Background

Patient access to ultrasound in low- and middle-income countries (LMICs) remains a major obstacle, compromising clinician decision-making and patient outcomes [1]. Point-of-care ultrasound (POCUS) is an invaluable adjunct to bedside diagnostic evaluation [2]. POCUS refers to ultrasound performed at the patient’s bedside by the clinician to provide care using a fast, portable, and non-invasive diagnostic tool [2]. It has been shown to improve the quality and safety of patient care through reducing time to diagnosis, improving diagnostic accuracy, and maximizing procedural safety [3].

There is substantial evidence to support the clinical value of POCUS to several specialties [2,3,4,5]. For instance, POCUS has been widely used in cardiac, lung, and abdominal scanning to detect many pathologies such as pleural effusion, pneumothorax, pneumonia, interstitial syndromes [2, 3], hydronephrosis, hepatomegaly [6], splenomegaly, and ascites [6]. Limited obstetric ultrasound improved accurate identification of cases and could be beneficial in a resource-limited maternity triage setting to improve midwives' diagnoses and clinical decision-making. Surprisingly, there is limited data on the use or integration of this paradigm-shifting technology into routine obstetrical practice in LMICs [3]. This is partly due to lack of ultrasound machines combined with lack of familiarity with the tools [3]. As POCUS is a relatively new technology, most frontline physicians in LMICs have little or no experience with its use. According to Kagima et al., the lack of POCUS training for clinicians, limited resources, and a fragmented healthcare infrastructure have affected the clinician’s capability, motivation, and opportunity in performing POCUS in LMICs [2].

POCUS is highly operator-dependent [3], and must be performed by competent practitioners [7]. Safe, competent, and effective use of POCUS requires training to close gaps in learners’ knowledge and skill [3, 8]. Physicians who are proficient in its use can quickly answer specific clinical questions at the bedside [3]. Fortunately, recent data suggest that those keen to learn POCUS can obtain adequate proficiency with minimal training [3, 6, 8].

Whilst several national and international bodies have developed specialty-specific POCUS curricula, at the time of the training, there had not yet been an approved obstetrics POCUS (OB POCUS) curriculum in Kenya [7,8,9,10]. POCUS is applicable to many medical specialties, including obstetrics. The WHO recommends every woman to have at least one ultrasound scan during pregnancy [11]. In resource limited settings these is a challenge due to unavailability of ultrasound machines and the technical expertise to perform the scans. However, it has been demonstrated that with training, clinicians can comfortably conduct POCUS. Indeed, since many LMIC clinicians practice obstetrics at some level, OB POCUS is likely relevant to the majority of LMIC clinicians’ practice [12, 13]. We report our experience in training 514 HCPs across 8 counties in Kenya on obstetrics POCUS.

Methods

Our training initiative was nested in a larger ongoing study on the impact of OB POCUS on patient outcomes, health systems, and policy and is a collaboration with three partners: (1) Global Ultrasound Institute (GUSI), which served as the training partner; (2) Butterfly Network, the ultrasound solution; and (3) Kenyatta University (KU), which served as the research and recruiting partner. Out of the 514 HCPs who were trained, 468 were from 8 rural counties with poor maternal and neonatal outcomes [14], while the remaining 46 were from KU and nearby facilities such as Kibera, Kiandutu, Gatundu, Kiambu, Thika, Ruiru, University of Nairobi, and Aga Khan University hospital (Table 1 below).

Table 1 showing per county number of participants trained and number of butterfly IQs received per facility
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As part of the Butterfly probe distribution project, the Kenyan team embarked on training 514 HCPs in OB POCUS skills specifically for pregnant patients in the second and third trimesters. This entailed knowledge and skills acquisition in five key thematic areas namely: overview scan for multiple gestation, fetal presentation and lie, placental location, amniotic fluid assessment, and fetal heart rate assessment. The project aimed to train the 514 HCPs over a period of 10 weeks. The learners were trained in groups of 50 HCPs every 5 days, with 10 instructors every day. Learners were issued Butterfly iQ + ™ hand-held ultrasound probes and Apple iPads loaded with just-in time education which they used during the training and later at their local work sites.

