Critical Care Program Research Articles

Rethinking Critical Care: Decreasing Sedation, Increasing Delirium Monitoring, and Increasing Patient Mobility

Sedation management, delirium monitoring, and mobility programs have been addressed in evidence-based critical care guidelines and care bundles, yet implementation in the ICU remains variable. As critically ill patients occupy higher percentages of hospital beds in the United States and beyond, it is increasingly important to determine mechanisms to deliver better care. The Institute for Healthcare Improvement's Rethinking Critical Care (IHI-RCC) program was established to reduce harm of critically ill patients by decreasing sedation, increasing monitoring and management of delirium, and increasing patient mobility. Case studies of a convenience sample of five participating hospitals/health systems chosen in advance of the determination of their clinical outcomes are presented in terms of how they got started and process improvements in sedation management, delirium management, and mobility. The IHI-RCC program involved one live case study and five iterations of an in-person seminar in a 33-month period (March 2011-November 2013) that emphasized interdisciplinary teamwork and culture change. Qualitative descriptions of the changes tested at each of the five case study sites demonstrate improvements in teamwork, processes, and reliability of daily work. Improvement in ICU length of stay and length of stay on the ventilator between the pre- and postimplementation periods varied from slight to substantial. Changing critical care practices requires an interdisciplinary approach addressing cultural, psychological, and practical issues. The key lessons of the IHI-RCC program are as follows: the importance of testing changes on a small scale, feeding back data regularly and providing sufficient education, and building will through seeing the work in action.

The transition from active treatment to initiation of end-of-life care within the intensive care unit: A clinician's perspective

Introduction: To achieve optimal patient outcomes, nurses working in critical care should hold a specialty qualification. Currently no uniform practice outcomes for critical care programs exist. Varying interpretations of a “critical care qualification” have been used as there are no agreed practice standards to measure outcomes. Additionally there have been no reported attempts to include health service consumer input into the development of practice standards. Study objectives: To develop national practice standards for graduates of critical care nurse education and a clinical assessment tool (SPECT) to measure practice. Methods:Amulti-step,mixedmethod design including a literature review, analysisof existingprograms (n=22)and identification of health consumer views via individual and group interviews (n=17). The findings informed a Delphi study of 105 nurse stakeholders to determine critical care graduate practice standards. The SPECT was based upon the Delphi results and pilot-tested. Results: The literature review, analysis of courses and health consumers viewswere used to develop 99 draft practice standards. The Delphi study resulted in 98 agreed standards (organised in 6 domains) that describe newly graduated critical care nurses should be able to manage the care of critically ill patients in most complex situations. They should not be expected to perform leadership roles. The standards were further arranged into a practical tool to measure graduate practice. This involved elimination of some duplication and re-grouping of some statements as elements. The SPECT contained 86 statements – initial testing revealed strong content validity, good internal consistency, test–retest and intrarater agreement, with at least moderate agreement for 94% of statements. The majority of panel responses (66%) were ranked as clinically feasible. Conclusion: For the first time health consumers have contributed to the components of critical care nurse graduate practice. The standards and SPECT provide the means to clearly define the expected practice level for graduates of critical care education programs. Acknowledgements: Thank you to: Australian College of Critical Care Nurses, Department of Health Western Australia, Helen Bailey Scholarship 2011, the participants for each phase of the study.

Practice expectations for graduates of Australian critical care nurse education: Development of the standard of practice and evaluation of critical-care-nursing tool (SPECT)

Introduction: To achieve optimal patient outcomes, nurses working in critical care should hold a specialty qualification. Currently no uniform practice outcomes for critical care programs exist. Varying interpretations of a “critical care qualification” have been used as there are no agreed practice standards to measure outcomes. Additionally there have been no reported attempts to include health service consumer input into the development of practice standards. Study objectives: To develop national practice standards for graduates of critical care nurse education and a clinical assessment tool (SPECT) to measure practice. Methods:Amulti-step,mixedmethod design including a literature review, analysisof existingprograms (n=22)and identification of health consumer views via individual and group interviews (n=17). The findings informed a Delphi study of 105 nurse stakeholders to determine critical care graduate practice standards. The SPECT was based upon the Delphi results and pilot-tested. Results: The literature review, analysis of courses and health consumers viewswere used to develop 99 draft practice standards. The Delphi study resulted in 98 agreed standards (organised in 6 domains) that describe newly graduated critical care nurses should be able to manage the care of critically ill patients in most complex situations. They should not be expected to perform leadership roles. The standards were further arranged into a practical tool to measure graduate practice. This involved elimination of some duplication and re-grouping of some statements as elements. The SPECT contained 86 statements – initial testing revealed strong content validity, good internal consistency, test–retest and intrarater agreement, with at least moderate agreement for 94% of statements. The majority of panel responses (66%) were ranked as clinically feasible. Conclusion: For the first time health consumers have contributed to the components of critical care nurse graduate practice. The standards and SPECT provide the means to clearly define the expected practice level for graduates of critical care education programs. Acknowledgements: Thank you to: Australian College of Critical Care Nurses, Department of Health Western Australia, Helen Bailey Scholarship 2011, the participants for each phase of the study.

