Building focused cardiac ultrasound capacity in a lower middle-income country: A single centre study to assess training impact

Wangari Waweru-Siika; Anders Barasa; Benjamin Wachira; David Nekyon; Barbara Karau; Fatimah Juma; Grace Wanjiku; Harun Otieno; Gerald S Bloomfield; Erik Sloth

doi:10.1016/j.afjem.2020.04.011

Building focused cardiac ultrasound capacity in a lower middle-income country: A single centre study to assess training impact

Afr J Emerg Med. 2020 Sep;10(3):136-143. doi: 10.1016/j.afjem.2020.04.011. Epub 2020 Jun 19.

Authors

Affiliations

¹ Department of Anaesthesia, Aga Khan University, Nairobi, Kenya.
² Department of Medicine, Aga Khan University, Nairobi, Kenya.
³ Department of Cardiology, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark.
⁴ Department of Emergency Medicine, Aga Khan University, Nairobi, Kenya.
⁵ Section of Global Emergency Medicine, The Warren Alpert Medical School, Brown University, Providence, RI, USA.
⁶ Duke Clinical Research Institute, Duke Global Health Institute, Department of Medicine, Duke University, Durham, NC, USA.
⁷ University of Cape Town, South Africa.

Abstract

Background: In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agreement between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training programme locally.

Methods: This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were assessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen's kappa >0.6 indicative of good inter-rater agreement.

Results: Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties.

Conclusions: Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives.

Keywords: Capacity building; Focused cardiac ultrasound; Low and middle-income; Training.