Participants

Kenyatta University selected 8 out of the 10 high priority counties as identified by USAID to have high maternal and neonatal morbidity and mortality rates [14]. These counties were Kitui, Kilifi, Kakamega, Nakuru, Taita Taveta, Baringo, Samburu, and Turkana. The HCPs trained included nurses, midwives, clinical officers, medical officers, radiographers, and sonographers. Most of the learners were non-physicians/non-sonographers in order to task-shift diagnostic ability to front-line providers since the majority of obstetric care is provided by them. Selected faculty members from Kenyatta University and selected HCPs from nearby health facilities in Kiambu county were also trained, with the latter facilities serving as demonstration centers for the trainings’ practical sessions.

Instructors

OB POCUS instructors were selected from various disciplines in the medical field. These included sonographers, resident physicians in obstetrics and gynecology and family medicine, as well as an emergency physician. All had some level of ultrasound experience prior to the project.

Instructor education sessions, entitled, “Lunch and learn sessions,” were held on 3 occasions. During each, master POCUS instructors taught the program’s instructors the course content as well as effective methods in POCUS education. OB POCUS topics in the course content adhered to the International Society for Ultrasound in Obstetrics and Gynecology (ISUOG) standard ultrasound techniques [15]. In addition to reviewing the course content, instructors also had an opportunity to scan pregnant models themselves, which helped in harmonizing knowledge and passing on skills to future learners. Instructors that required more time with the Butterfly iQ + ™ probe were permitted to borrow it for a week and obtain additional practice at their clinical sites.

Curriculum

Prior to each workshop, trainees completed a knowledge pre-test (see Additional file 1). The course itself was a structured 5-day training program employing online resources, didactic lectures, live demonstration on pregnant models, and practice opportunities with live patients in various hospitals near KU. During the training, it was emphasized that POCUS’ aim was to answer specific clinical questions to aid clinical decision-making, and appropriate indications for referral were reviewed. The training was followed by an observed assessment of scanning and diagnostic interpretation and a knowledge post-test (see Additional file 1). Upon returning to their home clinical sites, learners were offered remote image review opportunities through the GUSI online platform as well as continued support from other colleagues through WhatsApp groups.

Lectures

The lectures were structured around 6 main themes: clinical case, normal scan findings, pathology and pitfalls, troubleshooting, clinical integration, and summary or take-home points. These were delivered as 30-min sessions, followed by a question-and-answer session for 5 min.

Following each lecture, live demonstration was then done with a ratio of 1 instructor to 5 learners. The instructor would demonstrate to the learners the expected skill to be gained and allow each of them to practice. During these hands-on sessions, the following points were also emphasized:

  • Professionalism and etiquette in terms of behavior and speech towards the pregnant models.

  • Participation of all learners and allowing all participants to scan without interruption or voiceovers.

  • Probe care and safety of machines, including infection control.

On the first day of each training, learners were given logbooks (see Additional file 2). to record their scans throughout the week. Each learner was expected to have at least 20 scans in each of the 5 thematic areas by the end of the training period. Learners who appeared to be struggling during the skills sessions were also identified and personalized attention given to them. Learners were encouraged to rotate between different instructors in order to benefit from varying teaching styles.

Table 2 shows the 5-day training schedule.

Table 2 Training schedule
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Instructors’ daily reflections

At the end of each day, the instructors brainstormed on the day's activities. They highlighted things that worked and those that did not. This proved very insightful and provided areas of improvement for the subsequent training weeks.

Table 3 highlights instructors’ daily reflections.

Table 3 Instructors’ daily reflections
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Follow up

Having attained knowledge and skills to conduct a second and third trimester OB POCUS, learners were expected to inculcate it in their day-to-day clinical practice at their facilities. Additionally, they were encouraged to teach their colleagues. Through GUSI, free access to their website and content was offered to learners. This allowed for:

  • Refreshing of knowledge and scanning technique on the 5 thematic areas

  • Assess to recorded video lectures and live demonstrations

  • Uploading of scans by the learners from the devices to the GUSI online platform, with subsequent image review and feedback from GUSI instructors.

Results

Pre assessment and post assessment

The mean test score was 52.8% for the 446 learners that undertook the pre assessment. In comparison, the mean test score in the post assessment was 90.6% for the 432 learners that took it. This demonstrated a marked improvement in image recognition, theoretical knowledge in the 5 thematic areas and clinical application after 5 days of training.