2014 Critical Care Transport Workplace and Salary Survey

This 2014 survey polled critical care transport industry leaders, programs, and caregivers about workplace and salary information. Beyond descriptive information and salary data, the article details specific experience, education, and scope of practice within the critical care transport industry.

Survey of video laryngoscopy use by U.S. critical care fellowship training programs.

Recent studies on video laryngoscopy have demonstrated improvements in both safety and success of endotracheal intubation in the critically ill. We assessed the use of video laryngoscopy among internal medicine fellowship programs training physicians in critical care medicine. A 19-question survey was e-mailed to program directors of pulmonary/critical care and internal medicine critical care fellowship training programs. A completed survey was returned by 36% of invited program directors. Sixty-nine percent of respondents reported a change in their approach to intubation training over the prior 3 years, with 56% of changes attributed to the adoption of a video laryngoscope. Other reported changes include new training methods (23%) and adoption of a checklist (10%). A video laryngoscope is available for clinical use in 89% of the responding programs. The video scope is used as the primary device in 16% and is never used in 9%. In the remainder of programs, the video laryngoscope is only used for difficult intubations or after failure of direct laryngoscopy (32%) or the primary device is determined by the preference of the operator (32%). The majority of internal medicine critical care program directors who recently responded to an e-mail survey reported that they have changed their approach to teaching endotracheal intubation, driven largely by the adoption of video laryngoscopy for upper airway visualization. Nevertheless, despite widespread availability, video laryngoscopy is used uncommonly as the primary visualization device for intubation at the programs represented by the respondents to this survey.

Entrustable Professional Activities and Curricular Milestones for Fellowship Training in Pulmonary and Critical Care Medicine: Report of a Multisociety Working Group

This article describes the curricular milestones and entrustable professional activities for trainees in pulmonary, critical care, or combined fellowship programs. Under the Next Accreditation System of the Accreditation Council for Graduate Medical Education (ACGME), curricular milestones compose the curriculum or learning objectives for training in these fields. Entrustable professional activities represent the outcomes of training, the activities that society and professional peers can expect fellowship graduates to be able to perform unsupervised. These curricular milestones and entrustable professional activities are the products of a consensus process from a multidisciplinary committee of medical educators representing the American College of Chest Physicians (CHEST), the American Thoracic Society, the Society of Critical Care Medicine, and the Association of Pulmonary and Critical Care Medicine Program Directors. After consensus was achieved using the Delphi process, the document was revised with input from the sponsoring societies and program directors. The resulting lists can serve as a roadmap and destination for trainees, program directors, and educators. Together with the reporting milestones, they will help mark trainees' progress in the mastery of the six ACGME core competencies of graduate medical education.

Developing and Testing the Standard of Practice and Evaluation of Critical-Care-Nursing Tool (SPECT) for Critical Care Nursing Practice.

Nurses working in critical care often undertake specialty education. There are no uniform practice outcomes for critical care programs, and consumer input to practice standards has been lacking. A structured multiphase project was undertaken to develop practice standards and an assessment tool informed by critical care nursing stakeholders as well as patients and families-the Standards of Practice and Evaluation of Critical-Care-Nursing Tool (SPECT). Testing of the SPECT revealed adequate content validity index (CVI), domain CVI (range, 0.772 to 0.887), and statement CVI (range, 0.66 to 1.00). Reliability was adequate in terms of internal consistency (Cronbach's α > 0.864) and test-retest Spearman rank correlation (range, 0.772 to 0.887); intra-rater kappa agreement was significant for 102 of 104 statements with moderate agreement for 94.2% of statements. The SPECT appears to have clinical feasibility, preliminary validity and reliability, and provides a clear definition for the expected practice level for graduates of a critical care education program.

