BSNR training guidance for mechanical thrombectomy

Dr. R. Lenthall, Dr. N. McConachie, Prof. P. White, Dr. A. Clifton,

Dr. C. Rowland-Hill, UK Neurointerventional Group and British Society of
Neuroradiologists

Guidance for practitioners seeking training to participate in an acute ischaemic stroke thrombectomy service in the UK: a response to level-1
evidence of the benefit of mechanical thrombectomy for patients with acute ischaemic stroke and proven large vessel occlusion.
Guidance produced by members of the UK Neurointerventional Group and British Society of Neuroradiologists. March 2016

Preamble stroke is dependent on the swift, efficient function of a care

pathway involving multiple pre-hospital and hospital ser- vices. A
Following accumulating level-1 evidence of the benefit of multi-societal consensus document describing ser- vice standards
18
timely mechanical thrombectomy (MT) for patients with acute for practice in the UK has been published.
ischaemic stroke (AIS) due to proven large vessel occlusion (LVO), NICE have reviewed the evidence for MT and have recently
23
there is an urgent need to train an addi- published updated guidance. This guidance supports the use of
tional cohort of practitioners to enable introduction of MT as a MT providing requirements for patient
18
routine service in the UK. selection, operator training and service standards are adhered to.
In the USA and Europe practitioners from different clin- ical In this light there is need to define and train the clinicians who
backgrounds (radiology, neurology, neurosurgery, car- diology) will help expand and deliver this service in the future.
can enter Interventional Neuroradiology (INR) training. This Opening a blocked artery is a mechanical task common to
guidance proposes to create a pathway for practitioners (pre or multiple clinical specialties, however any clinician un- dertaking
post CCT) wishing to obtain RCR- recognised training to perform MT for patients with acute stroke will need detailed knowledge of
and participate in an acute stroke service in the UK. clinical neurology, neuroanatomy and neurophysiology. They will
This document draws on previous and current training guidance. require advanced radio- logical skills to evaluate neuroimaging
It has been produced in response to an antici- pated shortfall in studies and they will depend on broad case experience to interpret
service capacity and is intended to sup- plement, rather than replace imaging findings in the clinical context and to select and manage
current RCR training guidance. patients appropriately.
Key objectives of training will include: developing a thorough
understanding of neurological diseases, acquiring the range of
Introduction technical skills required to manage neuro- vascular conditions,
and refining the ability to make inde- pendent clinical decisions
Recent clinical trials have shown that if eligible patients with about timely, appropriate and safe interventional procedures (in
acute stroke caused by LVO are rapidly treated with MT, their relation to alternative non-interventional approaches).
prospects for independent recovery are significantly improved.
Successful management of patients with acute
 In addition to having procedural technical skills and experience
navigating catheter systems and thrombectomy devices in the clinical and anatomical scenarios. MT is not a single pro- cedure that
cervical and intracranial circulation, opera- tors will have to perform can be quickly learnt and applied in practice.
procedures under time pressure, frequently in challenging settings Any specialist contributing to provision of a MT service should
such as, difficult vascular access, patient movement and incomplete have completed a RCR-recognised training process. A patient is
visualisation of the cerebral circulation. entitled to know the training background and clinical experience of a
After completing training, practitioners will be required to join doctor providing their care that a clinician operating on them is
teams providing a MT service and to contribute to on-call provision. appropriately trained and experienced to undertake this procedure
Practitioners will need to maintain and refine their knowledge and competently and safely.
skills, as evidence and technology evolves. Training must account for the specific clinical back- ground
At current staffing levels, most INR services in the UK do not and prior experience of the trainee.
have sufficient resources to expand operating capacity to the level Trainees must acquire all of the skills required to provide a MT
required to deliver a 24/7 MT service immedi- ately. A crude service. This must include a comprehensive understand- ing of the
estimate would require UK operator numbers to double (from 90 to significance of imaging findings in the context of the patient’s clinical
180) to enable robust on-call rotas to be established in existing INR status. It is not good interventional practice for another clinician
