Table A4.
Training methods and delivery
| First author Year Published Location Rural / Urban Income classification | Training duration & delivery |
Trainees (Number, role/discipline, previous US experience) |
Instructors (Qualification of instructor/s & ratio of instructor to trainees) |
Curriculum Course topics & Practical skills taught (Obstetric only or multiple organs systems) |
Follow-up training & support (Refresher training, follow-up assessment, distance or online support & mentoring provided/offered) |
|---|---|---|---|---|---|
| Adler [66] 2008 Africa, Tanzania (refugee camp) Rural LMIC |
4 days- Morning lectures followed by afternoon practical. |
Multidisciplinary 10 trainees- 4 Physicians, 6 Clinical officers. US experience not specified/unclear. |
Instructor credentials and group sizes not specified. |
Multiple systems- Basic US physics, knobology, & reviews of clinical US including: US evaluation of 1st trimester pregnancy; Pregnancy dating & fetal position; FAST; US evaluation of the abdominal aorta; Hepatobiliary US; US-guided procedures; Soft tissue US; Basic echocardiography; Renal US. |
Follow-up at 2 years- 1 instructional session to reinforce prior learning. |
| Baltarowich [61] 2009 Africa- Sub-Saharan (Training conducted in USA) LIC/LMIC |
3 months- didactic lectures, case review sessions, informal teaching sessions, conferences, hands-on sessions using a variety of equipment, & clinical observation rotations. |
12 Physicians- 11 radiologists, 1 intern.US experience- 2 to 20+ years. |
Training groups of 6. 1:6 |
Multiple systems- Focus on OBs with In-depth training in: US physics, instrumentation, cross-sectional anatomy, abdomen, OB/GYN. Overview of diagnostic US in the areas of vascular, echocardiography, musculoskeletal, paediatrics, thyroid, prostate, sonomammography, & interventional techniques. Care & maintenance of US equipment, preparation techniques for effective teaching. |
Follow-up written test after 6 months, 8/12 trainees returned for a 4 week update program at 12 months. |
| Bell [22] 2016 Africa, Kenya Rural LMIC |
1 day & 1–2 follow-up sessions offered every 3–5 months for 1 year. |
Multidisciplinary 81 trainees- Equal proportion of doctors, nurses & clinical officers. Several sonographers & 1 lab assistant. Most with no US experience. |
US credentialed EM physicians. 4–5 trainees in practical sessions. Ratio 1:4–5 |
Multiple systems- Physics & machine use; OB exam for intrauterine pregnancy, cul-de-sac fluid, FH activity & position; The abdominal, pleural & cardiac assessment for free fluid; The thoracic exam for pneumothorax. |
1–2 follow-up refresher sessions offered at 3 to 5 months. |
| Dalmacion [25] 2018 Asia, Philippines Rural & urban study sites LMIC |
2–3 days- Classroom lectures & hands-on training. 2–3 days scanning pregnant women recruited by the study. |
Multidisciplinary 20 trainees- 6 doctors, 9 midwives, 5 nurses. US experience not specified/unclear. |
Credentialed OB sonographers. All lectures delivered by team leader. | Obstetrics only- Trained to identify & measure 5 OB US images- 1. Viability of the fetus 2. Number of pregnancies 3. Fetal presentation 4. Placental location 5. Amniotic fluid volume (AFV) using maximal vertical pocket |
*NR |
| Dornhofer [54] 2020 Indonesia, East Java Urban UMIC |
4 weeks- 6 sessions (3–4 days apart), 6 hours of lectures & 18 hours of practical. |
Multidisciplinary 51 Trainees- 19 physicians, 19 midwives, 13 nurses. 36 (65%) had no prior US exposure, 40 (73%) observed US in practice, 4 (7%) attended prior US course. |
8 Medical students- 1st year of medical education completed including- lectures on PoCUS for 8 organ systems & 10 hours of supervised hands-on training per organ system, assessment using healthy volunteers. Ratio 1:4 or 1:5 for hands-on training, 2 medical student instructors per US machine/station to 10 trainees. |