ABSTRACT 912

Background and aims: A neurological critical care physician specialist, Dr.Tasker, was hired with the objective of educating nurses and physicians in advance of initiating a new neurological critical care program. Education sessions were established to instruct the nurses in the medical –surgical ICU. Sessions transitioned from physician led presentations to nurse led case studies. Aims: To increase nursing knowledge in the care of the complex neurological patient population. Methods: Initial education started with physician led lectures, which transitioned to nurse driven patient presentations facilitated by DR. Tasker. Each session focused on the ICU course of the patient, summarized in a logical pattern allowing thoughtful pauses to encourage critical thinking along with review of scans/treatment regiments. Diagnoses included: traumatic brain injury, meningitis, metabolic disorder, and brain tumor, right parietal/temporal subdural hematoma and head bleed secondary to familial intrahepatic cholestasis II. Results: A formalized nurse led monthly discussion of complex neurological patients has been achieved. The formal discussion includes, patient’s initial presentation, first 24hours symptoms and management, ongoing ICU care, treatment, and follow up status of the patient. Discussions were supplemented with CT/MRI scans, medications and treatment regimes, along with discussion of what went well and what could we have done differently. Conclusions: Nurse led patient presentations led to the recognition of gaps in unit based nursing guidelines. Creation of algorithms and scamps to coordinate care and enhance team communication was accomplished once the need was recognized.

Welcoming new Associate Editors to The Journal

Welcoming new Associate Editors to The Journal

Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life.

Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life. We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6months of life for patients with chronic illness. Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service. For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables-the quality of palliative care education and the number of bedside tools-in ICU use. Each level of increased educational quality (1-5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use. We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.

Goals of Care Discussion and Withdrawal of Life-Sustaining Treatment Using High Fidelity Simulation (FR426)

1.Describe the process of a goals of care discussion and the withdrawal of life-sustaining treatments.2.Demonstrate best practices for creating an educational model for the withdrawal of life-sustaining treatments using high fidelity simulation. Simulation has emerged as a useful educational tool to teach communication skills and medical management of high stakes clinical scenarios. Determining goals of care for patients with critical, immediately life-threatening illnesses is a common conversation many trainees in emergency medicine, internal medicine, critical care, and palliative medicine often have with patients and families. Formal training in how to conduct these conversations as well as training in the implementation of the care plan when it includes removing life-sustaining treatments is lacking in many residency programs. We conducted an internal survey of our training programs and will share this data. We implemented an interdisciplinary training model for house staff in the New York University School of Medicine Emergency Medicine, Internal Medicine, Critical Care, and Palliative Medicine programs to enable physicians to feel more comfortable having these discussions, as well ensure patient and family needs are appropriately met during these complex encounters. A simulated patient with a history of multi-infarct dementia and a new massive cerebral hemorrhage is presented for management to the house staff. The patient has been intubated. The house staff have two tasks evaluated with this simulation exercise. First, trainees are scored using a checklist to assess their competency in the goals of care discussion with the surrogate decision maker (an actor). The decision is made to withdraw the ventilator. The trainees are then scored on a checklist focusing on proper symptom management, ventilator management, and managing family expectations preceding and during the withdrawal of mechanical ventilation from the high fidelity simulated patient. A debriefing session after the two part simulation is facilitated by expert faculty to review expected skill sets and the simulated patient experience. Trainees complete surveys both pre and post simulation. We will present data from those surveys that include attitudes, learners' reactions, and acquisition of knowledge.