centres. The RCR recommends (neurologist, stroke physician) to select
a minimum 1/6 rota frequency to provide a sustainable IR on-call the patient and instruct the operator, simply as a technician, when
5,8,12,15,17,19,20
19
rota. If UK trainee numbers were expanded to 20e25/year it would to perform a MT procedure.
take 4e5 years to train the required number of INRs (accounting for Qualified interventional radiologists and cardiologists have skill
up-coming retirements). sets that exceed core radiology training and are equivalent to INR
Within current specialty training programs in the UK, there is only training in specific areas. However, trainers and trainees should be
one subspecialty that provides training to perform MT (INR). The aware of the potential mismatch be- tween technical competencies
current training programme for INR takes six years. This is divided that may be acquired rapidly by clinicians with an interventional
into two parts. The first three years is dedicated to training in core background and disease- specific knowledge and clinical judgment,
radiology skills. The fourth year is focused on acquiring advanced which are acquired over a longer time, with broad case- experience.
competencies in diagnostic neurora- diology and the fifth and sixth Industry-sponsored educational courses, web-based teaching
years are dedicated to INR and scenario practice using simulators all pro- vide useful
15 educational opportunities. Whilst some of these options may
training and refining neuroradiology skills.
It is widely understood within the INR community that INR contribute towards acquisition of competence, they are not as-yet
training provides sound knowledge and a broad grounding in integrated into radiology training in the UK, they are not
technical skills, but that a consultant will continue to accumulate recognised as qualifications by the RCR/ GMC and they are not
essential case-experience during the early years of their equivalent to training delivered in a recognised UK training
consultancy. This on-going formative process usually occurs with program. Good quality web- based or simulation-based training
the close support and guidance of experienced consultant should be accounted-for and may become accreditable experience
colleagues. in the future (with a
5,9
In order to expand capacity to provide a MT service at a national recommended limit of 10% of total required experience).
level in the UK, it will be necessary to expand the UK INR training The natural history of neurovascular diseases and the
program. To address the required scale of expansion and the clinical procedural complications related to INR practice can be
imperative to provide a MT ser- vice, it is also important to consider associated with poor clinical outcomes, including severe disability
options for training a cohort of practitioners in an accelerated time and death. Operators will need the clinical and interpersonal skills
frame. As part of this process, it is proposed that INR training will be to deal with poor patient outcomes, clinical error, duty of candour
made available to clinicians from different clinical backgrounds. and investigation/complaint procedures.
To deliver this training successfully, the background and Focused training to provide only one specific therapeutic
competencies of individual trainees will be taken into ac- count procedure does not align with practice in any current UK specialty-
24
and the content of training will focus on the knowl- edge, skills training program, or with the anticipated process of credentialing.
and competencies that are essential to enable the practitioner to Many of the technical skills required to perform MT are common
function independently as part of a team to other INR procedures. In order to acquire these skills efficiently,
14,15,17
providing a MT service. the trainee will participate in many varied INR procedures during
In considering how to expand operator capacity to meet the their training.
anticipated demand for 24/7 MT, the subse- quent issues should be Training to acquire MT skills will involve a significant full-
accounted-for: time-equivalent commitment for individual trainees (due to the
Practitioners should adhere to the principles of Good Medical infrequent and unpredictable case referral rate for MT even in
Practice Where practitioners undertake invasive clinical large, high-volume centres). As a result of the time commitment
st
procedures for the 1 time, they should be properly trained and required to acquire the requisite case experi- ence in stroke, the
6,9 trainee will be in a position to acquire many of the skills required
directly supervised.
The term mechanical thrombectomy (MT) refers to a range of for the wider INR area of practice.
operative techniques that are tailored to specific
 R. Lenthall et al. / Clinical Radiology 72 (2017) 175.e11e175.e18
175.e1

