Stakeholder Perceptions of Point-of-Care Ultrasound Implementation in Resource-Limited Settings

Mission POCUS in Haiti

Introduction

Point-of-care ultrasound (POCUS) has enhanced patient care and safety around the world. Clinicians can now use a small diagnostic ultrasound imaging device to answer some binary clinical questions and manage patients more effectively. Since the COVID-19 pandemic, there has been a significant adoption of POCUS by clinicians worldwide.

Materials and Methods

A basic cardiac POCUS training was conducted in Haiti with focus on physics, instrumentation, and basic echocardiography.

Results

The Mission POCUS team trained 15 Haitian physicians interested in better serving their patients with the implementation of POCUS cardiac in their patient assessment.

Conclusion

POCUS skills will empower clinicians from around the world to make rapid and accurate diagnosis and help save lives by diagnosing life threatening conditions and manage patient appropriately. Our experience in Haiti showed that a short POCUS training course can help improve the knowledge of physicians.

Facilitators and barriers to in vitro diagnostics implementation in resource-limited settings: A scoping review

BACKGROUND

The World Health Organization (WHO) developed the model list of essential in vitro diagnostics (EDL) to guide countries to develop and update point-of-care (POC) per their disease priorities. The EDL includes POC diagnostic tests for use in health facilities without laboratories; however, their implementation might face several challenges in low- and middle-income countries (LMICs).

AIM

To identify facilitators and barriers to POC testing service implementations in the primary health care facilities in the LMICs.

SETTING

Low- and middle-income countries.

METHODS

This scoping review was guided by Arksey and O'Malley's methodological framework. A comprehensive keyword search for literature was conducted in Google Scholar, EBSCOhost, PubMed, Web of Science and ScienceDirect using the Boolean terms ('AND' and 'OR'), as well as Medical Subject Headings. The study considered published articles in the English language from 2016 to 2021 and was limited to qualitative, quantitative and mixed-method studies. Two reviewers independently screened the articles at the abstract and full-text screening phases guided by the eligibility criteria. Data were analysed qualitatively and quantitatively.

RESULTS

Of the 57 studies identified through literature searches, 16 met this study's eligibility criteria. Of the 16 studies, 7 reported on both facilitators and barriers; and the remainder reported on only barriers to POC test implementation such as inadequate funding, insufficient human resource, stigmatisation, et cetera.

CONCLUSION

The study demonstrated a wide research gap in facilitators and barriers, especially in the general POC diagnostic test for use in health facilities without laboratories in the LMICs. Extensive research in POC testing service is recommended to improve service delivery.Contribution: This study's findings contribute to a few works of literature on existing evidence of POC testing.

Implementation of a novel ultrasound training programme for midwives in Malawi: A mixed methods evaluation using the RE-AIM framework

Introduction

Despite recommendation that all women receive an ultrasound in pregnancy prior to 24 weeks', this remains unavailable to many women in low-income countries where trained practitioners are scarce. Although many programmes have demonstrated efficacy, few have achieved longterm sustainability, with a lack of information about how best to implement such programmes. This mixed-methods study aimed to evaluate the implementation of a novel education package to teach ultrasound-naive midwives in Malawi basic obstetric ultrasound, assessing its impact in the context of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework.

Methods

The study ran across six sites in Malawi between October 2020 and June 2021, encompassing three phases; pre-implementation, implementation and post-implementation. Twenty nine midwives underwent a bespoke education package with matched pre and post course surveys assessed their knowledge, attitudes and confidence and "hands on" assessments evaluating practical skills. Training evaluation forms and in-depth interviews explored their satisfaction with the package, with repeat assessment and remote image review evaluating maintenance of skills.

Results

28/29 midwives completed the training, with significant increases in knowledge, confidence and practical skills. Adherence to the education package varied, however many changes to the proposed methodology were adaptive and appeared to facilitate the efficacy of the programme. Unfortunately, despite reporting approval regarding the training itself, satisfaction regarding supervision and follow up was mixed, reflecting the difficulties encountered with providing ongoing in-person and remote support.