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Introduction: Emergency medicine residents and critical care fellows have only limited instruction on the challenges surrounding inter-facility patient transfers, which includes legal considerations (such as EMTALA), knowledge of particularities of the local EMS systems (equipment, provider qualification, protocols) and adequate communication with prehospital providers and the involved physicians at the receiving facility. Methods: Emergency medicine residents and critical care fellows (in Surgery, Internal Medicine, Anesthesiology and Pediatric critical care programs) at a tertiary care academic medical center participated in a hour lecture/interactive instruction on the medical and legal aspects of inter-facility patient transfers. This was followed by a discussion of case-based scenarios. Prior to the educational intervention, participants filled out a survey that tested their knowledge in these areas, including the legal background for patient transfers, liability associated with transfer, qualification of prehospital personnel, as well as equipment and standing orders used when transporting critically ill patients. Two to three weeks later, all participants filled out a follow up survey. Using case scenarios, these critical areas were tested and the participants provided information on how the educational session had affected their experiences and confidence regarding patient transfers in their daily work life. Results: Participants had generally poor knowledge of the legal aspects of inter-facility patient transfers, though emergency medicine residents were more knowledgeable of EMTALA-related regulations than critical care fellows. Both groups also had limited understanding of the clinical and legal scope of practice of prehospital providers involved in patient transports. Participants rated their knowledge as poor to average on the pre-test. On follow up, participants were noted to have a significantly improved knowledge base, with respect to both the medical and the legal aspects of inter-facility pateitnt transfers. They felt more comfortable in accepting and facilitating patient transfers and felt that the educational intervention had affected their practice in a positive way (improved communication with transferring facilities, better ability to judge the appropriateness and feasibility of transfers). Conclusions: A one-hour educational intervention objectively increased emergency medicine residents’ and critical care fellows’ understanding of the medical and legal aspects of inter-facility patient transfers. Participants also felt much more comfortable with patient transfers in their daily practice.

Utilization and impact on fellowship training of non-physician advanced practice providers in intensive care units of academic medical centers: a survey of critical care program directors

BackgroundNon-physician advanced practice providers (APPs) such as nurse practitioners and physician assistants are being increasingly utilized as critical care providers in the United States. The objectives of this study were to determine the utilization of APPs in the intensive care units (ICU)s of academic medical centers (AMCs) and to assess the perceptions of critical care fellowship program directors (PDs) regarding the impact of these APPs on fellowship training. MethodsA cross-sectional national survey questionnaire was distributed to program directors of 331 adult Accreditation Council for Graduate Medical Education-approved critical care fellowship training programs (internal medicine, anesthesiology and surgery) in US AMCs. ResultsWe received 124 (37.5%) PD responses. Of these, 81 (65%) respondents indicated that an APP was part of the care team in either the primary ICU or any ICU in which the fellow trained. The majority of respondents reported that patient care was positively affected by APPs with nearly two-thirds of PDs reporting that fellowship training was also positively impacted. ConclusionsOur survey revealed that APPs are utilized in a large number of US AMCs with critical care training programs. Program director respondents believed that patient care and fellowship training were positively impacted by APPs.

The current state of fellowship training in pulmonary artery catheter placement and data interpretation: A national survey of pulmonary and critical care fellowship program directors

PurposeGiven decreasing use of pulmonary artery (PA) catheterization, we sought to evaluate whether current pulmonary and critical care fellows have adequate opportunity to obtain proficiency in PA catheter placement and data interpretation. MethodsAll US pulmonary and critical care program directors were invited to participate in an anonymous online survey regarding current training opportunities in PA catheterization. ResultsThe response rate was 51% (69/136). Eighty-three percent reported that the number of PA catheterizations performed by fellows within their program has decreased in the past decade. Fifty-four percent estimated that their fellows currently participate in less than 10 supervised procedures during fellowship. The most frequently identified barriers to training were procedure volume and reluctance to place PA catheters in the medical intensive care unit. Forty-three percent of respondents agreed that training in PA catheter placement is currently adequate within their program, and 55% agreed that training in data interpretation is adequate. Only 39% of respondents believe that PA catheter placement should continue to be an Accreditation Council for Graduate Medical Education training requirement. ConclusionsMany current pulmonary and critical care fellows do not have the opportunity to gain proficiency in PA catheterization. Fellowship training programs should consider alternate means of training fellows in PA catheter data interpretation, such as simulation.

A Pediatric Critical Care Practice Group: Use of Expertise and Evidence-Based Practice in Identifying and Establishing “Best” Practice