There are two essential patient care pathways that will benefit
from provision of a comprehensive 24/7 INR on-call service, Interventional Radiology trainee
namely, a 24/7 MT service for patients with AIS and the
aneurysm coiling service for patients with ruptured brain An IR trainee wishing to convert to INR would need a minimum
aneurysms (best provided 7 days per week). Less frequently, of 2 years of training time in diagnostic and interventional
patients referred by other acute surgical services will also benefit neuroradiology (i.e. would need to commence INR training by the
from an on-call INR service, including Ear Nose and Throat start of ST5).
surgery (epistaxis and carotid blow-out)
and Trauma services (blunt/penetrating cranio-cervical vessel Non-radiology trainee wishing to convert to INR training
2,13,18,12
injury).
In this light, it would be advisable that any substantial national As-yet, there is no RCR/GMC approved path for trainees from
investment in a training process is optimised to enable the qualified other clinical specialties to enter into fast-track radi- ology training.
operators to contribute to a compre- hensive INR on-call service that At-present, trainees can either retrain in radiology, or alternatively
can meet all of the urgent complete their specialty training and retrain post-CCT.
2,13,18,19
needs of the wider referred population.
In this preferred model, trainees will acquire the ability to provide Components and estimated duration of INR/ MT
a wider- range of INR procedures (rather than MT alone). The range training post-CCT
of skill sets at completion of training would be determined by a
number of individual and centre- related factors (following Diagnostic and INR training can run concurrently.*
curriculum based training).
For training purposes, a qualified (post-CCT) practitioner entering Interventional radiologist post-CCT
INR training consultant interventional radiologist or cardiologist)
should be regarded as an experienced trainee. It is important that
(however qualified) a trainee should not be in a position to decide Advanced neuroimaging and neurosciences INR 6 months
training 12-18 months
when their INR training is completed (i.e. the process of determining
Total 12-24 months*
qualification is independent from the student).
After completion of training, maintenance of clinical and
technical skills will be essential. MT cannot be performed Diagnostic neuroradiologist post-CCT
infrequently with the expectation that clinical outcomes will be
equivalent to those achieved by experienced oper- INR training 18-24 months
ators providing the entire INR area of practice in high- volume Total 18-24 months*
18
centres.
This document does not set out a path for practitioners to train to Cardiologist post-CCT
perform MT alone, but this possibility is not spe- cifically excluded.
In a scenario where practitioners were trained to perform MT as their Core/advanced neuroimaging and neurosciences INR 12 months
only intracranial vascular procedure, assuming a reasonable on-call training 24 months
rota (1:6 or bet- ter), the operators would need to work in an Total 24 months*
extremely high volume MT centre to maintain case- experience and
competencies (>240 procedures per annum would Neurologist or neurosurgeon post-CCT
requiring a centre-catchment population of over 2.2
million). Core/advanced neuroimaging INR 12 months
A model where practitioners were trained to perform MT only training 24 months
might divide training and service resources in INR. This might Total 24 months*
impair service development, limit staffing levels in INR units and
limit staffing of 7-day services to treat pa-
tients with aneurysmal SAH.
13 See appendix 1 for duration of training in other countries. The
time-lines provided are estimates of training time required to
acquire competencies (rather than time in- tervals that define
Components and duration of INR training pre- recognition of competence). Competence may be achieved at a
CCT faster, or slower rate. Non- radiologists in the USA require a
minimum 6 months of cognitive neuroscience training to
14,15 credential for cervico-cerebral
INR trainee diagnostic/interventional procedures.
5,9