Conclusion

This programme was successful in improving trainees' knowledge, confidence and skill in performing basic obstetric ultrasound, largely on account of an adaptive approach to implementation. The maintenance of ongoing support was challenging, reflected by trainee dissatisfaction. By evaluating the success of this education package based on its implementation and not just its efficacy, we have generated new insights into the barriers to sustainable upscale, specifically those surrounding maintenance.

Stakeholder perspectives on current determinants of ultrasound-guided thoracentesis in resource limited settings: a qualitative study

OBJECTIVE

Preprocedure pleural fluid localization using bedside ultrasound has been shown to reduce complications related to thoracentesis and is now considered the standard of care. However, ultrasound-guided thoracentesis (USGT) has not been broadly adopted in many low-resource settings. With increasing affordability and portability of ultrasound equipment, barriers to USGT are changing. The aim of this multisite qualitative study is to understand the current barriers to USGT in two resource-limited settings.

SETTING

We studied two geographically diverse settings, Harare, Zimbabwe, and Kathmandu, Nepal.

PARTICIPANTS

19 multilevel stakeholders including clinical trainees, attendings, clinical educators and hospital administrators were interviewed. There were no exclusion criteria.

PRIMARY OUTCOME

To understand the current determinants of USGT adoption in these settings.

RESULTS

Three main themes emerged from these interviews: (1) stakeholders perceived multiple advantages of USGT, (2) access to equipment and training were perceived as limited and (3) while an online training approach is feasible, stakeholders expressed scepticism that this was an appropriate modality for procedural training.

CONCLUSION

Our data suggests that USGT implementation is desired by local stakeholders and that the development of an educational intervention, cocreated with local stakeholders, should be explored to ensure optimal contextual fit.

Training in Ultrasound to Determine Gestational Age (TUDA): Evaluation of a Novel Education Package to Teach Ultrasound-Naive Midwives Basic Obstetric Ultrasound in Malawi

Introduction

Although ultrasound to determine gestational age is fundamental to the optimum management of pregnancy and is recommended for all women by the World Health Organisation, it remains unavailable to many women in low-income countries where trained practitioners are scarce. This study aimed to evaluate a novel, context-specific education package to teach midwives basic obstetric ultrasound, including the determination of gestational age by measurement of fetal femur length.

Methods

The study was conducted across six sites in Malawi in January 2021. Following a virtual "training of the trainers", local teams delivered a 10-day programme encompassing both didactic and "hands on" components. Matched pre and post course tests assessed participants' knowledge of key concepts, with Objective Structured Clinical Examinations used to evaluate practical skills. To achieve a pass, trainees were required to establish the gestational age to within ±7 days of an experienced practitioner and achieve an overall score of >65% on five consecutive occasions. A matched pre and post course survey explored participants' attitudes and confidence in performing ultrasound examinations.

Results

Of the 29 midwives who participated, 28 finished the programme and met the criteria specified to pass. 22 midwives completed the matched knowledge tests, with the mean (SD) score increasing from 10.2 (3.3) to 18 (2.5) after training (P <0.0001). Mean difference 7.9, 95% CI 6.5-9.2. Midwives passed 87% of the Observed Structured Clinical Examinations, establishing the gestational age to within ±7 days of an experienced practitioner in 89% of assessments. Beliefs regarding the importance of antenatal ultrasound increased post course (p = 0.02), as did confidence in performing ultrasound examinations (p <0.0001).

Conclusion

This study demonstrates not only that ultrasound-naive practitioners can be taught to perform basic obstetric ultrasound dating scans, confidently and competently, after 10 days of training, but also that local teams can be orientated to successfully deliver the programme virtually. Previous ultrasound training initiatives, while often more comprehensive in their syllabus, have been of considerably longer duration and this is likely to be a barrier to upscaling opportunities. We propose that this focused training increases the potential for widescale and sustainable implementation.

Machine learning algorithm using publicly available echo database for simplified “visual estimation” of left ventricular ejection fraction

BACKGROUND

Left ventricular ejection fraction calculation automation typically requires complex algorithms and is dependent of optimal visualization and tracing of endocardial borders. This significantly limits usability in bedside clinical applications, where ultrasound automation is needed most.

AIM

To create a simple deep learning (DL) regression-type algorithm to visually estimate left ventricular (LV) ejection fraction (EF) from a public database of actual patient echo examinations and compare results to echocardiography laboratory EF calculations.

