Table 3.
Key outcomes investigated and findings
| First author Year Published |
Key outcomes investigated | Main Finding in relation to antenatal PoCUS | ||
|---|---|---|---|---|
| Adler [66] 2008 |
Frequency & application of PoCUS following training. | Pregnancy-related exams accounted for 24.1% of total. US is a feasible & sustainable imaging modality in a very low-resource setting (refugee camp). | ||
| Baltarowich [61] 2009 |
Trainee knowledge acquisition & retention – written test scores compared at 3 points in time over 6 months. | Mean test scores increased significantly- 58.4% at entry to 76.8% at end-of-program. Nine of the 12 physicians were selected to establish affiliated US training programs in their own country. |
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| Bell [22] 2016 |
Written & practical test scores; before & after refresher training. Frequency & application of PoCUS following training. PoCUS impact on patient management. |
Strong correlation between knowledge & practical skill scores. Increase proportion passing both knowledge & practical tests at follow-up, compared to initial session. 90% trainees completing more than 1 session maintained or improved scores. Follow-up survey- 2/3 to 3/4 reported using PoCUS over 20 times in previous 3 months, Obstetrical exams were most commonly performed and had the greatest impact on patient management. | ||
| Dalmacion [25] 2018 |
Trainee to instructor image comparison. Estimate of maternal/fetal deaths averted. |
95% agreement between the trainee & instructor US. Estimated 6.3% of maternal deaths & 14.6% of neonatal deaths possibly averted by the early US screening. | ||
| Dornhofer [54] 2020 |
Pre- & post-course written & practical examination scores (compare physicians, nurses, & midwives). Post-course survey of trainee scanning confidence. |
No participants passed (>65%) the pre-course examination. 43 (72%) passed the course & 12 (28%) failed. Written exam pass rate- Fifteen (79%) physicians, 11 (85%) nurses, & 13 (68%) midwives. Average practical examination score was 83% (SD = 16.2%) for physicians, 82% (SD = 11.4%) for nurses, and 71% (SD = 15.2%) for midwives. Physicians performed best on pre- & post course written exams, followed by nurses & then midwives. Nurses scores improved most, followed by physicians & midwives. The average practical score for physicians was significantly greater than midwives (P = .038). The average practical score for nurses was significantly greater than for midwives (P = .049). All trainees reported increased post course comfort levels performing PoCUS. |
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| Henwood [53] 2017 |
Expert review of trainee images. PoCUS application. PoCUS impact on patient management. |
100% sensitivity & 98% specificity for expert reviewed OB images (94% & 98% overall). Trainees most frequently used US for abdominal & OB applications. 81.3% of patients had at least one clinical decision changed because of a PoCUS. |
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| Kimberly [62] 2010 |
Practical assessment (OSCE) of skills & sustainability over time (2 & 6 months). Expert review of trainee images. Frequency & application of PoCUS following training. PoCUS impact on clinical decision making/patient management. |
Paired OSCE scores- slight overall improvement over time. Trainees most competent at identifying number of gestations (100%), & fetal presentation (96%), calculating FHR (48%) was more challenging. Scan review- FHR interpretation 96% agreement, placental location 91% agreement, BPD 70% agreement. Mean of 21 scans performed per trainee over 6 months. 2nd & 3rd trimester most common. Main indications recorded- Size to date discrepancy (44%) & determining fetal position (39%). US prompted change in clinical decision-making in 17% of cases. At 1 year follow-up- trainees average 10 PoCUS per week. 85% reported helping colleagues use US. 46% reported significant time constraints as main limitation. | ||
| Kolbe [26] 2015 |
Expert review of trainee images. PoCUS application/indication. PoCUS impact on clinical decision making/Patent management. |
Average expert rating of trainee images-6.54/10 in first 6 weeks & 7.17/10 in last 6 weeks. 52% (CI- 44-61%) of patients had a new diagnosis after PoCUS. A new diagnosis lead to change in management in 48% (CI 40–57%) of patients. | ||
| Kotagal [56] 2015 |
Change in self-assessment scores regarding attitudes, confidence & assessment of the value of US before & after training intervention. | Mean confidence score pre-test to post-test improved from 23.3 (±10.2) to 37.8 (±6.7). Before & after training, trainees overwhelmingly agreed US would improve their practice, make them a better surgical resident, & improve their practice in LRS. All agreed the US course helped them improve their PoCUS knowledge & skills. | ||
| Lathrop [58] 2011 |
Learner portfolio & hands-on workshop for US credentialing & training. Learner feedback meeting. |
All 4 trainees credentialed to perform US clinically within one month. Portfolios & evaluation rubric offered a consistent, systematic means to demonstrate the acquisition of skills for clinical practice. And were a more effective & practical method of demonstrating trainee competence & supporting credentialing over a physician’s subjective impression of trainees’ abilities. | ||
