Rapid, remote education for point-of-care ultrasound among non-physician emergency care providers in a resource limited setting

Introduction: Access to high-quality emergency care in low- and middle-income countries (LMIC) is lacking. Many countries utilise a strategy known as “task-shifting” where skills and responsibilities are distributed in novel ways among healthcare personnel. Point-of-care ultrasound (POCUS) has the potential to significantly improve emergency care in LMICs. Methods: 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) was calculated. Results: Over the study duration, 1153 ultrasound studies were reviewed. Average imaging frequency per ECP dropped 61% after the initial in-person training month (p = 0.01) when ECPs performed ultrasound independently, but rebounded once electronic feedback was initiated (p = 0.001), with an improvement in quality from 3.82 (95% CI, 3.32–4.32) to 4.68 (95% CI, 4.35–5.01) on an eight-point scale. The sensitivity and specificity of FAST exam during the initial training period was 77.8 (95% CI, 59.2–83.0) and 98.5 (95% CI, 93.3–99.9), respectively. Sensitivity improved 88% compared to independent, non-feedback months whereas specificity was unchanged. Conclusions: Remotely delivered quality assurance feedback is an effective educational tool to enhance provider skill and foster continued and sustainable use of ultrasound in LMICs. Keywords: ultrasound;non-physician, quality assurance, Hydroxyl radicals, remote feedback