It may be possible to acquire diagnostic and interventional skills

Core radiology training 36 months
in parallel (saving time). However, based on anticipated MT case
Advanced neuroimaging and neurosciences INR 12 months referral rates to UK Neuroscience centres, it is un- likely that any
training 24 months trainee would gain sufficient interventional case experience in a
training interval shorter than 18 months. The time-lines for
estimated duration of INR/MT training post-CCT complement
recommendations in a recent multi-
society consensus document which stipulates a minimum of one
year of clinical neuroscience and neuroimaging training prior to a Curricular content for MT/INR training
26
year of dedicated INR training.
It is anticipated that ‘qualified’ operators will join INR services Overarching training requirements for diagnostic and
and work in teams that enable/facilitate continued learning and interventional neuroradiology are outlined in the RCR documents
acquisition of case experience in a supported ‘Specialty Training Curriculum for Clinical Radiology’ November
14
environment (rather than commencing practice as single- handed 2015, and ‘Subspecialty Training Curriculum for Interventional
22 15
operators attempting to establish new services). Radiology’ November 2015, pages 18e25.
The RCR curricula provide an overview of training. A more
Training Centre Requirements comprehensive description of the syllabus covered during INR
training in the UK is provided in the BSNR document Interventional
17
INR training can only be provided in a recognised neuro- science Neuroradiology Curriculum V7.
22
training- centre or network, by experienced INRs. Training centres Focused training to enable provision of an MT service would
22 require thorough coverage of the specific curricular content in this
should be recognised by the UKNG/ BSNR/RCR/GMC. A training
centre must include a team of document.
3,11,22 Previous BSNR/RCR guidance has not set explicit targets for
at-least two INRs.
training activity or documented procedure rates. There are potential
The training centre must perform a minimum of 100 cerebral
1,16 disadvantages to setting targets, the achieve- ment of which may not
neurointerventional cases/year (European min- imum necessarily reflect an individual’s competence. However, the
8,11
150e200/year ) and the case-mix should include acute stroke (a following section outlines pro- cedural activity levels suggested by
high volume of stroke work is an implicit training requirement, but it training bodies within and outside the UK as guidance.
is impractical to set a specific target before anticipated MT service
development).
Reporting diagnostic imaging studies
The training centre must involve the trainee in every aspect of
patient care including:
A neuroradiology trainee typically reports a minimum of 40
Diagnostic neuroimaging reporting MDTs mixed CT/MR cases per week resulting in a low estimate of 1600
(especially neurovascular) Preoperative cases in a year.
assessment Published target activity levels for complex imaging reporting
Patient consent Procedural include:
planning
Activity Number Reference
Team sign in (WHO check)
MRI 2000 4
INR procedure CTA 50 9
Post-op ward round MRA 50 9
Ward based care (including intensive care) Post- Perfusion studies 25 9
op/surveillance imaging
Outpatient clinics Minimum targets such as these are likely to be far- exceeded, if
the trainee/fellow participates in provision of a neuroimaging
The training centre must ensure that the trainee partic- ipates in: service and reports all of the imaging studies related to the
interventional procedures that they are involved in.
Basic and advanced neuroimaging services (protocolling, The aim is to be able to report all CT/MRI imaging as it relates to
supervising and reporting a wide range of examinations) On-call neurovascular diseases and to be able to rapidly and independently
service provision discriminate imaging appearances of neurovascular disease from
Database activity and case registries Morbidity mimics/other pathology.
and mortality meetings Clinical audit Trainees should arrange regular evaluation of their reporting skills
Clinical research (whenever possible) (IPIX) and training supervisors should be aware of their trainees’
Interactions with clinical proctors and industry reporting discrepancies.
representatives
Cerebral catheter angiography
The training centre must support the following educa- tional
processes:
Expertise in diagnostic cerebral angiography provides the
foundation for safe and successful INR practice.
Provision of educational teaching sessions
There is good evidence that fluoroscopy times, patient
Trainee attendance at relevant educational meetings Educational
radiation dose and procedural complication rates decline with
supervision 5,9
Assessment of diagnostic imaging skills (IPIX) increased operator experience.
Assessment of technical skills (DOPS) Summative There is good evidence that observer interpretive error declines
5,9
assessment (ARCP/equivalent) as operator experience increases.
 R. Lenthall et al. / Clinical Radiology 72 (2017) 175.e11e175.e18
175.e1

Angiography during MT procedures:

Operators will need to correlate imaging appearances on non- Institution Experience Reference
invasive imaging (CTA, MRA) with imaging appear- ances at WFITN 160 procedures (30 primary operator) 7,8
catheter angiography. UEMS 150 procedures (50 primary operator) 11
Operators will need to identify: anatomical variation, arterial ANZSNR/ANZAN/NSA 60 aneurysms (30 primary operator 16
pathology and the effects of altered flow. 20 angioplasty or stent procedures 20
Misinterpretation of appearances may result in erro- neous particulate embolisations
10 liquid embolisations
decisions to withhold or apply specific measures, increasing patient
risk.
Examples of published recommended minimum angio- graphic
experience include: Arterial recanalisation procedures (MT)