| Lee [55] 2017 |
Pre & post course trainee knowledge assessment. Post training practical skills assessment and course evaluation survey (scanning confidence & intent-to-use US). |
Average pre-course exam score was 35.2% (2.4% pass rate). The average post-course exam score was 82.0% (92.7% pass rate). Average practical score on completion of the course was 83.2% (SD = 0.145) with 82.9% of the class passing (pass mark above 75.0%). Post-course survey- overall increased level of comfort performing all scans. Cardiac followed by OB US were anticipated to be most frequent indication. | ||
| Lindgaard [52] 2017 |
Expert review of trainee images. | Expert to trainee agreement for intrauterine pregnancy-100%, GA- 93%. Low-to-moderate complexity PoCUS exams performed by GPs with sufficient prior training have a very high level of inter-rater agreement when compared to exams conducted by radiologists & gynaecologists. | ||
| Mandavia [67] 2000 |
Trainee knowledge acquisition & retention- written test scores before & after training & at 10 month follow-up (stratified by discipline & US experience). Expert review of trainee images. Frequency & application of PoCUS. |
The mean pre-test score was 65%, mean post-test score 84%, No decline after 10 months. Pre-test variation based on US experience not evident after training. Image review- overall sensitivity of 92.4% & specificity of 96.1% (95% CI = 94% to 98%). OB only exams were 94% sensitive & 100% specific. Frequency of scanning varied widely (9–152), averaging 62 exams over 10 months. Biliary, renal and trauma were the most frequent indications for scanning. | ||
| Nathan [49] 2017 |
Written & practical skills assessment. Expert review of trainee images for errors in scanning parameters & diagnosis, using predetermined criteria. Site, patient & trainee demographics. |
36/41 trainees passed the practical test on first attempt at the end of 2 week course & 40/41 passed at the end of 12 week pilot period. Mean practical skills score increased- 78% on the first test to 92% on the fourth test. Of the 3801 US exams (32,480 images), 94.8% were rated as satisfactory by expert review. Concordance between trainee & reviewer US diagnosis was 99.4%. High-risk pregnancies were identified by the trainees in 6.7% (255/3801) of exams. | ||
| Rominger [24] 2018 |
Frequency & application of PoCUS following training. Expert review of trainee images. Impact on patient management & diagnosis. |
The most common studies were TA OB exams (45.5%) and abdomen/pelvis (26.6%). US scanning peaked after teaching sessions then gradually decreased over months. Highest recorded scans were after the final teaching session. Disagreement in findings in 4.3% of the images reviewed (none affected clinical management) & 6.5% with inadequate image quality to interpret. PoCUS changed patient diagnosis in 34% (24% for OB patients) & clinical management in 30% (20% for OB patients). In the scans that changed the diagnosis, 78% led to changed clinical management. | ||
| Shah [45] 2020 |
Practical OSCE assessment & accuracy of images & measures over time. Blinded expert image review for QA & inter-rater reliability of reviewers. Confidence levels pre-post training & at 3 months follow up. Post course evaluation/training perception interviews. |
Of 25 trainees, 22 passed (average score 89.4%) the OSCE on first attempt. Image quality improved with time; the final error rate at week 8 was less than 5%. Confidence levels increased- pre-course 1 point average to over 6 points post-course for all measures (maximum 7). Key informant interviews- indicated a desire for more hands-on training, longer training duration & challenges in balancing clinical duties with ability to attend training sessions. | ||
| Shah [48] 2014 |
Pre- & post-course knowledge & confidence assessment. Time & accuracy of scanning. |
For previously untrained trainees, pre- & post-test knowledge scores improved from 65.7% [SD = 20.8] to 90% [SD = 8.2] (p < 0.0007). Self-confidence improved significantly for identification of FHR, fetal lie, & EGA. Average times for completion of critical skills: cardiac activity (9s), FHR (68.6s), fetal lie (28.1s), & EGA (158.1 sec). EGA estimates averaged 28w0d (25w0d-30w0d) for the model‘s true GA of 27w0d. | ||
| Shah [47] 2009 |
Reporting impact of previously published training program (Shah 2008) Patient demographics & US application. Blinded expert image review of trainee images for quality & accuracy. PoCUS directed change of patient management. |
OB scanning was the most frequently used application followed by abdominal. Evaluation of GA, fetal head position, & placental positioning were the most common findings. Local staff performed 245 US scans in the 11 weeks after the departure of the US instructor. Expert to trainee agreement on scan review of 96%. US changed patient management in 43% of patients. | ||
| Shah [46] 2008 |
Initial US needs assessment, training curriculum development & implementation. Staff survey of prior US experience & hospital records review. |
10 of 15 physicians completed the training. Needs assessment-all 15 trainees rated OBs most important application. Focus group discussion- barriers to US services included distance, time & cost for transfers, lack of monitoring during transfers & US charges. Dissatisfaction expressed US report quality & inability to view images with written reports. | ||