Multiple systems- 6 session, 1 OB/GYN focussed 1. Basic US including US physics, machine knobology, probe manipulation, & scanning techniques. 2. Pulmonary US, evaluation of pneumothorax, pleural effusions, & pneumonia. 3. Cardiac US in the parasternal long axis view, parasternal short axis view, apical four chamber view, & subxiphoid view. 4. Abdominal US- hepatic, biliary, renal, intestinal, aorta, & inferior vena cava. 5. OB/GYN US including identification of intrauterine pregnancy, estimated GA, visualization of the ovaries, & bladder. 6. Combination of previous sessions to aid FAST & the Focused Assessment with Sonography for HIV-Associated Tuberculosis (FASH). |
*NR |
| Henwood [53] 2017 Africa, Rwanda Rural LIC |
10-day course. 6 months scanning assessment for image accuracy. |
17 Physicians- US experience not specified/unclear. |
EM physicians with expertise in PoCUS, consultant obstetricians & radiologists. |
Multiple systems- Introduction to PoCUS & common applications. OBs- Gestational sac, Yolk sac, Fetal pole, FHR, Endomyometrial mantle, CRL, BPD, FL, Fetal lie, placental location, Placenta previa, Hydramnios. Echocardiography, Abdominal, Lung, Spleen, Liver, Biliary, Renal, Soft tissue. |
Follow-up training every 6 weeks for 6 months trial period with regular practical assessments. Onsite image review & technical assistance. |
| Kimberly [62] 2010 Africa, Zambia Rural LMIC |
6 months- 3 training periods of 2 to 3 weeks interspersed by 2 to 3 months of independent scanning under minimal supervision | 21 Midwives- No prior US experience. | 3 emergency US fellowship trained physicians. | Obstetrics only- US machine use, cleaning & storage, Patient data entry, image saving (for review), & exam datasheet completion. Practical- Identify basic OB applications: Fetal presentation (vertex or breach), FHR (presence & use of callipers to calculate the rate), Placental location (anterior, posterior, low-lying, or previa), number of gestations & GA based on BPD & FL. |
1 year follow-up visit questionnaire of PoCUS application & frequency, no additional training. |
| Kolbe [26] 2015 Central America, Nicaragua Rural & urban study sites LMIC |
Daily morning didactic sessions & practical workshops, afternoon US of patients from the community (course duration unclear), followed by 3 months remote guidance & telecommunication. |
Multidisciplinary 4 trainees- 2 postgraduate rural medicine physicians, 1 nurse, 1 nursing assistant. US experience not specified/unclear. |
Experienced international sonographers. Ratio 1:4. |
Multiple systems- OBs- Normal pregnancy, Fetal viability; Complicated pregnancy (Ectopic pregnancy, Placenta previa, Placenta abruption). Other systems- Echocardiography, Hemodynamic evaluation, Pleural, Lung, Abdominal & Vascular US. |
Weekly 60–90 min remote guidance sessions & telecommunication supportfor 3 months following training. |
| Kotagal [56] 2015 USA, Washington Urban aimed at rural deployment HIC |
14 hours- 7 sessions of 2 hours over 3 months. |
16 General surgery residents-Limited previous US training (guidance for central venous catheter placement & a brief FAST training). |
Multidisciplinary faculty (Surgery, Radiology, Anaesthetics & EM) with expertise in PoCUS. |
Multiple systems- Topics- US physics, knobology, safety & artifacts; FAST; Skin & soft tissue US; OB US (early & late pregnancy); Focused echocardiography & volume assessment; Procedural guidance US (paracentesis, thoracentesis, & pericardiocentesis); Vascular US (abdominal aorta & deep vein thrombosis); US guided regional anaesthesia. |
*NR |
| Lathrop [58] 2011 USA, Indianapolis Urban HIC |
Half day workshop- 45 minute instruction session followed by practical. |
4 Advanced practice Nurses (APN)- 3 attended previous didactic US training. |
Credentialed US provider. Ratio 1: 2–3 for practical workstations. |
Obstetric Only- Instruction session (45 mins)- Review US standards of care, basic review of US physics & instrumentation, indications, clinical significance & documentation. Practical session- Fetal number, demonstration of life, estimate amniotic fluid, placenta location & fetal presentation. Learning portfolio- (a) documentation of didactic learning (certificates from US-related training or workshops attended); (b) readings (journal articles, clinical bulletins, & practice statements); (c) US cases. |
No follow-up of trainees reported but an additional future workshop planned to include more advanced skills, such as fetal biometry, first-trimester US, & cervical length measurement. |
