There is a growing number of UK healthcare staff accredited in the practice of focused echocardiography. According to the survey, each ICU has a median of four staff members accredited in performing focused echocardiography. This trend highlights the increasing recognition of echocardiography as a core skill for assessing and managing acutely unwell patients. In the UK, it has become a mandatory requirement for all acute internal medicine trainees ⁶ and is emphasised in the intensive care curriculum ⁷ .

Over time, intensive care units have established their equipment base with the units now having median two ultrasound machines with echocardiography capability, overcoming a significant historical hurdle. However, it’s noteworthy that almost half of the units lack the capability to remotely review images, a factor that holds significant implications for governance and long-term care of patients.

The combined impact of this staffing configuration and equipment availability is evident in their reduced time frames for acquiring focused echocardiography compared to comprehensive echocardiography for intensive care patients. The notable difference is particularly pronounced outside regular working hours, where echocardiography in critically unwell patients can take more than 24 h in 53% of comprehensive echocardiography, in contrast to 32% for focused echocardiography studies.

There are a significant number of limitations to this study including recollection bias in timings, understanding of urgency of echocardiogram request and less than half of all UK ICUs included. Moreover, there is potential selection bias with only intensive care units that have echocardiography capacity likely to respond.

This study highlights the current infrastructure and accredited personnel available across the UK for the provision of focused echocardiography in intensive care units. This constitutes a significant and crucial proportion of service delivery in the UK, particularly vital for addressing out of hours urgent echocardiogram demands, such as those involving critically unwell patients and organ donation assessment.

In the absence of a fully staffed 24/7 comprehensive echocardiography service for the NHS, focused echocardiography provides easier access to providing urgent and lifesaving access to echocardiography. There should be consideration of a nationally available database of accredited mentors and supervisors for future learners to access as well as to identify regions requiring further improvement in supervision. Further investigation is also required for the utility of echocardiography in critically unwell patients and for the implementation of consistent and equitable access across the UK.

Supplemental Material