Rapid, Remote Education for Point-Of-Care Ultrasound among Non-Physician Emergency Care Providers

Access to high-quality emergency care in low- and middle-income countries (LMIC) is lacking. Point-of-care ultrasound (POCUS) has the potential to significantly improve emergency care in LMICs.

POCUS was incorporated into a training program for a ten-person cohort of non-physician Emergency Care Providers (ECPs) in rural Uganda. We performed a prospective observational evaluation on the impact of a remote, rapid review of POCUS studies on the primary objective of ECP ultrasound quality and secondary objective of ultrasound utilisation. The study was divided into four phases over 11 months: an initial in-person training month, two middle month blocks where ECPs performed ultrasounds independently without remote electronic feedback, and the final months when ECPs performed ultrasounds independently with remote electronic feedback. Quality was assessed on a previously published eight-point ordinal scale by a U.S.-based expert sonographer and rapid standardised feedback was given to ECPs by local staff. Sensitivity and specificity of ultrasound exam findings for the Focused Assessment with Sonography for Trauma (FAST) were calculated.

 

 

Introduction

Access to high-quality emergency care in low- and middle-income countries (LMICs) is limited, despite the most recent call to action in 2007 by the WHO. In addition, these countries face an overwhelming proportion of the global burden of disease; child mortality rates, for instance, are often 10 to 20 times higher in LMICs than in high-income countries.

Many factors contribute to this lack of access to care, including a lack of skilled providers. Sub-Saharan Africa faces 25% of the global burden of disease with only 3% of the healthcare workforce. To combat this shortage, many countries have utilised a strategy known as “task-shifting” in which skills and responsibilities are distributed in novel ways among existing provider cadres and new cadres are formed were needed.

The shortage of skilled providers in these resource-limited settings is often compounded by a paucity of technologic resources, including diagnostic imaging technology. Portable, hand-carried ultrasound is inexpensive, easily deployable and clinically effective in settings where more advanced diagnostic modalities are not available. Training a cadre of non-physician clinicians in point-of-care ultrasound (POCUS) in a rigorous and sustainable manner thus has the potential to significantly impact the delivery of care in LMICs.

Early research has shown that non-physician clinicians can be trained to function independently in skills essential to emergency care. The use of POCUS by physicians in LMICs already has proven impact on patient management, such as electing surgical treatment or changing the medical plan of care.

There is limited research examining the ability of non-physician clinicians providing emergency care in LMICs to learn POCUS as an adjunct to standard care. Robertson et al. described the remote, real-time use of FaceTime to instruct and monitor POCUS by non-physicians in Haiti and Levine et al. demonstrated that FaceTime images in tele-review are non-inferior to those captured on the ultrasound machine. To date, there is no published data describing the use of tele-review to sustain POCUS usage and skill by non-physicians in LMICs.

Traditionally, ultrasound education of providers ranges from brief one- to two-day intensive training sessions to one-year modular courses. Other groups have found that without continued support, brief training sessions do not yield sustained skills retention. However, prolonged direct-observation training one-to-one at the bedside can be prohibitively resource-intensive in LMICs, especially if oversight is provided by non-local experts traveling to LMICs specifically to provide education. Here we describe a novel educational tool to provide rapid, “tele-review”, quality assurance and feedback to a group of non-physician clinicians in rural Uganda and its impact on continuing education and skills retention for broad-based POCUS.

Since 2009, non-physician clinicians have been trained in emergency care at a district hospital in rural Uganda, with program graduates referred to as Emergency Care Practitioners (ECPs). The hospital setting and training program are described in detail elsewhere POCUS was incorporated into the curriculum given limited access to radiography services. We performed a prospective observational evaluation on the impact of a remote, rapid review of POCUS studies on ultrasound utilisation and skills in a ten-person cohort of ECPs.

Methods

All patient encounters were logged prospectively into an electronic research database. Data collected included chief complaint, demographic information, testing ordered or performed (including ECP POCUS), results and disposition. ECPs acquired ultrasound images with a Sonosite Micromaxx (Bothell, WA) using a 2–5 mHz curvilinear transducer, 6–13 mHz linear transducer, or a 1–5 mHz phased-array transducer.

As part of the research study, information on ultrasound performed, sonographer and initial interpretation were recorded by ECPs and then uploaded by staff into a separate web-based database program designed by one of the authors (**) for remote quality assurance. Image review was performed remotely by U.S.-based emergency physicians with fellowship training in POCUS. Detailed feedback was emailed to local research staff who printed and distributed the feedback to the performing ECPs.

Our primary objective consisted of changes in educational ratings over time (interpretation and image acquisition). Our secondary objective consisted of ultrasound utilisation. Ultrasounds performed independently by visiting physicians were excluded. This work was approved by the Institutional Review Boards of [deidentified] and [deidentified].