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, 3.32­4.32) to 4.68 (95% CI, 4.35­5.01) on an eight-point scale. The sensitivity and specificity of FAST exam during the initial training period was 77.8 (95% CI, 59.2­83.0) and 98.5 (95% CI, 93.3­99.9), 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

Upper extremity injury management by non-physician emergency practitioners in rural Uganda: a pilot study

Introduction: Improper management of and resultant poor outcomes from upper extremity injuries can be economically devastating to patients who rely on manual labour for survival. This is a pilot study using the Quick DASH Survey (disabilities of arm; shoulder and hand); a validated outcome measurement tool. Our objective was to assess functional outcomes of patients with acute upper extremity injuries who were cared for by non-physician clinicians as part of a task-shifting programme. Methods :This pilot study was performed at the Karoli Lwanga Hospital Emergency Centre (EC) in Uganda. Patients were identified retrospectively by querying the EC quality assurance database. An initial list of all patients who sustained traumatic injury (road traffic accident; assault) between March 2012 and February 2013 was narrowed to patients with upper extremity trauma; those 18 years and older; and those with cellular phone access. This subset of patients was called and administered the Quick DASH. The results were subsequently analysed using the standardised DASH metrics. These outcome measures were further analysed based upon injury type (simple laceration; complex laceration; fracture and subluxation). Results :There were a total of 25 initial candidates; of which only 17 were able to complete the survey. Using the Quick DASH Outcome Measure; our 17 patients had a mean score of 28.86 (range 5.0-56.8). Conclusions : When compared to the standardised Quick DASH outcomes (no work limitation at 27.5 vs. work limited by injury at 52.6) the non-physician clinicians appear to be performing upper extremity repairs with good outcomes. The key variable to successful repair was the initial injury type. Although accommodations needed to be made to the standard Quick DASH protocol; the tool appears to be usable in non-traditional settings