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Concise Critical Appraisal: Development of the CCEeXAM

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Tatyana Shvilkina DO ; Brian J. Wright, MD, MPH

Bedside echocardiography has become increasingly widespread among physicians caring for critically ill patients. The Examination of Special Competence in Critical Care Echocardiography (CCEeXAM) was administered for the first time in 2019 to 524 physicians from multiple specialties. The examination was designed for physicians to demonstrate an objective competence and obtain certification in advanced critical care echocardiography (CCE).

Panebianco et al describe the rationale and process for developing the CCEeXAM.1 They divided CCE into two categories—basic and advanced. Basic CCE does not require certification and is endorsed as a core skill for critical care professionals. Advanced CCE involves additional skills in image acquisition and interpretation as well as competence in a variety of echocardiographic measures that are not part of basic CCE. Previously, noncardiologist physicians could not obtain certification in echocardiography, but only testamur status via the Examination of Special Competence in Adult Echocardiography (ASCeXAM). Since multiple specialties outside of cardiology perform and rely on echocardiography to care for patients, a certification process specific to CCE was developed for physicians of any specialty.
There are two pathways to qualify for certification. The first is the training pathway for applicants who have a minimum of one year of formal training in critical care. The second is the practice experience pathway for healthcare professionals who practice CCE but did not complete formal training in critical care. However, the practice experience pathway will expire for those finishing residency after the end of 2026. To achieve certification in CCE, in addition to passing the CCEeXAM, clinicians must submit an echocardiography log documenting performance of a minimum of 150 medically necessary critical care transthoracic echocardiography examinations.2
Panebianco et al describe the development of the examination for CCE and the demographics and results of the first examination administered.1 Representatives from critical care medicine, emergency medicine, anesthesiology, and ultrasound societies across North America were involved in its development. After consensus on major topics, they wrote items based on their area of expertise. The final examination comprised 200 questions. It was designed to test knowledge of both echocardiography and its application to critical care medicine.
The 524 examinees who sat for the first examination predominantly practiced in pulmonary/critical care (46.9%) and anesthesiology (30.7%), with smaller numbers from surgery, emergency medicine, neurologic critical care, and other disciplines. Those coming from formal critical care training constituted the majority (63.6%), with 48.1% working full-time academic positions, and 15.9% in fellowship training. The overall pass rate of the CCEeXAM was 81.3%.1
The strong interest in the CCEeXAM highlights the increasing role echocardiography plays in the management of critically ill patients. CCE is used in critical care environments to rapidly and noninvasively diagnose pathology that causes shock, hemodynamic instability, or respiratory failure, and to evaluate cardiac function and track response to interventions.3-6
Critical care physicians in all specialties now have the opportunity to achieve a standardized certification that establishes their ability and competence to perform, interpret, and apply the findings of echocardiography in their practice of caring for critically ill patients. As CCE becomes more widespread we will likely see an increase in the number of our colleagues credentialed in echocardiography. Likewise, it is hoped that a formal credentialing process will increase the number of clinicians who take their knowledge of CCE from the basic to the advanced level. Further research on how a formal credentialing process affects CCE utilization and critical care billing would be informative.


  1. Panebianco NL, Mayo PH, Arntfield RT, et al. Assessing competence in critical care echocardiography: development and initial results of an examination and certification processes. Crit Care Med. 2021 Mar 17. Online ahead of print.
  2. National Board of Echocardiography. Application for Certification in Critical Care Echocardiography (CCEeXAM). Accessed May 12, 2021.
  3. Mercado P, Maizel J, Beyls C, et al. Transthoracic echocardiography: an accurate and precise method for estimating cardiac output in the critically ill patient. Crit Care. 2017 Jun9;21(1):136.
  4. Silva S, Biendel C, Ruiz J, et al. Usefulness of cardiothoracic chest ultrasound in the management of acute respiratory failure in critical care practice. Chest. 2013 Sep;144(3):859-865.
  5. McLean AS. Echocardiography in shock management. Crit Care. 2016 Aug 20;20:275.
  6. Vieillard-Baron A, Millington SJ, Sanfilippo F, et al. A decade of progress in critical care echocardiography: a narrative review. Intensive Care Med. 2019 Jun;45(6):770-788.

Tatyana Shvilkina DO
Tatyana Shvilkina DO, is a clinical assistant instructor and advanced resuscitation fellow in the Department of Emergency Medicine at Stony Brook Medicine.
Brian J. Wright, MD, MPH
Brian J. Wright, MD, MPH
Brian J. Wright, MD, MPH, is a clinical associate professor and the program director for the Advanced Resuscitation Training Program in the Department of Emergency Medicine at Stony Brook Medicine. Dr. Wright is an editor of Concise Critical Appraisal.

Posted: 5/13/2021 | 0 comments

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