Recent Developments in Board Certification for Critical Care Echocardiography

The evolution of critical care ultrasound in North America has been remarkable. Rapid technological advances have moved cardiac ultrasonography from the sole domain of cardiology and into the hands of the bedside intensivists. The increased availability of this disruptive technology, paired with an evolving appreciation of its applicability to the critically ill patient, have led to widespread adoption by intensivists across the nation. However, given the risks and consequences of misuse and misinterpretation of this technology, it became clear that both the means to recognize expertise and the establishment of competency standards were needed. With these goals in mind, the National Board of Echocardiography (NBE), in conjunction with nine other medical societies, established the Examination of Special Competence in Critical Care Echocardiography (CCEeXAM) with the inaugural examination taking place in 2019.1 This exam is a comprehensive assessment of cardiac and non-cardiac ultrasound knowledge and image interpretation as applicable to the adult critical care population. It sets a standard for expertise in the clinical use of ultrasound in the intensive care unit. With the release of the exam, the NBE has further moved to establish formal criteria for board certification in Advanced Critical Care Echocardiography (ACCE) by establishing formal performance metrics for experience in the use of ultrasound.

Given the nascent nature of the CCEeXAM, a limited number of preparatory resources are currently available. As with most board certification examinations, an outline of the tested content is provided by the NBE and available online. Critical care societies, including the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM), have quickly moved to provide live review courses to aid in preparation for the exam. In addition to the live course, the SCCM also provides an online self-directed review course.

Unfortunately, at this time there is a lack of available textbooks specifically geared towards the CCEeXAM, although several review textbooks specific to the tested materials are currently in production. Echocardiography review texts for graduating cardiology fellows, such as Echocardiography Board Review (Wiley) and Clinical Echocardiography Review (Wolters Kluwer Health), remain popular resources for many in preparation for the examination.2,3 While these review books cover the majority of the CCEeXAM content outline, some of the subject matter may not be pertinent for the purposes of critical care echocardiography.

Examinees who successfully pass the written examination are granted NBE Testamur status. Physicians interested in moving on to ACCE certification need to possess a valid, unrestricted medical license and be board certified in their primary specialty. While an application for certification can be submitted at any time, the application is not reviewed by the certifying committee until the applicant has passed the CCEeXAM or the Examination of Special Competence in Adult Echocardiography (ASCeXAM). Currently, applicants who pass the ASCeXAM prior to 2020 can apply for the certification, although after 2022 the CCEeXAM will be the only permissible examination for certification. Once a candidate is certified, the certification is valid for a period of ten years from the time that the applicant passed either the CCEeXAM or the ASCeXAM.4

The NBE currently provides two separate certification pathways: the supervised training pathway and the practice experience pathway. The supervised training pathway requires the applicant to have successfully completed fellowship training in adult critical care medicine before applying for certification. For those completing training after December 2022, fellowship training in critical care must be obtained at an ACGME-accredited program. Additionally, the applicant must also have performed and interpreted 150 full transthoracic echocardiograms under the supervision of a qualified supervisor to fulfill the certification requirements. The NBE defines a complete critical care transthoracic echocardiogram as a point-of-care assessment that includes all obtainable elements of the transthoracic echocardiography examination. However, the exact elements and views that constitute a complete exam are not currently specified by the NBE. Notably, limited (i.e., goal directed) examinations and those performed for purposes of education or research are not accepted for certification.4

Applicants interested in obtaining certification through the practice experience pathway must have a minimum of 750 hours of clinical experience dedicated to critical care medicine and provide suitable evidence of verification as outlined by the NBE. This pathway also requires the applicant to have personally acquired and interpreted 150 complete transthoracic echocardiograms. A subset of these studies must be reviewed by a supervisor, again as defined by the NBE, and performed during the three years prior to the application. Further requirements in this pathway include completion of a minimum of 20 hours of AMA PRA Category 1 CME Credit activities devoted to echocardiography. Notably, certification through the practice experience pathway is set to expire in 2026.4

The NBE certification in ACCE allows intensivists to distinguish themselves as leaders in the field of point-of-care ultrasonography. Collaboration at the regional and national levels is now needed to ensure a recognizable presence of critical care anesthesiologists in this evolving field. A natural first step in this process could be creation of a database of anesthesiologist intensivists who have gained Testamur status or full ACCE certification and are interested in serving as mentors for future aspirants.

  1. Diaz-Gomez J, Frankel HL, Hernandez A. National Certification in Critical Care Echocardiography: Its Time Has Come. Critical Care Medicine 2017; 45(11): 1801-1804.
  2. Klein AL, Klein AL. Clinical Echocardiography Review. Philadelphia: Wolters Kluwer Health; 2017.
  3. Pai RG, Varadarajan P. Echocardiography Board Review: 500 Multiple Choice Questions with Discussion. Chichester, West Sussex, UK: John Wiley & Sons, Ltd; 2014.
  4. Application for Certification in Critical Care Echocardiography (CCeEXAM). National Board of Echocardiography,


John C. Klick, MD, FCCP, FASE, FCCM
Associate Professor of Anesthesiology and Perioperative Medicine
Milton S. Hershey Penn State Medical Center
Hershey, Pennsylvania
Babar Fiza, MD
Assistant Professor of Anesthesiology
Emory University
Atlanta, Georgia