OSCE

Of the 489 learners that did the OSCE, 99% (486/489) attained the pass mark of 13 out of 26. The mean test score was 87.3% - demonstrating a good grasp in obstetric POCUS skills. Learners who did not attain the pass mark were allowed to retake the OSCE and passed on the second attempt.

Discussion

Ultrasound is an extremely useful diagnostic imaging modality. It is noninvasive, provides real-time information, and is completely safe since it has no radiation exposure [10]. The use of POCUS is generally on the rise worldwide, but with challenges in LMICs partly due to lack of ultrasound machines and lack of familiarity with the tools [3]. The current paper reports the experience in training 514 HCPs in Kenya on obstetrics POCUS following a donation of hand-held probes from Gates Foundation through GUSI-Butterfly-KU partnership.

POCUS training

The current project employed a structured 5-day training program for HCPs encompassing online resources, didactic lecture sessions, live demonstrations, practice opportunities in various hospitals, assessment and a system for remote post-course support. Although effective instruction in the short training time available remains a challenge, it can be quite effective if used optimally. Fortunately, recent data suggest that those keen to learn POCUS can obtain adequate proficiency with minimal training, including online web-based training [3, 6, 8, 9, 16].

During the training, it was emphasized that the aim of POCUS was to answer specific clinical questions that aid clinical decision-making to optimize patient outcomes [16,17,18]. POCUS therefore aids in making a bedside, real-time diagnosis and to enhance clinical decision-making, but not to replace the traditional or comprehensive ultrasound examinations. Referrals to sonographers and radiographers for full comprehensive scans were encouraged even for patients who had a POCUS.

Who should be trained

The current project trained HCPs currently involved in maternal care such as nurses, midwives, clinical officers, medical officers, radiographers and sonographers. Since POCUS is inconsistently taught in medical school [8, 10], several studies have supported the incorporation of POCUS training in undergraduate medical education [3]. Studies have recommended integration of ultrasound training in undergraduate and residency training programs [19]. For instance, the majority of Canadian medical schools teaching ultrasound were able to devote 1 to 5 h per year in instruction time [6]. In addition, POCUS instruction as early as first and second year medical school has been shown to enhance knowledge acquisition and retention [6]. Surveys have shown that 50% of Canadian and 62% of US medical schools have integrated ultrasound into their curriculum, with 60% beginning in first-year [6, 8, 19]. These findings are part of a worldwide trend [9].

Jarwan et al. (2020) from Saudi Arabia assessed the needs and barriers to POCUS training among medical interns. They noted that POCUS is applicable to medical interns but significant skill gaps existed, including lack of time for training. They concluded that prioritizing the training of residents in POCUS would be a more effective use of the finite resources available for medical education instead of training medical interns who were mainly keen on medical licensing and applying for residency [3].

Resources

This study is part of a larger funded initiative to improve diagnostic imaging access in order to propel Kenya towards achieving improvements in their maternal health outcomes. To meet the WHO recommendations for antenatal imaging, health departments should prioritize the acquisition of hand-held ultrasound machines paired with clinician training, which may serve to reduce patient barriers to necessary medical imaging. Making bedside imaging available to critically ill patients and those that require imaging outside of normal business hours will allow clinicians to make life-saving diagnoses of high-risk conditions in their most critical patients [2, 3]. The integration of POCUS into routine clinical practice requires a substantial up-front investment, and the resources available for medical education are generally limited in LMICs. Further research should examine cost-benefit analysis, improvements and effects of routine OB POCUS on referral patterns and impact on patient health outcomes.

Limitations

The study has potential limitations. The assessment multiple choice questions had not been standardized nor validated in any other study or setting. They were developed by the authors and therefore may require reframing and validation in other training for a more widespread application.

Conclusions

We report the experience of training 514 HCPs in obstetric POCUS using didactic lectures and hands-on experience over a 5-day period using the ISUOG standard ultrasound techniques. Follow up data will be collected to assess the impact of the current training and deployment of portable ultrasound devices to mid-level HCPs in hard-to-reach areas with little or no access to ultrasound services.

Larger, more widespread OB POCUS training programs and estimation of their clinical impact are needed in LMIs. More broadly, the development of widespread POCUS training curricula for a wide variety of clinical applications should be embedded as an integral component of medical education in these settings. We encourage the integration of ultrasound training in medical schools throughout LMICs, which could have enormous potential impact on patient care in the future.