METHODS

A simple DL architecture previously proven to perform well on ultrasound image analysis, VGG16, was utilized as a base architecture running within a long short term memory algorithm for sequential image (video) analysis. After obtaining permission to use the Stanford EchoNet-Dynamic database, researchers randomly removed approximately 15% of the approximately 10036 echo apical 4-chamber videos for later performance testing. All database echo examinations were read as part of comprehensive echocardiography study performance and were coupled with EF, end systolic and diastolic volumes, key frames and coordinates for LV endocardial tracing in csv file. To better reflect point-of-care ultrasound (POCUS) clinical settings and time pressure, the algorithm was trained on echo video correlated with calculated ejection fraction without incorporating additional volume, measurement and coordinate data. Seventy percent of the original data was used for algorithm training and 15% for validation during training. The previously randomly separated 15% (1263 echo videos) was used for algorithm performance testing after training completion. Given the inherent variability of echo EF measurement and field standards for evaluating algorithm accuracy, mean absolute error (MAE) and root mean square error (RMSE) calculations were made on algorithm EF results compared to Echo Lab calculated EF. Bland-Atlman calculation was also performed. MAE for skilled echocardiographers has been established to range from 4% to 5%.

RESULTS

The DL algorithm visually estimated EF had a MAE of 8.08% (95%CI 7.60 to 8.55) suggesting good performance compared to highly skill humans. The RMSE was 11.98 and correlation of 0.348.

CONCLUSION

This experimental simplified DL algorithm showed promise and proved reasonably accurate at visually estimating LV EF from short real time echo video clips. Less burdensome than complex DL approaches used for EF calculation, such an approach may be more optimal for POCUS settings once improved upon by future research and development.

Training in Ultrasound to Determine Gestational Age in Low- and Middle- Income Countries: A Systematic Review

Introduction

Establishing an accurate gestational age is essential for the optimum management of pregnancy, delivery and neonatal care, with improved estimates of gestational age considered a public health priority by the World Health Organization (WHO). Although ultrasound is considered the most precise method to achieve this, it is unavailable to many women in low- and middle- income countries (LMICs), where the lack of trained practitioners is considered a major barrier. This systematic review explores what initiatives have previously been undertaken to train staff to date pregnancies using ultrasound, which were successful and what barriers and facilitators influenced training.

Methods

The systematic review was conducted according to PRISMA guidelines and the protocol registered (PROSPERO CRD42019154619). Searches were last performed in July 2021. Studies were screened independently by two assessors, with data extracted by one and verified by the other. Both reviewers graded the methodological quality using the Mixed Methods Assessment Tool. Results were collated within prespecified domains, generating a narrative synthesis.

Results

25/1,262 studies were eligible for inclusion, all of which were programme evaluations. Eighteen were undertaken in Africa, three in South-East Asia, one in South America, and three across multiple sites, including those in Africa, Asia, and South America. Five programs specified criteria to pass, and within these 96% of trainees did so. Trainee follow up was undertaken in 18 studies. Ten met recommendations for training outlined by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) but only 1 met the current standards set by the WHO.

Discussion

This systematic review is the first to evaluate this topic and has uncovered major inconsistencies in the delivery and reporting of basic obstetric ultrasound training in LMICs, with the majority of programs not meeting minimum recommendations. By identifying these issues, we have highlighted key areas for improvement and made recommendations for reporting according to the RE-AIM framework. With an increasing focus on the importance of improving estimates of gestational age in LMICs, we believe these findings will be of significance to those seeking to develop and expand the provision of sustainable obstetric ultrasound in LMICs.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019154619, PROSPERO CRD42019154619.

Feasibility, usability and acceptability of paediatric lung ultrasound among healthcare providers and caregivers for the diagnosis of childhood pneumonia in resource-constrained settings: a qualitative study

OBJECTIVES

Paediatric pneumonia burden and mortality are highest in low-income and middle-income countries (LMIC). Paediatric lung ultrasound (LUS) has emerged as a promising diagnostic tool for pneumonia in LMIC. Despite a growing evidence base for LUS use in paediatric pneumonia diagnosis, little is known about its potential for successful implementation in LMIC. Our objectives were to evaluate the feasibility, usability and acceptability of LUS in the diagnosis of paediatric pneumonia.