| Lee [55] 2017 Indonesia, Bandung Urban UMIC |
4 weeks – 6 sessions. Each session- 30 min lecture followed by 2 hours hands-on training. |
41 Physicians- 22 (53.7%) no prior US experience, 18 (43.9%) observed US in practice, 1 (2.4%) attended prior US course. |
Medical students- 1st year of medical education completed including- lectures on PoCUS for 8 organ systems & 10 hours of supervised hands-on training per organ system, assessment using healthy volunteers. |
Multiple systems- 6 sessions, 38 US milestones. 1- Basic US including physics, knobology, probe manipulation & scanning techniques. 2- Pulmonary US, evaluation of pneumothorax, pleural effusions & pneumonia. 3- Cardiac US in the parasternal long axis view, parasternal short axis view, apical four chamber view & subxiphoid view. 4- abdominal US (hepatic, biliary, renal, intestinal, aorta & inferior vena cava). 5- OB/GYN US (identification of intrauterine pregnancy, estimated GA, visualization of the ovaries & bladder). 6- combination of previous sessions to aid FAST & the Focused Assessment with Sonography for HIV-Associated Tuberculosis (FASH). |
Follow-up scheduled for 12 months to re-test trainees & assess use of US. |
| Lindgaard [52] 2017 Denmark, Odense Urban HIC |
2 days practical & feedback session following online learning package. |
5 General Practitioners- 4 specialist GPs, 1 final year resident. No formal US training. |
Instructors from Center of Clinical US, University of Aarhus. |
Multiple systems- E-learning online lectures- Basic US knowledge- physics & US equipment; Focused US examinations of thoracic structures, abdomen, vascular & musculoskeletal. Practical exams conducted- Intrauterine pregnancy; GA; Gall-stones; Ascites; Abdominal aorta. |
*NR |
| Mandavia [67] 2000 USA, California Urban HIC |
16 hours over 2 days. 8 hours lectures & 8 hours practical. |
Multidisciplinary 80 trainees- 16 attending physicians, 53 ED house officers, 4 physician assistants, 7 medical students. Prior US training experience- none (58), minimal 1–5hrs (6), moderate 5–10 hrs (9), & extensive >10 hrs (7). |
Board-certified US trained EM physicians & certified registered diagnostic medical sonographers. Ratio 4:1 per US/station for hands-on learning. | Multiple systems- Curriculum based on Society for Academic Emergency Medicine guidelines. Lectures- Basic physics; Pelvis & OB; Right upper quadrant; Renal; Aorta; Trauma; Echocardiography. Practical- OB skills included: Detection of early intrauterine pregnancy &/or free pelvic fluid; Detection of live fetus in 2nd/3rd trimesters. |
Follow-up identical test at 10 months & images performed over this time reviewed for accuracy. |
| Nathan [49] 2017 5 sites: Democratic Republic of Congo, Karawa Guatemala, Chimaltenango Kenya, Eldoret Pakistan, KarachI Zambia, Lusaka Rural LIC/LMIC/UMIC |
2 weeks- One third didactic sessions, two thirds practical scanning. 2 supervised US exams on each day of the course. |
Multidisciplinary 41 Trainees- 10 medical officers, 18 nurses, 6 midwives, 7 radiographers. No prior US experience. |
Training under the direction of a Radiologist. Local sonographer for ongoing training, QA & trainee evaluation. Image review by: Radiologist (25 yrs in OB US), 2 professors of OBs; a professor of radiology (10 yrs in OB US); & 2 lead OB sonographers.Training groups of 4 to 12 – ratio not specified. |
Obstetric only- Curriculum development- Didactic & hands-on instruction, printed materials, extensive quality assurance activities, educational outreach visits, daily schedule, speaker notes for PowerPoint slides, & explicit instructions for each practical scanning session. Topics- Patient communication, safety, & comfort; Infection prevention & control; Care & security of the equipment; US physics & instrumentation; Anatomic planes & introduction to tomography. Practical skills- Detection of cardiac activity; Fetal number, Fetal position, Amniotic fluid assessment; BPD; HC; AC; FL; Placental position; Cervical length at 16–24 weeks; Detection of some anomalies (ventriculomegaly, anencephaly, hydronephrosis, & spina bifida). |
