AMERICAN SOCIETY OF ECHOCARDIOGRAPHYPOSITION PAPER

1090

POSITION STATEMENT

The American Society of Echocardiography (ASE)recognizes that cardiac sonographers are frequentlymultiskilled and multicredentialed. It is the positionof the ASE that, above all, persons who perform car-diac ultrasonography should be fully trained and cre-dentialed in cardiac sonography. If a person is multi-skilled (practices another health-related discipline),he or she should be appropriately trained and cre-dentialed in that discipline as well. Possession ofmultiple credentials provides some evidence thatthe person has met specific minimum competenciesin those areas.This position supports effective, effi-cient, and high-quality patient care.

DESCRIPTION OF THE PROFESSION

As stated in the Scope of Practice for the DiagnosticMedical Sonographer,1 which has been endorsed bythe ASE, the diagnostic sonographer, which includesthe cardiac sonographer, uses high-frequency soundwaves and other diagnostic techniques for medicaldiagnosis. The professional level of this health careservice requires highly skilled, educated, and compe-tent persons who function as integral members ofthe health care team.

The diagnostic sonographer must be able to pro-duce and evaluate ultrasound images, integrate clini-cal information with ultrasound information andrelated data to tailor the echocardiogram, and pro-vide accurate diagnostic information that is used byphysicians to render a formal, final medical diagno-sis. The level of problem-solving and cognitive skillrequired for competent performance of echocardio-graphy coincides with a level of responsibility that isconsistent with a professional status versus a strictlytechnical role. Not only must these skills be acquiredby all persons performing cardiac ultrasonography,the skills and knowledge-base also must be continu-ally updated to reflect changes in the field (eg, viacontinuing education).

EDUCATIONAL REQUIREMENTS

Quality education and meaningful, professional cre-dentialing of cardiac sonographers are extremelyimportant to ensure competence of practitionersand to maintain and enhance the standards of prac-tice in echocardiography.Rigorous standards are nec-essary to support professional identity and appropri-ate status of the persons competent in the practiceof echocardiography.

Several pathways currently are used to educate car-diac sonographers, including programs dedicated tocardiac diagnostic ultrasonography, programs offeringcardiac and general diagnostic ultrasonography (ie,obstetrics and abdominal ultrasound), and thosefocused on cardiovascular technology. The ASE rec-ommends that institutions with such educational pro-grams provide a standardized curriculum of uniform

Multiskilling and Multicredentialingof the Health Professional:

Role of the Cardiac Sonographer

Sonographer Council of the American Society of Echocardiography:Jeanette A. St. Vrain, RDCS, Andrea C. Skelly, RDCS, MPH, Alan P. Waggoner, RDMS, MHS,

Linda D. Gillam, MD, Cristy L. Davis, BS, RDCS, RCVT, Eric J. Sisk, BA, RDCS,Margaret L. Knoll, RDCS, Cris D. Gresser, RN, RDCS, Cheryl Reid, MD,

Barbara Nichols McCallister, RN, RDCS, and Alan S. Pearlman, MD, St Louis, Missouri;Seattle, Washington; St Peters, Missouri; Hartford, Connecticut; Carmel, Indiana;

Seattle, Washington; Orange, California; Toronto, Ontario, Canada; Garden Grove, California;St Petersburg, Florida; and Seattle, Washington

From the American Society of Echocardiography, Raleigh, NC.Adopted by the ASE Board of Directors in January 1998.Reprint requests: American Society of Echocardiography, 4101Lake Boone Trail, Suite 201, Raleigh, NC 27607.J Am Soc Echocardiogr 1998;11:1090-2.Copyright © 1998 by the American Society of Echocardiography.0894-7317/98/$5.00 + 0 27/1/93419

