Efficacy of an ultrasound training program for nurse midwives to assess high-risk conditions at labor triage in rural Uganda.

Many high-risk conditions of pregnancy are undetected until the time of delivery in low-income countries. We developed a point-of-care ultrasound training protocol for providers in rural Uganda to detect fetal distress or demise, malpresentation, multiple gestation, placenta previa, oligohydramnios and preterm delivery. This was a mixed-methods study to evaluate the 2-week training curriculum and trainees' ability to perform a standard scanning protocol and interpret ultrasound images. Surveys to assess provider confidence were administered pre-training, immediately after, and at 3-month follow up. Following lecture and practical demonstrations, each trainee conducted 25 proctored scans and were required to pass an observed structured clinical exam (OSCE). All images produced 8 weeks post course underwent blinded review by two ultrasound experts to assess image quality and to identify common errors. Key informant interviews further assessed perceptions of the training program and utility of point-of-care ultrasound. All interviews were audio recorded, transcribed, and reviewed by multiple readers using a content analysis approach. Twenty-three nurse/nurse midwives and two physicians from one district hospital and three health centers participated in the training curriculum. Confidence levels increased from an average of 1 point pre-course to over 6 points post-course for all measures (maximum of 7 points). Of 25 participants, 22 passed the OSCE on the first attempt (average score 89.4%). Image quality improved over time; the final error rate at week 8 was less than 5%, with an overall kappa of 0.8-1 for all measures between the two reviewers. Among the 12 key informant interviews conducted, key themes included a desire for more hands-on training and longer duration of training and challenges in balancing clinical duties with ability to attend training sessions. This study demonstrates that providers without previous ultrasound experience can detect high-risk conditions during labor with a high rate of quality and accuracy after training.

Focused cardiopulmonary ultrasound for assessment of dyspnea in a resource-limited setting.

BACKGROUND: The diagnosis and management of acutely dyspneic patients in resource-limited developing world settings poses a particular challenge. Focused cardiopulmonary ultrasound (CPUS) may assist in the emergency diagnosis and management of patients with acute dyspnea by identifying left ventricular systolic dysfunction, pericardial effusion, interstitial pulmonary edema, and pleural effusion. We sought to assess the accuracy of emergency providers performing CPUS after a training intervention in a limited-resource setting; a secondary objective was to assess the ability of CPUS to affect change of clinician diagnostic assessment and acute management in patients presenting with undifferentiated dyspnea. METHODS AND RESULTS: After a training intervention for Haitian emergency providers, patients with dyspnea presenting urgently to a regional referral center in Haiti underwent a rapid CPUS examination by the treating physician. One hundred seventeen patients (median age of 36 years, 56 % female) were prospectively evaluated with a standardized CPUS exam. Blinded expert review of ultrasound images was performed by two board certified cardiologists and one ultrasound fellowship trained emergency physician. Inter-observer agreement was determined using an agreement coefficient (kappa). Sensitivity and Specificity with confidence intervals were calculated. Pre-test and post-test clinician impressions and management plans were compared to assess for a change. We enrolled 117 patients with undifferentiated dyspnea. Upon expert image review, prevalence of left ventricular systolic dysfunction was 40.2 %, and in those with systolic dysfunction, the average EF was 14 % (±9 %). The parasternal long axis (PLAX) single view was predictive of an overall abnormal echo with PPV of abnormal PLAX 95 % and NPV 93 % of normal PLAX. Weighted kappa for pericardial effusion between the Haitian physicians and two cardiology reviewers was 0.81 (95 % CI 0.75-0.87, p value <0.001) and for ejection fraction was 0.98 (95 % CI 0.98-0.99, p value <0.001). For lung ultrasound, a kappa statistic assessing agreement between the Haitian physician and the EP for pleural effusion was 0.73, and for interstitial syndrome was 0.49. Detailed test characteristics are detailed in Table 3. Overall, there was a change in treating clinician impression in 15.4 % (95 % CI 9-22 %) and change in management in 19.6 % (95 % CI 12-27 %) of patients following CPUS. A significant structural heart disease was common: 48 % of patients were noted to have abnormal right ventricular systolic function, 36 % had at least moderate mitral regurgitation, and 7.7 % had a moderate to large pericardial effusion. CONCLUSIONS: A focused training intervention in CPUS was sufficient for providers in a limited-resource setting to accurately identify left ventricular systolic dysfunction, pericardial effusion, evidence of interstitial syndrome, and pleural effusions in dyspneic patients. Clinicians were able to integrate CPUS into their clinical impressions and management plans and reported a high level of confidence in their ultrasound findings.