DESIGN

Prospective qualitative study using semistructured interviews SETTING: Two referral hospitals in Mozambique and Pakistan PARTICIPANTS: A total of 21 healthcare providers (HCPs) and 20 caregivers were enrolled.

RESULTS

HCPs highlighted themes of limited resource availability for the feasibility of LUS implementation, including perceived high cost of equipment, maintenance demands, time constraints and limited trained staff. HCPs emphasised the importance of policymaker support and caregiver acceptance for long-term success. HCP perspectives of usability highlighted ease of use and integration into existing workflow. HCPs and caregivers had positive attitudes towards LUS with few exceptions. Both HCPs and caregivers emphasised the potential for rapid, improved diagnosis of paediatric respiratory conditions using LUS.

CONCLUSIONS

This was the first study to evaluate HCP and caregiver perspectives of paediatric LUS through qualitative analysis. Critical components impacting feasibility, usability and acceptability of LUS for paediatric pneumonia diagnosis in LMIC were identified for initial deployment. Future research should explore LUS sustainability, with a particular focus on quality control, device maintenance and functionality and adoption of the new technology within the health system. This study highlights the need to engage both users and recipients of new technology early in order to adapt future interventions to the local context for successful implementation.

TRIAL REGISTRATION NUMBER

NCT03187067.

Impact of point-of-care ultrasound on the diagnosis and treatment of patients in rural Uganda

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Ultrasound is increasingly used by physicians at the bedside to diagnose and treat a variety of conditions and is particularly useful in the resource-limited setting. The purpose of this study was to determine whether point-of-care ultrasound (POCUS) performed by physicians changed the diagnosis or treatment of patients in mobile clinics in rural Uganda. Patients presenting to mobile clinics in Uganda were assessed by physicians and, when appropriate, POCUS was performed. When available, a radiologist reviewed ultrasound images in real time. A de-identified questionnaire was completed for each ultrasound and reviewed retrospectively. A total of 177 ultrasounds were performed. A radiologist reviewed 50% of the ultrasounds. In 73% of patients, the findings either confirmed (50%) or changed (23%) a diagnosis. In 53% of patients, the ultrasound findings changed the treatment plan. POCUS positively impacted patient care in rural Ugandan clinics by improving diagnostic capabilities and influencing treatment plans.

Point-of-Care Diagnostic Services as an Integral Part of Health Services during the Novel Coronavirus 2019 Era

Point-of-care (POC) diagnostic services are commonly associated with pathology laboratory services. This issue presents a holistic approach to POC diagnostics services from a variety of disciplines including pathology, radiological and information technology as well as mobile technology and artificial intelligence. This highlights the need for transdisciplinary collaboration to ensure the efficient development and implementation of point-of-care diagnostics. The advent of the novel coronavirus 2019 (COVID-19) pandemic has prompted rapid advances in the development of new POC diagnostics. Global private and public sector agencies have significantly increased their investment in the development of POC diagnostics. There is no longer a question about the availability and accessibility of POC diagnostics. The question is “how can POC diagnostic services be integrated into health services in way that is useful and acceptable in the COVID-19 era?”.

Hospitalist Perspectives of Available Tests to Monitor Volume Status in Patients With Heart Failure: A Qualitative Study

Acute decompensated heart failure is the leading admitting diagnosis in patients 65 years and older with more than 1 million hospitalizations per year in the US alone. Traditional tools to evaluate for and monitor volume status in patients with heart failure, including symptoms and physical exam findings, are known to have limited accuracy. In contrast, point of care lung ultrasound is a practical and evidenced-based tool for monitoring of volume status in patients with heart failure. However, few inpatient clinicians currently use this tool to monitor diuresis. We performed semi-structured interviews of 23 hospitalists practicing in five geographically diverse academic institutions in the US to better understand how hospitalists currently assess and monitor volume status in patients hospitalized with heart failure. We also explored their perceptions and attitudes toward adoption of lung ultrasound. Hospitalist participants reported poor reliability and confidence in the accuracy of traditional tools to monitor diuresis and expressed interest in learning or were already using lung ultrasound for this purpose. The time required for training and access to equipment that does not impede workflow were considered important barriers to its adoption by interviewees.