Institution Experience Reference

Considerations:
RANZCR 150 supervised 4 This procedure demands rapid arterial access, rapid navigation
American Heart 100 diagnostic angiograms 5 of a guide catheter system to a stable position, accurate
Association et-al assessment of arterial anatomy, rapid navigation of a
American College of 300 diagnostic coronary 5,9 microcatheter system and or suction thrombectomy catheter
Cardiology angiograms
American Academy of 100 supervised cerebral 5
intracranially and safe deployment and retrieval of a stentriever.
Neurology angiograms The operator must appreciate what equipment is best suited to
RCR 150 diagnostic angiograms 6 the anatomy and the procedure, where and how to navigate blindly
British Cardiac Society 200 diagnostic coronary 6 and what manipulation the arterial tree will tolerate (cerebral
angiograms
vessels are thin-walled, mobile/deformable, angulated and take
American College of 50 supplemented by other 9
Radiology experience multiple variable branching patterns).
ACGME INR training 100 before INR training* 9,* The operator must be equipped with the necessary technical
SIR 200 selective angiograms 9 and decision- making skills to be: able to contin- uously re-assess
UKNG/BSNR 2016 100 (can include non-MT This document progress, able to modify the strategy where appropriate, able to
INR cases)
decide when an effective treatment has been achieved and able to
* mandated requirement prior to entering INR training and not altered by prior
detect and manage complications promptly.
angiographic experience in any other vascular territory. In the clinical setting (often post IV thrombolysis) the
consequences of vessel perforation, vessel dissection or rupture
(due to inadvertent navigation into a perforator, small pial arterial
Carotid angioplasty and stenting branch, or aneurysm), may be fatal. Inefficient technique will also
increase procedural time, reducing benefit and increasing the risk
Institution Experience Reference of complications such as clot embolisation to another vessel
RANZCR 30 (15 as primary) 4 territory.
RCR 15 cases/year 6 Minimum recommended case experience:
UKNG/BSNR 2016 10 cases per year* This document

* This recommendation only applies to practitioners performing a wide range of Institution Experience Reference
INR procedures. In this setting it would be reasonable to include vertebral artery or
SIR 200 selective angiograms of which 50 9
intracranial artery angioplasty and stenting.
should be cervico-cerebral
30 procedures using microcatheters and
micro guidewires
Other stenting experience 5 stroke lysis cases under the (remote)
supervision of a proctor who has performed
at-least 10 cases
Institution Experience Reference 1 year of INR fellowship with the full
AAN, AANS/CNS, 10
RANZCR 50 peripheral stents (primary operator) 4 range of INR procedures
SNIS,
American College 100 peripheral angioplasty 5
SVIN
of Cardiology
AAN, AANS/CNS, 100 cerebral angiograms 10
American College 250 supervised coronary stent 5,9
SNIS, 30 intracranial microcatheter
of Cardiology procedures
SVIN navigations 10 mentored stroke
RCR 130 peripheral angioplasty 6
RCR 50 peripheral stents 6 therapies*
UKNG/BSNR 30 MT procedures This
document

INR operative procedures * the advisory figures provided relate primarily to intra-arterial throm- bolysis
(2009) and are not directly comparable to current MT techniques (which would be
associated with higher risks in less experienced hands).
These include primarily the treatment of ruptured and
unruptured intracranial aneurysms. See curricula for description 9,10
15,17 Both quoted publications relate to practice in the USA prior
of other related procedures. to 2010.
Evidence of satisfactory completion of
training for post-CCT trainees Underperformance

Post-CCT trainees will need to provide the following evidence Concerns relating to underperformance of a pre-CCT trainee
to enable recognition of suitable training experi- ence by the would be worked-through following established
UKNG/BSNR/RCR: policies/procedures.
Given the resource implications of INR training for a post-
Attendance record at the training institution(s).
CCT practitioner, any concerns about aptitude or
Documented reporting activity for basic and advanced
underperformance should be raised promptly.
neuroimaging studies Evidence that diagnostic perfor- mance is
equivalent to radiology SpRs at the equivalent level of training It is anticipated that training and review of progress for
practitioners who are post-CCT (IR/cardiologist/physician) will
(IPIX >5% per modality).
mirror the processes for radiology trainees. Adminis- tration of the
Log book documentation of the following minimum ac-
process will be the joint responsibility of the trainer and trainee.
tivity levels (half of each interventional activity should be as lead
The approach to underperformance or a deteriorating
operator (DOPS >10% per procedure). relationship between trainer and trainee would follow local
training program and Trust policies/procedures.