For the 12 week pilot period- Monthly follow-up & practical assessment. Local instructors met trainees to discuss performance & observe scanning progress bi-weekly. Image feedback from quality control website. Targeted remedial training given to some trainees. |
| Rominger [24] 2018 Mexico, Chiapas Rural UMIC |
16 days training over 12 month duration. Total of 4 sessions (each session 4 day course) every 3–4 months. |
10 Physicians-Little to no prior US experience. |
Obstetrician, Paediatric EM physician, EM physician & residents. 6 to 10 trainees per 2 instructors. Ratio 1:3–5 |
Multiple systems- 1- Introduction to US, equipment use & care, FAST, kidney & bladder evaluation, basic OBs. 2- Lung, skin & soft tissue, & musculoskeletal US. 3- OB/GYN physician taught focused on OBs. 4- Review of US basics, cardiovascular, advanced abdomen, & ocular. |
Case logs & images (35%) reviewed for quality assurance & feedback. |
| Shah [45] 2020 Africa, Uganda LIC |
2 days intensive training course followed supervised (Master trainer) scanning 2–3 days per week for 3 weeks. | Multidisciplinary 25 Trainees- 20 midwives, 3 nurses, 2 physicians. No prior US experience. |
Certified sonographer, OB/GYN resident physician, family physician & 3 EM physicians with US training. Instructors had prior experience in PoCUS in LMIC. Ratio 1:3 for practical scanning. | Obstetrics only- Short lectures & hands-on demonstrations using healthy volunteers, hands-on live scanning practice on 3rd trimester antenatal patients not in labor, & mock active labor patients. Topics- US knobs & Physics; US Safety; Principles of adult learning; US teaching methods; Hands-on training techniques; Fetal position; Placental position; Fluid volume; Multiple gestation; FHR; Estimating GA: BPD, HC, FL, TCD; Common learner mistakes. |
Twice weekly distance/online communication for 3 months.Confidence survey repeated at 3 months. Key informant interviews assessed trainee’ perception of training program |
| Shah [48] 2014 USA, North-western Urban HIC |
3 hours- 1 hour lecture, 2 hours practical. |
31 Emergency physicians- 17 attendings, 14 residents. Range of no prior experience to experienced. |
US fellowship trained EM physicians. 1:1 for hands-on instruction. |
Obstetric only- Mechanics of TA & TV US. General review of 1st trimester US including- Normal US findings in 1st trimester, Other abnormal US findings in early pregnancy (fetal demise, molar pregnancy), finding FHR using M-mode, measurement of GA using CRL, & ectopic pregnancy. Late pregnancy US including fetal lie & identification of the fetal head, & fetal biometry including measurement of BPD, FL, HC & AC. Practical- live models in the 2nd & 3rd trimester of pregnancy. |
*NR |
| Shah [47] 2009 Africa, Rwanda Kirehe & Rwinkwavu in Eastern Province Rural LIC |
9 weeks- 1 hour lecture (15 lectures total) followed by 1–2 hours practical. |
10 Physicians-Little to no prior US experience. |
US training sessions conducted by a 4th year EM resident with prior US experience (including OB US) during residency training & credentialing certification. |
Multiple systems- Principles of US physics; Machine operation; Potential uses of US; Outline of lecture series, training expectations, image & data sheet recording instructions. OB US including 1st trimester basics- ectopic or molar pregnancy, estimating GA, & evaluation of fetal position, cervix & placenta. Cardiac US; Hepato-biliary US; Renal US; Advanced applications- US evaluation of DVT, procedures including vascular access, abscess evaluation & drainage, US guided paracentesis & thoracentesis. |
Image accuracy & quality assessed by expert review. Telecommunication (email) support offered. |
| Shah [46] 2008 Africa, Rwanda, Kirehe & Rwinkwavu in Eastern Province Rural LIC |