Mary-Jeanne Manning and Susan Hamilton are clinical nurse specialists in the medical-surgical intensive care unit, Michelle Labreque and Denise Casey are clinical nurse specialists in the neonatal intensive care unit, Heather Kennedy is a clinical nurse specialist in the medicine intensive care unit, and Katherine C. Penny is a nurse practitioner in the cardiovascular program at Boston Children’s Hospital in Boston, Massachusetts. Martha A. Q. Curley is the Ellen and Robert Kapito professor in nursing science in the school of nursing at the University of Pennsylvania in Philadelphia and a nurse scientist in the cardiovascular and critical care program at Boston Children’s Hospital. For questions related to this article, contact Patricia Lincoln at patricia.lincoln@ childrens.harvard.edu. and meets monthly to move best practices into the clinical setting. Clinical concerns are identified and prioritized for completion. Problems are addressed by using an evidence-based process. This approach involves review of the literature and obtaining expert opinion through shared conversations with practitioners both within the hospital and at other similar institutions. Once information has been gathered, it is used to assist in developing strategies to plan and implement practice changes. In this article, we describe our process and discuss 3 large-scale projects that resulted in practice changes throughout the critical care areas with further dissemination to other units in the hospital. These include standardization of continuous infusions of medications, formation of a multidisciplinary group to evaluate continuous renal replacement therapy (CRRT), and development of a risk-screening tool for venous thromboemboli. Nursing leaders from 4 different intensive care units (ICUs) at Boston Children’s Hospital noted wide variation in nursing practices. These variations were obvious to nursing staff and the discrepancies in practice created a source of frustration for parents of children cared for in these units. Practice variation that is unnecessary has been linked to patient safety concerns. Collaboration to explore discrepancies in nursing practice was needed. Through this initiative, the Critical Care Practice Group (CCPG) was established to determine “best” practice and standardize nursing policy and practice guidelines across the clinical areas (cardiac ICU, neonatal ICU, medical ICU, and medical-surgical ICU). Clinical nurse specialists and staff nurses from each critical care area were invited to participate. The CCPG sets a yearly strategic plan

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Introduction: In June 2007 a CMS designated Rural Referral Center in North Carolina with 280 staffed beds initiated a high intensity critical care program. We present here the first five years of patient outcomes and financial information. Hypothesis: The development of a critical care program staffed by intensivists would result in a favorable hospital return on investment and patient mortality. Methods: An uncontrolled prospective observational study derived from billing data and outcome information from an APACHE IIB data base. Results: In the first five years, 4,186 patients were admitted to the 12 bed ICU (71% occupancy) with an average APACHE IIB score of 19.41. The predicted ICU length of stay was 5.36 days, the actual ICU length of stay was 4.21 days. Using previously accepted estimates of cost, this 1.15 day reduction in ICU length of stay equates to $7,697,180 in hospital savings. Program expenses included $279,000 for additional equipment and $4,310,419 to cover the shortfall between physician collections and expenses. With an ICU payer mix of 65% Medicare, 16% Medicaid, 12% commercial insurance and 7% patient self pay the average charge per patient day was $290 and average reimbursement was $132 per patient day. ICU acuity has risen steadily since program inception with a mean monthly APACHIE IIB score of 17.89 in July 2007 to 20.87 in July 2012. The incidence of respiratory failure requiring mechanical ventilation has been 45%. At the initiation of the program the Case Mix Index for the hospital was 0.9, after the first year this index rose to 1.4 and has maintained at that level. This increase is thought to be due to the increased acuity of ICU patients. This increase resulted in $3,000,000 in additional hospital revenue. The predicted in hospital mortality for these ICU patients was 32.83%, the actual mortality rate was 17.32%. Conclusions: Five years after the initiation of a critical care program the hospital had a bottom line for the intensivist program of $6,386,761. The return on investment was 1 to 2.48. The estimated lives saved that were predicted by APACHE IIB to die was 649.

Parent Presence during Invasive Procedures and Resuscitation

Parent presence during invasive procedures and/or resuscitation is a relatively underdeveloped and controversial practice. Much of the concern stems from the apprehension of the medical community. To evaluate whether implementation of formal practice guidelines and corresponding interprofessional education would improve clinicians' sense of preparation and comfort in providing parents with options during their children's procedures. Multiphase pre-post survey of (1) clinician perceptions and (2) practice from the perspective of clinicians and parents experiencing the same procedure. Data were collected over 4 years from a cardiovascular and critical care program in one U.S. children's hospital. More than 70% of clinicians participated in the perception surveys (n = 782) and 538 clinicians and 274 parents participated in the practice surveys. After the intervention, clinicians reported that parents were present during more invasive procedures and reported higher levels of comfort with the practice of providing options to parents during resuscitative events. Levels of comfort were higher in clinicians who had practiced skills in a simulated learning environment. During both phases, few clinicians reported that parent presence affected their technical performance (4%), therapeutic decision-making (5%), or ability to teach (9%). During the post phase, clinicians reported more active parent behaviors during procedures. Parents who reported receiving information to help them prepare for their children's procedures reported higher levels of procedural understanding and emotional support. Implementation of practice guidelines and interprofessional education had a positive impact on clinicians' perceptions and practice when providing parents with options and support during their children's invasive procedures and/or resuscitation.