Journal of the American Society of EchocardiographyVolume 11 Number 11 Sonographer Council 1091

quality to promote consistent quality education of car-diac sonographers. A comprehensive detailed discus-sion of the entire educational curriculum is beyondthe scope of this article; however, the curriculumshould include extensive and rigorous didacticinstruction and a supervised clinical internship. Thetraining should attain the minimum standards out-lined in the ASE Guidelines for Cardiac SonographerEducation.2 The entire curriculum must lead to com-petence in all aspects of cardiac sonography (2-dimen-sional [2D], M-mode, Doppler). This education alsoshould lead to verification of competence through thesonographer earning the appropriate professional cre-dential(s) specifically in echocardiography.2

CREDENTIALING

Currently the credentialing and demonstration ofproficiency in performance of cardiac ultrasonogra-phy testing is voluntary. Proficiency in cardiac ultra-sonography is assessed by objective examinations aspart of a “professional certification” or “professionalcredentialing” process. Appropriate examinationsand credentials should be earned from certifyingagencies that meet appropriate standards for psy-chometric validation of the examination and authen-tication of all related processes (including require-ments for continuing education). The ASE recom-mends that regardless of the pathway used to obtainskills and education in echocardiography, all cardiacsonographers should earn the appropriate creden-tial(s) specifically in adult echocardiography (if pri-marily practicing in adults) or specifically in pedi-atric echocardiography (if primarily practicing inchildren) or both, if necessary. The support for anechocardiography-specific credential is recommend-ed in the Continuous Quality Improvement docu-ment3 and, more recently, in the Guidelines forLaboratory Accreditation, as determined by theIntersocietal Commission for the Accreditation ofEchocardiography Laboratories.4 These guidelinesstate that by July 2000, cardiac sonographers shouldhave attained an echocardiography-specific creden-tial.The ASE supports these guidelines.

CLINICAL PRACTICE AREAS AND MULTI-SKILLING

Cardiac sonographers may work in clinical practiceareas that include horizontal and vertical multi-skilling, which are described below.

Horizontal Multiskilling

This term describes the demonstration of a moreuniform, high level of competency in numerousareas of expertise within adult and pediatricechocardiography and also may include competencein other ultrasonography specialties. Examples ofhorizontal multiskilling follow.

Within transthoracic echocardiography inadults or pediatric patients. Diagnostic modalitiesinclude 2D echocardiography, M-mode echocardiogra-phy,and spectral and color flow cardiac Doppler.Theseprocedures are performed in a variety of settings,including inpatient and outpatient, an echocardiogra-phy laboratory, at the patient’s bedside, or in intensivecare units,operating,or emergency departments.

Related to transesophageal echocardiogra-phy. Assistance with transesophageal echocardiog-raphy in adults or pediatric patients.This includes 2Dechocardiography, color and spectral Dopplerechocardiography, monitoring of patient’s vital signs(blood pressure, heart rate and oxygen saturation),assistance with patient preparation and recoveryfrom conscious sedation, and other tasks.

Extended echocardiography-related duties.In some instances, under the supervision of a quali-fied physician, sonographers may manipulate thetransesophageal probe, assist with imaging duringoperative procedures, and have other duties. Theseprocedures are performed in various clinical settings.

Specialized echocardiography procedures.Some of these procedures require specialized train-ing and skills and are undertaken under the supervi-sion of a physician.

1. Exercise and pharmacologic stress echo testing(eg, treadmill, bicycle or dobutamine, and iso-metric hand grip testing)

2. Fetal echocardiography3. Contrast echocardiography (using both right-

sided, agitated saline, and transpulmonary agentsadministered intravenously)

4. Interventional or intravascular cardiac ultra-sound-guided procedures (eg, pericardiocentesis,endomyocardial biopsy, catheter ablations, place-ment of closure devices, percutaneous balloonmitral commissurotomy, pediatric interventions)

5. Intraoperative cardiac ultrasound-guided proce-dures (eg, monitoring of wall motion, valvularrepair, valve replacement, repairs of congenitalcardiac defects and other defects)

Vertical Multiskilling

Vertical multiskilling may be defined as possessingskills in other areas of health care in addition to car-

Journal of the American Society of Echocardiography1092 Sonographer Council November 1998

diac sonography,which may require varying levels ofresponsibility, problem-solving, integration, analysis,diagnostic capability, and independent performance.Examples of such diversity include radiography, res-piratory therapy, and cardiovascular technology ornursing.