9 weeks- 1 hour lecture (15 lectures total) followed by 1–2 hours practical. | 15 physicians- 0–4 h of prior US training solely in OBs. | US training sessions conducted by a 4th year EM resident with prior US experience (including OB US) during residency training & credentialing certification. Cardiac echo lecture given by visiting Cardiologist.1:1 for scanning practice during ward rounds. Other group sizes not specified. | Multiple systems- Principles of US physics; Machine operation; Potential uses of US; Outline of lecture series, training expectations, image & data sheet recording instructions. OB US including 1st trimester basics- ectopic or molar pregnancy, estimating GA, & evaluation of fetal position, cervix & placenta. Cardiac US; Hepato-biliary US; Renal US; Advanced applications- US evaluation of DVT, procedures including vascular access, abscess evaluation & drainage, US guided paracentesis & thoracentesis. |
Image accuracy & quality to be assessed by expert review (Shah 2009). Telecommunication (email) support offered. |
| Shaw-Battista [29] 2015 USA, California Urban HIC |
10 asynchronous online modules followed by 4 hours training- 2 hour seminar, 2 hour practical. |
Multidisciplinary Initial course- 72 trainees- Midwives, nurses, family practice physicians, physician assistants Developed course- 162 trainees- Midwives, nurses, nurse practitioners, medical & midwifery students, family practice & OB physicians, physician assistants. Range of no prior US experience to experienced. |
Senior OB & family medicine residents (advanced trainees & licensed clinicians).Ratio 1:3–5 during practical sessions. |
Obstetrics only- Asynchronous online module topics- Indications for OB US; Documentation, communication, liability, & risk-reduction strategies; US physics, equipment, & optimizing image quality; Normal 1st trimester US; Abnormal 1st trimester US; Limited 2nd & 3rd trimester US; Fetal biophysical profile; 2nd & 3rd trimester fetal biometrics; Use of OB US on the labor & delivery ward; Interprofessional OB US training & practice. |
*NR |
| Shokoohi [51] 2019 Africa, Tanzania, Malawi & Uganda Rural & urban LIC/LMIC |
2 day training course. Online modules & educational materials provided. |
Multidisciplinary 49 Trainees (initial 63 with 78% response rate)- 7 midwives, 42 physicians (different specialties).21/49 never performed independent US,29/49 limited US training during residency. |
Sonographer. Ratio 1:3–4 during course. Ratio 1:1 for in clinic training. |
Multiple systems- Topics- review of the concepts for clinician- performed US, introduction to the US machine & controls, the focused assessment with sonography for trauma/focused assessment with sonography for human immunodeficiency virus/tuberculosis (FAST/FASH), abdominal US exam, echocardiography, lung, renal/bladder & abdominal US Midwives & obstetricians received focused training on gynaecologic US & 1st & 3rd trimester US. |
Telecommunication support- Online feedback on transmitted images from independent scanning after training |
| Stolz [30] 2015 Africa, Uganda LIC |
2 years- US lectures delivered intermittently over the 2-year ‘emergency care for non-physicians’ curriculum (train the trainer model) with the core US lectures occurring early in the programme. | 13 Nurses-US experience not specified/unclear. | EM physicians with fellowship training in emergency US or strong clinical competency in emergency US. | Multiple systems- 1. Introduction to PoCUS, Machine care, basic physics & US principles, image optimisation, knobology, safety, patient consent & documentation in the medical record. 2. FAST; 3. Echocardiography; 4. Hepatobiliary US; 5. Renal US; 6. Soft tissue US; 7. Lung US; 8. Aorta US; 9. Inferior vena cava US; 10. OB/GYN US- Evaluation of intrauterine pregnancy, signs of ectopic pregnancy, pelvic free fluid, adnexal mass, foetal heart rate, foetal movement, fetal dating & fetal presentation 11. Abdominal US; 12. Procedural guidance with US; 13. US assessment for deep vein thrombosis. |
*NR |
| Swanson [85] 2014 Africa-Uganda Rural LIC |
6 weeks- Lectures, small-group tutorials, audio-visual materials & supervised clinical scanning. |
14 midwives- 13 no prior US experience, 1 experienced. |
Primary instructors’ credentials not specified. Sonographer for ongoing scanning support. |
Obstetric only- Curriculum included US physics, relevant anatomy & physiology, instrumentation & basic maintenance. Screening included- cardiac activity (yes, no), fetal presentation (cephalic, breech & others) & fetal number, Placental position (normal, previa & low lying), Pain & bleeding (complete abortion, incomplete abortion, blighted ovum, ectopic pregnancy or placental abnormality). |