| Shaw-Battista [29] 2015 |
Pre & Post course knowledge assessment. Post course evaluation. Other project evaluations/outcomes ongoing & not reported including: pre- & post-online module knowledge of OB US, interprofessional competencies, & post-training knowledge following seminar & practical. |
Course evaluations were extremely positive. Trainees expressed enthusiasm to develop basic US competencies & recognised the applicability of new skills to clinical practice. Hands-on sessions were universally appreciated- requests for additional or longer sessions, more pregnant volunteers & reducing group size (trainee to faculty ratios). Trainees reported teaching varied types of trainees together as “innovative & helpful” but also perceived to be challenging. | ||
| Shokoohi [51] 2019 |
Trainee demographics including US experience. Frequency & application of PoCUS following training. Teaching of other staff/students. Challenges/barriers to integrating US into patient care. |
Main applications for PoCUS- cardiac exams followed by 2nd & 3rd trimester OB exams. Over 75% reported use of PoCUS in clinical diagnoses & 50% in determining treatment. 50% reported very frequently or often using US to teach within their clinics. Largest perceived barriers- lack of clinical educators US knowledge, lack of time, equipment security, difficulty accessing the Internet & equipment problems. | ||
| Stolz [30] 2015 |
Frequency & application of PoCUS over duration of training course. Patient/scan outcome. |
Of 22,639 ED patients evaluated, PoCUS examinations were performed on 1,886 patients. OB scans (9.3%) were 3rd most common scan after FAST (53.3%) & Echo (16.4%). PoCUS studies were performed more frequently than radiology department-performed studies. Positive findings were documented in 46% of all PoCUS exams. | ||
| Swanson [85] 2014 |
Expert review of trainee images. Diagnostic outcome following PoCUS. |
Expert review of trainee images- 100% sensitivity & specificity for identifying gestational number, 90% sensitivity & 96% specificity for fetal presentation. Trainee PoCUS altered clinical diagnosis in up to 12% of clinical encounters. | ||
| Vinayak [63] 2017 |
Post e-module assessment (pre hands on) & post course written assessment. Expert review of trainee images for quality & accuracy of interpretation. Patient outcome following PoCUS. Patient experience. |
E-module knowledge reported useful. All trainees passed the written post-course exit exam on 1st attempt. Reporting accuracy of trainees’ scans was 99.63%. Reduced AFI missed on 2 patients scans. Time to complete scan halved after completing 30 scans. All 246 patients felt the process was safe, convenient & reassuring, had a better antenatal visit experience & increased confidence in care delivery. More spouses attended then for routine antenatal visits. | ||
| Vyas [70] 2018 |
Post-training OSCE practical assessment. Image quality review & trainee identification of pathology. Patient outcome. |
Trainees were able to correctly identify fetal presentation, fetal number, & placental position in all enrolled patients. BPD correctly assessed in 95.3% & HC 90%. GA had a mean difference from expert sonographers of 1.5 days (BPD) & 0.26 days (HC). All 4 patients with abnormal findings were expert confirmed. | ||
| Wanjiku [21] 2018 |
Pre-training knowledge assessment. OSCE practical assessment with image quality scores. Frequency & application of PoCUS following training. |
OB images received the highest mean image quality score (compare to FAST, thoracic & echocardiography). Image quality scores increased with an increase in training sessions and decreased with increasing time since prior training. OB US were most frequently performed. Frequency of scanning positively correlated with written & image quality test scores. | ||
| Westerway [50] 2019 |
Trainee knowledge acquisition & retention – written & practical tests before & after training & at 6/11 month follow-up.Comparison of PoCUS courses (rural/urban sites, duration, student numbers).Course evaluation- satisfaction, engagement, understanding & relevance of learning. Scanning on return to work. |
Practical assessment at 6/11 months- minor prompting for image optimisation (depth, gain & imaging plane for fetal biometry) for all but 4 trainees who had peer support at work following training. All (55) trainees achieved the course objectives, regardless of format. Course evaluation- all trainees stated understanding what was taught & relevance to their clinical work. All trainees continued scanning on return to work. |
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Abbreviations AFI- amniotic fluid index BPD- Biparietal diameter CI- Confidence interval d- days ED – Emergency Department EGA- Estimated gestational age |
FAST- Focused assessment with sonography in trauma FHR- Fetal heart rate GA- Gestational age HC- Head circumference LRS- Low-Resource-Setting OB- Obstetric |
OSCE- Objective Structured Clinical Examination PoCUS- Point-of-Care Ultrasound QA- Quality assurance SD- Standard deviation US- Ultrasound w- weeks |
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