Examples of vertical multiskilling. Specificexamples of vertical multiskilling include cardiacarrhythmia identification, exercise stress testing,Holter and electrical event monitoring, hemodynam-ic monitoring, cardiac nuclear medicine examina-tions, phlebotomy, intravenous line insertion, basicand advanced cardiac life support, set-up and assis-tance with cardiac catheterization procedures, andcardiac rehabilitation.

Additional Clinical Practice Areas

Other areas of cardiac sonographer expertise mayinclude research and health professional education.Persons with such expertise may serve in the capac-ity of clinical instructor or didactic faculty in centersaffiliated with medical schools, in university or com-munity colleges, or in formal hospital-based educa-tional programs. Additional areas of expertise alsomay include development of and participation in sci-entific programs, training of preceptors and cardiacfellows,and providing extensive inservice education.Many sonographers are actively involved with indus-try in the research, development, and application ofemerging ultrasonography technologies as well as inmanagerial positions.

DISCUSSION

Cardiac sonographers are professionals who offer aunique and essential service in the health care sys-tem.They bring a high level of competence and pro-fessionalism to procedures, use critical-thinking andproblem-solving skills, and possess an in-depthunderstanding of echocardiography equipment,physical principles,and cardiac pathology and hemo-dynamics. They have the ability to work indepen-dently in the performance of various diagnosticexaminations and are important members of thehealth care team. It is expected that all cardiac sono-graphers will have proficiency in cardiac life supportand appropriate emergency procedures. Each disci-pline within diagnostic sonography has advanced,developed, and matured sufficiently to offer specific

credentialing examinations.2 To provide appropriate-ly trained and educated cardiac sonographers,schools of sonography and cardiovascular technolo-gy need to adapt their curricula to respond to thedemands of a changing environment.This educationmust lead to verification of competence throughobtaining appropriate credentials in echocardiogra-phy, and in other disciplines practiced, if the personis to work effectively and competently in a multi-skilled environment.

CONCLUSION

Ultrasonography is a complex, operator-dependentdiagnostic modality that has become increasinglymore sophisticated and technically demanding. Thuscomprehensive education leading to competenceand verification of such competence, via the appro-priate rigorous and psychometrically validated cre-dentials specifically in echocardiography,will contin-ue to be of great importance.

The ASE recognizes the need to maintain thequality of echocardiographic services as well as theneed to ensure effective and efficient use of per-sonnel in echocardiography. Multiskilling of per-sons, without insistence that such persons demon-strate competence in all areas in which they prac-tice by earning the appropriate credentials in thoseareas, may not constitute effective, efficient use ofpersonnel and has the potential to undermineestablished standards of quality patient care inechocardiography.

REFERENCES

1. The scope of practice for the diagnostic sonographer. 1st ed.Dallas: Texas Society of Diagnostic Medical Sonographers(SDMS).

2. Gardner CJ, Brown S, Hagen-Ansert S, Harrigan P, Kisslo J,Kisslo K, et al. ASE Guidelines for Cardiac SonographerEducation: report of the American Society of Echocardi-ography Sonographer Education and Training Committee. JAm Soc Echocardiogr 1992;5:635-9.

3. Kisslo J, Byrd BF III, Geiser EA, Gresser C, Gillam LD,Watkins-Ivy T, et al. Recommendations for continuous qual-ity improvement in echocardiography. J Am Soc Echocardi-ogr 1995;8(5 Suppl 2):S1-28.

4. Intersocietal Commission for the Accreditation of Echocardi-ography Laboratories. Essentials and standards for echocar-diography testing. Columbia (MD): Intersocietal Commissionfor the Accreditation of Echocardiography Laboratories;1997.