Ongoing training resource in onsite sonographer available to trainees on return to clinic |
| Vinayak [63] 2017 Africa, Kenya Outer regional & Rural LMIC |
4 weeks- 1 hour lecture, 6 hours practical, 1 hour feedback & debrief per day (days per week unclear). Several days of assessment after course completion. |
3 midwives- No prior US experience. |
‘Experienced sonographers. Ratio 1:3. |
Obstetrics only- 1. E-learning module- introduction to general principles of US, US physics & OB US. 2. Post module test 3. Didactic lectures- US knobology, general & OB US 4. Hands-on practical experience. Practical skills- HC, AC, FL & FHR & rhythm. Placenta location & distance of lower lip from the cervix & estimated the amount of amniotic fluid (obtained from four images, one image for each quadrant). |
*NR |
| Vyas [70] 2018 America, Panama (Training in USA) Rural HIC |
12 hours- 6 sessions on OB US instruction, termed “Rural Obstetric Ultrasound Triage Exam” (ROUTE). |
8 medical students- Prior basic US training in medical school curriculum. |
Trainer- 3rd year OB/GYN resident physician. Assessment by board certified OB/GYN physicians. |
Obstetric only- ROUTE including identification of- fetal lie, placental position, DVP, amniotic fluid index (AFI), BPD, & HC for 2nd & 3rd trimester. |
*NR |
| Wanjiku [21] 2018 Africa, Kenya Rural LMIC |
1 day practical training following self-directed online pre-training. | Multidisciplinary 33 trainees- Clinical officers, Nurses, Medical officers. All had previously completed a novel pilot PoCUS training program. Other prior US training excluded participation. |
Certified Instructors. | Multiple systems- Standardized OSCE trainees assessed on – FAST (Trauma assessment), 1st & 2nd/3rd trimester scanning skills, i.e., identification of the gestational sac, 1st trimester dating using crown-rump length, detecting & measuring the FHR, identifying the presenting part, locating the placenta, & measurement of HC & BPD. |
Follow-up in-facility testing scheduled 3–4 months after initial training. 3–4 month refresher training offered to trainees who failed practical assessment. |
| Westerway [50] 2019 Australia Rural & urban HIC Indonesia/Central Asia/Timor Leste UMIC/LMIC |
6 separate PoCUS courses compared. Ranging from 4 to 18 hours total. Up to 6 hours lecture, 3–12 hours practical. |
Multidisciplinary 55 trainees- 15 medical practitioners, 23 midwives, 9 nurses, 8 radiographers. No prior US experience. |
Experienced OB US tutors. Same lead lecturer for all 6 courses. Ratio from 1: 2–5 (average 1:4). |
Obstetric only- Curriculum- Clinical history- pregnancy progression; Knobology, image optimisation (depth, focus, gain) & probe use; Theory behind performing a limited fetal anatomical assessment & 3rd trimester fetal biometry. Practical checklist- Image optimisation; Probe movements; Fetal lie; FHR; Recognition of fetal anatomy (heart, stomach & bladder); Amniotic fluid estimate (single deepest pocket); Identification of cervix & placental position; Fetal biometry measurements (BPD, HC, AC, FL). |
Follow-up test & practical at 6 & 11 months |
| Key- *NR = not reported/described | |||||
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Abbreviations AC – Abdominal Circumference AFV – Amniotic fluid volume BPD – Biparietal Diameter CRL – Crown to Rump Length DVP – Deepest Vertical Pocket ED – Emergency Department EGA – Estimated Gestational Age EM – Emergency Medicine FAST – Focused Assessment with Sonography in Trauma |
FH – Fetal Heart FHR – Fetal Heart Rate FL – Femur Length GA – Gestational Age HC – Head Circumference HIC – High-income country LIC – Low-income country LMIC – Lower-middle-income country LRS – Low-resource setting |
OB – Obstetric OB/GYN – Obstetrics and Gynaecology OSCE – Objective Structured Clinical Examination TA – Transabdominal TCD – Trans Cerebellar Diameter TV – Transvaginal UMIC – Upper-middle-income country US – Ultrasound |
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