Activity Number
Cranio-cervical CTA reporting 150 Maintenance of skills
CTASI evaluation, or perfusion studies 50
Cranio-cervical MRA reporting 150
Cerebral catheter angiography (overlap allowed) 100 Any practitioner performing MT must work in a centre that has
Navigation of guide catheter systems 100 direct access to multidisciplinary care with cover from:
(cervical and intracranial)
Intracranial navigation of 100 Stroke Services
microcatheter/microwire systems
Anaesthetics Neuro
Coiling of an intracranial aneurysm 80
Device-assisted coiling techniques 40 Critical Care
(balloon, stent, other) Neurosurgery
MT for AIS 30 Vascular Surgery
Carotid, vertebral or intracranial 10
angioplasty/stent for atheroma
The centre must have 24/7 provision of CT/CTA and DSA
MT for AIS (in the event that stand-alone 80 3,4,18,22
training to perform angiography/interventional facilities.
MT is supported) In order to justify the personal and institutional invest- ment
involved in undertaking training to perform INR procedures, it is
Evidence of participation in M&M and clinical audit meetings.
essential that qualified practitioners work in institutions with a
Evidence of attendance at relevant educational meetings and
sufficient case-referral rate to main-
satisfactory CPD. 18,21
tain skills in clinical practice.
Supportive reports will be required from three UK training
supervisors at least two of whom will be INRs actively practicing The operator must perform no less than 40 intracranial
6,9,11,16 neurovascular procedures/year (minimum 1 per working week,
in the NHS. Training supervisors will be required to confirm
excluding diagnostic catheter angiography and iso- lated carotid
that the trainee/fellow:
artery stenting) to maintain competencies.
Examples of minimum criteria for maintenance of competence.
Reports basic and advanced neuroimaging studies rele- vant to
INR practice competently (equivalent discrep- ancy rates)
Institution Experience Reference
Selects patients for procedures appropriately
RANZCR 25 selective supra-aortic angiograms/year 4
Communicates well with the patient and family
RCR 15 carotid stent procedures/year 6
members UEMS Practicing INR >80% of time and meeting 11
Performs identified INR procedures safely and effectively CME/CPD requirements
Recognises and manages procedural complications Recognises ANZSNR/ANZAN/ 100 INR cases/3 years 16
procedural and personal limits NSA
Integrates well with teams and clinical services BSNR/RCR 40 intracranial vascular procedures/year This
document
Has the ability to admit to mistakes and learn from them

Training targets will inevitably excite debate, however the task of The implications of failure to maintain case experience
setting clear standards in training is likely to be less challenging than following training include:
the task of raising such standards post-hoc, once clinical practices
are established. De-skilling (whole team, not just the INR) Prolonged
treatment times (patient harm)
 R. Lenthall et al. / Clinical Radiology 72 (2017) 175.e11e175.e18
175.e1

Complications, loss of confidence (giving up INR) Retraining

needs Appendix 1
Wasting limited training resources

Recommended duration of core neuroscience training

Immediate considerations for the UKNG, BSNR, Location Duration (months) Reference
BSIR, RCR USA 6 5,9,10
Europe 12 11,25
Training
Approval of proposed training pathways for INR/MT.
RCR recognition of INR training centres (including Recommended duration of diagnostic neuroradiology training
assessment of equivalence of international training posts?). Location Duration (months) Reference
Improve access to INR training. Australasia 12 4
Expansion of INR training posts, ideally to 20 for the next 5 years USA 12 5
Establishment of the training post numbers required to support Europe 12 7,8,25
UK 12e24 14
future consultant posts (10/year).
Qualification
No change to FRCR or CCT for radiology trainees. Recommended duration of INR training
RCR-approved process for recognition of completion of INR
Location Duration Reference
training (for post- CCT doctor undertaking INR training). (A
USA 12 5
training certificate?) Europe 24 7,8,25
Post-qualification surveillance Annual verification of Europe 30 11
maintenance of competence via case-load documentation. UK 24 15
Annual reporting of quality standards: recanalization rates, ENT Australasia 24 16
26
rate, SICH rate.
6
Annual reporting of mortality/outcome data. Options:
In Europe, the UEMS Training Charter indicates that physicians
National audit UKNG/BSNR vs. process overseen
from all specialty backgrounds can be trained in INR. In order to
by RCR equivalent to CPD registration. (Site visits if thresh- olds
ensure that clinicians from different back- grounds receive consistent
not met?)
training, the Training Charter is based on 4 years full-time
Mobilisation of resources
training including: 1 year of
Multi-society sign-up to training guidance. Deanery support to
clinical neuroscience, 1 year of diagnostic neuroradiology and 2
expand training posts. 25
years of INR training.
NHS-Trust support to enable qualified clinicians to enter INR
training.
Markers of success
References
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