24/7 In-house Intensivist Coverage and Fellowship Education: A Cross-sectional Survey of Academic Medical Centers in the United States

The objectives of this study were to determine the current staffing models of practice and the frequency of 24/7 coverage in academic medical centers in the United States and to assess the perceptions of critical care trainees and program directors toward these models.A cross-sectional national survey was conducted using an Internet-based survey platform. The survey was distributed to fellows and program directors of 374 critical care training programs in US academic medical centers.We received 518 responses: 138 from program directors (PDs) (37% of 374 programs) and 380 fellow responses. Coverage by a board-certified or board-eligible intensivist physician 24/7 was reported by 33% of PD respondents and was more common among pediatric and surgical critical care programs. Mandatory in-house call for critical care trainees was reported by 48% of the PDs. Mandatory call was also more common among pediatric-critical care programs compared with the rest (P < .001). Advanced nurse practitioners with critical care training were reported available by 27% of the PDs. The majority of respondents believed that 24/7 coverage would be associated with better patient care in the ICU and improved education for the fellows, although 65% of them believed this model would have a negative impact on trainees' autonomy.Intensivist coverage 24/7 was not commonly used in US academic centers responding to our survey. Significant differences in coverage models among critical care medicine specialties appear to exist. Program director and trainee respondents believed that 24/7 coverage was associated with better outcomes and education but also expressed concerns about the impact of this model on fellows' autonomy.

Prince Edward Island: Building Capacity – The Implementation of a Critical Care/Emergency Program

Like other Canadian provinces, Prince Edward Island has a shortage of experienced nurses, especially in critical and emergency care. To increase the numbers of competent nurses, a PEI-based nursing course in these areas was identified as key to building capacity. This Research to Action pilot program successfully involved nurses in PEI-based emergency and critical care courses developed by the Nova Scotia Registered Nurses Professional Development Centre and funded by Human Resources and Skills Development Canada. The programs were offered on a full-time basis, lasted 14 weeks and included classroom and simulation laboratory time, along with a strong clinical component.Sixteen RNs graduated from the courses and became Advanced Cardiovascular Life Support (ACLS) certified. An additional 12 RNs were trained as preceptors. Feedback from participants indicates greater job satisfaction and increased confidence in providing patient assessments and care. Based on the program's success, the RTA partners proposed the establishment of an ongoing, PEI-based critical care and emergency nursing program utilizing 80/20 staffing models and mentorship. Their proposal was approved, with courses set to resume in January, 2012.

Barriers to ultrasound training in critical care medicine fellowships: A survey of program directors

Ultrasonography is an effective tool for making quick diagnoses and guiding therapeutic procedures. National organizations have advocated increasing the use of critical care ultrasonography. The purpose of this study was to investigate the prevalence of teaching of critical care ultrasonography in fellowship programs. In addition, we hoped to identify barriers to establishment of ultrasound training programs. All pulmonary/critical care and critical care medicine (CCM) program directors in the United States were invited to participate in an online survey. We asked respondents for demographic information about their programs and perceived barriers to training, as well as current training opportunities for their fellows in five aspects of critical care ultrasonography. A five-point Likert scale was used for survey answers. Web-based survey. Pulmonary/critical care and CCM program directors in the United States. Web-based survey. Ninety (66%) of 136 program directors responded. Ultrasonography training was offered by fellowship programs in the following areas: vascular access (98%), lung and pleural (74%), cardiac (55%), vascular diagnostic (33%), and abdominal (37%). Ninety-two percent of respondents agreed or strongly agreed that ultrasound training is useful, and 80% were interested in getting their fellows trained. Forty-one percent indicated that they lacked sufficient faculty trained in ultrasound use. Eighty-four percent agreed or strongly agreed that fellow turnover was an impediment to training. Forty-eight percent believed that cardiac echocardiography required a long training time. Although ultrasound training in vascular access was nearly universal, training in other aspects of ultrasound was less prevalent. We identified several barriers, including fellow turnover, insufficient faculty training, and perceived length of time required for echocardiography training.